Datasets:

meowterspace42
/

clinical_notes

Dataset card Data Studio Files Files and versions Community

Split (1)

train · 30k rows

text stringlengths 746 31k
We report a case of a 24-year-old male with a left-sided anterior subcoracoid shoulder dislocation () following a road traffic accident. This was the first episode of dislocation. The shoulder was closed reduced by the Kocher’s technique within 3 hours of trauma, and a post-reduction radiograph was taken to confirm concentric reduction. The shoulder was immobilized for 3 weeks ( and ), following which rotator cuff strengthening exercises were initiated. The patient was followed up, after the shoulder was reduced at 3 weeks, 3 months, and 6 months, and then, the patient reported after 2 years. This patient was a non-alcoholic healthy college-going student who was not on any medications. At 6-month follow-up, the left shoulder radiograph showed a sclerotic sector of the head with cortical erosions near the greater tuberosity ( and ). A magnetic resonance imaging (MRI) was done which revealed a geographic area of the anterior part of humeral head with an altered marrow signal, which was iso- to hyper-intense on short tau inversion recovery sequence, with a hypointense rim on T1 sequence. The differential diagnosis was a bone bruise or osteonecrosis of the humeral head. However, due to the sclerotic changes on the radiographs, possibility of osteonecrosis could not be ruled out and this required displaced medially, outside the bicipital groove ( and ), and the rotator cuff was normal. The patient had a stable shoulder with mild pain at the extremes of motion. A radiograph of the pelvis with both hips was normal, without any sclerotic changes of the femoral head. The patient was treated with cuff strengthening exercises, and he resumed all routine activities including leisure sporting activities. Bisphosphonate was not administered. At the end of 2 years, the patient had no functional restriction and had an excellent UCLA score. The shoulder radiograph revealed a mixed sclerotic and lytic lesion in the humeral head without any cortical defect and a maintained a congruent articular surface. The greater tuberosity erosions seen on the earlier radiographs became sclerotic without any further undermining ( and ). A repeat MRI of the shoulder at 2 years revealed a 19 mm3×17 mm3×12mm3serpiginous, geographic area, larger in size than the previous MRI, which was consistent with osteonecrosis of the humeral head without any deformation of the articular surface. There was a partial thickness tear with medial retraction of the subscapularis. The long head of biceps tendon was torn and retracted. The rest of the rotator cuff and glenoid labrum was normal ( and ). An MR angiography of the shoulder was performed to know the status of the circumflex vessels (, , , ). It showed attenuation of the some of the branches of anterior circumflex humeral artery, but all the vessels around the humeral neck were patent, but their course was not clearly defined. To enable a better visualization of the arteries around the neck of the humerus and to localize the site of obstruction of the artery, if any, a computerized tomography angiography of the left shoulder was performed at 2 years (, , , and ). This study reported that the origin and proximal part of the anterior circumflex humeral artery was not opacified while the distal part of the artery was seen filling with the dye through the collaterals. The posterior circumflex humeral artery was normal. On clinical examination, the patient was able to perform 170° shoulder abduction, with a normal scapulothoracic rhythm. The power of internal rotation of the shoulder was 4/5 as per the Medical Research Council grading on the left side, and the power of the rest of the shoulder movements such as external rotation, abduction, forward flexion, and extension was 5/5. The patient was advised biceps tenodesis with subscapularis repair. However, the patient was not willing for the same.
A 60-year-old male with a diagnosis of squamous cell carcinoma in the right main bronchus underwent right pneumonectomy. Two weeks after the operation, the patient developed acute empyema due to bronchopleural fistula at the right main bronchial stump which required two additional operations within 3 months of the initial pneumonectomy. He was finally fit for discharge in reasonable condition. His rib cage developed a degree of deformity, which was not extreme because we were able to avoid thoracoplasty to achieve complete repair.\nHe had the first attack of “asphyxia at the table” (severe breathlessness associated with eating) a year later and was admitted to our hospital. He presented with a massive dyspnoea and cyanosis, which disappeared gradually and spontaneously as oxygen was administered. Computed tomography (CT) images and bronchoscopy showed compression of the membranous portion of the left main bronchus (Fig. ). At that time, we did not take any interventional measures but advised the patient to avoid taking solid foods. However in the following 2 years, he had three episodes of emergency admission due to the same problem, and the symptoms became worse on each occasion. At the last admission, he had a cardiac arrest shortly after admission and underwent cardiopulmonary resuscitation followed by mechanical ventilation. We decided to introduce tracheobronchial nitinol stents under percutaneous cardiopulmonary support instead of performing surgical correction of mediastinal shift considering his history of surgical interventions.\nThe patient's trachea was distorted towards the right side and the left main bronchus curved sharply from the trachea, then ran horizontally to the left hilum. Because the strength of single stents might not be sufficient to sustain the bronchial lumen at that carinal portion, we used two nitinol stents (Covered Ultraflex™, ϕ 14 mm, length 8 cm and ϕ 16 mm, length 8 cm, Boston Scientific Corporation, Massachusetts, USA) that were placed partially overlapped for a length of 3 cm (Fig. ).\nAfter the successful deployment of two nitinol stents, the patient was discharged from hospital. In the following 3 years, he had three admissions due to pneumonia. A common cause of pneumonia in each admission was proven as Pseudomonas aeruginosa from his sputum samples that had resistance to some antibiotics.\nAfter those admissions, he had a stable period for more than 5 years without hospitalization, though home oxygen therapy was required. But ultimately, he had another phase of recurrent pneumonia and died of chronic respiratory failure 12 years after placement of the nitinol stents. No cancer relapse was demonstrated.
A 34-year-old G4P3 Caucasian woman was followed up antenatally because of a stillbirth in her previous pregnancy. She had had mild pre-eclampsia in her first pregnancy and a Caesarean section was carried out after unsuccessful induction of labor. Her second pregnancy and delivery were uneventful. The reason for the stillbirth in her third pregnancy was found to be an umbilical cord knot.\nIn the pregnancy reported here, our patient had polymorphic eruption of pregnancy (PEP) from 26 weeks' gestation and had three separate courses of oral steroids. Anti-D-antibodies were also found to be increased but in quantitative analyses their concentration, however, remained low. She was hospitalized once for a short period in late pregnancy because of an abnormal fetal heart rate recording.\nAt 36 weeks' gestation, a hypoechoic, 3.6 × 4.2 cm rounded mass was noted within the placenta on ultrasound examination (Figure ). An ultrasound scan with umbilical artery Doppler measurement after 28 weeks' gestation was normal and it is likely that the leiomyoma had gone unnoticed probably because no special attention had been paid to the placenta on that occasion. Another explanation could be that the leiomyoma grew very rapidly in the third trimester of pregnancy and it was too small to draw appropriate attention in earlier scans.\nShe had induction of labor due to worsening of PEP at 38 weeks' gestation. A viable male infant weighing 3330 g was delivered with Apgar scores of 9 at one minute and 9 at five minutes. The placenta was removed without difficulty.\nA round-shaped nodule was noted on the maternal surface of the otherwise normal placenta. The size of the nodule was 4 × 4 × 3 cm. It had a pale cut surface without hemorrhage, necrosis or calcification (Figure ).\nHistologically, the nodule was composed of bundles of smooth muscle cells. Nuclei were round or oval shaped and there were no atypical features or mitotic activity (Figure ). No attached myometrium was identified.\nImmunohistochemistry was positive for the smooth muscle actin antigen (Neomarkers, 1:500). Factor VIII related antigen (Dako, 1:750) and CD34 (Becton-Dickinson 1:20) marked only the endothelial cells, whereas cytokeratin of low molecular weight (Becton-Dickinson, 1:20), placental alkaline phosphatase (Dako 1:20) and desmin (Biogenex, 1:50) were negative. The method used for labeling was streptavidin-biotin. The tumor cells were positive for progesterone receptors but negative for estrogen receptors which is typical for leiomyomas during pregnancy [].\nChromosomes of the tumor were studied from paraffin sections by the fluorescence in situ hybridization technique with X- and Y-chromosome-specific probes and the tumor was found to carry XX chromosomes.
A 37 year old male came to the Department of Conservative Dentistry, Kyungpook National University Dental Hospital, Daegu, Korea, requesting treatment for an injured maxillary right central incisor. The patient reported that he fell off a bicycle and injured the tooth 1 day previously. Clinical and radiographic examinations showed an oblique crown-root fracture with pulp exposure of the maxillary right central incisor. The fracture line extended approximately 6 mm below the cement-enamel junction at the mesiopalatal aspect after removing the coronal segment (). The maxillary anterior teeth from the right canine to the left canine responded positively to a pulp vitality test including an electric pulp test and a cold test, with no tenderness to percussion. The maxillary right central incisor only had moderate mobility due to the fracture. The case was complicated because of esthetic problems in the maxillary anterior region, cross bite on the right lateral incisor, and crowding of the right central and lateral incisors. For facial analysis, irreversible hydrocolloid impressions of both arches were taken and a diagnostic cast was fabricated. The patient had skeletal class I malocclusion with bialveolar protrusion and dentoalveolar crowding of the maxillary anterior teeth (). Based on the analysis of the model, full-mouth orthodontic treatment involving forced eruption of the fractured tooth for overall facial improvement was firstly considered. However, the patient declined the recommended option due to its high cost, long treatment period, reluctance to undergo tooth extraction and extensive orthodontic procedures. Thus, orthodontic extrusion of the fractured tooth and realignment of crowded anterior teeth were planned as an alternative option.\nOn the first visit, emergency pulp extirpation and splinting of the tooth fragment to adjacent teeth using a bonding procedure were carried out to control pain and the esthetic problem. To re-align the palatally erupted maxillary right lateral incisor, labial movement of the tooth using removable orthodontic appliances such as a finger spring or a clear aligner may be used. However, removable orthodontic appliances apply force to the crown of a tooth through the palatally positioned spring or the elasticity of the material, resulting in a gradual tipping movement of the tooth. A large degree of inclination of the tooth axis during tipping can lead to unaesthetic results. Moreover, orthodontic extrusion of a tooth does not seem to be feasible with a clear aligner. Therefore, application of a fixed orthodontic appliance on the maxillary anterior area was planned to bodily move the tooth. A set-up model including a diagnostic wax-up was created to calculate the exact amount of tooth movement necessary and to predict the treatment results. As large overjet on the maxillary right central incisor was expected after re-alignment, space opening through interproximal reduction was also needed (). To measure the amount of space required to arrange the teeth ideally, the discrepancy of the maxillary anterior arch was calculated according to the following formula:\nArch-length discrepancy in the maxillary anterior region = (arch length from distal plane of the maxillary right second premolar to that of left second premolar) – (sum of the width of an individual tooth), where the width of an individual tooth is the largest mesiodistal distance perpendicular to the long axis of the tooth.\nThe calculated discrepancy was -2.0 mm. Stripping of interproximal surfaces of the maxillary left central and both lateral incisors had to be done by removing 0.5 mm and 0.25 mm, respectively, thereby gaining 2.0 mm of space. When the teeth were re-aligned in the set-up model after interproximal reduction, decreased overjet and esthetic teeth alignment were achieved (). According to the pre-operative analyses, the final treatment plan was designed: orthodontic extrusion followed by all-ceramic crown restoration of the maxillary right central incisor and orthodontic alignment combined with interproximal reduction of the crowded maxillary anterior teeth.\nBefore orthodontic extrusion was initiated, the root canal treatment was completed. The root canal was prepared up to an apical file size of 55/0.06 taper with ProFile nickel-titanium rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland). The enlargement procedure was followed by irrigation with 2.5% sodium hypochlorite. The prepared canal was filled with gutta-percha using a continuous wave compaction technique (B&L SuperEndo α2·β, B&L Biotech Co., Ltd., Ansan, Korea) and AH Plus sealer (Dentsply DeTrey, Konstanz, Germany). The access cavity was then temporarily sealed with resin-modified glass ionomer cement (Ionoseal, Voco GmbH, Cuxhaven, Germany). Prior to orthodontic treatment, the condition of the injured tooth and adjacent teeth was periodically monitored using clinical and radiographic examinations for three months due to the potential root resorption and vitality loss of the traumatized teeth.\nMinor tooth movement from the right first premolar to the left first premolar was scheduled to obtain the anchorage necessary to move the maxillary incisors. For orthodontic extrusion, a lingual button was attached to the labial surface of the maxillary right central incisor and 0.022 inch fixed pre-adjusted edgewise appliances (Victory metal bracket Roth, 3M Unitek, Monrovia, CA, USA) were bonded to the rest of the teeth involved in orthodontic movement. A 0.014 inch nickel-titanium archwire (SE Nickel Titanium Trueform, G&H Orthodontics, Franklin, IN, USA) was then placed for leveling and alignment of the teeth (). Extrusion of the central incisor and labial movement of the lateral incisor were done with elastic threads (Square Thread, Dentos Inc., Daegu, Korea) exerting a force of approximately 60 g, which were replaced every 4 weeks (). After 4 weeks, a 0.016 inch nickel-titanium archwire (SE Nickel Titanium Trueform, G&H Orthodontics) was used, and then exchanged for a 0.016 × 0.022 inch betatitanium alloy archwire (TMA Low Friction, Ormco Co., Glendora, CA, USA) after 8 weeks. After 12 weeks of orthodontic treatment, approximately 4 mm of extrusion had been achieved, exposing a good substrate for restoration. In addition, the palatally positioned right lateral incisor was labially re-aligned (). To open space for the maxillary right central incisor, interproximal reduction was performed using an orthostrip (Intensiv Ortho Strips, Intensiv SA, Montagnola, Switzerland, ) and a metal strip (Separating Strips, Dentaurum, Pforzheim, Germany, ) on the maxillary left central and both lateral incisors. The stripped enamel surface was smoothed using Sof-Lex Tooth Polishing Strips (3M ESPE, St. Paul, MN, USA), and then treated with 5% sodium fluoride varnish (CavityShield, 3M ESPE). An open coil spring was inserted between the right lateral incisor and the left central incisor to shift the left central incisor and both lateral incisors distally over 4 weeks. While moving the adjacent teeth, the extruded tooth remained in place for stabilization at the new position.\nAfter 16 weeks, an appropriate space for the maxillary right central incisor had been made and a coronal restoration was performed. A fiber post (#0.5 D.T. Light-Post, Bisco Inc., Schaumburg, IL, USA) was placed using dual-cured resin cement (Duo-Link, Bisco Inc.) and a composite core was built up (Gradia Direct, GC, Tokyo, Japan; Shade PA1, ). However, it was found that additional interproximal stripping would be necessary to clear more space for the right central incisor because of a size discrepancy between both central incisors. After the interproximal reduction and the additional 4 week tooth movement, tooth alignment was completed at 20 weeks of orthodontic treatment. To prevent any relapse, the teeth were stabilized for 4 weeks using the same fixed orthodontic appliances. After the retention period, all the brackets and wire were removed ().\nBefore final restoration of the maxillary right central incisor, a provisional crown with an additive contour at the facial gingival level was used for 1 month after crown preparation to correct a minor discrepancy of the gingival level between the 2 maxillary central incisors. A porcelain-fused-to-zirconia crown was finally constructed over the fractured tooth with the crown margin on the sound tooth structure (). Additional retention of the re-aligned teeth has been carried out with an invisible retainer. At the 5 month checkup following treatment, good esthetic, a stable crown position, and healthy periodontal tissues were observed. Neither vitality loss of the adjacent teeth nor pathologic signs from the injured tooth were present on follow-up clinical and radiographic examinations ().
A 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of emergency embolization procedure. Through the catheter, the embolization was performed from the installation of 02 micro-platinum springs until the complete arterial occlusion and consequent end of the blood flow of the PA (Fig. ). The selective angiography of the left internal maxillary artery was then performed in different projections to rule out another possible source of bleeding and the possibility of compensatory revascularization.\nThe patient was transferred and remained under observation for 12 hours in the intensive care unit. A new angiography was performed after 24 hours for control, confirming the complete resolution of the PA. The patient was submitted to a second surgery 72 hours after the hemorrhagic episode when a large part of the bone fragments were removed by intraoral access. Also the palpable and superficial portion of the projectile located in the genic region by infraorbital access was removed.\nThe patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up.
A 10-year-old Caucasian female patient was admitted to the General Hospital of Caxias do Sul with a 3-month history of diffuse abdominal pain worsening after eating. She also had food content emesis after meals and daily episodes of noninflammatory diarrhea. In the last 2 months began with abdominal distension. Abdominal ultrasonography showed extensive heterogeneous mass with cystic area in between measuring 25.0 cm × 17.6 cm × 8.0 cm compromising the entire abdominal cavity.\nIn the last month, the abdominal pain became worse in intensity. The patient had a weight loss of 6 kg in these 3 months. On physical examination, the patient was in regular general condition, pale, with a cystic consistency palpable mass occupying the entire abdomen.\nComputerized tomography scan showed a large expansive lesion, heterogeneous, predominantly cystic, with gross septa that enhanced with the contrast, measuring 22 cm × 20 cm × 13 cm with a small amount of free fluid adjacent to the mass []. Magnetic Resonance of the abdomen showed large expansive mass with predominance of hyperintensity on T2 located next to the mesentery, measuring 22 cm × 18 cm × 10.4 cm with compression of adjacent structures without signs of infiltration. The initial differential diagnosis was neuroblastoma and lymphoma.\nTumor resection was conducted the next day after admission []. Due to its proportions, midline laparotomy was indicated. The large mass was not adhered to the abdominal wall, its pedicle was located in the mesentery, and there were some adherences with the small intestine. After lysis of the adherences, the mass was enucleated without injuring any mesenteric vessel. The mesenteric origin of the mass suggested by the magnetic resonance was confirmed during the intraoperative period. The patient was discharged 5 days after the resection.\nThe macroscopic examination showed cystic encapsulated brown-clear portion and plain tissue, measuring 26 cm × 18 cm × 6 cm and weighing 2645 g. The histopathological diagnosis was benign-appearing spindle cells with marked vascularization by delicate vessels and myxoid areas. No capsular involvement of the mass was evidenced. In immunehistochemical staining, the tumor stained positive for vimentine and smooth muscle actin (SMA), but negative for CD117, CD34, S-100 protein, and desmine. From these findings, the diagnosis of leiomyoma was made.
A 43-year-old male patient, who is single and jobless at the onset of treatment, was referred to the clozapine case team in July 2017 for possible management of severe TD. The illness history of the patient is discussed here. In the year 2005, when the patient presented to the hospital for the first time, he had psychotic symptoms which lasted 1 year; at the time, he received the diagnosis of schizophrenia, catatonic type based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria. He was prescribed chlorpromazine 200 mg daily which resulted in control of symptoms and later on achievement of full remission. Later the dose of chlorpromazine was reduced to 100 mg daily, but after 6 months on the reduced dose, breakthrough symptoms appeared; then dose was restored back to 200 mg resulting in full remission again. The patient took chlorpromazine 200 mg daily for 8 years till he started to develop abnormal involuntary body movements. The first abnormal involuntary body movements were identified in August 2013. The dose of chlorpromazine was reduced gradually till 50 mg/day, and diazepam tablets were temporarily prescribed to alleviate distress. On November 2013, chlorpromazine was discontinued and the patient was prescribed risperidone 1 mg daily with gradual escalation of dose to 4 mg/day. Intermittently, benzodiazepines like diazepam and bromazepam were prescribed to alleviate distress. But the patient discontinued treatment for about 2 months with relapse of psychosis which necessitated admission. He was admitted to the hospital for the first time in June 2014; the diagnosis was schizophrenia, paranoid type with florid persecutory delusions and auditory hallucinations, as well as severe TD with involuntary choreoathetoid distressing body movements which involved the trunk. After admission, he was started on risperidone 8 mg/day along with 10 mg of diazepam with occasional addition of sedatives like promethazine 25 to 50 mg. One month later, he was discharged with hallucinations cleared but delusions still on, and dyskinetic movements still prevailing and getting worse every time. After one outpatient follow-up visit post-discharge, he discontinued treatment again. The reason for default was worsening of dyskinetic movements.\nAbout 2 to 3 months after default of treatment, his psychotic symptoms got worse to the level necessitating physical restraint with chains. He was admitted for the second time in September of the same year. His treatment was restarted with risperidone and benzodiazepines, and with occasional use of promethazine. The abnormal involuntary movements got worse with involvement of neck and both hands in addition to the trunk and shoulders. The movements were described as neck and back extension with swinging of both arms. He was refusing or unable to be interviewed due to the distress from the dyskinetic movements. The treatment was shifted to olanzapine 10 mg daily. But he had been given fluphenazine decanoate depot injection of 12.5 mg at the onset of the second admission which resulted in the occurrence of acute dystonia for which the anticholinergic trihexyphenidyl was given orally at 5 mg/day. The dystonic reactions were alleviated by trihexyphenidyl. Following 10 weeks of inpatient treatment, the patient was discharged with some improvement of psychotic symptoms. His previous medications were discontinued, and he was started on olanzapine 20 mg/day and clonazepam 2 mg/day at discharge.\nAt outpatient follow-up, the patient continued to have frequent relapse of symptoms and signs of psychosis, including homicidal intent. Risperidone was later restarted due to unavailability of olanzapine. He was admitted for the third time in October 2016 to the emergency department and was discharged 3 weeks later after he was treated with risperidone, and later olanzapine 20 mg/day; he also had received clonazepam. However, at outpatient follow-up visit, he reported that the abnormal body movements were worsening further and that he was being disabled due to which he was contemplating on suicide. He also started smoking cigarettes one pack daily to alleviate his distress. After this, the treating psychiatrists decided to consult the clozapine case team. In March of the same year, the patient was admitted for the fourth time with intention of starting him on clozapine. He was on risperidone 4 mg/day and clonazepam 2 mg/day when he was transferred to the clozapine case team in July 2017. At the onset of treatment, the TD movements were continuous and vigorous all the time except during sleep when movements disappeared. During the daytime, when he was awake, he was diaphoretic from the vigour of the muscle contractions and usually got exhausted and dehydrated. Abnormal Involuntary Movement Scale (AIMS) total score prior to the onset of treatment was 34. All necessary evaluation and workup were conducted, and the patient was declared fit to start clozapine treatment.\nAfter all preconditions were fulfilled, the patient’s previous medications were discontinued and he was started on clozapine treatment according to the dose escalation protocol starting from July 2017. Dose increment continued with all necessary monitoring. Soon after the start of treatment with clozapine, the dyskinetic movements increased and became distressing; he was given intravenous diazepam to alleviate his distress every time he had distress from the dyskinetic movements. Few days after the onset of clozapine treatment, clonazepam was also prescribed a dose of 4 mg/day, given divided twice daily. But dose of clonazepam was reduced to 2 mg/day, when dyskinetic movements started to show a decrease in intensity few days later. One month after the onset of clozapine treatment, the patient said he was better and requested to be discharged despite continued dyskinetic movements which episodically got exacerbated. He was free of psychotic symptoms, however. He was advised on coping mechanisms with ways of relaxing himself; clonazepam was discontinued and he was discharged in consultation with his relatives. Upon discharge, he was on clozapine 400 mg/day divided twice, with higher dose in the evening and clonazepam 2 mg to be taken on a need basis (10 tablets were dispensed). Two weeks later, during outpatient visit, the patient reported that he was better than before but still has occasional worsening of symptoms, which necessitated clonazepam use; the total score of AIMS was 19 at the time. Early October 2017, the patient presented with exacerbation of dyskinetic movements with sweating and exhaustion, and requested to be admitted again. He was admitted and was soon given intravenous diazepam 10 mg to stabilize him. He was prescribed clonazepam again at 2 mg/day and was also given haloperidol at 1.5 mg/day in a desperate attempt to suppress movements, but to no avail; haloperidol was discontinued 3 weeks after it was started.\nGradually, however, the dyskinetic movements started to decrease, and he was discharged from hospital 1 month after admission on clozapine 400 mg/day and clonazepam 2 mg/day. However, the dyskinetic movements were not adequately controlled, and the dose of clozapine was raised gradually to reach a dose of 500 mg/day, while clonazepam dose was raised to 4 mg/day. At the beginning of August 2018, the patient reported that the abnormal body movements were markedly decreased and that he did not consider them a problem anymore. After this, the dose of clonazepam was reduced to 2 mg/day with plan to taper and discontinue the drug. The patient started to work, but after dose reduction of clonazepam, the dyskinetic movements started to show increment to intolerable levels. Finally, since the end of August 2018, the treating team decided to keep the dose of clonazepam to 4 mg/day divided twice and to continue that dose indefinitely together with clozapine 500 mg/day divided twice daily. Since that time, the dyskinetic movements almost disappeared and were unnoticeable; the score of AIMS reached to a low level of 3. The patient was stable and effective at work with marked satisfaction with treatment. He adhered to treatment and continued to come for follow-up by himself. The benefit the patient got from the treatment started inspiring other patients with similar problems who started joining the programme of clozapine treatment to overcome their enormous suffering.
A 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabdominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder by the orthopedic surgeons with subsequent emergency irrigation, debridement, and open reduction and internal fixation (ORIF) of the open ankle fracture as well as reduction of the left ankle dislocation. He was extubated after the procedure and monitored in the ICU while the remaining preoperative medical workup was completed including X-rays and CT scans with 3D reconstructions of the pelvis reconstructions. A hydromorphone patient-controlled analgesia (PCA) pump was utilized for pain control.\nOn hospital day 2, the patient was deemed fit for surgery and was taken to the operating theater for a combined operation by the orthopedic surgeons for ORIF of the pubic diastasis, sacral fracture, and sacroiliac joint followed by the trauma surgeons to reconstruct the abdominal wall and inguinal canal. The trauma team performed the exposure of the pubic symphyseal region and the pubic diastasis. A Pfannenstiel incision was made, and the planes were dissected exposing the left spermatic cord. The orthopedic team then performed a gentle open reduction of the pubic diastasis taking care to ensure that the bladder and urethra were not incarcerated. The Asnis III cannulated screw system and a Matta pubic symphyseal plate (Stryker GmbH, Switzerland) were utilized under C-arm fluoroscopic guidance with appropriate alignment of the AP and inlet and outlet pelvis views. Once the Mata plate was in place and the orthopedic reduction was completed, we proceeded to reconstruct the anterior abdominal wall. Since the Cooper ligament was destroyed, it was dissected to allow direct visualization of the pubic rami. The abdominal wall defect was measured to be 10 × 12 cm. We then used a modified Stoppa technique by placing the 6 × 6 in Prolene mesh under the damaged internal inguinal ring, making sure the spermatic cord on the left side was not injured or pinched, securing it in place using sutures, including direct suturing to the periosteum of the repaired pubic symphysis and the plate as needed. The medial borders of the mesh were tucked inside the opened rectus sheath on the right side and secured laterally with fires of a 5 mm Covidien Endotack (Medtronic, MN, USA) to the remnants of the conjoint ligament. The midline was then repaired with sutures, including the mesh as reinforcement. The patient did well postoperatively with postreduction films demonstrating appropriate alignment (). He was discharged to rehab on postoperative day 5. There were no recurrences during the follow-up period of 10 years.
A 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabdominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder by the orthopedic surgeons with subsequent emergency irrigation, debridement, and open reduction and internal fixation (ORIF) of the open ankle fracture as well as reduction of the left ankle dislocation. He was extubated after the procedure and monitored in the ICU while the remaining preoperative medical workup was completed including X-rays and CT scans with 3D reconstructions of the pelvis reconstructions. A hydromorphone patient-controlled analgesia (PCA) pump was utilized for pain control.\nOn hospital day 2, the patient was deemed fit for surgery and was taken to the operating theater for a combined operation by the orthopedic surgeons for ORIF of the pubic diastasis, sacral fracture, and sacroiliac joint followed by the trauma surgeons to reconstruct the abdominal wall and inguinal canal. The trauma team performed the exposure of the pubic symphyseal region and the pubic diastasis. A Pfannenstiel incision was made, and the planes were dissected exposing the left spermatic cord. The orthopedic team then performed a gentle open reduction of the pubic diastasis taking care to ensure that the bladder and urethra were not incarcerated. The Asnis III cannulated screw system and a Matta pubic symphyseal plate (Stryker GmbH, Switzerland) were utilized under C-arm fluoroscopic guidance with appropriate alignment of the AP and inlet and outlet pelvis views. Once the Mata plate was in place and the orthopedic reduction was completed, we proceeded to reconstruct the anterior abdominal wall. Since the Cooper ligament was destroyed, it was dissected to allow direct visualization of the pubic rami. The abdominal wall defect was measured to be 10 × 12 cm. We then used a modified Stoppa technique by placing the 6 × 6 in Prolene mesh under the damaged internal inguinal ring, making sure the spermatic cord on the left side was not injured or pinched, securing it in place using sutures, including direct suturing to the periosteum of the repaired pubic symphysis and the plate as needed. The medial borders of the mesh were tucked inside the opened rectus sheath on the right side and secured laterally with fires of a 5 mm Covidien Endotack (Medtronic, MN, USA) to the remnants of the conjoint ligament. The midline was then repaired with sutures, including the mesh as reinforcement. The patient did well postoperatively with postreduction films demonstrating appropriate alignment (). He was discharged to rehab on postoperative day 5. There were no recurrences during the follow-up period of 10 years.
A 78-year-old Hispanic man presented to the emergency department (ED) of our hospital with abdominal pain accompanied by nausea and bilious emesis. His history was significant for an open appendectomy, laparoscopic cholecystectomy, and umbilical hernia repair. He had no significant family history and did not smoke, drink alcohol, or use illicit substances. The patient denied fever or night sweats but complained of anorexia and unintentional weight loss in the month leading up to admission. His physical examination revealed normal bowel sounds, no tympani on percussion, no palpable masses, no hepatosplenomegaly, no fluid wave, and a soft but diffusely tender and distended abdomen. Computed tomography (CT) of his abdomen and pelvis with oral and intravenous contrast revealed small bowel distention and a short segment of bowel wall thickening with enhancement in the right lower quadrant consistent with a partial SBO, likely arising from either local inflammation or adhesion (Fig. a). He was treated medically with bowel rest and decompression with nasogastric tube placement. The patient reported significant relief shortly after decompression, with complete resolution within 48 hours. His diet was advanced, and he was discharged to home with close outpatient follow-up.\nHe returned to our ED 2 days after discharge with recurrence of abdominal pain, distention, nausea, and bilious vomiting. Repeat CT of his abdomen and pelvis with oral and intravenous contrast showed a moderate increase in the small bowel distention with a transition point in the left middle abdomen consistent with moderate progression of the partial SBO. CT also revealed a 1.6-cm nodular density abutting the anterior aspect of the gastric antrum and lobulated anterior gastric antral wall thickening concerning for atypical gastritis or a gastric tumor (Fig. b). Because of an unsuccessful trial of decompression, the patient was taken to the operating room for adhesiolysis and possible bowel resection.\nIntraoperative findings included a completely obstructive mass within the ileum, a partial obstruction by two masses within the jejunum, and a nonobstructive gastric antral mass. He underwent two small bowel resections with excision of the small bowel tumors. Intraoperative frozen section analysis of the small bowel tumors was consistent with lymphoma. The tissue sample was positive for cluster of differentiation (CD)20, paired box protein 5 (PAX5), B-cell lymphoma protein (BCL)-6, and cellular myelocytomatosis (c-Myc), and it was negative for BCL-2, CD3, and CD5 (Fig. ). The result of Epstein-Barr virus polymerase chain reaction testing was also positive. Flow cytometry showed an abnormal B-cell population positive for CD10, CD19, CD20, CD22, CD38, and CD45 with kappa-light-chain restriction, but it was negative for T-cell markers, CD5, and lambda light chain (Fig. ). The final pathology was consistent with BL. He underwent a bone marrow biopsy and aspirate that was negative for lymphoma. Positron emission tomography (PET) demonstrated active disease on both sides of the diaphragm, including adenopathy in the chest, gastric antrum, and the greater gastric curvature, consistent with a stage III BL (Fig. a).\nAfter postoperative recovery, the patient was initiated on six cycles of adjuvant combination chemotherapy with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, hydroxydaunorubicin, and rituximab (DA-EPOCHR), as well as intrathecal (IT) methotrexate for central nervous system (CNS) prophylaxis. Overall, he tolerated the chemotherapy regimen well, except for a subsequent SBO during the sixth cycle that was managed conservatively. A post-treatment PET scan showed complete remission (Fig. b), and the patient is still being followed 14 months after initial resection.
In June 2011, a 56-year-old male was referred to our department by head and neck surgeon in order to improve his upper denture retention and stability. The patient was diagnosed with a squamous cell carcinoma of the maxillary gingiva (T4N0M0) in May 2005 and underwent an extended left maxillectomy, an anterior and middle cranial base resection, a left ophthalmectomy, and a flap reconstruction using the rectus abdominis muscle were performed. On physical examination, a recessed deformation on the left side of his face could be seen because of the left ophthalmectomy. The function of the left levator palpebrae muscle was eliminated to the level of a slight elevation by using the frontal muscle. A metal plate was anchored to the inferior wall of orbit. The left ethmoid bone, inferior nasal turbinate, the maxilla, alisphenoid, medial and lateral pterygoid muscle were already excised during the mesh titanium plate reconstruction of the anterior wall from the maxillary orbital region. Intraorally, the left maxilla had been excised from the midline, with the rectus abdominis muscle flap sutured directly to the soft palate. The peripheral mucous membrane around the left upper lip was already scarred, without the oral vestibule, and the flap margin had moved along with the surrounding soft tissue. The 70 × 50 mm flap was sagging from its weight and was in contact with the mandibular molars, reducing the volume of the oral cavity unless dentures were worn. The maxilla was removed from the midline to the maxillary tuberosity, while the mandible was removed from the anterior border of the ramus to the coronoid process. Dead space was eliminated because the abdominal rectus muscle was placed from the anterior cranial base to the oral cavity during reconstruction (Fig. ). No expiratory leakage or food reflux was observed, and the rhinopharyngeal closure was maintained. Prior to performing surgery, there was no tumor recurrence or metastasis. The patient had a mouth opening of 43 mm, which we judged operable and then conducted the flap reduction and elevation under general anesthesia in Dec 2008. Informed consent was obtained from the patient’s parents prior to study initiation, and all procedures were performed in accordance with the Declaration of Helsinki.\nSurgical reconstruction was performed as follows:An incision was made from the buccal side of the sutured edge (scar) in the abdominal rectus muscle flap (Fig. ). We can conduct a vestibular extension at the same time by incising this position. The adipose tissue was peeled from the buccal side to slightly beyond the skin flap center while maintaining approximately 5 mm thickness. The adipose tissue was reduced using a radio knife (8 g) (Fig. ). When we reduce fat tissue, we must avoid perforating of the skin. The skin was incised directly above the zygomatic bone, with tissue separation (avoiding exposure of the plate) to enable easy visibility of the zygomatic bone. Subsequently, the subcutaneous tissue was peeled from the zygomatic bone to the oral cavity for tunneling. Three mini QUICKANCHOR® (Depuy Mitek Surgical Products, Inc. Raynham, MA, USA) anchors were placed in the zygomatic bone, and anchor sutures were drawn through the subcutaneous tissue to lift the skin flap. A modeling compound was used to shape the margin of the celluloid splint (Fig. ). The advantage of flap suspension using Mitek anchors is the simple operability, less anchor positioning limitation, and easier length adjustment of the thread for suspension, which lead to easier fixation of soft tissue without slackness as well as clinically sufficient strength for fixation of ligament and tissue. On the other hand, less than 4 mm thickness of the cortical bone for suture anchor fixation causes insufficient fixation, therefore, determining placing position on the bone for fixation is necessary. Consequently, due to the versatility, the position that is considered optimal for stronger fixation and more efficient suspension can be selected as the anchor placing position, while the periosteum, corium, and scar tissue that are thought the most suitable for maintaining the strength can be chosen for the suture thread. Regarding the anchor placing position in this case, we determined 3 positions on the zygomatic bone and sutured flap corium taking into consideration a complete maxillectomy had been completed, which resulted in being able to lift the flap outward and upward.\nPostoperatively, the color of the skin flap was normal without congestion or necrosis. The celluloid splint was removed 10 days after the surgery with no infection or necrosis observed in the skin flap. We can find only fat, scar tissue, not carcinoma in the reduced fat tissure. At 3 months postoperatively, epithelialization and scarring were observed on the border of the skin flap and buccal mucosa, with no wound opening. Next, a denture that was stabilized to the right residual teeth with a clasp made. This prosthesis had two double Akers cast clasps unilaterally to retain the prosthesis by the four remaining molars. The major connector used anteria paratal plate. The patient was quite satisfied to be able to masticate, form an alimentary bolus, and swallow without any teeth falling out. No re-sagging of the skin flap or wound infection was observed at 3 years postoperatively. Patient follow-up will be continued at our department (Fig. ).
A 71-year-old man was admitted to our outpatient clinic, with nausea, epigastric pain, and weight loss that had lasted for seven months. Laboratory findings showed anaemia. The patient underwent an endoscopic evaluation, which revealed a huge ulcerative and infiltrative mass in the upper and middle third of the stomach and the biopsy specimen taken showed a moderated tubular adenocarcinoma. Contrast-enhanced computerised tomography (CT) scan revealed a thick engrossment of the two upper thirds of the stomach with enlarged perigastric lymph nodes and not liver, nor peritoneal metastases findings were shown. The patient underwent a D2 total gastrectomy with distal pancreatectomy and splenectomy. At surgery, the tumour was located in the upper two-thirds of the posterior wall of the stomach with enlarged lymph nodes at the lesser curvature and celiac trunk. There was serosal invasion and fixation to the anterior surface of the pancreas body. No liver or peritoneal metastases were found.\nOn gross examination of the specimen, we identified two attached ulcerative tumours located on the posterior wall of the stomach (). The proximal one close to the cardial region measured 6.5 × 5.5 cm, with a whitish grey coloration and with an elastic consistency; and closely attached, a fungating ulcerative reddish lesion (Borrmann type III) measured 8.5 × 8.0 cm and occupied the posterior surface of the middle third of the stomach. The latter fixedly attached to the anterior surface of the body of the pancreas. The spleen did not show alterations. In addition to the gastric specimen, 41 resected regional lymph nodes were submitted and studied. Microscopically, two separated gastric lesions were identified with different patterns in morphology and the distance in between was of 1 mm (). The proximal lesion corresponds to a large-cell neuroendocrine carcinoma composed of atypical cells with faint cytoplasmic features and prominent hyperchromatic nuclei (occasionally pleomorphic). The cells are distributed in an organoid architecture with solid nests and broad trabeculae solid pattern without glandular formation (). The distal tumour corresponds to a moderated tubular adenocarcinoma, composed mainly of tubules infiltrating the gastric wall with serosal exposure. The cells contain variable amounts of eosinophilic cytoplasm with scattered mucin material ().\nThe neuroendocrine phenotype of the large-cell neuroendocrine carcinoma was immunohistochemically confirmed with synaptophysin, which stain all (). Additionally, it showed focal expression for keratin (AE1/AE3) (). Other markers, such us CD45, CD3, CD20, CD30, and S100, were negative.\nThe tumour cells invaded veins as well as lymphatic nodes. Regional lymph node metastasis was detected in 17 out of 41 lymph nodes. Sections showed adenocarcinoma in all lymph nodes retrieved, but only one lymph node showed metastasis from the neuroendocrine carcinoma.
A 35-year-old woman who underwent peritoneal dialysis for 11 months because of ESRD secondary to chronic glomerulonephritis was hospitalized for living kidney transplantation. Proteinuria and renal dysfunction were observed during her pregnancy, and her serum creatinine level was 1.4 mg/mL at that time; thereafter, she was followed up by a nephrologist at our institution. Although renal biopsy was considered, the atrophic change of her kidneys was too severe for a renal biopsy for pathological diagnosis. She underwent ABO-incompatible living kidney transplantation donated from her 62-year-old mother. Her left kidney was procured, and the allograft had a single artery that showed no evidence of arteriosclerosis or stenosis (Fig. ). The transplanted artery was anastomosed to the internal iliac artery, and the transplanted vein was anastomosed to the external iliac vein. After the completion of anastomosis, Doppler US revealed an increased peak systolic flow velocity at around 250 cm/sec with > 200 cm/sec peak velocity at anastomosis correlating with significant stenosis (Fig. ). Arterial anastomotic stenosis was suspected; however, there was no evidence for it. At the same time, a change in hue was detected in a part of the transplant renal artery; that part of the artery turned dark brown, and hematoma was strongly suspected (Fig. ). Furthermore, that part was exactly where vascular clamping was performed temporarily in order to drain the air and check bleeding at the anastomosis. Therefore, transplant renal artery stenosis (TRAS) might have resulted from TRAD. The part of the transplanted renal artery was resected, and cold reflux was started again. Injury of the transplant artery was detected macroscopically, and the rest of the transplanted renal artery was anastomosed to the external iliac artery. After re-anastomosis, Doppler US revealed that the blood flow of the renal artery was adequate without an increase in the systolic blood velocity, resulting in sufficient blood flow throughout the allograft. Urine output was also observed as soon as the blood flow returned. An hour after the allograft blood flow returned, the allograft biopsy was performed at the lower pole of the allograft, and no bleeding from the operative field, including the biopsy site, was observed. An immunosuppression regimen including tacrolimus, mycophenolate mofetil, prednisone, and basiliximab was prescribed. After the kidney transplantation, her serum creatinine level decreased to 0.95 mg/dL (Fig. ). An allograft biopsy showed no evidence of rejection or acute tubular necrosis. Furthermore, pathological diagnosis of the resected artery was tunica media dissection.\n Written informed consent was obtained from the patient and her mother for participation in this report.
A 29-year-old Hispanic gravida 3, para 2-0-0-2 at 32 weeks of gestation presented to an outside hospital with a 3-day history of worsening chest pain, dyspnea, orthopnea, and shoulder pain. She was previously in good health without comorbid medical issues. Initial work-up at the outside hospital included a computed tomography (CT), which was significant for a large pericardial effusion with no evidence of pulmonary embolism (). She was transferred to our institution for further management.\nOn arrival, the patient was uncomfortable and leaning forward, with a blood pressure of 127/80 mmHg, pulse of 124 beats per minute, respirations of 24 times per minute, and an oxygen saturation of 97%. She appeared in distress. There was tachycardia and distant heart sounds on physical examination, but no jugular venous distension noted. Laboratory evaluation revealed no significant abnormalities. Arterial blood gas analysis demonstrated a mixed metabolic and respiratory acidosis. Cardiac ischemia markers were negative. An electrocardiogram (ECG) demonstrated sinus tachycardia and electrical alternans.\nA transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology and a left ventricular ejection fraction of 50% (). The patient had worsening chest pain and discomfort. The obstetric team performed fetal monitoring which demonstrated no abnormalities. A multidisciplinary team met at the patient's bedside and consisted of maternal fetal medicine (MFM), cardiothoracic surgery, neonatology, cardiac anesthesia, and cardiology specialists.\nIt was decided that surgical pericardial window and drainage with drain placement was the most appropriate treatment because the majority of the pericardial effusion was posterior and would not be amenable to percutaneous drainage. The patient received a dose of betamethasone for fetal benefit, and underwent an uncomplicated pericardial window and drainage under general anesthesia with standard monitoring and continuous fetal monitoring. A total of 400 mL of serous fluid was drained from the pericardial space. Obstetric nursing, neonatology, and MFM team members were present in case emergent cesarean delivery was required. The fetus had periods of minimal heart rate variability and intermittent late decelerations, but this improved at the conclusion of the procedure. Her vital signs normalized and symptoms resolved postoperatively. The pericardial drain was removed on the day of discharge, postoperative day 7.\nMaternal blood laboratory studies provided no obvious etiology. The pericardial fluid cultures and cytology were negative for tuberculosis, bacterial or fungal infection, or malignancy. Serum autoimmune and collagen vascular disease work-up was negative. Thyroid function tests were normal. Serum antibody titers were positive for Coxsackie B virus infection.\nThe patient had an uneventful postoperative course following pericardial window and drainage and returned at 38 weeks for scheduled repeat cesarean delivery and bilateral tubal ligation. A repeat echocardiogram prior to surgery revealed no reaccumulation of pericardial fluid. The cesarean was uncomplicated, and she gave birth to a live male infant weighing 3420 grams with Apgars of 9 and 9 at 1 and 5 minutes, respectively. She was discharged home on postoperative day 3. Her postpartum course was uncomplicated.
A 55-year-old man was referred from a regional hospital to a university hospital (level-one trauma center) for symptomatic nonunion of a right medial clavicle fracture that resulted from a fall injury. The patient was a smoker and was known for left reverse total shoulder arthroplasty, first right rib resection at a young age, bipolar disorder, and antisocial personality disorder. His baseline level of activity was low, as he was unemployed and did not practice a specific sport or physical activity. His range of motion of the left shoulder was limited due to his previous reverse total shoulder arthroplasty. When the patient was first evaluated at the outpatient clinic 5 months after the injury, the active range of motion of his right shoulder was reduced in all three planes to about 70 degrees in abduction, 90 degrees in flexion, and 30 degrees in external rotation due to pain and medial instability. The abduction strength was 4+ at the Jobe test. The primary complaint of the patient was not pain, but the sensation of instability at the fracture site during movement. Radiographic and CT imaging demonstrated a highly comminuted medial-end nonunion of the right clavicle (Figures and ).\nSurgical management of the nonunion with an open reduction and internal fixation was performed. In a semisitting position, the nonunion site was opened using a 10-centimeter longitudinal incision at the SC joint. ORIF was completed using a locking clavicle distal-end plate (Stryker, Mahwah, NJ) and a 3.5 mm lag screw. A left-side plate was positioned so that the larger portion (usually lateral portion) could fit on the clavicular medial end. One lag screw was used to maintain fracture reduction. Four locking screws were used on the medial side of the fracture, and three locking screws were used on the lateral side (). The SC joint was not bridged by the plate, and a stable fixation was obtained. Two weeks of immobilization in a sling were recommended to the patient, but it was suspected that his compliance to the proposed treatment was inadequate.\nDuring a follow-up appointment at his regional hospital five months postoperatively, the patient complained of increasing pain and instability at the SC joint. This injury limited the patient in some of his activities of daily living, such as dressing and personal hygiene. The wound healing seemed complete, and there was no sign of operative site infection. A new series of radiographs showed extensive plate loosening and migration of the five medial screws (4 locking+1 lag screw). Two medial locking screws were now over 3 centimeters away from the plate. The three distal screws remained properly positioned. The patient was referred to the university hospital for further evaluation. A CT scan of the shoulder and the affected SC joint confirmed hardware migration, displacement of the comminuted bone segments, and posterior displacement of the medial fragment of the clavicle with the SC joint still intact (Figures and ). A medial claviculectomy with stabilization of the remaining clavicle was proposed.\nUnder general anesthesia and in a semisitting position, the same longitudinal skin incision was opened to access the nonunion site. The plate and the three intact distal screws were removed. Three loose medial screws were removed, but two medial screws () remained unreachable. The comminuted bone fragments were removed, and the medial end of the right clavicle was resected for a total of 5 centimeters in length. Two 6-millimeter tunnels were drilled on both the sternum and medial clavicle in preparation for the figure-of-eight reconstruction technique. The tunnels were drilled directly through the medial end of the clavicle, while they were drilled with an oblique trajectory on the sternum from the anterior cortex towards its right articular surface. The patient's left palmaris longus tendon was harvested as the autograft of choice for this surgery, as the right palmaris longus was absent. A good quality, 15-centimeter-long palmaris longus tendon was obtained. The graft was passed through both tunnels in a figure-of-eight configuration and sutured near the SC joint (no pretightening). Both free ends were sutured to one another using Ethibond 1-0 (as described by Bae et al. []). Vicryl 0 sutures were used for subcutaneous closure, and staples were used for skin closure. Two weeks of immobilization were recommended to the patient with a shoulder sling.\nSurgery was well tolerated by the patient. Cultures taken during revision surgery remained negative. Wound healing was uneventful. Two weeks after surgery, the patient presented to the clinic for evaluation. He reported minimal pain and had a range of motion of approximately 150° in flexion and abduction. Eight months postoperatively, the patient did not present any residual pain or limitation on range of motion. Outcomes at 3 years of follow-up were excellent, with no range of motion limitation, no pain, and no clinical instability. Control radiographs showed no sign of reconstruction failure (). The patient was able to return to his previous level of activity and was able to perform his activities of daily living without any limitation.
A 52-year-old man with no significant prior medical history was brought to our emergency room with drowsy mental status that lasted ten hours after the onset of left hemiparesis and dysarthria. The patient's left extremities were weak, and muscle power was of grade 4 in upper and lower limbs. Brain computed tomography (CT) and magnetic resonance examinations revealed acute cerebral infarction in the right MCA territory and an extra-axial mass with homogenous enhancement in the medial portion of the right sphenoid ridge (). Magnetic resonance angiogram showed complete occlusion of the right ICA terminus (). The infarction included the right uncus, insula, medial occipitotemporal gyrus, basal ganglia, corona radiate, and precentral gyrus (). The tumor, which was consistent with a sphenoid ridge meningioma, encased and compressed the right ICA terminus. Cerebral angiography demonstrated complete occlusion of the right proximal M1 portion with slightly limited collateral circulation to the right MCA territory and a radiographic blush from the surrounding meningioma (). Flow in the right MCA had been partially reconstituted by supply from the ipsilateral anterior cerebral artery and the posterior cerebral artery, but was much reduced. A CT perfusion study obtained shortly after arrival showed dramatic prolongation of time to peak and mean transit time of the right MCA territory, indicating obviously decreased regional cerebral blood flow in the involved territory ().\nThe patient was admitted and started on dual antiplatelet therapy, induced hypertension, and volume expansion. However, over the ensuing 48 hours, the left hemiparesis deteriorated steadily to muscle power grade 2 in upper and lower limbs, and follow-up magnetic resonance imaging demonstrated enlargement of the area of the diffusion weighted abnormality (). Emergency extracranial-intracranial (EC-IC) bypass was performed uneventfully. We have adopted a "double-barrel" technique whereby both branches of the superficial temporal artery are joined with MCA recipients to augment flow to the whole territory of the MCA, while leaving the tumor as is (). The patient awoke in the recovery room with exhibited a dramatic improvement of his preoperative weakness over the next 48 hours. He was maintained on oral aspirin at 100 mg/day and clopidogrel at 75 mg/day. CT perfusion scans obtained on the 14th postoperative day revealed improved cerebral blood flow in the involved territory (). At the time of writing the plan was to follow the tumor. We are considering a gamma knife radiosurgery for meningioma, if needed.
A 15-year-old boy was referred to our department after the failure of a conservative treatment to an OCD lesion in his left knee. He presented at his orthopedic practitioner three months before referral to our department, complaining of pain in his left knee during sports activity such as baseball. At the initial visit, his height was 150 cm, which was below the -2 standard deviation (SD) cutoff (approximately -2.8 SD) of Japanese average of the same age, with a body mass index of 22. He had a history of OCD in the right elbow at the age of 11. The patient's father also had short stature (153 cm, -3.1SD) and had a history of OCDs in both knees, which was surgically treated after maturity. There was no other family history of OCD. There was no swelling or tenderness of the knee joint, and no abnormalities in the range of motion or joint laxity and stability were detected on physical examination. The boy did not have any pain during normal daily activities, including PE. An OCD of the medial femoral condyle (MFC) was detected by radiograph and classified as stage III, according to Brückl [] (). The lesion was confirmed by magnetic resonance imaging (MRI) of the left knee, which was classified as stage II, according to Nelson's classification [] (). He was treated conservatively by avoiding intense physical activity, while physical education (PE) at school was permitted. Despite the advertent treatment for three months, the radiographic finding of the lesion progressed to stage IV according to Brückl's classification () and stage III according to Nelson's classification on MRI (). At this moment, he was referred to our department for surgical treatment.\nSince the patient was asymptomatic at the time he was referred to our department, he was treated conservatively for another three months but did not show any improvement in radiographic finding. Thus, we decided to perform surgical treatment. The operative treatment consisted of an initial arthroscopy. The lesion was identified since there was cleavage in the rim of the lesion by probing (), and the cartilage was slightly levitated, but not completely detached from the subchondral bone. The size of the lesion was 10 mm in width and 24 mm in length. Arthroscopic drilling with a 1.6 mm Kirschner wire from the surface of the lesion in MFC was performed, creating ten penetration deep enough to reach the subchondral bone underlying the lesion, for the purpose of inducing bleeding from the bone marrow to stimulate healing (). The lesion was confirmed to have achieved bony union by radiograph three months after surgery; sports activities were permitted.\nThe postoperative course was successful until one year and four months after surgery when he fell and hit the left anterior knee. The radiograph taken immediately after this injury showed no abnormal findings. Since the patient started to feel pain on running, and since an event of locking of the knee joint occurred, we performed another radiographic examination one month after the injury but were unable to detect any abnormal findings, and the patient was conservatively treated. Four months after the injury, the knee became more frequently locked, and knee pain on flexion and swelling of the knee joint became evident, and another radiographic examination was performed. A defect in the lateral facet of the femoral trochlea that had been normal on the previous MRI before this event was detected by radiography, and the lesion was confirmed by MRI scan. The lesion was diagnosed as OCD in the femoral trochlea (Brückl classification stage V in the radiograph, and Nelson classification stage IV in MRI), and no kissing lesion was confirmed on the patella (). The osteochondral fragment was treated surgically by fixation to the bed by four biodegradable pins. The fragment was confirmed to be stable by computed tomography and MRI scans, and the patient was allowed to return to sports at four months after surgery.\nOne month after returning to sports (5 months after fragment fixation surgery), the patient returned to the office complaining of pain in his contralateral knee during sports activities without any obvious history of injury. Radiography and MRI scan were performed for his right knee, and an OCD lesion of Brückl's classification stage II and Nelson's classification stage I OCD in the lateral facet of the trochlea was identified (). The lesion was carefully observed and remained stable without any further restriction in physical activities. However, the lesion became unstable 17 months after its initial detection, and we performed an open reduction and internal fixation surgery under spinal anesthesia. The fragment was confirmed to have achieved union by three months after surgery.
A 55-year-old edentulous Turkish female patient was referred to the Department of Prosthetic Dentistry in Karadeniz Technical University for examination and treatment. The patient had a history of congenital palatal defect with an opening between oral and nasal cavities. Detailed case history revealed that the oronasal opening was present since year of birth and the defect was not treated surgically. The patient's major complaint was being edentulous after looosing her natural teeth because of periodontal diseases. She had never had obturator prosthesis until she lost her last teeth. Construction of obturator prosthesis was decided for the rehabilitation of the patient after clinical examination.\nLocal anesthetic spray (Xylocaine Pump Spray 10%, AstraZeneca, Sweden) was used for the palatal and post palatal region before making the impression. A tampon covered with Vaseline and anesthetic solution was placed in the defect cavity to protect the area from the residual impression material (Figure ). The tampon was tied with a rope in order to take it out easily after the impression. Preliminary impression was made with an irreversible hydrocolloid and a diagnostic model was obtained by using type III dental stone. A poly methyl metachrylate resin base with a posterior extension was built up on this model. A metal frame was shaped as to the size of the maxillary defect area (Figure ) It was tied with a metal cord and afterwards was suited to the cavity on the obturator's extended part, previously prepared with a bur (Figure ). Then the metal frame was molded with a modeling wax to achieve adequate fit of the bulb to the defect cavity (Figure ). The wax part was finished with acrylic resin. After the adaptation of the base to the denture bearing tissues was controlled, the second part of the bulb for separating the nasal and oral cavities from each other was constructed intraorally again using a modeling with wax (Figure ). This wax was extended as much as the patient feels discomfort. Intraorally contoured wax part of the acrylic base was also fabricated with acrylic resin. The extended wax part was also fabricated with acrylic. Acrylic base was examined intraorally for inconvenience especially during the patient's functional movements like chewing, speaking or swallowing (Figure ). Centric relation was determined with occlusal rims by using conventional maxillomandibular records. Acrylic teeth were arranged in a balanced articulation. After arranging the artificial teeth and reevaluating the occlusion, peripheral borders of the acrylic base was contoured with impression compound and final impression of the denture bearing tissues were made with zinc oxide eugenol impression paste. The obturator prosthesis was completed with conventional water bath polymerization technique (Figure , ). Relining was performed with a silicone based soft relining material (Ufi Gel Permanent, Voco, Postfach Cuxhafen, Germany) to avoid tissue damage and to obtain better seal and retention. The patient was recalled next day, one week after and every third months for control. The major complaint of the patient was sore spots in the lower jaw and this was eliminated by relieving the respective tissue surface of the denture base. Soft relining material was changed every six months. The patient was satisfied with the prosthesis regarding function and phonation during the one-year control period.
A 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.\nTo obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.\nThe right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ultrasound-guided venous catheterization was performed. To access the brachial vein, we used the short-axis out-of-plane approach to avoid mechanical complications of unanticipated artery or peripheral nerve injuries, and then used the long-axis in-plane approach to penetrate the anterior vein wall and cannulate the vein. After inserting the cannula, a guide wire was placed through the cannula using the modified Seldinger technique. We placed a single lumen polyurethane catheter (3 Fr., SMAC Plus, Nippon Covidien, Japan), a commercially available central venous catheter (there is no commercially available midline catheter in Japan). Successful insertion of the catheter was confirmed with ultrasound imaging (Fig. ). The catheter entered the vein 6 cm from the skin entry site (Fig. ). After placing the catheter, we checked venous flow using color Doppler imaging (Fig. ).\nSurgery was performed the following day with no adverse events. A split-thickness skin graft was harvested from the head, and grafted to the neck. The skin graft became infected several days later and the midline catheter was used for administration of antibiotics. A second skin graft was performed again postadmission day 16 and the catheter removed on postadmission day 24. She was discharged without complications.
The second patient was a 51-year-old man. He was admitted to our hospital for the presence of an enlarged anterior cervical mass for more than 4 years. He had a history of partial thyroidectomy in the local unit 5 years ago, but the detailed scope of resection and postoperative pathological results were unknown. Neck ultrasonography showed two gigantic masses measuring ~87 × 45 mm and 50 × 49 mm located in the left and right thyroid, respectively. The patient had no significant dysphonia, and laryngoscopy showed normal bilateral vocal cord activity. The results of fine-needle aspiration (FNA) in the left mass revealed some minute follicles, and consequently, a diagnosis of follicular thyroid carcinoma (FTC) was suspected. Further investigation with CTA () showed that the left internal jugular vein was invaded by the left mass; filling defects were found in the left internal jugular vein, left brachiocephalic vein, and SVC and extended to the right atrium, while the obstruction of the SVC segment was incomplete. The right internal jugular vein and the upper segment of the brachiocephalic vein narrowed only due to compression of the mass. In addition, several nodules measuring 0.5–2 cm were detected in the lung. No other distant metastases were detected by whole-body bone scintigraphy and PET/CT. Residual thyroidectomy plus bilateral neck lymph node dissection and SVC reconstruction were planned.\nDuring the operation, because the bilateral recurrent laryngeal nerve was too tightly wrapped by the tumor to be separated, we removed the bilateral recurrent laryngeal nerve at the same time. Then, because the neck was connected with the mediastinum by the incision, a tracheotomy was not performed to avoid sputum contamination of the mediastinum or even erosion of the EPTFE grafts. Therefore, bilateral posterior vocal cord resection was performed to ensure the postoperative respiratory function of the patient. No suspicious parathyroid glands were found in the operative area or in the excision tissues. The intraoperative findings are shown in .
In 2007, a 58-year-old white male with no history of tobacco use, hypertension, diabetes, or hypercholesterolemia, and no family history of coronary artery disease, was found to have a large solid right renal mass and associated tumor thrombus of the inferior vena cava and right atrium. He underwent right radical nephrectomy and tumor thrombectomy performed under extracorporeal circulation. Cardiac function was investigated, including coronary angiography and transthoracic and transesophageal echocardiography. These studies documented normal cardiac function and normal morphology of the coronary arteries. Pathological examination of the surgical specimens demonstrated pT3cN0Mx conventional (clear cell) renal carcinoma, Fuhrman Grade 3 with negative surgical margins. A regular follow-up program was started. A few months later, hepatic and contralateral renal metastases were detected. The patient started treatment with the tyrosine kinase inhibitor (TKI) sorafenib on a dose-escalation protocol. Treatment led to an initial partial response followed by stable disease for 6 months. During December 2008, in a setting of stable disease, he underwent hepatic resection and enucleation of the left renal mass. The hepatic and renal masses were confirmed to be metastases. Early radiological assessment after surgery showed no residual hepatic or renal disease, but possible involvement of the mesenteric lymph nodes. Sorafenib treatment was therefore restarted at a standard dose of 800 mg/day. Treatment led to complete disease response within a few months, and was very well tolerated by the patient, who did not experience any of the typical adverse effects of the drug.\nDuring February 2011, after 30 months of sorafenib treatment (6 months at 1600 mg/day and 24 months at 800 mg/day), the patient started to complain of worsening chest pain precipitated by normal physical exercise. A cardiac stress test showed exercise-induced ischemia. Coronary angiography showed critical sub-occlusion of the common trunk of the left coronary artery and the circumflex artery (Figure ). The patient subsequently underwent triple coronary artery bypass surgery and is now recovering and in good clinical condition. Sorafenib treatment has been discontinued.
A 24-year-old woman was referred to Chonnam National University Hwasun Hospital with a palpable nodule in the left side of her neck. A nodule had appeared on the site where she had undergone a left thyroidectomy for nodular hyperplasia two years previously. On physical examination, the nodule was found to be hard and painful when pressure was applied, and intermittent swelling of the left upper limb was noted, leading to suspicion of a chronically occluded left subclavian vein. A chest computed tomography (CT) scan showed a 3-cm mass-like lesion in the left supraclavicular area with suspected internal jugular vein invasion (). The diagnosis of the nodule as suspicious for metastatic carcinoma was made by sonography-guided fine needle aspiration cytology. Further testing, including positron emission tomography (PET)/CT, was performed on the assumption that the nodule reflected lymph node metastasis from an unknown primary site. Blood tests and tumor marker levels were normal. On PET/CT, the maximum standardized uptake value was 7.7 in the left supraclavicular area (). However, no detectable primary site was found. We then planned the surgical excision of the tumor in order to make a definitive histological diagnosis, in accordance with the patient’s desire to remove the tumor. The neck was extended in the supine position, and a left collar incision was performed. Contrary to our expectations, a tumor was found that arose from the internal jugular vein. The incision was extended medially and laterally in order to define the tumor boundaries and adjacent vasculature. The intraluminal mass extended inferiorly into the innominate vein and proximal subclavian vein. After the identification of a chronic innominate vein occlusion, the tumor was resected en bloc with the involved veins following ligation of the innominate, left internal jugular, and left subclavian veins. Unfortunately, no photographs were taken during or after the operation. The patient’s postoperative course was uneventful and no swelling of the left upper limb was observed.\nHistopathologically, the tumor was found to be composed of cords and nests of spindled epithelioid cells with intra-cytoplasmic vacuoles in a hyalinized stroma. Immunohistochemical staining for vimentin, CD31, and CD34 was positive (). The surgical margins were free from tumoral invasion. These histopathological and immunohistochemical findings were compatible with the diagnosis of an epithelioid hemangioendothelioma (EHE).\nThe patient was referred to the hematology department for adjuvant radiotherapy in order to ensure for better local control, and received a total dose of 60 Gy. Over the course of 18 months of follow-up, she has remained in good condition, with no evidence of local recurrence or distant metastasis.
A 41-year-old female presented to our emergency department a day after ingestion of 200 tablets of phenytoin 100 mg (20 g) and 100 tablets of glibenclamide 5 mg (500 mg) with suicidal intent. She was not a diabetic and these tablets were purchased by her mother who suffered from epilepsy and diabetes. She was taken to a local hospital, stomach wash and i.v. dextrose was given and referred to our centre. Referral slip had documented a pulse rate of 68/min and BP of 100/70 mmHg. At arrival to our ED she was stuporous. Her pulse rate was 56/min, BP of 70/50 mmHg with poor respiratory efforts. She was intubated and connected to mechanical ventilator immediately. Blood sugar was 112 mg/dl. A diagnosis of phenytoin toxicity causing hemodynamic instability was made and resuscitative measures initiated. Baseline ECG revealed sinus rhythm with bradycardia and no evidence of ischemia []. Arterial blood gas (ABG) showed fully compensated high anion gap metabolic acidosis secondary to hypotension. Serial phenytoin levels are shown in . Lab investigations revealed normal renal and thyroid functions with deranged liver function [].\nSince BP did not improve with fluid bolus, central line was placed and her central venous pressure was found to be 14 cm of normal saline. She was started on noradrenaline (NE) followed by dopamine infusion. Her inotropic support was titrated gradually and she required 40 μg/min of NE and 15 μg/min/kg of dopamine to maintain a BP of 90/60 mmHg and output of 1500 ml over the next 24 hours. On day 2 she developed bradycardia with rate of 40/min and BP dropped to 80/60 mmHg. ECG showed it to be a sinus bradycardia with a PR interval of 160 msec and corrected QTc of 430 msec []. Owing to hemodynamic instability, unresponsiveness to atropine and inotropes, she was transvenously paced through right femoral vein and ECG was recorded []. Following pacing, her inotropic requirements came down to about 20 μg/min of NE and 8 μg/kg/min of dopamine on day 3. Her temporary venous pacer was turned off on day 5 as her intrinsic rate improved to 80/min and she was off inotropes. She was on 10% dextrose infusion for first 3 days but hypoglycemia was never documented. On day 4 of hospital stay, her sensorium normalized, nystagmus was present. ECHO did not reveal any systolic dysfunction. She was extubated on day 6 and discharged on day 12. At discharge, she was completely asymptomatic without any neurologic sequelae.
A 63-yr-old man was transferred to our hospital due to his Progressive dysphagia that he had suffered with for 1 yr. His past medical history was not significant except for his dyspepsia of 4 yr duration and also his atrial fibrillation of 2 yr duration. No specific abnormality was demonstrated on the physical examination. The esophagogram demonstrated a contrast-filling defect from the cervical esophagus to the upper body of the stomach. The computed tomography (CT) scan demonstrated a soft tissue lesion in the esophagus from the level of the cervical esophagus to the level of the upper body of the stomach. This lesion consisted of a long slender stalk and an ovoid head. The dimension of the head of polyp in the stomach was about 8×5 cm in size. The central portion of the lesion showed attenuation identical to that of subcutaneous fat (). Esophagogastroscopy demonstrated a whitish polyp that originated from the left arytenoid (). On the endoscopic biopsy done on the head of the polyp, there was no abnormality except for the acanthotic squamous epithelium. Endoscopic ultrasonogram (EUS) demonstrated a heterogeneous echogenic lesion with a central star-shaped hypoechoic area. An operation was planned under the impression of fibrovascular polyp of the hypopharynx. The laryngoscopic and esophagoscopic evaluation of the hypopharynx under general anesthesia revealed that the stalk was attached to the anterior wall of the hypopharynx from the posterior mucosa of the left arytenoid to the post-cricoid region. A trial to divide the stalk at the base with a laser was done, but the base of the polyp was too broad to be divided under the laryngoscopic operative field. After a transverse cervical incision was made, left lateral pharyngotomy was made longitudinally from the left pyriform sinus down to the upper cervical esophagus. The mucosal origin of the remnant stalk was resected and suture-closed. The resulting mucosal defect was primarily repaired with interrupted 4-0 Vicryl sutures. After upper median laparotomy and division of the stalk, the mass was removed through gastrotomy. The dimension of the polyp was about 26×10×4 cm in size. Grossly, the polyp was covered with a mucous membrane and the divided surface showed as being yellow to white-tan with a myxoid appearance (). There was not any abnormality except for the traumatic mucosal bruise that was due to manipulation during operation. The histological features were those of a fibrovascular polyp. The polyp was lined by squamous epithelium with focal acanthosis. The core of the polyp was composed of adipose and fibrovascular tissue. The patient has been followed up without recurrence for 6 months postoperatively.
A 65-year-old man referred to the emergency department for evaluation of the lower extremity swelling associated with pain for four days. Physical examination demonstrated an overweight man (BMI 29.6 kg/m2) with extensive pitting edema of the left lower limb from the groin to the knee joint with calf tenderness. Color Doppler ultrasound revealed an extensive DVT involving common iliac, external iliac and common femoral vein as well as superficial femoral down to popliteal vein. He was treated by bed rest, elevation with bandaging of left leg, 6000 IU of low molecular weight heparin subcutaneously twice a day and further evaluation was performed to find the underlying etiology. Investigations including hematological, immunological, biochemical, lipid profile, protein S and protein C were normal. Abdominal and pelvic ultrasound (US) showed incidental finding of severe left hydroureteronephrosis with almost lost of cortical thickness, for that abdominal and pelvic computed tomography (CT) scan revealed marked left-sided hydroureteronephrosis and an impacting stone measuring (18 × 10 × 10 mm) at the level of L5/S1 () with signs of DVT affecting left iliac and femoral vein below the above mentioned region (). Next day percutaneous nephrostomy was performed to decompress the hydronephrotic kidney. He was kept as an inpatient for one week under observation then after discharged home on oral anticoagulation in the form of rivaroxaban 20 mg daily. Six weeks later, color Doppler US showed complete recanalization of the superficial femoral, popliteal as well as the proximal segment of deep veins of the leg but common iliac, external iliac and common femoral veins and proximal superficial femoral vein were still partially thrombosed. Under spinal anesthesia, left ureterorenoscopy showed an impacted stone at the level of iliac vessel pulsation causing edema and external compression of the iliac vessels. Through pneumatic lithotripsy, the stone was fragmented and JJ stent inserted (). Next day the patient discharged home and continued on taking his antithrombotic treatment (rivaroxaban 20 mg). The JJ stent was removed 3 weeks later. Three months after that, Doppler US showed complete recanalization of iliac vessels.
A 65-year-old woman was admitted acutely via the Accident & Emergency Department (A&E) with severe pelvic pain. Plain radiographs performed on admission revealed right-sided pubic rami fractures and discontinuity of the sacral alae suspicious of sacral fractures (Figure .) On questioning she gave a history of sudden onset pelvic pain with no prior history of trauma. She was a smoker, had previously consumed excessive amounts of alcohol as well as not following a particularly well-balanced diet. Since being widowed she had suffered an anxiety disorder which had prevented her from leaving the residential home she lived in. Following her menopause at the age of 47 years she had commenced hormone replacement therapy (HRT) which was discontinued 4 years later. Routine bloods taken on admission were all normal including the initial C-reactive protein (CRP). Subsequent additional blood tests revealed normal vitamin D, parathyroid hormone and thyroid function.\nDue to the severity of symptoms, the patient experienced pain disproportionate to that expected with a simple pubic rami fracture and lack of mobility despite analgesia and physiotherapy; an isotope bone scan was performed. Increased uptake was noted in the right pubic bone and both sacral alae consistent with both pelvic and sacral insufficiency fractures. A further area of increased uptake was identified in the lower thoracic spine representing a vertebral crush fracture (Figure ), which was confirmed with plain radiographs of the thoracic spine. Initial management was with analgesia and subcutaneous injections of calcitonin. These were later changed to two infusions of pamidronate and subsequently alendronate with calcium and vitamin D supplementation. Following a 2-week period of titrating analgesia and intensive physiotherapy, our patient was mobile with a Zimmer frame.\nUnfortunately days later she began to complain of a supra pubic mass and associated discomfort. Examination revealed a 5 × 5 cm fluctuant swelling to the right side of her vulva. Ultrasound imaging performed the same day supported the surgical opinion that this was likely to be a haematoma and it was therefore managed conservatively. Forty-eight hours later the vulval lesion began to discharge subcentimeter bone fragments (Figure ) mixed with yellow pus that cultured Staphalococcus Aureus. Bilateral sacral insufficiency fractures (Figure ) and osteomyelitis of the pubic rami fractures was diagnosed and confirmed by CT imaging the following day. Fragments of bone were visible extending into the vulva.\nThe patient was managed conservatively on a medical ward with input from surgical, gynaecology, microbiology and orthopaedic consultants. A prolonged course of intravenous flucloxacillin and fusidic acid was commenced. CRP and white cell count monitoring showed a slow decline and the patient's pain began to settle. Following two weeks of treatment with intravenous antibiotics she began to experience further severe pain around her sacrum. On rolling the patient to exam her pelvis was felt to move out of alignment. Minutes later venous bleeding was noted from the site of the unhealed vulval abscess. Urgent imaging and orthopaedic opinion was sought confirming a pelvic diastasis. Later that evening, she had an external fixation device fitted in theatre. Following application of this device her pain settled instantaneously as did the bleeding. For the remainder of her hospital stay she was treated with continuing antibiotics at the recommendation of the microbiologist. The external fixation device remained in situ for four weeks. Following its removal she underwent an intense period of physiotherapy and 12 weeks following initial admission was discharged to a nursing home mobile with a Zimmer frame and assistance from one nurse. Six months later she remains clinically stable.
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 22-year-old Sinhalese male patient presented to our clinic with a complaint of difficulty in swallowing and speaking due to a large growth on the dorsum of his tongue. It had been present from birth and had gradually enlarged over time. Due to the prevailing civil war in the country for over 30 years, he has had limited access to an Oral and Maxillofacial Surgery care during the past years and had been forced to live with this deformity. Though painless, the swelling affected his speech as his articulation was altered. In addition, the lump on his tongue caused difficulty in forming a food bolus and swallowing it, while the bifid tongue affected the cleansing of his mouth. The appearance of the abnormal shape of his tongue had harshly influenced his social life and he was subjected to bullying. He was nonsyndromic, and no other congenital anomalies were detected. On local examination, an asymmetrically bifid tongue involving the left side was noted. A large, firm, pink, nontender tissue mass was seen at the center of the tongue [].\nA lingual thyroid was suspected initially, but the iodine scan showed normal functioning of the thyroid tissue in the anterior neck. Interestingly, iodine was noted to collect in the tongue mass as well, and thereby suggesting salivary/thyroid origin. The patient was otherwise healthy. The treatment plan was the complete removal of the growth and correction of the bifid tongue by closing the primary (or primarily closing it) under general anesthesia []. No intraoperative complications were encountered, and full function of the tongue was preserved. The excised growth was sent for histopathological examination. Two weeks later, the patient was followed up in the speech clinic to assist in speech and swallowing. The histopathology reported that the mass was predominantly mucous salivary tissue. It showed both mixed and mucous lobules, and the histological diagnosis was a salivary hamartoma. The patient had no recurrences at 1-year follow-up.
A 36-year-old male pedestrian with no past medical history according to family who was at bedside was struck by a vehicle which was reported by witnesses to be going approximately 50mph. The man was reported to have been found by emergency personnel approximately 75 feet from the impact site. He was intubated on the scene and presented to the trauma bay with a Glasgow coma scale (GCS) of 3 T. Computed tomography (CT) of the brain showed evidence of traumatic brain injury including subdural, subarachnoid, intraparenchymal hemorrhages, and small areas of hemorrhage in brainstem consistent with diffuse axonal injury ().\nNeurosurgery was immediately consulted and recommended no surgical intervention at that time, the patient be placed on mannitol for presumed increases in ICP, Levetiracetam for seizure prophylaxis, continued ventilator for breathing, and that a repeat head CT be done in 6 h.\nThe next morning (Day 1), a repeat head CT showed global cerebral edema and a new right frontal epidural hematoma. At that time the patient met criteria for invasive ICP monitoring and was taken to the operating room for device placement through a left frontal burr hole. The ICP monitor was placed in the left frontal lobe with an opening pressure of 35 mmHg and within minutes of elevation of the head of the bed, hyperventilation, and hypertonic saline infusion had lowered to 10 mmHg (goal <20 mmHg). The patient was then transferred back to the surgical intensive care unit for monitoring and care where his hypertonic saline was continued with a goal sodium of 145−155. His Propofol was continued for pain control, and the patient was placed on norepinephrine, phenylephrine, and vasopressin to maintain a CPP between 50−70 mmHg, and mean arterial pressures (MAP) >65.\nOn day 2, a repeat head CT showed no increase in intra or extra axial collections, the vasopressors started to be weaned, the patient had a tracheostomy placed percutaneously for breathing via ventilator, and his potassium was measured to be 4.4. The next day, the patient was continued on norepinephrine and vasopressin to maintain goal pressures and underwent a repeat head CT which showed progressive ventricular widening and frontal pneumocephalus (). The patient was given a bolus of pentobarbital (10 mg/kg over 30 min followed by 15 mg/kg over 3 h) with a continuous infusion started at 1 mg/kg titrated up to 3 mg/kg to achieve burst suppression and placed on a video EEG to monitor brain activity during his induced coma. His ICP monitor was also adjusted by the neurosurgery team due to a kink in the fiberoptic cable causing fluctuating ICP readings ranging from -4 to 50 mmHg, after adjustment the ICP was reported to be steadily reading 50 mmHg and the patient was tachycardic and hypertensive.\nOn day 4, his potassium 10 h after pentobarbital infusion was started measured 3.6, the patient had an ICP of 22 with EEG showing burst suppression, and the neurosurgery team recommended keeping the patient in a pentobarbital induced coma for 5–7 days through the maximal swelling period and slowly titrating it down after that. 12 h after the last measurement of potassium, a repeat study showed a potassium concentration of 1.6 mmol/L and the patient was given 8 doses of 20 mEq/h of potassium chloride.\nThe next day, 4 h after the previous potassium measurement, potassium was measured to be 1.6 and after potassium chloride supplementation, serum potassium only increased to 1.8. Due to fear of arrhythmia the pentobarbital was titrated down over a period of 12 h and replaced by increasingly high dose Midazolam continuous infusion starting at 15 mg/hr and achieving burst suppression at 50 mg/hr. The patient’s potassium concentration 12 h after stopping the pentobarbitol infusion was 4.8 and has remained between 3.6 and 4.8 for the remainder of his stay in the SICU ( and ). The patient was stable hereafter and later transitioned to propofol and fentanyl instead of the midazolam and remained in the hospital with a GCS of 3 T for the total follow up period of 30 days and was later transferred to a long term acute care facility still with a GCS of 3 T, in a persistent vegetative state.
A healthy 42-year-old man visited the Department of Prosthodontics of Dar Aluloom University seeking a replacement for his missing mandibular right first molar which had been extracted several years ago after unsuccessful endodontic treatment (). His dental history also included orthodontic treatment for about two years to correct malocclusion (crowding in some areas and spacing in other areas because of his missing four first molars). The orthodontist referred him to the prosthodontic clinic to restore the narrow space in the mandibular right first molar area, which had not been closed by the orthodontic treatment. The clinical investigation revealed a narrow mandibular first molar space that contraindicated for implant placement (). In addition, the mandibular right second molar had an occlusal amalgam restoration with occlusal recurrent caries (). The majority of teeth were vital, and the oral hygiene was good. A periapical radiograph revealed a deep existing amalgam restoration in the mandibular right second molar, with no periapical abscesses or other significant findings. After making primary impressions for diagnostic casts and consultation with other specialists, a treatment plan was formulated to replace the missing tooth with a minimally invasive resin-bonded IRCFDP []. The patient was informed about the risk of the proposed treatment and its alternatives, including a conventional cantilever FDP and IRFDP. After rubber dam placement, the existing amalgam restoration on the second right molar and the caries were removed, providing a cavity for the inlay retainer, which followed the preparation principles for ceramic inlay restorations []. The inlay cavity was prepared without bevels with fine-grit diamond rotary instruments by removing sharp margins, smoothing the pulpal floor, and preparing two retainer-wings buccally and lingually. The enamel surface was reduced by approximately 0.5 mm to provide a 3 × 4 mm enamel area for bonding (). The reduction was parallel to the path of insertion of the inlay retainer. After abutment preparation, polyvinyl siloxane impression material was used for the final impression (Take 1 Advanced; Kerr Corp) in a stock tray and poured with Type IV dental stone (Fujirock; GC Corp). The stone cast was scanned with a laboratory scanner. The resin-bonded IRCFDP was designed as an inlay retainer with buccal and lingual retainer wings and a second premolar pontic and milled from an A2 zirconia shade block (Cercon HT Full Contour Zirconia; Dentsply Sirona) (Figures and ).\nAfter sintering, the framework was seated on the cast after minor corrections, and then, the marginal fit and internal fit were checked intraorally using an explorer and a silicone indicator paste (Fit Checker, GC Corp). The silicone indicator paste exhibited a homogeneous and thin thickness which was accepted. For the inlay retainer, the minimum thickness was 3 mm, and for the buccal and lingual retainer wings, it was 0.7 mm. The dimensions for the proximal connector were approximately 4 mm in height and 4 mm in width. After try-in stage () and to remove the residues of the saliva and blood, the bonding surface of resin-bonded IRCFDP was cleaned using hot water steamer. Then, the bonding surface of the inlay retainer and the buccal and lingual retainer wings were airborne-particle abraded with 50 μm Al2O3 for 10 seconds with 0.1 MPa pressure []. After that, the prosthesis was ultrasonically cleaned for 3 minutes in alcohol path to remove the abrasive residues. Consequently, the resin-bonded IRCFDP was stored in a special container while the preparation surfaces of the abutment tooth are cleaned and treated for the next cementation process.\nA rubber dam was applied during adhesive cementation, and the abutment tooth was cleaned with pumice. Then, the preparation surfaces of the abutment tooth were etched with a 37% phosphoric acid gel (Cica; Promedica) for 15-30 sec (according to the tooth structure; dentin or enamel). Then, the acid etch gel was sprayed off with water for 15 sec, and the tooth was thoroughly dried with air stream. After that, the enamel and dentin walls were conditioned with corresponding primer (Compobond LCM Primer; Promedica) which was mixed according to manufacturer's instructions and applied for 30 seconds before dispersing the excess using gentle oil-free air stream. Then, the adhesive material (Compobond LCM Adhesive; Promedica) was mixed according to manufacturer's instructions and applied for 15 seconds before removing the excess using gentle oil-free air stream and light cured for 15 sec. Finally, bonding surfaces of the prosthesis were primed with a ceramic primer (Aureocem DC Ceramic Primer; Promedica) using a microbrush. The primer was left for 60 s, and the excesses were removed with an oil-free air stream. After that, the cement (Aureocem DC Automix, Promedica) was distributed over the resin-bonded IRCFDP bonding surfaces, and the prosthesis was seated in place (). Steady finger pressure was applied during the setting time. After cementation, the function and occlusion were checked using articulator papers.
A 13-yr-old girl visited a local clinic for painful swelling of right arm after a minor trauma in 1988 (). A pathologic fracture was suspected upon initial radiographs, and as a result, an incisional biopsy was performed, which revealed a fibroblastic osteosarcoma. She was transferred to our institution after the biopsy and was diagnosed as having in clinical stage IIB according to the Enneking's classification. She had received preoperative chemotherapy consisting of cisplatin (100 mg/m2, every 3-4 weeks, total 780 mg/m2) and doxorubicin (60 mg/m2, every 4 weeks for a total of 293 mg/m2). Despite the treatment, the patient's poor clinical response and her parents' refusal to definite surgery led us to change the chemotherapy regimen. After seven courses of bleomycin, cyclophosphosphamide and actinomycin D, the tumor was resected with a wide margin, and reconstructed with a tumor prosthesis-bone cement composite. The changed chemotherapy regimen was considered to be effective based on the clinical and histologic response, and the patient had received 4 more courses of chemotherapy with the same agents. The patient complained of dyspnea during the last course of postoperative chemotherapy and was brought in for a cardiac consultation. The echocardiogram and endomyocardial biopsy revealed the patient to be afflicted with dilated cardiomyopathy, which was consideraed to have been caused by doxorubicin. Her cardiac symptoms were mild and well-controlled with diuretics, and she had been doing well for 12 yr until a mass in her neck was discovered.\nFine-needle aspiration cytology revealed papillary carcinoma in the right lobe of thyroid. She underwent total thyroidectomy without neck dissection and a pathologic evaluation of the tissue revealed the papillary carcinoma of conventional type (). The mass had a 1.2 cm diameter, and the tumor did not invade the thyroid capsule. She has not undergone radioactive iodine therapy and has been treated on thyroid replacement therapy. She showed no evidence of either malignancy at 18 yr after the diagnosis of her osteosarcoma and at 4 yr after the diagnosis of her thyroid carcinoma.
A 53-year-old Caucasian woman presented to our Emergency Department with acute-onset speech impairment and coordination defects. She awoke in the morning to notice that when she took her dog for a walk that she had difficulty manipulating the leash and felt clumsy with her right hand. She also had difficulty with her memory in that she placed a water bowl down for her dog but forgot to place water in it. She felt disorganized with her thoughts and was concerned enough to call her brother, who noticed that her speech was slurred. Emergency medical services were activated and the patient was brought to PIH Health Hospital. She had no complaints of any headache, double vision, difficulty swallowing, vertigo, numbness, or focal weakness. There was no lapse of consciousness nor were there any drop attacks or history of seizures.\nHer past medical history was significant for migraines with occasional visual auras and scoliosis. Family history was remarkable for an elderly grandmother who suffered a stroke. Personal habits included the use of occasional wine without history of tobacco or illicit drug use. Her medications at the time of admission included multivitamin supplements and hormone replacement therapy.\nPhysical examination revealed an afebrile, normotensive and pleasant woman who appeared her stated age and was in no acute distress. Neck examination did not reveal any carotid bruits and there were no murmurs noted on cardiac examination. Her cardiac rhythm was even.\nNeurological examination demonstrated that she was awake and alert on mental status testing with intact recent and remote memory without any formal thought disorders. Speech examination showed some word-finding difficulty with word substitutions and mild stuttering. No dysarthria was noted but it was felt that she had a mild aphasia. Cranial nerves 2 to 12 were all intact without deficits. Motor examination revealed intact strength at 5 out of 5 on the Medical Research Council (MRC) scale throughout without drift, focal atrophy, or fasciculations. No abnormal involuntary movements were noted and tone was normal. Coordination testing revealed slight right-sided finger-to-nose dysmetria. Sensory testing demonstrated intact sensation to all primary sensory modalities with the exception of slight proprioceptive loss involving her right upper extremity. There was a mild loss of stereognosis of her right hand. Gait examination was unremarkable. Her reflexes were intact throughout without any long tract signs.\nRadiologic and sonographic investigations included an emergency head computed tomography (CT) scan, which was unremarkable. Subsequent magnetic resonance imaging (MRI) of the brain was performed and revealed an acute left parietal operculum ischemic infarct with mid left temporal lobe involvement (Figure ) and findings suggestive of recent embolic infarcts in the centrum semiovale bilaterally. Carotid duplex imaging showed a less than 30% stenosis of the bilateral carotid arteries and transcranial Doppler studies were within normal limits. Magnetic resonance angiography (MRA) of the neck revealed a focal 2cm region of fusiform aneurysmal dilatation of the right subclavian artery along with a focal fusiform dilatation of the left brachiocephalic vein in the supraclavicular fossa with a diameter of approximately 1.1cm. MRA of the brain revealed a within normal limits intracranial circulation pattern. A chest X-ray did not reveal any acute cardiopulmonary disease.\nSerologic studies included an elevated total cholesterol level of 218mg/dL. A complete blood count and metabolic panel were normal, and no coagulation defects were seen.\nGiven the brain MRI findings suggestive of a possible embolic pattern, both transthoracic and transesophageal echocardiography were performed, which revealed findings consistent with an ASD and a right-to-left shunt. Ejection fraction was normal at 70% without evidence of any pericardial effusion or intracardiac thrombus.\nThe findings of an ASD on echocardiography coupled with an embolic pattern seen on the brain MRI scan lead to a magnetic resonance venogram (MRV) of the pelvis. The MRV revealed effacement of the proximal left common iliac vein due to impression by the adjacent left iliac common iliac artery without evidence of thrombosis, which was felt to be consistent with MTS.\nThe patient was placed on aspirin 325mg daily and asked to stop her hormone replacement therapy. The vascular surgery department was consulted and did not recommend any surgical intervention regarding her MTS or for her right subclavian fusiform aneurysmal dilatation or her focal fusiform dilatation of the left brachiocephalic vein. She was subsequently referred to a local tertiary facility where she underwent closure of her ASD.\nThe patient has been doing quite well to date with five years of follow-up without any new cerebral ischemic events. She remains active and functionally independent.
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.
A 42-year-old Indian female with average height and moderate built reported to the dental office, complaining of blackish discoloration on the lower jaw since 6 months and difficulty while eating; especially with the lower front teeth. Intraoral examination revealed nontender and painless bluish-black growth with rough and irregular surface extending over the gingiva of 35–44 regions, which revealed no findings of ulceration and bleeding []. There was major involvement over the labial aspect of mandibular gingiva followed by anteroposterior extension into the vestibule and oral aspect of lip mucosa; but with minimal extension of the lesion on lingual aspect. The patient noticed a small blackish patch approximately 1 cm × 1 cm which gradually increased to present size with associated mobility of teeth. The mobility was appreciable in almost all mandibular anterior teeth. The overall general examination of the neck, back, extremities, and chest was insignificant except for nevi. Thus, the cutaneous part of melanoma was ruled out. During general examination, submandibular lymph nodes were enlarged but nontender approximately 1.5 cm × 1.5 cm in dimension. No history of trauma or tobacco in any form was reported. All vital signs were within normal limits. After evaluating hematological parameters, an incisional biopsy was performed under local anesthesia, for a confirmatory diagnosis.\nIn microscopic examination, the H and E stained section revealed in situ melanotic pigments []. The section showed large cells with pleomorphic vesicular nucleus and brown pigment, few abnormal mitoses, and altered nucleocytoplasmic ratio invading into the connective tissue in the form of sheets, cords, and islands []. The tissue was also immunohistochemically stained for human melanoma black-45, a specific marker for melanocytes that also revealed cytoplasmic positivity of malignant melanocytes for the antibody [Figures and ]. After confirming the diagnosis as malignant melanoma, segmental resection, and bone grafting was performed by medical personnel. In posttreatment follow-up, patient reported with some other problems such as difficulty in eating and speech. The intraoral examination revealed uneven healing of resected part and further development of the bluish-black patch on left posterior mandible. Due to severe trismus and discomfort, we were unable to take a postoperative photograph. Wide excision of the growth and node biopsy was done and the patient is being recalled for follow-ups every 6 months. The patient is asked to notify any sign of recurrence.
A 69-year-old woman who was previously well, with no history of steroid or non-steroidal anti-inflammatory use, was referred to our unit with an iatrogenic oesophageal perforation. She had undergone a laparoscopic cholecystectomy 5 weeks earlier, complicated by a secondary intra-abdominal bleed requiring laparotomy and splenectomy. The post-operative period was further complicated by small bowel obstruction secondary to internal herniation. This required an emergency laparotomy during which a posterior gastric perforation was identified (Fig. ). Prior to transfer to our unit, the patient had undergone an upper GI endoscopy and attempted endoscopic placement of a VAC therapy device in order to treat this gastric perforation. Whilst attempting to progress the sponge component of the VAC device, the patient suffered an iatrogenic oesophageal injury. Computed tomography (CT) imaging demonstrated mediastinal emphysema, confirming a full thickness tear of the cervical oesophagus (Fig. ).\nFor management of this oesophageal perforation and definitive management of her gastric perforation, the patient was referred to the authors’ unit, a tertiary referral centre for upper GI surgery. In the first instance, a water-soluble contrast swallow was performed to assess the status of the oesophageal perforation. This demonstrated no leak of contrast (Fig. ) and therefore a diagnostic endoscopy under general anaesthesia was performed in order to assess the cervical oesophagus and also the known gastric perforation. This endoscopy demonstrated a healed oesophageal perforation but persistent gastric perforation with established cavity (Fig. ) containing an existing transabdominal Robinson drain. The cavity was felt to be of a size likely to heal without the need for further negative pressure vacuum therapy, so a T-tube was placed across it. The established track of the existing abdominal drain was used to guide placement of the T-tube. A nasojejunal feeding tube was placed under vision.\nNasojejunal feeding was commenced and the patient kept on clear fluids orally. Diet was slowly reintroduced and she went home with the T-tube in situ. This was later removed following outpatient assessment and the patient has made a good recovery.
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 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 healthy 32-year-old female patient was referred from the Department of Orthodontics for periodontal evaluation. The patient initially reported with the complaint of spacing between her upper front teeth, which was noticed 6 months back and increasing since then. On clinical examination, a midline diastema about 4 mm was noticed. Periodontal probing revealed a six mm periodontal pocket in relation to mesiopalatal aspect of the maxillary left central incisor. The tooth exhibited Grade I mobility. Clinical signs of trauma from occlusion were not evident. An aberrant frenum was also noted, which demonstrated a positive pull on the interdental papilla []. The oral hygiene status of the patient was good and the remaining areas had no clinical attachment loss. Intraoral periapical radiograph showed vertical bone loss in relation to the mesial aspect of maxillary left central incisor []. The case was diagnosed as chronic localized periodontitis. After the initial phase of the therapy, it was decided to surgically access the area for the management of the osseous defect.\nAfter adequate anesthesia, two semilunar incisions were made on both sides of the frenum. The medial extensions of both the semilunar incisions excised only the base of the frenal attachment, preserving the continuity of the flap []. The distal extensions of the incision were continued as intrasulcular incisions on the buccal, interdental and palatal aspect of the central incisors, separating the flap from the buccal attached gingiva and allowing the separation of a thick, broad papilla-preserving flap. The flap was elevated from the buccal to the palatal aspect visualizing the intra-osseous defect []. The defect was thoroughly curetted and root planed. After root biomodification with tetracycline hydrochloride, the defect was filled with an alloplastic graft material containing porous hydroxyapatite and bioactive glass []. The flap was repositioned and sutured without tension. A frenotomy was also performed to relocate the aberrant frenal attachment []. The surgical area was covered with a periodontal dressing. Postoperative instructions along with suitable antimicrobials and analgesics were given. Sutures were removed 10 days after surgery []. Recall appointments were performed at 1-month interval to assess postoperative healing and plaque control by the patient. At the 6-month postoperative review, it was observed that the area was free of inflammation with complete elimination of the periodontal pocket without any gingival recession. This denoted a clinical attachment gain of 4 mm. A wider zone of attached gingiva was evident at the site []. Radiograph demonstrated complete fill of the defect []. The patient was referred to the Department Orthodontics for management of the midline diastema.
A 30-year-old male patient presented with a 5-mo history of right neck masses, complaining of dysphagia and labored breathing.\nFive months ago, two thumb-sized masses grew in the upper and middle parts of the anterior right neck, then gradually enlarged, especially the tumor in the middle part, which enlarged rapidly. The patient disregarded the masses and did not seek evaluation and treatment. The patient subsequently developed dysphagia, labored breathing, dizziness, and occasional earaches. He was diagnosed with right neck masses in another hospital and underwent neck exploratory surgery, but the masses could not be removed due to severe bleeding. The two tumors continued to grow after surgery. The upper tumor increased in size over the short term and eventually developed into two adult fist-sized masses with associated symptoms.\nThe patient was diagnosed with a right parietal lobe neoplasm and hemorrhage at a local hospital due to the sudden onset of headaches and left limb weakness 8 mo ago. The patient underwent a craniotomy with hematoma removal and tumor resection, and the post-operative pathology was a metaplastic atypical meningioma (WHO grade II) with local de-differentiation (WHO grade III). Post-operatively, the patient had left limb weakness and hoarseness, but did not receive radiotherapy as recommended by the physician.\nNo family history of meningiomas or neck tumors.\nTwo masses were identified in the upper and middle parts of the right neck, about 10 cm × 8 cm in the upper part and 8 cm × 5 cm in the middle part, and an 18.0-cm lateral surgical scar was present between the two masses (Figure ). The trachea was deviated to the left and the right vocal cords were paralyzed. Grade 3 muscle strength was demonstrated in the left upper and lower limbs.\nThere were no obvious abnormalities in routine blood tests, coagulation function, liver and kidney function, blood electrolytes and other blood biochemical tests.\nComputed tomography and magnetic resonance imaging (MRI) revealed a right side calcified mass and an unclear boundary at the root of the neck measuring 7.1 cm × 5.8 cm × 6.0 cm. Another large cystic mass was present in the right parapharyngeal space and measured 5.9 cm × 9.2 cm × 8.1 cm. The two masses reached the right sublingual space and extended downward to the thorax. The adjacent blood vessels were displaced and the trachea, oropharynx, and hypopharynx were deviated to the left (Figure ). Head and neck angiography showed that the right common carotid artery was compressed and completely occluded and the diameter of the internal carotid artery was reduced. The jugular vein was enveloped by the tumor and occluded. A balloon occlusion test (BOT) showed no perfusion in the right common carotid artery. The anterior communicating artery was opened so that the left carotid artery could compensate for the contralateral cerebral circulation.
Patient: a 55-year-old Japanese female. None of the factors contributing to lateral compartment knee disease, such as obesity, complications, or psychiatric disorders, were present in the patient. During hyaluronic acid (HA) treatment, although we prescribed strength training to the patient, she did not perform it frequently enough because of severe pain. As the knee pain was caused by tripping while playing tennis, the possibility of trauma cannot be ruled out. In 2013, due to pain in both knees, she visited our hospital and was diagnosed with OA of the knee. In December 2017, while playing tennis, the right knee developed a knee collapse. She was examined at the hospital, and an MRI of the right knee was performed. Horizontal dissection of the lateral meniscus and cartilage defect on the lateral condyle of the femur were observed. Since 2018, injections of hyaluronic acid have been administered every 2 weeks, but joint edema and pain recurrence have been remitted. The patient had already undergone HA treatment and received multiple steroid joint injections; however, these interventions were not very effective. Moreover, the patient was unwilling to undergo these treatments. The patient was aware that our hospital would start providing regenerative medicine treatments and had been waiting for a year before the start of the treatment. During that period, the patient received HA treatment, which proved ineffective. Therefore, the patient requested ASC treatment in April 2018. In April 2018, MRI of the right knee was performed. A cartilage defect was found in the external condyle of the femur, and the patient desired ASC transplantation. The range of motion of the right knee is 0–145. Anteroposterior (AP) and lateral radiograph of the right knee are shown in Fig. . On 28 April 2018, 20 mL ASCs were collected from the abdomen. On 11 June 2018, the first ASC transplantation was performed on the right knee. On 2 July 2018, although the effect was experienced after 1 week
A 74-year-old Caucasian man presented to another urology center for mild lower urinary tract symptoms in 2003. A rectal digital examination of the prostate revealed an enlarged irregular prostate with right-side nodule. Laboratory tests including complete blood count, serum biochemical analysis, urine analysis, and urine culture were performed. All of the results of the tests were normal, except for his PSA value (23ng/mL). In response to the physical examination signs and PSA, he underwent a transrectal ultrasound-guided (TRUSG) prostate biopsy. The pathologic examination of the prostate revealed a Gleason score of 3+4=7 adenocarcinoma of the prostate. After the pathologic result, a computed tomography (CT) of his abdomen with contrast agent and scintigraphy of his bones were performed to decide the stage of the carcinoma. The investigations showed stage T2N0M0 disease. He was diagnosed as localized PCa and treatment alternatives were explained and discussed with him. He preferred radiotherapy and was treated with radiation to his pelvic lymph nodes (46Gy in 23 fractions) and three-dimensional conformal boost of his prostate (24Gy in 12 fractions).\nThe recurrence of the carcinoma was not observed in the follow up and he was free of recurrence until 2009. Six years after initial diagnosis and when he was 80-years old, he had a complaint of palpable left-side 2×2cm subcutaneous solitary mass, which localized just behind his scapula. He told us that he had noticed this mass for 2 months. The results of his laboratory tests including serum acid phosphatase and PSA were in normal ranges. The initial diagnosis was considered to be a lipoma and he was referred for a general surgery consultation. The general surgery department performed a diagnostic biopsy of the mass and totally excised the lesion. The pathologic examination of the mass showed small cell carcinoma metastasis with chromogranin + and the pathologist advised us to examine the lung or prostate for the primary tumor (Figure ). The patient undertook a TRUSG prostate biopsy and the pathologic result revealed small cell carcinoma within residual adenocarcinoma (Figure ). The Gleason score of the prostatic adenocarcinoma that accompanied small cell carcinoma was 2+2 with an amount of 7%. Like in the metastatic site, the specimen had neuroendocrine differentiation with a chromogranin+. We investigated other sites for metastasis and restaging investigations showed a 1cm metastatic lesion in his liver. His axial skeleton and bones were found to be unusually free of metastasis with nuclear scintigraphy. He consulted our medical oncology department.\nOur medical oncology department decided to treat him with combination chemotherapy with etoposide and cisplatin in six cycles. After the fourth cycle, partial response to the treatment was observed and his hepatic lesion was downsized on CT examination; however, he died due to disseminated myocardial infarction before starting the fifth combination chemotherapy cycle.
A 16-year-old Indian female came with a growth on the right side of the nose which was increasing in size, and a lesion on the right eye, both of which were present since birth. She was born of a non consanguineous marriage to a 36 year old lady at full term and the parents noticed a growth on the right side of face near medial canthus of the right eye of the child since birth.\nOn examination, a soft lobulated mass was noted on the right side of the nose, measuring 5 × 3.5 cm, with normal overlying skin []. On ophthalmological examination, the best corrected visual acuity was counting fingers 1/2 m in the right eye and 20/20 in the left eye. A notch was noted at the medial end of the right lower lid measuring 7 mm at the base, the medial margin of the notch being formed by the nasal lesion []. The right lower punctum was normal but the canaliculus ended blindly at the lateral margin of the lid coloboma. A limbal dermoid measuring 8 mm was noted at the right nasal limbus [], and an iris coloboma was noted at the 11 o’clock position. The remainder of the anterior segment and fundus examination was unremarkable. The left eye was within normal limits. An otorhinolaryngological opinion was sought, which did not reveal any significant abnormality other than the nasal lesion. A thorough systemic examination revealed no systemic anomalies. There were no other mass lesions anywhere else on the body. A computed tomographic scan was ordered, which showed a significantly hypodense lesion on the right side of the nose that was highly suggestive of a lipoma [].\nThe patient underwent an uneventful excision surgery under general anesthesia, through a lateral rhinostomy incision. Histopathological examination of the mass revealed a typical lipoma []. Direct closure of the eyelid coloboma was also performed. The patient is awaiting excision of the limbal dermoid for cosmetic reasons.
A 64-year-old lady presented to the emergency department following a fall and sustained isolated capitellar fracture (). On CT scan, this was found to be Type III capitellar fracture according to Bryan and Morrey’s classification (). She was taken to theater on a routine trauma list and an attempt was made to fix the fracture fragment but in view of severe communition and osteoporosis, it was not possible to fix the fracture and hence the fragment was excised (). She was found to have mild valgus instability on table. The elbow was immobilized for few weeks in back slab and then the patient was referred to physiotherapy. She achieved range of motion of 30–90 degrees in elbow joint with full supination and pronation.\nHer repeat radiograph at 4 months showed slight subluxation of the elbow toward radial side with some incongruency in humeroulnar joint. She continued to have pain in her elbow, especially on loading and also features of lateral instability. Radiocapitellar resurfacing option was thought of, but in view of very poor bone stock and subluxation, it was felt that this would not be suitable option for her. Other treatment options were discussed in the form of tendon interposition arthroplasty, total elbow replacement, and allograft reconstruction. All options were discussed with her and having understood the pros and cons of each procedure, she opted for capitellar reconstruction using allograft. The configuration of defect was replicated with the help of 3D printing prepared from her latest CT scans.\nThe freeze-dried humerus allograft was used for surgery. After GA, the patient was positioned supine on table and sterile tourniquet was used. Kocher incision was used and common extensor origin was identified and soft tissue was freed anteriorly and posteriorly to expose the lateral condyle and the size of defect was assessed. Soft tissue and synovium were removed with curette. Defect was measured with the help of ruler and guide wire and was found to be 24 mm (medial lateral) × 20 mm (height) × 16 mm depth. Similar size of capitellum and part of lateral trochlea was taken and cut precisely from allograft and care was taken not to oversize or under size it. This part of bone was placed over defect and fine-tuned with the help of burr. This was fixed with two Acutrak headless compression screws of 3.5 mm diameter () and care was taken to bury the screws head under the articular surface (, ). Wound was closed and the patient was immobilized in above elbow back slab for 4 weeks followed by mobilization in hinge brace for a period of 6 weeks.
A 63-year-old female without past medical history presented with left eye pain and headaches for five months. These symptoms acutely worsened over the prior three days with associated blurry vision and diplopia. The vision changes started gradually and without preceding trauma or an inciting event. They were associated with an intermittent left ear whooshing sound. Over the previous five months, she had one primary care visit, two neurology visits, five emergency department (ED) visits, and seven ophthalmology visits for these symptoms. At her previous visits, she was diagnosed with dry eye and keratoconus, an abnormal bulging of the cornea leading to vision changes, eye redness and pain, and headaches. In the ED her eye exam revealed a left large subconjunctival hemorrhage and chemosis ().\nHer neurologic exam revealed partial left cranial nerve III, IV, and VI palsies. Laboratory testing and computed tomography (CT) of the head were inconclusive. During the previous five months of visits, she had negative imaging including two CTs of her head without contrast, magnetic resonance imaging (MRI) of her brain with and without contrast, MR angiogram and venogram of her brain, MRI of her orbits with and without contrast, and an ophthalmic ultrasound of her left eye. The emergency team contacted the patient’s ophthalmologist given her worsening symptoms despite negative imaging. Her ophthalmologist reported a concern about an ongoing CCF despite continued negative imaging and recommended consulting neurosurgery. Given her cranial nerve deficits and acute worsening of symptoms, the neurosurgery team immediately consented and prepped the patient for diagnostic and therapeutic angiography. Subsequent digital subtraction angiogram was performed with direct localization of the fistula between the internal carotid artery and the cavernous sinus (). The fistula was coiled with complete closure of the fistula ().\nOverall, this patient had a four-month delay between initial symptoms and definitive treatment. At the time of discharge, her cranial nerve III and VI palsies resolved and cranial nerve IV palsy partially improved; however, her diplopia and blurry vision remained. These symptoms remained at the patient’s one-year follow-up.
An 11-yr-old boy presented to our clinic because of a gradual decrease of vision in both eyes for 2 months. He had a history of atopic dermatitis, which had been diagnosed at 1 yr old. He had no previous history of ocular trauma. He showed mild eruption and eczema in the face and trunk. He was on follow-up by a local dermatologist, and ophthalmologist. According to the local dermatologist, the skin lesion was stationary and there was no evidence of aggravation of atopic dermatitis. According to the previous medical record, which was obtained from the local ophthalmologist, his visual acuity was 20/20 one year before and both lenses were clear. On examination in our clinic, the best corrected visual acuity was 20/200 in both eyes. Fundus examination was done, and there were no specific abnormalities found. The intraocular pressure was within normal range. The patient showed posterior subcapsular and posterior capsular opacity of the lens in both eyes (). According to the patient's mother, the child had been on herbal medication for 8 months and she could not find any specific change in the child's physical condition during the period. The authors reviewed the prescription of the herbal medication and found that the main composition of the herbal medication was Scutellaria baicalensis, Sophora flavescens and Glycyrrhiza uralensis. The authors also had a full review of the patient's medical record and confirmed that the patient had never taken systemic steroid. We were able to re-confirm that no steroids were added to the herbal medication by reviewing the prescription of the herbal medication.\nThe patient had a successful cataract extraction under general anesthesia in both eyes at a 1-week interval. Phacoemulsification, posterior chamber intraocular lens implantation, and posterior continuous curvilinear capsulectomy in both eyes were performed. After irrigation and aspiration procedure, a thick posterior capsular opacity located near the optical center of both eyes was observed under the operation microscope, and it was definite that posterior continuous curvilinear capsulectomy was necessary for the recovery of the best visual acuity.\nAfter 3 months postoperatively, the best corrected visual acuity was recovered to 20/20 in both eyes, with a refraction of plano -0.50×150 in the right eye and -0.25 -1.00×170 in the left eye. There was no specific complication after the operation.
A 31-year-old female patient underwent left hepatectomy for an enlarging focal nodular hyperplasia tumor in April 2015. The diagnosis was confirmed by magnetic resonance imaging, which clearly showed typical features of focal nodular hyperplasia. Nevertheless, the patient was accepted for surgery due to the significant growth of the tumor (up to 6 cm in diameter) which doubled its size within 2 years. Following surgery, the patient presented with increasing jaundice (bilirubin of 9 mg/dl on day 7.) and abdominal pain with vomiting. Abdominal ultrasound confirmed a large fluid collection that was adjacent to the liver transection plane and proved to be bilious in origin at percutaneous drainage. A drain was left inside the collection and a biliary leak of around 300–600 ml/daily continued. At endoscopic retrograde cholangiography (ERC) which was performed twice, a slight leak combined with poor filling of the intrahepatic bile ducts was shown. At that time we believed the compromised filling of the intrahepatic bile ducts was due to the narrowing at the confluence. The common bile duct was stented endoscopically with a plastic (8.5 Fr) stent (day 8.) and as the leak continued, a self-expandable metallic stent (day 15.) was inserted. A few hours following the second ERC procedure, the patient presented with sudden abdominal pain, hypotension and a drop in hemoglobin from 12.2 to 6.6 mg/l due to a splenic rupture that was confirmed by the CT scan. An emergent relaparotomy was performed. During surgery, the patient required blood transfusion with inotropic support and her condition was unstable. In view of this, surgery was limited to splenectomy, abdominal lavage and drainage. Considering dense adhesions within the hepatoduodenal ligament and no obvious source of a biliary leak visible, no intraoperative investigations of the biliary tree were pursued. Following splenectomy the condition of the patient improved, however the biliary leak persisted. At this stage, it was thought to originate from the cut surface of the liver. Therefore, the patient was discharged home (day 23. and 8. following left hepatectomy and splenectomy, respectively) with the abdominal drain in-situ for further management in the outpatient clinic.\nAs the biliary leak continued, MRCP was carried out. This revealed a Bismuth type V [] BDI with a leak from the right posterior sectoral duct that had no communication with the remaining biliary tree being previously stented with the metallic stent (Fig. ). The patient was then offered surgical repair, which was performed 55 days following initial surgery. During relaparotomy, an open stump of the right posterior sectoral duct measuring around 3 mm of diameter was identified at the transection plane close to the liver hilum. A Roux-en-Y hepaticojejunostomy over a transanastomotic external biliary drain was created (Fig. ). The postoperative course was uneventful and the patient was discharged home 7 days after surgery. The self-expandable metallic stent was endoscopically removed at 7 months following primary surgery. She remains well and asymptomatic at 48 months of follow-up with undilated biliary tree on ultrasound and normal values of liver function tests.
A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast (Fig. a). We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved (Fig. b). Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space (Fig. ). At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.\nThe surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen (Fig. ). The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion (Fig. a). Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) (Fig. b). After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery.
A 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,.
A 57-year-old man was admitted to our department for erythematous swelling of his left groin, which had become symptomatic one month earlier.\nEleven years ago, the patient suffered a pelvic bone fracture along with a bladder rupture as a result of an automobile accident. He underwent surgical treatment at another hospital. Seven years ago, the patient had suffered a cutaneous sinus at the pubic area associated with pubic bone osteomyelitis, and underwent drainage and the removal of hardware at the same hospital.\nThis year, he reported symptoms of a urinary tract in fection repeatedly over a period of several months, which was not resolved by oral antibiotics. When transferred to our institution, he was febrile and the left groin showed erythematous swelling with a small fistulous opening, which secreted a serous discharge with a urine odor ().\nThe radiographs showed osteolytic and sclerotic bony lesions in the pubic ramus, suggesting bony sequestrum (). Magnetic resonance imaging (MRI) suggested an abscess within the pubic ramus and adductor longus extending to the subcutaneous tissue, as well as osteomyelitis in the adjacent bone (). A cystography showed no communication between the bladder and abscess. A computed tomography (CT) cystogram revealed an abscess containing air densities within the bony defect of the deformed pubic ramus. There were no contrast connections from the bladder to the abscess of the pubis and thigh ().\nThe fistulous tract from the groin abscess to pubic ramus was excised. The tract was obstructed at the midway. Thorough debridement of the sequestrum and fibrous infected tissue in the cavity of the pubic bone was performed after making a transverse skin incision just over the symphysis pubis. Subsequently, a search was made to obtain proof of leakage from the bladder. The tiny amount of clear fluid was found to leak from the fibrous tissue in the destructive cavity of the pubic bone adjacent to the bladder. It merged instantly with oozing blood and was difficult to differentiate from soft tissue bleeding. The bladder was filled with indigo carmine through a Foley catheter to determine if the fluid was urinary leakage. Communication of the pubic ramus with the bladder was verified. A further dissection around the hole was performed to identify the location of the hole precisely. The pubic cortex and bladder wall adhered to each other and the bladder fistula was found behind the hole of the cortex and connected directly into the destructive cavity of the pubic bone. Antibiotics-mixed bone cement was packed into the pubic bone to eradicate the osteomyelitis and fill the bone defect (). The bladder fistula and surrounding inflammatory tissue were excised and repaired in two layers, and an omentoplasty was performed by a urologic surgeon.\nThe urine and tissue cultures confirmed Pseudomonas aeruginosa. Appropriate antibiotics were administered after reporting the culture results. The Foley catheter was removed on postoperative day 13 and normal voiding was restored. After surgery, recovery was uneventful without a recurrence of the infection or the bladder fistula at the 1 year follow-up.
A 57-year-old female patient presented with a painful right breast in a previously implant based right breast reconstruction for correction of Poland syndrome [].\nClinical examination revealed hypoplasia of the right breast, absence of the right pectoralis major muscle, ipsilateral upper limb anomalies and pectus excavatum chest wall deformity without cardiac or respiratory impairment []. A Baker III capsular contracture was observed in the right reconstructed breast and a volume deficit over the inner and lower poles, compared with the left side, was also noted.\nThe patient was seeking treatment of the painful breast and aesthetic improvement of both the breast symmetry and the sternal depression. CT angiography imaging of the chest and abdomen showed a 2A1 pectus excavatum chest wall deformity according to Park's classification [], as well as a hypoplastic appearance and a substernal displacement of the internal mammary vessels. A free DIEP flap was considered for reconstruction.\nAfter the implant and capsule removal, a new subglandular pocket was prepared, extending from the mid-axillary line to the left border of the sternum and from the manubrium to the xiphoid process. Thoracodorsal artery and vein were prepared to accommodate the flap. At the same time a pre-shaped DIEP flap based on the size of the contralateral breast was raised and anastomosed to the thoracodorsal vessels []. Almost the whole flap was de-epithelialised, sutures were placed to maintain the pre-shaped breast mound and buried into the prepared skin pocket to reconstruct the breast, providing both breast projection and pendulous appearance, and also forming the anterior axillary line in the area of the pectoralis major tendon and filling the depressed chest and sternum area. A small 2 cm × 1 cm skin island was left intact and placed at the inframammary fold for flap monitoring. Nylon bolster sutures were placed through the skin to the adipose tissue of the flap and remained for 2 weeks to secure the flap position and avoid any flap displacement.\nPost-operative period was uneventful and at 24 months’ follow-up the patient was free of pain over the right breast and highly satisfied with the aesthetic breast and chest wall appearance [Figures and ].
A 40-year-old man sustained a blunt injury to his neck on falling off a stool. He presented soon after the incident in the emergency room with swelling of the face and neck with the change in voice. He was not comfortable lying down and preferred to sit up. There was no evidence of external injury to the neck. He was hemodynamically stable and maintaining oxygen saturation (SpO2) of 96-98% on room air. The anterior-posterior and lateral X-rays of the neck showed a rightward deviation of the trachea, evidence of soft tissue injury, and surgical emphysema []. The chest X-ray did not reveal any evidence of pneumothorax []. A computerized tomography scan of the neck could not be done as he was unable to lie down.\nHe was evaluated by the ENT resident who admitted him for observation in the general ward. Six hours later, the patient complained of difficulty in breathing and worsening of the surgical emphysema of the face and neck was noted. The SpO2 was 95% despite oxygen supplementation using a venture face mask set at FiO2 0.6. He was hemodynamically stable, alert, and talking. The anesthesiologist on call was requested to evaluate the patient. He immediately recognized the gravity of the situation and the possibility of blunt tracheal injury and decided that any further assessment and airway management was to be performed in the operating room (OR). The patient was shifted to the OR in the upright position on oxygen and a senior anesthesiologist was called in to help. The anesthesiologist's plan was to perform awake fiberoptic intubation or tracheostomy followed by an endoscopic evaluation of the extent of the tracheal injury.\nIn the OR, with the patient supported with pillows in the sitting position [], the airway was anesthetized with 4% lignocaine aerosol using a nebulizer, lignocaine viscous gargles and 1% lignocaine, 10 mL, injected slowly at the base of the tongue by the drip technique. Nasal pledgets soaked in 4% lignocaine and oxymetazoline drops were applied. Oxygen was supplemented initially using a face mask and later through the fiberoptic bronchoscope. He remained hemodynamically stable during this period. Awake nasal fibreoptic intubation was performed with ease. A blood-tinged streak/tear was noted in the anterior subglottic region, a 7.0-mm ID endotracheal tube was passed beyond the tear and the cuff inflated. In view of the patient's condition and the likelihood of further deterioration, the need to evaluate the tracheal tear and perform tracheostomy was discussed with the ENT surgeons. They opined to wait and observe the patient in the intensive care unit (ICU).\nIn the ICU, his condition rapidly deteriorated, surgical emphysema worsened (extended to the entire face, neck, chest wall, and upper limbs up to the fingers), and respiratory distress developed with SpO2 falling to 80%. Bilateral pneumothorax was now evident on the chest X-ray []. Bilateral intercostal drainage tubes were inserted and the ENT surgeons decided to perform a tracheostomy in the OR. A fiberoptic bronchoscope was passed via a swivel connector and oxygen administered with a breathing circuit to evaluate the tracheal trauma. The tip of the tracheal tube and Murphy's eye were found to be completely obstructed by edematous tracheal mucosa. The tracheostomy was performed under local infiltration supplemented by incremental doses of midazolam and propofol. Sevoflurane in 100% oxygen on spontaneous respiration was also administered.\nHypopharyngoscopy and microlaryngoscopy following the tracheostomy revealed gross edema of the ventricular bands, vocal cords, and a large left ventricular air cyst. An anterior subglottic mucosal laceration with the displacement of the cricoid cartilage was visualized. No further surgical intervention was done. The patient was observed in the ICU for 24 h and the surgical emphysema dramatically reduced. Two weeks later, he was evaluated under anesthesia and the tracheal tear was found to have healed well. The tracheostomy was decannulated prior to discharge.
A 21-year-old male with a right-sided complete cleft of primary and secondary palate who had primary surgery in childhood at another hospital was referred to our craniofacial centre for management of his facial skeletal deformities []. The patient was concerned about his lower jaw being ahead of his upper jaw, misaligned teeth, and flattened face.\nExamination revealed typical midface deficiency associated with cleft maxilla, which included lack of maxillary projection, flattened malar prominences, depressed nasal supratip and flared ala. Intraorally, the upper arch revealed complete collapse of the two lateral shelves with severe crowding and displacement of the upper dentition, concealing a wide anterior palatal fistula in continuity with an alveolar defect. Overall the maxilla was severely collapsed in all three-dimensional planes []. The discrepancy between the maxilla and mandible was 12 mm in the antero-posterior plane. The clinical and radiographic findings suggested maxillary hypoplasia in transverse and sagittal dimensions resulting in class III malocclusion with double sided cross bite\nThe objective of the treatment was to achieve an acceptable facial profile and dental occlusion with positive over jet and overbite. Treatment plan included the following, viz., correction of the maxillary retrusion by Le Fort I osteotomy; rigid external distraction; increasing the width of the collapsed maxillary alveolar arch; aligning the maxillary dentition, and closure of the oro-nasal fistula over the hard palate.\nThe severity of the dental crowding in the maxillary arch was not conducive for the placement of orthodontic brackets, and the short maxillary arch required lengthening, hence pre operative orthodontics was not carried out. ‘Surgery first’ method was adopted in this case for the same reasons. Rapid palatal expansion was not possible in this case since the expander could not be placed due to severe constriction of the upper alveolar arch in addition to the severe crowding of teeth. Considering the severity of the maxillary hypoplasia in all dimensions, maxillary distraction was performed using a standard rigid external distractor, the distractor was placed following a low Lefort I level osteotomy and activation of 18 days following a 5 day latency period. The distraction was overcorrected, as per our centre's protocol, due to the noted tendency to relapse after cessation of distraction.[] During the phase of activation, an anterior open bite developed due to anti-clockwise rotation of the maxillary segment []. The anterior movement also created an increase in the transverse dimension, as the posterior wider part of the maxilla was was now more anteriorly placed. Once the desired distraction result was achieved by daily monitoring of the distraction process, a consolidation period of 10 weeks was deemed optimal. After the consolidation phase, the patient was taken up for fixed appliance orthodontics, where banding and bonding of the upper arch were performed.\nThe 2 mm diameter and 11 mm length temporary anchorage devices (TADs) (LOMAS, Gmbh, Germany)[] were placed bilaterally in the infrazygomatic crest of the maxilla. The pilot hole was prepared at 60-75° and 13-15 mm above the occlusal plane from the maxillary first molars. The TADs were loaded immediately, and elastomeric chains were engaged from the mini screw to the pre molars and first molar teeth for intrusion []. The continuous force bilaterally intruded the posterior teeth within a span of 10 weeks thus reducing the divergence of the occlusal plane, and a positive overbite was achieved. []. The palatal fistula was closed using a tongue flap. A reasonable aesthetic and functional outcome was obtained. The maxilla was overcorrected to 15 mm taking into account the post-treatment relapse of 25%.[]\nThe biological principles of TAD[] in conjunction with management of skeletal deformity associated with cleft lip and palate is reviewed by several authors.[]
A 2-year-old male child presented with right-sided inguinal swelling with an empty left scrotum. The child also had a right-sided inguinal hernia which was completely reducible. TTE was diagnosed on physical examination and confirmed by ultrasonography and magnetic resonance imaging.\nLaparoscopy revealed that the right deep ring was widely open and the left testicular vessels were crossing from left iliac fossa toward the right side coursing behind the urinary bladder. The gubernaculum was wrapped within a peritoneal fold and was seen to extend from the closed left deep ring to the open right ring []. Testis was in the right inguinal canal, but it could be pulled back into the abdominal cavity. An elongated cylindrical structure was seen coming from behind the bladder and reaching the right inguinal canal. It was wedged between the two testes and their vascular pedicles. This was the hypoplastic Müllerian remnant. The vas of the left testis was found to end blindly 2–3 cm proximal to the epididymis. The peritoneum over the cleavage plane between this ectopic testis and Müllerian structure was incised and the loose areolar tissue was divided. An incision was made over the Müllerian structure so as to leave a cuff of Müllerian tissue along the left testis and its vessels, and the remaining main bulk was left in situ. This freed the testis with its vessels and vas. Further mobilization of the vessels from behind the bladder helped in gaining length, but the left vas was anchoring the left ectopic testis despite having an adequately mobilized pedicle. To gain more length, the peritoneal fold just distal to the blindly ending left vas was divided and this freed the left testis, which was then passed across a “neo-deep ring” just medial to the left inferior epigastric vessels. The right open deep ring was closed with a 4–0 polyglactin suture. A clinical review at 6 months after surgery ensured that the both testes are intrascrotal. The patient has been advised for annual follow-up.
A 10-year-old male patient reported to the dental clinic with the chief complaint of broken upper left front tooth associated with pain and sensitivity. A detailed history revealed the etiology as a fall from stairs 24 h back. The fractured tooth fragment was retrieved by the patient's mother from the site of injury and was stored in water. Medical history and other events associated with injury were noncontributory. Intraoral clinical examination revealed that maxillary left central incisor had undergone complicated horizontal crown fracture in the cervical one-third []. Palatally, the fracture line was oblique. The fracture fragment was intact, and it was approximating optimally with the remaining tooth structure []. The fragment was transferred to normal saline immediately to prevent dehydration. No mobility was noted in the fractured tooth. An intraoral periapical radiograph was advised to evaluate the extent of the fracture, the root status and to rule out an alveolar bone fracture. The fracture line was passing through the coronal pulp with the open root apex and without any alveolar bone fracture. Electric and thermal pulp testing were performed to evaluate the pulp vitality of all the upper anterior teeth, and the result was negative only on tooth number 21 whereas, all the adjacent teeth displayed a normal response. Hence, the diagnosis was established as Ellis Class III fracture with an open apex.\nA treatment plan was formulated which included apexification with mineral trioxide aggregate (MTA) followed by root canal treatment and either composite build up or reattachment of the fragment using fiber post. Parental informed consent was obtained after explaining the advantages and disadvantages of composite resin build versus reattachment. Since esthetics was the prime concern, fragment reattachment was considered as the best option. The fracture fragment was cleaned and rinsed with 2% chlorhexidine solution and lightly air-dried. Under local anesthesia, root canal treatment was initiated, followed by single step MTA apexification. The canal was obturated with gutta-percha points. Postspace was created by removing gutta-percha using peeso reamers. Since aesthetics was a concern, the prefabricated glass fiber post was used. A radiograph of the trial placement of glass post was taken to confirm the postposition. The coronal portion of the post was cut to fit into the fractured fragment. Key and lock system was used to attach the fragment with the post, for which an internal retention slot was placed on the dentin of the fracture fragment using a no 4 round bur [].\nConditioning of the root canal walls was performed using 37% phosphoric acid. Bonding agent was applied onto the canal walls/glass fiber post, air-dried gently and lightly cured for 15 s. Dual cure resin cement was applied to the canal walls and then fiber post was seated into the canal and excess cement was removed. A flowable resin composite was applied to the fractured tooth as well as a fragment and were reattached and light cured for 20 s from all aspects (facial, incisal, lingual, proximal). To improve the esthetics, a deep chamfer was placed at the fracture line after bonding. Then the composite resin was applied over that and light cured. Using a long needle shaped finishing bur the labial surface was polished. Finishing of the lingual surface was done using an egg shaped finishing bur. The tooth was functional and esthetically pleasing [] during the follow-up at 3, 6, and 12 months posttreatment. Radiographic evaluation did not reveal any periapical and periodontal changes. The patient was satisfied with the treatment outcome.
A 38-year-old woman who had recently undergone epidural spinal anesthesia for a caesarean section 4 days prior presented to the emergency department (ED) of our institute complaining of severe neck and low back pain. Postpartum, her postoperative course was complicated by dyspnea and chest pain that was found to be secondary to a new pulmonary embolism. During her initial hospitalization, she received antithrombotic therapy sustained by unfractionated heparin (with close monitoring of her clotting mechanism) and was bridged to warfarin therapy prior to her discharge to home. At the ED, she did not have any weakness, paresthesias, or changes in motor “function,” although she described some nonspecific back pain.\nOn examination in the ED, the patient had 5/5 strength in all muscle groups in the upper and lower extremities, no signs of sensory deficits, or signs of cauda equina syndrome, but she did have several beats of clonus in the lower extremities. Laboratory testing demonstrated only a mildly elevated international normalized ratio of 1.8, which was below the expected value. Magnetic resonance imaging (MRI) of the entire spine demonstrated a large amount of mixed epidural and subdural blood collection within the high thoracic and lumbar spine as well as cord edema near T6-7 [Figures –]. The epidural component was located in the upper thoracic spine. Cervical MRI demonstrated pathology consistent with acute/subacute subdural hematoma in the cervical spine [].\nAfter the diagnosis was made, the patient was admitted to the neurosurgical intensive care unit (neuroICU) for reversal of her mild coagulopathy (due to previous warfarin therapy) with the administration of fresh frozen plasma and vitamin K, as well as for pain control and surveillance. While in the neuroICU, she experienced an episode of tachycardia and shortness of breath for which she underwent thoracic computed tomographic angiography, which showed a small right basilar atelectasis. These symptoms were thought to be due to a transfusion reaction to the plasma and vitamin K. She was treated conservatively with pain control management and bedrest. After gradual mobilization, she was discharged without any neurological deficits or complications. Her atelectasis and pain were resolved; the hematoma had stabilized according to the last imaging study performed during her hospitalization. The last MRI study, obtained 9 months after her discharge, showed that the hematoma is slowly resolving. The patient is neurologically stable and is completely mobile, although she is still having episodes of low back pain and wears a brace for comfort.
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. ).
A 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of emergency embolization procedure. Through the catheter, the embolization was performed from the installation of 02 micro-platinum springs until the complete arterial occlusion and consequent end of the blood flow of the PA (Fig. ). The selective angiography of the left internal maxillary artery was then performed in different projections to rule out another possible source of bleeding and the possibility of compensatory revascularization.\nThe patient was transferred and remained under observation for 12 hours in the intensive care unit. A new angiography was performed after 24 hours for control, confirming the complete resolution of the PA. The patient was submitted to a second surgery 72 hours after the hemorrhagic episode when a large part of the bone fragments were removed by intraoral access. Also the palpable and superficial portion of the projectile located in the genic region by infraorbital access was removed.\nThe patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up.
A 23 year old male was transferred to the ICU one month after a fall from height and head injury. On admission the patient was in a persistant vegetative state with clinical evidence of dehydration. The patient was on 5 litres O2 per minute via trachestomy and arterial blood gases were within normal limits. Clinical examination revealed evidence of dehydration. Chest X-ray showed no abnormalities as shown in figure .\nTo correct dehydration and monitor volume status, a central venous line was inserted. Right subclavian approach was used. Four attempts to cannulate the subclavian vein were performed by a skilled intensivist using an 18 gauge needle but were all unsuccessful. During these attempts there was neither arterial puncture nor air aspiration. After getting little backflow of blood which was dark and nonpulsatile, ensuring a venous position of the needle, An 0.035" guidewire was then introduced afterwhich a dilator was advanced for 5 cm without apparent resitance. This was followed by sliding of a 7 french catheter over the guidewire, and the wire was then withdrawn without any resistance. Despite the smooth insertion of the catheter, there was a negative aspiration of blood which we attributed to severe dehydration. Central venous pressure was measured after insertion and was -1 mmHg so one liter of colloid was infused followed by 1 liter of crystalloids over a period of 12 hours.\nSeveral hours later, the patient started experiencing severe respiratory distress with rise in the central venous pressure from -1 mmHg to 16mmHg. Clinical examination revealed a respiratory rate of 40/minute and absent air entry on the right hemithorax as well as dullness to percussion. An arterial blood gas revealed hypoxia and combined metabolic and respiratory acidosis with Po2 of 49 mmHg, oxygen saturation 79%, pco2 54.9, PH 7.11 and HCo3 17.2. The patient started to develop severe bradycardia and hypotension necessitating atropine and mechanical ventilation. Bedside anteroposterior chest radiograph was performed as shown in figure panel B, which revealed the presence of massive right side pleural effusion and mediastinal shift to the left. The presence of pleural effusion was confirmed by syringe aspiration of clear fluid. A 28- French intercostal tube connected to underwater seal was then inserted followed by gradual withdrawal of the pleural fluid which was continuously clear till 3 liters were withdrawn over several hours. This was the same amount of fluid given to the patient through the subclavian catheter for correction of dehydration. At that time aspiration from the central venous catheter revealed the same clear fluid as that was drawn from the intercostal tube raising the suspicion of the intrapleural position of the venous catheter. The catheter was then removed from the subclavian vein and reinserted in the left internal jugular vein through an anterior approach. After withdrawal of the pleural fluid, marked relief of the respiratory distress and improvement of the oxygenation ensued.\n3 weeks later the patient was readmitted to the ICU for increasing difficulty in breathing. On examination, the patient was tachypnic with diminished air entry over the right lung and dullness to percussion and a purulent fluid coming from an opening in his right chest wall as shown in figure . Diagnostic aspiration of the pleural fluid revealed frank pus. Analysis of the pleural fluid revealed low glucose and PH and culture revealed methicillin resistant staphylococcus aureus. An intercostals tube was placed for drainage and the patient was started on vancomycin therapy.
A 48-year old woman was being treated for a malignant neoplasm of her left breast. The tumor was a moderately differentiated invasive ductal carcinoma (clinically T1 N0) that was discovered on physical examination and identified on subsequent mammogram. The various surgical options were discussed in depth with the patient, who decided not to undergo a breast conservation procedure or breast reconstruction. In addition, she elected to undergo a contralateral prophylactic mastectomy in order to address the approximate 0.5 – 1% per year risk of breast cancer in the unaffected breast. Therefore, her operative procedure was scheduled as a left modified radical mastectomy with SLNB and right prophylactic mastectomy. Her past medical history included migraine headaches and chronic sinus infections. Her past surgical history was significant for tonsillectomy, ankle surgery, dilation and curettage, and sinus surgery, all of which were performed under general anesthesia. The patient reported no drug, food, or other allergies. No previous perioperative anesthetic complications were reported by the patient.\nOn the morning of surgery, the patient was premedicated with 2 mg midazolam intravenously prior to the induction of anesthesia. General anesthesia was induced using fentanyl, propofol, and rocuronium, after which the patient was intubated in standard fashion. Anesthesia was maintained with nitrous oxide, oxygen, and isoflurane. The patient's left breast was then injected intraparenchymally with 5 mL of Lymphazurin 1% blue dye, which was followed by 5 minutes of light breast massage to mobilize the dye. Approximately 15 minutes later, after her chest wall had been prepped and draped, the patient experienced an acute episode consistent with cardiovascular collapse that was characterized by O2 desaturation and systolic blood pressures in the range of 30–40 mm Hg. The surgical procedure was halted (no incision had been made) and the patient was placed in the Trendelenburg position and given 100% oxygen. The possibility of a tension pneumothorax was eliminated by physical examination, which revealed robust breath sounds bilaterally. Intravenous fluids were administered (~2000 cc total) and 0.1 mg epinephrine (1:10 000) was given intravenously. Decadron (100 mg) and diphenhydramine (50 mg) were administered when the blood pressure failed to improve. She exhibited hives on her lower extremities bilaterally, but there was no blue discoloration to the skin. The patient was diagnosed with an anaphylactic reaction to the blue dye after these events. Her blood pressure stabilized and at that point she was placed on an epinephrine drip at 2 μg/min. The patient was then transferred to the surgical intensive care unit (SICU) for hemodynamic monitoring and ventilation management.\nApproximately 2 hours after injection of the blue dye, the patient experienced a second hypotensive episode during which her systolic blood pressure dropped to 65 mm Hg. She received additional fluid resuscitation along with 50 mg benadryl, and the epinephrine drip was increased to 4 μg/min. The patient soon stabilized and the epinephrine was weaned the next day. She was discharged from the SICU 36 hours after admission. She was maintained on methylprednisolone, diphenhydramine, and famotidine, and given instructions on the use of an epinephrine pen and albuterol inhaler. The patient did well and exhibited no further allergic symptoms. She underwent the planned surgery 2 weeks later utilizing radioactive colloid alone to identify the sentinel lymph node. Two sentinel lymph nodes were identified that were negative for metastatic disease. Further examination of the lymph node specimens revealed a 3 mm metastatic focus in the first lymph node and a 6 mm metastatic focus in the second. The patient underwent completion lymphadenectomy 4 weeks later.
We present the case of a 75-year-old male who was referred to the colorectal surgery clinic for evaluation after noting hematochezia, anal skin irritation, and rectal pain. Eight years prior, he had been diagnosed with leiomyoma of the rectum. At that time, he had undergone a biopsy of the lesion and local resection was performed several times. After each resection and biopsy, the pathology proved to be a benign leiomyoma.\nUpon his latest presentation, eight years after initial local resection, a physical exam revealed a palpable mass at the anorectal junction. Biopsy of the mass was now consistent with leiomyosarcoma, including moderate atypia and a high mitotic rate (40 per 10 high power field), as compared to his previous diagnosis of leiomyoma (Figures -).\nHe underwent staging workup with an MRI of the pelvis (Figure ). This proved the mass to be 3.5 cm in diameter, located at the anorectal junction, with extension into the prostate and possible involvement of the urethra. The decision was made for the patient to undergo surgery. The colorectal team, combined with urological surgical teams, performed a robotic pelvic exenteration, which included cystoprostatectomy, abdominoperineal resection, and ileal conduit creation.\nThe final pathology resulted in a grade 2 leiomyosarcoma that invaded the prostate and skeletal muscle. Zero of 26 lymph nodes were positive. Incidentally, he was found to have Gleason 3+4 prostate cancer that was staged as pT2. The postoperative course was uncomplicated and he was discharged home from the hospital.\nAs an outpatient, he completed adjuvant radiation therapy to prevent local recurrence of his leiomyosarcoma. Complete surgical resection cured his prostate cancer, but urology will continue to monitor him for recurrence with interval PSA levels. As for monitoring of his leiomyosarcoma, he will continue to undergo regularly scheduled physical exams and imaging to assess the recurrence or development of metastatic disease. He is currently free of disease 18 months after surgery based on his most recent MRI scan and physical exam.
A 2-year-old female child was brought to our institute with swelling beneath the tongue. The swelling was present since birth, which was of peanut size and increased to the present size in the last 2 months []. The child had difficulty in having food and also had breathlessness.\nOn examination, a single swelling was seen in the floor of the mouth, measuring approximately 4 × 3 × 2 cm. The mucosa over the swelling was red in color and showed a bluish hue. The consistency of the swelling was soft and the borders were regular. The surface was smooth and nonulcerated. There was no pain or tenderness. Radiological findings showed no abnormality. The CT scan findings revealed a well-defined cystic lesion of approximately 4.9 × 3.1 × 3 cm in floor of the mouth with a small locule extending posteriorly and compromising anterior pharyngeal space []. There was no evidence of cervical lymphadenopathy nor did the swelling show any relation with the thyroid gland. Based on the above findings, a clinical diagnosis of ranula was given and surgical excision was planned. Hematological investigations were done and the results were in normal limits. Chest X-ray showed clear lung fields and normal cardiac size and configuration. An intraoral approach was taken for the surgical excision of the lesion.\nThe swelling was excised completely and sent for histopathological examination. On gross examination, the lesional tissue was creamish brown in color and measured 4 × 3 × 1.8 cm in size, it was soft in consistency, with smooth borders and surface []. On sectioning of the specimen, a cystic cavity was seen containing a thick creamish brown cheesy material with a foul odor. The hematoxylin and eosin (H and E) stained sections of the specimen showed ciliated pseudostratified columnar and stratified squamous orthokeratinized epithelial cystic lining over the fibrovascular connective tissue [Figure and ]. Mucous cells and goblet cells were seen in the cystic epithelium. Connective tissue capsule showed dermal appendages like sweat glands, sebaceous glands and hair follicle. Adipose tissue and muscle tissue were also seen []. With observed histopathological picture a diagnosis of teratoid cyst was given.
A 74-year-old male patient (168 cm, 53 kg) visited our institution complaining of difficulty in swallowing for the past 8 years and the frequent occurrence of aspiration pneumonia for the past 1year. Lateral radiography of the cervical spine demonstrated extensive osteophyte formation from C2 to C4 () and decompression of the osteophyte was planned. His medical history was significant for diabetes. He had been diagnosed with stable angina but rejected PCI. Preoperative electrocardiogram and echocardiogram revealed tolerable status. Blood chemistry revealed hyperglycemia, but hepatic and renal function and coagulation were normal. On physical examination, the patient was alert and afebrile; and his vital signs were stable. Oral examination was unremarkable and neck extension was normal. He had minimal dyspnea in the supine position. Indirect laryngoscopy revealed a large hard mass protruding from the posterior wall of the hypopharynx that concealed the arytenoids cartilage (). A preoperative neck CT showed slight narrowing of the airway at the level of the epiglottis. Vocal fold mobility was preserved. No narrowing of the subglottic region was observed when flexible endoscopy was performed. Preoperative tracheostomy was done under local anesthesia and general anesthesia was induced with thiopental sodium 250 mg and rocuronium 50 mg and maintained with sevoflurane. Complete decompression of the osteophyte was performed for 210 minutes using an anterolateral transcervical approach, which proceeded without any complications. The postoperative course was uneventful. On the second postoperative day, indirect laryngoscopy was performed by an otolaryngologist to decide if removal of the tracheostomy cannulawas appropriate. However, this examination revealed significant laryngeal edema including the epiglottis and posterior laryngeal wall (). On 29th postoperative day, flexible endoscopic examination was performed again and copious secretion, decreased vocal cord mobility and narrowing of the upper airway were observed () and the patient was discharged on the 33rd postoperative day with a double cannula having a speech valve. On the 59th postoperative day, the tracheostomy cannula was removed () at the outpatient clinic without any complication.
A 64-year-old male patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (\n) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (\n).\nIn view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (\n). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (\n). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (\n,\n).\nThe immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension to the left vertebral artery origin, and a 4.5 cm distal anastomotic PAN. EVS of the proximal PAN was done using a 16 × 80 mm covered Medtronic stent deployed across the origin of the left vertebral artery (\n).The distal PAN was excluded using a 26 × 100 mm covered Medtronic stent extending from the level of the coarctation to the insertion of the extra-anatomic bypass graft (\n). Completion angiogram confirmed patency of the latter and occlusion of the left SCA to thoracic aorta graft as well as of both anastomotic PANs (\n). The postoperative course was uneventful and the patient remains asymptomatic 2 years later and will be followed up on a yearly basis.
A 53 year-old dark-complexioned male who underwent renal allograft transplantation four years ago, presented with swelling and pain of the left hand that had progressed over the last two months. Before his admission, he was managed as a case of cellulitis with antibiotics, magnesium sulphate dressings, and antiinflammatory drugs, with no improvement of symptoms. The swelling and pain was prominent in the distal palm and fingers, and increased in the dependent position with mild improvement on limb elevation. A reddish dusky hue was noticed for a few weeks in the distal palm and fingers []. There was no sensory impairment, paresthesia, or loss of movement of the hand. He denied any drug use other than his immunosupression regime of cyclosporine, azathioprine, and prednisolone. He did not smoke, consume alcohol, use illicit drugs, or operate heavy machinery.\nPrior to transplantation, he was on maintenance hemodialysis using a left radiocephalic fistula for two years. Subclavian canulation or anatomical details of the fistula were unavailable as he was under treatment at another center.\nExamination revealed an obvious swelling of the left hand with a minimal local rise of temperature, thinning with excoriation of the skin, and erythema of the distal palm and fingers []. Tenderness of the hand, especially distal to the carpal bones was seen. There was no wasting of hand muscles and movements of the hand were restricted due to severe pain. No sensory loss or evidence of median nerve compression was present. The arterial pulsations were normal and a patent left radiocephalic fistula was observed. The veins of the forearm as well as those around the wrist were thick-walled and bulging. The dusky hue and pain were enhanced when the hand was kept in a dependent position, and mildly reduced when elevated, or when the radial artery was digitally occluded. The veins of the hand did not collapse on limb elevation.\nThe oxygen saturation observed by a pulse oxymeter was normal. Ultrasound Doppler imaging showed a patent radiocephalic fistula with low resistance flow in the left radial artery and increased peak systolic velocity and spectral broadening. The cephalic vein proximal to the anastomosis showed high velocity turbulent flow (139 cm/sec) and wall thickening, suggestive of arterialization with arterial pattern flow. A dilated segment distal to the elbow showed turbulent flow. The cephalic vein distal to the fistula showed no evidence of color uptake. Subclavian, axillary, and proximal cephalic vein stenosis was ruled out with a Doppler study. Angiography was not attempted due to a high risk of radiocontrast-induced nephropathy.\nVenous hypertension of the left hand was diagnosed secondary to the AV fistula and revision / ligation planned. An end-to-side Cimino-Brescia fistula [] was seen intraoperatively with marked arterialization and dilatation of the proximal vein. Due to a difficulty in revising the fistula during surgery, it was ligated at the arterial ends; there were no complications. Within a few hours, resolution of the duskiness, pain, and swelling of the left hand was noticed postoperatively [].
An 89-year-old gentleman with no significant past medical history presented to the emergency department (ED) of a district general hospital with atraumatic right hip pain and inability to weight-bear. The patient had a long history of right hip osteoarthritis causing pain and functional limitation, for which he had been referred by his general practitioner to the orthopaedic team for consideration of total hip replacement three years previous. However, the pain experienced during the week preceding ED presentation was much more severe in character. Of note, he had been seen by his general practitioner in the week preceding ED attendance with intense right hip pain on weight-bearing and passive movement and had been referred to the elderly care team with a view to optimising pain management.\nPlain film radiography obtained in the emergency department () demonstrated a lytic lesion within the right femoral neck, intertrochanteric region, and proximal femoral metaphysis with evidence of cortical breach and progressive sunburst periosteal reaction.\nThe patient was admitted for further investigation and assessment. Computed tomography (CT) of the chest, abdomen, and pelvis () confirmed a bony lesion affecting both the right acetabulum and proximal femur with pathological intertrochanteric fracture and abnormal surrounding soft tissue. Magnetic resonance imaging (MRI) () findings were felt to be consistent with that of a primary bone tumor; tumoral necrosis was evident, and thigh muscles demonstrated oedema to the knee level. No lymphadenopathy was seen. Nuclear medicine scanning () demonstrated avid uptake in the right acetabulum and proximal femur with cortical breakthrough and marked extension to the surrounding thigh compartments but no uptake suggestive of distant disease. Fluorodeoxyglucose-positron emission tomography (FDG-PET) was not performed preoperatively.\nHistological analysis of needle core biopsies obtained via a direct lateral approach under ultrasound guidance of the right femur was undertaken; the findings of which were in keeping with that of diffuse large B-cell lymphoma (DLBCL). Sections through the cores demonstrated tissue infiltration by large round blue cells staining positively for leukocyte common antigen, CD20, BCL2, and BCL6 and negatively for CD10, CD3, CD5, and cyclin-D1. The Ki67 proliferation index was high at approximately 80%. Interface fluorescent in situ hybridisation detected a BCL2 translocation but no BCL-6 or c-myc translocations.\nThis gentleman was transferred to Northern Ireland's Regional Trauma Centre where he underwent proximal femoral replacement with acetabular reconstruction, owing to the presence of pathological fracture as visualised on CT. Pathological analysis of the operative specimen demonstrated a tumor present within the medullary cavity with cortical, periosteal, and soft tissue involvements. The osseous resection margin was clear; however, the soft tissue resection margin was involved laterally. Histological analysis confirmed DLBCL of germinal centre phenotype staining positive for CD20, BCL6, and BCL2 and negative for CD3, CD5, CD10, MUM-1, cyclin-D1, C-MC, and TdT. The proliferation index was again high with MIB-1 of over 90%.\nThe patient received postoperative care in the intensive care unit where he required inotropic support ahead of ward transfer. FDG-PET undertaken two weeks postprocedure demonstrated high FDG uptake at the surgical site, but metabolically active disease at other sites was not seen.\nHe was discussed at the haematological multidisciplinary meeting postoperatively, and the diagnosis diffuse large B-cell lymphoma (DLBCL), NOS (M9680/3), was agreed. He was deemed stage IEA due to the involvement of contiguous bones. The patient embarked upon six cycles of R-Mini-CHOP (a regimen of rituximab with decreased dose cyclophosphamide, doxorubicin, vincristine, and prednisolone []), a regimen which is in widespread use within the unit amongst those greater than 80 years of age.\nThroughout his R-Mini-CHOP treatment, the gentleman was able to fully weight-bear and made excellent progress with the rehabilitation team. Radiographically, implant alignment was satisfactory, and there was no evidence of prosthetic loosening. The patient subsequently declined radiotherapy treatment. Repeat FDG-PET was conducted five months following diagnosis; no further disease was demonstrated.
A 64-year-old male patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (\n) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (\n).\nIn view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (\n). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (\n). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (\n,\n).\nThe immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension to the left vertebral artery origin, and a 4.5 cm distal anastomotic PAN. EVS of the proximal PAN was done using a 16 × 80 mm covered Medtronic stent deployed across the origin of the left vertebral artery (\n).The distal PAN was excluded using a 26 × 100 mm covered Medtronic stent extending from the level of the coarctation to the insertion of the extra-anatomic bypass graft (\n). Completion angiogram confirmed patency of the latter and occlusion of the left SCA to thoracic aorta graft as well as of both anastomotic PANs (\n). The postoperative course was uneventful and the patient remains asymptomatic 2 years later and will be followed up on a yearly basis.
The present case report is about a 40-year-old male patient presented with the complaints of swelling in the right temporal region for 4 months. On detailed evaluation, he gave a history of dental infection leading to tooth extraction following which the swelling started. In addition, he also complained of holocranial headache of 15 days duration. On examination, the swelling was 3 × 3 × 4 cm in size and was non pulsatile, soft and fluctuant with ill-defined and diffuse borders. A small defect was palpable in the right parietal bone posterior to the swelling. At 24 h after admission, he developed sinuses over the swelling that were discharging pus. CT head revealed a defect of size 2 × 2 cm in the right parietal bone with irregular margins and the defect was involving both the inner and outer tables. The bony edge was undermined with an extradural collection of size 0.5 × 0.5 cm [Figure and ]. There was a collection within the right temporal muscle that was extending down into the infrazygomatic region suggestive of an abscess []. MRI revealed a T1 hypo T2 hyperintense well defined lesion situated within the right temporalis muscle and an extradural heterointense lesion below the bony defect [Figure and ]. However there was no evidence of intracranial extension. Bone scan of the patient was done and showed increased uptake in the right parietal bone suggestive of osteomyelitis. However as it could be either pyogenic or tubercular in etiology, a detailed evaluation for TB was undertaken. His chest X-ray showed a well-defined opacity in the right upper lobe. Erythrocyte sedimentation rate (ESR) was 60 mm at the end of 1st h and Mantoux was positive. TB interferon gamma was done and was positive. Since he had a discharging sinus and a temporal collection he was posted for surgery. A right sided reverse question mark incision was made exposing the temporalis muscle and the defect in the right parietal bone. A large portion of the temporalis muscle was replaced by necrosed tissue and pus []. The pus was extending inferiorly to involve the temporalis muscle below the zygoma. Thorough debridement of the devitalized tissue was done. The defect in the parietal bone was nibbled all around and sent for histopathological examination. There was granulation tissue located extradurally just beneath the defect. It was scooped out and sent for biopsy. After debridement, saline and betadine irrigation was done and the wound closed. Patient was started on antitubercular therapy with isoniazid, rifampicin, pyrazinamide and streptomycin as he was not receiving any antibiotics prior to surgery. Microscopy was negative for Grams staining and cultures were sterile. Histopathology report came as caseating granulomas with epitheloid cells, Langhans giant cells with acid fast bacilli seen. Post-operative period was uneventful. Sutures were removed on the 7th post-operative day and patient was discharged. At a follow-up of 4 weeks, patient has no swelling and the wound is well-healed.
The currently 31-year-old female was first seen at our institution at the age of 16 years due to severe ID, epilepsy and autistic features. The previous history of the patient was reconstructed from medical records, photographs and parental interviews.\nThe patient (Fig. ) was born from an uneventful pregnancy of unrelated healthy parents (at birth of the girl the mother and father were aged 26 and 29 years, respectively). The patient had one older sister who suffered from anorexia nervosa. A paternal cousin of the mother of the patient had Down syndrome, the maternal grandmother of the mother of the patient suffered from multiple sclerosis, and a maternal aunt of the father of the patient had schizophrenia.\nThe development of the patient in the prenatal and perinatal periods was largely normal. The labour was spontaneous in the 42nd week of gestation. The birth weight was 3950 g (97th centile) and the length was 52 cm (75th centile). Postnatal adaptation was uncomplicated, except poor suck. The patient was breastfed shortly and throve on artificial nutrition till two years of age. At around three years of age a period of food refusal started, and the girl ended up on glucose infusions. Till eight years of age such periods repeated at least three times. Since eight years of age she has eaten almost everything, but she did not chew and her dependence on ground food worsened with age. Constipation has been a major problem since the age of one year, with unsuccessful anal sphincter surgery at the age of 14 years.\nThe developmental milestones of the girl have been significantly delayed from the age of six months despite physiotherapy. She stood up at the age of 12 months, and achieved independent sitting and walking without support at the age of 18 months and three years, respectively. Her gait was unsteady with frequent crashes. Currently her posture and gait resemble “crouch” gait with anteflexed neck and increased flexion of the knees, although this wide-based gait with bent knees was not observed till the age of 16 years. Her hands are dystonic and tremor appears with voluntary movement. The speech development started on time. The patient started crooning at the age of three months and pronouncing syllables at the age of 12 months. Later she started to use a few words, but her verbal skills have stopped at the level of a one-year-old child.\nThe patient had significant growth delay. The skeletal maturation and the onset of puberty were delayed by about four years. The first menstrual period occurred at the age of 18 years. In childhood and early adolescence the patient had a gracile habitus and microcephaly. At the age of 16 years her height was 155 cm (3rd centile), weight was 41 kg (below the 3rd centile), and head circumference (HC) was 51.5 cm (below the 3rd centile). At the age of 18 years the height was 162 cm (20th centile), weight was 50.7 kg (12th centile) and HC was not measured because of lack of cooperation. At the age of 28 years the height was 167 cm (48th centile), the weight was 58 kg (45th centile) and the HC was 53.1 cm (11th centile).\nAt the age of two months the patient developed strabism, which was corrected by surgery at the age of 13 months. The facial phenotype in early childhood was not remarkable with a possible exception of full cheeks and larger ears. Later she started to show open mouth appearance and a long narrow face. At the age of 16 years her facial dysmorphism included long hypomimic face, prominent chin, narrow almond-shaped palpebral fissures, long nose with prominent nasal bridge and overhanging columella, open mouth appearance, high arched palate, large upper teeth protruding from the mouth, wide lower lip and large ears. She had long cone-shaped fingers with 5th finger clinodactyly and haluces valgi. Since 28 years of age the myopathic facial features have become more prominent, the face has become longer and more coarse in appearance, and a protuberant chin has been more evident. Currently the patient has her mouth constantly open, with protruding upper incisors, and the teeth are irregularly stored. Dysarthria and hypersalivation are also present.\nThe patient was an irritable baby with back arching and frequent startle reactions. Seizures started at the age of two years. Ictal behavioural arrest with blinking was followed by head drop and fall. She never had any other type of seizures. Topiramate was the most effective drug in controlling the epileptic paroxysms although many other antiepileptic drugs have been used. Since being on topiramate medication, she has been completely free of seizures. EEG repeatedly showed generalized irregular SW discharges. Cerebral MRI at the age of 18 years was normal. She started to show self-harming behaviour at four years of age. She was hitting her head, and later around puberty she started biting herself which led to extensive bruising. Aggression became evident at preschool age and had a tendency to worsen with age. Since the age of 15 years the aggression has become uncontrollable, and the patient has been treated with a series of antidepressants and behaviour-damping medication. Currently aggressiveness appears only occasionally. As an infant she used to wake up several times at night and she continues to have problems with sleep initiation, and has a short sleep time.\nAt the age of five years a diagnosis of autism was first proposed, and later the girl was diagnosed with pervasive developmental disorder, not otherwise specified, with severe ID. Currently, at the age of 31 years, the patient suffers from severe to profound ID and hyperactivity. Autistic features were predominantly observed at the pre-school age. Although they improved with age and currently are less evident, the insistence on sameness persists as well as oversensitivity to certain sounds. On the other hand, the patient likes physical closeness and contact.\nKaryotyping was performed according to standard protocols. Genomic DNA of the patient was analysed using the Human CytoSNP-12 BeadChips (Illumina, San Diego, CA, USA) according to the manufacturer’s protocol. For WES of the family trio, SeqCap EZ Human Exome Library v3.0 (Roche NimbleGen, Madison, WI, USA) was used for exome capture and HiSeq1500 system (Illumina) was utilised for paired-end massive parallel sequencing (see Additional file for details on microarray and WES data analysis).\nThe SYNGAP1 variant and its de novo nature were confirmed by Sanger sequencing of fragments amplified from the DNA of the family trio using primers targeting exon 10 and intron 10. The bioinformatic prediction of the impact of the variant on splicing was performed using programs Human Splicing Finder, MaxEnt, NNSPLICE, NetGene2, ESEfinder, Alternative Splice Site Predictor (ASSP), Splice Port and Cryp-Skip (see Additional file for details on primer sequences and data analysis). RNA was extracted from whole blood of the patient, her parents and normal controls using the PAXgene Blood RNA Kit (PreAnalytiX, Hombrechtikon, Switzerland). RT-PCR was performed using SuperScript III One-Step RT-PCR System with Platinum Taq DNA Polymerase (Invitrogen, Carlsbad, CA, USA) and primers targeting SYNGAP1 exons 8–9 and 12. The resulting cDNA fragments were Sanger sequenced.\nKaryotyping and microarray analysis of the patient did not reveal any significant aberrations. WES of the family trio identified a single de novo heterozygous variant in the SYNGAP1 gene (chr6:33406701, hg19, NM_006772.2:c.1676 + 5 G > A) in the patient, which was confirmed using Sanger sequencing (Fig. ). The variant was classified as a splice region variant as it affected position +5 of the splice donor of intron 10. The variant was absent in public variant databases. All tools used for the in silico analysis of the effect of the variant on splicing predicted disruption of the donor splice site of intron 10, and two tools which allowed also the prediction of the outcome (Cryp-Skip and ASSP) predicted the activation of a cryptic site in exon 10 (predicted to be 37 bp upstream of the regular site using ASSP) rather than skipping of the whole exon 10 (see Additional file for details). Several much less strong candidate variants inherited by the patient from one of her unaffected parents were also identified and are listed in Additional file .\nRT-PCR experiments with SYNGAP1 cDNA primers detected novel splicing products in the patient which were absent in the parents and normal controls. The variant indeed activated the predicted cryptic splice donor site 37 bp upstream of the regular end of exon 10. Because of the existence of an alternative splice acceptor site in intron 10 located 176 bp upstream of the regular start of exon 11 (which was also predicted using ASSP), two transcripts could be detected in the parents and controls: the regular transcript with a regular junction of exons 10 and 11, and an alternative transcript where the end of exon 10 was joined to the last 176 bp of intron 10 (the alternative start of exon 11) (Fig. ). The alternative transcript contained a frameshift and a premature stop codon (p.Val560Leufs34). In the patient, four different transcripts could be detected: the two described above and two which joined the activated cryptic donor site (thus lacking the last 37 bp of exon 10) with the regular and alternative start of exon 11. Both these transcripts also contained frameshifts and premature stop codons (p.Cys547Serfs7 and p.Cys547Serfs*117).
An 87-year-old woman with an intractable pain radiating over the left chest, suggestive of intercostal neuralgia, was referred to our spine center for further evaluation and management. Five weeks earlier, she experienced a ground-level fall, causing severe back pain. According to the initial evaluation conducted elsewhere, she was diagnosed as having OVF of the T10 vertebral body and managed conservatively with a brace and pain medication for one month. Her chief complaint gradually changed from bilateral back pain to an aching pain extending to the left thorax before her first visit to our hospital. What is noteworthy about the history of this case is that 8 years previously, she had had a painful OVF of the T12 vertebral body at the age of 79 years, which was treated with vertebroplasty using hydroxyapatite (HA) blocks and posterior pedicle screw instrumentation followed by iliac bone graft fusion from T11 to L1 at another hospital [].\nOn clinical examination at our hospital, the patient had no neurologic deficits, complaining of nothing but reporting a position-dependent severe chest pain on the left side, which intensified when sitting up from a supine position. Imaging studies revealed neither rib fractures nor abnormal findings of the chest cavity as a possible cause of the chest pain.\nOn the plain radiographs of the thoracic spine (), the anteroposterior (AP) views and the lateral views taken in the supine position showed the IVC within the T10 collapsed vertebral body as a gas-like radiolucent area, which disappeared on the lateral view obtained in the sitting position (i.e., the opening-closing phenomenon) most likely indicating an OVF of nonneoplastic and noninfectious origin [, ]. The lateral radiograph in the sitting position also demonstrated that the fracture line extended through the posterior fusion mass bone, grafted 8 years ago, indicating a potentially unstable flexion-distraction injury. Close observation of the AP radiograph obtained in the supine position revealed a gas-like radiolucency at the extravertebral space just lateral to the T10 collapsed vertebral wall ipsilateral to the side of her chest pain. The computed tomography (CT) scans, which have a higher sensitivity in detecting gas than radiography and magnetic resonance imaging (MRI) scans, more clearly showed an accumulation of gas located just below the head of the left 10th rib, the place radiologically termed the T10-T11 extraforaminal zone ().\nIn terms of the IVC contents of radiolucency on the plain radiographs, sagittal MRI revealed a gas-like signal void within the T10 collapsed vertebral body. Corresponding to the extravertebral area of radiolucency shown by the AP radiograph and the CT, both T1- and T2-weighted axial MRI showed combined gas-like and fluid-like signal intensities; i.e., a gas-like low signal intensity area with a fluid-like iso-signal intensity area on the T1-weighted image and a gas-like low signal intensity area with a fluid-like high signal intensity area on the T2-weighted image ().\nAll these findings from the imaging studies suggested that the patient's chest pain probably resulted from T10 nerve root compression at the T10-T11 extraforaminal zone by a mixed accumulation of gas and fluid, which most likely originated from the adjacent IVC within the collapsed T10 vertebral body as a result of the “force pumping mechanism,” as previously postulated [].\nBecause of the unstable nature of the fracture involving all structural components from anterior through posterior spinal columns, in addition to her persistent disabling pain not responding to conservative therapy, we carried out posterior spinal fusion from T7 to L2 with pedicle screw instrumentation followed by iliac bone graft (). Immediately after the surgical stabilization, the patient reported a complete resolution of the pain. This patient had no history of antiosteoporosis medications before the referral to our spine center. We administered pharmacological treatments postoperatively, consisting of teriparatide injections initially, followed by oral bisphosphonates. At a 2-year follow-up, she remained asymptomatic, and CT scans showed neither a gas accumulation nor a fluid collection both inside and outside of the T10 vertebral body.
A 32-year-old female patient was referred to our emergency department complaining of progressive, colicky abdominal pain accompanied by intermittent nausea and vomiting during a period of more than 3 weeks. The pain was localized in the epigastric region and radiated through to the back. In addition, the patient complained of generalized paresthesia as well as episodes of hot flashes and palpitations. There was no alteration in stool consistency or frequency. Her past medical history revealed no long-term medication or previous abdominal operations.\nOn physical examination, the patient had normal vital signs. Her abdomen was soft, non-tender and non-distended. Laboratory investigations showed a slightly elevated white blood cell count as well as C-reactive protein level. Beta-HCG test was negative. Computed tomography scanning of the pulmonary arteries was performed in order to rule out pulmonary embolism. The simultaneous display of the upper abdomen revealed a big cystic lesion, which seemed to be attached to the left kidney. Biochemical analysis and hormone testing showed no signs of a hyper functioning mass. Abdominal MRI revealed a maximum diameter of 12.5 cm. The origin of the cystic lesion was suspected either in the mesentery or the omentum majus (Fig. A and B). Considering the abdominal symptoms as well as the fact that neither origin nor dignity could be determined in this patient, a total surgical removal followed by histological examination was indicated.\nWe performed an upper midline laparotomy. To ensure a good anatomical overview, mobilization of the left colonic flexure was necessary and the omental bursa was entered. The distal part of the pancreas showed close proximity to the cystic lesion and needed careful separation. After adhesiolysis between the splenic surface, the posterior gastric wall as well as the parietal peritoneum, the left adrenal gland with its associated vein, was found to be the origin of the cystic tumor. Hence total adrenalectomy was performed in order to remove the intact cystic lesion (Fig. C and D). Following a short period of postoperative nausea and vomiting, gradual return to a normal diet was possible. The patient was discharged on the sixth postoperative day.\nThe histological examination of the specimen revealed an adrenal lymphangioma located in a normal structured adrenal gland.\nAt the 3-month follow-up, the patient presented with sleep disorder, nausea and weight loss. The ACTH stimulation test showed a relative adrenocortical insufficiency while DHEA-S levels remained normal. Consecutively the patient was treated with hydrocortisone, as needed during stressful situations. The further course remained uneventful (Fig.).
A 15-year-old female with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.\nDifferential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of bone, aneurysmal bone cyst, osteoblastoma, osteosarcoma or even Langerhans histiocytosis (LCH). Oncology recommended that the cervical spine lesion be biopsied for tissue diagnosis. Due to the unusual location of the lesion and risk of locally aggressive pathology, or possible tumor seeding along the biopsy track, interventional radiology was unable to perform a CT guided needle biopsy. It was therefore decided that the patient would require open neurosurgical biopsy for diagnosis.\nDue to the anterior and lateral location of the vertebral lesion, an anterior transoral approach to the C1 lesion was performed, in order to obtain a sufficient amount of the contrast enhancing component of the mass for pathologic diagnosis. The transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization, as well as stereotactic navigation, to expose the C1 anterior tubercle on the left side. Once exposure was completed, neurosurgery team utilized a matchstick burr to then drill the anterior outer cortex of C1. Multiple specimens from the fibrous tumor were taken, with curettes and pituitary forceps.\nThe sampled tissue did not show features of osteoblastoma or osteosarcoma, nor were there features of LCH or signs of infection. In the sampled region, the lesion consisted of a proliferation of nondescript stromal cells with intermixed multinucleated giant cells, and occasional clusters of foamy histiocytes (). Special testing for giant cell tumor of bone (G34W staining) was negative, as was fluorescence in situ hybridization (FISH) testing for Ubiquitin Specific Peptidase 6 (USP6), making a primary form of aneurysmal bone cyst unlikely. However, due to the aggressive nature of the patient’s osteolytic lesion and the significant risk for atlantoaxial instability associated with its location, it was decided to start the patient on Denosumab. Denosumab is an osteoclast inhibiting pharmaceutical agent, which was administered to the patient in order to stabilize and consolidate the lesion. Samples of the patient’s lesion were also sent out to a nationally recognized expert bone pathologist, whose findings were most consistent with benign giant cell rich lesion with histiocytes.\nThe patient was re-assessed three months postoperatively and MRI studies revealed that there was no interval decrease in the size of the tumor. In fact, there was a slight progression of the lesion anteriorly, despite treatment with Denosumab. After presenting the patient’s case at our institution’s multidisciplinary tumor board, it was decided to offer the patient a gross total resection of the offending lesion. This would inherently lead to significant atlantoaxial instability, therefore a posterior occiput to cervical three instrumented fusion was also warranted.\nThe transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization as well as stereotactic navigation, to expose the cervical vertebrae through the posterior pharynx. Fibrous tumor was identified and dissected until superior, inferior, and lateral margins of tumor resection were confirmed grossly, with fluoroscopy, and neuronavigation. Additional C1 anterior tubercle eccentric towards the right side was also taken, to include a normal bony margin. A small rim of tumor adherent to the vertebral artery was left behind. After the otolaryngology team closed the posterior pharynx, the patient was carefully turned prone, maintaining spinal precautions. Base of the occiput to cervical three was then exposed. C2 pedicle screws were placed. C3 lateral mass screws were placed. An occipital plate was sized. Screws into the occiput were placed. Fluoroscopy confirmed excellent position and spinal alignment. There were no post-operative complications and the patient was discharged home in good condition. Pathologic examination of the resected material at this time showed complete disappearance of the giant cells, due to Denosumab therapy, with the remaining lesional tissue resembling benign fibrous histiocytoma (). Post-operative imaging studies revealed a stable posterior cervical spine construct, along with minimal rim-enhancement along the vertebral artery, as expected (). At a three-week follow up visit in clinic, the patient’s incisions were healing well, she was neurologically intact, tolerating regular diet, and was eager to return to school.
This case report is of a 34-year old man who was married, Catholic, and a construction worker. He had primary school education with no history of previous hospitalizations, surgeries, transfusions, allergies, or known pathologies. He referred only to head trauma suffered 8 months ago by way of physical assault. The assault caused a nose-bone fracture with a nasal septum deviation to the right, but with neither purulent material nor a rinusinusal infectious process. He had only mild, intermittent, and sporadic obstructive dyspnea after the incident. The patient smoked 20 cigarettes a day for 21 years, from 13 to 34 years of age. Up to 5 months prior to his admission, he also suffered from alcoholism for 11 years, drinking 1000 ml of alcohol every week.\nHe was admitted to the hospital with an occipital headache which he had endured for 2 months. For over 1 and a half months, he had also experienced behavioral disorders and a disruption of higher mental functions. He had retrograde and anterograde amnesia with both echolalia and the presence of visual hallucinations. A private physician initially treated him with diazepam, pentoxifylline, diclofenac, and phenytoin, all with standard doses but with no improvement. Three weeks prior to admission, the patient experienced acalculia and multiple apraxia that did not allow the patient to perform ordinary work and other daily activities such as bathing, and dressing. At this point, the patient required the support of a family member. The individual was evaluated by a second physician who prescribed amitriptyline, bromazepam, B complex, and additional phenytoin. Five days later, the patient developed ataxic gait and was evaluated at a regional hospital where he was given treatment for poisoning (benzodiazepines with flumazenil and a gastric lavage with activated carbon). One week prior to admission, the man quickly and progressively lost the ability to hold himself up. He suffered from psychomotor agitation and myoclonic movements. The patient had a spastic tonicity of his limbs, associated with loud sounds and light. He demonstrated an altered state of consciousness with episodes progressively alternating between a soporose state and an awakened state. He demonstrated akinetic mutism (an indifference to the environment).\nHe was moved to the Red Cross Hospital where he was given empiric treatment for neuroinfection because data showed a neck stiffness, with a bilateral Babinski, a positive Brudziski, and a negative Kerning and substitutes. Antibiotic therapy was initiated based on a cefotaxime and metronidazole treatment. After failing to show improvement within 4 days, the individual was transferred to our unit where he remained for a period of 25 days and where the aforementioned symptoms continued.\nOn admission, the patient was received with vital signs within a normal range for his age. He was bedridden and unable to hold himself up. The individual was craniofacial, had intermittent drooling and nostrils without fistula nor the presence of discharge, only the septum veering to the right. The patient showed neck stiffness, without jugular venous engorgement. There were carotid pulses present and no lymphadenopathy at any level of body anatomy was detected. There were no cardiopulmonary or abdomen issues. Other elements of a general physical examination did not show evidence of disease. The patient was neurologically uncooperative and sluggish with alternated isolated episodes of psychomotor agitation. He registered 9 points on the Glasgow Coma Scale (GCS), with the following results: An ocular response to pain (2), localized pain (5), and emission of sounds (2). The patient demonstrated indifference to the environment, was aphasic, and had a fixed gaze. His right pupil was 3 mm and his left pupil 2 mm left, with consensual pupillary reflexes present. His eye fundi were without papilledema, hemorrhages, or exudates. There was evidence of horizontal nystagmus with rapid movement to the right. Other cranial nerves did not show this detected condition. The patient showed the presence of a neck stiffness, with Brudzinski present and a negative Kerning. His tendon reflexes increased in his lower limbs, with bilateral Babinski and a non-assessable walking. The patient demonstrated an asynchronous myoclonus of all extremities that was associated with loud sounds or light, and he had a tendency to turn his head to the right side.\nIn laboratory tests and during initial and subsequent clinical monitoring [(blood count, blood chemistry, serum electrolytes, liver function tests, gasometry analysis, serological tests for human immunodeficiency virus, hepatitis B, hepatitis C, VDRL, thyroid function tests, chest radiography, abdomen evaluation [], and simple skull computed Tomography (CT)], no alteration was noted. The cytology of the cerebrospinal fluid (CSF) was reported as acellular and negative to malignancy, and the CSF cytochemical was reported as having the aspect of liquid-like rock water, with glucose 59, chlorine 133, proteins 64, leukocytes 1, erythrocytes 20, and crenocytes 450. Further, an electroencephalogram (EEG) [] was performed. There was presence of cyclical and inverted waves observed in the occipital region, with a marked and diffuse slowing. With magnetic resonance imaging (MRI) of the skull with gadolinium, indirect evidence of corticosubcortical atrophy of the right occipital parietal lobe was clearly noted. It was, however, also observed on the left side, with a diffuse loss of volume of brain parenchyma, as well as evidence of the restriction of the diffusion of both putamen and caudate nucleus heads [].\nThe patient showed a lethargic state of consciousness that was in rapid decline. The patient was handled given his evolution upon admission to the hospital as having a rapidly progressing dementia syndrome. Creutzfeldt–Jakob encephalopathy was ruled out with a brain biopsy performed as a confirmatory diagnosis. The same result was reported with a histopathology, which showed a grayish color occipital tissue with the presence of infectious mycotic cerebral white–gray matter, giving a definitive diagnosis of brain tissue that tested positive for Aspergillus []. The patient died 7 days after completion of the brain biopsy.
This case report presents a sixty-four-year-old Caucasian male with a three-month history of intermittent right upper quadrant and epigastric abdominal pain. The patient previously underwent an extensive negative work-up for biliary pathology in addition to multiple emergency room visits without any diagnoses. The patient went to his primary care provider two days prior to surgical evaluation where he was noted to have a temperature of 100.4 °F (38.0 °C) and computed tomography (CT) of the abdomen and pelvis with IV contrast was ordered due to concern for appendicitis. There was no acute pathology identified on this scan. The patient has a past medical history of coronary artery disease, hypertension, type 2 diabetes mellitus, obstructive sleep apnea, and GERD. Past surgical history was significant for a prior umbilical hernia repair with mesh. The patient had no known allergies, no significant family history and no significant social history. Due to concern for acute appendicitis the patient was referred to the surgical clinic for further evaluation.\nAt the time of surgical evaluation, the patient reported a new, three-day onset of localized right lower quadrant abdominal pain. Review of systems revealed associated nausea and anorexia without vomiting, change in bowel habits, or rectal bleeding. On physical examination, the patient's vital signs were within normal limits. The patient appeared mildly uncomfortable but in no acute distress. His abdomen was obese with tenderness to palpation in the right lower quadrant as well as localized right lower quadrant percussion tenderness, rebound tenderness and a positive McBurney's point. Laboratory work-up was performed revealing a normal white blood cell count of 5.6 bil/L, electrolytes within normal limits, and a mildly elevated C-reactive protein level at 45 mg/L. The patient's CT scan had been performed at an outside facility and was unable to be personally reviewed but the report was available which reported no acute or abnormal intra-abdominal pathology.\nBased on the patient's physical exam and elevated CRP level decision was made to take the patient to the operating room for diagnostic laparoscopy with clinical concern for appendicitis. Other diagnoses in our different diagnosis were Meckel's Diverticulitis, inflammatory bowel disease, diverticulitis, perforated viscus, or an intra-abdominal malignancy. The patient received antibiotics and subcutaneous heparin preoperatively. The abdomen was sterilized using Chloroprep solution and was pneumoperitoneum was created using the Veress needle technique. Upon entry the omentum was noted to be in the right lower quadrant and inflamed in appearance. The appendix was identified and found to be normal in appearance. The rest of the abdomen was visually inspected with no immediate obvious pathology. Knowing the appendix was normally the decision was made to inspect the small intestine and remainder of abdomen to rule out other acute pathology. There was no evidence of inguinal or abdominal wall hernia. On inspecting the small intestine an inflammatory mass was identified with omentum tightly adherent to it located approximately 2 ft from the ileocecal valve. This mass was in the right lower quadrant of the abdomen. The omentum was carefully dissected free and the intestine closely inspected with an inflamed Meckel's diverticulum identified. The remaining small intestine was run with no further pathology identified. Based on a wide base and short length of the diverticulum the decision was made to perform a small bowel resection with primary anastomosis. The midline port was extended and a gel port was inserted. The Meckel's diverticulum was pulled through the gel port and an external bowel resection with primary stapled side to side anastomosis was performed.\nIntraoperative Imaging: , revealing mobilization of a large mass protruding from the small intestine later identified as a Meckel's Diverticulum.\nThe patient recovered well from surgery and was discharged three days postoperatively. Surgical pathology demonstrated benign small bowel with a Meckel's diverticulum with features of acute inflammation and rupture. Further pathological analysis demonstrated an ulcerated benign gastric-type mucosa as well as benign pancreatic tissue within the diverticulum, without evidence of malignancy. In office follow-up the patient was found to have an incisional wound infection of his midline incision which was treated with antibiotics and local wound care. A chronic draining wound developed and five months after his original surgery the wound was re-excised. He healed well afterwards with no further complication.\nHistological Evaluation: . Distorted gastric body type mucosa adjacent to ulcerated diverticulum mucosa. Note the eroded surface foveolar epithelium with associated acute inflammation, as well as the underlying gastric glands with parietal and chief cells. Hematoxylin and eosin, original magnification 100×. . Pancreatic exocrine type mucosa in the wall of the diverticulum. Lobules of pancreatic acinar cells surround mucinous ductal structures recapitulating extrabiliary bile ducts. Hematoxylin and eosin, original magnification 100×.
Case 4: A 63-year-old man had middle esophageal cancer (). On 26 November 2005, subtotal esophagectomy was performed through the left sixth intercostal space. From the 5th day, the patient had complex signs and symptoms, including fever, shortness of breath, increasing sepsis, and a large volume of chest drainage. An oral methylene blue test showed that methylene blue drained into the chest tube. By a radiography swallow contrast examination, we found that all of the water-soluble contrast medium had extravasated into the pleural space and drained into the chest tube. The patient was initially managed conservatively after diagnosis of the leak. After strict conservative therapy, the patient showed an increasing amount of sustained sepsis and multiple organ failure. On postoperative day 14, we had to perform thoracotomy from the primary incision, and found two thirds of anastomosis dehiscence. Although the anastomosis dehiscence was large and all of the contents of digestive fluid went directly into the cavity, chest tube drainage was efficient, and thus the cavity infection was not serious. There was gastric outlet obstruction and high tension between the gastric conduit and esophagus. Primary anastomotic repair was difficult and high risk. Therefore we closed the gastric conduit with a linear cutter stapler and returned it to the abdominal cavity. In the proximal esophagus, cervical end-esophageal exteriorization was performed and a feeding gastrostomy was placed. Prompt clinical improvement was noted under supportive therapy within the first few days, and the patient’s general condition quickly improved. In a second re-operation, the patient underwent a successful gastric conduit interposition by retrosternal channel on the 16th day after the second operation. The patient began oral intake on reconstructive postoperative day 9 and was discharged on reconstructive postoperative day 16. The total hospital stay was 55 days.\nWritten informed consent for the patients’ information and images to be published was provided by the patients and authorized by the Ethics Committee of the Tumor Hospital of Wuwei.
A 63 year-old man with a history of Crohn's disease for the past thirty years and hyperlipidemia presented with one week of abdominal pain, diarrhea and hematochezia. Abdominal pain was generalized, 6 by 10 in intensity on the pain scale, and dull in character. It was worsened by food intake and relieved by bowel movement. The abdominal pain was associated with fever, chills, nausea and vomiting. The patient also complained of painful rashes all over his body that had erupted suddenly about a week ago. The rashes were nonpruritic and had started on the dorsum of his hands and spread to involve his face, neck, chest and legs. He denied using any new creams, soaps, detergents or perfumes or any change in his bed sheets or clothing. He also denied contact with pets, recent travel, a similar rash in any other family member, or being bitten by an insect. He denied having had any similar rash in the past. He had a history of Crohn's disease for the past thirty years which had been in remission for several years, until the past few months when he began to have episodes of diarrhea and rectal bleeding. Colonoscopy two years ago had showed inflammatory bowel disease of segmental nature with rectal sparing and primarily involving the ascending and sigmoid colon. His medications included Asacol which he had been taking for past few months and azathioprine which was started two weeks prior to his admission. He had previously been on prednisone which was started two months earlier with his last dose being four days prior to admission. His vital signs on presentation were: Temperature 100.5°F, blood pressure 95/58 mmHg, heart rate 120/min and respiratory rate 21 b/min. On physical examination his abdomen was mildly distended with tenderness to palpation in the left lower quadrant. He also had a papular rash and plaques, with surrounding erythema, scattered over his face, neck, chest and legs. (See Figure ) These lesions were tender to palpation. Laboratory results showed an elevated white blood count (WBC) of 20.7 × 109 with 78% neutrophils and 14% bands. Comprehensive metabolic panel was significant for low sodium of 133 mEq/L and mildly elevated renal function with a blood urea nitrogen of 20 mg/dL and creatinine of 1.3 mg/dL and. His erythrocyte sedimentation rate (ESR) and C reactive protein were also high at 49 mm/hr and 161.6 mg/L respectively. Blood cultures were negative. Other laboratory tests, which included fungal serology, potassium hydroxide mount, gram stain, acid fast bacilli smear, bacterial culture, fungal culture and an acid fast culture of the skin rash, were all negative. He was started empirically on intravenous vancomycin for possible Methicillin Resistant Staphylococcus Aureus folliculitis, pending the results of investigations. Computed tomography (CT) scan of the abdomen on admission showed inflammation involving the colon and gastric and duodenal regions. Magnetic resonance angiography (MRA) of the abdomen was negative for mesenteric artery occlusion. Colonoscopy and esophagogastroduodenoscopy revealed pancolitis and gastroduodenitis consistent with Crohn's disease. Biopsy specimens taken from stomach, duodenum, ileum, ileocecal valve and colon revealed pancolitis, duodenitis and gastritis with no evidence of granuloma. The patient was diagnosed with an exacerbation of Crohn's disease and started on intravenous methylprednisolone 60 mg q 12 hrs, with continuation of azathioprine and Asacol. He was also given a dose of intravenous Infliximab. The rash showed no improvement after three days of antibiotics. A punch biopsy of one of the skin lesions revealed dense dermal infiltrate composed predominantly of neutrophils, with no evidence of vasculitis. This was consistent with the diagnosis of Sweet's syndrome. (Figure ). Antibiotic treatment was stopped. The patient's symptoms and rash rapidly improved with systemic corticosteroid treatment.
A 26 y/o male was admitted to the critical care service from the emergency department for severe anemia with variceal bleeding. The patient presented with active hematemesis citing a weeklong history of melanotic stool, hematemesis, and lightheadedness. There were no significant past medical or family histories of GI or pulmonary diseases. The patient's social history describes 2 glasses of wine per week for the last 4 years. Physical examination on consultation revealed an alert, young male with mild epigastric tenderness without pulmonary or cardiovascular findings. CT of the abdomen showed supradiaphragmatic “downhill” paraesophageal varices without cirrhosis or splenomegaly and pleural thickening with pleural calcifications. Upper endoscopy revealed numerous 4+ varices from the upper esophagus to the gastroesophageal junction which were banded. High resolution noncontrast CT the following day revealed right lung findings significant for volume loss, septal thickening of the secondary pulmonary lobules, and a “cobble stoning” indicative of pathologic interstitial edema (). V/Q scan revealed nearly absent right lung perfusion (). Subsequently, a CT of the chest to evaluate for pulmonary vein atresia showed normal left pulmonary veins with near complete functional arterial and venous systemic isolation of the right lung due to chronic right pulmonary vein obstruction. The left atrium was significant for a vertical septation resulting in complete isolation of the right upper and lower pulmonary veins (). A small caliber left to right to shunt was noted between the upper portion of the left atrium and the SVC via a patent sinus venosus (). Right lung findings were consistent with chronic pleural congestion, extensive arterial collateralization, and pericardial and peridiaphragmatic lymph node enlargement secondary to vascular congestion. The right lung was supplied by numerous hypertrophied intercostal and peripleural collaterals along the periphery in addition to hypertrophied bronchial artery collaterals. Systemic-pulmonary artery collaterals were also identified as arising directly from the lower thoracic and upper abdominal aorta just superior to the celiac trunk. These collaterals provided retrograde filling of the right pulmonary artery via hypertrophied phrenic artery collaterals forming a series of pulmonary-phrenic arcades and shunts along the diaphragm ().\nThe patient was stabilized and transferred to an outside institution where he underwent surgical resection of the obstructing atrial membrane. After surgery, the patients' hemoptysis, hematemesis, and melena resolved. Repeat upper endoscopy demonstrated no significant residual varices and CT bolus tracking images and echocardiography showed normal anterograde flow in right pulmonary artery.
A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast (Fig. a). We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved (Fig. b). Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space (Fig. ). At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.\nThe surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen (Fig. ). The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion (Fig. a). Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) (Fig. b). After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery.
An 18-year-old male farmer was admitted in the Government Ear Nose and Throat (ENT) Hospital with a history of non healing ulcer on right side of the cheek involving right and left eye with signs of orbital invasion (extensive proptosis, severe periorbital cellulitis and ulcer) from 1.5 month. The patient was suffering from high fever, complete blindness, severe headache and seizures; and he was non coherent and uncooperative. The lesion started as nonspecific sinusitis of 3 week's duration and was treated for symptomatic relief in a local hospital. The pain and discomfort continued to get worse and he developed a unilateral swelling on the right side of the cheek which was edematous, erythematous followed by formation of a small nodule which ruptured and formed an ulcer within 3 days. The patient approached a local physician where he was put on antibiotics, anti-inflammatory drugs and was also referred to a dentist to rule out dental infections. The dental infection was ruled and he was asked to continue the prescribed medications, but there was no relief and the condition deteriorated with increased ocular discomfort, severe headaches, sloughing of the ulcer which extended rapidly and involving nose, both the orbits with gradual loss of vision in next 2 weeks. The patient was admitted to the hospital due to repeated seizures, altered sensorium, non-coherence and was uncooperative. Clinical examination showed large irregular ulcer approximately 12 × 10 cm in size on the right side of the cheek, which extended from the right lower margin of the mandible to the medial and lateral canthus of the eye, involving half of the right side of the lips, exposing alveolar gingiva and teeth []. The skin around the ulcer was necrosed, indurated and edematous. The submandibular and submental lymph nodes were palpable, enlarged, tender and firm. However, the primary cause was undetermined and broad spectrum antibiotic therapy was initiated that included intravenous cloxacillin 500 mg every 6h, cefuroxime 750 mg every 8h and metronidazole 500 mg every 8h along with anticonvulsant treatment for 1 week along with surgical debridement of the ulcer. The severity of the lesion prompted us to do a thorough clinical and radiological evaluation to rule out gangrenous stomatitis, chronic granulomatous disease and any malignancies.\nThe complete blood picture and biochemical investigations showed a neutrophilic leukocytosis 12,000 cell/mm3 with left shift, differential leukocyte count of 76% neutrophils, 20% lymphocytes, 3–4% eosinophils, hemoglobin of 11 gm/dl, raised erythrocyte sedimentation rate (ESR; 40 mm at the end of 1h), random blood sugar of 140 mg%, and fasting blood sugar of 80 mg%. The patient was human immunodeficiency virus (HIV) and hepatitis B surface antigen seronegative; and the liver function and the renal function tests were within normal limits. The chest X-ray was clear and normal.Computed tomography (CT) scan of paranasal sinuses and the brain showed right maxillary and ethmoidal sinusitis with deviation of the bony nasal septum to the left, mild erosion of bony nasal septum and bone destruction. Widening of the optic nerve canal and the superior orbital fissure, probability of fungal etiology was also detected [Figure and ]. Exploration of the ulcer and debridement of necrotic tissue were done under local anesthesia and sent for histopathology, culture analysis. Histopathological examination of the debrided tissue showed elongated, broad, nonseptate hyphae, marked areas of necrosis with giant cells, thrombosis of vessels, diffused infiltration of lymphocytes, eosinophils and few plasma cells [Figure -]. The Grocott-Gomori's methanamine silver staining showed nonseptate, twisted, ribbon-like hyphae of zygomycetes []. Rhino-orbito-cerebral zygomycosis was suspected and partial surgical debridement of ulcer and surrounding necrotic area was done. Patient was put on intravenous liposomal amphotericin B 250 mg daily and itraconazole 200 mg twice daily for 10 days. The culture analysis on the Sabouraud-chloramphenicol-gentamicin agar after 2 days at 30 and 37°C grew a white cottony growth which covered the entire surface of the agar. The patient developed severe seizures, status epilepticus diminished reflexes and succumbed to death after 1 week of therapy.
35-year-old, gravida 3 para 0 woman was admitted for the anatomical survey of her fetus at the 21st week of pregnancy. During the US examination, we detected 11 × 10 mm solid mass between tongue and palate. This solid mass was homogeneous and originated from the bottom of the mouth The mass has no abnormal vessel architecture by Doppler US ().\nThere was no cleft lip. We decided to perform MRI to reveal extension of solid mass and rule out other head and neck anomalies (). Lips and hard palate were visualized as intact by both US and MRI. The parents had refused prenatal invasive genetic tests. The couple was informed about the possible risks in the pregnancy. Polyhydramnios did not occur in the remained pregnancy period that could be common. Before cesarean section (C/S) the neonatologists were informed about oral solid mass which might obstruct the airway of the neonate, and the possible need for the EXIT (ex-utero intrapartum treatment) procedure [].\nThe baby was delivered by cesarean section in 37 weeks and 4 days of gestation due to breech presentation. The baby's weight was 2690 gram and had 7 and 9 Apgar scores. In the first neonatal examination of the baby, there was a white, 2 × 2 cm solid mass between the tongue and palate in the mouth (). It has smooth surface. There was another pink coloured adjacent soft tissue mass that was evaluated as accessory tongue. Postnatal karyotype analysis was reported as 46 XX. Therefore, considering the relation between epignathus and congenital heart diseases, the postnatal echocardiography was performed and it revealed mild atrial septal defect and mild tricuspid insufficiency []. In the postnatal exam, she had low-set ear and flattened-based nose. The postnatal MRI revealed a 26 × 13 × 10 mm soft tissue mass, which has left paramedian location and seemed hyperintense in the T1 planes and isointense in the T2 planes. She underwent surgery in the neonatal period to excise oral solid mass. In the operation, following the excision of oral mass, incomplete cleft palate was surprisingly seen in the soft palate. In the histopathologic examination of the mass, the fat tissue was painted by S100 and surface epithelium with pancreatin []. Final histopathologic diagnosis was mature cystic teratoma. She underwent another surgery to excise accessory tongue and repair of incomplete soft palate cleft when she was 14 months old. Postoperative follow-up is normal after second operation.
The patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.\nBoth patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.\nIn the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quelling reaction using rabbit antisera (Statens Serum Institute, Copenhagen, Denmark). Drug sensitivity test was performed using a dry plate Eiken (Eiken Chemical Co., Tokyo, Japan), and was performed in accordance with CLSI M100-S-18 (hemosupplemented Mueller–Hinton broth, 22-h culture). The drug sensitivity in both strains was similar. As the next step, we performed a sequence typing match using the defined genetic sequence of the pneumococci was determined (aroE, gdh, gki, recP, spi, xpt, ddl) according to the method described in /, and it was compared with the sequence information present in the existing databases. Both strains matched completely.
The present patient was a 39-year-old Chinese man. After the patient started to get out of bed 1.5 months after Achilles tendon suture repair, fluid leakage and foreign body reaction occurred at the incision site. He came to our institution for treatment in 2016. We performed the same arthroscopic surgery on him as in the previous case (Fig. ). A strip was not used, but sterile dressing and cotton compression dressing were applied to the legs. After the surgery, the affected limb was fixed with plaster of Paris to immobilize it. Because wound infection could not be ruled out, intravenous antibiotics were administered, just once after the operation. The postoperative condition of this patient was good.\nHowever, in 2018, the patient noticed a subcutaneous bulge in the Achilles tendon area, localized skin redness, and tenderness. He came to our department for treatment 1 month later. We considered these symptoms to be caused by a foreign body reaction due to a piece of suture that was missed in the previous surgery. Therefore, under local anesthesia, we performed a 1-cm incision, found the thread, and removed it. No tourniquet was used in this operation, and no postoperative antibiotics were given.\nMRI results showed a significant improvement in the Achilles tendon area during follow up compared with preoperatively. Pain at the Achilles tendon was assessed using visual analogue scale (VAS) scores, with 0 indicating no pain at all and 10 indicating the maximum pain. The function and movement of the Achilles tendon were assessed using scores on the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and the Victorian Institute of Sport Assessment Achilles (VISA-A) questionnaire as well as the Achilles tendon total rupture score (ATRS). Because no Achilles tendon sports ability scores were available, we used the Tegner knee motion score to evaluate the overall lower limb function and recovery of motor ability in patients after surgery. At the last the follow up in 2019 (3 years after the operation), the patient's VAS had improved from 6 preoperatively to 0, his AOFAS score changed from 45 to 100, his VISA-A score from 33 to 76, his Tegner knee motion score from 1 to 3, and his ATRS from 19 to 92, which indicated that the function and movement of the patient's affected limb had improved satisfactorily.
A 54-year-old male was struck by a truck while riding a motorcycle and consequently impacted a guardrail. He was reportedly conscious, ambulatory, and unable to bear weight on his left leg at the scene. His pelvis was temporarily stabilized at an outside hospital, and he was transferred to our facility. A pelvic X-ray and a computed tomography (CT) scan of the chest, abdomen, and pelvis from the outside hospital demonstrated diastases of the left pubic symphysis and a fracture involving the left sacral wing extending to the left sacroiliac joint and a ruptured bladder. On arrival, he underwent a retrograde cystogram during Foley catheter placement, which demonstrated extraperitoneal bladder rupture.\nThe patient underwent an additional CT scan with contrast enhancement of the chest, abdomen, and pelvis with reconstructions of the thoracic and lumbar spine. At the same time, a CT scan of the head and cervical spine was performed. The images demonstrated extensive hyperdensity within the spinal canal subarachnoid space related to extravasation of contrast material, which was not previously observed on the outside hospital imaging [].\nThe imaging suggested that the contrast material extravasated out of the bladder into the extraperitoneal space []. Because of extensive fracturing of the left sacral pelvic tube with violation of the left sacral nerve roots, the contrast agent entered the subarachnoid space at the left sacral ala predominantly through the left L5 and S1 nerve roots [].\nThe patient underwent emergent repair of the bladder by the urological surgeon, and the pubic symphysis was secured with plates by the orthopedic team. Two days later, the patient underwent open reduction and internal fixation of the left sacrum and percutaneous pinning of the left sacroiliac joint by the orthopedic surgeons. The dural tear and cerebrospinal fluid leak were treated conservatively.\nThe patient was discharged home 13 days after presentation with family support, physical therapy, wheelchair, and crutches with instructions for no weight bearing on the left lower extremity. On follow-up 3 months later, X-rays demonstrated stable alignment, and on physical examination, he was healing well without complication.
A 71-year-old male patient was transferred to our department due to soft tissue defect in the left lower leg and infected Achilles tendinitis. The patient underwent incision and drainage of both lower legs with necrotizing fasciitis, at another hospital two months ago. Continuous wound care was performed; however, the left leg open Achilles tendinitis and soft tissue defects were not resolved.\nPhysical examination revealed a 12 × 5 cm wound with exposed Achilles tendon over the posteromedial aspect of lower one-third of the leg (Fig. ). His wound culture grew methicillin-resistant Staphylococcus aureus (MRSA).\nWe performed an operation with the patient placed in the supine position. All infection associated with necrotic Achilles tendon in the proximal muscle tissue was excised (Fig. ). After debridement, the patient had a 16 cm tendon defect from the muscle with the ankle joint in neutral position. He had 2 cm of the distal tendon attached to the calcaneus. We extended the skin incision to the outside of the zone of injury in the anterior aspect of the ankle, dissected anterior tibial artery and vena comitantes to perform vascular anastomosis out of injury zone. We made a template with surgical glove, which included the vascularized fascia lata for the reconstruction of Achilles tendon (Fig. ). We used the already manufactured template on the ipsilateral thigh, centering the flap over the perforator and drew the flap larger than the recipient site (Fig. ). A 14 × 7 cm ALF flap with a large piece of fascia lata (bilaterally, approximately 2 cm extra fascia is taken) was harvested (Fig. ). The donor defect was closed primarily over a silicon drain. For the reconstruction of tendon, the fascia lata was repaired first using multiple figure-eight sutures and modified Becker method[ with 4–0 prolene sutures at the separated end-to-end of the Achilles tendon. An end-to-end microvascular anastomosis was performed between the anterior tibial vessels and the flap pedicle vessels using 9–0 sutures microscopically after inserting the flap into the defect (Fig. ).\nPostoperatively, the ankle and leg were wrapped in a bulky dressing and immobilized with an above-knee splint and the flap was monitored intensively for 7 days. Anticoagulation therapy with prostaglandin E1 (10 μg/day) and heparin (5000 units/day) were administered for 1 week and aspirin 100 mg once a day for 4 weeks after the surgery. The flap survived completely without complications. Passive and active exercise of the ankle joint was started at 6 weeks after surgery. Subsequently, the patient underwent a graduated rehabilitation program, from a non-weight bearing exercise to partial-weight bearing exercise. Twelve weeks after the surgery, the patient was permitted full-weight bearing with gait training.\nAt 12 months of follow-up, the patient was able to resume full daily activities, felt a little discomfort at the donor site after more than 2 h of hiking, but was able to walk without pain and without the need for support, also was able to squat, showed an ankle range of motion of 15° dorsiflexion and 45° plantar flexion, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 (Fig. ).
A 26-year-old gentleman with no significant past medical history had been on a fishing trip 3 weeks prior to presentation and reported a possible tick bite to his right second toe. This was followed by a mild erythematous rash and swelling on his toe that resolved within 2 days. Two weeks later, he started having episodic subjective fevers and chills and developed a well-circumscribed macular rash on his left upper abdomen which gradually cleared within two to 3 days. He did not seek medical attention at any time.\nHe presented to an outside emergency room with presyncope and worsening fatigue for 1–2 days prior to presentation. Initial telemetry monitor strips demonstrated 2:1 AV block alternating with complete heart block and a junctional escape rhythm in the range of 30 beats per minute (bpm) (Fig. A). He was hemodynamically stable. He was started empirically on intravenous (IV) ceftriaxone therapy due to suspected Lyme disease and Ig M and Ig G Lyme titers were sent for outside analysis. A 2-D echocardiogram demonstrated normal right and left ventricular systolic function with no significant valvular dysfunction.\nTwenty-four hours after admission, he had loss of junctional escape with underlying complete heart block and asystole with near syncope. Emergent right subclavian access was obtained for temporary pacing and placement of an active fixation permanent pacemaker lead. The lead was connected to an externalized permanent pacemaker generator as illustrated in Figure A with settings at VVIR- 60–120 bpm. Chest X-ray confirmed appropriate lead positioning in the right ventricle as shown in Figure B.\nEvaluation was performed to detect an underlying rhythm daily, and there was partial intrinsic recovery following 6 days of antibiotic therapy with underlying complete heart block and junctional rhythm at 30 bpm. On the ninth day of his hospital stay, the junctional rates had increased to 45 bpm and the pacemaker was programmed into a backup mode at VVI-30. By the 12th day of admission, he was maintaining junctional rhythm with rates ranging from 45 to 50/min with periods of AV block and 2:1 AV conduction.\nInitial Lyme screening with enzyme-linked immunosorbent assay (ELISA) was positive followed by confirmatory Western Blot for Ig M. A peripherally inserted central catheter (PICC) was placed due to his previous good response to IV ceftriaxone and infectious disease recommendations for 4 weeks of IV antibiotics due to high grade AV block. He was discharged home on the twelfth day with IV ceftriaxone therapy planned for a total of 4 weeks and backup externalized pacemaker in place.\nHe was followed up in clinic 1 week postdischarge, and at that time on pacer interrogation, it was seen that he had not required any backup pacing and was maintaining normal sinus rhythm at 55–60 bpm. The external pacemaker was left in place. On the second follow-up a week later, he was still maintaining normal sinus rhythm and had not required any pacing. The external pacemaker and active fixation lead were removed. An electrocardiogram (EKG) demonstrated complete resolution of AV block (Fig. B). Comparative heart rate histograms at two and three weeks of antibiotic therapy are shown in Figure C and D, respectively. The antibiotic regimen was continued to complete 4 weeks of therapy.
A 30-year-old male patient reported to the Oral and Maxillofacial Surgery Department with a complaint of swelling in left lower jaw since 1year []. Patient gave a history of similar asymptomatic hard swelling in the same site 7 years ago. Records revealed an unilocular osteolytic lesion in the left mandible extending from the mandibular canine region to the second molar causing expansion of the jaw involving the lower border of the mandible []. A conservative surgical curettage was listed as having been done under general anesthesia and the pathological diagnosis was reported as a benign fibro-osseous lesion.\nPresent clinical examination revealed a diffuse extraoral swelling on the left side of the face extending from the midline of the lower lip to tragus of ear anteroposteriorly and extending from ala-tragus line to submandibular region superior-inferiorly. Skin overlying the swelling was normal and tender on palpation. Intraorally it was extending from the lower right lateral incisor to left ramus of the mandible with the obliteration of vestibule. No mobility of teeth was detected and the oral hygiene status appeared to be well maintained. No neurological deficits involving mental or inferior alveolar nerve were elicited.\nOn radiographic examination, orthopantomograph (OPG) showed a large multilocular radiolucency with well-defined sclerotic borders with the expansion of the cortical plates []. Serum alkaline phosphatase level was elevated with the value of 209 IU/L. Routine preoperative investigations were within normal limits and following a preanesthetic evaluation the patient was posted for resection of the lesion under general anesthesia. Segmental mandibulectomy was done under general anesthesia with the preservation of about 3 mm posterior border of the ramus and it was stabilized using 2.5 mm reconstruction plates []. Adequate stability of the reconstruction plate was ensured and the patient was put in intermaxillary fixation (IMF) immediate postoperative with nasogastric tube feed to ensure adequate stabilization. The patient was discharged on the third postoperative day following uneventful healing. Postoperative OPG revealed adequate fixation and functional occlusion []. The resected specimen was sent for the histopathological examination. The patient is under follow-up since 6 months and no signs of recurrence have been noticed.\nThe resected left mandibular segment along with teeth [] (41–38) on macroscopic examination measured approximately 10 cm × 7 cm × 5 cm, surface was brownish-white in color and consistency varied from firm to hard.\nMicroscopic examination of hematoxylin and eosin sections showed various hypercellular fibrous connective tissue stromas consisting of plump hyperchromatic fibroblasts with minimal collagen deposition arranged in the form of sheets and whorls. Numerous psammoma bodies having eosinophilic and fibroblastic rimming were distributed throughout the section [Figure and ]. Pseudocysts of varying sizes filled with erythrocytes were seen, adjacent to which multinucleated giant cells were evident [Figure and ]. This was typical of an ABC and seemed to be present at the distal end of the lesion. To assess the histopathological nature of the collagen stroma and calcified bodies, Picrosirius red and Alizarin Red stains were employed and the sections visualized under polarized microscope. Tissue stained with Picrosirius Red under polarizing microscope showed compact collagen aggregation in the calcifications and loose collagen in the stroma. Tissue stained with Alizarin Red under polarizing microscope showed varying densities of calcification. The origin and nature of the calcified bodies in a fibro-osseous lesion in the jaws is always a matter of debate. To identify the origin of the cells forming the hard tissue, the sections were stained with anti-osteonectin (Clone 15G12, monoclonal antibody, Novocastra™ Lyophilized antibodies, Leica Biosystems Newcastle Ltd., UK) an immunohistochemical antibody specific to osteoblast lineage of cells. Spindle cells in the stroma showed positivity whereas psammoma bodies were negatively stained [Figure –]. Based on the constellation of histologic, clinical, and radiographic features final diagnosis of PDO concomitant with ABC was given.
A 30-year-old woman was evaluated with complaints of dysarthria, dysphagia, dizziness, nausea, vomiting, and weakness of left arm and leg. According to her medical history, there was sudden development of dizziness, nausea, and vomiting symptoms one hour before her admission to the hospital and later complaints of dysphagia, dysarthria, and weakness of left arm and leg were added to her presenting complaints. There was no background or family history of the patient with the exception that she had given birth by Caesarean section, 10 days before, and was diagnosed with preeclampsia in the 33rd week of her pregnancy. In her first evaluation, the patient was in stuporous state and she had dysarthric speech. During examination of her eye movements, vertical and horizontal nystagmus were observed. There was flattening of left sided nasolabial sulcus with abnormal gag reflex observed during cranial nerve examination. In the motor system examination, the left upper and lower extremity muscle power were 3/5 level and her Babinski reflex was found to be an extensor response on the left side. During the sensory system examination, pain and thermal senses of the patient were decreased on the left side of the body and cerebellar tests were abnormal on the right side. Evaluation of the cranial MRI screening of the patient with the misdoubt of cerebrovascular disease showed results that were consistent with diffusion restriction which was thought to be acute infarct extending to inferior cerebellar peduncle with involvement of right sided posterolateral medulla oblongata (). In magnetic resonance angiography (MRA), stenosis was seen in the distal segment of right vertebral artery ().\nIn addition to lateral medullary syndrome symptoms, there was also contralateral muscle weakness observed in the patient. Therefore, we reached a conclusion that the patient had BNS and medical treatment was initiated accordingly. The patient was hospitalized for 15 days in our clinic. At the end of the fifteenth day her neurological symptoms improved except ataxia and dysarthria.
A 64-year-old male patient presented with a diffuse swelling in anterior region of mandible extending towards both right and left parasymphyseal region and extending inferiorly upto lower border of mandible. The lesion was of 1-year duration with rapid increase in size since 3 months [].\nIntraoral examination revealed an intrabony swelling in symphyseal and parasymphyseal region of mandible extending from 36 to 46. The lesion was of size 8 × 5 cm with expansion of both buccal and lingual cortical plates and mobility of 33,34,35,43 and 44. Floor of the mouth was raised but overlying mucosa was intact []. However, lymph nodes were not palpable. OPG showed an ill-defined radiolucency extending from 36 to 46 [].\nClinical diagnosis of malignant neoplasm was done and incisional biopsy was performed at Government Medical College and Hospital and histopathological diagnosis of metastatic carcinoma was given, details of which were not available.\nTo rule out renal cell carcinoma as a primary neoplasm, USG abdomen was done for kidney but was found to be normal except a small, single cortical cyst in right kidney of size 2 × 2 cm.\nHowever, in view of histopathological diagnosis of malignant neoplasm, wide surgical resection of mandible was done from right angle to left angle of mandible, sparing the rami of both sides. However, it was not followed by radiotherapy.\nThe resected specimen of mandible was sent to Government Dental college and Hospital, for processing. The gross specimen received was a resected part of mandible from left angle to right angle, of size 9 × 5 × 5 cm comprising 33, 34, 35, 43 and 44 teeth. Both the cortical plates were perforated revealing a soft tissue mass, firm in consistency on lingual side in symphyseal and parasymphyseal region of both right and left side, wheareas on buccal side this soft tissue mass was seen extending only on right side.\nMicroscopic examination revealed the presence of numerous, large irregular lobules of malignant odontogenic epithelial clear cells separated by fibrous septae []. These cells were large, polygonal with abundant clear cytoplasm and eccentrically placed nuclei exhibiting significant cellular and nuclear pleomorphism, hyperchromatism and few mitotic figures; revealing a typical monophasic pattern of CCOC consisting entirely of clear cells [].\nThe abundant clear cytoplasm of cells was positive for PAS stain []. This PAS positivity was diastase sensitive indicating intracytoplsmic glycogen content. These cells were immunoreactive for pan cytokeratin [] and negative for S-100 protein [].\nIn view of all the above findings, histopathological diagnosis of CCOC with monophasic pattern was given.\nThe resection of mandible was further followed by reconstruction of mandible with incorporation of plate, which subsequently got infected and thereby removed and then the patient was lost for follow-up.\nHowever, the patient reported back after 5 years with a diffuse swelling on left side of face since 2 months, associated with intermittent pain. Patient was unable to open the mouth completely because of the strictures formed in the labial and buccal vestibule. However, a soft tissue growth could be observed in lower labial vestibule in 32, 33 region extending onto the labial mucosa near the angle of the mouth on left side. A single, firm-to-hard submandibular lymph node was palpable on left side. OPG has revealed previous post-surgical findings. Provisional diagnosis of squamous cell carcinoma was made.\nIncisional biopsy was performed from a soft tissue growth in lower labial vestibule and was sent for processing. A specimen received was a brownish white soft tissue, of size 1 × 0.5 cm and was soft in consistency.\nMicroscopic examination revealed a highly confusing picture. Superficial part of the lesion consisted of severely dysplastic stratified squamous surface epithelium with infiltration of large sheets of malignant epithelial cells in subjacent connective tissue [Figure and ].\nWhereas deepest part of the lesion comprised of numerous small lobules of malignant odontogenic clear cells [Figure and ] and numerous small groups of darkly stained basaloid cells [] scattered in a loose connective tissue stroma, revealing a typical biphasic pattern of CCOC.\nIntermediate part of the lesion showed somewhat mixed picture with few areas of clear cells and basaloid cells intermixed with few malignant epithelial cells.\nThese clear cells were diastase-labile PAS positive [Figure and ] and were mucicarmine negative []. All the cells were intensely positive for cytokeratin 19 [Figure and ] and were negative for S-100 protein [] excluding the possibility of salivary gland neoplasm. Malignant squamous epithelial cells present in the superficial part of the neoplasm were negative for calretinin [] excluding the possibility of odontogenic origin.\nTherefore, the case was diagnosed histopathologically as recurrence of CCOC in soft tissue with typical biphasic pattern as against monophasic pattern seen in the primary neoplasm with an unusual association of primary squamous cell carcinoma.\nSince, the patient was old, debilitated and reluctant to undergo any further therapy; he was kept on symptomatic treatment and regular follow-up. But he did not report for follow-up and died of the disease almost after 1 year of recurrence.
A 41-year-old male laborer presented at our institution with complaints of pain, swelling, and stiffness of the knee of a one-year duration and a sinus over the anterior aspect of the proximal leg. The patient was riding a vehicle involved in a road traffic accident about six years ago in which he sustained an injury to the left thigh. The thigh became painful, swollen, and deformed after the accident. The patient was unable to bear weight on the limb. There was no associated wound. He was taken to a hospital in which the attending doctor had diagnosed a fracture of the left femur after radiological investigation. He was treated by open reduction and intramedullary K-nail insertion six years ago. He had visited the same operating surgeon for follow-up care for the past five years for the complaint of pain, pus discharge, and stiffness of the knee. He was treated conservatively for the same.\nOn examination at presentation to our institute, he was averagely built, walked with a limp, and supported with one axillary crutch. The left knee was moderately swollen, the overlying skin had blackish discoloration, with an active pus-discharging sinus over the anterior aspect of the tibial tuberosity (Figure ). The sinus was discharging turbid purulent fluid. The knee was tender, swollen, but not fluctuant with a reduced range of motion of about 10-20 degrees. There was a healed longitudinal surgical scar on the lateral aspect of the left thigh measuring 10 cm and another healed scar over the superior aspect of the left buttock measuring 4 cm. There was no tenderness or abnormal movement at the fracture site in the left thigh. There was a limb length discrepancy of 6 cm, the left lower limb shorter than the right. No previous radiographs were available for review. Current radiographs were showing distal migration of the K-nail across the knee joint (Figure ).\nA 5-cm long anterior midline incision was given over the proximal left leg, distal to the inferior pole of the patella. The IM nail was identified and pulled out (Figure ).\nThis was followed by the release of turbid purulent fluid, some of which were collected for microscopy, culture, and sensitivity. The K-nail measured 38 cm in length and 11 mm in diameter (Figure ). The sinus was curetted and dressed. The patient was discharged on the third postoperation day and the suture was removed on the fourteenth post-operation day. Pus culture grew more than three bacterial colonies. At the one-month follow-up, the pus-discharging sinus was healed and no active discharge was present.
A 32-year-old Caucasian male presented with a history of cerebral palsy and other cognitive deficits at birth with a VP shunt placement as well as during childhood. His cognitive baseline was at the fourth grade level. The patient and his caregiver stated that he has had multiple revisions in the past, which were performed at an outside hospital. In addition, he had a history of recurrent small bowel obstructions, for which he underwent a laparotomy for repair at an outside facility in 2007. He had two subsequent obstructions that resolved with bowel rest. He was initially admitted to our facility in October 2015 with abdominal pain, nausea, and vomiting, and was diagnosed with another small bowel obstruction. ESR on admission was 108; CRP was 14.30. CT of the abdomen at the time showed a pseudocyst in the abdomen measuring 15 × 14 × 10 cm [] near the gastric outlet surrounding the peritoneal portion of the catheter. He was taken to the operating room by the general surgery team for lysis of adhesions. One month later, he presented to the emergency room with another small bowel obstruction, which was managed conservatively with resolution of his symptoms. Repeat CT abdomen showed a stable pseudocyst in the abdomen. He was discharged home, but returned to the ER again 1 month later with similar symptoms. Again, CT of the abdomen showed a stable pseudocyst near the gastric outlet. At this time, Neurosurgery was consulted because it was thought that the pseudocyst could be causing obstruction of the gastric outlet.\nIt was decided to convert his VP shunt into a ventriculopleural shunt. He underwent removal of the distal portion of the catheter where the peritoneal portion was removed and a new distal catheter was placed in the pleural cavity. He tolerated this procedure well without complication. It was then recommended that the patient have the abdominal pseudocyst aspirated by interventional radiology. Subsequent studies grew no organisms.
A 53-year-old Caucasian man with a past medical history of recurrent pancreatitis for the last 18 months, depression, alcohol and tobacco abuse, was referred to our hospital after a 10-day hospitalization in a pulmonary clinic, where he was admitted due to dyspnea and two episodes of hemoptysis. An extensive workup had already been performed, including bronchoscopy, gastroscopy, chest and upper abdomen computed tomography (CT) scans. A diagnostic paracentesis had already been carried out and fluid samples were sent for further analysis. His upper gastrointestinal endoscopy and bronchoscopy did not show any remarkable findings, and his pleural fluid was plenteous in protein and amylase. His cytology reports were negative for malignancy and his pleural fluid adenosine deaminase levels showed no evidence of mycobacterial infection (Table ). He had a good clinical status, except for a mild shortness of breath on exertion. He reported no fever or chills and, despite having a good appetite the last six months, he noted a weight loss of 25kg. Additionally, he mentioned that over the last four months he had experienced difficulty in swallowing solid food. On admission, his physical examination revealed bilateral diminished breath sounds at the lung basis and a firm liver edge 5cm below the right costal margin. His laboratory results showed anemia, malnutrition and slightly elevated serum amylase (360U/L) (Table ). His chest CT scan revealed bilateral pleural effusions and a mass in the lower mediastinum (Figure ); these radiological findings were not present on his previous examinations nine months ago (Figure ). After a successful chest drainage clinical improvement was noticed, however, further chest CT imaging showed a longitudinal fluid collection in the mediastinum, along the lower esophagus, measuring 3×8cm (Figure A, B). This collection extended beyond the diaphragm and seemed to be connected with a small pseudocyst at the pancreatic tail (Figure ). He was on a specific enteral diet, lipase supplementation and octreotide (administered subcutaneously). Further evaluation with magnetic resonance cholangiopancreatography showed the pancreatic duct to be slightly dilated. No further interventions were performed at that time. A month later he was discharged in good clinical status and scheduled for outpatient observation.\nTwo months after his discharge he was readmitted with clinical signs of respiratory distress and bilateral pleural effusion was visible on his radiology chest imaging. The results from his serum blood and pleural fluid laboratory tests were similar to his first admission. As similar findings were identified on his chest and abdomen CT scan compared to the images from his last admission, a decision for surgical intervention was made. Upon completion of the preoperative diagnostic workup he was transferred to the general surgery ward. He was on a triple antibiotic regimen (meropenem, vancomycin and fluconazole) and was scheduled for elective surgery. On the fourth hospitalization day he suffered from nausea, vomiting and abdominal pain. His physical exam showed that his abdomen was rigid, with noted pain on the upper abdomen and guarding. His laboratory tests showed a significant drop in his hemoglobin level and his vital signs revealed borderline tachycardia. After resuscitation with fluids and blood transfusions, a CT scan of his abdomen was performed where an extended hematoma at the lesser sac was identified with no active bleeding. Subsequently, he underwent an elective embolization of the splenic artery followed by an emergency laparotomy. Intraoperatively, a sizable hematoma was found at the lesser sac, pushing his stomach anteriorly. Due to chronic inflammation his pancreas was fibrous and hard. The splenic vein was thrombosed and splenomegaly with left-sided portal hypertension was present. A distal pancreatectomy with splenectomy was performed; his post-operative course was uneventful and he was discharged on the 11th postoperative day.
The second patient was a 5-year-old girl who presented to the office with a history of receiving a diagnosis of FSGS at the age of 3.5 after proteinuria was identified when she presented to her pediatrician experiencing new onset enuresis. The family sought care from the authors due to chronic symptoms and illnesses in all family members and history of exposure to water-damaged environments in past and current homes. Due to the father's work, the family has moved frequently. They recall evidence of water damage and mold in several of their previous homes and confirmed the presence of elevated levels of indoor mold in their current home. The patient's diet was typical for her age and did not include excessive consumption of foods known to contain elevated levels of ochratoxin.\nTesting indicated the patient did not have a genetic cause for FSGS. Upon diagnosis she was placed on a 6-week course of high-dose prednisone and has since used tacrolimus and enalapril as well as galactose. Her protein excretion in urine is followed regularly, and her mother reports an increased level of proteinuria upon moving to their most recent home.\nShe was born by NSVD at 39 weeks gestation. APGAR scores are not available. Her mother reports she required some initial resuscitation, but improved quickly and did not require transfer to neonatal intensive care unit. At 5 days of age, she was found to have severe hyperbilirubinemia, with reported levels of 26 mg/dL. She was breastfed for 14 months.\nHer physical exam was remarkable for nasal mucosal swelling with clear discharge and erythematous right tympanic membrane consistent otitis media, slightly enlarged bilateral submandibular lymph nodes, and moderate sway when balancing on toes with eyes open and an inability to balance on toes with eyes closed.\nUrine mycotoxin testing was performed, and she was found to have significantly elevated level of ochratoxin A at 9.1 ppb (limit of detection 2.0 ppb). Aflatoxin and trichothecene mycotoxins were not detected in the sample. Of note, elevations in urinary levels of ochratoxin and trichothecene mycotoxins were found in other family members as would be expected with their shared inhalational exposure; however, the patient's level of OTA was significantly higher than that of the other family members.\nAt the time of presentation to this office, the patient was also reporting symptoms of night sweats, heat intolerance, frequent episodes of otitis media and conjunctivitis, dizziness, hair loss, fungal skin rashes, episodes of excessive thirst, and the recent onset of reversing letters when she writes. Additionally, she has a history of significant dental disease including requiring a root canal at the age of 4.\nThe patient was started on therapy including avoidance of exposure to water-damaged/moldy environments and property exposed to these environments and the use of nutritional support, liposomal glutathione, and sequestering agents including cholestyramine and charcoal. Within months of starting treatment, the mother reported a significant decrease in the patients urinary protein excretion with the lowest levels found to date on recent testing.
A 29-year-old female presented with a 1-year history of progressively worsening right foot pain described as “crushing and burning” radiating into the posterior calf but sparing the heel. She had a significant history of actin-related protein complex subunit 1B gene mutations, critical for actin cytoskeleton remodeling, causing immune dysregulation with recurrent infections and ulcers. Her prescribed neuropathic pain medications and opioids had not provided adequate relief. She also reported numbness over the plantar aspect of the foot, again sparing the heel. A couple weeks prior to presentation, she began noticing ankle plantarflexion and toe flexion weakness on the right. The patient denied trauma to the right lower limb or radiating lumbar pain.\nOn examination, there was no gross muscle atrophy. There were multiple well-healed skin ulcerations over the anterior tibial regions. The patient had full strength in the left lower limb. On the right, she had difficulty with toe flexion. Furthermore, ankle plantarflexion was easily overcome on manual muscle testing when the patient was lying supine, indicating marked weakness. Sensation to light touch on the right was diminished over the plantar surface of the foot sparing the heel. The patient perceived a maximally struck 128 Hz tuning fork for >10 seconds at the first metatarsal-phalangeal joints bilaterally. Reflexes were 2+ at the patellae and left Achilles but absent at the right Achilles.\nThe patient underwent MRI of the right foot without contrast which showed nonspecific muscular edema suggestive of nonspecific myositis or acute denervation, but no other abnormalities. Initially, she was evaluated by Neurology and Pain Medicine services who found her symptoms to be consistent with complex regional pain syndrome. She was then evaluated by Rheumatology who recommended an electrodiagnostic evaluation concerning vasculitis.\nNerve conduction studies and needle electromyography were performed (). The sural nerves showed borderline normal amplitudes with normal latencies. The right superficial peroneal sensory amplitude was low normal and decreased on the left. The mixed nerve medial plantar responses were absent bilaterally. The peroneal motor amplitudes were low normal bilaterally. The tibial motor amplitude was mildly diminished on the left and markedly decreased on the right. Needle electromyography demonstrated abnormal spontaneous activity which was most marked in the distal tibial musculature. There was no evidence of axonal continuity to the intrinsic musculature of the forefoot.\nTaken together, there was electrodiagnostic evidence of a generalized length-dependent sensorimotor polyneuropathy which was predominantly axonal in nature. There was also a superimposed tibial mononeuropathy on the right, likely localizing just proximal to the tibial take-off branches to the soleus muscle. The findings were consistent with the patient's report of recent severe pain involving the right foot accompanied by ankle plantarflexion and toe flexion weakness.\nThe patient was subsequently referred for a right sural nerve biopsy (). Biopsy confirmed the presence of chronic and ongoing small-vessel vasculitis with associated axonopathy. She underwent treatment with three days of pulse steroids followed by additional high-dose steroids and IVIG. Near discharge, cyclophosphamide per the Euro-Lupus protocol was initiated. As a result, the patient had considerable improvement in pain and was safely discharged home.\nOn follow-up interview with the patient after completing her cyclophosphamide treatments, she reported significant improvement in her functioning. She had advances in her ankle plantarflexion and toe flexion strength and was now able to walk again. The patient had also successfully completed a course of physical therapy which improved her mobility further. Additionally, her right foot pain was well controlled. The patient continues to follow-up closely with her providers for ongoing immunosuppressive treatment and pain management.
The patient was a 60-year-old man. Abdominal ultrasonography indicated that he had an abdominal mass. He reported having perceived lower abdominal pain 7 months before the initial examination, but it spontaneously remitted. The patient had no fever nor any history of conditions such as hypertension. A blood test revealed that he did not have anemia, thrombocytopenia, or coagulation abnormalities. The patient demonstrated slightly elevated levels of carcinoembryonic antigen (4.7 ng/ml) and soluble interleukin-2 receptor (603 U/ml), tumor markers that are elevated in gastrointestinal cancers and malignant lymphoma. Contrast-enhanced CT showed a 33× 31 mm abdominal aortic aneurysm and a 106 × 81 mm mass peripheral to the abdominal aorta. The mass did not feature a contrast effect, and its margin was enhanced in the venous phase (Fig. ). Sigmoid wall thickening and inferior vena cava thrombosis were also observed (Fig. ). We suspected the patient had a neoplastic disease, such as a malignant lymphoma or sigmoid colon cancer. Detailed examinations were consequently performed, and direct oral anticoagulant therapy was initiated to treat the inferior vena cava thrombosis.\nThe FDG-PET revealed an abnormal accumulation of FDG in the margin of the mass and the sigmoid colon, but not in any other organs. Colonoscopy showed only mild inflammation in the sigmoid colon, and a sigmoid colon biopsy revealed no significant findings. Chronic inflamed fibrous connective tissue was harvested from the periaortic mass using CT-guided biopsy. There were no findings indicative of infection or neoplastic disease, thus precluding a pathological diagnosis.\nAt 1 month after the initial examination, intermittent claudication occurred, prompting the performance of follow-up contrast-enhanced CT scanning. On CT scanning, we found an arterial occlusion from the infrarenal abdominal aorta to the bilateral common iliac arteries, the right external iliac artery, and the right internal iliac artery (Fig. ). These findings indicated the potential progress of the tumor to the aorta. Via a midline incision, biopsies of the mass and the lymph nodes peripheral to the sigmoid colon were obtained. However, these biopsies showed only connective tissue with inflammation and fibrosis and did not yield any significant findings. Since the developments, we elected to resect the mass and perform bypass surgery for definitive diagnosis and treatment after 3 weeks from biopsy.\nSurgery was performed using a transperitoneal approach via a midline incision. Adhesion was observed peripheral to the abdominal aorta, the bilateral iliac arteries, and the retroperitoneal mass. The abdominal aortic lumen was completely occluded by an old thrombus and plaque. Removal of the thrombus revealed a 35-mm intimal defect consistent with the direction of the retroperitoneal mass (Fig. ). Communication was observed between the intimal defect site and the retroperitoneal mass, which was filled with a partially organized old thrombus. During the intraoperative rapid pathological examination, the tissue inside the mass was diagnosed as a fibrin clot. The tumor tissue was not assessed. The area from the infrarenal abdominal aorta to the right common femoral artery and the left common iliac artery was bypassed using a Y-shaped woven Dacron graft. Pathologic examination showed that the mass tissue was a partially organized fibrin clot, thus agreeing with our intraoperative rapid diagnosis. On the basis of the intraoperative and pathologic findings, the patient was diagnosed with CCR-AAA with abdominal aortic occlusion. His intermittent claudication improved, and he was discharged on day 19 after surgery. Six months after the operation, the retroperitoneal mass disappeared on CT.
A 29-year-old male with a left wrist mass which he felt for the last 6 months before admission. The swelling began to appear noticeably when the patient fell to his left side while playing soccer. After the fall, the patient complained of pain in the left wrist and was brought to a traditional bone setter where he received several massage therapies. The mass was said to had been as big as marble at first. However, the patient did not seek for any medication until several months prior to admission. At that moment, the patient complained that the mass grew as big as baseball, and he started to feel pain. The patient was right-handed ().\nThe general state was within normal limit. During the local examination of the left wrist, there was a visible mass in the distal ulna sized 9 × 7 × 3 cm. The mass was hard, immobile, and painful upon palpation (VAS 1–2). The patient was still able to move his left wrist, but the range of movement was limited due to the pain. The DASH score and PRWE score were 46.67 and 45.5 respectively, which indicated severe disability.\nConventional radiography revealed a multi-lobular and radio-lucent area with a clear margin in the distal ulna (). There was no sign of fracture, but an osteolytic area in the ulnar metadiaphysis was found. Chest X-ray showed no sign of pulmonary metastases. Wrist MRI detected a lesion measured 8 cm in length and 4 cm in width, expanding and partially destroying the thin cortex. We sent the core biopsy speciment to histopathologic department and showed multinucleated giant cell with more than 20 nucleus. The patient was treated with en-bloc resection surgery by fully experienced orthopaedic surgeon who has more than 35 years in managing this special case (, ).\nThree weeks after the surgery, the pain on the wrist has reduced significantly and the patient was able to do abduction, adduction, flexion, extension, opposition as well as the normal side. The DASH score and PRWE score were 13,33 and 8 respectively which indicated mild disability ().\nThe DASH score was 4.17 after six months of surgery. The PRWE was excellent with score of 2. The patient might return to his normal daily activity without any disturbances. We encouraged the patient to take routine examination every six months for monitoring signs of recurrency as GCT has a high recurrency rate.
The patient is a 13-year-old male, recreational football player, who presented with pain and is unable to fully extend the knee fully after a low energy impact on his right knee, without episodes of locking or instability.\nOn physical examination the patient had normal alignment of the right lower limb, full flexion with pain on the medial side on the last degrees of flexion and the last 15° degrees of extension; tenderness on the medial joint line, painful click with McMurray test with no effusion, and no ligamentous laxity. Patellar tracking was normal. Simple X-ray of the knee showed no abnormalities and a discoid medial meniscus with peripheral and horizontal tear and the upper side of the meniscus folded in the intercondylar notch was found on magnetic resonance imaging (MRI) scan with no other abnormalities associated ().\nAn arthroscopy of the right knee was performed with the thigh in a leg holder using standard anterolateral and anteromedial portals under general anesthesia. A complete medial discoid meniscus with a partial longitudinal tear in red zone of the body and posterior horn was found. Its upper side was folded to the intercondylar notch behaving as a bucket handle tear (). The tear was found to be reducible with a probe. It was refreshed with a shaver () and the meniscus was repaired using an inside-out technique with a specific suturing device () [] and number 2 Force-Fiber suture (Stryker Endoscopy, San Jose CA). Once the tear was sutured and its stability tested with a probe the body of the meniscus was saucerized with a shaver and radiofrequency at the lowest intensity allowed by the device, to avoid damage to the auricular cartilage, reproducing the shape of a normal meniscus ().\nPostoperatively the knee was immobilized with a knee orthotic in extension during two weeks and partial weight bearing and limiting flexion to 90° during two more weeks. At three months sport was gradually resumed.\nSix months after the surgery the patient started with pain and incapacity to fully extend the left knee with no trauma associated (and asymptomatic right knee). On physical examination the patient had complete flexion and pain on the last 10° of extension, with tenderness on the medial joint line with no effusion or ligamentous laxity. Patellar tracking was normal. No abnormalities were found on X-ray and MRI showed a tear very similar to the contralateral knee ().\nAn arthroscopy was performed on the left knee in the same manner as the right one. A complete medial discoid meniscus was found with a longitudinal tear in red zone affecting the body and posterior horn, very similar to the right knee except the upper part of the tear was not folded on the intercondylar notch although it was easily displaced to the notch with the probe (). The meniscus was sutured with an inside-out technique using the same specific device and suture used on the right knee. Once the stability of the suture was tested the body of the meniscus was saucerized using a technique similar to that described above (). Postoperative care was the same as the right knee.\nThe patient was reviewed at 6 months, one year, and two years after surgery being asymptomatic and with same preinjury activity level.\nMRI was performed two years after the surgery and a reduction of the size and intensity in T2 signal of both repaired menisci was found ().
A 54 year old male, smoker, with no prior illnesses or surgeries, presented to the emergency room with sudden epigastric abdominal pain. He denied nausea or vomiting but on further inquiry he revealed that he had anorexia and vomited occasionally in the last 7 months, having lost 7 kg in that time span. He looked malnourished and his abdomen was distended and generally tender. A computed tomography (CT) was performed revealing massive gastric dilation due to pyloric stenosis. The patient was initially managed with nasogastric drainage, intravenous (iv) fluids, iv PPI and placement of a right subclavian central line for parenteral feeding. During placement of this central line an iatrogenic pneumothorax occurred and right chest tube was placed.\nOn day 3 the patient’s abdominal pain increased significantly and he showed signs of peritonitis. Another CT was ordered and a pneumoperitoneum was evident. The patient was rushed to the Operating Room and an exploratory laparotomy was performed, revealing chemical peritonitis, a 1 cm perforation on a pre- pyloric ulcer with pyloric scarring and stenosis. A subtotal gastrectomy was performed with a Billroth II reconstruction.\nPost-operatively the patient stayed in the Intensive Care Unit (ICU) for 23 days. He had septic shock due to an infected jugular central line that was placed later, and needed antibiotics and aminergic support.\nHe also needed the chest drainage (which was changed several times) for 26 days until complete resolution of the pneumothorax, However, once extubated, he had no trouble in resuming oral feeding. At day 34 the patient exhibited signs of shock again, and the ordered CT showed a sub-phrenic collection that resolved with an 8 day course of Meropenem and Vancomycin. He was finally discharged 40 days after surgery. The pathology of the surgical specimen confirmed benign gastric ulcer with no dysplasia associated.\nA month after discharge he was seen in the outpatient clinic and was well, tolerating diet and had gained weight. The patient was not tested for HP status and has been called for new consultation to determine if he is indeed positive for infection so that eradication can be performed if needed (, ).
A 63-year-old female was noted to have an adrenal mass during her medical check-up 7 years ago. She has underlying hypertension with one anti-hypertensive drug. Otherwise, she does not have endocrine disorders or associated comorbidities in the patient and relatives. During the initial finding, it was 4.5 cm in size. Since it was asymptomatic, she was decided for routine imaging follow up. She underwent a two-yearly computed tomography (CT) scan to monitor the growth of the tumour. It remained stable initially until recently it started to grow to a size of 7 cm. The CT features were in favour of right benign adrenal tumour but in view of the risk of compressive symptoms, she was decided for surgical resection of the tumour via laparoscopic retroperitoneal approach. The surgery went well without any intraoperative and postoperative complications. She was discharged after day 2. There was no further treatment or follow up required.\nGrossly the tumour was firm with a lobulated surface measuring 95 mm × 85 mm × 40 mm and weighing 140 g (). It was partly covered by fatty tissue with an intact fibrous capsule. Serial sections showed a well-circumscribed tumour with heterogeneous yellowish to a greyish cut surface. Few foci of small haemorrhagic spots were seen. No necrosis identified. There is a remnant of adrenal gland attached to the lesion measuring 70 mm × 10 mm × 6 mm. Cut section of the adrenal gland is unremarkable.\nHistologically, it is a well-circumscribed tumour composed of lobules of mature univacuolated adipocytes separated by fibrous septae and rimmed by a thin capsule (A). There were intervening blood vessels and bone marrow elements containing trilineage hematopoietic cells with an increase in the number of megakaryocytes (A and B). Foci of haemorrhages were seen within the adipose component. No lipoblast or atypical stromal cell seen. No necrosis or calcification identified. There was an attenuated adrenal cortical tissue seen at the periphery (C and D). No evidence of malignancy seen. The features are in keeping with myelolipoma.
A 63-year-old woman was hospitalized for abdominal distension. The levels of carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 showed no elevation before surgery, and the CA125 level was 258.32 U/ml. Ultrasonography showed that the left posterior aspect of the uterus increased in size owing to the presence of a solid cystic mass 12 cm in diameter, of irregular shape, and with unclear boundaries. The solid part presented circulation signals, whereas the cystic part showed poor sound penetration with fine dot echo. The left ovary was enlarged, which implied that space-occupying lesions were present. Other findings included adenomyoma and adenomyosis, mass in the left posterior aspect of the uterus, and ascites. We performed rectovaginal examination of the patient before surgery, and the anterior rectal wall had a cystic mass of about 10 cm, which was convex toward the rectum. Pelvic magnetic resonance imaging revealed solid, cystic, irregular, and space-occupying lesions in the left adnexal area and before the rectum, presenting long T2 signals and equal short T1 signals. The thickness of rectal wall was increased. The solid part of the diffusion-weighted imaging lesion showed high signal intensity with unclear boundaries, whereas the cystic part showed the fluid level, and enhanced scanning of the solid part revealed obvious heterogeneous enhancement, and the borders between the lesion and adjacent structures were unclear (). The patient was diagnosed with ovarian carcinoma on the basis of the ultrasound results and was scheduled for cytoreductive surgery. During the surgery, ~1,000 ml of light bloody fluid was found in the pelvic cavity, and the left ovary was enlarged by the presence of a 5 × 4-cm solid cystic mass with a surface resembling a cauliflower. The omentum is thickened, and the surface is smooth. No significant abnormalities were found in the omentum and lymph nodes. Smooth solid cystic mass of 12 cm in diameter was found in the anterior rectal wall in the pelvis and partially adhered to the left peritoneum. The part of the mass that adhered to the left peritoneum was resected on suspicion of peritoneal invasion. Thereafter, we carefully separated the mass along the surface of the rectum and completely removed the mass. In the process, the sticky brown liquid flowed out, and the inner wall of the tumor was seen to have brittle papillary protrusions. After removing the rectal mass, we sutured the serosal layer of the rectum. Examination of frozen sections confirmed adenocarcinoma, but it did not reveal peritoneal invasion. Cytoreductive surgery was then performed and included routine hysterectomy and bilateral salpingo-oophorectomy, lymph node dissection, appendix dissection, and omental dissection. Histopathological examination revealed high-grade serous carcinoma resulting from rectal endometriosis and complicated with bilateral high-grade serous ovarian carcinoma, but it showed no lymph node metastasis. Photomicrographs of the sampled cyst wall showed fibrous connective tissue, hemorrhagic denaturation, and hemosiderin deposition. Contiguous with endometriosis, the high-grade serous carcinoma infiltrated throughout the sub-serosa, as shown in . The immunohistological examination indicated that WT-1 was positively stained and that the rectal tumors near endometrial glands were positive to estrogen receptor (ER) staining (). A diagnosis of high-grade serous carcinoma resulting from rectal endometriosis and complicated with ovarian cancer was finally made.
The patient was a 26-year-old Caucasian Greek male (178 cm, 75 kgs) was admitted to the Cardiology Department for the evaluation of a retrosternal constant pain of 3 hours duration. The pain started abruptly without any preceding symptoms. The pain was excruciating retrosternal pain and radiating to his right arm with a 8/10 intensity. The examination of the patient was unremarkable and his medical, surgical and family history was negative. The patient had no clinical features of Marfan syndrome. His biochemical values were normal.\nOn examination, the patient was now in moderate pain (4-5/10) but he was very anxious and worried because he had never experienced this type of pain. He actually was in active duty in the army until recently (15 days before) and he was extremely active to all the exercises he had to perform. He never had any form of disease or hospitalization. His pulse was 100/min and his blood pressure was 130/65 mmHg. No murmurs or extra sounds were audible on cardiac examination. Chest x-ray was essentially normal (Figure ). ECG was on sinus rhythm without any abnormalities. Cardiac ultrasound set the question of aortic dilatation with the possible presence of hematoma in the aortic wall or a small intimal flap in the proximal ascending aorta. Although there was an intact aortic and mitral valve function. No pericardial effusion was noted. A chest computerized tomography showed the presence of an ascending aortic aneurysm at 6 cm and a circumferential aortic tear with the possible presence of an intimal tear in the ascending aorta as well (Figure ).\nThe patient was emergently operated. We performed ascending aortic replacement under the support of cardiopulmonary bypass and moderate hypothermia. Intraoperatively a complete circumferential aortic tear was noted just above the sinotubular junction. The entry and exit point of the dissection were confined in the ascending aorta. Ascending aorta was replaced with a 26 Dacron graft. The patient recovered well and discharged on seventh postoperative day. Pathology revealed no specific findings in the resected aortic segment. A three years follow up showed that the patient was negative and in excellent clinical condition.
A 23-year old male patient was referred to our clinic with complaints of dysuria and intermittent macroscopic hematuria for the last month. He had a past medical history of muscular dystrophy without treatment and no previous surgical procedure.\nPenile skin and uretral meatus was normal. There was no palpable substance suggestive substance of a stone in urethra. The perineal skin was also normal and there was no inflammation or infection sign.\nThere was microscopic hematuria in urine analysis and no pathologic sign in sonography. In pelvic X-ray a five centimeters long tapestry needle was detected in the proximal penile urethral localization and it was confirmed with retrograde urethrography ().\nCystourethroscopy was performed to the patient in lithotomy position under spinal anesthesia. It revealed the needle was trapped in bulbous urethral mucosa (). The needle was right in front of the external urethral sphincter and featheredge of it was in the sphincteric area (). Because of this dangerous localization of the needle, we planned to open surgery for removal of it.\nThe perineal skin incision was preferred because of posterior urethral localization of the needle in endoscopic visualization. Under the fluoroscopic visualization, localization of the needle was identified at lithotomy position and a three centimeters long perineal skin incision in front of needle projection was performed. Obtuse end of the needle was palpated in corpus spongiosum after the incision. A one-centimeter incision of corpus spongiosum was performed and the needle was successfully removed with mosquito clamp with minimal damage. There was no iatrogenic injury in the urethra and there was only a 5 mm hole after the extraction of needle. Corpus spongiosum was repaired with 2/0 vicryl following insertion of an 18 F Foley catheter. The skin was repaired with 4/0 rapid vicryl.\nThere were no complications in the postoperative period. The tetanus prophylaxis was performed and patient was discharged on first day after the operation. The urethral catheter was removed 7 days postoperatively and first month follow-up revealed normal voiding.\nThe patient questioned about how happened the entrance of tapestry needle into his urethra. Patient had no self-insertion of it in his history and he was sure.

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.