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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.
An 87-year-old man was referred to our hospital with dyspnea. Based on the NYHA classification, his dyspnea exacerbated from class II to IV during 1 week. Although coarse crackle was not observed, pitting edema in the lower limbs was observed on physical examination. A 12-lead surface ECG showed bradycardia and revealed atrial fibrillation rhythm with left bundle branch block, and the width of QRS duration was 144 msec. Echocardiography demonstrated an ejection fraction of 30–40%. Despite medical therapy and cardioversion to sinus rhythm, his dyspnea still showed class III on the NYHA classification. After denying ischemic heart disease by coronary angiogram, we concluded the patient was a candidate for CRT. CRT implantation was performed without any complications (Fig. A). The patient's left ventricular dysfunction improved clinically. One week after CRT implantation, he was discharged with no significant laboratory data, chest X-ray, and echocardiography data.\nHowever, at 1-month follow-up, he complained of fatigue on exertion. Physical examination revealed no specific findings. Although the QRS morphology was not different from that at 1 week after CRT implantation, 12-lead surface ECG showed atrial fibrillation. In addition, heart enlargement was observed by chest X-ray. From the parameters of echocardiography, heart failure was negative. However, moderate pericardial effusion which was not observed at 1 week after CRT implantation was observed (Fig. B). Therefore, we suspected the fatigue must be caused by the increased pericardial effusion. Although computed tomography suggested atrial lead perforation (Fig. ), anemia was not observed from the laboratory data and the value of the atrial lead impedance and sensing threshold were not different from those at 1 week after CRT implantation. The pericardial effusion which was observed by computed tomography was located not at the ipsilateral side of the atrial lead, but at the opposite side. From above findings, we concluded that the pericardial effusion was not due to lead perforation. Signs of cardiac tamponade were absent by echocardiography. In addition, despite the 2-week observation period, pericardial effusion did not increase. Therefore, we decided to continue observation with no treatment. However, at 3-month follow-up, his pericardial effusion gradually increased (Fig. A and B) with low-grade fever. Laboratory data showed elevation of inflammatory marker (CRP 7.51 mg/dL) with absence of anemia. Although he had a fever, it was a low-grade fever of 37.3°C. The WBC from the laboratory data was within normal of 7900/μL with normal fraction. In addition, the atrial lead impedance and sensing threshold were not different from those at 1 month after CRT implantation. Therefore, pericardial effusion due to infection or lead perforation was not suspected. From the above findings, postcardiac injury syndrome was suspected as the cause of effusion. Although treatment using colchicine is not as common as NSAIDs or steroids , for the syndrome, colchicine is able to produces an anti-inflammatory effect with less side effects . Treatment using colchicine was deemed preferable, to drainage of the effusion. Therefore, colchicine intake (1.0 mg/day) was started. After 3 days, inflammation marker started to decrease. Furthermore, the effusion was diminished at 1 month after the start of colchicine therapy (Fig. C).
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube insertion. There was granulation tissue visible sprouting through the tract externally (Figure ). The patient had no signs of peritonitis and the abdomen was soft. On flushing the tube with saline, peritubal leakage was noted and there was resistance to flow. Endoscopic examination was performed to visualize the position of the internal bumper. On endoscopy, the internal bumper was not visualized. Only a small dimple was seen in the mucosa of the anterior wall of the stomach (Figure ). The internal bumper appeared to have migrated through the tract and was entirely covered by the gastric mucosa with only a small dimple seen at the site of the tract. An ultrasound of the abdomen was performed which showed that the internal bumper was in the intramuscular plane of the rectus abdominis muscle (Figure ).\nAs the patient’s GCS was still poor with no mature swallowing reflex, we planned to remove the old PEG tube and replace it with a new one for continued enteral feeding. The procedure was performed under general anaesthesia. Under fluoroscopic guidance, a guide wire was passed through the previous PEG tube from outside piercing the gastric wall. Then the old PEG was removed by gentle firm traction and the tract was dilated using dilator passed over the guide wire. The position of the dilator inside the stomach was confirmed by injecting a contrast dye under fluoroscopic visualization. Since the tract was well formed, a 20 Fr balloon replacement gastrostomy tube was inserted from outside and secured (Figure ). Once again the position was confirmed by fluoroscopy and free flow of saline. The patient was started on PEG feeds later on the same day and had no complications. The patient was followed up for a month and was on continuous PEG feeds without any complications.
A 23-year old male presented to his primary care physician's office with a five month history of vague abdominal pain. The pain was described as intermittent and was located in the left lower quadrant. The pain was not brought on by any particular events, nor was it relieved by anything specific. The patient had six episodes of pain in the previous five months, each lasting approximately one hour.\nThe patient had a past medical and surgical history that was only significant for a congenital megaureter on the left side, for which he underwent ureteral reconstruction as an infant, with no further issues. Prior to our operation for the mesenteric cyst, he was found to have normal laboratory values, including markers for malignancy. A preoperative CT of the abdomen () showed a 7.8 × 8.0 cm intraabdominal, homogenous cystic lesion which was unilocular, with a thin capsule located on the mesentery of the small intestine.\nBased on the preoperative CT, a minimally invasive operation was chosen. A total of three trocars were used for the surgery. Initially, a 10 mm trocar was placed at the umbilicus via the open Hasson technique, with two additional bladeless 5 mm trocars placed under direct vision in the bilateral lower quadrants ().\nDuring the laparoscopic exploration, it was noted that the mesenteric cyst was in the left lower quadrant. It was a thin walled structure, with yellow fluid, and was fixed to the mesentery posteriorly, with no other points of attachment (). The cyst was mobilized from the mesentery using the harmonic shears and a suction irrigator. Once free, the contents were aspirated completely, and the remaining cyst wall was removed from the abdomen via the 10 mm port with a surgical retrieval bag. The patient was discharged home the following day, tolerating a regular diet, and subsequently made a complete recovery.\nPathological examination of the cyst revealed the fluid to be benign. The wall of the cyst was found to be fibrous with a histology consistent with a lymphangioma ().
A 9 year-old male presented with Factor VII deficiency and multiple congenital abnormalities. Prior to her pregnancy with this child, his mother (currently 50 years old) had nine in vitro fertilization attempts that ended in miscarriage. One of these miscarriages was documented as trisomy 21 at 18 weeks gestation. This patient was one twin of a fraternal twin pregnancy conceived on the 10th round of in vitro fertilization. His sister was born healthy and her cytogenetic evaluation has not been performed. This twin pregnancy was complicated by premature labor requiring 13 weeks of maternal bed rest prior to delivery via C-section at 36 weeks gestation. The patient's birth weight was 3 lbs, 14.5 oz and his Apgar scores were 9 and 9 at 1 and 5 minutes, respectively.\nAt birth, the patient was noted to have an imperforate anus that was repaired with a colostomy at 15 days of life. An ultrasound of the brain showed agenesis of the corpus callosum, which was later confirmed on MRI. Both an echocardiogram and a renal ultrasound were normal.\nFor the first year of life, the patient failed to thrive. He underwent two successful operations for his imperforate anus at ages 9 and 11 months, after which he began to gain weight appropriately. Development was delayed; he sat at 9 months, pulled up at 11 months, walked at 22 months, and spoke single words at 15 months. His pediatricians noted "borderline microcephaly" and low muscle tone. He has been receiving speech therapy and physical therapy since age 1. At age 6 years, he developed grand mal seizures which have been successfully managed with medication. He had repeated upper respiratory infections and was noted to have enlarged tonsils that may have contributed to sleep apnea. As part of his pre-operative work-up for tonsillectomy, he was discovered to have elevated prothrombin and partial thromboplastin times of 21.3 seconds and 36.8 seconds, respectively. Factor VII deficiency (17% of normal) was subsequently diagnosed; Factor X levels were 54% of normal. The patient, however, has never had a severe bleeding disorder. It was the combination of Factor VII deficiency and multiple congenital malformations that prompted the genetics work-up, including karyotype. He had abnormal tooth eruption and required dental surgery and frenulectomy. Neither surgery required coagulation assistance.\nThe patient's parents are healthy, as is his fraternal twin sister and a younger brother, age 7. Review of systems was notable for chronic constipation requiring daily enemas. He is currently on Depakote 325 mg bid and has no known drug allergies.\nOn physical examination (Figure ), the patient's height is 51 inches (10th centile), his weight is 42 pounds (3rd centile) and his head circumference is 49.5 cm (<3rd centile, the 50th centile for a 2 year-old). His inner and outer canthal distances are at 97th centile. He has thick, curly hair with one hair whorl and a normal posterior hairline. His forehead is prominent and his face is triangular. His palpebral fissures are somewhat almond-shaped and upslanting. He has mild ptosis. He has a high nasal root, hypoplastic alae nasi with prominent columella, a thin upper lip, downturned corners of the mouth, and a small, pointed chin. He has some mild facial asymmetry. His ears are normally placed and rotated without tags or pits; however, there is a slightly flattened appearance to both auricles. His palate is high arched and he has a small notch in his uvula. He has several dental caps and his lower front teeth are abnormally rotated. His chest is normally shaped without pectus deformity. His chest circumference and inter-nipple distance were 50th and 75th centiles, respectively. He has multiple hypopigmented macules on his torso and one café-au-lait spot on his left shoulder measuring approximately 3 cm × 2 cm. He has approximately 10 degrees of scoliosis, mild lordosis and a small sacral dimple. There are surgical scars from his colostomy and anal repair. He has normal male genitalia, Tanner Stage 1. He has decreased elbow and shoulder extension. His distal extensibility is normal. His 5th fingers are slightly short relative to the 4th distal inter-phalangeal crease and show clinodactyly. His palmar creases are normal. Heart, lung, and abdominal examinations were normal. His knees were normal and he has pes planus.\nOn ophthalmologic examination, the patients best-corrected visual acuity is 20/50 OU with a +6.25 + 1.25 × 95 OD and +6.25 + 1.75 × 95 OS prescription. He has no measurable stereopsis. Color vision, ocular ductions, ocular alignment, pupillary examination, confrontational visual fields, and slit lamp examination were all normal. Dilated fundoscopic examination showed bilateral, mild optic nerve hypoplasia.\nEndocrine studies, including a thyroid panel, a random cortisol, prolactin, and follicle-stimulating were within normal limits. The patient's bone age is at the upper limits of normal by Pyles and Greulich critreria.\nRoutine karyotyping showed a translocation of material of unknown origin onto 13q33 (Figure ). FISH probes for all telomeres were used to confirm the presence of an unbalanced translocation with distal 16p (16p13.3 → ptelomere) translocated to 13q33. Thus, the patient is monosomic for genes at 13q33 and distal, as well as trisomic for genes at 16p13.3. The nomenclature for this karyotype is 46, XY, der(13)t(13;16)(q33;p13.3). Because the transcription factor gene, ZIC2, lies close to the breakpoint and because mutations in ZIC2 are known to cause holoprosencephaly (a midline defect), we confirmed the breakpoints by performing FISH analysis using ZIC2 specific bacterial artificial chromosome (BAC) probes, RPCI 11 12-G12 selected from NCBI and Ensembl databases (BACPAC Resources, Children's Hospital Oakland Research Institute, Oakland, CA). These FISH studies confirmed that ZIC2 was present on both chromosome 13's and that the breakpoint was distal to 13q32, consistent with our impression that the breakpoint is at 13q33. Cytogenetic analysis of both parents was recommended given the history of previous miscarriages, but has not yet been pursued by the family.
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 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up.
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 27-year-old male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.\nOn the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain. He showed a good prognosis in terms of aortic dissection after a review of aortic CT, but we found significantly increasing lesions in his lung, such as flake density increased shadow, less clear boundary, visible cavity and bronchial meteorology (Fig. c). The patient had no renal insufficiency and sinusitis but had eye damage with scleritis. The next day, the patient was readmitted to our hospital. At first, we considered pulmonary infection because of the combination of fever, haemogram, pulmonary shadow and cavitary lesions. Hence, we administered moxifloxacin. After 12 days, we reviewed chest CT again and found that the lung lesions became significantly heavier than before (Fig. d). Moreover, the patient still had intermittent fever, and the infection treatment was ineffective. At the same time, the patient developed conjunctivitis in the left eye and pain in the finger joints. Thus, we started to suspect pulmonary infection. We checked connective tissue disease-related indicators, such as ANCA, anti-nuclear antibody and immune indicators. The proteinase 3 (PR3)-ANCA (c-ANCA) level was 180 IU/mL, and the MPO-ANCA (p-ANCA) level was 10 IU/mL. Rheumatoid factor and anti-O experiments were positive, and anti-nuclear antibody spectrum was negative. We then performed a bronchoscopy, including brush biopsy, bronchoalveolar lavage and transbronchial lung biopsy. The pathological results suggested inflammatory cell infiltration, cellulose exudation and necrosis in clamped lung tissues (Fig. a). However, these pathological changes may be insufficient to diagnose GPA. We therefore carefully re-examined the pathological findings of the patient’s aorta and pericardium one year ago. Surgical biopsies obtained from the aorta and pericardium tissue showed that the epithelioid cells and multinucleated giant cells formed a granuloma (Fig. b), small vasculitis (Fig. c and Additional file : Figure S1 and Additional file : Figure S2) existed in the aorta and cellulose exudation and inflammatory granulation tissue hyperplasia were present in the pericardium (Fig. d).Combining with the two pathological results, clinical manifestations and laboratory tests, we invited a radiologist and a pathologist to perform a multidisciplinary discussion in the initial diagnostic assessment of the patient with suspected GPA. Finally, the diagnosis of GPA was established. Then, immunosuppressive therapy with i.v. steroids (methylprednisolone 40 mg twice daily) and cyclophosphamide 125 mg·day− 1 was initiated. The patient is currently followed up with the above treatment programs. We also adjusted the treatment program according to the patient’s disease progression. At present, the patient recovers well and is in stable condition.
A 33 year old lady with a prior history of a missed miscarriage, presented to our antenatal clinic at six weeks of gestation. She was diagnosed to have Wilson’s disease four years ago while undergoing evaluation for muscle weakness. The urinary copper level was high while serum copper and cerulopasmin levels were found to be below normal limits and she was started on zinc sulphate three times a day.\nThe patient had conceived spontaneously and was asymptomatic at the time of presentation. Zinc sulphate was continued at 30 mg thrice a day throughout her pregnancy. As a part of her baseline workup, an ultrasound upper abdomen was performed which showed portal hypertension. Serum copper level was 33 μg/dL while serum ceruloplasmin was 0.05 g/L. The blood pressure during her first antenatal visit was within normal limits. However, it was found to be raised (150/100 mmHg) at 18 weeks of gestation due to which methyldopa 500 mg three times a day was started subsequently. Blood pressure on her following visits remained between 130/80 mmHg and 140/90 mmHg. Anomaly scan performed at 22 weeks of gestation did not reveal any congenital anomaly. At 24 weeks of gestation, 50 grams glucose challenge test was performed for screening of gestational diabetes mellitus which was found to be deranged; one hour value of 177 mg/dl (normal value = 140 mg/dl). Oral glucose tolerance test was therefore performed which also revealed raised blood glucose levels confirming the diagnosis of gestational diabetes mellitus. Her sugars, however, remained well controlled through dietary measures throughout the antenatal period. A growth scan was performed at 34 weeks of gestation which showed a live fetus with an estimated fetal weight of 2.1 kg with normal amniotic fluid index. Serum copper and ceruloplasmin levels performed during this time period were 70.86 μg/dL and 0.07 g/L, respectively. During her 38th week of pregnancy, she developed preeclampsia with a blood pressure of 140/95 mmHg and proteinuria of 0.3 mg/dl. Therefore, induction of labour was offered. The bishop score prior to the induction was four and cervical ripening was performed through an intra-cervical foley’s catheter followed by an intra-vaginal prostaglandin E2. Syntocinon was later started at a cervical dilatation of 3 cm. However, an emergency caesarean section had to be performed due to non-progress of labour. An alive baby boy weighing 3.3 kg with a good Apgar score was delivered successfully. Her blood pressure normalized during the postpartum period. One year later, the patient had another spontaneous pregnancy which terminated in a missed miscarriage at 7 weeks of gestation.
We review a 30-year-old nulliparous female with hypermenorrhea, intermenstrual bleeding, and chronic pelvic pain for 4 months, prior to her office visit. A transvaginal ultrasound revealed a double uterus with a single cervix (bicornuate uterus) with the presence of 3 intramural leiomyomas (fibroids) in the right double uterus, measuring 41 × 33 × 33 mm, 57 mm, and 43 mm, respectively. The patient's relevant medical history included an open myomectomy 6 years ago with the removal of 4 leiomyomas, without the patient's knowledge of their location, and also a complicated appendectomy with peritonitis 1 year afterwards. She is programmed for laparoscopic myomectomy with previous bowel preparation and multidisciplinary evaluation in case of dense bowel adhesions. Bowel preparation was achieved with oral administration of sodium dibasic phosphate and 45 mL of sodium monobasic phosphate in half a glass of water, taking a separate, second glass of water 30 minutes later. Same dose was repeated 60 minutes later. Laparoscopy was performed placing an intraumbilical 5 mm trocar by direct vision and 1 accessory 5 mm trocar on the right and left lower pelvic quadrant, 3 cm above the iliac crest. Upon the introduction of the laparoscope multiple adhesions were observed (see ); the uterus was not visible upon initial evaluation. The left accessory trocar was placed and adhesiolysis was performed with ultrasonic energy instrument, in order to correctly identify and place the right accessory trocar. Once the adhesions were removed in the right lower quadrant of the pelvis, the accessory 5 mm trocar was placed as previously described. Removal of multiple adhesions from bowel to uterus had to be performed as well as from left and right ovaries and their respective Fallopian tubes (see ). Once the adhesions were removed, the bicornuate uterus was identified and leiomyomas were located on the right portion of the uterine body. We continued with adhesiolysis until the union of both uterine cavities was observed above the uterine isthmic portion. At this point, a diagnostic hysteroscopy was performed to identify both uterine cavities and exclude any types 1–3 leiomyomas. After the hysteroscopy, a conventional laparoscopic myomectomy was performed. Myomectomy was facilitated by the local infusion of argipressin (50 mg in 100 mL saline solution) around the fibroids.\nIncision of the pseudocapsule with ultrasonic scalpel was performed and traction with a toothed grasper assisted in the fibroid enucleation. The 3 fibroids were removed, and hemostasis was performed (see ). We proceeded to use the Rotocut 2 “Karl Storz” reusable power morcellator (see ) to extract the leiomyomas and the uterus was sutured in a three-layer approach.\nReoxygenated methylcellulose gelatin (Surgiflo®) and reoxygenated methylcellulose matrix (Surgicel Snow®) was placed on the uterine serosa with the intention of covering the barbed suture and preventing adhesion formation. The final pathology report identified the tissue as leiomyomas with a total morcellated weight specimen of 101 grams. Patient was discharged 20 h later without complications.
A 42-year-old female (gravida 4, para 2, abortion 1) at 24 weeks of gestation, presented to the Emergency Department with the complaint of right iliac fossa pain of 8 h duration. It was gradual in onset, progressive, severe in intensity, and non-radiating without nausea, vomiting, anorexia, or fever. She had no past medical history and she has never had any surgical procedure in the past. She did not take any drugs or medications. She did not smoke but takes alcohol occasionally. Her family history is negative for any malignancy. On examination she was tender on palpation in right iliac fossa with no rigidity or guarding but with rebound tenderness. Her WBC count was high (13.8 × 103/μl) with increased neutrophil count and high lactic acid of 3.3mmol/L. US abdomen did not show the appendix per se due to gassy abdomen, but minimal fluid was seen in right iliac fossa with viable intrauterine fetus.\nShe was observed for 24 hours but her pain and tenderness increased significantly, and she underwent diagnostic laparoscopy. The Surgery was performed by a middle grade Surgeon specialist under the supervision of the Attending. Intraoperatively, the appendix was found to be thickened and almost 1 cm in diameter with severe inflammation. The appendix was ligated at the base using endoloop and cut near the base. After that the appendix was safely placed in the endobag and removed from the body. She had an uneventful recovery post-surgery. She was discharged home after 2 days without any concerns. Histopathology reported acute appendicitis and low grade mucinous appendiceal neoplasm of about 1.4 cm near the tip of appendix. There were no lymph nodes present. Dysplastic changes were confined to the mucosa whereas resection margin was free (See, , , , ).\nOn her follow up visit after 2 weeks from surgery she was seen in clinic and found healthy with no adverse effects from surgery. She was informed about her pathology results. She received the news with a shock, but she was reassured. The Surgery team never suspected this outcome. She was suggested to follow up for further investigations and treatment. Her case was discussed in oncology multidisciplinary meeting. It was concluded that she should be further investigated with MRI pelvis & colonoscopy and be offered HIPEC. She underwent an uneventful normal vaginal delivery at 40 weeks gestational age. Post-delivery, she resumed follow-up. She underwent further imaging where her colonoscopy result was normal and MRI pelvis showed no intraperitoneal metastasis. Patient was offered treatment option of HIPEC which she refused. She came for follow up in the clinic for 10 months but after that she stopped coming to the appointments and lost follow up.
A 22-year-old nulligravid Caucasian female with Angelman syndrome presented with a four-month history of premenstrual nausea and vomiting and abdominal pain. Patient had been hospitalized each of the prior four months due to these symptoms of cyclic nausea, vomiting, and leukocytosis which occurred approximately monthly and were attributed to a stomach virus. Gross hematuria was not reported. There is no family history of urinary tract malignancy. Family history is notable for pancreatic cancer and ovarian cancer in non-first-degree relatives. Her prior surgical history includes teeth extractions and arm surgery. The patient does not smoke, but her father does smoke outside home. An ultrasound of the pelvis was obtained during a hospital admission which showed a 7 mm echogenic focus along the posterior wall of the bladder. Urogynecology then evaluated her as an outpatient. On presentation to urogynecology with her mother (primary caregiver), patient was noted to be physically well developed and well-nourished and in no acute distress in a wheelchair. She had abnormal facies and mentation. General physical and abdominal examinations were normal. Patient was unable to tolerate a full examination in the office; therefore, the decision was made to proceed with an examination under anesthesia and cystourethroscopy. Cystourethroscopy revealed an estimated 1.5 cm papillary cauliflower-like lesion on the right bladder sidewall lateral to the ureteral orifice. Cytology revealed atypical urothelial clusters. Biopsy revealed low grade Ta urothelial carcinoma, negative for invasion of lamina propria, with muscle not present for evaluation. Immunohistochemical stains CK20 and P53 were negative. The pathology specimen was reevaluated and noted as low grade papillary urothelial cancer without identified invasion and without muscularis propria sampled. Patient was referred to urology for further evaluation and treatment. Urology performed a transurethral resection of the bladder tumor which was noted to be 1 cm on a narrow stalk. Complete resection of the bladder tumor was performed with mucosa around the stalk of the bladder tumor removed as well with no evidence of bladder perforation. Final pathology was consistent with noninvasive low grade papillary urothelial carcinoma. Patient will continue to be followed by urology for surveillance cystoscopy under anesthesia every 3 months.
A 4-year-old boy was referred to our unit in August 2017 from another hospital because he developed sudden left lumbar cruralgia after a moderate back injury that occurred 2 weeks prior during a recreational activity. The child also had a fever, which started almost simultaneously with the head injury. The past medical history was unremarkable (as well as the familial and the psychosocial history), with the exception of frequent episodes of respiratory tract infections.\nAt the physical examination, the child was conscious and was complaining of lumbar pain radiating to the anterior thigh, palpation of the lumbar spine evoked the pain, no stiff neck was present, no skin markers were detected, and his body temperature was 38.5 °C. The neurological examination revealed no motor or sensory deficits, bladder disorders, or bowel disorders; however, the patient could not walk because of the intense pain. Once admitted, the child underwent spinal cord magnetic resonance imaging (MRI), which showed an intra- and extradural lesion extending from the lower L4 vertebra to the S2 vertebra, resulting in compression of the medullary conus and roots. The lesion appeared to be a fluid collection, with contrast enhancement, similar to an abscess (Fig. ). Blood leucocytosis and increased levels of inflammation markers were detected.\nThe day after admission, a surgical excision of the lesion was performed through a L5-S1 laminectomy. A purulent collection that filled the epidural space was completely removed and sent for microbiological examination. At the S1 level, a partially collapsed lipoma of the filum that occupied the subdural space was progressively separated from the nerve roots under neurophysiological monitoring and excised by sectioning the terminal filum. The procedure was completed by duraplasty. The L5-S1 laminae were not replaced in order to leave the spinal cord decompressed. The regeneration properties of the bone at this age and the static behaviour of the sacral vertebrae are likely to close the bony gap, avoiding instability problems.\nA histological analysis of the surgical samples confirmed the diagnosis of a lipoma.\nThe postoperative course was uneventful. The child showed a rapid recovery from the preoperative pain. The culture of the abscess revealed the presence of a methicillin-sensitive Staphylococcus aureus, so a targeted antibiotic therapy was carried out for 4 weeks. Postoperative MRI (performed 1 month later) showed a normalization of the radiological picture (Fig. ). At the current follow-up (16 months), the child is asymptomatic.\nA 4-year-old boy was referred to our unit in May 2018 from the Pediatric Intensive Care Unit where he was admitted 2 days prior with a suspected case of Guillain-Barré syndrome. The clinical history had started with urinary incontinence associated with paraparesis, which quickly progressed and prevented ambulation. The past familial, medical and psychosocial history was unremarkable.\nAt the time of admission, the patient was conscious; the neurological examination demonstrated paraparesis (2/5) with severe deficits in dorsiflexion of the feet, a moderate deficit in trunk elevation, diffuse hypoesthesia of the lower limbs and urinary incontinence. The MRI scan of the spinal cord (Fig. ) documented a large dorsolumbar syringomyelia secondary to a severe tethered cord, supported by a small lipoma of the conus, which was stretched to reach the S3-S4 level.\nThe child underwent surgery immediately after the MRI scan. Through an L5-S4 laminectomy, the dural sac was opened to explore and decompress the spinal cord. The small distal lipoma was dissected and removed, which immediately detethered the spinal cord.\nThe diagnosis of a lipoma was confirmed by histological examination.\nThe postoperative course was uneventful. The child showed a progressive improvement in both paraparesis and urinary incontinence, which were normalized after 3 weeks. The hypoesthesia significantly improved but still persisted in the 7-month follow-up. The postoperative MRI scan, performed 3 months after surgery, showed the detethering of the spinal cord and the significant reduction of the syringomyelia (Fig. ).
A 39-year-old man presented to the outpatient clinic with sudden vision loss that had started 15 days previously. His visual acuity in both eyes was at the level of hand motion. Pupillary light reflexes and eye movements were normal. Anterior segment biomicroscopy findings and intraocular pressure were normal. On dilated fundus examination, hypopigmentation was present in the retina and macula, as well as points of hyperpigmentation. At initial presentation, the hyperpigmentation was mainly around the disc and in the peripheral retina (). Intense points of hyperfluorescence were present in fundus autofluorescence (). Widespread window defect was seen on angiography (). Hyperreflective points of accumulation were detected over the RPE on optical coherence tomography (). Visual-evoked potential testing was requested for the patient and showed prolonged P100 wave latencies in both eyes.\nThe patient was taking antidepressants for psychiatric reasons and was reluctant to give a detailed history. There was no remarkable family history and when the patient was questioned in detail, it was learned that he worked in a salt factory and had attempted suicide with iodine approximately 20 days earlier because of psychological problems. Although the patient could not remember the exact amount, he estimated that he had consumed 200 mL of mildly diluted iodine. The patient reported color vision disruption starting 2-3 days after this event, followed by vision loss. Thyroid function tests, complete blood count, and biochemical examinations were requested. The T3, T4, and thyroid stimulating hormone levels were normal. Treatment with vitamin B and micronutrient supplements was started and follow-up was scheduled for 1 month later. In the follow-up examination, vision was at the level of counting fingers from approximately 1 meter and color vision was still impaired. On fundus examination, there was an appearance of increased hyperpigmentation, especially around the disc and in the peripheral retina at 2 months after iodine intake. The findings persisted 1 month later. Visual acuity was at the level of 0.1 (-1.75) Snellen lines in the right eye and counting fingers from 1 meter in the left eye. Hyperpigmentation around the disc was determined to have advanced and choroideremia had developed in the right eye, and pigmentation had become evident around the disc and in the peripheral retina in the left eye at 3 months after iodine intake (. Visual field examination was performed and there was determined to be absolute scotoma in both eyes.
The first case we present is that of a 29-year-old woman who presented to the clinic with the complaint of an enlarging left breast mass. She first noticed that this mass almost 2 years ago and mentions that it has been growing in size and becoming more erythematous and tender. She did not report any recent weight loss or change in appetite. She is married with 2 children, and she does not have any illnesses. She smokes hubble-bubble almost 4 times per week and does not drink alcohol. Surgical history is significant for 2 previous Cesarean sections with no complications. History of her current illness dates back to June 2016 when the patient felt a mass in her left breast; upon further investigation, she was diagnosed with idiopathic granulomatous mastitis and later (December 2017) developed an abscess that drained on its own. She was initially treated with methotrexate and later switched to prednisone and mycophenolate with minimal improvement. At the clinic, her vitals were within normal limits, and on physical examination, there was a left breast lump found at the upper inner quadrant with some erythema and inflammation surrounding it. Moreover, there was some skin retraction in this area.\nCore biopsy done at an outside hospital in June 2017 revealed no granulomas. Ultrasound done at that time showed a persistent ill-defined hypoechoic mass that appeared initially subdermally and was spanning more than 4 × 1.4 cm. Moreover, multiple deeper masses were seen, one of which was not located within the breast measuring 12.3 × 8.5 mm. Axillary nodes were insignificant and not well appreciated on imaging.\nFine-needle aspirate done in July 2017 was negative for malignancy and was reported to have abscess formation. The slides revealed a heavy inflammatory infiltrate predominantly composed of polymorphonuclear leukocytes. No ductal epithelial cells were seen.\nCore biopsy done in November of the same year showed multiple noncaseating epithelioid granulomas composed of epithelioid histiocytes, lymphocytes, neutrophils, and occasional multinucleated giant cells. Some granulomas contained neutrophils forming microabscesses with surrounding empty microcysts ().\nThe Ziehl–Neelsen stain for acid-fast bacilli was negative. This leads to the diagnosis of idiopathic granulomatous mastitis which is a diagnosis of exclusion.\nA repeat MRI done during June 2018 showed heterogeneous fibroglandular tissue with mild background enhancement. There are also numerous tiny rim-enhancing fluid collections in the left breast, the largest measuring 8 mm involving the upper inner and lower inner quadrants, some of which are fistulizing to the skin. Findings have regressed compared to the prior MRI.\nAs with the previous MRI, no enlarged axillary or internal mammary adenopathy was seen.\nThose findings are consistent with biopsy-proven idiopathic granulomatous mastitis extensively involving the upper and lower inner quadrants of the left breast.
The patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.\nBoth patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.\nIn the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quelling reaction using rabbit antisera (Statens Serum Institute, Copenhagen, Denmark). Drug sensitivity test was performed using a dry plate Eiken (Eiken Chemical Co., Tokyo, Japan), and was performed in accordance with CLSI M100-S-18 (hemosupplemented Mueller–Hinton broth, 22-h culture). The drug sensitivity in both strains was similar. As the next step, we performed a sequence typing match using the defined genetic sequence of the pneumococci was determined (aroE, gdh, gki, recP, spi, xpt, ddl) according to the method described in /, and it was compared with the sequence information present in the existing databases. Both strains matched completely.
A 24-year-old Caucasian female presented to the emergency department with a history of intermittent RUQ pain associated with nausea and malaise. She reported similar episodes of her symptoms three times a year for the past 4 years. The pain was not associated with meals or posture. She did not have any significant past medical history and did not take any regular medicines. On examination, she was hemodynamically stable; there was no fever or tachycardia and her blood pressure was within normal limits. Abdominal examination showed no evidence of peritonitis but revealed tenderness in the RUQ and epigastric regions. Urine dipstick for blood and pregnancy was negative. Full blood count and serum biochemistry showed a normal white cell count of 5.8×109/L with normal renal and liver function tests. The initial differential diagnoses by the admitting causality officer included biliary colic and peptic ulcer disease. She was admitted and started on opiate analgesics and antispasmodics and her symptoms gradually improved. Ultrasound scan of the abdomen demonstrated a normal liver and gallbladder with no evidence of gallstones but with a dilated CBD of 8.5 mm. Two days following admission, she underwent magnetic resonance cholangiopancreaticography, which again showed no gallstones, but also conversely no evidence of intra- or extrahepatic biliary dilatation with a CBD of normal diameter.\nOn review of our patient’s previous hospital admissions, we noted that 60 days prior, she had presented with similar episodes of RUQ pain; ultrasound scan of the abdomen and an esophagogastroduodenoscopy were normal. Two years prior to that, she had presented to a different unit with similar symptoms and at the time radiological investigations revealed a dilated CBD of 11 mm with no other abnormality.\nOn further enquiry into her social history, the patient admitted recreational use of oral ketamine over the past 4 years, all episodes of which coincided with her intermittent abdominal symptoms. She denied the use of any other illicit drugs and only moderately consumes alcohol.
A 23-year-old woman underwent primary reparative surgery for bilateral epiblepharon at the age of 5 years. Postoperatively, there were no serious complications in the first postoperative year. However, at the age of 17, she noticed that an abnormally large proportion of her right sclera was visible when her eyes were in their natural position. Five years later, she finally decided to undergo corrective surgery ().\nThe initial physical examination confirmed that apart from her cosmetic eye problem the woman was otherwise healthy. In the primary position of gaze, the distance from the lower limbus of her right cornea to the upper margin of her lower right eyelid was approximately 2 mm, whereas the lower limbus of the patient's left cornea was almost touching the upper margin of the lower left eyelid.\nTo repair the retracted right lower eyelid, first, local anesthesia was induced with 2 mL of 2% lidocaine and epinephrine (1:100,000 dilution). Then, an incision was made in the lower eyelid along the scar caused by the previous surgical procedure (). Although it was technically difficult to separate the lower eyelid retractors from the palpebral conjunctiva, the separation of the anterior and posterior lower eyelid retractors was successfully achieved. During this process, a certain amount of the scar tissue caused by the previous operation was also removed. Subsequently, the connections between the tarsus and the posterior lower eyelid retractors were broken.\nAuricular cartilage was harvested via an incision made in the reverse side of the external ear and placed between the lower edge of the tarsus and the posterior layer of the lower eyelid retractors (). The cartilage was fixed to the edge of the tarsus and the posterior layer of the lower eyelid retractors with 6-0 nylon sutures, respectively. The length of the horizontal implanted auricular cartilage was approximately 11 mm, and its vertical height was approximately 3 mm. The anterior layer of the lower eyelid retractors was left intact. At the end of the procedure, the pretarsal orbicularis oculi muscle and the lower edge of the tarsus were secured and permanently enclosed so that they did not touch the cilia on the ocular surface. The skin incision was then sutured with interrupted 6-0 nylon sutures.\nThe patient did not exhibit exposure keratitis or wound infection during the postoperative period. One year after the repair, there was no gross difference in the distance between the lower margin of the corneal limbus and the lower eyelid on either side. In addition, the corrected right lower eyelid moved down sufficiently during downward gazing, and the patient appeared to be extremely happy with the results ().
The present patient, a 55-year-old Saudi female, was diagnosed with PRP in 2009. PRP initially manifested as classic bilateral discoloration of the fingers ranging between pallor, bluish, and reddish, with mild pain and numbness. The patient did not suffer from joint pain, swelling, or deformity and did not exhibit skin rash, oral ulcers, or dysphagia. Her symptoms were exacerbated by cold weather and stress. The patient is a lifelong nonsmoker. She was initially treated with aspirin, nifedipine, and prednisolone by another health facility, but no notable improvement was observed. Upon our initial assessment, she exhibited no features of connective tissue disease and the physical examination was remarkable for bilateral cyanosis of the fingertips, with a left middle finger ulcer, whereas a lower limb examination revealed bluish discoloration of the right and left second and third toe tips. Distal pulse and motor and sensory evaluations were normal. Laboratory investigation for autoimmune analysis and serology and malignancy screening were normal ().\nThe patient was admitted to our hospital in July 2010 with severe digital pain and ulceration. Magnetic resonance angiogram of her upper extremities did not show any features of vasculitis, aneurysm, or stenosis. Computed tomography (CT) scanning of the aortic arch demonstrated a normal aorta and normal branches with no obvious vascular abnormality. CT angiogram demonstrated attenuated, irregular right and left ulnar arteries. The patient underwent bilateral selective ulnar angiography and distal angioplasty, which indicated distal disease at the level of the palmar arches. Biopsy of the left little finger showed no significant histopathological abnormalities and was negative for vasculitis.\nPrednisolone therapy was discontinued, and the patient was given a trial of sildenafil (12.5 mg) twice a day, as bosentan was intolerable due to side effects (nausea and dizziness). Disease progression was noted and the patient suffered from severe digital pain and bilateral ulceration of the tips of her fingers. These symptoms required another admission to the hospital and treatment with intravenous (IV) heparin infusion and IV iloprost for a total of 7 days, which led to a minimal improvement in her symptoms. Due to persistent symptoms (), rituximab therapy was initiated and she received first cycle in 2012 (1 g two weeks apart). Follow-up after 2 months indicated a significant improvement in her signs and symptoms.\nFollow-up after six months of rituximab therapy indicated a complete resolution of the digital ischemia (). In January 2015, the patient experienced a recurrence of her previous symptoms (), which were resolved by a second cycle of rituximab (375 mg/m2 weekly for 4 weeks). As of the most recent follow-up in April 2016, the patient remains in full remission ().
A 33-year-old woman had a history of recurrent transient ischemic attacks (TIAs). The first episode occurred at 28 years of age. Sudden onset of right-sided weakness occurred and recovered spontaneously after 2 hours. Further, when the patient was 29 years old, sudden aphasia occurred and subsided spontaneously later in the day. Moreover, when she was 30 years old, right-sided weakness and aphasia occurred simultaneously, and she visited Seoul National University Hospital for the first time. On cardiac magnetic resonance imaging (MRI), a congenital left ventricular diverticulum (LVD) at the apical lateral wall of the left ventricle was discovered (). The LVD was 2.6×3 cm in size, and the wall motion of the diverticulum was synchronous with that of the left ventricle. There was a possibility that the LVD was the source of the cardiogenic embolism that induced the recurrent TIAs. However, at that time, the patient did not undergo an operation and was just observed, with daily administration of aspirin (100 mg).\nWhen the patient was 33 years old, right-sided weakness and aphasia recurred. This time, brain MRI showed acute infarction in the left middle cerebral artery territory. Cardiac MRI showed no change in the LVD. Computed tomography (CT) angiography also revealed an LVD (). The patient recovered from the cerebral infarction after anticoagulation therapy. Although there was no definite evidence of a thrombus in the LVD, we decided to operate this time.\nThe operation was performed using standard cardiopulmonary bypass. Median sternotomy was conducted, and standard ascending aorta and bicaval venous cannulation was used. Several pieces of gauze were placed below the heart, and the apex was elevated. The diverticulum was located between the second diagonal branch of the left anterior descending coronary artery and the second obtuse marginal branch of the left circumflex coronary artery, near the apex (). After the cardiopulmonary bypass was started, ventricular fibrillation was induced by cold cardioplegia infusion and cold saline irrigation of the heart. During ventricular fibrillation, the margin of the diverticulum was well palpated. After marking the margin of the diverticulum with a marking pen, we incised it. There was no definite thrombus in the diverticulum cavity. There was a defect measuring approximately 2×3 cm communicating with the left ventricular cavity (). The defect was repaired using a Dacron patch (Bard Peripheral Vascular Inc., Tempe, AZ, USA) (). Further, the remnant diverticulum cavity was filled with FloSeal (Baxter Healthcare Co., Westlake Village, CA, USA). The incised apex was closed, and aneurysmorrhaphy with plication was performed ().\nThe patient recovered without any complications and was discharged on the eleventh postoperative day. Postoperative cardiac MRI and CT angiography confirmed thorough obliteration of the LVD ().
A 53-year-old, disheveled male presented to the ED with complaints of anxiety and depression with concomitant suicidal ideation. The patient noted worsening depression over the prior four to six months. His anxiety and depression led him to quit his job of 28 years as a bakery manager due to the inability to concentrate or follow directions. He attributed this to his worsening depression. The patient quit driving six days prior to presentation after an episode of forgetfulness caused him to run off the road. Review of systems revealed intermittent chest pain as well as decreased appetite and a 20-pound unintentional weight loss in the preceding several months, which the patient attributed to overwhelming anxiety. His wife also described multiple episodes in which he would blankly stare at nothing for seconds before returning to baseline.\nThe patient had a history of depression for many years prior to this presentation. However, the patient had never considered suicide or had difficulty with activities of daily life (ADL) prior to the last four months. His primary care physician documented normal physical examinations on an office visit within the prior month for depression and anxiety. His sertraline dose was increased by his primary care physician without improvement in symptoms.\nIn the ED, the patient’s physical examination was remarkable only for slow, tangential speech with repetitive answers. Initial laboratory testing, including toxicology, was unremarkable. Due to his chest discomfort at initial presentation, two serial troponins were obtained before deeming the patient medically stable. He signed a voluntary commitment for psychiatric treatment and was admitted to the behavioral health unit. On the inpatient psychiatric unit, the patient continued with depression and anxiety. While he no longer felt suicidal, he developed significant paranoia. His inattention worsened and he became increasingly disoriented. His speech, while slow, remained clear. However, despite several trials of antidepressants and antipsychotics, his symptoms persisted.\nDue to the progression of his symptoms over several weeks, the patient was reevaluated medically. It was felt that his neurologic status was related to his psychiatric illness. Several days later, he developed brief episodes of an arm drop, as well as frequent staring episodes. At that point, neurologic consultation discovered deterioration when compared to previous neurologic examination. His speech was now solely confabulation. While strength and sensation remained intact, the patient now had mildly increased tone. Magnetic resonance imaging (MRI) of his brain, with and without contrast, a lumbar puncture (LP), and an electroencephalogram (EEG) were obtained.\nMRI with diffusion-weighted imaging demonstrated high signal intensity/restricted diffusion in bilateral cerebral cortices and basal ganglia. As depicted in the , the abnormality was more pronounced in the right hemisphere. Such findings can be seen with CJD, encephalitis, toxic/metabolic processes, and ischemic injury.\nThe EEG demonstrated slowing over the right hemisphere with anterior rhythmic slowing consistent with a diffuse encephalopathy. Cerebrospinal fluid (CSF) evaluation demonstrated large amounts of T-tau protein and was positive for CJD protein 14-3-3. These test results confirmed the diagnosis of CJD. The patient continued to decline cognitively; he was transitioned to hospice care and expired within one month of initial presentation to the ED.
A 58-year-old woman without significant medical history visited an outpatient clinic because of radicular compression at L4 level due to scoliosis. The patient underwent posterior pedicle screw fixation with Universal Spinal System (USS) Synthes, which provided segmental stabilization and decompression from D12 to L5. In the first postoperative day, the patient developed mild dyspnea, which prompted the attending clinician to perform an anteroposterior chest radiograph (Figure ). The radiograph revealed bilateral pleural effusion, which was more pronounced on the left side. At the same time, the blood sampling revealed a decrease in hemoglobin levels. Thus, we decided to insert a chest tube to drain blood. In the second PO day, after the blood volume stabilized, the patient underwent a contrast-enhanced CT scan of the chest and abdomen. The CT scan revealed the resolution of the hemothorax (Figure ) and showed the presence of tissue in the thorax with a radiological density similar to that of fat tissue. This finding was associated with the displacement of one pedicle screw that breached the anterior limit of the vertebral body, thereby penetrating into the peritoneal cavity (Figure ). There was no evidence of other thoracoabdominal lesions.\nDiaphragmatic injury and subsequent herniation of the omentum into the thorax were discussed with the general surgeon, neurosurgeon, and anesthetist, and we decided to perform double-access surgery to both remove the pedicle screw in the prone position and to confirm and repair the diaphragmatic injury in the supine position.\nIn the third PO day, after the pedicle screw was removed, we performed explorative laparoscopy with three trocars. We observed a partial axial torsion of the gastric fundus and herniation of the omentum. We checked for the absence of visceral and parenchymal injuries and found a diaphragmatic tear near the left aortic pillar. Then, we reduced the omentum into the abdomen. Primary suture was not a suitable treatment option because of the retraction of the diaphragmatic edges. Therefore, we repaired the hernia using a polypropylene dual mesh (CMC®; Clear Mesh Composite Dipromed SRL, San Mauro Torinese, Torino, Italy), which covered the defect with a 3-cm overlap, and it was fixed using Absorba Tack™ (Covidien, Mansfield, MA, USA) There were no intraoperative surgical or anesthetic complications (Figure ).\nThe remainder of the postoperative period was uneventful. The patient was fed in 48 h and was discharged after 7 days. Our patient was followed-up at the outpatient clinic at 1 and 3 months, and the patient had no functional complaints.
A ten-year-old female patient reported to the author’s clinic with a complaint of painful swelling on the left upper lip region. The patient had first noticed the swelling eight months back, which was initially asymptomatic and gradually increasing in size. The patient later developed pain in the region of swelling over the last two months. The pain was dull and continuous in nature. The patient had no known underlying medical conditions. Family history revealed no significant finding.\nExtra-oral examination revealed a marked asymmetry, with a swelling arising from the left side of the upper lip at the region of canine fossa. The overlying skin appeared normal. The swelling was hard in consistency, had a normal temperature, was tender on palpation and the overlying skin was pinchable. There was no paraesthesia or lymphadenopathy.\nOn intra-oral examination, the swelling appeared ovoid in shape, measuring approximately 1.5 cm x 1 cm. The overlying mucosa appeared normal with no secondary changes (Figure ). On palpation, the mass was hard in consistency and was not adherent to the underlying tissues. The patient elicited tenderness on palpation.\nCT images revealed a well-defined calcified mass of size 11 mm x 6.2 mm x 10 mm seen on the left subcutaneous plane of the upper lip and extending into the adjacent muscular plane. There was no evidence of communication with the maxilla. No adjacent inflammatory changes were seen (Figure ).\nThe management involved the surgical excision of the lesion in toto under local anesthetic solution containing 2% lidocaine HCl with vasoconstrictor (1:100,000 adrenaline). The lip was retracted and the lesion was fixed by pressing a finger against the base of the tumor. An incision was placed over the labial mucosa covering the lesion (Figure ). Once the muscle layer was reached, blunt dissection was performed to relieve the lesion from the muscle (Figure ). The lesion was completely excised (Figure ) and placed in 10% formalin solution and sent for histopathological examination. The wound was sutured using 3-0 black braided silk suture material (Figure ).\nThe excised lesion was elliptical in shape and was 1 cm x 0.6 cm x 1 cm in size. It was greyish white in color, hard in consistency, and gritty in texture. The tissue was covered entirely by a capsule.\nMicroscopic examination of the Hematoxylin and Eosin stained section revealed a well-circumscribed and fully encapsulated ﬁbro-osseous lesion characterized by abundant cellular ﬁbrous tissue with scattered trabeculae of lamellar bone and spherical ossicles. These ossicles exhibited varying degrees of calcification. These psammoma bodies like ossicles were acellular with a concentric lamination. The lesion is suggestive of a psammomatoid variant of juvenile ossifying fibroma. No cellular atypia or dental tissues were present (Figure ).\nModified Gallego's staining of the decalcified section revealed cementum-like deposits in red color (Figure ).\nThe patient was recalled after seven days postoperatively. The suture was removed and the surgical site was well irrigated with normal saline. The site appeared to be healing well and the patient did not report any sign of discomfort. The patient was recalled after one month and the surgical site was completely healed. Follow-up was done at periods of three months, six months, and one year. There was no evidence of recurrence of the lesion after one year.
A 68-year-old female was referred to our office with a history of right-sided breast cancer treated with right skin-sparing and left nipple-sparing mastectomies with immediate implant-based reconstruction performed in the Dominican Republic 25 years prior to presentation. She was unsatisfied with her reconstruction and suffered from significant aesthetic deformity and breast pain for which she presented to our office in December 2017.\nHer examination was notable for bilateral Baker Grade III capsular contracture with significant animation deformity and retraction of the pectoralis major muscle into the axilla. She was also noted to have significant bilateral discrepancies in the height of her inferior mammary fold and breast projection. Following extensive counseling, she elected to undergo revision of her reconstruction with tissue expander placement. Due to insurance issues, her surgery was not performed until February 2019 at which time she underwent bilateral capsulectomies, re-attachment of the pectoralis major muscles, and placement of pre-pectoral small size AeroForm tissue expanders with final fill capacity volume being 400 mL. An acellular dermal matrix was utilized for soft tissue reinforcement.\nThe patient had an uncomplicated postoperative course and began expansion after 2 weeks. After 2 months, her expanders had been filled with 280 mL of carbon dioxide. During this time, the patient was undergoing evaluation for chronic headaches and nose bleeds by her private primary care provider who was not part of our university health system. The patient was referred for an MRI of the head unbeknownst to the plastic or breast surgery service. While undergoing the MRI, the patient experienced immediate chest pain and tightness along with a notable increase in breast size bilaterally. The examination was aborted, and the patient was transferred to a community hospital where she underwent work up for acute coronary syndrome and was discharged home after 2 days. She then presented to our hospital’s emergency department due to persistent increase in the size of breasts and progressive chest pain. Both her breasts were very firm and tense with evidence of skin compromise and gradual increasing size of bilateral breasts () based on serial photographs provided by the family. She underwent bilateral tissue expander decompression with an 18-gauge needle at the bedside with immediate relief of pain ().\nShe was discharged home after 2 days of observation; she subsequently returned for outpatient exchange of tissue expanders to 525 mL high profile silicone implants, 81 days after placement of AirXpanders, and 12 days after her MRI. She was satisfied with her aesthetic results and noted total resolution of her pain on follow up 5 months after tissue expander to implant exchange ().
A 29-year-old male, warehouse worker, presented with a noticeable mass in the left side of his abdomen and weight loss of three and half stones over a four-month period. His past medical history and family history were unremarkable. Physical examination revealed a large, nontender, and fixed left-sided abdominal mass and a normal neurovascular examination except an isolated reduction in light touch sensation in the L2-L3 dermatomes of his left leg only.\nAn abdominal and pelvic magnetic resonance imaging (MRI) and computed tomography (CT) demonstrated a large, 19 × 16 × 11 cm mass arising from the anterolateral aspect of the L3 pedicle with peripheral calcification, completely obliterating the distal psoas muscle and causing a considerable mass effect to surrounding structures, with displacement of the left kidney. Distally, the tumour extended to the level of the pelvic inlet but not into the spinal canal (Figures and ).\nCT guided biopsy of the left abdominal mass confirmed the diagnosis of a low-grade chondrosarcoma arising from an osteochondroma from the lateral body of the L3 vertebrae. The difficult anatomical location and the large size of the lesion greatly increased the complexity and risks of any surgical approach. In order to improve the chances of surgical success and reduce and prepare for possible risks and complication such as catastrophic haemorrhage, spinal instability, and paralysis/neurological deficit, a two-stage surgical procedure and a multidisciplinary team approach to a curative en bloc tumour resection were utilized.\nIn the first stage, a posterior midline incision to expose the lumbar spine was performed. Bilateral pedicle screws were placed at the levels of L2 and L4, with rods fixated at the end of the procedure for spinal stabilisation. Bilateral laminectomies and facetectomies were performed leading to exposure of the nerve roots, of which the left L3 nerve root was identified and ligated. A partial osteotomy was carried out at the level of L3 within the vertebral body to allow ease of hemivertebral body resection with the forthcoming en bloc tumour resection.\nThe second stage of the procedure involved an anterior thoracolumbar approach with the patient in the supine position. The intra-abdominal contents including the major vessels were identified and appropriately mobilised, allowing clear exposure and access to the left-sided tumour and the vertebral bodies of L1 to L5. The anterolateral aspects of the left ribs from 10 to 12 were resected to allow access to the superior part of the lesion. The tumour was resected en bloc with an intact envelope, surrounding soft tissue and completion of the L3 hemivertebral column resection osteotomy with partial resection of the vertebral bodies of L2 and to a lesser extent L1 and L4. After closure of the anterior wound, the patient was placed prone. The previous posterior midline wound was reopened and extended to expose the thoracolumbar spine from T12 to L4. The original posterior instrumentation was extended to include T12 and L1, with only right unilateral pedicle screws to L2 and L3 and bilateral pedicle screws to T12, L1, and L4. Spinal fusion from T12 to L4 using intervertebral titanium cages filled with allograft and demineralized bone matrix for additional stability was performed. The posterior needle biopsy tract was resected and the large excised tumour was sent for histopathological evaluation, which affirmed the previous biopsy results of a low-grade classical secondary chondrosarcoma with all margins free of tumour (Figures and ).\nPostoperatively, he had significantly reduced sensation in his L2-L3 dermatomes, due to the intraoperative sacrifice of his left-sided L3 nerve root, which was expected; otherwise he was well with no other symptoms. He was discharged after 3 weeks of hospital admission with a hard back and front brace for 6–8 weeks. At five-year follow-up, the patient had no new symptoms, local recurrence, or metastatic disease ().
A 67-year-old woman with enlarged abdomen, dull pain in the lumbar region on the right, palpitation and moderate weakness was admitted to the Urological clinic department of I.M. Sechenov First Moscow State Medical University in July 2014. The patient reported no relevant clinical family history. The patient signed informed agreement to undergo diagnostic procedures and treatment, as well as to participate in the study, and for the presentation of clinical and molecular data in scientific and medical literature. This case report was approved by the local Ethics Committee at the Research Centre for Medical Genetics, Moscow, Russia.\nThe patient underwent an ultrasonic examination that revealed a mass in the right kidney with a size of 176 × 164 mm. Multi-slice spiral computed tomography showed that right kidney was displaced upward, rotated anteriorly because of spherical soft tissue mass in the middle and lower segments of the kidney with a size 206 × 186 × 188 mm and clear contours in the structure of which arterial vessels were determined (). Lesion extended into the sinus of the right kidney, ingrew in ureter at the ureteropelvic junction and more distal and encircled pelvis. Lesion also lied tightly next to psoas major muscle and inferior vena cava. The pyelocaliceal system of the right kidney was expanded: a calyx and a pelvis were 30 mm and 45 × 28 mm in size, respectively. The mass unevenly accumulated a contrast agent. Excretion of the contrast agent by the right kidney was absent.\nBased on the obtained diagnostic data, the multidisciplinary board was held, implying the participation of surgical oncologist, oncologist, pathomorphologist, a specialist in radiation diagnostics and urologist. The nephrectomy of the right kidney and regional lymphadenectomy was performed. During the operation, it was noted that the inferior vena cava from the adrenal gland to aortic bifurcation is involved in the tumor process. The invasion into the liver was not observed. The resected tumor had a size of 300 × 253 × 150 mm and 4 kg of weight (). Incision shows that the right kidney was completely replaced by tumor mass ().\nDespite the successful surgery, the follow up was not possible by the reason of patient’s death in post-operative period. The cause of death was not related to nephrectomy.\nThe microscopic examination of the tumor revealed plexiform bundles of spindle-shaped cells with large hyperchromatic nuclei, among which multinucleated cells were found. High mitotic activity (17 mitoses per 10 fields with magnification ×400) and foci of necrosis were observed (). The immunohistochemistry showed positive reaction for smooth muscle actin () and desmin () and negative reaction for CD99, CD43, CD117, S-100, MCK/PCK, and DOG-1. Taking into account the histological and immunohistochemical data, the changes correspond to Grade 3 kidney leiomyosarcoma (overall score of 6 points: tumor differentiation, 3; mitotic activity, 2; necrosis, 1) according to FNCLCC gradation of soft tissue tumors ().
A 59-year-old jobless man presented at our hospital with a 2-month history of transient right popliteal pain when standing after squatting and while descending stairs. He was 170 cm tall and 55 kg in body weight and had not suffered from any antecedent trauma. Clinical examination of the right knee revealed a full range of motion without catching and locking episode. No swelling, warmness, erythema, tenderness (including the medial joint line) or hydrops was found around the knee. There was no anterior, posterior or lateral instability. He did not have pain during manual instability tests. McMurray's test reproduced pain but no click at the medial joint line. No mass was palpable around the knee. Standard radiographs showed no sign of osteoarthritis. An MRI revealed a grade 2 horizontal tear according to Mink's classification of the posterior segment of the medial meniscus [] (Fig ). A multilobulated meniscal cyst arising from the posterior horn of the medial meniscus to the posterior septum just behind the posterior cruciate ligament (PCL) was also detected (Fig ). Communication tracts between horizontal tear of the meniscus and the cyst were identified on the MRI coronal plane (Fig ).\nArthroscopic surgery was performed under spinal anesthesia without a pneumotourniquet. The knee was flexed at more than 90 degrees on the operating table using a foot stopper. Anterior cruciate ligament, PCL and both lateral and medial meniscus were intact under arthroscopic examination. The posteromedial compartment was examined from the anterolateral portal through an intercondylar space. The surface of the posterior horn of the medial meniscus was intact and no cyst-like lesion was found on the edge of the posterior segment of the medial meniscus. Starting the procedure for making a trans-septal portal, the posteromedial and posterolateral portals were created according to the approach reported by Ahn et al []. After making a posterolateral portal, a rod with a sheath was inserted through the posterolateral portal to the septum. Pushing the sheath into the septum, the arthroscope was then inserted into the posteromedial portal. While maintaining the view of the medial side of a septum, a 1.5-3.0 mm Kirschner wire was pushed into the septum through the sheath from the posterolateral portal and then the septum was perforated. The Kirschner wire was pushed 2 or 3 times into the septum to enlarge the initial hole so that the switching rod could easily pass through the septum. Then, the switching rod was inserted from the posterolateral portal to the posteromedial portal via the trans-septal portal. Once the trans-septal portal was created, the arthroscope and instruments are easily interchangeable through the two posterior portals according to the posterior "back and forth" approach presented by Louisia et al []. Viewing from the posteromedial portal, proliferated synovial tissues expanding from the posterior horn of the medial meniscus to the posterior septum were found (Fig ). The cyst and posterior septum were resected by a punch and a motorized shaver inserted from the posterolateral portal while viewing from the posteromedial portal. When the cyst ruptured, a clear mutinous fluid seeped from the cyst cavity. A meniscal tear was not found although the posterior edge of the medial meniscus was carefully examined by a probe after cyst resection (Fig ).\nAn MRI examination 9 months after the operation revealed that the meniscal cyst had disappeared and abnormal intensity inside the medial meniscus decreased (Fig ). The patient's popliteal pain also disappeared completely during the 9-month follow-up period.
A 67-year-old man from India, who was recently diagnosed with latent tuberculosis, presented to an outside hospital and was admitted for six days with generalized fatigue and hypotension. On presentation, he reported a 2-week history of generalized fatigue with systolic blood pressures in the 60s, as recorded at home. He also reported a 30-pound weight loss which was attributed to diuretic use and dietary changes in the setting of congestive heart failure. With these complaints, his losartan (angiotensin receptor blocker) dose was reduced, which was ineffective in alleviating his symptoms. His history was notable for an LTBI diagnosed three months prior to presentation, for which he was being treated with INH (300 mg daily) and pyridoxine. He had been treated for 11 weeks by the time he presented, and was noted to tolerate the therapy well for at least four weeks without changes in dietary or sleeping habits, per documentation by his primary care provider. His medical history was otherwise notable for atrial fibrillation, beta thalassemia, and tachycardia-induced cardiomyopathy with reduced ejection fraction. He had no known history of liver disease or diabetes. His other medications included apixiban, metoprolol, furosemide, losartan, and hydroxyzine (for insomnia). He had no prior history of heavy alcohol consumption or recreational drug use, and he worked in the electronics and computer industry. There was no family history of cirrhosis or other liver disease.\nHis initial workup was notable for elevated liver function tests, as shown in . A computed tomography scan of the abdomen demonstrated no intrahepatic biliary dilation and no apparent fatty change. An abdominal ultrasound revealed a simple cyst and heterogenous echotexture, with mild subcapsular nodularity. Based on his workup, his liver dysfunction was postulated to be drug-induced liver injury from INH or apixaban. Both medications were discontinued. He was discharged for outpatient management. However, follow-up laboratory testing indicated an increasing bilirubin, which resulted in readmission to the hospital. A liver biopsy was considered but not performed, as his bilirubin levels began to downtrend.\nOne week later, the patient experienced a syncopal episode while having a bowel movement, and was admitted to a different hospital. He presented with altered mental status and generalized pruritis. Laboratory data revealed worsening liver function () and acute kidney injury, for which he was treated with albumin, midodrine, and octreotide. His pruritis improved with the introduction of cholestyramine.\nAutoimmune serologies, including antinuclear antibody, antimitchondrial antibody, and anti-smooth muscle antibody, were negative. Viral hepatitis serologies were negative. HIV infection was ruled out. The patient’s acetaminophen level, urine toxicology screen, and serum ferritin level were within normal limits. A transjugular liver biopsy was performed and demonstrated cholestatic hepatitis, thought to be drug- or toxin- related. His mental status initially improved with lactulose, but worsened thereafter, prompting a transfer to our hospital for consideration of liver transplantation for acute liver failure, about six weeks after initial presentation.\nPhysical examination at time of transfer was remarkable for jaundice, icteric sclera, and altered mental status. He was somnolent but arousable to noxious stimuli, oriented only to self, intermittently following some commands, and had notable asterixis. He had an irregular rhythm and a murmur on cardiac examination, vesicular breath sounds, and a benign abdominal examination. He was noted to have Grade III hepatic encephalopathy in the setting of acute liver failure, and was admitted to the intensive care unit before being listed for liver transplantation as Status 1A. On day four in the hospital, he underwent orthotopic liver transplant surgery, and was extubated on post-operative day one. He was transferred to the floor on post-operative day three, but subsequently suffered a sudden aspiration event resulting in a pulseless electrical activity and fatal cardiopulmonary arrest.
A 63-year-old Tibetan woman had been diagnosed with squamous cell carcinoma of the vulva 6 months previously at a local hospital due to the discovery of a vulvar mass. At that time, the patient refused surgery due to the large trauma of the operation, and refused to receive radiotherapy, chemotherapy, or other treatment. After leaving the hospital, she was recuperating at home and was taking short-term Chinese medicine treatment. The specific drugs and doses were not provided. The tumor of the vulva gradually increased, and there was a skin defect on the surface of the tumor, as well as intermittent small amounts of bleeding.\nTwo months before admission, there was bleeding due to rupture of the vulvar mass; the amount of bleeding was about 600 mL. The bleeding stopped after the patient had received local compression and hemostatic treatment. The patient was admitted to the hospital because of vulvar pain and a small amount of bleeding. There was infection and exudation on the surface of the tumor. After admission, MRI of the patient's pelvis showed that the left vulvar mass was indistinct in the surrounding tissue of the left labia majora, and there were multiple enlarged lymph nodes in the pelvis and groin (Fig. ).\nIn order to improve the prognosis and prevent bleeding, superselective arteriography and embolization were performed on the 12th day after admission. During the operation, digital subtraction angiography showed that the blood to left vulvar mass was supplied by the left internal pudendal artery (Fig. ). During the operation, 20 mg cisplatin and 500 mg fluorouracil were given as arterial infusion chemotherapy, followed by embolization of the tumor blood supply artery with gelatin sponge particles. After embolization, on follow-up angiography, the tumor's vessels and staining had disappeared (Fig. ).\nOn the 7th day after the operation, the tumor in the vulva was necrotic and exfoliated (Fig. ), and the skin defect at left labia majora appeared (Fig. ). The patient was given daily disinfection and change of dressing, the defective area of the vulvar skin became smaller, and the patient had no other serious complication. About 40 days after the interventional operation, the vulvar skin defect had healed (Fig. ). The patient continues to be therapized with radiotherapy.
The patient in this study was a 14-year-old right-hand dominant male, presenting with the main complaint of pain and swelling in the right little finger. The symptoms were presented after he punched a wall. Swelling and tenderness were observed on the fifth metacarpal after examination of his right hand. In addition, radiographs showed a nondisplaced metacarpal neck fracture on his right little finger (Fig. a). The finger was put in a cast for 1 month and the patient was then instructed to begin active motion exercises after removal of the cast.\nAfter 5 months, he noted gradual pain in the long finger and ring finger metacarpophalangeal (MCP) joint. The patient came to our department again due to the persisting discomfort, reduced grip strength, and limited extension of the MCP joint. He exhibited mild swelling and tenderness to palpation at the long finger and ringer finger MCP joint. Moreover, active and passive motion was painful, and the Visual Analogue Scale score for pain was 5. There was full active flexion, but the extension was limited to 30° and was associated with pain. The obtained X-rays images indicated subchondral collapse and sclerotic changes in the metacarpal head (Fig. b). The serological investigation for inflammatory markers was normal, while CT scanning demonstrated cystic, osteochondral defect, and sclerotic changes (Fig. ). The patient had no history of any predisposing systemic illnesses such as autoimmune disease or steroid use. Thus, he was diagnosed with AVN of the metacarpal head or dieterich's disease based on the clinical and radiographic findings.\nConservative management was initially offered due to the young age and spontaneous remodeling. He was then treated using splint immobilization for 3 weeks in combination with nonsteroidal anti-inflammatory drug and physiotherapy. The patient was also advised to use his hand as normally as possible within the limits of pain. He experienced gradual relieving of the pain in the region of the MCP joint after 4 months and there were no obvious restrictions of activities of daily living. In addition, conservative treatment and follow-up were recommended although there was no significant change in the imaging examination.\nThe follow up examination done 26 months after fracture indicated that there was a painless full range of active motion. Radiographs showed remodeling of the long finger and ring finger metacarpal head (Fig. ). Moreover, there were no radiographic signs of hyperostosis, osteosclerosis, or osteoarthritis. MRI indicated no bone marrow edema, joint effusion, or subchondral fractures within the affected metacarpal head (Fig. ). In addition, the image examinations revealed that further remodeling of the MCP joint had occurred. The patient's cosmetic result and range of motion were excellent at the last follow-up (Fig. ), and the grip strength and range of motion of the affected MCP joints were almost equal to the contralateral. Furthermore, the Visual Analogue Scale score for pain was zero, and no residual pain was left. Therefore, no further specific treatment was recommended.
A 38-year-old female patient came with a chief complaint of difficulty standing up from squatting position since 2 years ago. The patient also suffered heaviness and numbness from her hips that radiated to both of her knees and ankles. The symptoms worsened steadily in the past 4 months with both lower limbs getting weaker. Laboratory results came out normal, with no signs of infection or positive tumor markers. Radiological examination showed no apparent abnormalities as well. An MRI was obtained, and a tumor mass in the intradural region level of T10–T12 was found (). At that time, the patient was offered surgery, but she chose to undergo treatment with a bone setter. Around two months later, the patient returned to hospital with profound weakness on her lower extremity. Her physical examination revealed paresis from her thigh on both lower extremities grade 1-2/5 power in left and right lower limbs, respectively. Increased patellar reflexes were found on both limbs. Another MRI was performed and showed that the mass had grown to lumbar vertebrae L2, accompanied with worsening of the neurological statuses and impaired sensibility, as well as defecating and urinating problems (). From the history, spinal manipulation procedure was performed by a bone setter, although no specific techniques were available for review.\nA surgical procedure was proposed for exploration and decompression to the patient. The operation started by opening the lamina on T10–T12 levels, followed with laminectomy and hemostatic procedure to stop the bleeding, until the dura was exposed (). A dense mass from T10 to T12 was palpable from the dura layer. After we exposed the lamina, we observed that the dura was tense from touch, and a solid mass underneath the dura was palpable from T10 to L2. Intradural tumor excision was performed by a sharp 3 mm incision in the midline of the dura and then continued with blunt dissection, opening the dura layer to caudal L2 and to cranial T10. Dura was then parted with stay thread until the vessel-rich tumor mass was exposed. The tumor mass was excised, and the surgical field was contaminated by blood from hematomas from tumor vessels (). Bleeding was found to originate from the anterior part and posterior part of the cord, no bleeding source from the cerebrospinal fluid nor the subarachnoid space. The tumor mass was successfully evacuated with fragments of hematomas and necrotic tissues. The dura layer was then closed with a continuous suture. The tumor mass was fixed and transported for histopathology examination ().\nAt the time of discharge, the patient did not regain the function on her lower extremities (1-2 out of 5 on neurological motor examination). After six months of follow-up, some improvement on her lower extremity function was noted. Motor strength was returned to 3-4 out of 5, and the patient was able to ambulate using a walker. No improvement of her bowel and bladder symptoms was noted.
In March 2005, a 67-year-old Korean woman visited a hospital with a two-month history of coughing. The patient was on antihypertensive treatment and had received treatment for tuberculosis one year before. She had no history of smoking; however, she might have been exposed to passive smoking while working as a washroom cleaner. A 2 cm mass was observed in the upper lobe of her left lung and transthoracic needle aspiration biopsy revealed adenocarcinoma.\nThe patient underwent a left upper lobectomy in March 2005 and her postoperative stage was determined as T2N0M0. After surgical resection, there was no recurrence for approximately one year. However, multiple growing nodules were detected in the remaining part of her left lung on a follow-up computed tomography (CT) scan performed in June 2006. Serial CT scans revealed that the slow, but continuously growing nodules were recurrent lung cancer.\nThe patient refused further surgical treatment or any invasive procedure. Therefore, first-line chemotherapy with gemcitabine and cisplatin was initiated in April 2007. Although a follow-up CT after two cycles showed stable disease (SD), administration of chemotherapy was ceased because she could not tolerate the drug toxicity.\nAfter five months of rest, a CT revealed growing nodules; hence, second-line treatment with 250 mg/day gefitinib was started in November 2007. A partial response was shown on follow-up CT in December 2007 (Fig ). The dose was adjusted depending on tolerability, and eventually decreased to 250 mg every third day because of grade 3 skin toxicity.\nThe lung nodules had started growing since May 2009. While Response Evaluation Criteria in Solid Tumors (RECIST) indicated progressive disease, she did not experience any worsening of symptoms; therefore, we continued treatment with gefitinib. Although a follow-up CT showed a smoldering progression of metastatic lesions (Fig ), continued treatment with gefitinib controlled the pulmonary adenocarcinoma for more than six years. Treatment with gefitinib was discontinued in April 2014 because she no longer received reimbursement from the health insurance review and assessment service of Korea and could not afford the cost of therapy.\nRecently, peptide nucleic acid (PNA) clamping real-time polymerase chain reaction was performed using DNA extracted from paraffin block-fixed tissue acquired during surgery in 2005. PNA clamping revealed an activating mutation of the EGFR gene, an exon 19 deletion.
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 59-year-old female patient with a long history of low back pain presented with swelling and distending pain in her lower extremities for 1 month; all her symptoms were aggravated after overexertion and improved with rest. Her lower limb symptoms were less severe in the morning and worse at night; however, since 1 week before the presentation, the swelling seldom resolved.\nOn physical examination, the patient showed stable vital features. During the walking test, the patient presented with intermittent claudication, which was more prominent on the left side. Her left thigh perimeter was 59 cm in the morning and 63 cm in the evening, while the right thigh perimeter was 55 to 59 cm. On examination of the spine, the patient had percussion pain and tenderness on the L4 and L5 spinous processes and in the corresponding paraspinal muscle. The distending pain in the calf and heaviness appeared after walking or standing for 200 m or for 5 minutes. In the lying position, there were no remarkable neurological symptoms, but there was a slight loss of key muscle force and pitting edema over the lower extremities. According to the visual analog scale (VAS), the patient scored 6 for her low back pain and 4 for her calf pain.\nLaboratory tests and electrocardiograph demonstrated normal renal and cardiac functioning, which excluded the probability of renal or cardiac edema. Lower extremity ultrasound showed no DVT or venous obstruction. To identify the etiology of her low back pain, lumbar magnetic resonance imaging (MRI) was conducted, which revealed lumbar disc degeneration (LDD) and anterior lumbar disc herniation (LDH) in the segment L4-5 (Fig. ). Furthermore, the narrowed IVC was visualized in the space between the anterior protrusion and right common iliac artery, both on the MRI and abdominal CT (Figs. C, D and 2A–C). An abdominal Doppler ultrasound indicated over 50% patency loss of the IVC due to the compression induced by the anterior LDH (Fig. D). Further examinations such as a venogram and CT with contrast were rejected due to the invasiveness and the patient's refusal of the contrast agent. Based on the current results, this patient was diagnosed with L4-5 lumbar disc anterior herniation, moderate IVC stenosis, and dMTS.\nFor surgery, we aimed the treatment at the anterior LDH instead of endovascular management because of the severe IVC compression of the anterior LDH and the evidence against DVT. RF was adopted instead of conventional intravenous stents. The patient was settled in a prone position, and the L4-5 disc and 2 puncture points were confirmed via C-arm fluoroscopy. After routine disinfection and sterile towel placement, local anesthesia was applied. Monitored by C-arm fluoroscopy, the puncture needles were inserted bilaterally and symmetrically until the needles reached the edge of the Kambin triangle (Fig. A). After confirming that the needles were in the correct direction, they were further inserted through the annulus fibrosus into the nucleus pulposus towards the midline, on the anteroposterior view (Fig. B). Then, the monopolar RF electrode was placed through the puncture needle to the central part of the disc complex. After confirming the absence of nerve irritation, thermocoagulation was applied at 50 °C, 60 °C, and 70 °C for 60 seconds each, followed by 80 °C and 90 °C for 90 seconds each without rest between temperature changes. During RF thermocoagulation, the patient reported only warmth at the site of her low back pain, and no burning feeling on either lower extremity. The total operation time was less than 30 minutes, and blood loss was minimal.\nAfter the procedure, the patient's swelling on both extremities started to relieve within 5 hours, and it completely diminished after 48 hours. Her VAS decreased to 1 and 0 at her lower back and calves, respectively. Postoperative abdominal ultrasound confirmed that the venous patency of the left common iliac vein increased to 70%, which represented mild venous stenosis (Fig. ). On follow up, only occasional slight lower back pain was reported, and her leg symptoms did not recur at 12 months after surgery.
A 26-year-old gravida one, para one female without significant past medical history presented to the Emergency Department from a community clinic due to concern for appendicitis. She had been seen at a community clinic earlier that day for chronic right lower quadrant pain of two months' duration. An ultrasound was performed at that community clinic showing a large right adnexal mass. On presentation to the Emergency Department, the patient was afebrile with normal vital signs. Her exam was significant for fullness of the right adnexa and mild tenderness to palpation of the right adnexa. No images were available of the previously obtained ultrasound and repeat imaging was obtained while the patient was in the Emergency Department. Repeat ultrasound showed a heterogeneous right adnexal mass, part solid-part cystic in appearance, measuring 12.6 × 8.2 × 7.9 cm with internal vascularity (). Lab work showed anemia; however, white blood cell count was normal. Due to patient's young age and low suspicion for malignancy, epithelial ovarian cancer tumor markers were not obtained. Inhibin A and B levels were assessed and found to be normal. As there was no preoperative concern for infection, C-reactive protein levels and sedimentation rate were not assessed. Based on imaging, the mass was thought to be a dermoid cyst and surgical removal was planned.\nOn the day of surgery, the patient denied any changes in her health history and reported continued right lower quadrant abdominopelvic pain. She was taken to the operating room for a planned laparoscopic cystectomy. Upon laparoscopic entry into the abdomen, the pelvic mass was noted to be densely adherent to the uterus, the right pelvic sidewall, and bowel epiploica (). The right fallopian tube and ovary were not able to be visualized and were suspected to be encompassed within the mass. The right ureter was also visibly coursing through the mass. Attempt was made to locate the vermiform appendix but was unsuccessful.\nDue to dense adhesions that could not be fully addressed laparoscopically, laparotomy was performed. Delineation between the bowel margins and pelvic mass was difficult to distinguish and General Surgery was consulted intraoperatively for assistance. During the lysis of adhesions, rupture of the mass occurred and purulent fluid was noted. The mass was then completely drained and the abscess capsule was removed from the surrounding tissues. No bowel resection was required, as the mass was able to be dissected from the epiploica and did not involve bowel serosa. Attempt was again made to locate the vermiform appendix; however, the appendix was unable to be found.\nAt the time of abscess rupture, the Anesthesia team reported newly purulent urine present in the Foley catheter. A urinalysis was sent, which later returned without signs of infection. A cystoscopy was performed revealing polypoid inflammatory formations of the internal bladder mucosa adjacent to the site of previous pelvic abscess. No efflux of urine was noted at the right ureteral opening. Urology was consulted for concern for ureteral damage and a right retrograde ureteropyelogram was performed. The retrograde ureteropyelogram showed no evidence of dye extravasation; only mild hydroureter was noted. The case was completed thereafter.\nThe patient's postoperative course was unremarkable. Piperacillin-tazobactam was administered for 24 hours after surgery due to intraoperative spillage of the abscess. She was then started on an oral amoxicillin/clavulanic acid course. She was discharged home on postoperative day two with the presumed diagnosis of chronic tuboovarian abscess.\nShe was then seen in clinic two weeks later for follow-up after completing her antibiotic course. At the follow-up visit, she was doing well and reported resolution of her pain. Pathology was reviewed and was consistent with an endometrioma with fallopian tube and ovarian tissue present. Intestinal gland-lined mucosa was identified and determined to be an autoamputated vermiform appendix. Adhesions, bacteria, and acute and chronic inflammation were also present.
We present the case of a cardiac benign metastasizing leiomyoma incidentally found in a patient who presented to our hospital after a motor vehicle accident.\nA 36-year-old female patient presented to the emergency department of our hospital with right-sided blurry vision after being involved in a motor vehicle accident. The patient was a restrained back seat passenger and sustained a right eye trauma with no other injuries nor loss of consciousness. She was found to have traumatic uveitis. CT scan of the head and sinuses showed no evidence of fracture or acute pathology. A CXR was performed to rule out any rib fracture and found a 1.1 cm pulmonary nodule in the right midlung. A contrast CT scan confirmed the presence of 1.1 cm nodule within the anterior inferior aspect of the right upper lobe and found an additional 1 cm nodule within the posterior superior aspect of the right upper lobe. Both nodules were well circumscribed, compatible with benign nature. Unexpectedly, a large defect was noted within the contrast-enhanced right ventricle and was thought to be a large thrombus extending to the right ventricular outflow tract (). The patient was started on therapeutic anticoagulation overnight. A transthoracic echocardiogram (TTE) and a subsequent transesophageal echocardiogram (TEE) disclosed the presence of a large mobile mass in the right ventricle arising from the interventricular septum. Turbulent flow was demonstrated in the right ventricular outflow tract (Supplemental Material video ()). Cardiac magnetic resonance imaging showed an oblong soft tissue mass that measured 4.9 cm in length abutting the pulmonary valve. The mass occupied the entire RV outflow tract ().\nThe patient denied any symptoms including chest pain, dyspnea, syncope, or weight loss. Physical exam was significant for a systolic murmur. On further history taking, she reported that she underwent a hysterectomy 12 years earlier for “myomas” but denied any personal or family history of malignancy.\nAbdominal/pelvic CT scan was performed and confirmed the absence of the uterus. No definite evidence of primary or metastatic disease was found with the exception of a 2.2 × 1.7 cm soft tissue nodule at the left aspect of the vaginal cuff, which was thought to be the left ovary. CA 125 level was within normal limits.\nIn the absence of evidence of primary malignancy, surgical resection of the cardiac tumor was pursued.\nIntraoperatively, the mass was noted to be encircling the tip of a papillary muscle which was supporting the chordae to the anterior leaflet of the tricuspid valve. The mass was completely excised with sacrifice of the chordae tendinae traversing the lesion () and subsequent tricuspid valve repair (expanded polytetrafluoroethylene neochords and anteroposterior commissuroplasty).\nHistologically, the tumor was composed of smooth muscle proliferation and a very low index of proliferation (Ki-67 < 10%), supporting a benign process. No atypia or necrosis was noted.\nImmunohistochemically, tumor cells were strongly positive for smooth muscle α-actin, desmin, estrogen, and progesterone receptors, supporting a leiomyoma lineage.\nThe diagnosis of fibroma was excluded in light of the desmin stain positivity and elastin stain negativity. Immunostain for myogenin was negative, excluding the diagnosis of hamartoma of mature cardiac myocytes.\nFDG PET-CT was performed postoperatively and revealed a faint FDG uptake within the 2 previously identified pulmonary nodules (SUV 1.4) and the soft tissue nodule on the left aspect of the vaginal cuff, later identified as parasitic leiomyoma by transvaginal ultrasound (US) and not the left ovary as initially thought.\nNo additional sites of metastasizing leiomyoma were identified.\nThe patient recovered from cardiac surgery without complications. She was subsequently started on aromatase inhibitor treatment (anastrozole). CT scan of the chest-abdomen-pelvis 3 months after surgery showed stable pelvic and lung masses and no evidence of recurrent disease in the right ventricle. No interval growth of other masses was found. The patient remains asymptomatic 6 months after surgery.
A fifty-year-old, female patient underwent a severe pain at the cervical part and the left upper extremity from 1 day before her visit to the hospital and MRI was carried out. However, since the patient continuously moved due to the severe pain, the imaging was stopped after only the image of a part of the sagittal plane was taken. It was decided that the MRI should be carried out after pain control, and the patient was sent to the department of pain medicine. By the visual analogue scale, the pain was evaluated to be level 3 at the neck and level 9-10, which was very severe, at the left upper extremity. The Spurling sign was positive (+) and mild muscular weakness was found. It was decided to perform an epidural nerve block in order to control the pain. Under the C-arm guidance, the epidural nerve block was tried in the sitting position. The epidural space was found by the loss-of-resistance technique with air and 0.5 ml of a contrast material was injected to confirm the epidural space. Then, 2.5 ml of the contrast material was injected additionally and its diffusion to the C2-C3 position was verified. After that, 0.75% lidocaine 3 ml was injected and the epidural nerve block was carried out. For 1 hour following the nerve block, EKG, SpO2, blood pressure, and consciousness of the patient were monitored. The MRI was resumed since the pain was reduced to the degree where the patient was able to take the supine position for more than 10 minutes. In the T2 image of the sagittal plane that was taken for the second time, the C3-C4 and C5-C6 herniated disc were suspected (). However, the C3-C4 lesion which was suspected as the herniated disc was considered to be an air shadow in the CT cross-sectional image that was taken for the operation (). The T2 image of the sagittal plane that was partially taken before the nerve block was compared in order to identify the lesion, and the result showed that it was a new shadow that had not existed before the nerve block procedure (). Nerve root compression was found at the left C6 in the electromyogram that had been performed in advance, but no C3-C4 herniated disc was found before the nerve block. The shadow looked as if it was by air in the CT image and the shadow in the C3-C4 intervertebral space () was different from the shadow of the C5-C6 herniated disc in the T1 and T2 cross-sectional images (). Therefore, we concluded that the shadow was an artifact by air and decided to carry out only the operation for the C5-C6 herniated disc. The patient underwent a C5-C6 anterior cervical discectomy and fusion (ACDF) during the next day and received an MRI 2 days after the operation. No air shadow was found in the C3-C4 intervertebral space in the postoperative MRI (). The pain of the patient was greatly reduced so that the visual analogue scale could be 0 to 1 on the 8th day after the operation and thus the patient was discharged.
A 77-year-old Japanese man presented with a follicular thyroid tumor, and the blood thyroglobulin level was 1800 ng/ml. He had no medical history or medications, but his mother and brother had history of colorectal carcinoma and prostate carcinoma. He had smoked three cigarettes for 3 years, and he did not consume alcohol regularly. He received right thyroid lobectomy, and the pathological examination showed no malignant findings such as vascular invasion or capsular invasion. The thyroglobulin level decreased to 14 ng/ml postoperatively. Follow-up at our hospital was discontinued.\nNine years after the operation, he presented to our hospital again with numbness of the right leg and difficulty of walk. On examination, weakness of the right lower limbs was observed but no mass was palpable on the lower back and lower limbs. CT showed a tumor 90 mm in size from the lumbar spine to the sacrum, causing spinal cord compression (Fig. ). Blood tests showed that the thyroglobulin level was increased to 11,600 ng/ml. Ultrasonography of thyroid showed a 14 mm iso-echoic mass in the residual left lobe suggesting follicular tumor. We diagnosed him with thyroid cancer with bone metastases. External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases, followed by total thyroidectomy and radioactive iodine therapy (RAI; 131-I 100 mCi).\nThe pathology of the residual thyroid gland was follicular tumor. Although we examined the whole thyroid, including the previous specimen of right lobe, we could not find any malignant features such as vascular invasion or capsular invasion. However, we diagnosed follicular thyroid carcinoma owing to the presence of bone metastasis. Scintigraphy of RAI therapy showed high accumulation on the right pelvis and the thyroid bed (Fig. ). The numbness in the right thigh and weakness of the lower limbs improved after the start of treatment, and the thyroglobulin level decreased to 3940 ng/ml. However, 4 months after RAI therapy, the symptoms of numbness and weakness in the lower extremities recurred. The tumor size of pelvic bone metastasis was re-increased, and the thyroglobulin level increased to 5270 ng/ml. The patient was diagnosed with RAI-resistant thyroid follicular cancer, and lenvatinib was introduced.\nLenvatinib was introduced at dose of 24 mg per oral once daily, and he was started on calcium blocker and angiotensin II receptor blocker because of hypertension. Two weeks later, he developed National Cancer Institute (NCI) Common Terminology Criteria for Adverse Event (CTCAE) grade 3 paronychia of the right foot, which was improved by partial nail avulsion, intravenous administration of ceftriaxone, and discontinuation of lenvatinib for 3 weeks. Lenvatinib was reduced to 14 mg and resumed. Although no significant adverse events occurred after dose reduction, emphysema was found in the intestinal wall of the ascending colon on a scheduled CT image taken 14 weeks after the introduction of lenvatinib to determine the therapeutic effect (Fig. ).\nThe patient visited our hospital 9 days after the CT examination as planned. He had no abdominal or digestive symptoms. On examination, temperature was 36.8 °C, blood pressure 115/75 mmHg, and pulse 63 beats per minute. Physical examination of neck and abdomen was normal, and neurological abnormalities of the legs were not observed. Laboratory testing revealed a white cell count of 4400/μL (reference range 3900–9800/μL), hemoglobin level of 11.4 g/dL (reference range 13.5–17.6 g/dL), and platelet count of 279,000/μL (reference range 131,000–362,000/μL). Blood levels of electrolytes and C-reactive protein were normal, as were results of tests for renal function and liver function. Urinalysis was normal, including urine protein. Re-examination of CT was performed, and it showed the air in the intestinal wall was reduced. Because there were no findings suggestive of intestinal ischemia or perforation, he was diagnosed with pneumatosis intestinalis and lenvatinib was discontinued. He was not hospitalized and did not need any medications.\nThe numbness of the right leg worsened after withdrawal of lenvatinib, so the patient was required to restart lenvatinib at a dose of 10 mg after a week of withdrawal. Three weeks later, we tried increasing the dose of lenvatinib to 14 mg. However, we needed to reduce back to 10 mg because of anorexia (Fig. ). Two months after the diagnosis of pneumatosis intestinalis, CT showed that the emphysema of the intestinal tract had completely disappeared. Three years and 5 months passed since the introduction of lenvatinib; we continued lenvatinib treatment, and the therapeutic effect remains partial response. There was no recurrence of PI.
A 54-year-old man visited our clinic after 20 days of experiencing intermittent left hearing disturbance, and 1 week of left aural fullness and otorrhea at November 2007. He had a history of hypertension and diabetes mellitus for which he was on medication, and had received stenting for an acute myocardial infarction 2 years previously. A mass and crust were observed on the inferior portion of the left EAC on physical examination (); the tympanic membrane looked normal. The right ear had a normal appearance. When we removed the crust on the inferior portion of the EAC, it bled easily. This left EAC mass had been identified at another hospital 1 year previously, and a biopsy performed 6 months later led to a diagnosis of hyperkeratosis. During follow-up with left ear dressings at the other hospital, the tumor in the left EAC increased in size and a new protruding mass on the inferior portion of the tympanic membrane was discovered. According to the temporal bone computed tomography (CT) and physical findings, the tumor was considered to be granulation tissue, and the patient was observed for 4 years. When he visited our clinic again because of persistent otorrhea and keratin debris in the left EAC at March 2011, CT revealed bony destruction of the inferior EAC wall (). Another biopsy of the mass was performed, and the lesion was reported as papillomatosis (). During treatment with local 25% podophyllin and intravenous antibiotics, the patient developed left-sided facial palsy. Because of the growth of the mass was identified in temporal bone CT and MR () and aggravation of otalgia, on November 2012, excision via transotic approach was performed. Histological examination of the specimen confirmed a diagnosis of verrucous carcinoma (). Postoperative follow-up by CT and magnetic resonance imaging revealed invasion of the clivus and Meckel's cave by carcinoma (). Although the patient received chemoradiotherapy, the size of the tumor increased. Thirty-one months after the transotic excision of the verrucous carcinoma, a further excision was carried out using a transcochlear approach. The frozen biopsy analysis performed during the surgery identified infiltration of cancer into the middle cranial fossa. Histological examination of the tumor confirmed squamous cell carcinoma (), and the patient died with cancer 1 year later.
A male patient (77 years old) presented 3 days after an operation for “trepanation and drainage of chronic subdural hematoma” at a local hospital. The patient run a fever for 2 days and was admitted to the hospital on July 15, 2018. In his past medical history, the patient had suffered from diabetes for 25 years and had achieved mediocre effect by controlling his blood glucose levels with insulin. Admission PE: His Glasgow Coma Scale score was E3V5M6. On the right side of the wound, redness and swelling were observed at 1 operative incision, and there was a pink purulent secretion spilling out of the incision. The bilateral pupils were 2.0 mm in diameter and showed slow direct and indirect reactions to light. The limbs showed low muscle tension. The muscle strength of the left upper limbs was grade I, while that of the lower limbs was grade II, and that of the right limbs was grade V. Hyperreflexia was observed in the deep and superficial reflex in the right limbs, and the Babinski sign was positive. The patient's neck was stiff at a position of 3 transverse fingers. Findings on cranial CT showed a localized defect of the right parietal bone, a low density area in the right subdural space of the frontal, parietal, and temporal regions. The right brain tissues were compressed, and the cerebral sulcus was shallow and had disappeared. The right ventricle was compressed and decreased in size. The median line had shifted toward the left side (Fig. A, B).\nDuring the operation, a drainage tube was placed subdurally through the original drill hole, and a large amount of purulent liquid and a small amount of bloody liquid were collected. The patient was diagnosed with “subdural empyema”, and craniotomy was performed. The dura mater was cut open at the site of the defect, a large amount of purulent yellow-white fluid was found subdurally in the frontotemporal part of the wound, and local separation had occurred (Fig. C, D). The subdural abscess was removed, and the pus was collected for culture. After the operation, the patient's temperature essentially returned to normal with an occasional low fever. The results of pus culture indicated “Klebsiella oxytoca” (Table ). Third-generation cephalosporins was combined with linezolid and administered for treatment. The patient was discharged 35 days after admission. A postoperative CT examination showed the patient had achieved a good recovery (Fig. E, F). When discharged, the patient had good mental status and was able to answer simple questions correctly with occasional speech disorder. Normal muscular tension was observed in the limbs, muscle strength was grade IV, and the mobility of the left limbs was poorer than that of the right limbs. At 3 months after the operation, the patient's general state had recovered with self-care.
A 64-year-old male patient was referred to our tertiary care hospital and liver transplant center for further evaluation of ALF. Upon admission to our intensive care unit (ICU), the patient was already intubated and mechanically ventilated (biphasic positive airway pressure mode, fraction of inspired oxygen: 50%, inspiratory pressure: 18 mbar, positive end-expiratory pressure: 8 mbar, respiratory rate: 12/min) and required high doses of noradrenalin (5 mg/h) to maintain a blood pressure of 120/65 mmHg.\nThe patient was initially admitted to the referring hospital the day before because of increased liver values found during a visit at his general practitioner (). Due to further worsening of liver values, the patient was transferred to referring hospital’s ICU and then prepared for transfer to us. The patient had to be intubated before transfer and was already in need of catecholamine therapy. The differential diagnosis of sepsis had led to initiation of a broad-spectrum antibiotic therapy with meropenem and vancomycin.\nThere was no sign of preexisting liver disease on either imaging or in medical history and no indication of increased or chronic alcohol consumption either. The medical history of the patient further showed an acute coronary syndrome and a complete atrioventricular block requiring implantation of a cardiac pacemaker about 6 months prior to the current admission. Due to an infected pacemaker pouch, a revision was performed 4 months ago.\nAfter admission to our ICU, the initial workup consisted of an extensive laboratory analysis, an electrocardiogram (ECG) and an abdominal ultrasonography examination. Antibiotic therapy was continued unchanged. Liver ultrasonography showed normal liver morphology without signs of steatosis or cirrhosis. Biliary obstruction could be excluded and liver vessels (portal vein, hepatic artery, liver veins) were open and showed sufficient blood flow on duplex sonography. However, hepatic veins appeared dilated, and inferior vena cava was congested. In the context of a predescribed impaired cardiac function, an echocardiography was performed. The latter indicated highly impaired biventricular function with diffuse hypokinesia (left ventricular parameters: ejection fraction: 27%, end-diastolic volume: 117 mL, end-systolic volume: 86 mL, inner diameter diastolic 50 mm, inner diameter systolic: 44 mm) and thereby confirmed ALF secondary due to cardiac failure as primary working diagnosis. A dobutamine therapy was started (10 mg/h) immediately. The ECG () was initially interpreted as atrial fibrillation (122 bpm) with aspects of a right bundle branch block, yet it already appeared atypical to the treating physicians at that time. Laboratory analysis revealed a further increase in liver values (). In addition, a markedly elevated troponin T was found (1887 pg/mL, upper limit of normal: 50 pg/mL). Thus, an urgent coronary angiography was performed. It revealed dilated left ventricle as well as coronary artery disease with 25% stenosis in all three major coronary vessels. No treatment of stenosis was performed during coronary angiography due to the low degree of stenosis. In the meantime, the patient’s family reported that the patient complains of progressive exertional dyspnea for 1 week, supporting the working diagnosis of cardiac failure. For further evaluation of the yet unclear cardiac failure, the cardiac pacemaker was checked. This revealed a normal pacemaker function, but rhythm recordings showed dissociation of the atrial and ventricular rhythm with a markedly higher ventricular rate compared to atrial frequency. This, together with the fact that there was no stimulation by the pacemaker, led to the conclusion that the current rhythm was of ventricular origin (). Based on this, the diagnosis of a slow VT was made, which, according to the pacemaker recordings, already persisted since 6 days. Due to the hemodynamic relevance, electric cardioversion was attempted a total of 8 times (up to 200 J, biphasic) but remained unsuccessful. Amiodarone treatment was initiated (300 mg bolus, then 900 mg/24 h) but did not terminate slow VT either, which next lead to treatment with lidocaine 2% (25 mL bolus, then 4 mL/h). Overall, it was not possible to terminate persisting slow VT and, despite administration of increasing doses of catecholamines, the patient showed progressive hemodynamic failure, which finally led to the patient’s death the day after admission to our ICU.
A 24-year-old woman presented at our gynecological outpatient department with a tumor in the lower abdomen, suspected to be a lump in the ovary or the uterus. The tumor was discovered by her gynecologist at a routine transvaginal ultrasound investigation. The woman was a refugee from Syria. Communication was hindered by language differences and our inability to obtain an adequate translator.\nHer medical history included pain, fever, weight loss, and menstrual disorders. She had undergone three Caesarean sections, the last of which had been performed two years ago in a European country. Further details of her medical history were not known.\nThe gynecological examination showed a painless palpable resistance to the right of the uterus. Our transvaginal and transabdominal ultrasound investigation revealed a cystic lesion measuring 9.4 cm × 5.7 cm in this area (Fig. ). We suspected the tumor to be a malignancy of the ovary or a pseudocystic lesion as a consequence of the three Caesarean sections. No further imaging diagnostics were done. Clinical chemistry showed no sign of infection or malignancy, such as an increasing CRP or tumor markers (CA 125).\nWe decided to perform a laparoscopic exploration and remove the tumor either by laparoscopy or laparotomy. In accordance with clinical findings, the operation site showed a swelling between the uterus and the bladder (Fig. ). The ovaries and other abdominal sites were free of lesions. We decided to remove the tumor by laparoscopy, which then turned out to be a retained surgical sponge with granulation tissue (Fig. ). The foreign body and the surrounding tissue were removed completely.\nThe patient was given preventive intravenous antibiotic treatment with cefuroxim and metronidazol postoperatively for five days, based on the likelihood of infection of the surgical sponge. After completion of antibiotic treatment she was discharged from the hospital on the sixth day, with no symptoms or restrictions.\nThe diagnosis of a retained surgical sponge was verified by histological examination (Fig. ).
A 46-year-old male presented to the Department of Orthopedics, The First Affiliated Hospital of Nanchang University Medical School (Nanchang, Jiangxi, China) with a complaint of intermittent pain in the left hip for six months and aggravation of this symptom one month previous to admittance. The medical and family history of the patient was not significant. The general physical examination was normal, with the exception of limited movement and percussion pain in the left hip. A central nervous system examination revealed normal mental capabilities, a functioning motor and sensory system and no neck rigidity. All the cranial nerves were intact. X-ray and computed tomography (CT; ) of the left hip revealed a femoral trochanteric lesion and a suspected osteoclastoma. The patient underwent left femoral tumor curettement with bone cement implantation. Intraoperative and post-operative histological examinations revealed an osteoclastoma (). One week after the surgery, the patient was discharged without any complications. However, the patient was admitted to hospital again two weeks later due to a sudden epileptic seizure that lasted for 4–5 min. The patient also felt significant pain in the left hip subsequent to regaining consciousness. X-ray of the pelvis () revealed a fracture of the left femoral neck and CT of the brain () revealed a lamellar and low-density shadow in the left frontotemporal region of the brain. Cranial magnetic resonance imaging (MRI; ) revealed an abnormal signal intensity in the left frontotemporal region of the brain, indicating a suspected metastatic tumor or glioma. The patient underwent a left lateral fissure craniotomy and a gross total resection of the lesion. An anaplastic astrocytoma (World Health Organization scale grade III) was diagnosed following an examination of a tissue sample (). Subsequently, the patient underwent an additional total hip arthroplasty (THA) due to the fracture of the left femoral neck (). The post-operative period was uneventful and the patient was referred to the Department of Oncology two weeks later. The patient was administered adjuvant radiotherapy with (total dose, 60 Gy) and 6 cycles of chemotherapy as follows: Temozolomide was administered at a dose of 250 mg on days 1–5 and the course was repeated every 28 days. The patient was doing well with no evidence of local or distant recurrence more than six months after the surgery. Approval for this study was obtained from the ethical review committee of The First Affiliated Hospital of Nanchang University Medical School and all the investigations were conducted in conformity with the ethical principles of research. Informed consent was obtained from the patient for participation in the study.
A 75-year-old gentleman of Indian origin presented to a regional Ear, Nose, and Throat Department as a tertiary referral. The history of a painful lump over the left side of his upper neck was for approximately one year. The patient reported that the lump fluctuated in size and was initially painful but this improved with time. The accuracy of history was limited by the fact that the gentleman had a thick beard and may not have noticed the enlargement during shaving or from the external appearance. The pain was intermittent but worse after talking for long periods. He did not have any difficulty eating, shortness of breath, or alteration of hearing. There was no history of preceding trauma. Otherwise the patient was in good health, with no significant comorbidities.\nOn examination the lump was located in the level 2 area of the neck extending into the preauricular area. The mass was firm and pulsatile. There was no facial nerve weakness or paralysis.\nAll routine blood investigations, which included full blood count, renal function, clotting, C-reactive protein, liver function, fasting glucose, and lipids, were within normal limits. An ultrasound scan (US) of his left parotid region demonstrated a large aneurysm measuring 45 mm in maximum diameter, closely related to the left parotid gland. A subsequent computed tomographic (CT) angiogram was performed (Figure ()). This showed a thick walled aneurysm superficial to the mandible arising from the maxillary branch of the external carotid artery (Figure ()). Doppler US of his aorta and popliteal vessels excluded any further concurrent aneurysms.\nAfter discussions in the vascular surgical multidisciplinary meeting and with the patient it was decided to attempt endovascular embolisation.\nThe external carotid artery was selectively catheterised with a 5 French vertebral catheter. Angiography during the procedure showed a very tortuous maxillary artery and the giant aneurysm arising from its midportion. The outflow branches appear to be arising from the sac itself and therefore we concluded that this was a true aneurysm. A microcatheter (Progreat-Terumo, Japan) was used to superselectively embolise the outflow vessel and the aneurysm inflow with (Vortex Coils-Cook Inc, USA) coils (Figure ()). Immediate angiography showed a successful procedure with no demonstrable flow in the aneurysm (Figure ()). Subsequently Doppler US of the aneurysm was performed which confirmed that there was thrombus and no flow in the aneurysm sac. There were no postprocedure complications and the patient was safely discharged home the following morning. At 6-month follow-up the mass has disappeared on clinical examination. Doppler ultrasound shows a tiny (<5 mm) area of residual flow at the aneurysm neck. No further treatment is planned.
In February 1998, a 54-year-old Korean woman visited a local clinic presenting with nasal obstruction. A mass in the right nasal cavity was resected under local anesthesia without suspicion of malignancy and histopathologic diagnosis of immature teratoma with a predominant neuroblastomatous component was made. Magnetic resonance imaging after resection showed neither remnant nor metastatic lesions. In May 1998, a gray- to black-colored mass with a foul odor regrew in her right nasal cavity. The recurrent tumor was excised and again showed immature teratoma with a neuroblastomatous component (). Adjuvant radiation therapy to the nasal cavity was administered (60 Gy over 6 weeks, at a daily dose of 2 Gy) and there was no evidence of recurrence until May 1999.\nIn October 1999, she presented with a cough, and subsequent chest computed topography (CT) scans showed two pulmonary masses in the right upper lobe with mediastinal lymphadenopathy. Bronchoscopy revealed a beefy mass obstructing the right upper lobar bronchus, and the biopsy specimen showed malignant tumor cells characterized as compact sheets of small round cells, hyperchromatic nuclei, inconspicuous nucleoli associated with squeezing artifacts, and a scant amount of cytoplasm; there were no other mature epithelial components or adipose tissue (). All the systemic staging work-ups were negative. These findings led us to the conclusion that the lung mass was a new primary small cell carcinoma of the lung. She was treated with concurrent radiochemotherapy (CRCT) from December 1999 to March 2000, which consisted of thoracic radiation therapy (TRT) of 44 Gy over 4.5 weeks (at a daily dose of 2 Gy) and four cycles of chemotherapy with intravenous cisplatin and oral etoposide; the first two cycles were delivered concurrently with the TRT.\nAfter achieving a clinically complete response, she was followed-up regularly with serial chest CT scans that revealed only radiation pneumonitis until ten months following CRCT. In November 2001, a new cystic lesion with fat-like density on chest CT scans appeared in the previously irradiated site, and it slowly grew until October 2003. In addition, thickening of the right upper lobe bronchus became apparent on CT scans taken in June 2003, and another new low density mass replacing the right upper lobe appeared around the cystic mass lesion on CT scans in October 2003 (). The bronchoscopic biopsy specimen was histologically the same as the initial bronchoscopic specimen, and there were increased uptakes in the right upper lung and right supraclavicular area on 18F-fluorodeoxyglucose positron emission tomography. Chemotherapy consisting of irinotecan and carboplatin for salvage purposes was begun, however, the patient died of septic shock two weeks later 69 months after the initial diagnosis. Until her death, there was no evidence of tumor recurrence in the nasal cavity, nor elevation of teratoma markers throughout the disease course.
A 6-year-old female with a history of left FH and limb-length discrepancy presented for orthopedic evaluation of knee instability. Anterior tibial instability appeared to be the most pressing clinical issue with frequent subluxation episodes. The patient’s medical history revealed a left Achilles tendon lengthening at 11 months of age. Bilateral imaging of the legs revealed an absent left fibula (). The patient’s left leg was 3.5 to 4 in. shorter than the right with the left foot also smaller in size than the unaffected right side. On the affected left side, she was also ACL and PCL deficient. Physical exam revealed a normal straight leg raise with full range of motion, a grossly positive Lachman at 30° of knee flexion and a positive tibial sag at 90° of knee flexion. Varus–valgus stress tests in full extension and in 30° of flexion were normal.\nPrevious consultations with a pediatric orthopedic surgeon addressed procedures to potentially equalize the length of the legs through limb lengthening. Specifically, a tibial osteotomy of the left leg with the application of ring external fixator was recommended. It was also recommended that prior to the lengthening surgery, the knee ligaments should be stabilized. The patient was primarily symptomatic with instability from the anterior; this was visibly evident with anterior tibial subluxation episodes during walking. She was thought to be a candidate for ACL reconstruction using the Micheli procedure, a physeal-sparing technique utilizing the patient’s iliotibial band (ITB) autograft. However, due to the degree of anterior laxity and the expected small width and thickness of the ITB, graft augmentation procedures were considered.\nIn the operating room, the exam under general anesthesia again revealed a grossly positive Lachman with an excess of 2 cm of anterior tibial translation and a positive pivot shift. Her medial collateral ligament and laterlal collateral ligament were intact and stable and the PCL absent. A photo of the legs demonstrates the marked difference in limb length ().\nAfter incision and exposure of the lateral thigh, a portion of the ITB was harvested producing a graft, 120 mm in length and 10 mm wide (). As the graft was considerably small in cross-section, and the anterior tibial laxity was quite significant, the decision to use a semitendinosus allograft to augment the reconstruction was made (). The allograft was baseball stitched to the ITB under tension.\nArthroscopic examination of the knee was consistent with the clinical examination finding of complete absence of both the cruciate ligaments (). In addition, she had a relatively small notch. The geometry of the notch was not altered at the time of surgery because of the relatively horizontal position of the ACL graft, nor was the posterior cruciate ligament deficiency addressed. The femoral portion of the graft was sutured to the intermuscular septum, while the tibial side was sutured to the periosteum of the proximal anterior tibia at 0° of extension after being passed intra-articularly. This patient was very young and therefore had a small transverse meniscal ligament. After intra-articular routing of the graft, it was decided to not place the graft under the intermeniscal ligament as is normally done in the Micheli procedure as a precaution to avoid damage to intermeniscal ligament. After the graft was secured to the tibia with sutures in the periosteum (), the Lachman exam was repeated and the anterior laxity of the tibia on the femur had been minimized. Anterior tibial translation was reduced to an appropriate 3 mm at 30° of flexion. The patient tolerated the procedure well and left the operating with the leg in full extension in a posterior splint. The patient returned to the clinic 13 months postoperatively. She subjectively reported that she has been very active playing on the playground with friends and feels that the knee is quite stable and strong. Her physical exam revealed full range of motion from 0° to 140° with no terminal flexion pain, a stable Lachman’s exam, good quadriceps contraction from a straight leg raise, and no tenderness to palpation along the ITB. Radiographic imaging of the knee and tibia revealed no growth alterations or damage to the physes on the proximal tibia or distal femur.
A 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.\nThe patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After the transplanted kidney was repaired, a viable male infant with Apgars of 8 and 9 weighing 2460 g was delivered.\nPostoperative serum creatinine levels remained stable between 1.1–1 .3mg/dL and the patient maintained adequate urine output. Renal ultrasound immediately postpartum and 1 month postpartum demonstrated normal arterial and venous flow with no evidence of ischemia or perinephric hematoma.
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.
A 52-year-old female patient presented to the Clinic of Plastic Surgery because of three nodular masses on her scalp. The nodular lesions were localized at the occipital, parietal, and sagittal regions with diameters of 5, 3, and 2.5 cm, respectively. No ulceration was observed on the surface of the lesions. The patient reported that the masses had been existing for four years. The dimension of the mass in the occipital region had increased recently, but those of the others did not change. The patient described no trauma or chronic irritation. The patient underwent surgery, and the three excised mass materials were sent to the pathology clinic. The examination of the specimen revealed that the masses excised from the parietal and sagittal regions were macroscopically and microscopically compatible with trichilemmal cyst. The mass excised from the occipital region consisted of a brown-colored nodular lesion with an irregular granular surface with cream-colored fields on top. The section surface of the material was composed of solid and cystic fields that were cream colored. The histopathological evaluation found solid islands standing back-to-back in a desmoplastic basement and a neoplastic formation composed of epithelial cells that were designed in a cordon-like structure and that demonstrated moderate degree of pleomorphism and atypia. The tumor cells commonly had a wide eosinophilic cytoplasm (). The rare presence of tumor cell groups with wide translucent cytoplasm was also marked (). The tumor included foci of trichilemmal keratinization. Necrosis was not found. Increased atypical mitotic figures, which were more intensely found in the peripheral fields, were present (). Mean mitotic count was 10/10 HPF. The tumor was observed to form a relatively regular margin with peripheral fields, partly elongate to the peripheral fields in small infiltrative foci, and exceed the surgical margin (). The immunohistochemistry test revealed 40% membranous staining with CD34 in the tumor cells (). The Ki-67 proliferation index was approximately 20% (). P53 staining was strongly positive in 80% of the cells (). According to the morphological findings, the lesion was a low-grade MPTT. The patient underwent a reexcision procedure at the Clinic of Plastic Surgery. No tumor was encountered in the reexcision material within the surgical margin. No relapse or metastasis was detected during a 24-month follow-up of the patient.
A previously fit 67-year-old, British, Caucasian retired engineer was assisting in heavy manual labour when he sustained a crush injury to his big toe. He had seen many of these managed conservatively by the medical profession before, so it was two weeks before he sought medical assistance. He visited his general practioner (GP) when the nail was lifting off, concerned that it may be infected. This gentleman was admitted into hospital where the nail was surgically removed and he was given a week's course of flucloxacillin. He attended emergency department every other day to have the dressings changed and in time it slowly healed.\nFour to six weeks later he began to suffer from loose stools. Again he managed this at home, initially with Imodium and then with codeine from his GP. After about a week, these agents failed to control his motions and he noted that the odour was now more offensive. Stool cultures were negative for Shigella, Salmonella, E. coli and Campylobacter. He saw his GP again, and was now showing signs of dehydration, so he was admitted to hospital, isolated and put onto intravenous fluids and metronidazole. Blood tests demonstrated acute renal failure with systemic sepsis.\nFour days later, stool cultures confirmed the presence of Clostridium difficile. He was now opening his bowels every half an hour day and night. Fluid resuscitation continued and his abdominal plain films showed grossly dilated loops of bowel. After a week, vancomycin and dietary supplements were added and the team began to liase with their surgical colleagues as his symptoms had not abated. After twenty days he was so hypoalbuminaemic that his peripheral oedema hampered peripheral access; therefore nasogastric feeding was commenced. He continued to deteriorate and the medical and surgical teams were concerned about that he had a persistent megacolon and gross colonic oedema seen on sigmoidoscopy. After considering the options carefully, a defunctioning ileostomy was created following a total colectomy, four weeks after admission.\nHe came round from the operation with his left foot in extreme pain. It was noted to be cool, dusky and have inpalpable distal pulses and found to have an arterial clot. This failed to improve and required a femoral-peroneal bypass. His post-op recovery was further complicated by the need for intensive dietary support as his pressure areas began to ulcerate. His wounds were infected with MRSA, but did not ulcerate. A month later, he noticed that his left foot was cooler again. To his dismay the surgeons confirmed that the graft had occluded and so he went on to have a left below-knee amputation. This wound was again complicated by MRSA infection. After time at a community hospital he was discharged home, sixteen weeks after admission with complete recovery and followed up in the prosthetic clinic.\nSince 1977 Clostridium difficile has been recognised as the cause of pseudomembranous colitis. The bacterium is an anaerobic, toxigenic, gram-positive rod. It produced spores which can survive for months on surfaces, with many people remaining asymptomatic carriers. The role of antibiotics in disrupting normal bowel flora and therefore predisposing to infection has been well described before.\nSwift identification and then removal of precipitating factors are the initial parts of treatment. Oral metronidazole or vancomycin alongside fluid and electrolyte replacement is often enough to improve symptoms. Patients who fail to respond need dietary supplementation, consideration of live yoghurts and withholding Proton pump inhibitors and early surgical review. Despite all this intervention, recurrence is common. This emphasises the current focus on initial prevention.
The patient is an 86-year-old white male with a past medical history of hypertension and a 12-year history of a hiatal hernia. He does not have a history of diabetes, hyperlipidemia, or coronary artery disease. He is a non-smoker, active for his age, and has no recent history of chest pain. The patient takes 25 mg of metoprolol twice a day for his hypertension and 40 mg of omeprazole daily for GERD.\nThe patient presented to the emergency department with a chief complaint of persistent nausea. He received an abdominal film during his work-up which revealed a large hiatal hernia, which along with his persistent nausea, the possibility of gastric volvulous was entertained []. The patient subsequently underwent an abdominal CT scan that ruled out gastric volvulous and demonstrated a large hiatal hernia in which the stomach was almost entirely in the thorax []. An electrocardiogram while patient was in Emergency Department revealed new ST segment elevation in the inferior leads without reciprocal changes []. The patient continued to have persistent nausea and started to develop pleuritic left sided chest pain. His vital signs remained stable with a temperature of 98.4, 16 respirations a minute, heart rate of 70, blood pressure of 156/63, and an oxygen saturation of 98% on room air. He was admitted for 24-h observation. His cardiac markers remained within normal limits. An echocardiogram revealed no wall motion abnormalities and a preserved ejection fraction.\nDuring the hospitalization, the patient had a number of episodes of large volume emesis, resulting in dramatic improvement of his symptoms. Repeat electrocardiogram revealed resolution of the ST segment elevation []. The patient received supportive care during his hospitalization and was referred to cardiothoracic surgery at discharge. Two months later, the patient received a laparoscopic Nissen fundoplication. The procedure and post-operative course were without complications and the patient has been in good health since the surgery.\nArrhythmias such as atrial tachycardia, atrial fibrillation, supraventricular tachycardia, paroxysmal atrial flutter as well as electrocardiographic changes such as T wave inversion have been reported with large hiatal hernias in previous case reports. The exact mechanism of these electrocardiographic changes is not well understood. Kounis and colleagues hypothesized that an increase in direct or indirect pressure to the global surface of the heart caused electrical alternation seen on electocardiography.[] Schilling and colleagues hypothesized two theories in their case of paroxysmal atrial flutter. First, that compression of the heart caused either ischemic changes or an anatomic conduction block causing the reentry. Second, that the hiatal hernia may cause compression of the vagal innervation to the heart causing electrocardiographic changes.[]\nPatients with large hiatal hernias have been reported to have cardio-pulmonary symptoms as well as electrocardiographic and echocardiographic manifestations in several case reports. These findings are reviewed in []. Hokamaki and colleagues described an interesting case of a 79-year-old woman who developed diffuse ST segment elevation after decompression of a large hiatal hernia.[] In their report, they hypothesize that rapid decompression of the hiatal hernia may have caused pericardial inflammation resulting in pericarditis. Tursi and colleagues also hypothesized that their finding of a supraventricular arrhythmia may have been caused by pericardial irritation.[]\nOur case represents a patient with focal ST segment elevation of the inferior leads, a new electrocardiographic finding associated with large hiatal hernias. The exact mechanism of these electrocardiographic changes is not known. We hypothesize that the focal ST segment elevation in the inferior leads could be related to torsion or compression of the epicardial artery from direct pressure from the hiatal hernia. These electrocardiographic changes could also be related to rotational changes of the heart associated with compression from the hiatal hernia. This may also explain the changing depth and duration of the inferior Q-waves. Regardless of the exact cause of these electrocardiographic changes, once the patient's had repeated episodes of large volume emesis, his hiatal hernia decompressed leading to resolution of his electrocardiographic findings.
In March 2017, a 35-year old woman, gravidity 3, parity 2 was seen at the staff clinic following a needlestick injury (NSI). She was 22 weeks pregnant at the time of the NSI. As part of the NSI protocol, the source patient had his blood sample screened for hepatitis B, hepatitis C and human immunodeficiency virus (HIV). All three were non reactive. Her blood sample was also screened for hepatitis B, hepatitis C and HIV. Her HIV screen and hepatitis C screen were non reactive. Her hepatitis B screen was negative for hepatitis B surface antigen (HBsAg), with a HBsAb titre of 92 mIU/mL, undetectable hepatitis B virus (HBV) DNA load but a positive HBcAb.\nThe patient has been working as a healthcare worker for 10 years and was immunised against hepatitis B before the start of her employment. She had the same hepatitis B, hepatitis C and HIV workup done in 2008, 2011, 2013 and 2015. Her HIV and hepatitis C screen were non reactive. She had a negative HBsAg and HBsAb titre of more than 10 mIU/mL. Of note, her HBcAb was negative on all four occasions.\nThe patient did not recall any overt exposure to hepatitis B infected blood or body fluid before the NSI. She received an intramuscular Rho (D) immune globulin (Human) injection when she was 8 weeks pregnant and received an intramuscular influenza vaccine (2016-2017 northern hemisphere influenza vaccine) when she was 17 weeks pregnant.\nThe results of the hepatitis serology were discussed with the patient. This led to a lot of anxiety in the patient. Many queries were raised regarding the causes of a positive HBcAb on a background of hepatitis B immunisation, the implications on her health and the health of her fetus, the ability to continue with cord blood storage, as well as the ability to continue working as a healthcare worker. She was referred to a hepatologist and the results of the hepatitis serology were discussed with her obstetrician.\nBlood samples from the healthcare worker were repeated 7 weeks after the NSI and again at 18 weeks after the NSI. The HBcAb was negative and HBV DNA was undetectable in both repeated blood tests. The rest of the results were unremarkable.\nDue to the serial blood tests showing negative HBcAb, the positive HBcAb in the initial results was treated as a false positive. The patient was discharged from follow up.
A 67-year-old man from India, who was recently diagnosed with latent tuberculosis, presented to an outside hospital and was admitted for six days with generalized fatigue and hypotension. On presentation, he reported a 2-week history of generalized fatigue with systolic blood pressures in the 60s, as recorded at home. He also reported a 30-pound weight loss which was attributed to diuretic use and dietary changes in the setting of congestive heart failure. With these complaints, his losartan (angiotensin receptor blocker) dose was reduced, which was ineffective in alleviating his symptoms. His history was notable for an LTBI diagnosed three months prior to presentation, for which he was being treated with INH (300 mg daily) and pyridoxine. He had been treated for 11 weeks by the time he presented, and was noted to tolerate the therapy well for at least four weeks without changes in dietary or sleeping habits, per documentation by his primary care provider. His medical history was otherwise notable for atrial fibrillation, beta thalassemia, and tachycardia-induced cardiomyopathy with reduced ejection fraction. He had no known history of liver disease or diabetes. His other medications included apixiban, metoprolol, furosemide, losartan, and hydroxyzine (for insomnia). He had no prior history of heavy alcohol consumption or recreational drug use, and he worked in the electronics and computer industry. There was no family history of cirrhosis or other liver disease.\nHis initial workup was notable for elevated liver function tests, as shown in . A computed tomography scan of the abdomen demonstrated no intrahepatic biliary dilation and no apparent fatty change. An abdominal ultrasound revealed a simple cyst and heterogenous echotexture, with mild subcapsular nodularity. Based on his workup, his liver dysfunction was postulated to be drug-induced liver injury from INH or apixaban. Both medications were discontinued. He was discharged for outpatient management. However, follow-up laboratory testing indicated an increasing bilirubin, which resulted in readmission to the hospital. A liver biopsy was considered but not performed, as his bilirubin levels began to downtrend.\nOne week later, the patient experienced a syncopal episode while having a bowel movement, and was admitted to a different hospital. He presented with altered mental status and generalized pruritis. Laboratory data revealed worsening liver function () and acute kidney injury, for which he was treated with albumin, midodrine, and octreotide. His pruritis improved with the introduction of cholestyramine.\nAutoimmune serologies, including antinuclear antibody, antimitchondrial antibody, and anti-smooth muscle antibody, were negative. Viral hepatitis serologies were negative. HIV infection was ruled out. The patient’s acetaminophen level, urine toxicology screen, and serum ferritin level were within normal limits. A transjugular liver biopsy was performed and demonstrated cholestatic hepatitis, thought to be drug- or toxin- related. His mental status initially improved with lactulose, but worsened thereafter, prompting a transfer to our hospital for consideration of liver transplantation for acute liver failure, about six weeks after initial presentation.\nPhysical examination at time of transfer was remarkable for jaundice, icteric sclera, and altered mental status. He was somnolent but arousable to noxious stimuli, oriented only to self, intermittently following some commands, and had notable asterixis. He had an irregular rhythm and a murmur on cardiac examination, vesicular breath sounds, and a benign abdominal examination. He was noted to have Grade III hepatic encephalopathy in the setting of acute liver failure, and was admitted to the intensive care unit before being listed for liver transplantation as Status 1A. On day four in the hospital, he underwent orthotopic liver transplant surgery, and was extubated on post-operative day one. He was transferred to the floor on post-operative day three, but subsequently suffered a sudden aspiration event resulting in a pulseless electrical activity and fatal cardiopulmonary arrest.
We present a case of a 36 year old male who was admitted with recent onset of shortness of breath. CT pulmonary angiogram demonstrated large right sided pulmonary emboli (Figure ). Moreover, a filling defect was noticed in the right atrium (Figure ). The defect appeared to be lobulated, irregular, of low attenuation and arising from the free atrial wall. On transthoracic echocardiography (Figure ) the mass was demonstrated to be extending through the tricuspid valve. A presumptive diagnosis of right atrial myxoma with complicating pulmonary embolism was made. Urgent surgery was arranged. At the time of surgery the right atrial appendage was noted to be very congested and "angry looking". Total cardiopulmonary bypass was established using aortic and bi-caval cannulation. The right atrial cavity was found to be replaced by a friable tumor which had "fronds like" appearance (Figure ). The mass was extending through the tricuspid valve to the right ventricle. A sample of the tumor was subjected to frozen section examination which suggested the diagnosis of Leiomyosarcoma. The entire free wall of right atrium was excised extending from and to the origin of vena cavae. Anteriorly the incision was carried forward up to the atrioventricular groove, taking care to preserve the right coronary artery while ensuring macroscopic clearance of tumor. The resection margins were submitted for histological examination and were subsequently proven to be tumor free. The right atrium was reconstructed using autologous pericardium (Figure ). Bilateral pulmonary embolectomy was also performed. Histological examination of tumor confirmed the frozen section findings. On the cut surface, the tumor had a whirled white appearance, with focal brown areas. The microscopic examination revealed the presence of a spindle cell tumor, forming fascicles orientated at right angles. The study revealed the morphological aspect characteristic to leiomyosarcoma.\nAlthough resection margins were clear the margin width was deemed to be inadequate. After recovery from surgery the patient was submitted to chemotherapy with Doxirubicin and Isofomaide. A tumor surveillance plan involving serial echocardiograms is planned.
A 25-year-old gravida 1 para 0 woman at 35.6 weeks of pregnancy who weighed 57 kilograms was admitted to our hospital because of irregular uterine contractions. The patient had been buried for 48 hours in the ruins after an earthquake. She had undergone more than 30 surgical procedures within the previous 6 years. Her legs and abdomen were severely injured in the earthquake. She underwent left, total leg and right below-knee amputations, left hip resection due to clostridial necrotizing fasciitis, transverse colostomy, cystic and vulvar reconstructions, and colostomy reversal surgery approximately 2 years before becoming pregnant. In addition, she also suffered from spinal shock after the accident. Her sensory and motor function below the level of T10 did not recover until 8 months later. In addition, the patient had progressed to a chronic stage in which her reflex activity was regained. This stage was characterized by disuse atrophy, flexor spasms, and exaggerated reflexes.[ To bear the weight of her body, she had to sit, lie down, or lie on her side. As a result, the uneven distribution of the stress caused compensatory changes in her spine, leading to severe scoliosis.\nThis patient had 2 episodes of congestive heart failure during her previous surgical interventions that required hospitalization in an intensive care unit (ICU). When she was admitted to our hospital, the fetal heart rate and movement were monitored closely. Dexamethasone was used to promote fetal lung maturation. At 36.4 weeks of gestation, her uterine contractions became more frequent, and preterm delivery was inevitable. Spontaneous vaginal delivery was not an option because of the patient's incomplete pelvis structure due to the previous left hip resection and extensive keloid tissue over the perineal region (Fig. ). A cesarean delivery was planned after multidisciplinary consultation and meetings with the patient.\nGeneral anesthesia was planned due to the patient's traumatic stress experience. Preoperatively, we ruled out deep venous thrombosis using Doppler sonography. The patient's right internal jugular vein was cannulated preoperatively due to difficult intravenous access. The patient inhaled oxygen in the operating room in the semidecubitus position. In preparation for a potentially prolonged operation, arterial access was also established according to the standard American Society of Anesthesiology monitoring guidelines. We used the central venous pressure (CVP) and pleth variability index (PVI) to guide fluid management. The bispectral index (BIS) and continuous total hemoglobin were also measured. The patient's blood pressure was 105/63 mm Hg, her heart rate was 102 beats/min, her oxygen saturation was 99% when breathing oxygen (>4 L/min), and her CVP was 6 cm H2O. After intravenous hydration with 300 ml of lactated Ringer solution (approximately 10 ml/min), she was positioned in the supine position with left uterine displacement to minimize aortocaval compression.\nAfter sterile preparation, general anesthesia was induced through rapid sequence induction with ketamine, propofol, and succinylcholine, following adequate preoxygenation. A surgical incision was made immediately after successful tracheal intubation. To deliver the fetus as quickly as possible, a high transverse abdominal incision and a low transverse segmental uterine incision were used by the obstetric team to avoid surgical scars and peritoneal adhesions. A male infant weighing 2940 g was delivered in 3 minutes. Apgar scores were estimated to be 10 at 1 minute and 10 at 5 minutes. Anesthesia was maintained with a reduced sevoflurane concentration and sufentanil. Warm blankets were used during surgery, and parts of the patient's limbs were protected. The patient was stable during surgery with no significant blood loss. The patient's intraoperative systolic blood pressure was 110 to 130 mm Hg, her heart rate was 100 to 110 beats/min, her BIS was 45 to 65, and her CVP was 5 to 8 cm H2O. The duration of surgery and anesthesia were 34 minutes and 1 hour and 42 minutes, respectively. Intraoperatively, the estimated blood loss was approximately 500 ml, 800 ml of lactated Ringer solution was administered during surgery, and 200 ml of clear urine was collected. The patient was extubated after surgery and was then transferred to the ICU. At 42-days of follow up, she exhibited no signs of any postoperative complications.
A 27-year-old nursing female came to the Department of Oral and Maxillofacial Surgery, Kalinga Institute of Dental Sciences, with a chief complaint of mild intermittent pain and a swelling which was gradually increasing in size on the left mid-facial region for 6 months. The patient had undergone a C-section delivery 3 months back. There was no other relevant medical or family history of the patient. On extraoral examination, there was a facial asymmetry with a solitary diffuse swelling on the left side near the nasolabial fold of size approximately 1 cm × 1 cm []. The swelling was hard and nontender, and there was no associated regional lymphadenopathy. Intraorally, there was a diffuse swelling of size approximately 3 cm × 2 cm present in the left side maxilla extending from the lateral incisors to the first premolar, obliterating the buccal vestibule []. There were 30 permanent teeth present with the absence of the upper right and lower left third molars. The patient was advised to undergo orthopantomogram and cone-beam computed tomography (CBCT) imaging, which revealed a round unilocular radiolucent image of an intraosseous lesion with a well-defined border in the left maxilla extending from the periapical region of the lateral incisor to the mesial root of the first molar []. The lesion had engulfed a radio-opaque mass, which was supposedly an impacted tooth located within. The images also showed multiple impacted supernumerary teeth in the maxilla and mandible [Figures –]. Surgical excision was planned and performed under general anesthesia, in which the affected area was approached through a vestibular incision. The tumor was encapsulated and was attached with two impacted supernumerary teeth, which were fused and shaped as the maxillary premolars []. The tumor was removed and sent for histopathological examination. The patient was healthy postoperatively without any specific complaints.\nThe section of the given specimen showed a connective tissue component composed of densely packed collagen fiber bundles, arranged parallel resembling a capsule. The capsule enclosed a cystic space. The inner wall of the cystic space was lined by an odontogenic epithelial lining []. The epithelial lining was proliferative in nature at the one end and is composed of spindle-shaped epithelial cells. These epithelial cells were also forming duct-like structures. The peripheral cells of the ductal pattern showed a palisading structure and reversal of polarity []. Some areas showed calcification inside the epithelial island. Based on these above histological findings, a final diagnosis of AOT was given.
A 64-year-old Caucasian man was admitted to our hospital with a ten-year-history of a mild diffuse abdominal pain associated with anorexia. He reported no noticeable weight loss or other symptoms. His family history was unremarkable and he had no history of previous abdominal surgery.\nOn physical examination, we noted a mass in the left upper quadrant of the abdomen, which was mobile. A CT scan of the abdomen revealed a homogeneous, non-enhancing mass, 70 × 100 mm in size, in the mesenteric region near the small bowel, with a consistency suggesting thick mucinous or proteinaceous material, which possibly represented an intestinal wall tumor. There were no other relevant findings.\nAt laparotomy, a solid mass measuring 80 × 100 × 120 mm was identified at the root of the jejunal mesentery, infiltrating the adipose tissue and bowel wall, and in close association with the superior mesenteric and the middle colic vessels (Figure ). The mesentery contained several large lymph nodes. A small amount of free peritoneal fluid was present. The mass was totally excised with a loop of jejunum and without apparent interference with the blood supply to the bowel. However, bowel ischemia did occur, and the patient required a second laparotomy three days later. The ischemic injury seemed to be secondary to venous obstruction. It was necessary to resect an additional segment of small bowel measuring 600 mm in length. A primary anastomosis was performed.\nOur patient recovered well, and was discharged from the hospital one week after the second laparotomy. The final tissue diagnosis showed spindle-shaped fibroblasts with elongated nuclei and a benign appearance. The cut surface was tan, whorled, and firm, without necrosis, cystic change, or hemorrhage. Microscopy showed loosely arranged spindle cells with bland, oval nuclei and minimal cytoplasm (Figure ). There were also plump spindle cells with tapering ends, with oval, vesicular nuclei and moderate amounts of eosinophilic cytoplasm. There were many thin-walled vessels of varying caliber. There were no cells with epithelioid features, and any inflammatory cells, calcification, osseous metaplasia, necrosis, or mitoses. The tumor had infiltrated the muscularis propria and had non-infiltrating margins. The tumor cells were negative for antibodies to CD117, S100, CD34, and smooth muscle actin, and positive for desmin. The small sample of peritoneal fluid was free of malignant cells.\nA diagnosis of fibromatosis of the jejunum and mesentery was made. Six months after resection, a CT scan of the abdomen showed no evidence of residual or recurrent tumor. Our patient had no evidence of disease at follow-up 16 months after surgery. However, the clinical data and radiologic findings gave rise to a diagnostic dilemma: was the lesion an intermediate or high-risk malignant GIST originating from the bowel wall and spreading to the mesentery, or was this a benign lesion such as IAF originating from the mesentery and infiltrating the bowel wall?
A 64-year-old male presented in March 2014 with nausea, weight loss, dull pain in the left upper quadrant radiating to the back, and trembling fever. His medical history consisted of diabetes mellitus, paroxysmal atrial fibrillation, and previous alcohol abuse. In 2008, he presented with repeated episodes of acute edematous pancreatitis. CT imaging revealed chronic calcifying pancreatitis with multiple stones in a dilated MPD. Extracorporeal shock wave lithotripsy in conjunction with MPD stenting was performed during repeated sessions until the MPD was cleared. This patient remained free of pancreatitis. He was lost to follow-up at the end of 2012.\nIn March 2014, laboratory results showed an elevation of the CRP level to 180 mg/dL and a normal serum lipase value. On CT, a large heterogeneous mass in the pancreatic tail with invasion of the anterior pararenal fascia and the adjacent small bowel loop and splenic vein thrombosis were revealed (). Both findings, which were suggestive of malignancy, were confirmed by endoscopic ultrasound (EUS). However, monolayer cytology following fine-needle aspiration (FNA) did not indicate malignancy, only showing low cellularity and large amounts of blood in the sample. The level of CA19.9 was normal and further evaluation for metastatic disease was negative. The patient was presented at our multidisciplinary pancreatic team meeting and was scheduled for pancreatic tail resection with the patient's informed consent.\nIntraoperative inspection showed edema and fibrosis of the tissue surrounding the pancreas with adherence to the stomach and small bowel. Histomorphological examination showed active granulomatous pancreatitis with small abscesses and sulfur granules (Actinomyces colonies) were observed, lacking evidence of malignancy (). There was extensive fibrosis with adherence of the mass to the spleen.\nThe patient was started on IV amoxicillin clavulanic acid (4 × 1 gram) postoperatively, resulting in a rapid clinical response with the disappearance of all symptoms. After the initial four weeks of IV treatment, the patient was started on oral amoxicillin (3 × 1 gram) for an additional six months. He has remained asymptomatic since this time.
A 78-year-old man was admitted to our ward for the incidental finding at the ultrasound of a solid mass in the liver, without symptoms. His past surgical history consisted of only a laparotomic cholecystectomy for acute cholecystitis, with a liver biopsy diagnostic for aggressive chronic hepatitis (the patient was HBV and anti HCV negative). The patient was in good general condition, but significant morbidity was noted: chronic renal failure (creatinine value 1.4 mg/dl), chronic obstructive pulmonary disease, hypertension, and a recent asymptomatic myocardial infarction. The liver function was normal. At the computed tomography (CT) scan, a 4.3 × 3 cm neoplastic lesion was found in segments IV and V. There was no macroscopic involvement of portal tree and hepatic artery. Magnetic resonance imaging (MRI) showed the main lesion with a cystic or necrotic central portion and a peripheral enhancement with late pooling; a little satellite nodule was also discovered. Imaging was suggestive either for a peripheral intrahepatic cholangiocarcinoma or for a liver metastasis from an occult cancer, probably arising from the gastroenteric tract. Tumor markers seemed to support this last hypothesis: CEA, 30 ng/mL; Ca, 19-9 > 12,000 U/mL; and alpha phetoprotein 3 UI/mL, strongly suggestive for a cancer arising from a secretory epithelium. An 18 F-FDG PET scan showed captation in the previously described sites (liver and colon), without any other visible spots. Colonoscopy showed a neoplastic stenosis in the transverse colon, limiting the direct visualization of the right colon. A CT colonoscopy confirmed the neoplastic involvement of the splenic flexure without signs of colonic occlusion and our endoscopic biopsy was positive for adenocarcinoma.\nWith a preoperative diagnosis of colon cancer with synchronous liver metastasis, the clinical case was evaluated by a multidisciplinary team. The age of the patient, the chronic liver failure, and the recent acute coronary syndrome were considered by the oncologist as contraindications to chemotherapy, neoadjuvant nor palliative. A further cardiologic evaluation showed no contraction of the infero-posterior part of the myocardium with a slight reduction of the ejection fraction (40%). Myocardial scintigraphy showed a stable hypoperfusion in the corresponding zone and a limited reversible hypoperfusion at the inferior portion of the septum; the dipiridamol test was negative for ischemic signs and symptoms. The patient was considered by the cardiologist at low to medium risk of a severe ischemic accident in the postoperative period. The anesthesiologist defined an increased risk for surgery with an ASA score of 3 (American Society of Anesthesiologists’ score).\nA synchronous segmental colonic and liver resection was planned.\nThe intraoperative evaluation confirmed the splenic flexure neoplasia with a single hepatic lesion, lying in the gallbladder fossa with an extensive gastric adhesion. No ascites and no macroscopic nodal involvement were evident. Intraoperative ultrasound was negative for further hepatic lesions.\nFirst, we performed the resection of the splenic flexure of the colon with a regional lymphadenectomy, postponing the anastomosis after the liver resection. During dissection of the stomach out of the liver, a small necrotic cavity was opened with the appearance of several free biliary stones along the hepatic pedicle. The frozen biopsy of the residual granulomatous-like tissue at the gastric border was positive for ab extrinseco infiltration of adenocarcinoma, with a deep involvement up to the submucosal layer. The tumor showed duct-like structures lined by cuboidal cells. A cribriform pattern was present and there was heterogeneity of the neoplastic epithelial cells within the same gland together with the lack of tall columnar cells of intestinal type adenocarcinoma and lack of necrosis in the glandular lumina. Stroma was abundant and desmoplastic. These features were suggestive for a bilio-pancreatic adenocarcinoma instead of an intestinal one (Figure \n). As a result, the diagnosis was changed into multiple synchronous primitive neoplasms: intrahepatic cholangiocarcinoma (ICC) and colonic cancer. This unexpected finding required a more complex surgical procedure, including gastric resection and hepatic pedicle lymphadenectomy. The hypothesis of a curative procedure (no other localizations were evident) and the absence of any otherwise therapy (the patient was unfit for the chemotherapy) forced towards a radical, extended surgery. We proceeded with a liver bisegmentectomy (segments IV and V), hepatic pedicle lymphadenectomy, distal gastric resection, colonic anastomosis, and omentectomy. A peritoneal pelvic sampling was also performed (Figure \n).\nOn postoperative day 2 an asymptomatic myocardial infarction occurred, requiring a short recovery in the Intensive Coronary Care Unit of without any specific therapeutic care other than endovenous heparin. No surgical complications were recorded. The patient was discharged on postoperative day 20.\nThe histological evaluation confirmed two distinct tumors: (1) adenocarcinoma of the colon infiltrating the adipose tissue, G2, with 3/16 metastatic nodes (Dukes C, Astler–Coller C2); and (2) adenocarcinoma of the biliary ducts with a central colliquative necrosis, a perineural, vascular, and lymphatic invasion and the metastatic involvement in five out of 10 perihepatic nodes and in four out of 10 perigastric nodes. The hematoxylin-eosin evaluation was suggestive for this diagnosis, but above all the complete panel of monoclonal antibodies. Immunohistochemical analysis with cytokeratin 20 (ck 20, clone ks 20.8, Novocastra Menarini), ck 7 (clone ov-tl 12/30, Dako), and cdx2 (clone AMT 28, Novocastra Menarini) defined two distinct profiles of positivity: ck20 positive, ck7 negative, and cdx2 positive for the colonic cancer, and ck20 negative, ck7 positive, and cdx2 negative for the liver (Figure \n). The anti-hepatocyte monoclonal antibodies tested on the liver cancer were negative (Figure \n). The immunohistochemical panel applied to the metastatic lymph nodes showed the same results: ‘colonic’ positivity for the metastatic nodes along the mesocolon and ‘biliary’ profile for the hepatic pedicle and perigastric nodes (Figure \n). Several unexpected small metastatic lesion of biliary origin were discovered in omentum and perigastric tissue; pelvic peritoneum was also positive for neoplastic involvement.\nAt this point, we reconsidered the past surgical history (urgent cholecystectomy 4 years before): the operating report described a difficult surgery, the gallbladder being removed after a wide opening of the wall. A pathology re-evaluation confirmed the initial diagnosis of acute necrotic ulcerative cholecystitis with slight dysplasia.\nThree months after surgery, a diffuse abdominal recurrence (liver, spleen, adrenal gland, and mesenteric nodes) was noted. The patient died 9 months after surgery.
In March 2012, a 40-year-old woman with a long history of bipolar disorder discussed with the treating psychiatrist the possibility of planning a pregnancy. The patient had been free of manic episodes for ten years. She was on maintenance treatment with lithium 1,200 mg/die and olanzapine 2.5 mg/die and was worried about the potential teratogenic effects of lithium as well as the potential adverse effects of olanzapine during pregnancy.\nIn the past, she had suffered from five severe manic episodes that had always led to hospital admission (). Each episode was characterised by persistent elevation of mood, increased energy and activity, psychomotor agitation, aggressiveness, a decreased need for sleep, marked distractibility, and flight of ideas. During all manic episodes, delusions were present, with marked loss of contact with reality. As frequently reported by the patient, manic episodes had always been associated with significant personal distress and social dysfunction, but, between episodes, a full recovery with normal functioning had always been achieved.\nIn terms of drug treatments, during the first two episodes, she was given haloperidol and benzodiazepines, and on discharge after the second admission, drug treatment was withdrawn as a result of a shared decision-making process (). After a third manic relapse with hospital admission, lithium was added to haloperidol and benzodiazepines. This combination treatment was effective only in the short term, as in 2001 a new manic episode occurred during treatment (as documented by lithium blood concentration of 0.8 mEq/litre). Haloperidol was stopped and olanzapine started as an add-on treatment. In 2003, the patient abruptly stopped all drug treatments and subsequently suffered from a new episode with hospital admission. The same drug treatment was restored, and after recovery the patient agreed to see the treating psychiatrist on a weekly basis, in order to check lithium blood levels, treatment adherence, and mood. From 2003 onwards, the patient remained fully adherent to the therapeutic plan, lithium blood levels were stable at around 0.8-0.9 mEq/litre, mood remained stable, and a full and lasting recovery was achieved. Illness insight was high, and she was so frightened about the possibility of a new manic episode that the treating psychiatrist allowed her to call on his personal cell phone in case of emergency. In ten years, from 2003 to 2013, no calls had been received.\nAfter initial talks with the treating psychiatrist about the possibility of actively seeking a pregnancy, during 2012, the patient had consultations with the treating gynaecologist and family doctor, who gave advice on pros and cons of stopping versus continuing drug treatment. Subsequent discussions involved the patient's partner, who had never seen the patient during a manic phase and was in favour of stopping all medicines. A decision was finally taken of stopping olanzapine and gradually withdrawing lithium, decreasing 150 mg every 15 days. Agreement was reached to keep weekly contacts with the treating psychiatrist.\nThe patient remained well until February 2013 when, still in treatment with lithium 300 mg/die, during a holiday in Rome, she started making phone calls to the treating psychiatrist, and the phone talks revealed that she was experiencing mood elevation, a progressive decreased need for sleep, marked distractibility, and increased energy and activity. Contact with reality did not appear to be lost. The patient's partner was advised to increase lithium and to take the patient back to Verona, where she was admitted to hospital, as it was impossible to manage this new manic episode in community. The patient spent more than two months in hospital and became psychotic, very aggressive, and agitated. Lithium was restored at 1,200 mg/die and olanzapine at 20 mg/die. At discharge, full recovery was achieved, although she felt sedated and mentally slowed down. Full-illness insight was rapidly restored.
A 25-year-old, right-hand-dominant female patient underwent release of flexion contracture for chronic boutonniere deformity to the ring finger of her dominant hand at another center. According to report of the operating room, the repair was done through a midaxial incision and the digit k-wired in extension. There were no particular vascular trauma or intraoperative complications documented in the report. The patient suffered from a temporary episode of digital ischemia on postoperative day 1, which improved upon K-wire removal. The rapid improvement in perfusion in the subsequent days leads us to believe that this episode was not related to a thrombotic event. However, the patient presented to our institution on postoperative day 10 when she suffered another episode of ischemia. At this time, the examination of the ring finger on the right hand revealed no capillary refill and no bleeding upon puncture (, left). Patient denied any additional trauma, previous symptoms of thoracic outlet syndrome and had no personal or family history of hypercoagulable disease.\nAngiography showed absent vascularization in the digital arteries of the affected finger, from the level of the middle of the second phalanx. Vasospasm in this setting was unlikely because episodes of reperfusion would have been visualized during the angiographic study. The inflammatory reaction secondary to ischemia can be visualized through the hyperemic appearance of the vessels distally, as opposed to the adjacent fingers (), which also indicates an occlusive disorder rather than vasospasm. The appearance of the digital vessels suggested a thrombotic rather than embolic nature of the occlusion, and after discussion with the patient, intra-arterial thrombolysis was initiated.\nThe thrombolysis was accomplished through a nontapered 4F Glidecath catheter (Terumo, Tokyo, Japan), inserted at the level of the right femoral artery. Because of the very distal lesions, in a young patient, with very spastic forearm arteries, it was decided to perform the thrombolytic drip with the catheter tip in the brachial artery. The thrombolytic regimen consisted of Alteplase (Roche, Mississauga, Canada) 2 mg bolus and 1 mg per hour (total 30 mg received over 28 hours) and intravenous heparin with a subtherapeutic target partial thromboplastin time of 40 to 50 seconds, as per our in-hospital intra-arterial thrombolysis protocol. (target partial thromboplastin time 60-75 seconds).\nThirty hours after the initiation of thrombolysis, a repeat angiography confirmed almost complete reperfusion of the digital arteries at the distal interphalangeal joint that correlated with the clinical appearance of the digit (, middle). Thrombolysis was interrupted and therapeutic intravenous heparin was maintained. A hematology consultation was asked to rule out any hypercoagulation disorder.\nBridging to warfarin was started 6 days postthrombolysis with a target international normalized ratio of 2 to 3. Unfortunately, she was weaned from the heparin while her international normalized ratio was not yet in the therapeutic range and the vessels rethrombosed. This was confirmed by angiography, and intra-arterial thrombolysis was performed with successful revascularization. The patient was restarted on therapeutic dose of heparin and carefully bridged to Coumadin.\nUpon discharge, the distal pulp of the fingertip underwent necrosis because of the prolonged ischemic time. The thrombolysis nonetheless salvaged the portion distal to the middle of the second phalanx that was ischemic on presentation to our center. The distal pulp was allowed to delineate and it spontaneously amputated itself after hospital discharge.
A 66-year-old man with a smoking history, dyslipidemia, and a coronary bypass surgery procedure done 7 months before came to the emergency hospital with fever and cellulitis in the left popliteal fossa.\nA clinical examination revealed a pyrexic patient with a painless, pulsatile swelling of the left popliteal fossa with signs of local inflammation (), and distal pulses were present. His contralateral leg had intact femoral, popliteal (expansive) and distal pedal pulses.\nThe blood tests showed a significantly raised white blood cell count of 17.30×109/L. The blood cultures initially were negative.\nDuplex scan showed a large popliteal aneurysm of 8.0×7.2 cm with gas inside the popliteal sac (), without deep vein thrombosis. A 3.1 cm popliteal artery aneurysm was noted on the right side and both great saphenous veins were not apt for bypass.\nAn urgent computed tomography (CT) angiogram showed a large fusiform aneurysm of the left popliteal artery of approximately 8×7 cm with gas inside the aneurysmal sac, without contrast extravasation. There was a contralateral popliteal aneurysm of approximately 3 cm. ().\nSurgery was performed through a standard medial approach. After proximal and distal control of the popliteal artery the aneurysm was excluded with ligation of the popliteal artery. Vascular continuity was restored with a basilic vein graft of the left arm from the first popliteal portion to the distal third portion (). The aneurysm was opened and decompressed through a posterior approach. There was organized thrombus with evidence of purulence, thus multiple cultures were sent, including tissue from the aneurysm sac. We decided closure of the posterior approach by secondary intention. After the operation, distal pulses were present.\nHistologic examination revealed bacterial colonies and polymorphonuclear inflammatory infiltrates (); cultures of the operative specimens were positive for Staphylococcus aureus. The result of an echocardiogram was normal and no other focus of sepsis was found. He received antibiotic therapy with vancomycin and metronidazole for a month.\nThe patient was discharged home on the 22nd postoperative day, with oral antibiotic (dicloxacillin) for one month and antiplatelet therapy with aspirin.\nOne month after discontinuing the antibiotics, the patient returned with recurrence of cellulitis in the left popliteal fossa. A repeat duplex scan showed a patent bypass with a nonresolving hematoma of 10×4 cm without gas. The hematoma was evacuated through a posterior approach, without evidence of purulence. The patient was discharged home on the 7th postoperative day with oral antibiotic for one month.\nThe patient recovered well, with healed posterior surgical wound. Clinical follow-up showed no signs of recurrent infection and patent bypass after a year.
A 78-year-old female patient was referred to the Dental Clinic of the University of Padua in order to evaluate a painless swelling on the palatal mucosa located near the superior left canine. The lesion, as described by the patient, was first noticed 10 years before. The patient was a nonsmoker and was under treatment for hypertension (with ACE inhibitor, beta blocker, and low-dose aspirin). Oral examination revealed two adjacent lesions, covered with normal coloured mucosa, measuring 7 × 5 × 5 mm and 4 × 3 × 3 mm (). The main lesion appeared as a hard painless gingival swelling with smooth surface; the smaller one was a pedunculated outgrowth of the palatal mucosa with soft consistency. No associated lymphadenopathy was detected. X-ray examinations (intraoral radiograph and computed tomography) showed slight bone resorption in correspondence of the lesion (Figures and ).\nExcisional biopsy of the two lesions was performed under local anaesthesia, and the tissues were submitted to histopathological examination. Microscopic examination of the main lesion showed a mucosal mass covered by stratified squamous epithelium (). The lamina propria contained multiple cords and small islands of epithelial tumour cells with ameloblastic features. The peripheral tumour cells often exhibited hyperchromatic, columnar nuclei with a palisaded arrangement and areas of reverse nuclear polarity. In some areas, the cells of the tumour islands showed an acanthomatous pattern with central squamous differentiation (, left side). Other parts of the lesion consisted of narrow ribbon-like cords that were suggestive of an early plexiform pattern (). The minor lesion also revealed the presence of tumour cells with a desmoplastic pattern, consisting of thin cords (only a few cells in width) of odontogenic epithelium dispersed in a dense collagenous stroma ().\nAccording to the clinical, radiographic, and histopathological exams, a PA was diagnosed. Four months after the excisional biopsy the surgical wound appeared healed by secondary intention. Further surgical approach (a radical resection) was deemed unnecessary and a two-month follow-up was planned. After two months the lesion area was clinically unchanged. A second CT performed 10 months later did not show the superficial bone resorption, confirming the tumour was not infiltrating the bone (). After one year no relevant clinical alteration could be observed ().
A 75-year-old male presented to the local emergency department exhibiting symptoms consistent with anaphylaxis. When found by his son in law he was flushed and unresponsive. On arrival of emergency medical personnel he was found to be hypotensive with blood pressure values of 80/60 mm Hg, hypothermic at 34.7 °C orally, and hypoxemic with a sPO2 of 88 % by pulse oximetry. He received a 500 cc IV normal saline bolus with EMS. In the emergency department he remained hypotensive with a blood pressure of 71/44 mm Hg. He was treated with 3000 cc of IV crystalloid, epinephrine 1:1000 0.3 mg IM once, diphenhydramine 25 mg IV with a second 50 mg IV dose, ranitidine 150 mg IV once, and methylprednisolone 250 mg IV once with improvement. He suffered a type 2 MI, which was felt to be related to anaphylaxis-associated hypotension after assessment by Cardiology. A serum tryptase value was not obtained by the emergency room physician at the time of his presentation.\nHe had no previous history of anaphylaxis, atopy, lymphoproliferative disorder or other neoplasm. His daily medications included aspirin 81 mg daily, and this, in addition to his other regular medications was continued post reaction. He did not take additional doses of aspirin, over the counter or herbal products on the day of reaction. He had not been started on any new medications. There was no family history of atopy. The Allergy and Clinical Immunology Service was contacted by the emergency physician, at which time the food intake history was unclear, and given his profound hypotension at presentation, a concern of a MCAS was raised. This is consistent with suggestions to investigate for MCAS in patient’s presenting with anaphylaxis with profound cardiovascular derangement and lacking documented urticaria, even if likely attributed to an IgE mediated reaction []. He was therefore discharged on cetirizine 10 mg orally daily, prednisone 50 mg orally for 5 days, diphenhydramine 25–50 mg orally q6 h as needed, and an epinephrine auto-injector. He was subsequently assessed in the Adult Allergy and Clinical Immunology outpatient clinic.\nBetween the anaphylactic episode and his appointment at the Allergy Clinic [approximate time 1 month] he consumed Atlantic cod without reaction. A food history obtained at his first visit revealed his initial event had developed following ingestion of a mixed fish and shellfish stew, which he had consumed without reaction on a regular basis. Following the meal he was alone in his room, until being found unresponsive by his son-in-law 3 h later. The patient could not recall the timeline of onset of symptoms, as his recall of the entire event was limited. Due to the concern of a potential underlying MCAS and the severity of his initial reaction it was felt safest to continue H1 receptor antagonist therapy, and due to the interference of anti-histamines on skin prick testing this was deferred for use of ImmunoCAP® [serum specific IgE (Phadia, Sweden)] for shellfish, finned fish and Hymenoptera venom. He was given an epinephrine auto-injector to be used in the event of subsequent anaphylactic reaction. At follow up his serum specific IgE was high positive for Shrimp at 13.7 kUA/L, and Crab at 7.3 kUA/L, moderately positive for Lobster at 2.9 kUA/L and Clam at 0.9 kUA/L, while testing negative with values <0.35 kUA/L for Salmon, Walleye Pike and Whitefish [].\nWhile both skin prick testing and serum specific IgE demonstrate the existence of clinical sensitization, they do not provide evidence for clinical allergy. Serum specific IgE has been reported to be in agreement with skin prick testing from between 50 and 90 % of the time, with average values between 70 and 75 %, and similar values in agreement between supervised challenges []. The interpretation of skin prick tests and serum specific IgE requires evaluation of historical features, physical examination and, at times, supervised challenge []. Although a supervised oral food challenge would have provided definitive evidence of an IgE mediated food allergy rather than sensitization, this was not undertaken due to the severity of his presentation with development of a myocardial infarction, his baseline limited myocardial reserve, and multiple comorbidities. It is acknowledged this limits the definitive confirmation of IgE mediated food allergy, but was made on a risk–benefit decision in the best interests of the patient.\nA serum tryptase level drawn during his first appointment at the Allergy Clinic was 15 ng/ml [with a normal range from 1 to 11.4 ng/ml], an elevation not diagnostic of systemic mastocytosis, but suggestive of a mast cell activation disorder []. A creatinine obtained demonstrated a value of 92, corresponding to an eGFR of >60 ml/min, ruling out reduced renal clearance as a cause of accumulation of serum tryptase [].\nTo further evaluate for a potential mast cell disorder, a 24-h urine methylhistamine level was obtained, demonstrating a value of 103 μg/g Cr (normal range 30–200 μg/g Cr). A serum protein electrophoresis demonstrated no evidence of an M protein. He was seen by the Adult Hematology/Oncology Service at Cancer Care Manitoba to definitively exclude a diagnosis of systemic mastocytosis, for which a bone marrow biopsy and c-KIT testing were completed. His c-KIT mutation testing was negative. A bone marrow biopsy demonstrated normal trilineage hematopoiesis with normal differentiation and maturation without definitive morphological evidence of mastocytosis or lymphoma, specifically revealing no large lymphoid aggregates, abnormal plasma cells, or spindle cells suggestive of mastocytosis. Accompanying flow cytometry demonstrated revealed a sample composed of 23 % lymphocytes, of which 84 % were T cells, 8 % NK cells, and there was a CD4/8 ratio of 0.9. Remaining cells were polyclonal B cells without evidence of lymphoma, plasma cell neoplasm, or mastocytosis. Tryptase was consistently elevated at 17 ng/ml on repeat testing.\nGiven his elevated tryptase, he was maintained indefinitely on cetirizine, and continued to avoid both fish and shellfish, but did require emergency department monitoring following administration of his epinephrine auto injector in January 2015 following ingestion of a perogy, of which the precise constituents were unknown, and development of a diffuse urticarial rash. He was treated with a 3 day course of 50 mg of oral prednisone.\nHe fulfills the proposed diagnostic criteria for diagnosis of a suspected MCAS based on guidelines published by Valent and colleagues, however we acknowledge the challenge of establishing the diagnosis in the context of a documented IgE mediated food allergy, and he may be best classified as a Secondary MCAS [IgE-dependent disease related] [, , ].
A 61-year-old previously healthy female was transferred from an outside hospital for a second opinion for a liver transplant. She first noticed fatigue, weakness, and abdominal swelling three months prior to her admission at the outside hospital. CT of the abdomen with contrast showed cirrhosis and multiple masses with arterial enhancement in her liver. She underwent a liver biopsy. Pathology was reported as a low-grade vascular tumor. She presented to a larger academic center where she underwent an exploratory laparotomy with open liver biopsy to further investigate the liver lesions. There was no visual evidence of omental spread. The pathology was reviewed by multiple tertiary centers specializing in hepatic malignancies and was reported as a low-grade vascular lesion, which was likely small vessel neoplasm. After denial for LT secondary to an unknown low-grade vascular tumor, she presented to our medical center. MRI of the liver showed multiple enhancing liver masses (Figure ). Oncology was consulted and she was diagnosed with benign liver vascular tumors with an overall favorable prognosis.\nShe was listed for liver transplant with a model for end-stage liver disease-sodium (MELD-Na) score of 25. The patient had normal renal function prior to her admission with a creatinine level of 0.79 mg/dL, which increased to 3.3 mg/dL after her admission which was thought to be secondary to hepatorenal syndrome (HRS) type I. Her creatinine level did not improve despite medical management and hemodialysis (HD) was initiated prior to transfer to the University Medical Center. She continued on HD for approximately 10 weeks prior to her LT and was listed for combined liver and kidney transplant.\nShe underwent an orthotopic liver transplant 10 weeks after presenting to the UNMC. Microscopic evaluation of the tumor cells showed positive immunohistochemical staining for the ETS-related gene and was negative for human herpesvirus-8. A Ki-67 labeling index of the solid areas was approximately 30%. Overall, the amount of necrosis and the elevated mitotic rate was sufficient to classify the tumor as a Federation Nationale des Centres de Lutte le Cancer grade 3 of three angiosarcomas (Figure ).\nShe was scheduled for a living donor kidney transplant three days after her liver transplant, but it was postponed due to increased urine output on postoperative day four. Her creatinine level was 2.22 mg/dL and blood urea nitrogen was 73 mg/dL at the time of discharge.\nShe was undergoing routine image testing every three months after transplantation. Unfortunately, she was found to have a recurrence in the form of innumerable liver and bone lesions at 16 months post-transplantation. Despite starting her on chemotherapy with taxol, the patient passed away 31 months post-LT.
A 45-year-old housewife had come to our outpatient department with complaints of persistent sadness of mood and decreased interest in daily activities since 2 months. She would not find pleasure in activities like watching television or talking to neighbors, which she used to like previously. She also would occasionally have crying spells without any reasons. She would feel that her life is a waste and that it was better to die rather than live such a life. However, there was no history of any suicidal attempt or any self-harm behavior. Her sleep and appetite had also decreased. She also started remaining withdrawn, not talking much, and not taking part in household activities. These complaints had started 2 months back when she got separated with her husband due to an altercation with him. She claimed that there used to be constant verbal altercations between them since the past 20 years of their marital life over varied issues. But this time, the fight led her to leave his house and stay with her mother, though they had not filed for a divorce. There was no previous history of similar complaints. She did not have any manic features, delusions, hallucinations or obsessive-compulsive symptoms. Her past medical and surgical history was also insignificant. There was no history of psychiatric illness in her family. On mental status examination, she was groomed normally and demonstrated occasional crying for a few minutes during the interview. Her mood was sad and she conveyed ideas of hopelessness, helplessness, and worthlessness. We diagnosed her as having Major Depressive Disorder as per Diagnostic and Statistical Manual 5 criteria and started her on escitalopram 10 mg/day in divided doses. On regular follow-up, in 2 weeks she showed 40% improvement in her symptoms, so we continued the same. 6 weeks after being on escitalopram therapy, she reported that she noticed jerky movements of her leg that occurred just as she was beginning to fall asleep often causing her to awaken suddenly for a moment. The jerky movement would characteristically occur in 15–30 min after falling asleep. Initially they would occur once a night, but later the frequency increased to twice or thrice every night. She also started having difficulty in falling asleep and would not get proper sleep. She thus developed daytime fatigability and sleepiness. There was no history of accompanying unconsciousness or any frothing at the mouth or uprolling of the eyeballs or any abnormal involuntary movements during daytime. She denied any history of nightmares or night terrors or other parasomnias. She was diagnosed as having sleep starts or hypnic jerks. She was reassured and was started on clonazepam 0.5 mg at night. After 10 days of starting Clonazepam, she reported a significant reduction in her jerky limb movements. We have tried to reduce clonazepam and take patient off clonazepam but the patient was very much apprehensive of recurrence of jerks so requested us to let her be on same, so she is still on clonazepam and well maintained.
A 57-year-old African American woman with a longstanding history of dilated cardiomyopathy secondary to mitral insufficiency was evaluated for a mitral valve repair and MAZE procedure at an outside hospital (OSH). Preoperative hemodynamic monitoring was instituted with a single stick left transinternal jugular PAC placed in the standard fashion as well as a left radial arterial line. The PAC was easily advanced using pressure curves and secured for periodic evaluation of pulmonary capillary wedge pressure. On induction of anesthesia at the OSH she had severe hypotension with pulseless electrical activity for 15 minutes. She was resuscitated with multiple boluses of epinephrine and subsequent infusions of norepinephrine, milrinone, and amiodarone. Median sternotomy was performed emergently; however the procedure was aborted and an intra-aortic balloon pump (IABP) was placed for supportive care and resuscitation. The sternotomy was then closed without placing the patient on cardiopulmonary bypass and she was transferred to our tertiary level care center for critical care management and a mitral valve repair.\nOn arrival, the norepinephrine was discontinued and she was placed on a dobutamine infusion; milrinone and amiodarone were continued. Preoperatively her transesophageal echocardiogram demonstrated severe systolic dysfunction with an ejection fraction of <20%, a normal sized right ventricle with moderately reduced systolic function, an enlarged left atrium, and severe mitral regurgitation with a thickened mitral valve. Six days after admission she successfully underwent a redo sternotomy with repair of the mitral valve using a 26 mm Edwards annuloplasty band. She arrived in the intensive care unit with infusions of dobutamine, milrinone, and amiodarone and the IABP still in place.\nTwo days after surgery the drips were discontinued and the IABP was removed. That same afternoon the decision was made to remove the PAC from her left internal jugular vein. After appropriate positioning, sterile technique, and assurance that the catheter balloon was deflated, the catheter sleeve was disconnected from the introducer sheath. A slow, smooth, and steady motion was employed to pull back the catheter and met with significant resistance. Two subsequent attempts at pulling and advancing the catheter were attempted to no avail, suggesting a problem. Chest radiography at the bedside was performed which demonstrated kinked PAC at the confluence of the left internal jugular vein and left subclavian vein (). The chest roentgenogram from that same morning demonstrated that the pulmonary artery catheter was in proper position without any kinks. Vascular surgery was consulted for recommendations regarding its removal.\nAfter review of the chest X-ray, gentle initial traction was applied in an attempt to remove the catheter; significant resistance was again noted. A hybrid operating room was prepared in order to pass a semistiff or stiff guide wire to help straighten out the catheter. While awaiting transfer to the operating room the decision was made to attempt to deepen the sheath over the catheter to help straighten it out. Ultimately, with a combination of steady backward traction and forward advancement of the sheath, the catheter was retracted into the sheath allowing for a successful and safe recovery. Once the sheath was removed, the coil pattern, or kinking, of the catheter was evident and reproducible ().\nHemostasis was achieved with a manual compression. The patient tolerated the procedure well and ultimately was discharged from the hospital to a skilled nursing facility for convalescence.
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 active man was referred to our clinic complaining of persistent (4 months duration) numbness of the right lower limb, without any low back pain. The patient had no history of medical problems including symptoms of back pain. The only event, possibly related to the present complaints, was an adductors injury 15 years previously, suffered while playing basketball. The large swelling, which developed at that time, was treated by a few days of bed rest. Since then the patient had been athletically active and he was in training for at least 4 days per week.\nThe numbness was becoming worse after prolonged sitting and the patient mentioned a feeling of relief while standing or even walking. Training did not affect the intensity of the symptoms.\nThe Lasegue's sign was positive (in 25° of right hip flexion) and there was a sensory deficit on the dorsal surface of the right foot, to the first interdigital space. Motor weakness or reflex disturbance did not occur and the lumbar spine had a free and painless range of motion. In addition, examination of the hip, pelvis and spine did not indicate any pathology.\nPlain anteroposterior and lateral radiographs of the lumbar and pelvic areas (Figure ) revealed a normal lumbar spine but also a sizeable global bony mass just below the ischial tuberosity, in contact with a smaller mass. Computed tomography (CT) (Figure ) and magnetic resonance imaging (Figure ) scans revealed two heterotopic bone masses within the muscles. Electromyography findings revealed deep peroneal nerve dysfunction accompanied with pathological measurement of f-wave latency. A whole body technetium bone scan was normal.\nAn operation for nerve exploration and heterotopic bone removal was planned. A posterolateral approach of the right hip was performed. During the procedure, the joint capsule was preserved intact. The sciatic nerve was found to be bluish, distorted and compressed in an hourglass fashion around the larger (4 cm in diameter) heterotopic bony mass. Another smaller bony mass of 4 cm diameter was found behind the nerve. Each mass was enclosed in a fibrous capsule, which, in the case of the larger mass, could not be easily removed because of the presence of strong fibrous bands connected to the sciatic nerve.\nBoth heterotopic bone masses were dissected and removed. The sciatic nerve was left bluish, lying in a waved manner within the local muscles. Histopathological examination reported the presence of mature bone tissue.\nWeight bearing started during the second postoperative day. Symptoms decreased during the third postoperative month and the deep peroneal sensory dysfunction was fully recovered 1 month later. This recovery was documented clinically and by electromyography. The patient received biphosphonates (disodium etidronate, three times daily) for 6 months to avert the recurrence of heterotopic bone formation.
The first case we present is that of a 29-year-old woman who presented to the clinic with the complaint of an enlarging left breast mass. She first noticed that this mass almost 2 years ago and mentions that it has been growing in size and becoming more erythematous and tender. She did not report any recent weight loss or change in appetite. She is married with 2 children, and she does not have any illnesses. She smokes hubble-bubble almost 4 times per week and does not drink alcohol. Surgical history is significant for 2 previous Cesarean sections with no complications. History of her current illness dates back to June 2016 when the patient felt a mass in her left breast; upon further investigation, she was diagnosed with idiopathic granulomatous mastitis and later (December 2017) developed an abscess that drained on its own. She was initially treated with methotrexate and later switched to prednisone and mycophenolate with minimal improvement. At the clinic, her vitals were within normal limits, and on physical examination, there was a left breast lump found at the upper inner quadrant with some erythema and inflammation surrounding it. Moreover, there was some skin retraction in this area.\nCore biopsy done at an outside hospital in June 2017 revealed no granulomas. Ultrasound done at that time showed a persistent ill-defined hypoechoic mass that appeared initially subdermally and was spanning more than 4 × 1.4 cm. Moreover, multiple deeper masses were seen, one of which was not located within the breast measuring 12.3 × 8.5 mm. Axillary nodes were insignificant and not well appreciated on imaging.\nFine-needle aspirate done in July 2017 was negative for malignancy and was reported to have abscess formation. The slides revealed a heavy inflammatory infiltrate predominantly composed of polymorphonuclear leukocytes. No ductal epithelial cells were seen.\nCore biopsy done in November of the same year showed multiple noncaseating epithelioid granulomas composed of epithelioid histiocytes, lymphocytes, neutrophils, and occasional multinucleated giant cells. Some granulomas contained neutrophils forming microabscesses with surrounding empty microcysts ().\nThe Ziehl–Neelsen stain for acid-fast bacilli was negative. This leads to the diagnosis of idiopathic granulomatous mastitis which is a diagnosis of exclusion.\nA repeat MRI done during June 2018 showed heterogeneous fibroglandular tissue with mild background enhancement. There are also numerous tiny rim-enhancing fluid collections in the left breast, the largest measuring 8 mm involving the upper inner and lower inner quadrants, some of which are fistulizing to the skin. Findings have regressed compared to the prior MRI.\nAs with the previous MRI, no enlarged axillary or internal mammary adenopathy was seen.\nThose findings are consistent with biopsy-proven idiopathic granulomatous mastitis extensively involving the upper and lower inner quadrants of the left breast.
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 35-year-old G4P2012 presented to labor and delivery at full term in early labor with spontaneous rupture of membranes. She had undergone living donor kidney transplant 8 years prior for ESRD suspected secondary to IgA nephropathy versus post-streptococcal glomerulonephritis. She was maintained on Prograf and prednisone throughout her pregnancy with a stable baseline serum creatinine 1.2 mg/dL. Obstetrical history was significant for two prior uncomplicated Cesarean deliveries, both prior to her kidney transplantation. It was unclear from her records whether she had undergone counseling regarding pregnancy post-transplant. She declined a of trial of labor after Cesarean section despite counseling on the risk of injury to the transplanted kidney given its location in the operative field, which was confirmed on transabdominal ultrasound prior to the case.\nThe patient was taken to the operating room for and indicated repeat Cesarean section. Routine dissection was performed down to the level of the fascia through a Pfannenstiel incision and the fascia was carefully transected horizontally in the usual fashion. When the superior fascial edge was lifted for traction to allow for dissection from the underlying rectus muscle, brisk pulsatile bleeding was noted. The transplanted kidney was noted to be densely adherent to the overlying anterior abdominal wall, and avulsion of a portion of the transplanted kidney was confirmed (Fig. ). Direct pressure was applied to the organ while the Trauma Surgery team was consulted. The avulsion was repaired using 3–0 pledgetted Prolene sutures in interrupted horizontal mattress fashion and using Evarrest compound. At this time, the decision was made to extend the skin incision in the vertical midline for improved access to the uterus given the concern for further shearing forces to the exposed transplanted kidney in the process of delivering the baby. The rest of the case was uneventful. No blood product transfusion was necessary. After the transplanted kidney was repaired, a viable male infant with Apgars of 8 and 9 weighing 2460 g was delivered.\nPostoperative serum creatinine levels remained stable between 1.1–1 .3mg/dL and the patient maintained adequate urine output. Renal ultrasound immediately postpartum and 1 month postpartum demonstrated normal arterial and venous flow with no evidence of ischemia or perinephric hematoma.
A 49-year-old woman admitted to our hospital complaining of breathing-dependent chest pain and dyspnea with progressive onset lasting for 2 h. The pain was acute at onset, sharp in nature, worse on deep inspiration, did not radiate and was not reproducible with palpation. A day before presenting to us, she was admitted to another emergency unit with an acute pain in the right abdomen. Her symptoms had been interpreted as dyspepsia and she was discharged from the hospital with simple treatment.\nThe most remarkable of her past medical history was that she had been undergone total hip replacement 8 years ago at another institution. Previous pelvic radiograms of that period were not available.\nOn presentation, the patient was in mild respiratory distress with a respiratory rate of 30 breaths per min, heart rate of 90 bpm and oxygen saturation measured via pulse oximetry of 93% on room air. A respiratory examination revealed that right-sided findings of reduced chest expansion, diminished breath sounds and dullness in the lower right chest were found.\nLaboratory investigations were within normal limits. The ECG was unremarkable. Chest X-ray showed the presence of a metallic image ∼5–6 cm long, located in the right hemithorax. There was a large hemothorax but no pneumothorax (Fig. ). The investigation was complemented by a chest computed tomography (CT) that confirmed the presence of a metallic wire in the right pleural space.\nTaking into account the hemodynamic state of the patient, her physical examination, the laboratory results and the CT-scan findings, we decided to perform an urgent surgical removal of the K wire under general anesthesia.\nShe was placed in a left lateral decubitus position and a posterolateral thoracotomy in the fifth right intercostal space was used. The wire was removed without complications. Surprisingly, no injury was noted to any intervening abdominal structure intra-operatively. As a precaution, a 28-F chest tube was placed. There was no air leak or bleeding postoperatively and the tube was removed on the second postoperative day. The postoperative outcome was favorable and the patient was discharged on postoperative Day 4 with a normal chest radiogram (Fig. ).
An 11-year-old boy presented to the emergency department after he was knocked over and his chest was trapped under a soccer goal. He was shocked on arrival and had bruising on the chest.\nThe patient was sent to our emergency department within 1 h, with clear consciousness. On physical examination, he was in a poor general state, but hemodynamically stable, except for tachypnea and tachycardia. There were several bruises over the right and left costal margins and abdominal wall. The abdomen was tense with diffuse tenderness. The extremities were freely movable. Auscultation revealed mild expiratory wheezing over both sides of the chest. Blood and biochemical tests showed an elevated leukocyte count of twenty thousand, and the results of liver function tests (AST and ALT) were elevated to over one thousand. A chest radiograph revealed heterogeneous consolidation in the left lung with a thin-walled cystic lesion (). There was no history of severe pneumonia or respiratory symptoms prior to the accident. Chest CT demonstrated focal areas of consolidation and several cavities over the posterior segments of the right and left lower lobes, with the biggest cavity within the left lobe (size: 90 × 20 mm; ). There was an air-fluid level in the largest cavity, as well as minimal pneumomediastinum and minimal pneumothorax. The CT of the abdomen revealed traumatic laceration of the liver: parenchymal disruption involving less than 50% of the right hepatic lobe with an intrahepatic hematoma (). The patient was admitted to a pediatric ward. He was treated by observation and received broad-spectrum antibiotics. His condition was relatively stable and subsequently improved. He was discharged 19 days later, showing signs of spontaneous resolution of the lesions (residual liver hematoma: 33 × 38 × 35 mm; residual pneumatocele: 19 × 16 mm). The patient was followed up by the surgical outpatient service. After 9 months, a chest radiograph showed complete resolution of the traumatic pneumatocele, and abdominal ultrasound demonstrated complete resolution of the residual liver hematoma.
We present the case of a 36-year-old Caucasian man with a history of self-inflicted penile strangulation by a ring in childhood. He said that he committed this act at the age of 10 years to ‘play’ but the exact circumstances of this incident remain unclear. Our patient had begun to self-stimulate by introducing pieces of electrical cable into the urethra a few years before the current episode where the cable was completely retained in the urethra. Contrary to what might have been expected, he remained asymptomatic and presented with neither dysuria nor hematuria nor urinary incontinence. A physical examination on admission found an emotionally stable patient with no sign of neurosis or psychosis. An examination of the external genital organs found a scar at the base of the penis corresponding to the history of self-inflicted penile strangulation and a hard mass in the perineal urethra corresponding to the cable (Figure ). No leakage of urine was found.\nThe biologic findings were normal.Plain film of the urinary tract showed a hollow tubular object measuring the size of the urethra and reproducing its shape up to the urinary bladder (Figure ).\nThe radiopaque image corresponded to an electrical cable that extended from the urethra into the bladder. We opted for endoscopic treatment because the consultation delay was relatively short and since the hollow shape of the cable might allow its capture.During urethroscopy, we were surprised by the presence of a urethral stricture tight enough to block the progression of the cystoscope (Figure ), but decided to go through with the procedure by performing urethrotomy on the urethral stricture. Urethrotomy was laborious in the face of very fibrotic tissue that was very hard to cut. Finally, we were able to cross the stenosis and reach the extremity of the cable (Figure ) but its extraction was still hampered by the freshly incised stenosis. After several attempts, we managed to remove the cable, which measured 25cm long and was about 1cm in diameter, without requiring open surgery (Figure and Figure ).\nThe procedure ended by placing a bladder catheter inserted over a guide that had been introduced at the beginning of the operation. Our patient was discharged from the hospital after two days and the catheter was removed after 10 days. He did not show any infectious complications.
A 32-year-old woman who was breastfeeding her first baby for 6 months, presented to our Breast Clinic with the complaint of a palpable left axillary lump. She had noticed a lump in her left axillary region before the pregnancy, which became enlarged during the pregnancy and breastfeeding periods.\nPhysical examination revealed a 4 cm mass in the subcutaneous tissue of the left axilla. The mass was nontender and unattached to skin. There were no evidences of inflammation such as skin color discoloration in the left axilla or fever. Ultrasound examination of the axillary region revealed a hypoechoic, well-defined mass with irregular shape and margins and nonparallel orientation measuring 2.5∗3.5∗4 cm which was suspicious for a malignant lesion ().\nColor Doppler ultrasound was performed and did not show vascular flow in the axillary mass. Ultrasound examination of the left breast did not reveal any significant abnormality and lymphadenopathy was not seen in the axilla.\nThere was no significant abnormality at the right breast and axilla except for the proliferative changes of glandular tissue which is a normal finding during lactation and was seen in both breasts.\nConsidering that the patient was in breastfeeding period, our first diagnosis was a galactocele in the accessory breast, but because the sonographic appearance of the axillary mass was not consistent with the ultrasound criteria of a true simple cyst or a typical benign lesion, both the clinician and the patient were concerned and insisted on performing an interventional procedure to rule out possible malignant nature of the lesion. Ultrasound-guided aspiration using a 20-gauge needle was performed for confirming an axillary galactocele. Milky fluid was aspirated and the mass disappeared completely ().\nThe aspirated materials were sent for laboratory evaluation. Cytopathologic examination was negative for malignant cells. Based on these findings, the diagnosis of a galactocele of the axillary accessory breast was made.\nAdditional diagnostic investigations were not indicated in our patient and she was reassured to have a follow-up sonographic examination after 3 months. She returned 4 months later and ultrasound examination was performed. There was no evidence of any left axillary mass and accessory breast tissue with proliferative changes was noted ().
A 3-year-old boy reported to our department with the chief complaint of swelling and bleeding from the maxillary left posterior region since 1 month. History revealed fever and bilateral swelling of eyes since 1 month, for which the child has underwent medication from local doctors. The parent's medical history was insignificant. He was the second child of a healthy nonconsanguineous parent.\nGeneral examination revealed weak, thin built boy with bilateral proptosis [] having difficulty in speech, eating, and swallowing since 1 month. No abnormalities of hand and feet were observed. Intraoral examination revealed soft, fluctuant, tender bilateral diffuse bluish swelling of posterior part of hard palate adjacent to the primary molars. Primary maxillary left molars were displaced buccally []. A single ulcer with rolled borders was seen extending from the distal part of the maxillary left primary second molar to the tuberosity area. Tooth bud of the permanent maxillary left first molar was displaced occlusally [].\nPanoramic radiograph showed the radiolucent lesion of approximately 4 cm × 3 cm in size on the left side of maxilla extending from the maxillary left primary canine and to the tuberosity area []. Tooth bud of the permanent maxillary left first molar and maxillary left second primary molar was displaced occlusao-posteriorly and occlusally, respectively. Hanging teeth appearance was seen with maxillary primary left molars and maxillary permanent left first molar. An ill-defined radiolucent lesion was also seen in the maxillary right posterior region extending from maxillary primary right molars to maxillary permanent right first molar. The developing tooth bud of maxillary permanent right first molar and maxillary primary right second molars was displaced distally and occlusally [].\nBased on the clinical and radiographic features, a provisional diagnosis of malignancy was made. A complete blood profile and bone marrow aspiration cytology were advised. The complete blood profile was within normal limits. However, bone marrow smear showed round tumor cells arranged in cohesion clusters and sheets having hyperchromatic nuclei. Ferrous arrow showed rosette formation. These features were suggestive of malignant round cell tumor. During this period, the crown of the permanent maxillary left first molar exfoliated. To more accurately depict the lesion cone beam computed tomography (CBCT) of maxilla was planned. Coronal view of left side of maxilla (CBCT) showed a lesion of diameter 4 cm × 3 cm with an irregular border and bony expansion []. Three dimensional CBCT image showed a marrow-destroying mass on the left side of the maxilla of approximately 4 cm × 3 cm in size and buccally displaced primary maxillary left molars []. After 2 days, patient reported with exfoliated primary maxillary left second molar.\nThe patient was referred to a medical college for further subtyping of malignant round cell tumor and to rule out the metastasis to other parts of the body. Immunohistochemistry, ultrasonographic-guided fine-needle aspiration from the right suprarenal area, magnetic resonance imaging of the orbital plane, and multislice spiral CT of the abdomen were advised. Ultrasonographic-guided fine-needle aspiration from the right suprarenal mass confirms the presence of malignant small round cell tumor: Possibly neuroblastoma. Magnetic resonance imaging of the orbital plane and contrast study reveals multiple well-defined heterogeneous, lobulated, altered, signal intensity mass lesions of varying sizes involving bilateral orbit, bilateral maxillary sinuses, and surrounding soft tissue suggesting metastasis. Multislice spiral CT of the abdomen showed well-defined lobulated heterogeneously enhancing mass lesion in relation to the superomedial aspect of the right kidney with few calcification and encasement of abdominal vessels with skeletal metastasis suggesting neuroblastoma. Due to lack of facility of immunohistochemistry of the malignant round cell tumor was not possible. Patient and parents were explained regarding malignancy and complexity of dental treatment. The patient was then referred to the Government Medical College for further management.
An 11-year-old girl was referred to our hospital in August 2010 with a lesion in the right cheek area which was progressively enlarging. The patient complained that her nose and mouth corner were crooked and that her face was swelling. In clinical examination, the patient had a slight asymmetry in the right midface as a result of buccal and palatal cortical expansion from the right maxillary canine to the molar region, resulting in depression of the nasal alar and mouth corner (Fig. ).\nA panoramic radiograph showed an increased bone density on the right maxilla and zygoma and obliteration of the right maxillary sinus. Computed tomography (CT) revealed a 4.5 × 4 × 4.5 cm, expansile ground-glass opacity lesion involving the right maxillary sinus, right maxillary alveolar process, zygoma, and hard palate. Bone scan revealed an irregularly shaped hot uptake in the right maxilla, and no abnormally increased uptake was observed at any other sites (Fig. ). The physical examination did not show any other lesions, and the patient had no history of pain, trauma, loosening of teeth, or trismus. Based on the typical radiologic findings, the patient was diagnosed with FD, and no additional biopsy was performed. The patient had regular follow-up every 6 months to monitor the lesion’s progress. At the 1-year follow-up, the development of tooth germ within the lesion was normal, and slight expansion of the lesion to the bucco-lingual side was observed. Because we thought the patient was still growing and increasing in height, we decided to conduct an ongoing progress observation.\nAbout 3 years later in December 2012, there were no significant changes of the FD lesion, but the distance from the mouth corner to the inner canthus was about 2 cm longer on the right side than on the left. Periodic observation was continued, and in August 2017, corrective surgery was planned because the maturation of the lesion was confirmed to be complete and there were no changes in the size of the lesion. At that time, the distance from the mouth corner to the inner canthus was 2.5 cm longer on the right side than on the left, and the distance from the occlusal plane to the outer canthus was 5 cm longer on the right side than on the left. Bone contouring surgery, the primary treatment for facial asymmetry and fibrotic bone lesions, was planned (Fig. ).\nThe patient wanted to improve asymmetrical facial appearance through the surgery. Therefore, we aimed not only to remove the FD lesion, but also to make the patient’s facial as symmetrical as possible. For this, direct visualization and surgical approach to the infraorbital rim and lateral area of zygoma were required, but the surgical approach through buccogingival incision had limited access to these areas. On the other hand, the midfacial degloving approach was expected to help reestablishing symmetric facial contour by allowing direct comparison of the lesion with the normal side. Moreover, this approach provides esthetically acceptable outcomes, leaving no scars and no functional disability. Therefore, we decided to perform the operation through the midfacial degloving approach.\nWith the patient under orotracheal anesthesia, the lesion was removed by the midfacial degloving surgical procedure. Local anesthesia with 2% lidocaine with epinephrine (1:100,000) was infiltrated into the maxillary vestibular mucosa and into the nose. The procedure is performed with a maxillary vestibular incision and three intranasal incisions to expose the entire midface skeleton that include (1) bilateral intercartilaginous, (2) complete transfixion, and (3) bilateral piriform aperture incisions (Fig. ).\nA buccogingival incision was made in the maxillary vestibule approximately 5 mm superior to the mucogingival junction and extended from the second molar to the contralateral second molar. Periosteal elevators were used to elevate the tissues in the subperiosteal plane fist over the anterior maxilla and then extending widely to encompass posterior tissues behind the zygomaticomaxillary buttress. The infraorbital neurovascular bundle was identified superiorly and dissected. Subperiosteal dissection along the piriform aperture stripped the attachments of the nasal labial muscularture to allow its complete release from the midface skeleton. The mucoperiosteal flap was elevated up to the piriform aperture.\nThe intercartilaginous incision divided the junction between the upper and lower lateral cartilages (Fig. b). An incision was made along the inferior border of the upper lateral cartilage, beginning at the lateral end and extending medially curved into the membranous septum anterior to meet transfixion incision (Fig. a). Laterally, the incision was sufficient that it extended to the piriform aperture. The lower lateral cartilage was eventually displaced superiorly during the degloving procedure, whereas the upper lateral cartilage remained attached to the midface skeleton. The transfixion incision was used to separate the membrane septum/columella from the cartilaginous septum. An incision was made along the caudal border of the septal cartilage from the medial end of the intercartilaginous incision toward the anterior spine (Fig. a). The intranasal incision was made by a full-thickness incision down through the periosteum of the piriform margin and the nasal floor.\nDissection through the intercarilaginous incision allowed access to the nasal dorsum and bones (Fig. b). Sharp subperichondrial dissection with a scalpel or a blunt dissection with scissors freed the soft tissues above the upper lateral cartilage as in a standard open rhinoplasty. The dissection should be within the subperichondrium plane to prevent injury to the overlying musculature and blood vessels of the nose. Elevation extended laterally to the nasomaxillary sutures and superiorly to the glabella. Retraction of the freed soft tissues allowed sharp incision to be made with a scalpel or with sharp periosteal elevators through the periosteum at the inferior edge of the nasal bones. Elevation of the soft tissue laterally to the piriform aperture was also performed so that the maxillary vestibular dissection was easily connected to this pocket.\nAfter the connection of the nasal and oral incisions, the midface was degloved. The midface skin was separated from the maxilla and the nasal pyramid. The upper lip and the intact nasal columella, nasal tip, and alar cartilages were then retracted by two Penrose drains introduced through the nostrils over the nose to the level of the inferior orbital rim. This approach provided visualization of the medial maxillary wall, pterygoid junction, nasofrontal suture, infraorbital rim, and laterally to the temporal process of the zygoma (Fig. d). Under direct visualization, the overgrowing bone lesion was then excised using osteotomes and saws. The right maxilla was drilled further at the orbital rim and laterally till zygomatic complex. The contour of the midface was reestablished using burr to give a cosmetically normal looking midfacial skeletal contour while protecting the infraorbital nerve (Fig. ). For the removed lesion, a biopsy was performed for the accurate diagnosis and histologically confirmed as FD. The soft tissues were then carefully redraped and the nasal tip brought back into position. The intranasal incisions were closed using 4-0 resorbable sutures (vicryl), and the transfixion sutures were precisely performed to determine the final position of the nasal tip and prevent vestibular stenosis. The cinch suture of alar base was used to prevent postoperative alar base widening. The intraoral incisions were closed using a 3-0 black silk. Nasal packing into the maxillary dead space with Vaseline gauze was done for 3 days in order to minimize the postoperative bleedings.\nThe patient’s postoperative course was generally uneventful. There was moderate nasal crusting for 3–4 days. Mild swelling with periorbital ecchymosis disappeared after 2 weeks, and transient paresthesia around the infraorbital nerve spontaneously resolved after 3 month. No postoperative complications such as epistaxis, vestibular stenosis, or esthetic problems of the nose were seen. Clinical and radiographic examinations obtained 4 months after surgery showed the anatomical structures were in a stable state without recurrence of FD (Fig. ). The esthetic result was satisfactory for the patient, and occlusal state was also well maintained (Fig. ). Therefore, no additional orthodontic treatment or orthognathic surgery was performed.
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 74-year-old woman was referred by her gastroenterologist with painless jaundice. She presented with several months of decreased appetite and a three week history of light colored stool with dark urine. An endoscopic ultrasound was performed and revealed a hypoechoic, irregular, 3.4 cm mass in the head of the pancreas. The common bile duct and pancreatic duct were obstructed from the mass. No vascular invasion, celiac or peri-celiac lymph nodes were noted. Two biliary stents were placed and no biopsies were taken during the procedure.\nPrior to considering the patient a candidate for surgery, a high resolution computed tomography (CT) scan was performed with pancreatic protocol in non-contrast, arterial and venous phase to determine resectablity. CT scan was consistent with a double duct sign with markedly dilated pancreatic and common bile duct and intrahepatic biliary dilation secondary to mass on the pancreatic head. An interesting variant in anatomy was also identified, which was important for proper surgical planning. The superior mesenteric artery was found to be originating from the celiac axis. (Figure , , )\nPancreaticoduodenectomy is utilized selectively in the management of patients with neoplastic lesions of the pancreas and periampullary region. In these patients, the role of CT angiography (CTA) is important in determining tumor respectability and it allows one to evaluate for variant arterial anatomy. Preoperative knowledge of variant anatomy can assist in selection of treatment options and facilitate in surgical dissection and avoid iatrogenic injury.\nThe celiac artery supplies the liver, spleen, pancreas, and some of the stomach and duodenum. The superior mesenteric artery (SMA) supplies the small intestine, ascending colon, and a large portion of the transverse colon. Variation of arterial anatomy is common and occurs in nearly half of the population []).\nWe report a patient undergoing preoperative evaluation with CTA finding of Superior Mesenteric Artery (SMA) originating from the celiac artery. This celiac-mesenteric trunk is rare (<1%), however has been described [].\nIn the embryo, the three paired arteries of the trunk originate from the aorta. Posterior arteries are parietal, lateral arteries are urogenital, and anterior arteries are intestinal. In human embryos the primitive intestinal arteries (vitelline arteries) are connected by a Tandler's anterior longitudinal anastomosis []. When the connection between celiac trunk and SMA remains presents, it tends to form a small vertical arch just behind the body of the pancreas. The rarely reported arterial anastomosis between the celiac trunk and SMA is known as the arc of Bühler's according to McNulty et al. []. An arc of Bühler was identified in 4 patients (3.3%) out of 120 combined celiac and superior mesenteric artery angiograms, in a study by Saad et al. []. In one study the arc of Bühler was identified in 14 cases among 340 selective celiac and superior mesenteric arteriographic studies []. They also stated that the arc of Bühler between the celiac and superior mesenteric arteries has to be considered as an embryological persistence 10th and 13th primitive arteries, which is associated with the persistence of ventral longitudinal anastomosis [,]).\nIn our patient the CTA also demonstrated a subtotal occlusion of the origin of the celiac axis. There was significantly enlarged inferior mesenteric artery, which is likely due to the retrograde perfusion of SMA and celiac arteries.
An 83-year-old male underwent an extensive regional R1-resection for a SCC lesion on his right ear and reconstruction with removable skin flap in 2012, followed by parotidectomy six months later and level II lymph node resection due to relapse of the SCC to the right parotid gland. He received an adjuvant first-line chemotherapy and radiotherapy (9 cycles) with 5-FU, cisplatin and second line chemotherapy with Methotrexate 8 mg weekly, with initial good response to treatment. Unfortunately, a few months later his disease started to progress. The patient is now on chemotherapy with cetuximab (last dose 36 hours ago), without any distal metastases but with regional outspread of the disease to his right ear and mandible.\nThe patient presented to the Emergency Department of Nicosia General Hospital with epigastric pain and vomiting during the last five days, without bloody stools. The patient was afebrile, with mild abdominal distention and without peritoneal signs. Leukocytes, amylase, and lactic acid were all within the normal ranges. Abdominal radiograph revealed free air intraperitoneally and abdominal/pelvic computed tomography revealed findings of small bowel ischemic necrosis in the presence of free intraperitoneal air and air in the intestinal wall ().\nThe clinical suspicion of bowel perforation was part of the differential diagnosis and the decision of an emergency surgical operation was made. Emergency exploratory laparotomy revealed a part of small intestine (2 m) with ischemic signs, including air bubbles and bowel edema but the bowel was considered to be viable and no resection was performed. Thorough exploration of peritoneal cavity did not reveal any other pathological signs or intestinal leak. We concluded that the findings could only be associated with the pathogenesis of pneumatosis intestinalis.\nTwo drainage tubes were placed and the patient was sent to ICU for postsurgery follow-up and weaning. After 24 hours the patient was transferred to surgical ward for further treatment. After six days of hospitalization and complete resolution of symptoms the patient was discharged.
A 52-years-old man was transferred to our intensive care unit in July 2016 because of an acute episode of respiratory failure after using anesthetic drugs 8 days earlier. He felt easily fatigued and developed insidiously limb weakness in the previous 6 months. He attributed this to toothache resulting in a poor appetite. However, he was still able to maintain his daily life and keep on working. His family noticed that he lost 7.5 kg of body weight in 6 months and took him to the gastroenterology department of a local hospital. He received a painless gastroscopy and colonoscopy examination using propofol on 19 July 2016. He regained consciousness very slowly for over forty min and was found to have hypoxemia with a blood oxygen saturation degree (SO2) of 86%. After expectant treatment of oxygen inhalation, he recovered to a relative stable condition and drove home. He developed increasing shortness of breath in the following days, which eventually deteriorated into acute respiratory failure. Arterial blood gas (ABG) analysis showed a pH of 7.25, and a PaCO2 of 86.25 mmHg. Although the PaO2 level was in a normal range by treatment of oxygen inhalation, the diagnosis of type II respiratory failure was considered because of hypercapnia. A pulmonary function test suggested a moderate restrictive ventilator impairment. No evidence of pneumonia or bronchitis was found through Computed Tomography (CT) scanning. Since he developed recurrent episodes of hypoxemia, hypercapnia and delirium, he received artificial ventilatory assistance on July 26th. Next day, he was transferred to our hospital.\nHe denied a family history of neuromuscular disease, central nervous system dysfunction, genetic disorders, diabetes mellitus, or vision and hearing dysfunction. His mother was emaciated and suddenly passed away of unknown reason at the age of 60. His siblings were reportedly healthy.\nOn admission the patient was in a mild agitated state. He looked very thin and his height was 1.65 meters and weighed 47 Kg. His body temperature was 36.8°C, pulse rate 90/min, respiratory rate 25/min, and blood pressure 116/69 mmHg. The SO2 level was 100% with oxygen inhalation by nasal mask at 3.0 L/min. No abnormality was found in the respiratory and cardiovascular systems. A neurological examination showed that cranial nerves function was normal. There was no ptosis, external ophthalmoplegia, diplopia or facial weakness. The proximal upper and lower limb muscle power was mildly decreased (Medical Research Council grading criterion, grade IV) and his distal muscle strength was approximately normal. His tendon reflexes were diminished. No abnormalities in the long tract, sensitive system, meningeal irritation or cerebellar signs were noted.\nLaboratory investigations revealed normal levels of liver function, kidney function, blood glucose, blood ammonia, serum electrolytes, blood clotting function, serum creatine phosphokinase, thyroid function, rheumatologic antibodies, tumor biomarkers, folate, and vitamin B12. The peripheral white blood cell count was normal, but the percent of segmented neutrophils increased to 84.6%. ABG analysis showed a pH of 7.24, a PaCO2 of 120 mmHg and a PaO2 of 198 mmHg with O2 inhalation. Blood lactate level at rest in the first test of our hospital was normal but fluctuated from normal to >12 mmol/L (0.7–2.1 mmol/L) in the successive tests. Because of a presumptive diagnosis of myasthenic crisis, he received pyridostigmine for a week without any improvement. No abnormalities were found in the levels of the serum anti-acetylcholine receptor (AChR) antibodies.\nElectrocardiogram, a computed tomography scan of the chest and Magnetic Resonance Imaging of the head and cervical spinal cord were normal (). There was no abnormality in the repetitive nerve stimulation examination and the motor and sensory nerve conduction velocity. Needle electromyography (EMG) revealed small, short-duration and polyphasic motor unit action potentials in the musculus biceps brachii, deltoid, quadriceps femoris, sternocleidomastoid and rectus abdominis bilaterally, which is consistent with myopathic disorders. Tandem mass spectrometry analysis for organic acid in blood and urine was performed to detect lipid storage myopathy and the results remained in a normal range.\nA muscle biopsy of the left musculus biceps brachii was performed. Myopathic alterations were observed but no evidence of obvious inflammation, necrosis and degeneration was found. The fiber size was variable and fiber shapes were mildly irregular by Hematoxylin-eosin staining (). Some RRF were evident as shown in . Increased enzyme activities in some muscle fibers were observed using cytochrome c oxidase (COX). Expressions of MHC-I, R, C, N-dystrophin, α, β, γ-sarcoglycan, and dysferlin were normal. No abnormalities were seen in the staining of NADH, Periodic Acid Schiff (PAS), oil red O (ORO), and Adenosine Triphosphate (ATP) synthase. Screening for putative point mutation by polymerase chain reaction (PCR) revealed an A3243G mutation (88%) in the mitochondrial tRNALeu gene from total DNA extracted from the peripheral blood specimen ().\nAccording to the findings of EMG and muscle biopsy, the patient was diagnosed as mitochondrial myopathy with mtDNA A3243G point mutation. He was given a cocktail treatment of vitamin-C, B1, riboflavin, coenzyme Q10, cobamamide, and L-carnitine. Non-invasive ventilatory support with bilevel positive airway pressure (BiPAP) therapy via a basal mask was continued for 22 days, and then the artificial ventilator assistance was only used at night. The follow-up ABG analysis results were normal. His mental state, body weight and exercise tolerance improved gradually. He was discharged with the ventilator. The patient was reviewed for more than 2 years. Nocturnal BiPAP had been well-tolerated and ABG analysis was performed every 2 weeks. His limb power regained to the normal extent and his weight increased to 60 kg.
An 11-year-old girl accompanied by her mother was reported to the Department of Pediatric and Preventive Dentistry, Navodaya Dental College and Hospital. The chief complaint was narrated by the mother describing the unaware daytime and nocturnal thumb sucking habit of her daughter till the present age. An appropriate habit history and clinical evaluation was done along with the patient pretreatment record including radiographs, study models, and photographs.\nIt revealed that she was the 3rd child to her parents who belongs to a middle class family. The other two elder siblings also had the habit. Her relationship with her peers was good but she was subjected to being cursed upon practicing the habit. Psychological evaluation revealed positive attitude towards discontinuing the habit practice.\nExtraorally, it revealed depression just above the corner of the mouth, and the lips were slightly inwards at the corner of the mouth. Intraorally, there were anterior open bite of 2 mm, proclined upper/lower incisors except left lateral incisor which was palatally locked, unilateral posterior crossbite involving the two premolars with constricted maxilla on the left, compensatory tongue thrust, and mild lisping in her speech.\nA brief treatment plan was formulated comprising initially parent and patient counseling. This was done by discussing the problems or the deleterious effects of a persistent sucking habit with the audiovisual aids. Patient responded positively and was motivated to stop practicing the habit. Parents were also counseled to motivate and support her in discontinuing the habit.\nShe was started on the modified quadhelix appliance with a roller (). During this she showed positive attitude and was willing to try the appliance as an aid to stop the habit. She was on a passive appliance initially followed by activation of the appliance to correct the deformities for a total period of 9 months. At the end of the treatment, she intercepted the habit practice and the deformities were refrained and transformed to a proper relationship (Figures , , and ). There was correction of anterior open bite and correction of posterior crossbite along with the alignment of the palatally locked incisor.
A 32-year-old Hispanic female with no past medical problems presented to the Ben Taub Emergency Department with shortness of breath and severe chest pain. She was G2P2A0 and 3 days earlier, she had undergone an uneventful repeated cesarean section. While undergoing triage, the patient lost consciousness and became unresponsive. She was found to be pulseless and apneic and her initial rhythm was ventricular fibrillation. Advanced cardiac life support protocols were started and the patient underwent defibrillation twice before conversion to a sinus rhythm. The postresuscitation 12-lead electrocardiogram (ECG) showed ST-segment elevations in the anterior leads with reciprocal ST depressions (see ). At that point, she was transported emergently to the cardiac catheterization laboratory and was found to have dissection of the left anterior descending artery (LAD), and 3 stents were placed. During catheterization, she required temporary transvenous pacing and an intra-aortic balloon pump (IABP). After stabilization, she was transferred to the cardiac intensive care unit (CCU). Her systolic blood pressure stayed above 100 mm Hg with inotropic support. One day later, the patient reconverted to ventricular fibrillation and required another defibrillation. She was returned to the catheterization laboratory a second time and was noted to have proximal dissection of the LAD beyond the initial stents placed and received 3 more stents for a total of 6 stents. She was returned to the CCU, again requiring inotropes, temporary pacing, and IABP to manage the cardiogenic shock. Over the next several days, the patient slowly improved and was weaned off inotropes. The IABP was removed and she underwent extubation.\nAfter the initial acute phase of hospitalization, the patient continued to remain hemodynamically stable. The chest radiograph results showed gradual improvement of her condition with remission from respiratory failure. Her hemoglobin levels and hematocrit remained stable during the latter part of her admission. She was able to ambulate and began working with physical therapy for rehabilitation exercises. She was eventually discharged with vital signs within normal limits. Her predischarge echocardiogram showed a left ventricular ejection fraction of 30% to 34%, which was unchanged from an echocardiogram done earlier during her hospitalization. The echocardiogram showed hypokinesis of the anterior wall of left ventricle, but no left ventricular wall thrombus. She was discharged in good condition and given Aspirin, Plavix, Lisinopril, Coreg, and Aldactone.\nOne month later, the patient again presented to the emergency department complaining of intermittent chest pressure for 2 days, which was not associated with shortness of breath or sweating. Her vital signs were normal and cardiovascular, pulmonary, abdominal, musculoskeletal, and genitourinary examination results were normal. Cardiac enzyme levels were within normal limits, and ECG showed T-wave inversions V3-V6, Q waves in V1-V4, but no acute changes from the discharge ECG. Three sets of cardiac enzyme results remained negative. All ECG changes were consistent with the post MI ECGs. Exercise stress test was ordered, and the patient tolerated 9 minutes of exercise, with no ischemia. She was further evaluated by the cardiology service and subsequently discharged and given Aspirin, Lisinopril, Coreg, and Plavix.
A 50-year-old male presented with complaints of chronic, intermittent abdominal pain. The patient had a 20-year history of mild-to-moderate amount of alcohol consumption. There was no history of jaundice, fever or weight loss. His laboratory tests revealed no significant abnormal findings. Serum amylase and lipase, and tumour markers [CA 19-9, carcinoembryonic antigen (CEA)] were within normal limits. The patient was subjected to a CT examination. On unenhanced CT image, a poorly defined soft tissue mass was seen in the pancreaticoduodenal (PD) groove with a hypodense cystic lesion within the mass (). On post-contrast study, the lesion showed minimal enhancement in the portal venous phase ( and ), but delayed imaging at 2–3 min showed mild persistent enhancement of the lesion compared with the pancreatic parenchyma that was consistent with scar tissue () and a non-enhancing cystic lesion within the lesion. The lesion showed poorly defined fat planes with the adjacent second part of the duodenum on its right side and pancreatic head on the left side. Mild thickening of the wall of the second part of the duodenum adjacent to the lesion with variable luminal narrowing was noted. The common bile and pancreatic ducts appeared grossly normal. The pancreatic body and tail were normal. In order to clearly delineate the ductal system and the periampullary region, and to know the extension of the lesion, the patient was also subjected to an MRI examination. Axial two-dimensional fast imaging employing steady-state acquisition () sequences showed soft tissue signal intensity lesion in the PD groove with a cystic lesion within the lesion and the aforementioned CT scan findings. MR cholangiopancreatography sequence () revealed smooth and regular tapering of the pancreatic and common bile ducts. The gallbladder was distended and the cystic duct was normal. Incidentally, a few simple cysts (Bosniak 1) were noted in both the kidneys. The patient was advised further surgical intervention but he refused and was managed with conservative treatment. At present, the patient is asymptomatic.
A 17-year-old male presented with a one-week history of abdominal pain and dysuria. He described the abdominal pain as sharp and localized to the infraumbilical and right inguinal regions. He reported a decrease in appetite. He lost approximately 15 kg over the preceding five months. He had no fever. He had normal bowel movements without blood or mucus. His past medical history was significant for recurrent anterior abdominal wall abscesses. The initial abscess occurred five months prior and he was treated with intravenous (IV) antibiotics at an outside facility. At that institution, computed tomography (CT) of the abdomen was reported as demonstrating significant bowel wall thickening of the TI with adjacent inflammatory stranding. After the antibiotic course was completed, a repeat CT showed resolution of the abdominal wall abscess but persistence of the bowel wall abnormality. Two months later, he developed a second episode of abdominal wall abscess formation that required percutaneous surgical drainage and antibiotic therapy (amoxicillin and metronidazole). Aspirated serous fluid contained few leukocytes and was sterile. After this second episode, he underwent esophagogastroduodenoscopy (EGD) and colonoscopy at the outside institution. The EGD was normal and colonoscopy revealed erythema with ulcerations in the TI. Histopathology confirmed severe chronic inflammation of TI. He was prescribed an oral 5-aminosalicylic acid for inflammatory bowel disease. He was not compliant with taking this medication. His abdominal pain slightly improved for a brief period of time. A follow-up colonoscopy was planned at the other institution but he was admitted to our hospital with the current presenting symptoms.\nOn admission, his vital signs were within normal limits. Physical examination revealed a soft, non-distended abdomen with mild tenderness in the infraumbilical and right inguinal regions. A small area of erythema and induration, approximately 2 cm in diameter, was present just inferior to the umbilicus. There was minimal guarding but no rigidity or rebound. No umbilical discharge was noted. Laboratory evaluation demonstrated elevated inflammatory markers and normal hemoglobin, platelet count, albumin, and urinalysis. The CT of the abdomen revealed a rim enhancing ovoid shaped fluid collection in the midline of the suprapubic region (just below the umbilicus) measuring 10.5×3×2.5 cm (). This abscess cavity contained multiple small foci of gas tracking from the umbilicus to the superior-ventral aspect of the urinary bladder wall. Contiguous with the ovoid fluid collection and just lateral to the right rectus abdominis muscle, there was a smaller abscess approximately 1.5 cm in diameter. The CT also revealed significant thickening of the wall of the distal ileum that was in close contiguity with the urachal remnant suggesting the presence of an enterourachal fistula (). The prior CT performed at the outside hospital at the time of initial presentation was reviewed at our institution and revealed a patent urachus at the same location of the current ovoid shaped abscess (). He was started on IV piperacillin-tazobactam. He underwent EGD and colonoscopy. EGD was normal. Colonoscopy revealed severe erythema and ulceration in the TI and colon appeared normal. Biopsies from TI revealed chronic severe ileitis with architectural distortion. The colonic biopsies were normal. Magnetic resonance enterography (MRE) confirmed the CT scan findings and clearly demonstrated a fistula from the TI to the urachal remnant abscess (). Quantiferon-TB gold test was negative and chest radiograph was normal. He was diagnosed with fistulizing CD based on the endoscopic, histologic, and MRE findings. Induction therapy for CD with prednisone was initiated. Percutaneous drainage of the abscess was performed. The aspirated fluid was purulent with neutrophilic predominance and no organism was cultured. He completed two weeks of IV piperacillin-tazobactam and two weeks of oral ciprofloxacin and metronidazole therapy. At the completion of the antibiotic course, a CT scan with sinogram (contrast administered through the drainage catheter) showed no residual fluid collection and no significant filling of the abscess cavity with contrast. The drainage catheter was removed. Repeat MRE showed interval improvement of the TI thickening, complete resolution of the anterior abdominal abscesses, and a blind-ended fistula from the TI without communication to the urachal remnant. His inflammatory markers slowly normalized. Prednisone was gradually weaned and he was started on azathioprine for maintenance therapy. He was referred for a colorectal surgical consultation and underwent laparoscopic exploration of the abdomen. The old abscess cavity was identified and noted to be tightly adherent to the anterior abdominal wall and in close proximity to the inflamed TI. Ileocecectomy with primary anastomosis and complete resection of the abscess cavity was performed. The enterourachal fistula could not be identified and likely obliterated with the medical management. Resection of the urachal remnant could not be simultaneously done due to dense adhesions. Histopathology of the resected specimen confirmed active CD. A repeat colonoscopy ten months after the surgery revealed the CD in remission. He had no recurrence of abscesses during the follow up. A complete resection of the urachal remnant has been planned.
A 32-year-old Caucasian woman requested preconceptional counseling on account of her family history of MFS. Her brother had been diagnosed with the syndrome several years ago and he had recently undergone a successful surgery for aortic aneurysm. He was found positive for a heterozygous nonsense FBN1 mutation 2049C > A (C683X). The patient was clinically asymptomatic and her detailed physical examination by internist, cardiologist, and ophthalmologist did not reveal any signs of the disease. She had genetic consultation and testing and she was also found to be a carrier of the same mutation. Standard tests were carried out (complete blood account, biochemistry) as well as echocardiography and MRI of the heart and large vessels. There were no cardiovascular abnormalities in the patient and the diameter of ascending aorta at the level of Valsalva sinus was 34 mm. She was advised to undergo controlled ovarian stimulation, in vitro fertilization (IVF) combined with preimplantation genetic diagnosis (PGD) to conceive a healthy child. From our perspective we had a comprehensive discussion with the patient regarding the risks of ovarian stimulation as well as the risks of a subsequent pregnancy should it occur. The patient was aware of all the risks associated with the procedure but she was willing to proceed.\nShe underwent controlled ovarian stimulation according to a short GnRH antagonist protocol. Eighteen oocytes were retrieved and underwent intracytoplasmic sperm injection (ICSI). Thirteen oocytes were fertilized. Out of those, 9 embryos proceed to the 8-cell stage (day 3 after retrieval) and underwent embryo biopsy. On the 9 blastomeres obtained, genomic DNA was used for PCR amplification of exon 16 in the FBN1 gene, with primers designed to detect the nonsense FBN1 mutation 2049C > A (C683X). The corresponding PCR product was sequenced in both the forward and reverse orientations. Three embryos were identified with the nonsense FBN1 mutation 2049C > A (C683X). Five embryos had inconclusive diagnosis and there was only one apparently healthy embryo. This embryo was transferred at the blastocyst stage (day 5 after retrieval). Two weeks later she had a positive pregnancy test and 4 weeks after the transfer she had a transvaginal sonogram which revealed a singleton pregnancy with positive fetal heart rate.\nDuring the course of her pregnancy she had frequent obstetrical visits as well as with her cardiologist. Every trimester she had echocardiographic evaluation of the heart and large vessels which remained unchanged throughout the pregnancy. The aortic diameter did not exceed 27 mm and the sinus of Valsalva 35 mm without any other cardiovascular pathology. She remained hemodynamically stable throughout her pregnancy with blood pressure measurements of 110 to 90 mmHg for the systolic and 65–80 for the diastolic. At 20 weeks of gestation she was diagnosed with decreased cervical length of 18 mm and she underwent a successful cervical cerclage (Shirodkar). At 28 weeks she was diagnosed with gestational diabetes mellitus which was subsequently controlled with SQ-insulin. She had also developed iron-deficiency anemia (hemoglobin: 9.0 g/dL, hematocrit: 28.4%) not responding to oral iron supplementation and she was treated with intravenous iron therapy according to the protocols of our department. At 34 weeks' gestation she was admitted with premature contractions. The cerclage was removed. Epidural anesthesia was administered for pain control. She eventually delivered vaginally a healthy premature male infant weighting 2440 gr. with Apgar scores 7 in 1st minute and 10 in 5th minute. The patient had an uncomplicated postpartum course and she was discharged home on postpartum day 3. The infant was admitted to the NICU for observation and underwent genetic testing for disease. There is no mutation revealed and the infant was discharged after 10 days. The patient remained asymptomatic after delivery and she had another echocardiographic evaluation at 4 weeks and 3 months postpartum with no significant changes.
An 18-year-old male student sustained an accidental gun shot injury to the left hip region, with a country made lead shotgun, during bird hunting. There were multiple small entry wounds in the left trochanteric area caused by tiny pellets. There was no fracture. Initially he was given local wound care and systemic antibiotics. After the wounds healed, the patient was unable to bear the weight on the left hip joint due to pain and started non-weight bearing walking with crutches. He continuously complained of a sudden severe catching pain in the hip joint in a particular position of the thigh while swaying the limb during the crutch walking, and in the bed during change of posture. He was taking nonsteroidal anti-inflammatory drugs and massage for the same. He reported four months after injury. His plain X-rays (AP and lateral view) of hip joint showed multiple pellets in the region of the proximal femur with one pellet lodged in the hip joint [Figure and ].\nThe patient was taken up for an arthroscopic retrieval of the bullet with a preparedness of an arthrotomy in case of failure. The patient was positioned supine on the fracture table with a standard mid-line perineal post. In spite of the thin built of the patient, distraction at the hip joint was difficult and required heavier traction. The standard antero-lateral portal and the lateral (supra trochanteric and anterior partrochanteric) portals were used. A 30° scope was used. In the absence of the arthroscopic pump, the effect of gravity was used in distending the hip joint by raising the height of the irrigation fluid. The visualization of the bullet was initially not easily possible due to chronicity having resulted in the growth of organized scar tissue around the projectile. Debridement of the hyper-trophic synovium was done with the shaver, resulting in some bleeding inside the joint, making the arthroscopic picture blurred. The scope was placed adjacent to the bullet with the help of the image intensifier []. Visualization was possible by lowering the blood pressure of the patient, and raising the fluid pressure inside the hip joint by enhancing the height of the fluid bottles and lowering the operation table. The surrounding area was cleared with the shaver blade and thermal ablator leading to visualization of the bullet, which was lying firmly impacted in the supero-lateral acetabular wall.\nIt was not possible to move the bullet with the probe or the canula of the arthroscopic trocar. A long thin osteotome from the revision hip arthroplasty set was used to disimpact the bullet []. The disimpaction of the bullet left a well circumscribed crater in the acetabular wall []. The bullet was manipulated with the probe to a convenient location in the hip [], where grasping was possible with a loose body grasper.\nArthroscopic examination of periphery of the joint was made with 30° and 70° scopes to rule out any other loose fragments. No major defect in the femoral head was noticed except for a small abrasion in the supero-posterior area. The total duration of the procedure was 70 minutes. The three portals used in the procedure were sutured []. The removed bullet was roughly spherical shaped with approximate one cm diameter [].\nThe patient became pain free the same evening and started partial weight bearing on the next day of surgery. However, he complained of mild temporary numbness in the perineal region probably resulting from heavier traction, which recovered completely in three months. At one month, the patient started normal full weight bearing. The hip flexion on the affected side was short by 30° than the normal, abduction and adduction were short by 20° and five degrees respectively and external and internal rotations by five and 10° respectively. At 13 months follow-up, the patient had returned to normal activity without any functional limitations.
A 53-year-old male was admitted to the hospital with chest discomfort that had persisted for five days. His medical history was unremarkable, except for a tuberculosis infection 10 years earlier. Elevated cardiac enzyme levels were observed, including 0.1 ng/mL of troponin T and 11.1 ng/mL of creatine kinase-myocardial band. Electrocardiography showed that the ST segment was elevated at the anterior lead. A chest X-ray showed pulmonary congestion. Transthoracic echocardiography revealed a reduction of the ejection fraction to 35%, with severe hypokinesis of the anteroseptal area. The patient was diagnosed with myocardial infarction accompanied by pulmonary edema. Selective coronary angiography showed 90% stenosis in the proximal to mid-portion of the left anterior descending (LAD) artery. The lesion was long and irregular. We decided to insert two stents into the lesions. The first stent was inserted uneventfully into the proximal LAD artery, after which an attempt was made to insert the second stent into the mid-portion of the LAD artery because of the irregularity of the lesion. However, when the stent was extracted from the balloon, it was trapped and deformed. One part of it floated in the left coronary sinus (). We tried to push and withdraw the stent by snaring it, but failed. We planned the surgical removal of the trapped stent and a coronary artery bypass graft. With cardiopulmonary bypass, we were able to remove the stent through the aortotomy site (). We also performed left internal thoracic artery bypass to the distal portion of the LAD artery. The next day, the patient was extubated and he recovered well. However, on the second postoperative day, he had a sudden cough that produced fresh blood. He was intubated again and was subjected to chest computed tomography (CT). The chest CT showed active bleeding from the right middle lobe (). A lesion was also found in the bronchoscopy examination. We resectioned the right middle lobe. The lesion in the right middle lobe may have existed before the coronary angiography. In the follow-up echocardiography, the wall motion of the left ventricle was good. The ejection fraction increased from 35% to 65%. The patient had postoperative pneumonia and acute renal failure. He was treated with active intensive care including antibiotics, hemodialysis, and pulmonary rehabilitation. His condition waxed and waned. He was improving and underwent conservative treatment including hemodialysis in the general ward. However, unfortunately, he passed away at 5 months after the operation due to aspiration pneumonia.
A 61-year-old male, was diagnosed with 5.5 mm thick, Clark level IV, nodular melanoma without ulcerations on his right back in May of 2007. He underwent a wide local excision of the primary melanoma and a sentinel node biopsy in the right axilla, which revealed one lymph node positive for metastatic melanoma. He subsequently underwent a lymph node dissection of the right axilla; none of 32 lymph nodes was positive for metastatic melanoma. After the lymph node dissection, a computed tomography (CT) scan of the body revealed no evidence of metastatic disease. He was fine until September of 2009, when he had a solitary metastatic melanoma in the left lung, for which he underwent left upper lobe lingular-sparing lobectomy with the resection of the nodule in November of 2009. He remained free of disease until November of 2011, when he was found to have new metastatic lesions in the right middle lobe of lung and peritoneum, and he received 4 doses of ipilimumab (3 mg/kg) and then, 2 doses of the combination of TPI-287 (abeotaxane) and temozolomide with further progression of the peritoneal lesions and stable disease in the lung. Subsequently, in June of 2012, the peritoneal lesions were surgically resected. However, in April of 2013, a MRI scan of the brain revealed multiple parenchymal metastatic lesions and clear leptomeningeal enhancement spread to the left cerebellar sulci and the left frontal cortical sulci (Fig. ). His spinal MRI was normal. He had no neurological symptoms related to the LMD. A CSF analysis demonstrated the presence of few melanoma cells. A CT scan of the body also revealed progression of the lung lesions and new peritoneal masses. He started treatment with vemurafenib at 960 mg twice a day since a molecular analysis showed that his primary melanoma harbored a BRAF V600E mutation. He tolerated the treatment well with mild photosensitivity. In June of 2013, a MRI scan of the brain revealed improvement with decrease in size of parenchymal metastatic lesions and regression of leptomeningeal disease (Fig. ). A CSF examination showed no malignant cells. In addition, a CT scan of the body also demonstrated clinical response in the lung and peritoneal metastatic lesions. Follow-up scans revealed further improvement of LMD in August of 2013. Unfortunately, he had disease progression in the brain, leptomeninges, peritoneum and subcutaneous lesions in October of 2013 (Fig. ). He was treated with whole brain radiation followed by the combination of dabrafenib and trametinib in November of 2013. He developed moderate fatigue from the treatment, which resolved with decreased dose of dabrafenib and trametinib. A MRI scan of the brain demonstrated improvement of the LMD and brain parenchymal metastatic disease in December of 2013 and February of 2014. As of the most recent follow-up evaluation in April of 2014, a MRI scan of the brain showed continued disease response in all metastatic sites including the leptomeninges and brain parenchyma (Fig. ). The patient remained free of neurological symptoms throughout the treatment duration. However, his extracranial metastatic disease progressed in the peritoneum and the subcutaneous tissues and he expired in October of 2014 which is 19 months after the diagnosis of brain and leptomeningeal metastases.
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.
The case was an 82-year-old woman, with a body weight of 61 kg , who was referred to the emergency room with complaints of severe abdominal distention and dyspnea. She was admitted in the internal medicine ward with a primary diagnosis of ascites due to cirrhosis, based on the presence of the Caput medusae sign and clinical suspicion of ascites. She had a past history of eight abortions. She also mentioned an episode of abdominal distention about 40 years ago with a slow evolution. She also complained of a loss of the ability to walk during the last 10 years. During the last 2 years, her dyspnea has worsened gradually, so that she was unable to sleep in the supine position and obliged her to rest in lateral decubitus and semi-sitting positions. She had no other significant history of digestive problems during the recent years.\npattern B. Hard and sticky debris of cyst after aspiration.\nAbdominopelvic ultrasonography showed a heterogeneous hypoechoic lesion filling the whole abdominal and pelvic cavities. Hematologic, serologic and hepatic tests were reported to be normal. After a surgery consult, an abdominal and pelvic computed tomography scan (CT) with intra-venous (IV) contrast revealed a giant hypodense cystic mass of about 30x32 x43 cm located in the entire abdominopelvic cavity. It also revealed cystic wall calcifications in several areas that were extended to the abdominal skin border (). With the differential diagnostics of ovarian cystadenoma, mesenteric cyst and omental cyst, the medical team decided to perform laparotomy in which a large cyst was revealed that had displaced the intestines to the sides of the abdomen. There was an important cyst calcification near the left abdominal wall, of about 2x4 cm. Anterior wall of the cyst was covered by the greater omentum, with manifestations of a vascular pattern (). Cyst aspiration was performed and the sample was sent for pathological analysis. About 20 liters of cystic contents were aspirated. After decompression of the cyst, atrophy of the uterus, ovaries, stomach and spleen were observed. The posterior wall of the cyst adhered intimately and extensively to the mesentery, which prohibited the complete cyst release from the surrounding structures. The debris contained within the cyst was hard and sticky; therefore, the cyst was washed using Povidone-iodine 10% and the debris inside the cyst was removed (). Finally, we performed a partial cystectomy and ensured external drainage. After five days, the patient was breathing normally and her weight was 44 kg (17 kg weight loss) (). The pathology report confirmed a hydatid cyst in the sample of cystic wall, but smear and culture of cystic contents were negative.\nThe patient was discharged home and prescribed oral Albendazol with a dose of 15 mg/kg per day. After two weeks, the drain tubes were removed and she could walk without any help after 10 years and sleep in supine position after 2 years.
A 26-year-old female with history of Chiari type 1 malformation, status post intracranial shunt and scoliosis leading to cervical spinal fusion at age 10 presented with left upper arm swelling for seven hours. She stated there was mild, pressure-like sensation and endorsed associated radiating numbness to her fingertips. She denied any pain, but explained she had chronic baseline sensation deficits on the left side of her body as a sequelae from her cervical spinal fusion and thus had diminished ability to sense pain to her left upper extremity since the age of 10. She did not recall any inciting insult, repetitive movement during work or exercise, or trauma to the arm. The patient stated she had an etonogestrel/ethinyl estradiol vaginal ring placed approximately three months earlier and had not had any complications. Her only risk factor for venous thromboembolism was her contraception.\nUpon arrival, her vital signs were all within normal limits. On physical exam she was calm and in no acute distress. Her left upper extremity was swollen circumferentially from the distal deltoid to the antecubital fossa, with the greatest area of swelling on the posterior-medial aspect of the left upper extremity overlying the triceps. Her left upper extremity had full passive and active range of motion without pain. Although she had decreased sensation, she reported no change from her baseline complications post cervical spinal fusion. She had 2+ distal radial and ulnar pulses. There was no increased warmth or erythema when compared to the right upper extremity, and she was without ecchymosis. She had five out of five grip strength bilaterally. Her left upper medial posterior compartment was moderately tense. The rest of her extremities had five out of five strength bilaterally.\nBased on physical exam, the leading life-threatening diagnosis was upper extremity deep vein thrombosis (DVT). However, the patient had no other risk factors or clinical signs of DVT except for marked upper extremity swelling and etonogestrel/ethinyl estradiol vaginal ring. She was saturating well on room air, without any tachycardia or pleuritic chest pain, and thus initial suspicion for acute pulmonary embolism (PE) was low. Infection was thought to be unlikely given there was no overlying erythema, no warmth, and no systemic signs of infection. Compartment syndrome was considered but thought to be less likely given her compartments were mostly soft, and there was no history of trauma. Although, given the patient’s baseline sensory deficits, occult trauma was still thought to be possible. Lymphedema was seen as less likely without any history of prior surgeries in the axilla that would place her at risk.\nInitial work-up consisted of a complete blood count (CBC), basic metabolic panel (BMP), coagulation panel, a formal left upper extremity (LUE) DVT ultrasound performed by an ultrasound technician, and an electrocardiogram (ECG). The ECG was obtained to evaluate for any subtle signs of PE, given a diagnosis of DVT was in consideration. Her CBC and BMP were within normal limits. Her ECG revealed normal sinus rhythm, without evidence of right heart strain. Her formal LUE DVT ultrasound was negative for any venous thrombus (, panels 1 and 2).\nThis initial negative work-up prompted a point-of-care ultrasound (POCUS) to further evaluate the cause of swelling. Images were notable for soft tissue edema including pockets of interstitial fluid between the muscle bellies and perivascular fluid around veins of the upper arm, which upon review were also noticeable in images obtained by the ultrasound technician (, panel 3). These findings indicated a possible inflammatory process or a source of venous congestion from a more proximal source. Furthermore, POCUS revealed there were muscle fibers of mixed echogenicity along with notable disorganized muscle fibers, which upon review were also notable in images obtained from the ultrasound technician (, panel 4), which could have been consistent with rhabdomyolysis. These findings prompted a D-dimer, which when resulted as abnormal, prompted both a computed tomography (CT) venography of the chest and upper extremities and CT angiogram of the chest. To assess for potential complications of venous congestion resulting in compressive ischemia such as rhabdomyolysis and early compartment syndrome, a serum creatinine kinase (CK) level was ordered.\nAdditional laboratory results revealed an elevated D-dimer 1860 milligrams per milliliter (mg/mL) (normal limit <500 mg/mL) and CK 7990 units per liter (U/L) (normal limit 30–223 U/L). With these results, the concern for complications such as rhabdomyolysis or compartment syndrome rose. The patient was started on intravenous fluids and aspirin. CT venogram revealed chronic severe luminal stricture of the left axillary vein. The rest of the veins of the chest and upper extremities were widely patent. CT angiogram was negative for PE or any arterial abnormality. The patient was admitted to the hospital with vascular surgery consultation.\nDuring her inpatient stay, CK trended down from 7990 U/L to 1094 U/L over the next three days. The patient’s arm swelling improved throughout her hospitalization and remained well perfused without signs of worsening limb ischemia or compartment syndrome. Vascular surgery recommended no acute surgical intervention, discontinuation of use of the etonogestrel ethinyl estradiol vaginal ring, and a short course of aspirin. They arranged for close outpatient follow-up. Her case was discussed during vascular surgery case conference, a weekly educational conference in which attending and resident physicians discuss and provide recommendations for complex cases. Given her symptoms had resolved on re-evaluation two months after her admission, vascular surgery opted for continued conservative management and monitoring with repeat CT venograms.
A 14-year-old boy had laparotomy for a mesenteric cyst 7 years ago during which he had a transurethral bladder catheter passed. Few weeks after discharge from the hospital, he began to experience difficulty in passing urine. It started as straining at urination with a poor stream which worsened over time. Over the cause of the past 7 years, he has had multiple dilatations which did not resolve the problem until a suprapubic catheter was passed for him a year ago and referred to see the urologist at KATH.\nOn examination, he had normal growth for his age. He had a two-way suprapubic catheter in situ with indurations along the penile and bulbar urethra.\nA retrograde urethrogram demonstrated a partial narrowing of the penile and bulbar urethra ().\nA routine urine examination was done which revealed leukocytosis for which reason a urine culture was requested that isolated Klebsiella species sensitive to only amikacin.\nA one-week course of parenteral amikacin was given after which a repeat urine culture was negative.\nOther tests done included a full blood count and kidney function tests which were all within normal ranges. Thus, patient was scheduled for urethroplasty.\nPatient positioning was the standard lithotomy with padding of the pressure points with administration of general anaesthesia with oropharyngeal intubation.\nA 7 cm × 2 cm lower lip oral mucosa graft starting from the right lateral angle of the mouth extending to the left cheek (Figures and ) was harvested. The submucosa was injected with lidocaine mixed with epinephrine (1 : 200,000) to raise a wheal which helped with easy harvesting of the graft while ensuring adequate haemostasis. A gauze was placed appropriately in the pharynx to prevent blood from entering the trachea or oesophagus. The mucosal defect at the donor site was left to heal by secondary intention. The graft was defatted removing all muscle fibers to retain only mucosa and lamina propria. Tiny fenestrations were made into it and then kept in saline until needed.\nA midline perineal incision was made through the skin, subcutaneous tissues, and fascia. The perineal muscles were divided in the midline and carefully dissected away from the urethra. The urethra was then circumferentially mobilized off the corporeal bodies from the bulbar to the penile urethra going beyond the strictured segments as defined by a catheter passed per the urethral meatus and a bougie dilator proximally from the cystostomy wound by sharp dissection with fine scissors.\nThe urethra was then rotated 180° bringing the dorsal aspect ventrally with the aid of sutures placed proximally and distally on the dorsal aspect of the urethra (). A dorsal stricturotomy was made over the strictured segment starting distally from the immediately adjacent patent urethral segment over the catheter tip (Figures and ). This was to ensure that the urethral mucosa was visible throughout the stricturotomy.\nThe oral mucosa graft was quilted to the ventral aspect of the corporeal bodies, and the left edge of the urethral plate was sutured to the left lateral aspect of the graft in interrupted fashion using vicryl 4/0 (Figures and ).\nA size of 16Fr urethral catheter was advanced into the bladder, and the contralateral edge of the urethral plate was then sutured to the right edge of the oral mucosa graft over it ().\nPostoperatively, a size of 16Fr catheter wound drain was left in situ and closed wound dressing done (). A spigot was applied to the urethral catheter which was then plastered loosely to the thigh to prevent excessive movement within the urethra. A urine bag was connected to the suprapubic catheter for continuous drainage of urine. Patient was continued on parenteral cefuroxime for one more week. The wound drain was removed on day 2 when it was found not to drain any longer.\nThe donor site healed within 7 days without any complications with no special dressing ().\nBoth the suprapubic and urethral catheters were removed 4 weeks postoperatively when RUG showed no urinary extravasation (). Patient has been reviewed at 3, 6, and 12 months postoperatively with no urinary concerns.
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 40-year-old man presented to us with a 2-year history of slowly enlarging, painless mass in his left upper lid with resultant progressive ptosis []. The patient complained of constant sense of heaviness in the upper lid as well as partial ptosis. The superior field of vision was reduced. Ocular examination was suggestive of a firm, non-tender nodule of size 2 × 1.5 × 1 cm on the left upper lid. The mass was non-adherent to the skin or the underlying tissue. A small ulcer 5 mm × 8 mm was present on the lateral margin of the mass []. The medial skin and conjunctiva were indurated and signs of inflammation were present. The lid appeared to have lost its function and was unsalvageable. Provisional clinical diagnosis was that of an eyelid malignancy. Fine needle aspiration cytology of the lesion was inconclusive.\nThe lesion was excised using a supratarsal incision. An ellipse was planned along the ulcer present on the lateral margin (0.8 mm) to excise the ulcer in continuity with the swelling. The lesion was 1.5 cm in diameter with a well-defined capsule, located below the subcutaneous tissue and above the muscle layer almost abutting the supraorbital rim. The incision was deepened and the lesion was isolated from the surrounding tissue by blunt dissection outside the capsule. Dissection was easily done in the extracapsular plane and the lesion was excised completely. No communication with the supraorbital nerve could be identified. However, the eyelid had strong evidence of induration and oedema, though no evidence of infiltration by the lesion was seen. As diagnosis of malignancy was suspected initially, the medial portion except for a small lateral margin was excised to ensure clear margins and reconstruction was done using a tarso-conjunctival flap from the lower eyelid in conjunction with a skin graft harvested from the left medial arm []. The lateral rim of eyelid was closed primarily in continuity with the flap. The flap was divided at 3 weeks interval and the postoperative course was uneventful [].\nHistologically, the tumour was formed by fusiform cells arranged in interwined bundles. The nuclei were fusiform and tended to form palisades. No histopathological features of malignancy were present. Immunohistochemistry for S-100 protein was strongly positive. These findings established the diagnosis of Schwannoma. Histopathology of the excised lid was suggestive of inflammatory changes. The patient recovered uneventfully and the ptosis resolved after ablation of the tumour with the improvement perceptible in the immediate postoperative period. There is no evidence of recurrence after 1 year of follow up.
A 27-year-old man was admitted to our hospital with a 10-day history of headache and vomiting. He was born with multiple pigmented areas on his skin; specifically, there were multiple confluent hairy nevi on his extremities, back and most of the anterior trunk. His psychomotor development was retarded. No significant family history was elicited on the interview. The neurologic examination and laboratory findings were unremarkable.\nThe nonenhanced CT scanning showed multiple intracranial lesions; these included a hyperattenuated mass with an adjacent cyst in the left temporal lobe, an irregular fatty mass containing marginal calcific foci within the temporal horn of the right lateral ventricle and a midline posterior fossa cyst with hypogenesis of the cerebellar vermis (). The unenhanced MR scans showed a left temporal lobe mass with high signal intensity on the T1-weighted images and mixed low signal intensity on the T2-weighted images. In addition, there was a right intraventricular mass with bright signal intensity on the T1-weighted images and heterogeneous signal intensity on the T2-weighted images, relative to the cerebral cortex (). Further, there was hypoplasia of the inferior cerebellar vermis, dilatation of the inferior fourth ventricle and an enlarged posterior fossa, which confirmed the presence of a Dandy-Walker variant (). The Gd-DTPA enhanced T1-weighted images showed minimal marginal enhancement of the cystic lesion of the left temporal lobe mass with associated diffuse leptomeningeal enhancement (). No apparent enhancement was noted in the right intraventricular mass. An excisional biopsy of the proximal hairy melanocytic nevus of the left ankle was done; the diagnosis proved to be a melanocytic congenital nevus. Left craniectomy was performed for the subtotal removal of the tumor. Areas of black pigmentation were seen in the brain cortex. The cyst adjacent to the left temporal lobe mass contained xanthochromic fluid. The histologic sections of the temporal lobe mass revealed a melanocytoma, and the cyst wall showed a reactive gliosis. Microscopic examination also demonstrated a diffuse melanocytosis of the leptomeninges.
The first case we present is that of a 29-year-old woman who presented to the clinic with the complaint of an enlarging left breast mass. She first noticed that this mass almost 2 years ago and mentions that it has been growing in size and becoming more erythematous and tender. She did not report any recent weight loss or change in appetite. She is married with 2 children, and she does not have any illnesses. She smokes hubble-bubble almost 4 times per week and does not drink alcohol. Surgical history is significant for 2 previous Cesarean sections with no complications. History of her current illness dates back to June 2016 when the patient felt a mass in her left breast; upon further investigation, she was diagnosed with idiopathic granulomatous mastitis and later (December 2017) developed an abscess that drained on its own. She was initially treated with methotrexate and later switched to prednisone and mycophenolate with minimal improvement. At the clinic, her vitals were within normal limits, and on physical examination, there was a left breast lump found at the upper inner quadrant with some erythema and inflammation surrounding it. Moreover, there was some skin retraction in this area.\nCore biopsy done at an outside hospital in June 2017 revealed no granulomas. Ultrasound done at that time showed a persistent ill-defined hypoechoic mass that appeared initially subdermally and was spanning more than 4 × 1.4 cm. Moreover, multiple deeper masses were seen, one of which was not located within the breast measuring 12.3 × 8.5 mm. Axillary nodes were insignificant and not well appreciated on imaging.\nFine-needle aspirate done in July 2017 was negative for malignancy and was reported to have abscess formation. The slides revealed a heavy inflammatory infiltrate predominantly composed of polymorphonuclear leukocytes. No ductal epithelial cells were seen.\nCore biopsy done in November of the same year showed multiple noncaseating epithelioid granulomas composed of epithelioid histiocytes, lymphocytes, neutrophils, and occasional multinucleated giant cells. Some granulomas contained neutrophils forming microabscesses with surrounding empty microcysts ().\nThe Ziehl–Neelsen stain for acid-fast bacilli was negative. This leads to the diagnosis of idiopathic granulomatous mastitis which is a diagnosis of exclusion.\nA repeat MRI done during June 2018 showed heterogeneous fibroglandular tissue with mild background enhancement. There are also numerous tiny rim-enhancing fluid collections in the left breast, the largest measuring 8 mm involving the upper inner and lower inner quadrants, some of which are fistulizing to the skin. Findings have regressed compared to the prior MRI.\nAs with the previous MRI, no enlarged axillary or internal mammary adenopathy was seen.\nThose findings are consistent with biopsy-proven idiopathic granulomatous mastitis extensively involving the upper and lower inner quadrants of the left breast.
A 21-year-old male sustained a single gunshot wound with entry over the left scapula. At the scene, the emergency medical response personnel found him on the ground alert, unable to move his legs, and noting pain all over his body. He was hemodynamically stable in the field. Ground ambulance immobilized the neck with a cervical collar and brought him to a local level 1 trauma center. At arrival to the trauma bay, he had a Glasgow coma scale score of 15. He was primarily complaining of bilateral hand numbness. On further examination, he had no motor or sensory function present in the lower extremities. In the upper extremities, sensation was present but diminished from T1 and above, with no sensation below T1. Motor function in the upper extremities was graded 3 (based on ASIA impairment scale) in all the key muscles on the right and only grade 2 on the left in the deltoid and biceps muscles with no motor further distal. Next, he was taken to the computed tomography (CT) suite for imaging of the head, neck, and thorax. Imaging, from the CT scan, revealed bullet tract through the posterior lateral left upper hemithorax, left scapular body, left lung apex, and base of left neck with bullet fragments terminating in the C6 vertebral body. Initial studies showed no acute intracranial abnormalities; however, there were fractures of the left C5 and C7 transverse foramina and processes and left C6 vertebral body and lamina fractures with bony and bullet fragments in the left aspect of the spinal canal at the C6 level (). As a result, there was a dense left epidural hematoma within the spinal canal at C2 through C7 levels. At the time, CT neck angiogram showed that the left extracranial vertebral artery was occluded, beyond 1 cm from its origin. Subsequently, the patient underwent angiography to further assess the cerebral vascular supply. On the angiogram, occlusion of the proximal portion of the left vertebral artery was noted with reconstitution in the distal portion of the artery near the occipitocervical junction (). No contrast extravasation from the left vertebral artery was noted. Patency was noted in the right vertebral artery and bilateral common, internal, and external carotid arteries. Vascular surgery specialists, after conducting and reviewing the angiogram, determined that no further intervention was required as the right vertebral artery along with bilateral internal carotid arteries was patent.\nFollowing the imaging studies and angiogram, the patient was admitted to the surgical intensive care unit (SICU) for continuous neurologic and hemodynamic control and observation. On the next hospital day, the patient was optimized by the vascular surgery team and the surgical intensive care unit trauma team and was deemed stable to proceed forward with surgical intervention of the spine. Given the spinal cord injury and preparation for spinal surgery, anticoagulation was not started prior to reporting to the operating room. The goals of the surgery were to decompress the cervical spinal cord and to provide stability to the spinal column.\nThe patient received a successful awake fiber-optic intubation with protection of the cervical spine and then general anesthesia was induced. Via a standard left sided Smith-Robinson approach, anterior cervical corpectomy of C6 and anterior cervical decompression were performed within C5–C7. Bony and bullet fragments were removed from within the canal and following decompression, and while avoiding excessive distraction, the anterior column was reconstructed using an appropriately sized interbody cage device packed with autologous bone graft. Anterior cervical plate and screws were used to provide stability to the cage-graft construct and maintain the proper cervical alignment (). Following the procedure, the patient remained intubated for airway edema concerns. The sedation was weaned after transporting the patient to the SICU from the operative suite; however, he remained unarousable. Given the neurologic change in the patient status, an emergent head CT scan was conducted and showed an acute basilar infarct.\nHead and neck CT angiogram were subsequently performed and showed new basilar artery segmental occlusion consistent with migration of a thrombus from the distal left vertebral artery. Both neurology and neurosurgery teams recommended hyperosmolar treatment, as the patient was not considered a good candidate for revascularization. Twelve hours later, repeat head CT scan showed progressive hydrocephalus and brainstem and cerebellar infarcts with impending herniation (). The patient was subsequently diagnosed with brain death and, with consent from his family, care was withdrawn.

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