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A 63 year old man with history of right median nerve EHE treated with wide local excision
in 2013 presented to a primary care clinic 4 years later with pain along his right arm below
his shoulder. He had received a radiograph of the right elbow and radiograph of the chest
every 6 months for the past 4 years without evidence of recurrence. After history and
physical examination of his arm, he was diagnosed with a benign muscular pathology
potentially of the rotator cuff tendons. However, despite conservative treatments, the pain
persisted and worsened. Although the pain was not in the same location as his previous
tumor, his providers were concerned for tumor recurrence. He underwent CT scan of the right
upper extremity in December of 2017, which showed post-surgical changes and no evidence of
recurrence. The pain intensified, so in April of 2018, he had a PET-CT which showed abnormal
uptake in the right forearm but no abnormal uptake in the area of pain and no evidence of
metastatic disease. A biopsy was taken of the FDG avid area of the right forearm and
interpreted as a traumatic neuroma. The patient was advised to continue conservative
treatments. In February of 2019, due to intensifying pain, a radiograph of the right upper
extremity showed an abnormality over the cortical surface of the distal aspect of the
humeral shaft with a new lytic lesion. A repeat PET-CT in June of 2019 showed FDG avidity of
the mid to distal right humeral shaft with associated periosteal changes and a medial soft
tissue mass with two satellite nodules in the humeral neck area just above the elbow. A
CT-guided biopsy of the right humeral mass confirmed recurrence of high-grade EHE. He was
diagnosed with soft tissue recurrence and local bone metastasis of EHE. His case was
discussed with a multidisciplinary team, who agreed to pursue surgical resection of his
tumor.
Four days prior to surgery, |
A 50-year-old man without any systemic disease or drug history was sent to a hospital after he incurred an electric shock injury while using a handicraft grinder by his two hands. This machine was adapted to a 60-Hz, 110-V alternating current supply. Upon receiving the shock, the man could not sever contact with the machine until 5 minutes later. He fell from a height of 1 meter on his buttocks. He remained conscious but experienced weakness and numbness in the left extremities, and his speech was slurred. He denied any head contusion happened during fall down. On arriving at the hospital, he was alert and his eyes were oriented to the right. Muscle strength on the left side was decreased, with a grade of 2 on the Medical Research Council Scale. The results of laboratory investigations, including complete blood count, coagulation function, and levels of electrolytes, serum glucose, liver enzymes and creatine kinase were all within the normal limits. The findings on chest X-ray scan, electrocardiogram and electrocardiogram were normal. A computed tomography (CT) scan of the brain showed no obvious abnormalities. With the impression of ischemic stroke with left hemiplegia, the patient was administered thrombolytic therapy with recombinant tissue plasminogen activator (r-tPA) within 3 hours after stroke onset, but no clinical improvement was noted. A magnetic resonance imaging scan of the brain showed an acute infarction in the right frontotemporal area involving the right basal ganglia and corona radiata. Magnetic resonance angiography showed segmental narrowing of the siphon of the right internal carotid artery (ICA) and the M1 segment of right middle cerebral artery (MCA) []. There were no stenosis or other abnormal finding founded in right common carotid artery or extracranial ICA by MRA study. Conventional angiography were arranged 4 hours after r-tPA, and showed a smaller-caliber lumen of the right ICA and irregular lumen of the distal M1 branch of the MCA. The M2 branch of the MCA proximal to the angular branch was patent. Focal narrowing of the M1 branch was manipulated by to-and-fro movement of the microcatheter, and vasospasm was treated by intravascular injection of nimodipine. After treatment, the flow in the right ICA region improved []. A rehabilitation program, including physical, occupational and speech therapy, was arranged for the patient. This patient can walk with quadricane for daily activities and dysarthria improved in 2 months. |
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 68-year-old man presented for evaluation of a new asymptomatic bump on his left arm. His previous skin examination had been six months earlier and the lesion had not been present. He previously had three basal cell carcinomas (on the left temple, left side of his upper lip, and left mid back excised 32 years, four years and two years earlier, respectively) and one squamous cell carcinoma (on his right upper back that was excised seven years ago). He also had actinic keratoses that were treated with liquid nitrogen cryotherapy.\nHis past medical history was significant for severe acne vulgaris as an adolescent, hypercholesterolemia, hypertension, and prostate cancer that was diagnosed one year ago. He is currently with no evidence of malignant disease after treatment which included a robotic-assisted laparoscopic prostatectomy (with negative margins for tumor) and a bilateral pelvic lymph node dissection (with none of eight nodes positive for cancer). His current oral daily medications included amlodipine 10 mg and simvastatin 20 mg.\nCutaneous examination showed a six by six millimeter flesh-colored nodule on the extensor aspect of his left arm near the elbow (Figure ). A shave biopsy of the superficial portion of the nodule was performed. The site was treated topically with mupirocin two percent ointment, three times daily, until it had healed.\nMicroscopic examination of the hematoxylin and eosin-stained tissue specimen showed strands and nodular aggregates of atypical basaloid tumor cells in the dermis reaching the deep margin of biopsy; the overlying epidermis was thin with effacement of the rete ridges and sparse overlying orthokeratosis (Figure ). Deposition of amorphous material filled the dermal stroma between the tumor aggregates (Figure ); the amount of amyloid present was abundant (+++). The lateral aspect of the specimen showed solar elastosis in the upper dermis above the tumor and below the epidermis (Figure ).\nCorrelation of the clinical presentation and pathological findings established the diagnosis of a nodular basal cell carcinoma with extensive amyloid deposition and adjacent solar elastosis. The residual tumor was excised and a side-to-side layered closure was used to resolve the surgical wound. The surgical site was healed without recurrence at a follow-up examination nine months later. |
A 40-year-old female with negative smoking and medical history was admitted with productive cough, progressively aggravating dyspnea on exertion, and recurrent pulmonary infections for the previous 2 months. The chest X-ray showed total atelectasis of the left lung (Figure ), and the thoracic CT-scan revealed a mass of the left hemithorax, which probably originated in the mediastinum and extended to the whole left pleural space (Figure ). The mass showed heterogeneous density containing soft tissue elements, fat, cystic areas and foci of calcification, which is the classic imaging appearance of a benign teratoma on CT. Magnetic resonance imaging (MRI) was performed to specify the anatomic relationships and confirm the tumor morphologic features. The MRI yielded useful information about the vital structures of the mediastinum, whether invaded or externally compressed by the tumor. Specifically, the MRI confirmed a round, non-homogeneous, well circumscribed mass of a 12 cm diameter, exerting compression on the mediastinum great vessels and the left hilar structures (vessels and airway) (Figure ). The bronchoscopy found stenosis of the trachea by external compression, and narrowing in the foramen of the left main bronchus resulting in difficulty in the insertion of the bronchoscope. The mediastinal tumor markers (α-fetoprotein and β-human chorionic gonadotropin) were both normal. As the findings of CT and MRI suggested a benign teratoma, a complete resection was contemplated. Since the mass was supposed to be respectable, surgical management was first in the priority list of therapeutic options. The cytological examination through transcutaneous needle aspiration or biopsy of the tumor were considered redundant and were omitted, because of the dispersion risk and the necessity for total removal so as to ameliorate the respiratory function and re-expand the left lung. Moreover, needle biopsy allows examination of only a small amount of tissue and may be inadequate for definitive diagnosis []. As already underlined in the literature, diagnosis and therapy rely on surgical excision, and even with large sized tumors whose complete resection is impossible, partial resection still relieves symptoms, frequently without relapse []. Pulmonary function tests were impaired: FVC 1.19 (36.7% of predicted) and FEV1 1.01 (41.5% of predicted), whereas a-FP, βCG were normal.\nThe patient underwent a total resection of the mediastinal mass via a left posterolateral thoracotomy. Entry into the pleural space was performed through the fifth intercostal space, and, because of the tumor large size, extension of the incision was necessary to obtain safe visualization of the cavity and proceed to tumor mobilization. Approaching via left thoracotomy makes access to the mediastinal structures difficult but permits control of the whole hemithorax up to the hilar structures. Many adhesions existed with the left pulmonary artery, the left main bronchus, the pericardium, the aorta, and the diaphragm, and a combination of blunt and sharp dissection for the division was applied uneventfully. Because of difficulty in the mobilization of such a huge mass, a purse string suture permitted aspiration of sebaceous content via a small incision in the wall. As the size diminished, manipulation was facilitated. The tumor, excised en block, was white-gray colored, well circumscribed, and thick capsuled. A tube thoracostomy was introduced, the collapsed left lung was easily re-expanded, and the patient was extubated. The patient recovered well from the operation and was discharged on the 2nd postoperative day. Preoperative atelectasis of the left lung was totally resolved (Figure ), and the pathological examination revealed a benign mature teratoma with dermoid cyst characteristics, containing sebaceous and gelatinous material. Two years later, the patient is doing well out of recurrence. |
A 64-year-old female was admitted to our hospital due to dysphagia and chest pain persisting for 2 months. The medical history of the patient and her family was not significant. She presented herself at our thoracic department. Results of physical examination were normal. Gastroscopy revealed an esophageal submucosal protrusion with a smooth surface. This mass was about 25 cm from the superior incisor (). We didn't perform endoscopic biopsy because of its benign features on endoscopic imaging.\nThe chest computed tomography showed a round high-density shadow on the right edge of the esophagus at the level of the azygos vein (, ).\nAfter preoperative preparation, the complete thoracoscopic enucleation was performed under double-lumen endotracheal intubation of anesthesia. The patient was placed in left lateral decubitus position about 450 frontal incline (semi prone position). The screen was in front of the patient. The surgeon and the assistant surgeon were at the back of the patient. Three trocarts were used. The first trocart of 1 cm in diameter was in the sixth intercostal space at the anterior axillary line for the camera. The second trocart of 1 cm in diameter was in the seventh intercostal space at the posterior axillary line for instruments and devices. The third trocart of 0.5 cm in diameter was in the fourth intercostal space at the middle axillary line for instruments ().\nWe didn't use artificial pneumothorax by CO2 insufflation. The thoracoscopic visualisation demonstrated an esophageal intramural tumor at the level of the Azygos vein ().\nThe mediastinal pleura was incised longitudinally above the tumor. The esophageal segment containing the tumor was exposed. The muscle of the esophagus was cut to expose the tumor that has a white, grey color and smooth surface. The tumor was sutured with a vicryl 2.0 to facilitate pulling up the tumor. The tumor was isolated and enucleated completely out of the mucosa. We performed the enucleation of the tumor without cutting the Azygos vein (, ).\nThen we injected 50 ml of air into the esophageal lumen but no bubble of air at the bed of the tumor was recognized. The muscular layer of the esophagus was closed by interrupted sutures of vicryl 3.0. The mediastinal pleura was also sutured (). The tumor was placed in an endo-bag and removed out of the thoracic cavity through the incision at the eighth intercostal space at the posterior axillary line. We washed the thoracic cavity by crystal solution. After checking the bleeding at the sites of trocars, a chest tube 28F in size was placed into the pleural space through the incision for the camera. All incisions were sutured by silk. The procedure lasted for 2 h. There were no perioperative complications. The blood loss was minimal.\nAfter the operation, the patient was transferred to the surgery intensive care unit. 6 h later, she was transferred to our thoracic surgery department. On the first postoperative day, the patient swallowed 10 ml of methylene blue solution. There wasn't any leakage of the methylene blue in the chest drainage. On the same day, the chest x-ray was normal. Therefore, the chest tube was removed. The patient ate soft food on the third postoperative day and normal diet from the fourth postoperative day. She discharged from the hospital on the fifth postoperative day. The pathological result is leiomyoma (). The immune-histochemical staining was positive for desmin and smooth muscle actin. Furthermore, it was negative for CD 34 and CD 117.\nDuring the follow up three months later, the patient didn't have the dysphagia and the vague chest pain. The barium swallowing x-ray was normal ().The patient was satisfied after operation. She stated that she would recommend other patients for the complete thoracoscopic enucleation of the esophageal leiomyoma.\nThis case was operated by Dr. Trong Vu Than who is the chief of the thoracic surgery department of Da Nang hospital in Vietnam. He is a senior thoracic surgeon who has a vast amount of experience in video assisted thoracic surgery.\nWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. |
A 65-year-old Caucasian man with history of hypertension was admitted to our neurology department with sudden loss of consciousness associated with right-sided hemiplegia. An electrocardiogram (ECG) showed atrial fibrillation (AF) with rapid ventricular response; his echocardiogram ejection fraction of 60% with no wall hypokinesia and computed tomography (CT) results confirmed ischemic changes in the area of distribution of the left anterior cerebral artery. He was started on intravenous amiodarone (Angoron; Sanofi Aventis) for rate control. Over the next few hours our patient's level of consciousness deteriorated and he required intubation and transfer to our intensive care unit. A few days later, he developed septic shock complicated with acute renal failure, and in addition to broad-spectrum antibiotic treatment empirical antifungal treatment with itraconazole (Micronazole; Pharma Line) was also prescribed. Soon after administration of the first dose our patient became profoundly hypotensive (blood pressure 50/30 mmHg) without obvious ECG changes. He responded to fluids, bolus and adrenaline infusion and within a couple of hours vasoactive drugs were discontinued. This hypotensive episode was considered septic, as no other apparent cause was identified.\nOver the next few days, while our patient was stabilized and his renal function improved he developed anisocoria due to a new ischemic stroke on the opposite side, complicated with brain edema. He was treated conservatively and his level of consciousness progressively improved; he was weaned off the ventilator but due to the presence of a tracheotomy and intermittent septic episodes his stay in the intensive care unit was prolonged. Two months after his intensive care unit admission, fungi were isolated on blood cultures and our patient was started on itraconazole treatment, awaiting sensitivity test results. At that point, he had a high temperature but was breathing spontaneously and was hemodynamically stable. He was also receiving oral amiodarone 200 mg/day. After receiving the first dose of 200 mg itraconazole through a central venous catheter, our patient's blood pressure dropped suddenly from 150/90 mmHg to 50/30 mmHg and he subsequently lost consciousness and output; his ECG was compatible with pulseless electrical activity, with a rate of approximately 55 beats/minute. Our patient was connected to the ventilator again, cardiac massage was performed for three minutes and 2 mg of adrenaline was administered until the return of spontaneous circulation. Subsequently, noradrenaline infusion at a rate of 150 μg/minute was started, a dose that was progressively reduced and discontinued. His arterial blood gases, electrolytes and troponin immediately after resuscitation are shown in Table . His ECG after the arrest showed atrial fibrillation (AF), 100 bpm with prolonged corrected QT interval, with no other changes. A few hours later his QT interval returned to normal. Our patient's level of consciousness did not show any deterioration and results of a follow-up brain CT scan were slightly improved compared to the results of the previous scan. This episode was eventually attributed to sepsis from fungemia and the antifungal treatment was changed to caspofungin 50 mg (Cancidas; Merck) awaiting sensitivity test results. All medications administered to our patient on the day of the arrest are presented in Table . Five days later, our patient's blood culture results became available. Candida parapsilosis was isolated, sensitive to fluconazole and itraconazole, and antifungal treatment was down-staged to itraconazole. Due to an uncontrolled heart rate he also received a 300 mg of bolus amiodarone. A few minutes after receiving the itraconazole (200 mg) he suffered another pulseless electrical activity arrest; this time cardiac massage was performed for 10 minutes, and bolus adrenaline and atropine were administered until he was resuscitated successfully. His arterial blood gases, electrolytes and troponin immediately and six hours after resuscitation were again unremarkable. This time it became clear that itraconazole was related to the arrests and was discontinued. From then on, our patient remained stable and 15 days later was discharged back to our neurology ward. |
A 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression and remained clinically stable on off-treatment; however, new tissue was visible surrounding the right renal pelvis and the calices (). The same therapeutic regimens (tamoxifen and docetaxel) were proposed to the patient based on the previous good response; unfortunately, the patient refused any treatment. |
A 68-year-old man presented for evaluation of a new asymptomatic bump on his left arm. His previous skin examination had been six months earlier and the lesion had not been present. He previously had three basal cell carcinomas (on the left temple, left side of his upper lip, and left mid back excised 32 years, four years and two years earlier, respectively) and one squamous cell carcinoma (on his right upper back that was excised seven years ago). He also had actinic keratoses that were treated with liquid nitrogen cryotherapy.\nHis past medical history was significant for severe acne vulgaris as an adolescent, hypercholesterolemia, hypertension, and prostate cancer that was diagnosed one year ago. He is currently with no evidence of malignant disease after treatment which included a robotic-assisted laparoscopic prostatectomy (with negative margins for tumor) and a bilateral pelvic lymph node dissection (with none of eight nodes positive for cancer). His current oral daily medications included amlodipine 10 mg and simvastatin 20 mg.\nCutaneous examination showed a six by six millimeter flesh-colored nodule on the extensor aspect of his left arm near the elbow (Figure ). A shave biopsy of the superficial portion of the nodule was performed. The site was treated topically with mupirocin two percent ointment, three times daily, until it had healed.\nMicroscopic examination of the hematoxylin and eosin-stained tissue specimen showed strands and nodular aggregates of atypical basaloid tumor cells in the dermis reaching the deep margin of biopsy; the overlying epidermis was thin with effacement of the rete ridges and sparse overlying orthokeratosis (Figure ). Deposition of amorphous material filled the dermal stroma between the tumor aggregates (Figure ); the amount of amyloid present was abundant (+++). The lateral aspect of the specimen showed solar elastosis in the upper dermis above the tumor and below the epidermis (Figure ).\nCorrelation of the clinical presentation and pathological findings established the diagnosis of a nodular basal cell carcinoma with extensive amyloid deposition and adjacent solar elastosis. The residual tumor was excised and a side-to-side layered closure was used to resolve the surgical wound. The surgical site was healed without recurrence at a follow-up examination nine months later. |
A 50-year-old female patient was referred from a private dental clinic to our hospital for a proper diagnosis and treatment of the left mandibular second molar. Her chief complaint was gingival swelling around the tooth. A sinus tract was traced to the distal aspect of the distal root (). In the periapical radiographs, a toothlike fragment was observed where the sinus tract was traced. She had a surgical extraction of #38 6 months ago, and a class II gold restoration on #37 thereafter. Her prior dentist suspected a distal root fracture of #37. There was no response to cold or electric pulp test on #37. The tooth was not sensitive to percussion or bite tests. There was no abnormal mobility, and a periodontal probing test appeared normal except for apical full-depth probing on the distal root. The initial diagnosis of #37 was pulp necrosis with chronic apical abscess, and the existence of tooth remnants of #38 was also considered as a contributing factor. We decided on a nonsurgical endodontic treatment for the necrotized second molar. The patient was informed that the lesion would not respond to root canal therapy, so a surgical approach should be considered to remove the tooth fragment.\nAfter removal of the gold onlay on #37, root canal treatment was initiated according to the above-mentioned protocol. Even after 3 canal preparations were completed up to #35 and copious 2.5% NaOCl irrigation was performed, the sinus tract on the distal side remained (). Surgical removal of the #38 fragment was decided. Computed tomography (CT, Somtom Sensation 64, Siemens, Erlangen, Germany, 120 kVp, 90 mA) was performed to evaluate the location of the fragments, which were observed on the distal proximity of #37 (). An oral surgeon expected that removal of tooth remnants might be difficult without excising a large amount of cortical bone. Therefore, an intentional replantation of #37 was planned, while the tooth fragments of #38 were retrieved from the extraction socket.\nOne week before surgery, an orthodontic elastic separating ring was inserted into the interdental space between #36 and #37 to increase the mobility of #37. The surgical procedure was performed as planned without any complications. The extracted #37 was retro-prepped and retro-filled with mineral trioxide aggregate (white ProRoot MTA, Dentsply Tulsa dental, Tulsa, OK, USA). While an endodontist worked with the extracted #37, an oral surgeon removed the tooth fragment from the extraction socket of #37 (). After placing the tooth back into the socket, there was no mobility, and no additional splinting was needed thereafter. Total tooth fragment removal was confirmed with periapical radiographs (). One week after surgery, the tooth was slightly mobile and sensitive to percussion. The patient was instructed to have a temporary resin crown for protection. However, when the patient visited our clinic for a 3-month follow up, the tooth remained asymptomatic, and the periapical radiolucency had decreased. The results of a periodontal pocket probing were within normal limits. The 1- and 2-year follow-up radiographs revealed a gradual decrease in radiolucency (). |
A 39-year-old male was admitted to our clinic with the history of back pain for 3 years. The pain was located at the mid thoracic region. He had been diagnosed with tuberculous spondylitis and he had received antituberculous chemotherapy for 6 months, but his symptoms were not improved. Further, he had also been treated with local drainage of pus from his back twice in a 2 years period. The plain X-ray revealed 50% vertebral collapse at T7, which resulted in a slight kyphotic deformity (). Unfortunately, 1 month later, his symptoms progressed and acute neurological deterioration was detected. The emergency MRI revealed T7 vertebral collapse with a retropulsed fragment compressing the dural sac. In addition, a extensive prevertebral abscess that extended from T6 down to T12 was also identified ( and ). He underwent surgical decompression and fixation, using our presented technique, with the drainage of the large extensive abscess by partial transversectomy of T11. The patient recovered from the operation uneventfully and immediate improvement of his neurological status (ASIA score improvement from D to E) was observed.\nA 35-year-old woman came to our clinic with progressive weakness of the lower extremities for 6 days. The motor weakness was detected only on her right leg, but a sensory deficit was observed on both legs below the knee. The initial X-ray revealed an erosion of the upper and lower vertebral endplates and destruction of the intervertebral disc of the T11-T12 vertebral segment that result in kyphotic deformity. MRI demonstrated inhomogeneous signal intensity and destructive lesion at the T11-T12 vertebral segment, which resulted in segmental kyphosis and caused dural sac compression at the T11 vertebral level (). Formation of a paravertebral abscess was also detected (). The patient was scheduled for emergency surgical decompression using our presented technique (). The post operative course was uneventful and neurological improvement (ASIA score improvement from C to E) was observed.\nA 40-year-old woman was admitted to our clinic with back pain and progressive weakness of both legs. The X-ray revealed superior end plate erosion at T11 and destruction of the intervertebral disc space, which resulted in kyphotic angulations at this vertebral segment (). MRI in this case demonstrated the destructive lesion of the T11 anterior endplate and abnormal signal intensity of the vertebral body with spinal canal compromise due to necrotic material, and MRI also demonstrated abnormally increased signal intensity of the T9 and T10 vertebrae. Vertebral shortening osteotomy was performed at the upper half of the T11 vertebral body using our presented technique (). The patient recovered from the operation uneventfully and improvement of her neurological status (ASIA score improvement from C to E) was observed during the follow-up\nperiod. |
A 72-year-old female was referred to the Mayo Clinic with a recent diagnosis of metastatic stage IV adenocarcinoma of the left lung. The patient was a non-smoker, initially visited her primary care physician with a chief complaint of a chronic cough that did not respond to antibiotic therapy. On October 12, 2007, a chest CT scan was performed which demonstrated a left lower lobe mass, as well as a left pleural effusion, and a liver mass. On October 18, 2007, thoracentesis demonstrated evidence of malignant cells. Approximately two liters of fluid was removed. A PET scan performed on October 22, 2007 showed diffuse hypermetabolic uptake in the left upper chest wall, liver, left femur, and left lower lung. A repeat CT scan on October 25, 2007 demonstrated re-accumulation of the pleural fluid. A mass within the right lobe of the liver and lower lung was also evident. The patient was referred to an oncologist.\nOn November 1, 2007, as a part of the examination, the medical oncologist detected an abnormal mass located on the left posterior buccal keratinized tissue adjacent to tooth number 34, 35. No lymphadenopathy was detected. On the same day, the patient was referred to the Periodontics division, Department of Dental Specialties, Mayo Clinic.\nAn intraoral examination revealed an erythematous growth located on the facial and lingual interdental papillae of the teeth numbering 33 and 34 [] and 34 and 35 []. The probing depths throughout the mouth were within normal limits and the patient denied a recent history of trauma. The lesion measured approximately 10 mm in diameter buccal to tooth number 34 and 7 mm in diameter on buccal to tooth number 35. On palpation, the lesion was firm and painless. In addition, lingual papilla interproximal to tooth number 34 and 35 appeared erythematous and edematous. An excisional biopsy was performed on the buccal interdental gingiva of tooth number 34 and 35 and submitted for histologic examination.\nImmunohistochemical stains were performed for CK7, CK20, TTF-1 and p63. Histologic section of the adenocarcinoma showed squamous mucosa on top with infiltrating sub mucosal tumor. Some tumor cells nests involve sub mucosal lymphatic spaces. The tumor cells were positive for CK7 and TTF-1, weakly positive for p63 and negative for CK20 [Figures and ]. These results support the diagnosis of adenocarcinoma. |
We present a 52-year-old right-handed Caucasian male with a medical history of HIV, hepatitis C, hypertension, and type II diabetes with a chief complaint of sudden onset severe upper back pain. The patient stated that the upper back pain started while he was conducting a Zoom lecture as a math teacher. He denied any trauma or injuries. He also denied any regular use of anticoagulant medications, but did take aspirin 81 mg daily for general cardiovascular health. He also denied any subjective fever or chills. He stated that the pain was 8/10 in severity. Within hours, he started to notice weakness in his right and right hand which prompted him to call the ambulance and was brought to the hospital. As the weakness became more severe, he began to develop numbness in the right hand and right leg. The patient was admitted and a magnetic resonance imaging (MRI) of the cervical spine was performed.\nRadiographically, MRI of the cervical spine without contrast revealed an epidural fluid collection identified posterior to the cord at the C4-C7 levels measuring up to 1 cm thick []. The cord appeared compressed and was most pronounced at the C6 and C7 levels with mild increased cord signal. The signal characteristics were compatible with epidural hematoma.\nThe patient was emergently taken to the operating room for posterior C5-C7 decompressive laminectomy and evacuation of intra-SEH. On removal of the lamina and ligamentum flavum, there was visualization of epidural hematoma. The purple, clotted, thick, gelatinous material was completely evacuated and sent to pathology for confirmation. There was no obvious vascular malformation noted and there did not appear to be any trauma in the adjacent soft tissues. There did not appear to be any unusual bleeding problems intraoperatively. Complete evacuation of hematoma and decompression was achieved. The histopathological specimen consisted of a 2 × 2 × 1 cm aggregate of dark brown-purple clotted blood fragments. The pathological diagnosis confirmed SHE with no malignancy cells. The patient was returned to his hospital room for continued recovery and physical therapy rehabilitation. He was subsequently discharge to acute rehabilitation facility. The above patient represents a case of idiopathic SSEH. |
A 38-year-old gravida 3 para 2 presented with scanty vaginal bleeding and mild lower abdominal pain in early pregnancy. Her last menstrual period was two months prior to presentation. She conceived naturally and the pregnancy had been uneventful until her presentation. She had had two previous CS: the first was planned for primigravida breech presentation and the second was performed for fetal distress in a woman with previous CS. She had no significant medical history. On clinical examination, she looked generally well with normal general, cardiovascular, respiratory and abdominal findings. On vaginal examination, there was some scanty blood at vaginal introitus. A sterile speculum exams showed a normal looking cervix with scanty blood at the external cervical os. A bimanual examination showed an anteverted uterus which was bulky. The external cervical os was closed with no adnexal tenderness or cervical excitation tenderness. A urine pregnancy test was positive and therefore this patient was managed as a case of threatened abortion. An appointment for clinical review and pelvic ultrasound was scheduled at the outpatient department (OPD) the next day. The scan showed a singleton intrauterine pregnancy with a gestational age of 7 weeks 4 days. The bleeding per vaginam had subsided and therefore she was scheduled for review in a week. However, five days after this OPD visit, she presented to the gynaecology emergency room with repeat minimal bleeding per vaginam and mild lower abdominal pain. Her cervical os remained closed and a repeat pelvic ultrasound scan with an abdominal probe showed a bulky uterus with a gestational sac that appeared to be within the endocervical canal. A sonographic impression of cervical ectopic pregnancy was made. She was admitted and the laboratory investigations showed haemoglobin level of 12.6 g/dl, her WBC = 7.19 × 109/L and platelet level 288 × 109/L. Her serum beta-HCG level was 105,000 mIU/ml. Her liver function tests and blood urea electrolytes and creatinine were normal. She had a repeat abdominal ultrasound scan 2 days into admission. This scan was done in combination with a transvaginal ultrasound. The findings were a bulky uterus with a gestational sac that appeared to be within the endocervical canal but on transvaginal interrogation, the gestational sac appeared to be at the upper part of the endocervix above the isthmus and in close proximity to the endometrial cavity. The chorionic tissue appeared to cover the internal os. No adnexal mass or pouch of Douglas mass was seen. The impression was a low implantation pregnancy likely to be a developing placenta praevia or a cervical pregnancy at 9 weeks. She was managed as a case of cervical ectopic pregnancy at this point and she received 50 mg of intramuscular methotrexate and had a repeat serum beta HCG done 3 days after, which showed a level of 106,730 mIU/ml. A repeat pelvic ultrasound showed a gestational sac containing single viable fetal pole in the lower segment of the uterus bulging into the bladder (). The myometrial wall thickness between the gestational sac and the bladder was 2 mm. There was accumulation of hypoechoeic fluid in a lattice appearance suggestive of clots behind the gestational sac (). The endocervical canal was empty (). A sonographic diagnosis of unruptured Caesarean section scar ectopic was made. She was counselled for exploratory laparotomy same day and had dissection into the thinned out uterine wall through the Caesarean section scar, removal of the gestational sac and use of figure of eight stitches to secure haemostasis at the site of attachment of the gestational sac. The dissection invariably ended up as a hysterotomy which was repaired after evacuation of the conceptus (). The findings were a fourteen week size uterus with a bulge in the lower portion (). There was a gestational sac approximately one centimeter from the internal cervical os of the uterus embedded in the myometrial wall with retroplacental clots of approximately 400 ml (Figures and ).There was thinning out of the wall of the lower uterine segment (). She had normal fallopian tubes and ovaries and the total blood loss was approximately 800 ml. Her recovery was uneventful and she was discharged home on the third postoperative day. |
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 73-year-old white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).\nTissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.\nOn the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.\nAn emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging (MRI) of his thoracic and lumbar spine. The MRI revealed a left psoas hematoma (Fig. ). A CT of his pelvis performed the same day also showed a right psoas and iliacus hematoma. Due to these findings, hematology recommended discontinuing enoxaparin and reverting to a low intensity heparin infusion, as well as placement of an inferior vena cava (IVC) filter. The following day his left leg began exhibiting the same symptoms as his right leg. There was concern regarding the risk of progressive and irreversible nerve damage due to compression if the hematomas were not promptly drained. IR was consulted and advised that if the drainage were to occur while our patient was on anticoagulation, the risk of rebleeding into the retroperitoneum would be high and potentially nullify any benefit from drainage. Our patient would also be at risk of hemodynamic instability if the current hematomas were acting as tamponades against further bleeding. An additional complicating factor was the risk of further thrombosis due to the presenting saddle PE. Hematology was consulted for recommendations on pausing anticoagulation, but they were hesitant to offer a timeframe as there was no established safe period to enable this type of procedure to take place. Eventually, a window period of pausing the heparin infusion for 3 hours pre-procedure and up to 6 hours post-procedure was decided upon in the event that our patient agreed to have the drainage performed.\nThroughout this sequence of events, our patient and his wife were aware of the plans and considerations on how to proceed. They were informed of the recommendations and concerns made by neurology, hematology, and IR, as well as the risks and benefits of intervention versus non-intervention.\nAfter speaking with his wife, our patient decided to undergo the procedure. The low intensity heparin infusion was stopped 3 hours beforehand and the IR team then performed drainage of the right retroperitoneal hematoma, placing two pigtail catheters in our patient’s right flank (Fig. ). In total, the hematoma was drained of 215 milliliters of blood, 10 milliliters of which were drained during the procedure itself. The left psoas hematoma was not found to be amenable to drainage.\nOur patient tolerated the procedure well, and the heparin infusion was restarted 6 hours after it was completed. A repeat neurological examination demonstrated improved lower extremity strength bilaterally as well as the return of sensation to light touch. Hip flexion improved to 3/5 bilaterally, and knee flexion and extension improved to 4/5 bilaterally. Deep tendon reflexes remained absent. Four days later, the pigtail catheters were removed. His recovery was complicated by anemia requiring blood transfusions totaling 4 units of packed red blood cells (PRBC). Other sources of potential bleeding were evaluated and not found. A repeat CT on hospital day 10 (Fig. ) showed a stable right-sided hematoma, and our patient did not experience any further neurologic deficits. He was transitioned again from the heparin infusion to enoxaparin after 3 more days. His hemoglobin and hematocrit remained stable. During this time, he worked with physical therapy, who recommended discharge to a skilled nursing facility where his strength began to improve somewhat. Follow-up was scheduled with neurology and hematology. On hospital day 18, he was safely discharged. |
A 12-year-old Sudanese boy with a known case of trisomy 21 was brought to our institution by his parents because of a 3-month history of right-sided weakness and focal seizures not associated with loss of consciousness. The boy had a history of headache but no fever, vomiting, or weight loss. He had no history of contact with a patient with tuberculosis, and he had received all his vaccines, including bacille Calmette-Guérin vaccine. The parents reported that their child had a history of multiple abdominal and cervical swellings that had been biopsied 1 year previously, but the biopsy result was inconclusive.\nClinical examination of the boy revealed that he had features consistent with trisomy 21; all of his anthropometric measurements (height, weight, and head circumference) were below the third percentile for age and sex, which is the expected finding in this child owing to short stature being associated with trisomy 21 [] and associated tuberculosis. All his vital signs were normal. He had variable cervical and abdominal lymph nodes, which were firm but not tender. His general system examination was normal. A CNS examination of the right upper and lower limbs showed a hemiplegic gait increased tone, brisk reflexes and upgoing toe. Otherwise, the boy had intact higher functions and cranial nerves as well as a normal fundal examination result.\nInvestigations showed normal blood counts and an erythrocyte sedimentation rate of 80 mm in the first hour. The results of the patient’s renal and liver function tests were normal. His human immunodeficiency virus screening result was negative. The result of his tuberculin skin test was reactive (13 mm). His chest x-ray was normal. His echocardiogram was normal, but his abdominal ultrasound showed extensive paraaortic lymphadenopathy, which was discrete and solid with no hepatosplenomegaly. MRI of the brain showed numerous hemorrhagic mass lesions of variable size situated in the left temporal, left frontoparietal, and right parietal lobes associated with appreciable edema exhibiting vivid, amorphous enhancement after contrast dye was instilled (Fig. ).\nLymphoma was the suggested diagnosis, and the result of the patient’s bone marrow examination was normal. Subsequently, a cervical lymph node biopsy showed central caseous necrosis surrounded by multiple coalescing granulomas (Fig. ) consisting of Langerhans giant cells and adjoining aggregates of epithelioid macrophages and lymphocytes (Fig. ).\nThe diagnosis of brain tuberculomas was contemplated, and the child was commenced on antituberculosis treatment (isoniazid, ethambutol, pyrazinamide, and rifampicin), and the plan was to treat him for 18 months with this in addition to dexamethasone and carbamazepine. The boy showed gradual improvement in his power and gait and did not have any more seizures, and there was appreciable reduction in the size of the lymph nodes, both cervical and abdominal. The boy was discharged to home after 4 weeks. Unfortunately, the patient was subsequently lost to follow-up. |
We present the case of a 30-year-old Nigerian male who was brought to the Surgical Emergency Department of the Lagos State University Teaching Hospital Ikeja 22 hours after he had inserted a constricting ring over his penis. He had developed a painful penile shaft swelling distal to the ring with suprapubic pain and swelling secondary to acute urinary retention. There was associated urethral bleeding.\nThere had been failed attempts at removing the ring by self and the resulting severe pain drew the attention of his relatives who brought him to the emergency room.\nHe had a history of a psychiatric illness and the patient claimed he was under a spell and had heard a voice that instructed him to insert a ring over his penis. He denied using the ring to sustain erection and claimed it was his first time of inserting a ring over his penis.\nThe patient had a history of deterioration in personal and general performance with underachievement dating back to 7 years prior to presentation when he voluntarily dropped out of the university and had done nothing tangible thereafter.\nTwo weeks prior to presentation, the patient's relatives had noticed some unusual behavior in him characterized by talking to self and rubbing salt over his body and the patient claimed he was being chased by unseen people.\nHe had a history of alcohol, cigarette, and cannabis abuse for about 15 years.\nOn examination, he was in acute urinary retention with a tender suprapubic distention up to the level of the umbilicus.\nThere was a thick constricting ring at the root of his penis. There was a markedly swollen oedematous penis distal to the ring with marked reduction in sensation over the penis and glans ().\nWe made a diagnosis of Constrictive Penile Injury (Bhat Grade III) with acute urinary retention [].\nHe had a suprapubic cystostomy done to relieve the acute urinary retention as a urethral catheterization was impossible.\nAttempts were made to remove the constricting ring by the use of aspiration, application of cold compress, and lubrication initially and later by the use of the string method.\nFollowing failed attempts at removing the device with these different manipulations and unsuccessful attempt at cutting with the manual saws available in the hospital coupled with the fact that the patient appeared to have imminent penile gangrene, a decision was made to call the fire service for a power driven saw.\nThe ring was successfully removed by cutting it at two different points () with a power driven arc saw () under conscious sedation at the emergency room.\nThermal injury was prevented by intermittent cooling with ice packs and injury to underlying tissue was prevented by insinuating a pair of artery forceps between the penis and the ring ().\nDressing of the resulting penile skin ulceration was done and the plastic surgery team was invited for possible additional wound care.\nThe patient was also reviewed by the psychiatric team who made a diagnosis of schizophrenia and commenced the patient on haloperidol. He was to be followed up on an outpatient basis in the psychiatry clinic.\nThe patient reported normal nocturnal erections while on admission. Further evaluation of the suspected urethral injury with urethrogram and a urethroscopy was planned but this was declined by the patient who opted to retain his suprapubic catheter.\nThe patient also declined any additional wound care by the plastic surgery team and the wound was healing satisfactorily by secondary intention as at 2 weeks after the initial presentation ().\nHe subsequently defaulted from care. |
A 10-year-old girl visited the outpatient clinic to evaluate the flatness of the right hand, which was incidentally noticed by her parents. She is left-handed, and she had no history of specific discomfort or functional limitation in the right hand. There was no special problem during the prenatal and perinatal period, as well as any family history of any hand anomaly.\nSevere atrophy of the thenar eminence of her right hand was identified (). We also recognized that the IP joint of the thumb was not fully extended (). In addition, the EPB and APL tendons were not obvious enough to make skin fold during extension of the thumb. Passive range of motion of the thumb was normal. Active range of motion in adduction and flexion of her thumb was normal, whereas those of abduction and extension showed limitations. She could extend her thumb to neutral position, whereas the opposite thumb could hyperextend. This limitation did not seem to influence her functional movement of the thumb. Passive and active range of motions of her wrist and other fingers, except the thumb, were within normal range. There were no abnormal physical findings and function in the other extremities. In addition, we could not find any abnormalities in the head and neck, as well as chest and abdomen.\nMuscle power was checked by manual muscle testing and precision dynamometer G200 (Biometrics Ltd., Newport, UK). In manual muscle testing, the muscular strength of shoulder, elbow, wrist, and other fingers, except the right thumb was normal. In the right thumb, strength of flexion and adduction exhibited good grade, whereas extension and abduction were fair to good grade. Grip strength of the right hand, checked by the dynamometer, was 60% of that of the left hand. Sensory test of the right upper extremity, including the thumb, was normal. Tinel's sign and Phalen's test on the right side showed a negative result.\nIn the motor and sensory conduction studies on the right hand, compound muscle action potential of the median nerve was not evoked, but other nerve conduction studies, including the median sensory nerve, ulnar motor and sensory nerve conduction studies, were within a normal range. In the needle electromyography, there were neither insertional activities nor volitional motor unit action potentials in the APB muscle. These findings were in accordance with absence of this muscle.\nBones and joint of her right extremity showed no abnormality in the simple X-ray findings. On magnetic resonance imaging (MRI) study, the FPL tendon, AP and FPB muscles were observed in the palmar side, showing a normal course to an insertional point. However, the APB and OP muscles were not seen (). In the dorsal side, the APL and EPB tendons were not observed (). The EPL tendon was found, but it showed an abnormal insertion toward the radial side of the proximal phalanx, not to the distal phalanx ().\nShe could control her right hand as possible as the greater part of the functional movement, and there were no limitations of the activities of daily living, within the range of her age; therefore, we didn't consider surgical intervention. However, we recommend that she needs to get occupational therapy and education to prevent retardation of hand function development, because the affected hand was nondominant and has overt weakness. |
Prior to her presentation with us, the 67-year-old lady had visited a major hospital in the national capital for symptoms of a rapidly progressive mass in the neck with dysphagia. There she had been diagnosed as suffering from ATC [], and recalls having being provided frank and ample information about prognosis and the available treatment options. The patient there had refused all forms of intravenous chemotherapy and surgery. She had also refused RT since she did not want to spend much time in a city away from home.\nShe presented to our department owing to close proximity to her residence. The already well-informed patient made aware to us that her main intention was to spend as much time as possible with her family at home, and that she was unwilling for intravenous chemotherapy, prolonged course of RT, or any form of surgery. Thus, a compromise was made to settle for a short course palliative RT of 20 Gy in five fractions. However, a month later, the patient reported progression of her symptoms, and there was clinical progression of the disease.\nThough intravenous chemotherapy with either of doxorubicin or paclitaxel was again offered as an option, the patient refused the same and requested for a treatment which could be orally had at home. We thus discussed the new approach of orally delivered metronomic chemotherapy, and after a full discussion of the potential disadvantages and advantages of the new approach, the patient requested to be given the same. The metronomic chemotherapy delivered as a three-drug regimen, which was empirically designed as a pragmatic three-weekly cycle comprising oral cyclophosphamide (50 mg once a day on days 1–15); oral methotrexate (5 mg once a day on Mondays, Wednesdays, and Fridays); and oral celecoxib (200 mg once a day on Tuesdays, Thursdays, and Saturdays).\nThe patient experienced a dramatic response and after the first cycle, in that she was able to take oral feeds without the requirement of a nasogastric tube. After a further three cycles the patient is free of all previous symptoms. Computed tomography revealed a complete response []. The patient has tolerated six cycles of the regimen without any hematological toxicity.\nGiven the fact that the degree of response is highly unexpected in ATC, after the sixth cycle, the blocks were reviewed for the purpose of ruling out more chemosensitive tumors. Since only a scant volume of tissue was available from the preserved blocks, the same could only be processed for staining with three immunohistochemical stains—the leukocyte common antigen (LCA), neuron specific enolase (NSE), and CD99. This was done so as to rule out lymphoma and small round cell tumors, both of which are known for their chemosensitivity. |
A 14 month old female patient was referred to our out-patient clinic with a congenital malformation of the right foot. Both pregnancy and delivery was unremarkable. There was no family history of congenital malformations. Clinical examination showed that the trunk, upper limbs and the left lower limb were normal. There was no limb-length discrepancy. Normal range of motion of the knee, subtalar and ankle joints on the right lower limb was noted. Motion of the metatarsophalangeal (MTP) joints appeared normal. There were obvious supernumerary digits on the medial aspect of the right foot. Between the hallux and four normal toes, there were four duplicated toes with syndactyly between the first and the second. The lateral four digits appeared normal []. Radiographs of the lower extremities revealed normal findings other than the right foot. On radiographs of the foot, there were eight fully developed digits with metatarsal bones, small rudimentary digit without metatarsal bone and with first metatarsal being hypoplastic []. Based on the clinical and radiographic findings, a diagnosis of mirror foot was made. Corrective surgical procedure was performed under general anesthesia and tourniquet control. A wedge resection of the four duplicated rays was performed followed by complete release of the first MTP joint. Release of the tight abductor hallucis tendon was performed. The first ray was brought laterally to close the wedge and was held in place with a Kirschner wire []. The postoperative course was uneventful. A long leg cast was applied. After extraction of Kirschner wire, we lost contact with patient for 7.5 years. The patient reviewed back at the age of 9 years with her mother. She had difficulties walking and shoe wearing. A cutaneous scar was noted over the medial aspect of the right foot as a result of the previous surgical intervention. The right foot was wide; with abduction of the first MTP joint []. Radiographs revealed a wide space between the first and second rays. Angulation of first MTP joint (near 130°), with a supernumerary tarsal bone was noticed between the medial and intermediate cuneiform bones []. All metatarsals were in adducted position. During the second surgical procedure excision of supernumerary tarsal bone was performed. Reposition of the first metatarsal bone was performed and held in place with a 2 mm Kirschner wire. Correction of hallux varus was held in place with 1, 8 mm Kirschner wire. Reinsertion of the tight abductor halluces tendon was performed. A long leg cast was applied for two weeks. After this period the sutures were removed and short leg cast was applied for following four weeks. After six weeks full weight bearing was allowed. The final result was satisfactory functionally and aesthetically []. |
A 30-year-old male patient post motor vehicle accident was admitted through the emergency to King Khalid University hospital with multiple injuries, the main concern on admission was a cervical fracture at level C3 and C4 with a very unstable cervical spine he had to undergo a fixation of the halo frame to stabilize his cervical spine under local infiltration with Lignocaine, he had also sustained pelvic fracture and compound fracture both bones in the left upper limb.\nHe was scheduled as an emergency case for debridement, open reduction and internal fixation of radius and ulna of the left arm. On examination, the patient was fully conscious and oriented, he was in the halo frame, his back was positioned at 45 degree angle due to the halo frame and access to his airway was limited and difficult for conventional endotracheal anesthesia. The choice of anesthesia in this situation was discussed with the patient and regional anesthesia under ultrasound guidance was offered to him, the patient consented to the anesthesia procedure. The orthopedic surgeon was informed about the inability to move the patient to the OR table and after consultation it was decided to do the procedure on the patients trolley with all aseptic precautions. An ultrasound guided supraclavicular block was planned (as the surgeon was planning to use the tourniquet) and explained to the patient. The difficult intubation trolley along with equipment for awake fiber optic intubation was prepared and checked inside the OR in case of any adverse outcome or failed regional block.\nA large bore IV line (16G) with lactated ringer was introduced on the right hand under local anesthesia, monitors like ECG, pulse oximetry, end tidal carbon dioxide (14G cannula connected to the face mask) were attached. The supraclavicular area was cleaned with Iodine and Alcohol and draped with a transparent drape. An M-Turbo Ultrasound Machine (Sonosite Inc Bothell WA) with a High frequency linear probe (HFL38 13-6 MHz) was prepared with sterile gel and the image of the brachial plexus was acquired with appropriate adjustments of the gain, depth and focusing on the target for block, 20 cc of Bupivacaine 0.5% and 2% Lignocaine (50-50) were prepared in two 10cc syringes. A stimuplex needle 50mm 22 G (B Braun) was introduced under ultrasound guidance by the in-plane technique, the needle tip was directed to the angle between the first rib and the subclavian artery after confirming that the aspiration was negative for blood the first 10ccs of the drug was injected observing the spread of the drug and the displacement of the brachial plexus in a upward and lateral position, another 10ccs of the drug was injected around the superior extent of the brachial plexus.\nSurgery commenced 10 minutes after the injection, after testing for anesthesia in the surgical field. The patient was sedated with 2mg Midazolam and the surgery was uneventful. Surgery lasted for one hour and 20 minutes; all the monitored parameters were within normal limits and the patient was transferred to the post anesthesia care unit with oxygen mask and to the floor after one hour. |
The patient, a 60-year-old woman, had a childhood onset of anxiety and anorexia nervosa, with symptoms of anxiety connected to food intake, restricted eating, and, later on, purging. The course of the eating disorder was remitting and relapsing with episodes at age 14, 28, and, most recently, age 44. The last episode had a prolonged course and, over time her, depressive symptoms became more and more severe, and since the age of 47, her main problem was MDD, with significant symptoms of anxiety. By the end, her eating disorder had clear depressive components with thoughts of being a burden on relatives, of eating being worthless and having suicidal ideations about starving to death. At the age of 54, the patient was committed to a closed psychiatric ward.\nThe patient had tried and failed psychotherapy, including several different classes of antidepressant, for example, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, mood stabilizers, neuroleptics, ketamine infusions, and transcranial magnetic stimulation with little or no effect (details of medication trials are presented in detail in Table ). The only treatment providing relief was electroconvulsive therapy (ECT), and since many years ago, she had had three sessions of ECT every 4 weeks. Unfortunately, ECT resulted in a gradual loss of memory, finally removing most of her memories from before her 30th year of age. Attempts to reduce the frequency of ECT sessions failed as this resulted in several suicide attempts while being treated.\nTherefore, after extensive screening and obtaining her informed consent, the patient was included in an ongoing study of DBS for major depressive disorder (MDD). The MFB was chosen as the target based on a recent report, which highlighted the acute and quick effect of this treatment .\nWhen she was evaluated before surgery at baseline, the patient weighted 40 kg with a body mass index (BMI) of 16.6. She was deemed to be severely depressed. She scored 43 points on the Montgomery–Asberg Depression Rating Scale (MADRS), 22 on the Hamilton Rating Scale for Depression (HAM-D), and 34 on the Hamilton Rating Scale for Anxiety (HAM-A). She preferred lying alone in a dark room. She exhibited reduced facial mimicry. She responded adequately to questions, but with short sentences and a monotonous voice.\nAt age 56, the patient underwent implantation of two DBS electrodes (Medtronic model 3389) in the area of the MFB in the posterior hypothalamic area, just anterior to the red nucleus (Fig. ). Stimulation was initiated 2 days after surgery. When the patient returned 1 week later, the effect was perceived as being dramatic. She considered herself to be “quite happy.” She had a normal facial mimicry, spoke fluently, and smiled occasionally.\nBipolar stimulation was delivered using three contacts on each side, at 130 Hz and 60 μsec. The voltage was gradually increased and after 4 months was 2.8 V on the left side and 3.0 V on the right. A further increase was not possible as it caused blurred vision. At 6 months, MADRS was reduced to 26 points, HAM-D 22 and HAM-A to 21 (results are presented in detail in Table ).\nTen months after the procedure, the patient complained of blurred vision. Numerous adjustments of stimulation and the cessation of lamotrigine (given the possibility of the drug being able to attenuate visual side effects) were tried in the following period without success . The symptom was partly stimulation induced, but even after the stimulation had been turned off for 2 weeks, some minor symptoms remained. The stimulation was restarted with a voltage reduced to a level where the side effects were tolerable, however, with a reduced effect on her psychiatric symptoms.\nTwo years after the first procedure, the patient was therefore re-operated upon, with implantation of bilateral electrodes (Medtronic model 3387) in the BNST (Fig. ). The patient received monopolar stimulation through two contacts on each electrode with a gradually increasing voltage. At 12 months, the patient received 130 Hz, 120 μsec and 4.3 V bilaterally. The stimulation in the MFB was reduced and turned off simultaneously without any signs of deterioration.\nThe improvement seen after BNST DBS was more gradual, but very profound. Nine months after surgery, the patient was released from the psychiatric ward and returned to her home. Prior to this, she had been subject to hospital care, initially, due to her eating disorder and lastly due to severe MDD with suicidal ideation, for almost 4 years. She is now living full time at home with her family and is participating in social gatherings and outdoor activities. She considers herself to be profoundly improved, and at 12 months, her MADRS was reduced to 13 points, with an HAM-D score of six and an HAM-A of 5 points.\nThroughout the postoperative periods, neither of the surgical procedures had any significant effect on her anorexia, in terms of BMI. However, following the second procedure, all her anxiety concerning food and eating vanished. She has virtually stopped vomiting, her food intake is more stable and less prone to large variations, and tube feeding could be discontinued. However, in the words of the patient, she continues, out of habit to eat just enough to keep her weight stable, even in the absence of anxiety or obsessive thoughts. She is now, however, motivated to start behavioral training to change this pattern. |
A 67-year-old man was known to be a heavy smoker; he had also been uncontrolled hypertensive and hyperlipidemic for years. He presented to our emergency department with attacks of rhythmic arm shaking. He reported acutely feeling dizzy and then his left arm started to shake at a rate of about 3-4 Hz. This attack recurred four times lasting for about two minutes each, yet aborted spontaneously without medications. Consciousness was never impaired and there were no other symptoms, except that both frequency and duration increased upon position changing. Moreover, he reported previous similar attacks two months ago, and at that time they lasted only for few seconds. His vitals upon presentation were within normal: heart rate was 78 beats per minute, blood glucose level was 127 mg/dL, oxygen saturation was 96% in breathing room air, and body temperature was 37.5°C. His blood pressure was 130/80 mmHg. Urgent CT of the brain done and was normal. His initial laboratory investigations were within normal ranges, so focal motor seizures were thought to be the most likely diagnosis. He was given a loading of 1,000 mg intravenous phenytoin, but this did not reduce the frequency of the attacks. He was admitted to hospital for extensive work-up including full laboratory investigations, echocardiography, and pelviabdominal ultrasonography, which did not reveal any abnormalities. MRI with gadolinium enhancement administration showed only periventricular ischemic changes and atrophic changes related to age, without any gadolinium-enhanced lesions. Moreover, his epilepsy panel and tumor markers were negative, and prolonged electroencephalogram (EEG) video monitoring failed to capture any epileptic activity, and only continuous slowing over right frontoparietal lobes could be detected. We started him on carbamazepine with a target dose of 400 mg twice daily, along with modification of his antihypertensive medications. Mild improvement of attack frequency and duration was achieved. Meanwhile, the patient was discharged with a plan to follow-up in neurology clinic with recommendation for prolonged cardiac Holter monitoring.\nThe patient continued to have similar attacks and attended neurology clinic after two weeks with mild left side weakness, upper limb grade 3/5, and lower limb grade 4/5. Although we considered this as Todd's paralysis, new MRI showed watershed infarction with diffusion restriction over right hemisphere (Figure ) and so he was readmitted again. Moreover, Doppler ultrasound and magnetic resonance angiography (MRA) of the cerebral vessels disclosed severe stenosis (>90%) of the right ICA at the level of the bifurcation (Figure ).\nAt this point, a diagnosis of low-flow TIAs presenting with limb shaking, as a result of cerebral hypoperfusion, was made; meanwhile, the patient received intensive medical therapy including dual antiplatelets with high-dose statins and we started to withdraw antiepileptic medications. Furthermore, he was referred to our neurology interventionist for urgent stenting of his symptomatic right ICA, in order to prevent extensive brain ischemia or total ICA occlusion. The procedure was safely done within few days with only moderate headache post stenting (Figure ), and significant weakness improvement was achieved with physiotherapy over few weeks and the patient remained asymptomatic in the 12-month follow-up period. |
Our patient was a two-year-old child who was first in birth order, born eight weeks premature, with a very low birth weight, to a primigravida mother of 23 years of age. In view of prematurity and respiratory distress shortly after birth, he was managed as a case of respiratory distress syndrome with surfactant administered on days one and two of life. He was also treated for neonatal hyperbilirubinemia on day three of life for 24 hours with phototherapy alone. No exchange transfusion was required. He was discharged home on day eight after establishing oral feeds and on room air. Discharge neonatal check was normal. He passed the neonatal hearing test, and since birth, his medical history had been unremarkable for significant medical concerns. His parents had a nonconsanguineous marriage, and there was no family history of any significant childhood illness, including speech delays and spontaneous abortions. He was noticed to have abnormal behavior by his mother at one year of age. There were also developmental concerns expressed by the mother. The child did not interact well with his parents and preferred to express his needs with physical gestures rather than verbally, but he could speak bisyllables when coaxed.\nUpon evaluation by a local pediatrician, his thyroid stimulating hormone level (TSH) was found to be raised at 18 months of age, for which he was started on levothyroxine. The abnormal behavior persisted. By now, he was not using any words but made growling noises when upset and throw things around. He was not making eye contact, choosing to look toward the ground or at the ceiling when being talked to. In other domains of development, he was keeping up with his peers, and no concerns were expressed. Age-appropriate vision testing was carried out which was normal. Upon evaluation at our child development center, he was labeled as high risk of autism as per the Modified Checklist for Autism in Toddlers scoring system at two years of age. His TSH levels had normalized by now. We liaisoned with the neurology team to rule out organic causes for his behavior and development. Blood tests including lead levels, full blood count, TSH, and electrolytes were normal. He tested positive for MTHFR mutation (heterozygous), factor V Leiden mutation (heterozygous), and plasminogen activator inhibitor type 1 deficiency (homozygous). These findings led us to start him on high-dose folic acid (2.5 mg, once a day, orally, daily) along with behavioral training and speech therapy at our center. On follow-up three months later, the mother reported improved behavior with the child using words to express his needs, albeit infrequently. He was now making some eye contact when addressed directly. When Childhood Autism Rating Scale (CARS) was performed six months later at 30 months of age, it was not indicative of any feature of autism. No adverse effects of drug therapy were reported. Regular follow-up examinations have reported improvements in general behavior and speech. At four years of age, he was able to interact well with children in his playschool, loved to share lunch and toys, and recite stories. |
The patient, a 55-year-old female, was admitted in the hospital on July 5, 2019, because of the discovery of an abdominal mass that had been present for more than 4 months. Approximately 4 months prior, the patient inadvertently found a hard upper abdomen mass but reported no associated pain. The patient self-reported the tumor to be about the size of an egg but reported no nausea, vomiting, abdominal pain, diarrhea, haematemesis, blood in the stool or other discomfort. A local hospital computed tomography (CT) enhancement scan revealed a solid cystic mass in the upper abdomen, and the initial segment of the jejunum was unclear, suggesting the possibility of a stromal tumor. The patient was physically healthy. The examination upon admission revealed a soft abdomen that allowed the abdominal mass to be palpated. The mass was hard and appeared to contact the upper left abdominal area, and the size was approximately 5 × 6 × 5 cm. The patient's level of activity was good, and there was no tenderness. After admission, the relevant examinations were completed, and no obvious abnormalities were found in the laboratory tests, which included routine blood tests, biochemistry tests, and tumor marker analyses.\nThe upper abdomen enhanced CT showed the following: an abnormally dense shadow was present across the upper abdomen, but the side was clear, and the tumor size was approximately 6.2 × 5.8 cm. There was an uneven density within the lesion, with obvious visible enhancement present in 1 area and a cystic nonenhanced area. The lesion was closely related to the intestinal tract of the small intestine (beginning approximately at the jejunum), and a small arterial branch was seen inside. There were no obviously enlarged lymph nodes beyond the retroperitoneum (Fig. A–C).\nFirst, the patient underwent ultrasound-guided abdominal biopsy, and the postoperative pathology results showed the following: the cells showed alveolar and trabecular growth and were of a consistent shape, with round or oval nuclei and visible nuclear inclusion bodies. No clear mitotic figures were found. The results of immunohistochemical marker staining were as follows: chromogranin A (CgA)+, synaptophysin (Syn)+, cytokeratin +, vimentin–, CD56-, β-catenin membrane+, CD10–, PR–, CD117–, CD34–, CD7+, CD20–, CR–, and Ki-67 positive rate <1% (Fig. A–F). Considering the pathology and immunohistochemistry results together, NET was considered, with a suspicion of neuroendocrine tumor G1. The patient was diagnosed with d-NET. After surgical contraindications were excluded, laparoscopic-assisted partial duodenal resection was performed under general anesthesia on July 17, 2019. The operation was successful, and the tumor was completely removed (Fig. D). The specimen was sent for pathology testing. The postoperative pathology results showed the following: an intestinal NET (G2) invading the serosa, and the surgical margin was not affected. The postoperative immunohistochemistry results were as follows: CgA+, Syn+, cytokeratin +, vimentin–, CD56 partial weak+, CD117–, DOG-1–, CD34–, S-100–, SMA–, desmin–, and Ki-67 approximately 2% (Fig. A–F). A pathological stage of WHO pT2NX was assigned.\nAfter the operation, gastrointestinal decompression, a limited diet, acid suppression, anti-infection strategies, and fluid replacement were employed. The patient's condition gradually improved, and she was discharged. One-month and 3-month on follow-up after surgery, showed no evidence of recurrence. |
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. |
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 71-year-old man, who did not complain of any physical pain, decided to consult our hospital's hepatology department owing to outpatient laboratory data and ultrasonography results that suggested slight liver dysfunction and an upper abdominal tumor, respectively. The patient's medical history included appendectomy at the age of 16 years, right thigh fracture at the age of 22 years, and hyperlipidemia since he was 60 years old. Laboratory data showed aspartate aminotransferase, alanine transaminase, and alkaline phosphatase levels of 28, 43, and 469 IU/L, respectively. However, following abdominal ultrasonography (AUS) (), computed tomography (CT) (), and upper gastrointestinal endoscopy, a 4.5 cm submucosal tumor at the lesser curvature of the stomach was highly suspected. Upper gastrointestinal endoscopy showed an elevated, nonepithelial lesion with a smooth surface in the lesser curvature of the stomach (). AUS revealed a leaf-shaped tumor with a mosaic pattern and a heterogeneous parenchyma. Moreover, endoscopic ultrasonography (EUS) () showed that the same tumor seemed to be continuous with the fourth layer, and contrast-enhanced CT revealed that the heterogeneous parenchyma was located between the head portion of the pancreas and the left liver lobe. The size of the tumor was approximately 49 × 29 mm. The tumor mass appeared to protrude from the stomach wall (Figures –). AUS and CT did not indicate liver tumor, lymph node swelling, and peritoneal dissemination. The preoperative diagnosis was submucosal tumor, a suspected GIST of the stomach.\nLaparoscopic partial resection of the stomach was subsequently performed. Although the tumor was located at the lesser curvature of the stomach, its origin could not be determined by surgical findings alone. As the lesser omentum and fat around the tumor were exfoliated, the tumor appeared to be continuous with only a portion of the stomach wall. The tumor, as well as a portion of the stomach, was completely resected, including the stomach wall believed to be continuous with the tumor (). The procedure time was 65 min with no blood loss. Length of stay was 8 days after operation. No complication was detected.\nA diagnosis of leiomyosarcoma was established. Histopathologic examination of the tumor revealed a multinodular but smooth outer surface and foci of fleshy and pale cream-yellow areas underneath (Figures and ). Pathological findings showed that the tumor was not continuous with the stomach serosa (). Moreover, microscopic examination revealed long intersecting fascicles of spindle cells (hematoxylin and eosin staining), confirming the diagnosis of leiomyosarcoma (). Immunohistochemical staining showed that the tumor was negative for c-kit (), CD34 (), S-100 (), and DOG1 and positive for α-smooth muscle actin (α-SMA) (), desmin (), HHF-35, h-caldesmon, and calponin. High Ki-67 (MIB-1) expression (55.4%) and mitotic rate (39/50HPF) were also observed.\nAfter providing informed consent that there are no established drugs as postoperative adjuvant chemotherapy, and at 6 months and 1 year after surgery, no signs of recurrence were detected by CT. |
A 28-year-old woman complained of severe left hip pain and difficulty walking. The pain started to develop when she was in her early twenties, with the intensity increasing with the intensity of physical work. She consulted a nearby orthopaedic department. The attending physician diagnosed her as having hip OA and referred her to our hospital for advanced examination and treatment. The patient was a nurse. She had no clinical history of treatment for hip disorders such as developmental dysplasia of the hip in childhood. With regard to her hip pain, she reported that the pain was present both at rest and during walking. Regarding her left hip, she additionally had tenderness at the femoral triangle of Scarpa, and both Patrick's test and anterior impingement test had positive results. The ROMs of her left hip were 130° in flexion, 20° in abduction, 30° in adduction, 30° in external rotation, and 10° in internal rotation, whereas ROMs of her right hip were limited especially in abduction and internal rotation, and she reported groin pain at the end of the motion. Her Japanese Orthopaedic Association (JOA) hip score was 57/100. Her left hip radiograph showed degenerative arthritis categorised as Tönnis grade 2, and bone cysts were noted on the femoral heads ().\nSince improvements of joint congruity and space width were not investigated in hip abduction and adduction radiographs, we concluded that joint preservation surgeries such as periacetabular osteotomy could not be indicated for this patient. Moreover, she refused to undergo THA because of her young age. She was treated with NSAIDs and was instructed to perform general muscle and ROM exercises around the hip joint for 6 months. However, her hip pain did not improve, and repeat radiographs revealed OA progression. Hence, we recommended intensive jiggling exercise combined with medication.\nOne year after the initiation of jiggling exercise, the patient's hip pain notably improved, despite the absence of changes in the hip radiographs (). She was able to interrupt NSAID treatment. Three years later, the patient's hip pain remarkably improved and the radiographs of the hip joint showed notable improvement in terms of congruity and space width (). At the last follow-up, 4 years after the indication of the jiggling exercise, radiography revealed improved joint remodelling (). The ROMs of her left hip were slightly increased as 130° in flexion, 30° in abduction, 30° in adduction, 40° in external rotation, and 10° in internal rotation. Additionally, the JOA hip score was 84/100, which was assessed to be clinically effective. |
A 65-year-old woman presented with abdominal pain and hypophagia for 2 weeks. She had a medical history of alcoholic pancreatitis. A computed tomography (CT) scan of her abdomen and pelvis revealed thickening of the transverse colon wall. Colonoscopy showed an ulcerated tumor in the transverse colon, and histological analysis indicated moderately differentiated adenocarcinoma. Serum carcinoembryonic antigen (CEA) levels were normal, and no sites of distant metastasis were reported on preoperative examination. She underwent a laparoscopic extended right hemicolectomy using the non-touch isolation technique. Histopathological examination of the specimen revealed a moderately differentiated adenocarcinoma invading the subserosal layer with low venous invasion (v1) and no lymphatic invasion (ly0). The surgical margins were negative. A total of 92 lymph nodes were removed, of which none showed metastases. The tumor was diagnosed as stage IIA (T3, N0, M0) according to the International Union Against Cancer tumor, node, and metastasis (TNM) classification (7th edition) []. The patient had an uneventful recovery and was on regular follow-up every 3 months without adjuvant chemotherapy.\nFifteen months after her colectomy, a CT scan demonstrated a tumor in the antero-lateral rectal wall that was 20 mm in diameter, and a right ovarian tumor that was 25 mm in diameter (Fig. ). The ovarian tumor was a cystic mass with a solid component on magnetic resonance imaging (Fig. ). Colonoscopy revealed a superficial elevated lesion in the middle rectum that was shown by histological examination to be moderately differentiated adenocarcinoma (Fig. ). Serum CEA levels were normal. These findings were indicative of rectal cancer with ovarian metastasis, or double primary cancer of the rectum and ovary. A diagnostic and therapeutic laparoscopy detected no disseminated peritoneal metastases or liver metastases. Intraoperative cytological examination of the peritoneal lavage was negative for carcinoma. An operative rapid pathological diagnosis of the resected right ovarian tumor indicated metastasis of the colorectal cancer. Thus, we performed laparoscopic low anterior resection preserving the left colic artery with partial resection of the vagina, and bilateral adnexectomy.\nThe resected rectal tumor measured 20 × 18 mm (Fig. ). Histological examination demonstrated a moderately differentiated adenocarcinoma that had invaded the vagina and formed a metastasis in one of 32 lymph nodes. High venous invasion (v3) and low lymphatic invasion (ly1) were observed. The adenocarcinoma was mainly present in the submucosa and muscularis propria with a small range of invasion to the vagina (Fig. ), while the carcinoma-involved region of the mucosal layer had mucosal colonization representing the spread of metastatic tumor cells along the basement membrane of preexisting crypts and/or villi (Fig. ) []. There was no adenomatous precursor at the edge of the tumor, and surgical margins were negative. The right ovarian tumor was moderately differentiated adenocarcinoma that was positive for cytokeratin (CK) 20 and negative for CK7 immunohistochemical staining, indicating metastasis of colorectal cancer. The rectal and ovarian tumors shared high similarities with transverse colon cancer in architectural and cytological atypia (Fig. ). Both adenocarcinomas of the transverse colon and rectum were negative for p53 immunohistochemical staining and RAS wild type in genetic assessment (Fig. ). These findings support a diagnosis of rectal and ovarian metastases from primary transverse colon cancer.\nThe patient recovered well after surgery, and adjuvant chemotherapy was decided after a multidisciplinary meeting. She was treated with eight cycles of oxaliplatin and capecitabine, and neither relapse nor metastasis has been observed 18 months after surgery.\nThe incidence of colorectal metastasis from primary colorectal cancer is rare, and distinguishing primary from metastatic colorectal cancer can be challenging. To our knowledge, only three reports in English and six in Japanese have described suspected cases of colorectal metastasis of colorectal cancer [–]. We reviewed a total of eight patients, including seven out of the abovementioned nine patients with detailed clinical information as well as our own (Table ). The patients were three males and five females, with a median age of 66.5 years (range 52–88 years). Ascending colon cancer was the most common primary tumor (n = 3), followed by tumors of the sigmoid (n = 2), transverse colon (n = 2), and cecum (n = 1). Metastatic colorectal lesions were located in the rectum in all cases. In terms of other metastatic sites, seven patients had other metastases (lung, liver, spleen, abdominal wall, axilla, and ovary) and one had no other metastases.\nA previous study of 278,208 malignancies in a nationwide Japanese pathologic autopsy database from 1990 to 2003 identified 18,252 case with metastatic colorectal cancer. Of these, 1302 (7.1%) were from primary colorectal cancer []. The database does not include information about the suspected metastatic pathway (hematogenous, lymphogenous, direct invasion, or dissemination), but most metastatic tumors in the database are attributed to direct invasion or disseminated metastasis, reflecting late-stage disease. However, the number of reported clinical cases might not represent the actual incidence of colorectal metastasis from colorectal cancer. One possible reason for the rarity of reported colorectal metastasis cases is that most cases occur as part of systemic advanced disease, for which surgical resection will not be performed []. The other reason is that diagnosing metastasis is difficult [, ]. Although gastrointestinal metastatic carcinoma usually represents a submucosal tumor, differential diagnosis (as primary disease or metastasis) becomes difficult if the tumor invades the mucosal layer. Estrella et al. argued that metastatic carcinomas involving the mucosal surface frequently mimic second primaries, so histologic features cannot reliably distinguish metastatic from primary carcinoma []. Additionally, primary colorectal cancers resembling submucosal tumors have been reported in previous studies [, ]. This explains why colorectal metastases may be misdiagnosed and treated as primaries.\nDistinguishing primary from metastatic colorectal cancer can be challenging, but a comprehensive evaluation of histological features, clinical history, and tumor distribution enables making the correct diagnosis and implementing the optimal treatments []. In this case, we suspected a metachronous metastasis for the following reasons. First, histological findings demonstrated that the adenocarcinoma was mainly present in the submucosa and muscularis propria with mucosal colonization, which is a supportive finding for metastatic carcinoma, as this indicates a low possibility of primary rectal cancer and implantation of the transverse colon cancer. Second, the rectal and ovarian tumors were very similar to the transverse colon cancer in terms of architectural and cytological atypia, further suggesting metastasis of primary transverse colon cancer. Third, there was no adenomatous precursor at the tumor edge, indicating metastatic cancer. Fourth, both adenocarcinomas of the transverse colon and rectum were negative for p53 in immunohistochemical staining and RAS wild type in genetic assessment, indicating metastatic rectal cancer from primary transverse colon cancer.\nIn reviewed cases, the exact mechanism of colorectal metastasis from primary colorectal cancer has not been fully elucidated; thus, the possibility of hematogenous or lymphogenous spread remains. We suspected hematogenous or lymphogenous metastatic pathways to the rectum from the primary transverse colon cancer because the carcinoma was mainly located in submucosa and muscularis propria; however, there was no additional evidence than tumor localization. In this case, the rectal tumor penetrated into a small range of the subserosal layer with invasion to the vagina; additionally, there was a metastatic ovarian carcinoma. Peritoneal metastatic invasion primarily toward the deep layer of the rectal wall cannot be ruled out. The metastatic colorectal lesions were located in the rectum in all reviewed cases, and this suggests that peritoneal spread to Douglas’s pouch or the rectovesical pouch is a possible pathway for colorectal metastasis from primary colorectal cancer.\nConsidering that the majority of reported cases had multiple metastases, the existence of other metastatic lesions might be a risk factor for colorectal metastasis. Therefore, more attention should be paid to colorectal lesions when other metastatic sites have been identified. Colorectal metastases usually represent late-stage disease and have poor prognoses; however, prolonged survival after surgery and complementary therapy can be achieved in some patients []. In this case, neither relapse nor metastasis has been observed 18 months after surgery. The follow-up periods varied too widely to evaluate patient prognosis in reviewed cases. Therefore, additional studies are needed to better understand this rare metastasis and to determine the optimal therapeutic strategies. |
A 57-year-old ethnic Danish woman was admitted to the Department of Plastic Surgery at Aarhus University Hospital for delayed reconstruction of her right breast. Two years earlier the patient had had a mastectomy of the right breast due to ductal carcinoma in situ (DCIS) and Morbus Paget of the breast. The patient had undergone adjuvant therapy with chemotherapy and Trastuzumab and received treatment with letrozole at the time of the first operation. At no time had the patient received radiation treatment of the breast. In addition to letrozole, the patient used Acrivastine and Pseudoephedrine for rhinitis, as well as Simvastatin for hypercholesterolemia and multivitamins. There was no medical history of allergic reactions or dermatological disease, although a rash had previously been noted in conjunction with the use of micropore scar tape. Upon proper information the patient opted for delayed breast reconstruction with autologous fat transfer and the Brava system.\nThe patient was prescribed the use of Brava for four weeks prior to autologous fat transplantation: 10 hours a day for the first 3 weeks, and 22 hours a day in the week prior to operation. It was possible for the patient to use the Brava system also at work. The patient was supplied with the prescribed skin care products for use with the Brava system. Autologous fat transplantation was performed a total of 7 times over a period of 19 months. Fat transplantation volumes ranged between 30 cc and 200 cc and total transplanted fat was 957 cc. A Khouris 3 mm extraction cannula connected to a 10 cc syringe was used to harvest fat. The harvested fat was then centrifuged at 1200 rpm and the supernatant oil was removed. The prepared adipose tissue was then injected subcutaneously and into the pectoral muscle using a Coleman type 2 cannula on a 3 or 10 cc syringe. Scar tissue was subjected to rigottomy with 3 dimensional micromeshing using a 12- to 18-gauge needle. Brava therapy was resumed 8 weeks after each of the fat transfers. Furthermore, in conjunction with the aforementioned 7 autologous fat transplantations, the patient also underwent mastopexy and excision of a suture granuloma of the left breast and z-plasty of the mastectomy scar of the right breast.\nAfter the second series of autologous fat transplantation, the patient developed irritative rash of the skin which had been in contact with the Brava system; the irritation of the skin persisted and increased in intensity with the continued use of Brava. After the fourth series of treatment, the evolvement of blisters resulted in sleepless nights due to pain and itching, which required prescription of sedatives and antihistamines (). Furthermore Mildison a hydrocortisone based ointment and Comfeel Plus were applied to the skin. Due to these skin lesions, multiple additional consultations were necessary at our wound clinic. The blisters subsided only after discontinuation of Brava. A silicon allergy test was performed and found negative. Due to the pain and itching, the use of Brava was reduced with approximately 2 hours daily during the final 5 series of treatments. Aesthetic analysis was performed using preoperative and postoperative photographs. Both patient and surgeon evaluated the reconstruction of the breast as optimal with a soft and natural appearing breast after 7 series of treatment. |
A 65-year-old male presented with a three month history of progressive left hip pain. His past medical history was noteworthy for a non-ischemic cardiomyopathy for which he underwent a heart transplant ten years prior to presentation. He had a history of osteoarthritis for which he had undergone bilateral hip replacements complicated by a left prosthetic hip infection with Cutibacterium acnes. His past history was also positive for rheumatoid arthritis, hypertension, and type 2 diabetes.\nThe first stage of his left hip revision after his first episode of prosthetic joint infection with C. acnes occurred pre-heart transplantation and he was treated with 6 weeks of vancomycin following hardware explantation. His second-stage hip revision occurred over a year later, following his heart transplant. His post-transplant course was otherwise uncomplicated, without any episodes of graft dysfunction, rejection, or infectious complications over the previous nine years. He was maintained on tacrolimus and mycophenolate mofetil since his transplant without recent corticosteroid exposure.\nWith regard to his present symptoms, along with the pain, he noted occasional night sweats. He reported receiving 2 hip injections for the pain (one into his hip joint and another into his trochanteric bursa, both on his left side) by his outpatient orthopedic doctor about 2 weeks prior to presentation that provided temporary relief. Sterile precautions were reportedly observed during in-clinic procedures. Following the injections, the patient noticed a progressive fluctuant area swelling of his left lateral thigh and hip. Aspiration of that area 4 days prior by his outpatient orthopedist yielded purulent-appearing fluid that was Gram stain negative for organisms, with no growth seen either on aerobic or anaerobic cultures. Three days prior to admission, he underwent hip arthrocentesis that showed cloudy fluid with 65,000 white blood cells per microliter and a differential of 95% polymorphonuclear neutrophils. Gram stain was negative, and no crystals were seen. Culture of the synovial fluid was later finalized as no growth. However, prosthetic joint infection was suspected and so the patient was admitted for surgery.\nThe patient was an active dog breeder (Yorkies, Maltese, and Morkies), with over 10 dogs at home at any one time, and had recently participated in the birth of several puppies. There was no history of illicit or injection drug use. He also noted being scratched on his legs by the dogs in the past, but could not recall any recent scratches or bites recently.\nOn admission, he was well appearing and comfortable at rest. All vital signs were normal and he was afebrile. He noted mild pain with passive and active movement of his left hip, however, he was able to ambulate. Oropharyngeal exam was unremarkable with good dentition. His bilateral shins had evidence of previously-healed scratches. On the lateral aspect of his thigh was a tender egg-sized swollen area of fluctuance and erythema, without increased warmth or obvious drainage or sinus tract.\nLaboratory evaluation was notable for a peripheral white blood cell count of 6300 per microliter. Erythrocyte sedimentation rate and C-reactive protein levels were 63 mm/hour and 5.4 mg/dL, respectively. Hip X-ray did not show loosening or disruption of his prosthesis. He did not receive any antibiotics prior to surgery. Two sets of pre-operative blood cultures were drawn and finalized as no growth. Medications at the time of presentation included methotrexate (2.5 mg daily), mycophenolate mofetil (250 mg twice daily), and tacrolimus (1 mg twice daily). His diabetes mellitus was well-controlled with dietary changes and his most recent hemoglobin A1c measurement was 6.2%.\nThe area of the suspected abscess the lateral thigh was incised and drained. The proximal prosthetic body, femoral head, and acetabular liner were all removed, the joint was irrigated and debrided, and hardware was replaced in a one-stage fashion. Vancomycin and tobramycin-containing beads were placed. Intraoperatively, frank purulence within the joint was not observed. Five separate tissue specimens were sent for bacterial, fungal, and mycobacterial culture. Post-operatively, vancomycin and ceftriaxone were begun empirically pending further culture data.\nApproximately 2-3 mm of each tissue submitted was embedded whole in fungal media. The remaining tissue from each site was ground in 1 mL Tryptic Soy Broth. Mycobacterial, fungal, and bacterial growth media were inoculated with ground tissue suspension. Gram, Acid Fast, and Calcofluor White stains were prepared from touch preps of intact tissue and ground tissue suspensions. All stains of tissue were negative for organisms. Bacterial cultures were incubated at 35 °C in a 5–10% CO2 incubator for aerobic cultures and in the BD BBL GasPak anaerobic pouch for anaerobic cultures. After four days of incubation, tissue cultures collected from the left hip (one of 5 total submitted) grew small, translucent, spreading colonies from the anaerobic blood agar incubated under anaerobic conditions. Gram stain of the colonies demonstrated spiral-shaped gram-negative rods (Fig. ). Matrix-assisted laser desorption time of flight (MALDI-TOF) mass spectrometry yielded and identification of Anaerobiospirillum succiniciproducens, which is currently unclaimed in the bioMerieux Vitek-MS database. Therefore, 16 s ribosomal RNA gene sequencing was performed, with the best matches using NCBI Blast Nucleotide Sequence Database to Anaerobiospirillum succiniciproduces and Anaerobiospirillum species with > 99% query coverage and identity. Ultimately, the laboratory report was released as “most closely resembles Anaerobiospirillum species; Identified by DNA sequencing.” 16S sequencing was not performed on any other samples including blood.\nMycophenolate was held temporarily in the setting of infection. Following identification of the organism, vancomycin was discontinued and ceftriaxone (2 g daily) was continued to complete 6 weeks total of antibiotic therapy. He tolerated treatment well to date, without evidence of recurrent infection.\nSaliva and perirectal anaerobic cultures of two of the patient’s dogs (both Maltese) were performed using flocked swabs submitted in anaerobic agar gel transport media, and cultured on standard anaerobic media. No organisms resembling Anaerobiospirillum spp. were isolated.\nFollow up 2 months later was unremarkable for relapse of infection, after completion of intravenous antibiotics,. |
A 3-year-old girl was admitted to our department because of ingestion of multiple magnetic balls 6 days prior admission on August 9, 2018. She had abdominal pain, without vomiting, fever, or hemorrhage. The magnets were not passed 6 days after ingestion. The abdominal examination was normal. X-ray indicated the presence of 5 dense round shadows in the left middle abdomen (Fig. ). After completing the preoperative investigations, gastroscopy was performed under general anesthesia with endotracheal intubation. The child was placed in the left lateral position, and the gastroscope was passed through the mouth into the esophagus in the normal fashion. The mucosa appeared normal. We found 2 global magnets in the gastric body, one was seen embedded in the gastric wall, and congestion and edema were observed in the surrounding mucosa. The gastroscope was then further advanced into the duodenum and 3 spherical magnets were seen. Two were embedded in the duodenal wall, and congestion and edema were observed in the surrounding mucosa. The gastric and duodenal magnets were firmly attracted to each other with gastric and duodenal mucosa in between. The foreign body forceps were first inserted and grabbed the bottom of one of the duodenal magnets. Considerable grabbing force was to overcome the attracting force between the magnets and the magnets were separated and the 3 duodenal magnets were eventually removed with a foreign object basket. A circular ulcer was observed in the mucosa with its crater reaching the muscular layer. The gastroscope was advanced into the body of the stomach, then the foreign body forceps was inserted and used to grab the bottom of the gastric magnet. The 2 gastric magnets were eventually removed with a foreign object basket. A circular ulcer was observed in the mucosa with its crater reaching the muscular layer (Fig. ). Postoperatively, no complication occurred. A nasogastric tube was used to maintain nutritional intake. Abdominal x-ray was performed, and revealed no complications (Fig. ). |
A 50-year-old male with a history of intravenous (IV) drug abuse presented to the hospital with acute onset back pain. The patient had a 10-year history of chronic back pain as well as a history of cervical radiculopathy, for which he underwent anterior cervical discectomy and fusion 6 years ago. The patient stated that his back pain had been worsening over the past 3 weeks. The patient presented to the emergency room several times in the last couple of weeks prior to admission. His back pain was presumed to be related to his previous history, and he was discharged home on opioid analgesics.\nOn admission, the patient reported severe squeezing back pain extending from his lower to middle back. The pain was described by the patient as a 10/10 in intensity with radiation to his buttocks. The pain was not relieved by lying down and was aggravated by activity. The patient did not exhibit any lower extremity weakness, numbness, or bladder/bowel dysfunction, and he denied any fevers or night sweats. On physical examination, palpation of the spine revealed diffuse tenderness. Straight leg raising test was negative.\nIn the ED plain X-ray of the lumbosacral spine revealed degenerative changes of the lumbosacral spine but no evidence of infection, malignancy, or fracture (see ). The patient was sent to the inpatient ward for observation with an initial diagnosis of chronic back pain.\nInitial laboratory findings revealed a mildly elevated white blood cell count at 12,000 and anemia with hemoglobin at 9.5. Erythrocyte sedimentation rate was found to be 92. With these laboratory abnormalities and persistent symptoms, magnetic resonance imaging (MRI) was done to further evaluate the back pain. MRI examination of the lumbosacral spine revealed osteomyelitis with discitis at T10-T11 level with some retropulsion of both vertebral bodies causing mass effect on the spinal cord (see ). The patient was immediately started on IV dexamethasone, and he underwent CT-guided aspiration of the intervertebral disc space the following day. Following the procedure, the patient was started on cefepime and vancomycin while awaiting culture results from the aspiration.\nBlood cultures as well as cultures of the disc aspiration material grew Enterobacter aerogenes. Vancomycin and cefepime were substituted with ertapenem, because of antibiotic sensitivity results.\nThe patient's clinical condition started to improve on day 5 of admission, and he was discharged with long-term antibiotics therapy.\nPatient was followed up 8 weeks later with resolution of his back symptoms. |
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 32-year-old Turkish man was admitted to the emergency department because of severe intrascapular back pain, an episode of unconsciousness and weakness of both legs. Bilateral proximal muscle weakness of the lower extremities had started approximately 4 hours before admission and progressed rapidly. Three hours after appearance of the weakness the patient collapsed and was unconscious for 2 minutes, accompanied by urinary incontinence. No seizure was observed. After regaining consciousness he complained about severe intrascapular back pain, stabbing in nature without radiation. Initially the blood pressure was 80/60 mmHg, the heart rate was 100 bpm and the blood glucose level was 223 mg/dl. Emergency treatment with rapid infusion of cristalloid fluids was started and the patient was transferred to the hospital. When the patient arrived at the emergency department the blood pressure was 110/60 mmHg and the heart rate was 120 bpm. On his trunk and arms were confluating erythematous patches which appeared 3 days ago. Body temperature was normal. His muscle strength was found to be 2/5 on the MRC scale (Medical Research Council Paralysis Scale) in both lower extremities and 3/5 in both upper extremities. The deep tendon reflexes were somewhat diminished, otherwise neurological and physical examination were normal. He smoked 50 cigarettes a day and his alcohol intake was moderate. The family history was negative for cardiovascular disease. Beside nephrectomy after traumatic kidney rupture in childhood no relevant previous disease was present and no previous muscle weakness was noticed. However he reported that he consulted his GP the same morning for treatment of the erythematous patches. The GP gave him a pulse i.v. corticosteroid infusion (250 mg prednisolone).\nThe electrocardiogram revealed a sinus tachycardia of 118 bpm, a prolonged QTc interval, ST-segment depressions in all leads and T-U-wave complexes in the lateral leads (). To rule out an aortic dissection a contrast computed tomography of the chest was performed immediately after admission, however no structural abnormality was detected. The only noticeable finding was a severely reduced cardiac output, recognized at the delayed contrast of the arteries. The biochemical laboratory analyses were within normal limits, except of a serum potassium level of 1.2 mmol/l [Norm 3.5-5.0 mmol/l], a ph of 7.26 [Norm 7.37-7.45], a bicarbonate level of 16.9 mmol/l [Norm 22-30 mmol/l], a base excess of -9.0 mmol/l [Norm -2.0-3.0 mmol/l] and a chloride level of 116 mmol/l [Norm 95-105 mmol/l], a TSH (Thyroidea stimulating hormone) level of <0.01 µIU/ml [Norm 0.27-4.20 µIU/ml], a fT3 (free trijodthyronine) level of 10.82 pg/ml [Norm 2.53-4.34 pg/ml] and a fT4 (free thyroxine) level of 3.2 pg/ml [Norm 0.9-1.7 pg/ml]. After receiving the laboratory results TPP was diagnosed and intravenous administration of potassium chloride was begun. Because of prior contrast medium exposure a therapy with methimazol and perchlorate was started. After administration of 30 mmol of potassium chloride within 3 hours, the patient got serious cardiac bradyarrhythmias followed by an asystolia which required mechanical reanimation for a short period of time. The serum potassium level at that time was 1.6 mmol/l. During the following 4 hours the patient developed a rebound hyperkalemia with a potassium level of 9 mmol/l which however did not induce any complications and lasted for 60 minutes despite any medical interventions. After intravenous administration of overall 90 mmol of potassium chloride the patients muscle strength and serum potassium were fully restored within 12 hours. Further laboratory diagnostics showed a high titre of thyrotropin-receptor antibodies, [7,4 IU/l (Norm <1,0 IU/l)] and a high titre of thyroid peroxidase antibodies [540 IU/ml (Norm <34 IU/ml)], both providing evidence of Graves’ disease []. Ultrasound examination revealed a normal sized thyroid gland with an inhomogeneous pattern. The skin changes were diagnosed as Pityriasis versicolor. |
A 12-year-old boy was referred to the Department of Pediatric Dentistry, Dicle University, Diyarbakır, Turkey for examination, evaluation and treatment of gross attrition and considerable sensitivity of his teeth. A detailed medical, dental, and social history was obtained. He was both self-conscious and unhappy as regard the appearance of his teeth. Clinical examination revealed that tissue loss affected all teeth. The enamel layer was very thin and Brown (pigmented), the cuspal structure was completely absent in the occlusal portion of the molars which were most severely affected, and enamel pit defects (pigmented stains deep) were present in the anterior teeth (Figures , , and ). However, the clinical appearance of cervical and approximal enamel seemed to be normal. It was thought that the patient likely suffered from a hypomature type of AI. The patient's occlusal vertical dimension and rest vertical dimension were assessed. The interocclusal rest space had increased because of attrition of the molars. The exposed dentin was hypersensitive. Clinical and radiographic examination of the patient revealed deep carious lesions in the maxillary four teeth, and the mandibular left first molar had been extracted because of severe attrition and caries approximately 10 months earlier.\nA treatment plan was developed with the following aims: to reduce the reported sensitivity of the teeth, to modify the occlusion, to restore mild crowding and masticatory function, and to improve the aesthetics. The patient was informed of the diagnosis and all treatment plans were discussed with him and his parents. He could not afford prosthetic treatment, including porcelain or ceramic restorations. Therefore, the treatment plan included placement of direct composite resin restorations in maxillary and mandibular anterior and posterior teeth. These materials were chosen because it cost less than ceramic and porcelain restorations and with the hope that it would ensure aesthetic and functional rehabilitation until the patient could cover the cost of porcelain restorations.\nFirstly, according to the manufacturer's directions maxillary and mandibular posterior teeth of patient were restored using posterior composite resin (3 M ESPE-Filtek P60, St. Paul, MN, US), after deep caries in maxillary premolar and molar teeth were removed. Later, on the maxillary and mandibular anterior teeth, a 0.5 mm facial reduction was prepared for direct composite resin laminate veneers. In addition, the finish line at the proximal and cervical aspects of the teeth preparations was extended, and a rounded finish line throughout was prepared for the restoration. All teeth preparations were completed without sharp line angles. Maxillary and mandibular anterior teeth of the patient were restored using composite resin (3 M ESPE-Filtek Supreme XT Universal, St. Paul, MN, US) (Figures , , and ).\nThe patient was recalled at 2-month intervals. The 24-month recall clinical and radiographic examination revealed no pathology associated with the rehabilitation, and the patient's aesthetic and functional expectations were satisfied (). |
In June 2011, a 56-year-old male was referred to our department by head and neck surgeon in order to improve his upper denture retention and stability. The patient was diagnosed with a squamous cell carcinoma of the maxillary gingiva (T4N0M0) in May 2005 and underwent an extended left maxillectomy, an anterior and middle cranial base resection, a left ophthalmectomy, and a flap reconstruction using the rectus abdominis muscle were performed. On physical examination, a recessed deformation on the left side of his face could be seen because of the left ophthalmectomy. The function of the left levator palpebrae muscle was eliminated to the level of a slight elevation by using the frontal muscle. A metal plate was anchored to the inferior wall of orbit. The left ethmoid bone, inferior nasal turbinate, the maxilla, alisphenoid, medial and lateral pterygoid muscle were already excised during the mesh titanium plate reconstruction of the anterior wall from the maxillary orbital region. Intraorally, the left maxilla had been excised from the midline, with the rectus abdominis muscle flap sutured directly to the soft palate. The peripheral mucous membrane around the left upper lip was already scarred, without the oral vestibule, and the flap margin had moved along with the surrounding soft tissue. The 70 × 50 mm flap was sagging from its weight and was in contact with the mandibular molars, reducing the volume of the oral cavity unless dentures were worn. The maxilla was removed from the midline to the maxillary tuberosity, while the mandible was removed from the anterior border of the ramus to the coronoid process. Dead space was eliminated because the abdominal rectus muscle was placed from the anterior cranial base to the oral cavity during reconstruction (Fig. ). No expiratory leakage or food reflux was observed, and the rhinopharyngeal closure was maintained. Prior to performing surgery, there was no tumor recurrence or metastasis. The patient had a mouth opening of 43 mm, which we judged operable and then conducted the flap reduction and elevation under general anesthesia in Dec 2008. Informed consent was obtained from the patient’s parents prior to study initiation, and all procedures were performed in accordance with the Declaration of Helsinki.\nSurgical reconstruction was performed as follows:An incision was made from the buccal side of the sutured edge (scar) in the abdominal rectus muscle flap (Fig. ). We can conduct a vestibular extension at the same time by incising this position. The adipose tissue was peeled from the buccal side to slightly beyond the skin flap center while maintaining approximately 5 mm thickness. The adipose tissue was reduced using a radio knife (8 g) (Fig. ). When we reduce fat tissue, we must avoid perforating of the skin. The skin was incised directly above the zygomatic bone, with tissue separation (avoiding exposure of the plate) to enable easy visibility of the zygomatic bone. Subsequently, the subcutaneous tissue was peeled from the zygomatic bone to the oral cavity for tunneling. Three mini QUICKANCHOR® (Depuy Mitek Surgical Products, Inc. Raynham, MA, USA) anchors were placed in the zygomatic bone, and anchor sutures were drawn through the subcutaneous tissue to lift the skin flap. A modeling compound was used to shape the margin of the celluloid splint (Fig. ). The advantage of flap suspension using Mitek anchors is the simple operability, less anchor positioning limitation, and easier length adjustment of the thread for suspension, which lead to easier fixation of soft tissue without slackness as well as clinically sufficient strength for fixation of ligament and tissue. On the other hand, less than 4 mm thickness of the cortical bone for suture anchor fixation causes insufficient fixation, therefore, determining placing position on the bone for fixation is necessary. Consequently, due to the versatility, the position that is considered optimal for stronger fixation and more efficient suspension can be selected as the anchor placing position, while the periosteum, corium, and scar tissue that are thought the most suitable for maintaining the strength can be chosen for the suture thread. Regarding the anchor placing position in this case, we determined 3 positions on the zygomatic bone and sutured flap corium taking into consideration a complete maxillectomy had been completed, which resulted in being able to lift the flap outward and upward.\nPostoperatively, the color of the skin flap was normal without congestion or necrosis. The celluloid splint was removed 10 days after the surgery with no infection or necrosis observed in the skin flap. We can find only fat, scar tissue, not carcinoma in the reduced fat tissure. At 3 months postoperatively, epithelialization and scarring were observed on the border of the skin flap and buccal mucosa, with no wound opening. Next, a denture that was stabilized to the right residual teeth with a clasp made. This prosthesis had two double Akers cast clasps unilaterally to retain the prosthesis by the four remaining molars. The major connector used anteria paratal plate. The patient was quite satisfied to be able to masticate, form an alimentary bolus, and swallow without any teeth falling out. No re-sagging of the skin flap or wound infection was observed at 3 years postoperatively. Patient follow-up will be continued at our department (Fig. ). |
A 26-year-old male reported to the Dental Department, with the chief complaint of swelling and difficulty in breathing for about 5 months. The extraoral clinical examination revealed a diffuse swelling on the left side of the face obliterating the nasolabial fold. The swelling was associated with slight pain and continuous headache. Patient also complained of continuous tear discharge from the left eye. Computed tomography scan revealed a soft tissue lesion completely obliterating the left maxillary sinus and extending up to the nasal cavity; right maxillary sinus was normal. The swelling extended anteriorly up to external nasal orifices and posteriorly to the nasopharynx. The nasal septum showed deviation to the right side. Left ethmoid sinus was also found to be involved. The (orthopantomogram) showed similar radiolucency of the lesion which was interrupted by some flecks of radiopacitites [Figures and ]. Also, both the maxillary canines were impacted with the left maxillary permanent canine involved with the lesion and were closely associated with the small flecks of radioopacity.\nThe presence of keratin and cholesterol crystals in the fine needle aspiration cytology report directed toward the cystic lesion having keratin in the lumen. A provisional diagnosis of OKC was arrived upon. Complete enucleation of the lesion was carried out under general anesthesia, which was followed by extraction of all the left maxillary teeth. Along with the lesion frontoethmoid sinus was also excised as the lesion had involved the same. After completion of the surgical procedure the entire cavity was completely cleaned and was packed with Gel foam. Prosthesis (obturator) was made from the presurgical records and was delivered to the patient after surgery. Following the surgery, the healing of the surgical wound was uneventful and the patient was kept under observation to check for recurrence.\nThe histopathological examination revealed the cystic space which was lined by a continuous layer of stratified epithelium of 6-8 cell layer thickness with prominent basal cell layer and the absence of rete ridges. The stratified epithelium was orthokeratinized in nature with prominent stratum granulosum layer. Abundance of orthokeratin was present in the cystic lumen. The connective tissue showed minimal or no inflammatory response. One portion of the lesion was hard and solid which was processed by decalcification. The decalcified section showed presence of dentine and pulp like tissue arranged in an irregular pattern. Enamel spaces were seen in some areas. On the basis of thorough histopathological examination, the final diagnosis of orthokeratinizing odontogenic cyst associated with complex odontoma was given [Figures and ]. |
A 20-year-old girl from the state of Assam, India, reported to Mahendra Mohan Choudhary Hospital, Guwahati, Assam. Her chief complaint was gingival enlargement in the upper right region since 3 to 4 years with difficulty in maintaining oral hygiene and unilateral mastication from left side. History suggested that the patient noticed the facial asymmetry 3-4 years back. The gingival enlargement also appeared gradually and increased to the present size and not associated with any kind of pain. Further history revealed that the patient was unmarried and has never taken any medications that could cause gingival enlargement suggesting any idiopathic etiology for the condition.\nPhysical examination did not reveal any abnormal findings in general condition, mental health. Clinical examination revealed facial asymmetry, with enlargement of the right side of the face []. Right scleral show was present. The nose on the affected side was asymmetric, with thickening of the ala and the base of the nose. The size of the nostril appeared to be equal. Both upper and lower lips appeared normal. No other facial deformity was noted.\nIntra-oral examination revealed gingival enlargement in the right upper quadrant extending from the right central incisor till the 2nd molar []. The enlargement covered two thirds of the clinical crowns of the above mentioned teeth. The probing depth was measured with a periodontal probe which revealed combined type of pockets in the enlargement region []. Also, a localized enlargement was noted in the lower right anterior region covering the crowns of lateral incisor and canine. The growth was more evident on the buccal surface than palatal. On palpation, the tissues were firm and fibrous in consistency, extending onto the attached gingival and vestibule. This caused difficulty in maintaining proper oral hygiene and also mastication. The teeth appeared to be of normal size. No significant occlusal discrepancy was noted. Size of the tongue appeared normal.\nOrthopantomogram (OPG) revealed no significant abnormalities. No bony changes were appreciated []. Clinical and radiological examination confirmed enlargement was limited to the soft tissues and there was no hard tissue involvement. Microscopic findings showed irregular acanthosis and papillomatosis of stratified squamous epithelium. Underlying fibrous stroma infiltrated by predominantly inflammatory infiltrate of lymphocytes and plasma cells, leading to the diagnosis of inflammatory fibrous hyperplasia.\nLaboratory studies did not reveal any significant deviation from normal. |
A 61-year-old male with a past medical history of hypertension presented to our ED with a chief complaint of fatigue. The patient had been visiting friends and relatives in the DRC and had returned to the US two days prior to presentation. History was obtained primarily from the patient’s son as his father was delirious, which limited his ability to provide a comprehensive history. The son stated that the patient’s symptoms began one week prior to presentation while still in the DRC. The patient returned to the US in a feeble state per the son. He had very little oral intake over the prior week and would wake up confused and disoriented during the three days prior, including not recognizing his own house or shower on the day of presentation. The patient’s confusion would wax and wane but seemed worse upon wakening in the morning and after napping, and would improve throughout the day. He reported night sweats and chills but no known fevers. He had multiple episodes of dark diarrhea, but no bright red blood or black stools. He had a mild cough but no dyspnea or chest pain. He also reported nausea without vomiting.\nA review of systems was otherwise negative including absence of headache, vision changes, numbness, focal weakness, or skin eruptions. The patient did endorse multiple mosquito bites but had been on malaria prophylaxis with doxycycline, which he had continued to take upon his return to the US. The patient’s compliance with medication along with other precautions and malaria preventative measures such as mosquito nets and permethrin spray was not determined in the ED due to the patient’s critical illness and need for resuscitation. He visited the international travel clinic prior to his trip and had been vaccinated for both yellow fever and typhoid. He was unaware of any sick contacts.\nOn arrival, his vital signs were significant for hypotension with a blood pressure of 103/62 millimeters mercury, tachycardia with a pulse of 123 beats per minute, an oral temperature of 100.3 degrees Fahrenheit with oxygen saturation 98% on room air. Differential diagnosis included meningitis, Ebola virus disease (EVD), chikungunya, enteric fever, filariasis, tick-borne rickettsiae, schistosomiasis, dengue, yellow fever, and malaria. An immediate consult to infectious disease (ID) was placed due to the concern for recent travel to an EVD-endemic area. The ID service determined that the patient was not in a place that had known active EVD at the time; therefore, EVD protocol was not initiated. An electrocardiogram (ECG) was obtained, which showed sinus tachycardia with a QTc interval of 369 milliseconds (msec).\nHis physical exam was notable only for lethargy. He was slow to answer questions but would answer appropriately. He had no focal neurologic deficits and was alert and oriented to self, place and year, but not to month. He had no neck pain, neck stiffness, jaundice, scleral icterus, or skin eruption.\nLaboratory evaluation was significant for a normal white blood cell count with thrombocytopenia (platelets 111 per microliter ]K/mcL] [reference range 135–371 K/mcL]) and anemia (hemoglobin nine grams per deciliter [g/dL] [reference range 14.0–18.1 g/dL], and hematocrit 25% (reference range 41–49%). His serum sodium was slightly low at 131 millimoles per liter (mmol/L) (reference range 136–145 mmol/L) with otherwise normal electrolytes and a normal serum creatinine. Glucose was 177 milligrams/dL (mg/dL) (reference range 70–99 mg/dL). His alanine aminotransferase and aspartate aminotransferase were elevated at 228 units (U/L) (reference range 5–55 U/L) and 125 U/L (reference range 5–40 U/L), respectively. Total bilirubin was elevated at 3.1 milligrams per deciliter (mg/dL) (reference range 0.2–1.2mg/dL), as well as direct bilirubin a 1.3 mg/dL (reference range 0.0–0.5 mg/dL). His serum lactate was 4.9 millimoles (mmol)/L (reference range 0.5–2.2 mmol/L), lactate dehydrogenase elevated at 964 U/L (reference range 125–220 U/L) with a low haptoglobin and a normal prothrombin time test. Urinalysis was without signs of infection. A peripheral blood smear was obtained, which showed malarial parasites present concerning for Plasmodium falciparum infection with an initial parasite load of 10%. Multiple (between one and three) intra-erythrocyte rings were seen within single erythrocytes, which are consistent with malaria and was confirmed by ID.\nThe recommendations of the ID consultant were doxycycline and intravenous (IV) quinidine, and the patient was admitted to the ICU for continuous IV therapy and closer monitoring of his mental status as well as for the need for frequent laboratory draws and ECGs. IV quinidine can cause significant hyperinsulinemia and resultant hypoglycemia; therefore, the patient received hourly glucose checks. In addition, quinidine can prolong the QT interval, and the patient required hourly ECGs with ID recommendations of stopping quinidine if QTc increased by greater than 50% of patient’s initial baseline and holding the medication until the QTc fell to less than 25% above the original value.\nThe patient continued to have waxing and waning levels of consciousness and required 24 hours of IV quinidine after which his peripheral smear showed a malarial burden of 0.7%, and he was transitioned to oral quinine. He did not have episodes of hypoglycemia and his longest QTc interval was 540 msec. The patient’s mental status slowly improved as his malarial burden decreased. He required three days in the ICU and was then transferred to the floor. He completed a three-day course of oral quinine while in the hospital, and his final smear had a parasite load of 0%. The patient was discharged on hospital day five on oral doxycycline to finish a total seven-day course. He followed up in the ID clinic two weeks after discharge and had no sequelae. His mental status had returned to normal, he had had no fevers, and had begun to regain his strength. |
This 79-years-old gentleman was admitted from the Infectious Diseases clinic, in April 2011. He presented to the clinic with night sweats, intermittent fevers, rigors, lethargy, weight loss, poor appetite, and generalised arthralgias. He described a change in the bowel habit over the previous few months with constipation and mild abdominal discomfort. His C-reactive protein was 58. This was his fourth follow-up clinic appointment following a recent hospital discharge.\nHis past medical history included the following: August 2010 admission for relapsed septic arthritis of a right native knee, joint fluid aspirated at that time isolated Pseudomonas aeruginosa and blood cultures repeatedly isolated Pseudomonas aeruginosa and Enterobacter; July 2010 admission for probable recurrent septic arthritis, blood cultures isolated Streptococcus constellatus and Aerococcus; December 2009 admission for a primary septic arthritis, culture of synovial fluid isolated Streptococcus constellatus. In 1993 he had undergone an aortic aneurysm repair with insertion of an aorto-bi-iliac Dacron surgical graft.\nOn his admission in December 2009, because of the in situ aortic graft, he had undergone a CT abdomen and pelvis which showed normal appearances of the aorto-bi-iliac graft. The scan was repeated on each subsequent admission, in July 2010 and August 2010, each time showing normal appearances of the graft and no evidence of a fluid or gas collection around the abdominal aorta or iliac arteries. On admission from clinic, he underwent investigation for PUO in which he had multiple sets of blood cultures collected and 3 sets of isolated lactobacillus ().\nHe underwent a whole body scan showing a pool of activity in the right knee suggestive of chronic low-grade persistent infection. A transthoracic echocardiogram and a colonoscopy to investigate the altered bowel habit were carried out and were both negative. At this time a fourth repeat CT abdomen and pelvis was requested. This showed small extramural pockets of gas at the level of the graft bifurcation and a further possible tiny pocket of gas at the cranial aspect of the graft, appearances which would be suspicious for sepsis related to the graft.\nAt this point, there was multidisciplinary team input from vascular surgeons, vascular radiologists, infectious diseases and microbiology and appropriate management options were discussed. The two available options were (1) explantation of the graft with extra-anatomical bypass and (2) long-term suppressive antibiotics with serial CRP and imaging. In view of his age, that the WCC was within normal limits and the CRP was falling, the equivalence of the CT finding, and the fact that the surgery to remove the graft would carry a significant mortality and morbidity risk, the decision was made to start IV antibiotics for a minimum of 6 wks. The caveat to this approach was that in the event of worsening sepsis despite antibiotics and/or CT evidence of worsening perigraft infection or development of aortoenteric fistula, then surgery would be carried out.\nIV Daptomycin (6 mg/kg) (plus gentamicin initially) was commenced after confirmatory MIC testing of the lactobacillus to Daptomycin; this was the most recently and most persistently isolated pathogen. Daptomycin was well tolerated by the patient. At 6 weeks, based on good clinical response, this was changed to oral amoxicillin plus clindamycin, and the patient was discharged home. Within 48 hrs of discharge he represented with rigors and fevers. He was readmitted and a repeat CT showed increasing air encircling the right most anterior limb of the aortic graft. At this point the decision was made to carry out surgery to remove the graft.\nIn July 2011, the infected graft was explanted, the space washed out, and bilateral axillofemoral bypass graft inserted. Intraoperatively, a perforated duodenum was reported, which was the likely source of the multiple bacteraemias isolating the variety of gut organisms seen. This was repaired involving a retrocolic gastrojejunostomy and feeding jejunostomy, in an operation lasting more than 10 hours ().\nTo date, the patient remains well at home, the graft remains patent and perfusing the leg, and he has chosen not to continue oral suppressive antibiotics. |
A 26-year-old female patient visited the Department of Oral Medicine and Radiology with a chief complaint of spontaneous, painful constrictive movements on her right side of face with a feeling of constriction in her neck leading to difficulty in breathing. Patient was apparently normal 2 years back when she experienced spontaneous, intermittent, unilateral paroxysmal, severely painful involuntary spasmodic contractions on the right half of face which lasted for 3–5 minutes, repetitive throughout the day and which relieved on conscious opening of mouth to reappear again on next occlusal contact. The symptoms were distributed along the right half of forehead region, involving same side jaw up to right half of her neck. The neck constrictions were also associated with spasms internally in throat area causing difficulty in breathing. During these episodic contractions her jaws involuntarily closed and her tongue deviated towards the opposite side, with slurring of speech. The painful contractions were triggered while brushing, eating food, touching on right side of face, and excessive talking, breathing. During these episodic contractions her jaws involuntarily closed and tongue deviated to the opposite side with slurring of speech and episodes of accidental tongue bite on several occasions. Grimacing, reddening, and breathlessness were the associated findings. Her past dental and personal history was unremarkable except for a history of assault on the same side of face in the form of domestic violence. Her dental history reveals extraction of 48 six months back which was uneventful with normal postsurgical healing period. She had no history of consanguineous marriage and had no first-degree relative with neurological disorders. Patient reports multiple attempts towards treatment by various specialists including ENT and Psychiatrist, who prescribed her tricyclic antidepressants, gabapentin, with no cure; on the contrary she was branded as a psychiatric patient. Stressful events in her everyday life made the symptoms worse. The patient felt being rejected, sad, frustrated, depressed, and even anxious because the painful symptoms remained undiagnosed for a long time. The patient also experienced symptom-related depression, anxiety, and insomnia, which also created much anxiety among her family members.\nExtraoral examination was marked with spontaneous fasciculations with respect to right side of face, with an appreciable bulge associated with diffuse swelling and redness. On intraoral examination the episodes began with fine involuntary fasciculations in the right masseter and temporalis which progressed to severe dystonic contractions of the face and neck within few seconds causing grimacing of the face with difficulty in breathing following which the patient assumed a body posture holding the right side of face and neck gasping for breath, trying to open her mouth in an attempt to breath. Once she forcefully opened her mouth the spasms would reduce within a span of 2-3 seconds and eventually stopped. Her TMJ examination revealed an anterior disc displacement without reduction; fine fasciculations were observed in her right side masseter and temporalis region. Marked reddening and an observable bulge were appreciated on the right half of forehead and jaw region. Brain MRI did not show any definite abnormal brain findings or brainstem lesion. Consultation with the neurologic department ruled out other neurologic disorders and this was confirmed by the absence of any other accompanying neurologic deficits. The cranial nerve examination was unremarkable. Hemifacial involuntary spasmodic contraction of masseter and temporalis was seen producing repetitive pattern of jaw closing pattern and tongue movements.\nOn palpation frank fasciculations were appreciated along the body of masseter and anterior and posterior bands of temporalis. Mild fasciculations were felt along the muscles of neck. These movements were more pronounced during clenching of posterior teeth and speech and chewing movements. The dystonic movements diminished with oral sensory feedback such as voluntary opening of mouth by the patient in an attempt to breathe through mouth.\nInvestigations included assessment of temporomandibular function with TMJ tomographic views which revealed an excessive anterior movement of the condyle on open mouth position (). MRI brain scan () revealed no focal pathology. Blood investigations were done for serum calcium levels to rule out hypocalcemic tetany which revealed parameters in normal range. |
A 66-year-old female with a history of mucinous adenocarcinoma of the cervix presented to the neurosurgery outpatient clinic for evaluation of a sellar mass found during workup of adrenal insufficiency and hypothyroidism. The patient did not have unusual headaches or vision problems. Three months prior to discovery of the sellar mass, she was diagnosed with stage IIb mucinous adenocarcinoma of the cervix and was treated with chemotherapy. At the time of neurosurgery clinic presentation, she was neurologically intact, including full visual fields. Laboratory work-up demonstrated pituitary insufficiency with central hypothyroidism.\nThe initial magnetic resonance imaging (MRI) revealed a 1.8 × 1.1 cm contrast-enhancing mass within the sella, with extension to the suprasellar cistern and optic chiasm abutment. Preoperative imaging obtained the following month in preparation for surgery demonstrated that the mass had grown to 2.2 × 1.5 cm ().\nThe patient underwent an endoscopic endonasal approach for resection of the intradural sellar mass. Intraoperative findings demonstrated a very firm, infiltrative, vascular mass with dense adherence to surrounding structures, including the dura, medical cavernous walls, and diaphragma. Intraoperative frozen section pathology was consistent with metastatic carcinoma. The tumor was debulked until normal appearing pituitary tissue was identified and the margin of tumor adherence to the diaphragma was reached. Postoperatively, the patient did well without new hormonal deficiencies or vision problems. A subtotal resection (>80%) was achieved (). Gross histology and immunohistochemical staining ultimately confirmed the diagnosis of metastatic mucinous adenocarcinoma of the cervix (Figures and ).\nThe patient's immediate postoperative course was unremarkable. Given the diagnosis and intraoperative/postoperative findings of subtotal resection, adjuvant chemoradiation therapy was encouraged but the patient refused additional treatment. She was discharged home two days after surgery. She developed decreased left eye visual acuity and ptosis one week after surgery. A CT of the head at this time did not show any intracranial hemorrhage and a repeat MRI showed new enhancement suggestive of tumor recurrence within the sellar and suprasellar regions. The patient was started on steroids but declined any further treatment, including repeat surgery. Her ophthalmic symptoms ultimately progressed to a complete left cranial nerve III palsy four weeks after surgery. Follow-up MR imaging at five weeks after surgery revealed significant progression of the tumor to 2.9 × 2.4 cm with significant suprasellar extension (). Though a computed tomography scan of the chest, abdomen, and pelvis at this time demonstrated no new neoplastic burden, a radiotracer bone scan demonstrated likely new metastatic lesions in the skull, bilateral humeri, bilateral acetabula, bilateral femurs, and the lumbosacral vertebrae. After further discussion with her gynecologic oncologist and radiation oncology, the patient again refused pursuing any further treatment, including palliative radiation or systemic therapies and elected to pursue home hospice. The patient died approximately two months after surgery. |
A 39-year-old male patient presented with alleged history of bee sting injury over the face and trunk following which he developed edema of the face and neck. He had a history of retching, vomiting a few hours following aforementioned event, and he developed dyspnea with chest discomfort. He was evaluated elsewhere, where he received steroids and bronchodilators for suspected anaphylaxis. In view of worsening symptoms, he was referred to our hospital for further management.\nOn arrival to the emergency department, he was tachypneic, hypoxemic, and tachycardic and was in severe respiratory distress with oxygen saturation of 80% on room air. His trachea was emergently intubated in view of worsening hypoxemia despite oxygen support and severe respiratory distress and vasopressor support initiated to maintain the hemodynamics. After initial stabilization in the emergency department, he was shifted to critical care unit for continuation of care.\nPhysical examination revealed edema of the face and neck regions with bilateral crackles. In view of chest pain and lung signs, cardiologist opinion was sought, but ECG and echocardiography were normal. Arterial blood gas analysis revealed metabolic and respiratory acidosis with dyselectrolytemia, and serum urea and creatinine levels were elevated, which were managed conservatively. Laboratory evaluation was suggestive of hemoconcentration with the rest of the parameters within normal limits. Hypoxemia persisted despite ventilatory support, and clinical examination revealed decreased air entry on the left side and increasing subcutaneous emphysema over the neck. Diagnosis of pneumothorax was made, which was supported by absent lung sliding and lung point on ultrasonography of chest and pneumothorax on roentgenogram of chest on the left side. Tube thoracostomy was done for left pneumothorax and drained 650 mL of blackish brown fluid, which was sent for analysis.\nHRCT chest was done suggestive of pneumomediastinum with right pleural effusion for which right tube thoracostomy was done, which drained 350 mL of brownish black fluid. Pleural fluid analysis was suggestive of exudative collection with total count of 8000 cells with neutrophil predominance of 80% and increased lactate dehydrogenase levels. Medical gastroenterology consultation was taken. The upper gastrointestinal endoscopy was performed but inconclusive.\nBy the third day of hospitalization, the roentgenogram of chest improved, the patient was normoxemic, and hemodynamics was stabilized. He was weaned off the vasopressor support and the ventilator support and eventually got extubated. In view of persistent thoracostomy drain on the left side, contrast-enhanced CT of chest and abdomen with oral contrast was performed. During procedure, there was a gradual accumulation of contrast into the left pleural cavity and draining into the left thoracostomy drain. Pleural fluid amylase was grossly elevated to 55,324 units/dL. Hence he was provisionally diagnosed as having esophageal rupture and planned for surgical repair or endoscopic stent placement.\nRepeat upper gastrointestinal endoscopy revealed full-thickness perforation at the hiatal pouch on the gastric side with normal stomach and duodenum. The perforation was feeding into the pleural cavity and filled with purulent secretions. An over-the-endoscopy clip was placed immediately to seal the perforation, and self-expandable metallic stent placement was planned later as a staged procedure. Postprocedure immediate contrast study did not reveal any leak with free flowing of contrast into the stomach.\nThe patient general condition gradually improved with decreasing drain in the right thoracostomy tube, and hence, the drain was removed. Gastrografin study was scheduled after 48 hours to detect any postprocedure leak. The patient was eventually discharged in hemodynamically stable condition to another hospital. The patient was being followed up later with us and there was no gastrograffin leak into the pleural cavity on check upper gastrointestinal endoscopy with intact sealed perforation. He was started on oral liquids and discharged home in stable condition. |
A 75-year-old otherwise healthy woman was referred to us with a large tender erythematous morpheaform plaque without ulceration on the lower part of her leg. This plaque had begun as a small nodule on the shin 1 month prior to this visit. It had gradually extended outward in a centrifugal pattern despite oral antimicrobial treatment by her family physician. She was initially diagnosed and treated as a case with cellulitis and with poor clinical response. This patient denied having had a sore throat or arthralgia in the previous months. Other than diabetes mellitus type II, she had no significant medical history. She had been taking oral hypoglycemic agents for many years. On physical examination, it became evident that she had a large erythematous plaque measuring 30 × 30 cm2 on the anterolateral aspect of her lower left leg []. There was mild edema and local tenderness on the leg plaque. The color of this morpheaform plaque varied from red to brown, and its surface was mildly scaling. A skin biopsy specimen was then taken from the newly extending area on the left calf. Histopathological examination revealed that the pathologic changes were mainly in the subcutaneous tissue, in which the septa were thickened and there existed lymphohistiocytic infiltrate and a few neutrophil and occasional multinucleated giant cells. Some inflammatory cells had infiltrated into the periphery of the fat lobules (Septal panniculitis) []. The vessels have not any obvious pathology. A mild perivascular inflammatory infiltrate was also present in the dermis. The overlying epidermis was mildly acanthotic and hyperkeratotic. These findings suggested a diagnosis of erythema nodosum migrans. The results of laboratory investigations were within normal limits. A skin test of PPD and the titer of antistreptolysin O (ASO) proved negative. The chest radiograph has normal appearance. On the basis of the clinical pathological findings, we diagnosed the patient's eruption as erythema nodosum migrans. The patient was treated with oral indomethacin, and topical clobetasol propionate lotion twice daily; this resulted in significant gradual improvement over a period of 1 month. |
A 75-year-old woman was admitted to our hospital for 1 h of persistent severe chest pain. Apart from smoking, she had no cardiac risk factors. At the time of admission, the electrocardiogram showed ST-segment elevation in leads I,avl. Laboratory data showed that the serum creatine kinase and troponin I had elevated. According to the results of electrocardiogram and laboratory data, STEMI was definitly diagnosed. Primary percutaneous coronary intervention (PCI) was indicated immediately. The coronary agiography (CAG) revealed triple vessel disease with left circumflex as the culprit which was occluded in the proximal segment (Fig. ).\nWith the indication of aspiration thrombectomy and percutaneous coronary balloon dilatation, the coronary reperfusion therapy was achieved (Fig. ). The symptom of chest pain was relieved. Meanwhile, the cardiac surgeon was invited for consultation, and his recommendation was to complete the CABG surgery after the acute phase of AMI. We ended the operation because the goal of primary percutaneous coronary intervention was achieved. The initial course went well, and the patient’s condition was stable gradually after PTCA. However, she suddenly exhibited severe chest pain, dyspnea, agitated, and profuse sweating 6 days after hospitalization. Physical examination indicated a blood pressure of 79/44 mmHg, a heart rate of 98 beats/minute. An electrocardiogram examination did not show ST-segment elevation again. She was given dopamine to raise the blood pressure and fluid to maintain the circulation capacity immediately. The patient presented cardiac syncope suddenly following the onset of atrial fibrillation with a heart rate of 140 beats per minute after half an hour. In consideration of further hemodynamic impairment caused by tachyarrhythmia, electrical defibrillation was urgently administered to restore sinus rhythm. Emergency echocardiography demonstrated pericardial tamponade. After pericardiocentesis with ultrasound guidance and continuous drainage of hemorrhagic pericardial effusion, the patient’s haemodynamic condition returned to stability. The catheter drainage of pericardium stopped when there was no fluid drainage in 2 days. Subsequent echocardiography revealed an abnormal cardiac chamber adjacent to the lateral wall of the left ventricle. Doppler echocardiography demonstrated to-and-fro signals in a myocardial defect (11 mm) in the lateral wall. And LVEF was 55%. These findings supported a diagnosis of congestive haemodynamic impairment caused by the rupture of the left ventricle after acute myocardial infarction followed by the presenting of acute pericardial tamponade. Timely pericardial drainage stabilized haemodynamics and pericardial adhesions sealed the rupture and contained the bleeding, and a pseudoaneurysm of the left ventricle formed eventually. Considering the tendency of rupture of pseudoaneurysm that may lead to death at any time, we recommended that the patient should receive surgical treatment as soon as possible. However, due to the resolute refusal and advanced age of patient, the conservative treatment was performed. Drug regimens included dual antiplatelet, statin, β-blocker and diuretics.\nAfter discharge, the patient was followed up for a long time (36 months). During the first 2 months of follow-up, the volume of pesudoaneurysm increased to 65 × 55 mm(Fig. ). Despite repeated warnings that pseudoaneurysm may further rupture causing sudden death, and recommendation for surgery as soon as possible, the patient persisted in conservative treatment. During this period, the patient’s condition was relatively stable, without obvious symptoms. However, an amazing change occurred in the following days of follow-up. One year after the onset of AMI, color doppler ultrasound revealed no progressive increase in the size of the pseudoaneurysm(53 × 44 mm), but the blood flow within the aneurysm cavity decreased(44 × 19 mm). Echoes of the thrombus had been seen in the other areas within the aneurysm. At the 1.5 years of follow-up, the thrombus almost filled the aneurysm cavity. Partial blood flow imaging had been seen only nearby the defect of the left ventricular. Further myocardial contrast echocardiography clearly verified these findings (Fig. ). Because of the dynamic changes in the pseudoaneurysm showed that the risk of ventricular aneurysm rupture gradually reduced, we maintained the conservative treatment program. 2.5 years after the onset of AMI, she was admitted for angina once again. After admission, conventional color doppler ultrasound showed no significant change in pseudoaneurysm compared with 1 year ago. Cardiac multislice computed tomography (MSCT) clearly revealed a 64 × 48 mm pseudoaneurysm adjacent to the left ventricle. There was no contrast enhancement in it (Fig. ). As angina pectoris manifested, coronary angiography was reviewed after admission. The result revealed lesions in three branches of the coronary artery, with 90% stenosis in the middle segment of the left anterior descending (LAD) and 95% stenosis in the distal segment of the right coronary artery (RCA) (Fig. ). Therefore, LAD and RCA PCI were given, and one stent was implanted respectively (Fig. ).\nThe symptoms of angina were significantly improved after operation. Our patient continued outpatient follow-up after discharge, and was symptom free. There was no significant change in medication during the 3 years of treatment. Dual antiplatelet therapy was continued for 3 years. |
In November 2005, a three-month-old boy was admitted to our department with a three-week history of easy irritability and poor oral intake. He had an uneventful vaginal delivery in August 2005. However, there was a mild scalp bulge, suspicious of a cephalhematoma. A computed tomography (CT) scan of the head showed a widened foramen rotundum and an abnormal density in the right cavernous sinus (). The boy was discharged home since he did not exhibit any abnormal neurologic signs. Two months later, the boy presented again with poor oral intake, easy irritability, and insomnia during the night. An MRI scan of the head showed a large cystic lesion filling the entire middle cranial fossa, compressing the right temporal lobe. There was also evidence of a relatively small solid portion of varying signal intensity; this area enhanced heterogeneously after the administration of intravenous contrast medium. The lesion was also in the pterygopalatine fossa, and the two areas communicated through a more widened foramen rotundum as compared to the previous study. The right cavernous sinus was occupied entirely by the lesion, with medial displacement of the internal carotid artery (). The presumptive diagnosis was cystic glioma.\nThe patient was subsequently referred to our care. When he arrived in our department, the patient again presented with easy irritability. Clinical examination revealed no definitive neurological abnormalities except cranial asymmetry with a prominent temporal squama on the right side. No other cranial nerve abnormalities were noted. The results of the motor and sensory examinations were normal.\nA right frontotemporal approach was used. After the dura was opened, a large lesion was found occupying the temporal fossa and elevating the basal dura mater. Only a remnant temporal lobe, which was displaced dorsocaudally, was identified. First, a small hole was made, and the clear yellow fluid in the cyst was aspirated. The basal dura mater was then incised inferiorly. The tumor contents, readily apparent at the anteromedial area of the temporal fossa, consisted of fat tissue, nerve-like tissue, and other unidentifiable tissues. The dura was firmly adhered to the tumor capsule, and it had to be removed along with the tumor. Using the microscissor and dissector, we were able to detach tumor from dura with strenuous effort. When we approached the medial edge of the tumor, we could identify the oculomotor nerve piercing the dura as it entered the cavernous sinus. Cranial nerve IV and the trigeminal nerve (V1 and V2) roots could not be identified on the medial side of the tumor. As the dissection proceeded laterally, we found that the floor of the middle fossa and the anterosuperior surface of the petrous bone were eroded. The root of cranial nerve V was then identified; it appeared to be elongated. The Gasserian ganglion was identified, apposing the temporal squama. It is possible that the V1 root might have been traumatized during attempts to remove a portion of the adherent tumor. The tumor exited to the pterygopalatine fossa through the foramen rotundum. V2 and V3 were identified. We tried to remove the tumor through the widened foramen rotundum. Fortunately, the tumor was easily removed. The tumor was excised macroscopically and radically (). When the patient was extubated after the operation, right oculomotor nerve paresis was evident, and a cranial nerve VI palsy was suspected. MRI scans obtained immediately after the operation did not demonstrate any residual tumor (), and the patient was discharged ten days after the surgery. A pathological examination revealed a mature teratoma consisting of tissue representative of the three germinal layers ( and ). Five months after the operation, the patient visited our outpatient department. The patient's condition was good, and did not experience any residual cranial nerve paresis that had been evident immediately postoperative. The MRI scan () from April 2006 showed no tumor recurrence or postoperative change. The patient will be followed on an outpatient basis, without further treatment.\nThe tumor was composed of ectoderm, mesoderm and neuroectoderm. A low-power view demonstrated cystic changes (). Architecturally malformed brain tissue was noted (). A high-power view showed neurons with laminar distortion and multifocal calcification (). A multilocular cystic area with lining epithelium was noted ( and ). Scattered glands resembling salivary glands (), adipose and muscle tissue () were seen. |
A 38-year-old primigravida (weight 68 kg, height 154 cm) admitted for safe confinement, at 38 weeks of gestation, was posted for elective caesarean section due to non-progression of labour. The patient had an uneventful antenatal period, with no history suggestive of pregnancy induced hypertension. Physical examination findings, blood and urine reports were within normal limits. The patient was fasting for 8 h and was willing for spinal anaesthesia.\nThe patient was shifted to theatre and was preloaded with 750 ml of Ringer Lactate solution. Spinal anaesthesia procedure was performed with the patient in left lateral position with a 25 Gauge Quincke needle at L3-L4 interspace. Free cerebrospinal fluid flow was obtained in the first attempt itself and 2 ml of 0.5% hyperbaric bupivacaine solution was injected into the subarachnoid space. The level of sensory block was assessed by pin prick method and the maximum level achieved was at T4. A female baby was delivered with an APGAR score of 7 at 1 min and 9 at 5 min. The intraoperative as well as the immediate post-operative periods were uneventful.\nOn first post-operative day (POD), in the ward, she complained of severe occipital headache with radiation to the neck in the upright position which was relieved by lying supine. There was no fever, neck rigidity or vomiting. Blood pressure as well as the blood counts were normal. A diagnosis of post-dural puncture headache was made and she was managed with IV fluids (1000 ml of Ringer lactate/day, in addition to oral fluids), intravenous paracetamol 1 g 8 h and bed rest. Severity of pain came down and the patient was comfortable.\nOn the third POD she started to complain of severe continuous headache in the occipital region with no relief even in a recumbent posture, with no vomiting or visual disturbances. Soon the patient developed generalized tonic clonic convulsions which were initially managed with midazolam 2 mg intravenously followed by phenytoin 600 mg bolus and 100 mg 8 h administered intravenously. The seizure lasted for <2 min, and the patient became conscious but confused. The vitals remained normal throughout. Finally the patient was shifted for radioimaging and axial fluid attenuated inversion recovery magnetic resonance imaging (MRI). The image showed bilateral symmetric hyperintensities in the occipital cortex []. Higher level image also showed cortical hyperintensities involving frontoparietal cortex of both sides []. These features were suggestive of PRES. The patient was further managed with intravenous magnesium sulphate, as it provides the most favourable outcome when PRES is diagnosed in pregnant patients. Initially, 4 g in 100 ml was given as a bolus infusion over 20 min followed by 2 g/h for 24 h and nimodipine 60 mg 6 h was added orally. Both were continued for 5 days with daily serum magnesium level monitoring for the pathology to revert and later stopped as the patient was asymptomatic with no neurological deficits. Subsequently she was discharged on 8th POD and remained asymptomatic till date. |
A 4-year-old boy, born in Zhejiang Province of China, was admitted to Yuying Children's Hospital affiliated to Wenzhou Medical University in June 2014 with complaints of productive cough accompanied with high fever for 5 days. He was the first-born child to unrelated healthy parents, born at 38 weeks of gestation after an unremarkable pregnancy. His birth weight was 3.5 kg, and meconium was passed on the first day of life. The patient had no history of meconium ileus or diabetes mellitus and lacked family history of CF. Tracing back his medical history, the patient was formula feeding but failure to thrive with a weight of 6.8 kg at the age of 8 months and had intermittent diarrhea. For further evaluation of the condition of growth and development, the patient was taken to a local hospital at the age of 8 months, and received complete blood count and liver function tests. And the results indicated liver involvement with slightly elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) with values of 78 and 82 U/L, respectively. The patient suffered from recurrently and slightly elevated ALT levels ranging from 70 to 92 U/L and AST levels ranging from 80 to 90 U/L. In addition, the common etiologies that easily lead to increased levels of ALT and AST were also excluded, such as cytomegalovirus and hepatitis B virus infection. Initially, these symptoms were not paid enough attention by the physicians or parents because the elevated levels of ALT and AST can recover to normal levels automatically without treatment or through the injection of magnesium isoglycyrrhizinate before four years of age.\nPhysical examination for the patient at the age of 4 years showed a weigh of 16.5 kg with a height of 104 cm. The patient had a BMI of 15.3, which was in the 50th percentile for his age. The physical examination also revealed tachypnea and a barrel-shaped chest. The liver was palpable ~2 cm below the right costal margin, and the spleen was palpable about 1 cm below the left costal margin. Clubbed fingers were absent. Laboratory examination indicated increased ALT and AST values of 93 and 92 U/L, respectively, whereas other markers such as γ-glutamyl transferase (GGT), bilirubin, bile acid, fasting blood glucose, albumin, and globulin were within normal limits. Other laboratory investigations including of complete blood count, serum electrolytes, urine, arterial blood gas, amylase, and lipase were normal. The sputum and bronchoalveolar lavage fluid cultures tested positive for Pseudomonas aeruginosa. The Sudan III dye test of fecal matter indicated fat droplet positivity. Pulmonary function tests failed to be performed because of the difficulty at this young age for the child. Additionally, the lack of laboratory facilities caused impracticability of the sweat chloride test. Utilizing computed tomography (CT), we identified severe bilateral paranasal sinusitis () and diffuse fatty infiltration of the liver () in the patient. In addition, the chest CT scan verified the presence of bilateral bronchiectasis and marked peribronchial thickening, especially in the middle and lower lobes (). Extensive sticky and purulent secretion were observed in the lungs by bronchoscopy (). Based on the aforementioned pathological findings, the patient was primarily diagnosed with CF.\nGenetic testing of the patient revealed a homozygous nonsense mutation from a C-to-T substitution (c.1657C > T) in the CFTR gene, which was inherited from both his father and mother (). This single-nucleotide variant changed an arginine at position 553 into a premature termination codon (p.R553X). Notably, CF screening using amniotic fluid of the mother during her second pregnancy also indicated the fetus (sibling) to be a p.R553X carrier.\nOther than hypertonic saline nebulization, high-frequency chest wall oscillation, expectorant administration, pancreatic enzyme replacement therapy, and supplementation with vitamins A, D, E, and K, the child was prescribed intravenous ceftriaxone to address the P. aeruginosa. Respiratory symptoms gradually improved after 7 days of treatment, and he was discharged on the 15th day after admission. Ursodeoxycholic acid was prescribed after confirmation of genetic diagnosis, but taken irregularly by the patient. Therefore, the medicine failed to bring about the desired effect. Remarkably, the patient was later re-hospitalized two times because of pulmonary infections and liver involvement. Liver function test showed that the levels of both ALT and AST ranged from 90 to 120 U/L. Further examination of abdominal CT and ultrasound have suggested the progression of hepatic cirrhosis. The final hospital admission in August 2016 was due to complaint of a stomachache for 3 days.\nAbdominal CT showed a wave-like margin of the liver and many areas of multifocal hypoattenuation in the liver, which indicated the occurrence of hepatic cirrhosis on the basis of diffuse hepatic steatosis (). Simultaneously, the patient presented with pancreatic atrophy and splenomegaly (). In addition, both chest CT scan and bronchoscopy showed the characteristics of bilateral bronchiectasis, marked peribronchial thickening, and extensive sticky and purulent secretion, similar to that observed in 2014 (). The abnormal prothrombin time (PT) and activated partial thromboplastin time were 20.2 s (normal control: 13 s) and 52.6 s (normal control: 36 s), respectively. The international normalized ratio (INR) was 1.85, which confirmed the diagnosis of liver failure. |
A 40-year-old male patient came to the hospital emergency after a gunshot lesion in the cervical region. He was conscious, hemodynamically stable, and without signs of active bleeding or cervical spine injuries. Physical examination showed significant edema in the region of the mandibular angle, trismus, restriction of mandibular movements, absence of rhinorrhea or epistaxis, and soft tissue injury compatible with the bullet entrance orifice in the right posterior cervical region without clinical signs of exit bullet orifice.\nComputed tomography showed a comminuted fracture of the coronary and mandibular right ascending branches associated with ipsilateral zygomatic-orbital fracture (Fig. ) and the presence of artifacts compatible with the firearm projectile, suggesting an upward trajectory toward the face (Figs. ,).\nAfter physical and imaging evaluation, vascular surgery and neurosurgery teams opted for conservative treatment. However, the maxillofacial surgery team indicated surgical removal of the bone fragments due to the restrictions of the mandibular movements and removal of the fragments of the projectile due to discomfort and superficialisation in the genic region.\nOn the third day after trauma, under general anesthesia, removal of the bone fragments was initiated by intraoral access in the ascending ramus of the mandible, which evolved intraoperatively with an intense arterial bleeding, incompatible with the surgical procedure. Local compression maneuvers were performed using compresses, attempts to pinch with instruments after local exploration and the use of hemostatics, but they were not enough to contain the bleeding. After failure, it was decided to submit the patient to angiography of the external carotid artery.\nThe examination was performed by percutaneous puncture of the right femoral artery and selective catheterization of the external carotid artery and internal maxillary artery, which verified the presence of an PA (Fig. ) with indication of emergency embolization procedure. Through the catheter, the embolization was performed from the installation of 02 micro-platinum springs until the complete arterial occlusion and consequent end of the blood flow of the PA (Fig. ). The selective angiography of the left internal maxillary artery was then performed in different projections to rule out another possible source of bleeding and the possibility of compensatory revascularization.\nThe patient was transferred and remained under observation for 12 hours in the intensive care unit. A new angiography was performed after 24 hours for control, confirming the complete resolution of the PA. The patient was submitted to a second surgery 72 hours after the hemorrhagic episode when a large part of the bone fragments were removed by intraoral access. Also the palpable and superficial portion of the projectile located in the genic region by infraorbital access was removed.\nThe patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up. |
The patient was a 65-year-old Japanese man who was examined by his family doctor for the chief complaint of nocturia. He was treated for benign prostatic hyperplasia, but the symptoms did not improve. Ultrasonography (US) and computed tomography (CT) were performed and an intrapelvic tumor was suspected. The patient was then referred to our department.\nNo definite abnormal findings were observed on blood biochemistry tests. His prostate-specific antigen level was within the normal range at 0.92 ng/mL. Values for other tumor markers also fell within the normal ranges. A giant tumor with a central, hypoechoic region was noted on the right side of the prostate during US.\nContrast-enhanced CT showed a tumor measuring 100 mm along the major axis and mainly present from the right side of the prostate (). The tumor was composed of solid and cystic components associated with contrast enhancement. We suspected the tumor originated from the right seminal vesicle. However, based on vasography examination, the right seminal vesicle was shifted to the left side, but its shape was maintained. We concluded that the tumor originated from the prostate ().\nWe suspected infiltration of the bladder when we examined sagittal views. However, cystoscopy showed no obvious bladder infiltration, and the neck of the bladder was displaced to the right side by the tumor. A prostatic biopsy was performed in our hospital. Immunostaining was positive for both cytokeratin AE1/AE3 and vimentin. The patient was finally diagnosed with a poorly differentiated adenocarcinoma ().\nBased on the results of pathological examinations, the patient was diagnosed with cT4N0M0 prostatic cancer. We administered combined androgen blockade treatment and chemotherapy with docetaxel, but they were ineffective. Therefore, we discussed the options with the patient and decided to perform surgery. While discussing the surgical technique, we communicated viable options, such as total intrapelvic resection and total cystectomy. We explained that the decision would be made based on the intraoperative findings.\nWe decided to perform total prostatectomy. The mucosal surface of the bladder was maintained and the bladder was preserved. The tumor was continuous with the capsule on the right side of the prostate.\nMacroscopically, we observed an oval-shaped tumor with a smooth surface and distinct margins that was continuous with the prostatic capsule (). The resected surface was made up of solid components of a grayish white color, with areas of necrosis and hemorrhage.\nHistologically, we saw the proliferation of short spindle and polygonal cells on a background of abundant vessels showing vascular mural hyalinization ().\nImmunohistostaining was positive for cytokeratin AE1/AE3 and CD34.\nStaining was negative for c-kit, desmin, α-SMA, and EMA, and the Ki 67 index was less than 2%. A definitive diagnosis was also difficult to achieve based on these immunostaining results. By consulting Dr. Hasegawa, the Director of Pathology at Sapporo Medical University, we reached a diagnosis of a solitary fibrous tumor, based on the fact that the tumor tested positive for CD34 and STAT6.\nPostoperatively, there were no obvious complications and the patient was discharged. The patient's clinical course has progressed favorably with no obvious recurrence 18 months postoperatively. |
A 39-year-old woman underwent a total mastectomy for breast cancer (clinical stage IIIA) and, thereafter, waited 1 month before completing four courses of treatment with fluorouracil, epirubicin, and cyclophosphamide (FEC therapy). Thereafter, she received four courses of trastuzumab and tamoxifen for roughly 7 consecutive weeks until the day before delivery (). At the initiation of chemotherapy, she experienced amenorrhea and lower abdominal distension. However, a commercially available pregnancy test was negative, which might have been a false-negative result owing to high amounts of hCG in the urine, the so-called “hook effect”; the symptoms were, therefore, considered as treatment side effects. Thus, ultrasound testing for pregnancy was not conducted and discontinuation of tamoxifen was never considered. As a result, the mother had been receiving tamoxifen until the delivery. Five months after the initial administration of chemotherapy, she experienced a strong lower abdominal pain without fever and delivered a baby at an emergency outpatient unit. This was the first time that her pregnancy was noticed.\nThe female neonate had a birth weight of 1664 g, a height of 40.5 cm, and a head circumference of 30 cm with Apgar scores of unknown (1 min) and 7 (5 min). Owing to a respiratory disorder, the infant was intubated and transported to our hospital. The gestational age as estimated from the last menstrual period remembered by the mother was 29 weeks and 6 days; however, the Dubowitz neurological assessment placed the gestational age at approximately 32–34 weeks. The infant was diagnosed with respiratory distress syndrome, received surfactant replacement therapy, and gradually improved until extubation on day 3 of life. The infant had both good feeding and weight gain with no findings of malformation on echocardiography, abdominal ultrasonography (performed at day 0), or brain magnetic resonance imaging (performed at day 39). The infant was discharged at 1 month of age. Nearly normal growth and motor and mental development have been continuously observed within the infant over 5 years of follow-ups with the interval of every 3–6 months. Her height has been over −2 standard deviation (SD) for Japanese children since the age of 6 months, and her body weight has been over −2 SD since 2 years of age. At 5 years of age, her height was 109.5 cm (−0.1 SD) and weight was 14.4 kg (−2.0 SD) (). She could hold her head steady at 4 months of age. She could not perform thumb-finger grasping until she was 1 year old. She could walk alone at 1 year and 5 months, and she could run and speak 2-word sentences at 2 years of age. Her intelligence was deemed to be within the normal range, as the result obtained after evaluation using the Tanaka–Binet intelligence scale was equivalent to an IQ of 94 when she was 4 years old.\nBlood concentrations of tamoxifen and its metabolites (N-desmethyl tamoxifen, 4-hydroxy tamoxifen, endoxifen) were determined in the mother and the infant at 3-4 hours after birth. The details of drug concentration have been reported before []. Similar blood concentrations were observed in mother and infant, confirming mother-to-fetus tamoxifen transmission; to the best of our knowledge, this is the first time this confirmation has been made. |
The patient was a 48-year-old Chinese woman with a history of thalassemia minor but otherwise well. She first presented to the hospital for a routine health screening at which she had complained of a persistent cough for a few months and reported a reduction in exercise tolerance during this period. On the physical examination, she was found to have a pansystolic murmur radiating to the axilla. An electrocardiogram (ECG) revealed left ventricular hypertrophy with atrial enlargement. Chest x-ray confirmed an increased cardiothoracic ratio, left atrial enlargement, and blunting of the left costophrenic angle. In view of findings suggestive of heart failure, the patient was referred to a cardiologist for further management.\nOn further questioning, the patient reported that she had experienced a loss of appetite and loss of weight over the preceding 2 months and was having occasional left-sided abdominal discomfort. In addition to the systolic murmur, the cardiologist found an abdominal mass measuring 10 cm in the left hypochondrium, which he could not get above cranially and which descended with respiration. With an initial working diagnosis of possible infective endocarditis with splenomegaly, a transthoracic echocardiogram and an ultrasound of the abdomen were obtained.\nThe transthoracic echocardiogram showed a lef t ventricular ejection fraction (LVEF) of 34%. There was moderate global left ventricular hyperkinesia, mild concentric left ventricular hypertrophy, and a severely dilated left atrium (). No valvular vegetations were seen. The results of an ECG and measurement of cardiac enzyme markers were also unremarkable. A computed tomography (CT) coronary angiogram was ordered for further evaluation, revealing normal coronary arteries and an Agatston calcium score of 0.\nThe abdominal ultrasound done after the echocardiogram revealed a large left kidney measuring 14 cm with a large heterogeneous solid mass-like component predominantly in the mid and upper pole with adjacent increased vascularity, suspicious for a renal malignancy. The patient was referred to our urology department for further management. We performed a CT intravenous pyelogram (, ), which clearly illustrated a large left renal mass measuring 14 cm×13 cm×11 cm and arising from the mid/lower pole with involvement of the renal pelvis, ureter, and left adrenal gland. The staging scans showed no evidence of metastasis. The patient was offered an open left radical nephrectomy.\nIntraoperatively, a locally advanced left renal tumor was noted, with involvement of the mesentery of the descending colon. A decision was made to perform en bloc left hemi colectomy along with radical nephrectomy.\nPostoperatively, the patient recovered well without any complications. On postoperative day 8, we repeated a transthoracic echocardiogram. Heart function had dramatically improved, with an increased LVEF of 45% to 50%, whereas the global left hyperkinesia was noted to have resolved. The patient was eventually discharged on postoperative day 8.\nFinal histology revealed a clear cell RCC with predominant sarcomatoid features, involving at least 90% of the lesion. The tumor measured 14 cm and was noted to have invaded into the perinephric tissues, beyond Gerota's fascia, and into the adrenal gland. The tumor was of Fuhrman's nuclear grade 4 and vascular invasion was seen but the resection margins were free of tumor. A regional lymph node was negative for metastasis, whereas 1 of 3 nodules invading into the descending colon was positive for disease. |
A 75 year old female reported to our clinic with complaint of painless intraoral swelling over the lower anterior jaw, causing difficulty in speech and interference in tongue movements. The patient had first noticed the swelling five years earlier. No history of facial trauma was reported. The patient was under medication for hypertension for the past fifteen years. She gave a history of cardiac surgery five years back and was subsequently on anti-platelet therapy. History of multiple teeth extractions over a period of time was given, of which no record was available. On examination a non-tender bony hard swelling was present over mandible alveolus, extending across the midline from 32 to 44 region, measuring about 5 cm x 3 cm. The swelling extended lingually to the tip of the tongue. The mucosa overlying the swelling was normal. Patient was partially edentulous with poor oral hygiene. Mandibular left canine and premolar teeth present over lateral aspect of the swelling exhibited grade III mobility. Other mandibular anterior teeth were missing.\nOrthopantamogram (OPG) showed a radiopaque lesion in mandible anterior region, extending from the crest of the alveolar ridge upto the inferior border of the mandible, superoinferiorly and measuring about 5 cm in its greatest dimension. The lesion had well defined margins and could be demarcated from the surrounding normal bone. A mandibular occlusal radiograph showed radiopaque mass expanding the buccal and lingual cortices (Fig. ). Based on clinical and radiological examination a working diagnosis of solitary central osteoma of mandible was made. An incisional biopsy was planned and executed under local anesthesia. Microscopy of the decalcified sections of the specimen (Fig. ) revealed areas of dense compact bone with osteocytes. Large amount of areas showed homogeneous mass of bone which appeared sclerotic with absence of osteocytes and osteblasts. Fibro-fatty marrow was seen with a moderate inflammatory infiltrate. The above features confirmed diagnosis of osteoma.\nFor management of the lesion, both option of complete excision under general anesthesia and a conservative approach by recontouring of the jaw under local anesthesia was discussed with the patient, physician and anesthesiologist. Considering her age, medically compromised status and non-malignant, non-infiltrative nature of the lesion conservative surgical management was preferred choice after consensus. After attaining adequate regional anesthesia, a crestal incision was place over the alveolar bone and envelop flap raised, exposing the bony mass. The lesion appeared more yellowish and could be easily differentiated from the surrounding normal bone. The mandibular right canine and first premolar were extracted. The excess hard tissue overlying the alveolar ridge was contoured. The flap was approximated and sutured (Fig. ). The excised specimen was submitted for histopathological evaluation, which showed a hard mass consisting entirely of dense lameller compact bone. The clinical, radiographical and microscopic findings confirmed diagnosis of central osteoma of mandible. The post-operative period was uneventful and the healing was within the anticipated time period. The patient was followed up after one year, where satisfactory bony contour of anterior mandible, with no further growth of the residual lesion was noted (Fig. ). The patient was advised long term follow-up to rule out any recurrence in future. |
A 35-year-old housewife presented with mildly pruritic scaly eruptions on the back and front of chest for 2 weeks. Earlier, she had a single large similar eruption on left breast 10 days ago. She gave a history of upper respiratory infection 2 weeks before the onset of first lesion, when she had a mild fever, coryza, and malaise lasting for 5 days. She received a combination of ibuprofen+paracetamol and cetrizine orally, prescribed by a family practitioner for 3 days. She had been treated with the same drugs several times earlier by the same physician.\nThere was no history of similar lesions in the past. Her past and family health was unremarkable.\nThere was no history suggestive of allergic or irritant contact dermatitis in the present case. She did not receive any other systemic medications in the recent past. Travel history was insignificant. She distinctly denied a history of tick bites.\nThe first lesion was a large oval plaque measuring approximately 7 cm × 6 cm, almost occupying the whole left breast, with peripheral collarette scaling and central clearing with minimal itching. She was treated by a family physician with topical miconazole cream for 10 days without significant resolution. The patient refused the front of chest to be photographed and hence, a picture of herald plaque could not be taken. Prescriptions brought by the patient were verified specifically and did not contain topical or systemic steroids.\nShe suddenly developed the subsequent lesions as multiple, sharply demarcated, large scaly lesions of irregular shape on front and back of trunk as well as lateral thighs extending upto the hips on both sides somewhat in symmetrical distribution. The size of individual lesions varied from 5 to 7cm in longest diameters. The periphery of few of these lesions still showed collarette scaling at places. Only the plaque on right upper back showed to be placed along the line of cleavage and others were not so classical [Figure , ].\nAll the eruptions consisted of scaly plaques with central clearing and peripheral scales. Collarette scaling was seen at places on the affected areas. There palms and soles and mucosal surfaces were uninvolved.\nHer general and systemic examinations revealed no abnormality. Investigations including complete blood counts, blood sugar levels, urinalysis, HIV antibodies, and VDRL test (done in repeated dilutions) were negative or normal. The fungal scrapings were repeated twice and did not reveal any evidence of fungal elements. She did not, however, agree for skin biopsy.\nShe was prescribed topical betamethasone dipropionate 0.025% ointment twice a day topical application and desloratidine tablet 5 mg once a day. The lesions slowly resolved within 2 weeks, with slight hypopigmentation. There was no recurrence for 6 months of follow up. |
The patient was a 70-year-old male who presented to the orthopedic outpatient clinic with a slowly progressive swelling around his right thigh over the past 10 years. The patient had observed the swelling grow to its present size which was relatively painless in the past, but painful for the past 6 months, thereby causing difficulty in his activities of daily living. The pain was present even at rest and radiated to the right leg. On clinical examination, there was a smooth, lobulated, painless, and firm swelling covering the back of the thigh extending anteriorly, medially as well as laterally. On the posterior surface, it was approximately 25 × 10 cm, with anterior lobulation approximately 15 × 5 cm (). Medial as well lateral extensions were diffuse. The plain radiograph of the limb showed no bony involvement. Magnetic resonance imaging (MRI) revealed a well circumscribed encapsulated lobulated soft tissue mass measuring 25 × 15.5 × 10cm in the lower half of the thigh appearing heterogeneously hyperintense on T2 STIR sequence with a T2 hypointense rim and a hypointense T1, giving a whorled appearance. The mass was located mainly in the posterior compartment (just deep to superficial fascia and intermuscular planes), extending into anterior compartment along the lateral aspect of thigh caudally extending up to levels of the femoral condyles ( and ). No obvious invasion of the neurovascular bundle was seen; however, it was displaced medially lying in close proximity to the swelling. Tumor workup such as computed tomography of the chest and ultrasonography of the abdomen was normal. Routine blood investigations revealed mild anemia and ESR of 24mm/h. A biopsy was performed which was suggestive of a benign myxoid neoplasm. Having obtained the pathological diagnosis, surgical excision was planned for which due consent was obtained. Excision was performed by a single curvilinear incision over the posterior thigh, curving from superomedial to inferolateral direction, incorporating the biopsy site into it. The tumor was identified as swelling with a shiny white capsule, with rubbery consistency, lying in a subcutaneous plane extending to the intermuscular plane. The tumor was excised en-bloc without any spillage measuring 23 × 18 × 6 (). The post-operative period was uneventful with no neurovascular deficit. Histopathology report showed moderately cellular growth with an abundant myxoid matrix containing oval to spindle cells with monomorphic nuclei and bland chromatin. No nuclear atypia or increased mitosis was seen (). Immunohistochemistry markers were done which revealed accentuation of blood vessels on SMA, which was negative in tumor cells, few cells positive for S-100 and Ki-67 was <1% indicative of low proliferative index. Histopathological diagnosis was consistent with intramuscular myxoma. At the final follow-up of 26 months, the patient was asymptomatic and showed no signs of recurrence. |
A 12-year-old boy sprained his left ankle by forced inversion while playing soccer. He and his mother were referred to our clinic 2 days after the injury. No issues were noted in his family history, developmental history, or psychological conditions. He was a right-handed active Japanese boy with normal physical development, 140 cm tall, weighing 31 kg. He suffered from the same left ankle sprain 3 months before the present injury, although he recovered completely within a few days at that time.\nAt the first visit, he could walk using his left foot, reporting pain in the lateral aspect of the ankle during motion at an intensity of 85 mm on a 100 mm VAS. X-ray images showed no abnormal changes in the ankle joint or surrounding bones. An analgesic poultice was prescribed and he was allowed to walk with the diagnosis of a grade-1 ankle sprain. Running, sports, and physical activity were prohibited and the patient was requested to revisit 1 week later. Two days after the first examination the patient visited again, reporting increasing pain with a 94 mm VAS score. The painful area had expanded to the entire foot. He could not bear weight on his left foot with allodynia and hyperpathia in the sole. These were obviously unusual signs for a grade-1 ankle sprain. A supporting band was worn and non-weight-bearing ambulation using a pair of crutches was instructed by a physical therapist. Oral acetaminophen (400 mg/day) was prescribed, but was ineffective. On the fifth day, VAS score increased to 100 mm both in motion and at rest. Intense allodynia and mild edema were observed in the entire foot. The patient reported difficulty standing on his left foot because of fear of evoking pain induced by touching his foot on the floor. Subcutaneous bleeding suggestive of underlying ligamentous ruptures was not seen anywhere in the foot. CT performed to detect deep injuries, such as bone contusions, revealed normal findings in bony structures and soft tissues. Trophic and thermal changes were unclear. A diagnosis of CRPS I was made, being compatible with items 2 (motor dysfunction), 3 (abnormal pain processing), and 5 (asymmetric edema) of the Japanese Clinical Diagnostic Criteria of the Japanese CRPS I Research Group (). Celecoxib (100 mg/day) and pregabalin (25 mg/day) tablets were prescribed to alleviate the symptoms suggestive of inflammatory and sensitized conditions. Physical treatments including assisted active and passive range of motion (ROM) exercise and ice-massage, hot packs, and gradual weight bearing were started to obtain graded desensitization. These physical treatments lasting 20 minutes in each session were conducted once a day and were continued until the final visit. The physician and physical therapists instructed the patient and his mother in CRPS I and the validity of the treatments at every visit. On the 11th day, VAS score for pain during motion was reduced to 53 mm and the patient was able to move his ankle and touch the sole of his foot on the floor. On the 22nd day, VAS was remarkably reduced to 2 mm and allodynia and edema were completely gone. The administration of celecoxib and pregabalin was terminated. On the 35th day, he reported no pain. He could walk naturally, run, and jump with the injured foot. Therefore, outpatient care was discontinued. No recurrent events have occurred for 2 years after the final visit to date. Thus, he recovered from acute CRPS I in its early phases.\nshows the transitions of VAS scores and treatment modalities. |
A forty year old woman was referred to our center with a sudden paroxysmal headache after shouting. The history of occasional classic migraine-typed headache with visual aura responding to common analgesic drugs of at least two years duration was found, although she did not have such shouting-induced headache before that. Moreover, there had been a history of diastolic hypertension which was resistant to 25 mg of captopril three times a day since one year ago. The blood pressure was self-monitored at home ranging from 90 to110 mmHg in diastolic ones. Also, she complained frequent sinus bradycardia in the 35-50 beats per minute range with unknown source, any relation to medications, and concurrent with onset of hypertension which sometimes was treated with intravenous atropine. In past medical history, elective cesarean section and hernioplasty were dominant. She did not have any history of sleep apnea or any signs and symptoms related to increased ICP.\nThe general physical examinations were normal except for pulse rate of 55 beats per minute and diastolic hypertension of 95 mmHg. In neurologic examination, there was no evidence of meningeal irritation, and cranial nerves, mental status, sensory and motor system functions were normal. Also, deep tendon reflexes were mildly exaggerated (+ 3) in all limbs. The brain MRI was done to rule out the structural causes of cough-induced headaches. According to MR imaging, Chiari I malformation was discovered in the patient ().\nThe skin was incised from inion to C7 spinous process with a midline incision. The occiput, C1 and C2 laminas, and foramen magnum were explored, and then craniectomy and C1 laminectomy was done. After dura exploration and adhesion dehiscent, thick tonsillar bands were burned with bipolar and dura was expanded with femoral muscle fascia. ()\nIn the six-month follow up period, the patient did not have any neurological symptoms such as headache. She had no more hypertension and sinus bradycardia which was measured by herself or a physician. Follow up MRI was presented in . |
A 50-year-old male was brought to the emergency department after he jumped from a 5-meter bridge in an attempted suicide and fell on the hard concrete below. Upon admission, the patient was agitated, disoriented, and in intense respiratory distress. Examination revealted that the patient’s airway was clear, but there was a bilateral absence of breath sounds and hyperresonance on percussion. The patient was hemodynamically stable. He was intubated due to respiratory failure. Bilateral chest tubes were inserted based on a high clinical suspicion of pneumothorax. Thereafter, the patient developed a large subcutaneous emphysema, despite the fact that the chest tubes were functioning with his severe air leakage. Past medical history was unremarkable with no previous formal depression diagnosis. A social history check showed daily marijuana and tobacco use.\nThe patient was sent for a head, neck, thorax, abdomen, and pelvis CT scan. The scan revealed giant bullous emphysema on the superior lobes bilaterally, right pneumothorax with a collapsed lung, along with multiple rib fractures, and lung emphysema (, ). A hip dislocation was detected, and closed reduction was performed.\nThe patient was sent to the ICU, where he improved clinically after conservative treatment with continuous negative pressure suction using a 20 cm water column. He was extubated after 48 h, with persistence of the air leakage on both chest tubes.\nOn the day following extubation, he developed hypoxia associated with disorientation and agitation and had to be intubated again. Hypoxia was postulated from pulmonary contusion and ventilator-associated pneumonia worsening his already baseline compromised lung. He developed sepsis, and subsequently acute kidney injury with the need for dialysis.\nDuring the course of 5 days, the patient presented hypoxia and a severe mixed metabolic and respiratory acidosis, despite the use vancomycin and piperacillin/tazobactam. The treatment with bilateral chest tubes associated with continuous negative pressure aspiration did not correct the air leakage, which caused an important lost of tidal volumes on the ventilator. Changes in ventilator parameters (increases in PEEP, tidal volumes, etc.) did not improve his oxygenation or decrease his pCO2. In an effort to expand his lungs and improve his ventilatory function, we decided to perform a bilateral bullectomy.\nAs the patient had poor surgical status, only a right bullectomy was performed 8 days after the trauma. The right side was chosen over the left, because it showed more compression and a larger residual, healthier parenchyma. After surgery, the right side fistula was resolved (). Four days after surgery, the patient developed a right-sided empyema, right lung incarceration, and blood clots in the chest tube (). In order to resolve these issues, videothoracoscopy and decortication of the right lung were performed, which resulted in the resolution of these problems () and improvement in ventilatory parameters with conservative treatment for the left lung. Notwithstanding antibiotic treatment and successful surgical interventions, the patient died on the 25th day of hospitalization due to infectious complications. |
A 40-year-old male presented to our hospital after a motorcycle collision where he was traveling approximately 75 mph and collided with a guardrail. He was hypotensive but alert and required a left needle thoracostomy for decreased breath sounds. On arrival, he remained hypotensive with blood pressures 60 mmHg systolic. He was intubated and a massive transfusion protocol was activated. He was found to have left chest deformity, and a left chest tube was placed with an initial return of >2000 cc blood.\nHe was taken to the operating room emergently for a left thoracotomy where he was found to have multiple comminuted rib fractures, multiple large pulmonary lacerations, a left diaphragm injury, and bilateral hemothoraces. A fragment of bone was found abutting the pericardium, and the thoracotomy was converted to a clamshell thoracotomy to better evaluate the heart. The pericardium was incised and the heart was found to be intact. A tractotomy was required to control pulmonary hemorrhage and the left chest packed. An exploratory laparotomy was performed which was negative except for superficial splenic lacerations. His other injuries include a left humerus fracture and left scapula fracture.\nPostoperatively, he remained hypotensive with systolic blood pressures in the low 80s mmHg and hypoxic despite massive transfusion including 38 packed red blood cells, 36 plasma, and 4 units of platelets. A this point, we had exhausted our hospital's blood supply and prognosis remained poor. He was started on vasopressors and resuscitation continued.\nWhile in the intensive care unit, he failed to respond to additional fluid resuscitation and hemorrhage was felt to be controlled. He was given a dose of empiric hydrocortisone at 100 mg and continued every 8 h. Over the next few hours, the patient stabilized with systolic blood pressures into the 150s mmHg systolic. Vasopressors were weaned and fluids decreased.\nThe patient's family was contacted later in the night and provided his medical history. The patient had a history of hypopituitarism from previous head trauma and has been taking levothyroxine and hydrocortisone for several years.\nThe patient was returned to the operating room 2 days later for washout, rib fixation, and closure of his left chest. He was later extubated on posttrauma day 6.\nHis remaining hospital course was complicated by left bronchopulmonary fistula, pulmonary embolism, and heparin-induced thrombocytopenia. He was discharged on the 47th day of hospitalization. At 1-year follow-up, he has continued to recover and he has returned to work and has not got respiratory difficulty. |
We evaluated a 67-year-old man with a 3-year history of posterior neck pain and headache with vertigo that resulted from a head injury sustained in an accident. The medical and family histories were negative for headaches. There were no significant findings on a brain magnetic resonance (MR) image immediately after the accident and a brain MR angiographic image 1 year after the accident. A neurosurgeon referred him to our pain clinic for pain control after confirming normal findings of a computed tomography scan of the temporal bone and cerebellopontine angle cistern.\nThe chief complaint was posterior neck pain which continued all day except while at work. There was a pain-relieving point in the posterior neck area that reduced the pain when he applied pressure with his finger. He rated his pain as 3-4/10 using a 0-10 numerical rating scale. The physical examination revealed that there was no mass-like lesion in the neck area and no pain related to neck motion. There was only degenerative changes in the simple X-ray image of cervical spine (). Vertigo with headaches began after the accident and occurred approximately 4 times a day and lasted 5 minutes. Nausea accompanied the vertigo, but there was no loss of consciousness. There were no aggravating or relieving factors related to the vertigo. He had tinnitus and fullness in his left ear.\nWith a diagnosis of cervicogenic headaches, he underwent C2 dorsal root ganglion and third occipital nerve blocks with 2 ml of 0.5% lidocaine and 10 mg of triamcinolone at each site guided by radiologic imaging. Infiltration of local anesthetics near the pain-relieving point was done. He was treated with medication for true vertigo with a diagnosis of Meniere's syndrome. Five days later, the headaches improved, but the posterior neck pain persisted. The injection of local anesthetics had a temporary effect. Thus, 10 days after the 1st visit, after explaining the procedure, efficacy, and side effects of PRF, we placed the patient in a prone position. Under radiologic image guiding, the pain-relieving point in the soft tissue of the posterior neck was between the 2nd and 3rd cervical vertebrae, 1.5 cm from the midline. The 8-cm RF electrode with a 5-mm active tip was advanced to the pain-relieving point at a depth of 1 cm (). After clarifying the location of the pain-relieving point through test stimulation with 50 Hz and 0.5 mA that shows concordant pain as usual, we performed PRF for 120 seconds at 40℃. Immediately after the procedure, the patient rated his pain in the posterior neck as 0/10 using a 0-10 numerical rating scale. Eleven days after the PRF procedure, relief of headache and posterior neck pain was maintained with slight dizziness. The patient reported continued relief of headache and posterior neck pain by telephone follow-up for 5 months. |
A 65-year-old right-handed black Ethiopian male referred to the outpatient neurology clinic in Tikur Anbessa Specialized Hospital with a complaint of diffuse, symmetrical body fat deposition which was started 15 years back as belly fat and slowly grows to involve his anterior chest with bilateral breast enlargement. The mass continued to gradually increase until it attains the current size which now involves his torso, both upper arms and thighs. The mass spares his face and distal limbs. Since the past six months, he experienced deep aching pain in his knees and ankles bilaterally and recently the joint pain got worse with new onset low back pain. For the above complaint he visited a nearby clinic and his symptoms were attributed to his excess body weight (114 kg) at that time and treated with oral analgesic and advised to control his weight through diet and regular exercise. However, all of his symptoms persisted with worsening of back pain and walking difficulty. Which made him homebound and need another person assistance to stand and walk around the house. Otherwise, he did not have breathing or swallowing difficulty, abdominal pain or distal limb sensory or motor abnormalities. He denied any history of alcohol abuse, tobacco or illicit drug use but occasionally he consumed 1 to 2 beer in social events and holidays. He usually found it difficult to find a cloth that fits him otherwise he was relatively healthy. He lost his truck driving job since the recent worsening of symptoms and become financially dependent on his wife. He was married and a father of three boys. All of his siblings were alive and healthy except his older sister, who was hypertensive. His family history was negative for similar condition.\nOn physical examination, his body mass index was 39.6 kg/m2 (weight − 113 kg, height − 1.69 m) otherwise vital signs were normal. There was diffuse bilateral symmetrical, non-tender, soft swelling of his trunk, shoulder, upper arms and thighs with bilateral breast enlargements. [Figure (A)]. Also, he had thick and redundant skin folds with huge lipomas in his back torso sparing the neck [Fig. (B)], and disproportional enlargement of both arms and thighs as compared to a normal appearing forearm and shine [Fig. (A) & (B)]. On neurologic exam, straight leg raise test was difficult to perform because of the central mass. He had mild lumbar vertebrae tenderness. The motor and sensory exams were normal. No joint swelling, tenderness, or crepitation detected. The rest of his examination was non-revealing. Table summarized the baseline laboratory findings where most of the results were in the normal range except hyperuricemia (10.6 mg/dl). Magnetic resonance imaging (MRI) of the cervical [Fig. (A)] and lumbar [Fig. (B)] vertebrae showed diffuse subcutaneous fat deposits in the posterior neck and lower back with multilevel degenerative disc prolapse and osteophytic changes. Biopsy from the mass revealed non-capsulated sheets of mature adipocytes with modest fibrous infiltration which is consistent with the pathologic features of benign lipomatosis.\nThe patent was diagnosed with type II Madelung’s disease and lumbar degenerative disc disease with and hyperuricemia. We started with on parenteral nonsteroidal anti-inflammatory (Diclofenac) and physical therapy. A week after starting the supportive therapy his symptoms subsided and discharged home with oral analgesics. Advised on lifestyle and dietary modifications to control the hyperuricemia including abstinence from alcohol, avoiding high glycemic foods and sugary drinks that will limit his total daily calorie intake between 800 and 1000 calories, adherence to low purine diets such as nuts, whole grains, vegetables and fruits rich in vitamin C and engaging in regularly physical activity with at least 30 min of brisk walking for 3–5 days per week. The patient refused surgical treatment. One month in his follow up, he lost 2 kg with good functional recovery but lipomatosis remined unchanged. He was kept on regular follow-up in the endocrine, rheumatology and neurology outpatient clinics. |
A 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.\nHe was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later which was thought to be at least partially related to subclinical cirrhosis. He was ultimately discharged to inpatient hospice and died shortly thereafter. |
A 22-year-old male, who was a car mechanic by occupation, presented to us with complaints of abdomen discomfort for several hours. After a detailed history, he revealed that as a prank played by his friends, there was the placement of a nozzle into his external anal orifice and release of highly compressed air through it, the previous day in his workshop. Following this event, the patient immediately developed giddiness and breathlessness. The patient presented to us after nearly 1 day and a clinical examination revealed a pulse rate of 76/min, blood pressure of 110/72 mm of Hg, and respiratory rate of 20/min. Abdomen examination showed mild abdomen distension with tenderness in the umbilical and hypogastric region, with subcutaneous emphysema in the abdomen wall extending up to the lower chest. Digital rectal examination revealed a defect of 1–2 cm in the lower rectum at about 4–5 cm from the anal verge with no blood staining of gloved fingers with a normal sphincter tone.\nX-ray abdomen erect revealed dilated bowel loops []. Computed tomography scan of the abdomen revealed evidence of air pockets in both ischiorectal fossae and pelvis with subcutaneous emphysema tracking to intramuscular plane noted at the lower chest wall, the lower anterior abdominal wall around the perineal region, pelvic region, and scrotum with large bowel loops appearing grossly dilated [].\nAn extraperitoneal rectal injury was suspected from the above scenario and the patient was examined under general anaesthesia. A long tear of about 8 cm posteriorly in the rectum at around 5 cm from the anal verge was identified. We initially proceeded to construct a transverse loop colostomy for fecal diversion to facilitate healing of rectal wounds and to relieve the distension, but on encountering further injuries as mentioned below, we proceeded with an exploratory laparotomy to repair the other injuries. On opening the peritoneum, the following were found: (1) distension of large bowel and small bowel; (2) long-segment serosal tear anteriorly along the upper rectum, sigmoid for a length of 20 cm; (3) another segment of serosal tear along the anterior wall of transverse colon; (4) long-segment serosal tears in the caecum, anteriorly and posteriorly for a length of 7 cm []. A transverse loop colostomy was constructed and the rectal tears were sutured with 3-0 Vicryl by interrupted sutures. Serosal tears in the colon were sutured with 3-0 Vicryl. The postoperative period was uneventful and the patient was discharged with a functioning loop colostomy.\nThe loop colostomy reversal was done after 8 weeks and the postoperative period was uneventful. Follow-up at 6 months revealed that the patient did not have symptoms or disturbances with bowel habits. |
A mother was seen at the district hospital 4 days after the onset of symptoms of her 4 months old female baby. On admission the child was semiconscious, dyspnoeic and had severe hypoglycaemia. The child died 8 hrs after admission. Below is a day to day account of the development of the sickness based on the mother's experiences of the care received at the PHC facilities where she first sought help for her sick baby.\nDay 1: The child started having diarrhoea and vomiting. The mother took her child to a nearby public dispensary. At the dispensary, mother was given metronidazole tablets to give the child at home.\nDay 2: Observing no improvement in the child, the next morning mother went back to the same dispensary. This time she was given one packet of oral rehydration solution and was told to continue giving metronidazole tablets as well.\nDay 3: The diarrhoea and vomiting was getting worse. The child was getting weaker and started breathing fast. The mother decided to go straight to the health centre (next higher level facility). On arrival, she was ordered by the clinician to go and buy an injection (antibiotic) from the local drug store which she was told was going to help the fast breathing. After the child had received the injection she was then asked to take her to be investigated for malaria at a nearby private laboratory. There she paid, had the child tested and brought back the results which revealed malaria parasites. She was then told to go and buy quinine syrup. Later on the same day, the mother was told that her child's condition wasn't improving and that she should go to buy a second drug (antibiotic).\nDay 4: The child was getting worse and was breathing very badly. The mother was sent to buy a third drug (antibiotic). The mother requested to be referred to the district hospital, but she was told even there they would give the child the same drug so she should rather go and buy the drug as advised. Later in the evening the quinine syrup the mother was giving her child by mouth was coming back through the nose. By that time the child could no longer breastfeed or eat but was still conscious. That is when she was referred the child to the district hospital. The mother was given a driver to bring her and her child to the district hospital, but no nurse was willing to accompany her. The child died 8 hrs after admission\nSimilar experiences of inadequate care were shared by other informants. In the following section the different deficiencies related to investigations, drugs, qualified health staff and services are further illustrated through the health seeking accounts of care takers. |
A 65-year-old female was transferred with endotracheal intubation from another hospital to our emergency medical center. She had not been diagnosed with any other diseases, except hypertension and depression. She had ingested carbamate insecticide in an attempted suicide, but had not taken any other corrosive agent. The patient was found unconscious at home and taken to another hospital. When she arrived at that hospital, respiratory arrest was suspected and she immediately underwent endotracheal intubation and <5 min of CPR. The endotracheal intubation was successful on the first attempt without any difficulties. An aluminum stylet wrapped in polyvinyl chloride was used for the endotracheal intubation, but the stylet was removed when the tube crossed the vocal cord. In addition, a 7 mm size endotracheal tube (ETT) was used, but the cuff pressure was checked by manual palpation conducted by an emergency nurse instead of using a manometer. In addition, no adjustments to the cuff pressure were made after the initial treatment. The patient was then transferred to our hospital with stable vital signs. Her oxygen saturation was 98% on pulse oximetry. The size of the ETT was 7 mm, the insertion depth of ETT was 21 cm, and the cuff pressure was considered appropriate by manual palpation. Chest X-ray was conducted and pneumomediastinum was suspected []. Chest X-ray also revealed that the ETT was inserted too deeply and the tube cuff was overinflated []; however, those findings were overlooked at that time. Chest computed tomography (CT) was performed and showed incorrect position and overinflated cuff of ETT clearly, as well as suspicious posterior trachea tear []. A manometer revealed that the cuff pressure was 40 cmH2O. Tube cuff pressure and depth were corrected to 25 cmH2O and 18 cm, respectively. Follow-up of chest CT 2 days later clearly revealed a posterior tracheal wall rupture [] and bronchoscopy was conducted. A 4 cm size longitudinal rupture was observed at the posterior lower tracheal wall on bronchoscopy []. However, no esophagography was performed to determine if there was also an esophageal perforation. Emergency surgery for tracheal wall repair was performed because of increased subcutaneous emphysema. Although esophagography was not performed, it was thought that there was no esophageal perforation because the patient was able to eat without any problems from 5 days after the operation and she was discharged at 8 days after tracheal surgery. The patient's written consent has not been obtained. [This study was approved by the institutional review board of Inha University Hospital (INHAUH 2018-04-001). IRB authorized the patient's consent exemption]. |
A 33-year-old woman presented with a spontaneous expanding intrathyroid hematoma causing acute airway obstruction. The hematoma occurred suddenly and caused gradual progression of symptoms that resulted in multiple emergency department (ED) visits with eventual airway compromise. The patient's account is presented in Appendix 1.\nThe patient first presented to the ED with a chief complaint of anterior neck discomfort, neck stiffness, and neck swelling that had developed over the course of the day. She had no history of preceding trauma, coagulopathy, or use of anticoagulants. She was sent home on oral antibiotics. Three days later, she presented to the ED for a second time, noting ongoing neck pain, increased stiffness, and increased swelling. Review of systems was negative. She was discharged home with an outpatient referral for a thyroid ultrasound. The thyroid ultrasound, which was completed 4 days after her initial presentation, demonstrated an asymmetrically enlarged left thyroid lobe containing a heterogenous hypoechoic mass measuring 7.7 × 5.1 × 5.6 cm, suspicious for a hemorrhage into a preexisting thyroid nodule. An outpatient referral to Otolaryngology was made. She returned to the ED for a third time to report worsening of neck swelling and pain and was discharged home to await Otolaryngology consultation. Two days later, the patient presented to the ED for a fourth time with a significant increase in neck swelling, pain, dysphagia, and for the first time, respiratory distress. Past medical history was significant for increased body mass index (BMI). She was 3 months postpartum for a planned cesarean section at 38 weeks with her second child. Her only medication was an oral contraceptive pill. There was no personal or family history of thyroid disease.\nOn initial ED presentation, the patient was noted to have edema, erythema, and tenderness on palpation of the left side of her neck, which progressed over subsequent ED visits (Fig. A). On her fourth ED presentation, the patient was noted to be stridulous while supine. At this point, she was intubated for airway protection in the operating room by the anesthesia service. There was no significant narrowing of the upper airway. On admission to the intensive care unit (ICU), examination of the neck revealed palpable fullness near the left thyroid and significant submandibular swelling bilaterally (Fig. B). She was febrile on presentation to the ICU, but otherwise her vital signs were stable.\nFollowing intubation, a computed tomography (CT) scan was performed (Fig. A and B) revealing a 7 × 5.5 × 5 cm large ovoid complex lesion in the left thyroid lobe with deviation of the larynx. The findings were highly suspicious for hemorrhage into the left lobe. Blood work demonstrated a downward trend in hemoglobin (108–97 g/L). Blood cultures were negative for infectious organisms.\nAfter securing the airway, the patient was transferred to a tertiary care center. After obtaining informed consent, a left hemithyroidectomy was completed. Intraoperatively, a hematomatous nodule was found on the anterior aspect of the thyroid gland. Extensive hemorrhage was noted within the strap muscles and left thyroid bed extending to the carotid sheath. There was no acute bleeding while in the operating room. A hemithyroidectomy was performed in the standard fashion with careful dissection of the recurrent laryngeal nerve. Antibiotics were continued and the patient was started on dexamethasone to reduce airway edema.\nThe patient was intubated for 72 hours postoperatively until there was a cuff leak. Postextubation endoscopy revealed a patent airway, and normal vocal cord function.\nThe pathology report described the gross specimen as a tan-brown, smooth lobe containing a solid, red-brown, granular mass measuring 7.0 × 4.0 × 4.0 cm. The majority (90%) of the thyroid lobe was composed of necrotic thyroid follicles and hemorrhagic necrotic material, with no evidence of malignancy.\nFollow-up ultrasound at 3 months revealed no nodules on the contralateral side and a normal left postthyroidectomy bed. |
A 44-year old man presented to us with a high velocity motorbike accident after a head-on collision with a truck. On arrival to the A&E, he was alert and conscious but was hypotensive and tachycardic. He complained of pain in the groin and both knees. There was no significant past history. Examination revealed extensive bruising of the pelvic region, scrotal swelling and bilateral knee effusions. Initial radiographs showed an open book type pelvic fracture but no other bony injuries were identified. Stress views of the knees in theatre revealed ligamentous laxity bilaterally. The pelvis was stabilised with an external fixator after initial resuscitation and splints applied to both knees.\n12 hours later, the patient complained of pain in the right elbow. There was no previous history of elbow injury or arthritis. On examination, there was minimal swelling over the elbow and tenderness over the radial head. There was a flexion attitude of the right elbow. Although he had good flexion and extension of the elbow, forearm pronation and supination were restricted and painful. There was no evidence of posterior interosseus nerve palsy. Radiographs showed an anterolateral dislocation of the radial head with no associated fractures of the radius, ulna or disruption of the distal radioulnar joint. (Figure &) Closed reduction was achieved by supinating the forearm and applying pressure on the radial head following which immobilisation was done in an above elbow plaster with the forearm in supination and elbow in 90 degrees of flexion. (Figure &) The elbow was tested for stability post reduction and was found to be stable. On screening there was no evidence of a coronoid or radial head fracture. Immobilisation was continued for 3 weeks with serial radiographs done at week 1 and 2 to make sure the radial head was in reduced position. Elbow mobilisation was started after removal of the plaster under supervision of the physiotherapist. The patient was followed up at 3 and 6 months. At 6 months he had no residual pain at the elbow and movements were full elbow flexion & extension, full supination with restriction of last 10 degrees of pronation. There was no evidence of instability of the elbow. |
The patient has given consent for the clinical details of the case to be published in a medical journal.\nA 32-year-old male weighing 70 kg presented to Respiratory Medicine department of our hospital with a history of cough, progressive dyspnea and hemoptysis. Dyspnea was positional in nature, relieved in lateral and sitting position. The patient was a chronic smoker and had quit smoking 1 year back. Auscultation of the chest revealed bilateral monophonic wheeze and conducted sounds. The chest X-ray revealed loss of lung volume and collapse of the lower lobe on the left side. The arterial blood gas analysis at the time of admission revealed PaO2 of 54.4 mmHg on room air which improved to 71 mmHg after nebulization and bronchodilator therapy. Preoperative pulmonary function tests revealed obstructive ventilation defects with reduced vital capacity, and flow volume loops demonstrated flow limitation during both phases of respiration. Computed tomography scan of the neck and thorax revealed a 21 mm × 17 mm × 15 mm broad base mass arising from the left posterolateral wall of the trachea, occluding the tracheal lumen by 80% and located 1.5 cm proximal to carina []. Preoperative bronchoscopy confirmed a tracheal mass 9 cm from the vocal cords obstructing approximately three-fourth of the tracheal lumen []. It was possible to negotiate a 6.0 mm outer diameter bronchoscope (Pentax video bronchoscope EB-1570, Pentax Corporation, Europe GmbH) through the space available in posterolateral aspect, beyond which the carina was clearly visible and free of any infiltration. An apparently vascular mass did not bleed on fine needle aspiration biopsy. The tissue biopsy revealed the mass to be an adenocarcinoma and therefore the patient was scheduled for resection of the tumor with primary anastomosis of the trachea through right anterolateral thoracotomy. The airway was evaluated as Mallampati class I and other biochemical and hematological parameters were normal. Patient received a course of broad spectrum antibiotics, bronchodilator therapy and nebulization preoperatively.\nSince it was possible to negotiate a 6.0 mm bronchoscope beyond the tumor on preoperative bronchoscopy, it was decided to place 32 cm long 5.5 mm internal diameter micro laryngeal surgery (MLS, Ivory polyvinyl chloride [PVC]) tube distal to the tumor for primary airway control. Alternatives in case of failure to negotiate the growth were also kept in mind. Therefore, a set of graduated rigid bronchoscopes with the presence of an experienced otorhinolaryngologist was ensured until the primary control of airway was attained.\nStandard noninvasive monitoring was done using anesthesia monitor (S/5™ critical care monitor, Datex Ohmeda, Helsinki, Finland). An arterial cannula was placed in the left radial artery for invasive blood pressure monitoring and arterial gas analysis. Awake fiberoptic intubation was done after topical anesthesia of the upper airway in a position in which patient reported least discomfort that is, 30° head up and slight right up tilt. Under fiberoptic guidance, a 5.5 mm ID MLS tube was placed distal to the growth but proximal to carina. After confirming the placement through fiberoptic bronchoscope (FOB), the patient was anesthetized and paralyzed with injection propofol 2 mg/kg, fentanyl 2 μg/kg and vecuronium 0.1 mg/kg. Prior to the positioning, patient started desaturating with SpO2 falling to 70%. On auscultation, breath sounds were absent on the left side. Thinking that the endotracheal tube (ETT) might have migrated to the right main stem bronchus, the tube was withdrawn gradually till bilateral breath sounds were present. The SpO2 gradually improved to 95%. Fiberoptic examination revealed the MLS tube still distal to the tumor and proximal to carina. Patient was positioned as desired for the surgery. Anesthesia was maintained in air: O2 with FiO2 0.5, propofol infusion at 3-4 mg/kg/h and fentanyl infusion at 2 μg/kg/h. After anterolateral thoracotomy and surgical exposure, tracheal wall was incised below the tumor and a sterile 5.0 mm cuffed PVC ETT was placed in left main stem bronchus (MSB) by the operating surgeon and connected through a Bain's circuit (enclosed in a sterile drape) to a separate anesthesia workstation for ventilation of the left lung. Likewise, a sterile 5.0 mm cuffed tube was placed in the right MSB. Now bilateral ventilation was instituted through endobronchial tubes connected to Y-connector attached to anesthesia workstation []. The ETT's inserted in this manner provided adequate ventilation while preventing the spillage of blood and debris into the distal airways at the same time. Meanwhile, the orotracheal MLS tube was withdrawn proximal to the tumor and a 4 cm length of the trachea inclusive of the tumor was excised with primary anastomosis of the trachea. On closure of the trachea, endobronchial tubes were removed one by one and ventilation resumed through the oral MLS tube. The entire perioperative period was uneventful and trachea extubated at the completion of surgery with the resumption of spontaneous respiration. Neck flexion was maintained at an angle of 15° to minimize the tension on the tracheal anastomosis.\nThe patient was transferred to intensive care unit (ICU) and was kept on noninvasive ventilation (iPAP 8 mmHg and ePAP 5 mmHg) for 48 h to prevent postoperative atelectasis and later on oxygen through venturi face mask (FiO2 0.5). The patient was subsequently discharged from the ICU on 6th postoperative day. Histopathology of the tumor revealed an adenoid cystic carcinoma. Postoperative bronchoscopy revealed healed operative site. |
Our patient is a 76-year-old woman who presented to a peripheral hospital with sudden onset dyspnea, nausea, orthopnea, chest pain, and vague abdominal discomfort. She had a history of vague headaches and a family history of hypertension and ischemic heart disease but did not have a formal diagnosis of hypertension herself. Initial examination and investigations revealed a normal hemoglobin level (12.1 mg/dL), minimally raised neutrophil count, and a normal renal profile. Chest X-ray revealed severe congestive cardiac failure with markedly raised blood pressure (230/130). ECG showed normal sinus rhythm with left ventricular hypertrophic changes which were incorrectly interpreted as left bundle branch block (LBBB). A quick bedside echo revealed moderate left ventricular hypertrophy with a normal left ventricular ejection fraction (LVEF) and no significant valvular lesions (such as mitral or aortic regurgitation or aortic stenosis) which could have accounted for her clinical deterioration. She was commenced on an intravenous nitrate infusion and transferred to the cardiac catheterization laboratory in our tertiary care facility for a presumed acute coronary event leading to decompensated cardiac failure.\nOn arrival to our facility, the patient was extremely moribund and complained of severe dyspnea and chest discomfort. Her blood pressure was still unchanged at 230/130 mm Hg. Additional antihypertensive pharmacotherapy was considered; however, in view of her unstable clinical status, we decided to shift her to the cardiac catheterization laboratory.\nCoronary angiogram revealed nonobstructive coronary artery disease with severely raised end diastolic pressure. In view of the nature of her presentation, renal angiography was performed which showed a normal right renal artery while an ostial occlusion of the left renal artery was noted (Figures and ). Based on the emergent nature of patient's presentation we decided to proceed with percutaneous intervention (PCI) of the culprit lesion. The left renal artery was reengaged with a JR4 guide catheter and 5000 units of Heparin were administered. The lesion was probed with a Prowater wire whose passage proved difficult; therefore, a 1.25 mm support balloon was used to cross the lesion. Intrarenal position was confirmed by advancing wire into upper and lower pole arteries. This was followed by sequential balloon dilatation with 1.5 mm, 2.5 mm, and 3.0 mm balloons. Intravascular ultrasound (IVUS) was used to assess the lumen of the renal artery. It was found to be a 5.0 mm vessel with severe thrombus load. Thromboaspiration was performed with an export catheter. A Liberte bare metal stent (5.0/12) was inserted and expanded to 16 atm. It was postdilated with a noncompliant balloon to 20 atm and proximal stent edge was flared in the aorta. Multiple injections of isosorbide dinitrate were given (total of 15 mg). IVUS was performed after stenting which revealed appropriate stent size and expansion with good angiographic result (). A fractional flow reserve (FFR) wire was used to measure the gradient across the ostial right renal artery which showed a maximum gradient of 10 mmHg. This was consistent with the angiographic data and hence no intervention was performed on the right side.\nBlood pressure rapidly normalized and the clinical status of the patient improved after intervention. Patient had a detailed echo the following morning, which confirmed a normal left ventricular ejection fraction, left ventricular hypertrophy with grade 1 diastolic dysfunction, trace to mild MR, left atrial dilation, trace aortic regurgitation, and mild tricuspid regurgitation. An abdominal ultrasound revealed no significant renal abnormalities. Telemetry revealed frequent premature atrial complexes (PACs) and premature ventricular complexes (PVCs) overnight which settled over the following 48 hours. No evidence of atrial fibrillation was noted.\nShe has been followed up on half yearly basis since and her blood pressure and heart failure control have remained satisfactory. She was prescribed dual antiplatelet therapy for 18 months. A CT aortogram was not performed in her case as atherosclerosis is the commonest cause of renal artery stenosis in people aged >45 years and we felt that further radiation and dye exposure was not warranted. |
A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.\nThe baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment. |
A 9-year-old Saudi Arabian boy was referred to our hospital for further investigation of slowly resolving pneumonia. He was a product of full-term, uneventful pregnancy, with good birth weight and had an unremarkable neonatal period. Apparently, he remained healthy until the age of 5 years when he started to have recurrent attacks of cough and dyspnea, which were treated with bronchodilator and prophylactic steroid in addition to frequent use of oral antibiotics, with good response. Six months prior to presentation to our hospital, he started to show gradual clinical deterioration. He presented with lower respiratory tract infection not responding to several courses of oral antibiotics. He had no history of recurrent otitis media or sinusitis, no history of skin abscesses, dermatitis or any other skin lesions, and no history of chronic diarrhea. He received all vaccinations as per routine schedule with no apparent complications. The parents were first-degree cousins, but apart from the atopy which both parents have, there was no history of immune deficiency, chronic lung disease, recurrent infections, or early deaths.\nOn physical examination, he showed signs of respiratory distress, tachypnea and hypoxia. His height (120 cm) and weight (17 kg) were below the 3rd centile with weight far more affected than height. There were no dysmorphic features, but he had grade three clubbing of the hands and feet. The tonsils were normal and there was no lymphadenopathy. Although he had received BCG vaccine at birth, there was no evidence of BCG scar. On chest examination, there was coarse crepitation bilaterally. Other systemic examinations were unremarkable. The patient was put on broad spectrum antibiotics. CT scan of the chest showed bronchiectatic changes. Sweat chloride test was normal at two different time points (30 and 35 mmol).\nImmunological findings are shown in and . The high IgE level indicated normal isotype switching and thus ruled out the hyper IgM syndrome. This possibility was further excluded by the intact expression of CD40 on the surface of B lymphocytes and CD154 on CD4 T cells post PMA stimulation for 4 hours. We were not able to test the ability of B cells to mount antibody response as he was started on intravenous immunoglobulins; however, they appeared to produce reasonable pre-vaccination levels. HIV tests for both antibodies and RNA levels were negative. The adenosine deaminase B level was 1.5 IU/g Hb (normal range, 0.3-1.5 IU/g Hb). A purine nucleoside phosphorylase deficiency was unlikely with normal uric acid level (171 μmol/L; normal range, 60-240). Short tandem repeat analysis of patient peripheral blood showed 2.4% maternal T lymphocytes engraftment and 2.6% myeloid cells engraftment. The HLA typing showed full compatibility with his mother. Lung biopsy revealed eosinophilic infiltrate and a Grema stain was positive for PJP (). Based on these data, he clearly had a T- B+ SCID phenotype with maternal T cell engraftment. Therefore, he was treated with intravenous co-trimoxazole (Septrin, GlaxoSmithKline, UK) for four weeks with a good clinical response and placed on intravenous immunoglobulin replacement therapy. HSCT was initiated. Subsequently, he was admitted again with a CMV infection confirmed by a high CMV viral load that responded well to ganciclovir. The patient was screened for mutation in RAG1, RAG2 and Artemis genes via genotyping and direct gene sequencing, but no mutation was detected, possibly because the mutations were outside the coding regions of the screened genes, or possibly there were defects in other candidate genes, some of which might be novel, that are yet to be discovered in this patient. He was being investigated to delineate the underlying genetic defect.\nThe HLA typing was done on peripheral blood lymphocytes and on epithelial cells from a buccal smear. HLA class I low resolution and HLA Class II high resolution typing was performed. HLA typing was performed using sequence-specific oligonucleotides (Lifematch, Tepnel Lifecodes Molecular Diagnostics, Stamford, CT 06902, USA) and sequence specific primers (Invitrogen Corporation, Carlsbad, CA 92008, USA) described elsewhere. It revealed full matching between the patient and his mother as follows: A*02, A*26, B*49, B*50, Cw*06, Cw*07, DRB1*0701, DRB1*1301, DRB3*01/02/03, DRB4*01, DQB1*0202, DQB1*0603; and for the father: A*26, A*68, B*50, B*51, Cw*06, Cw*15 |
A 66-year-old man, presented to our hospital in February of 2010, about five months after the occurrence of soft tissue swelling on the right laterocervical area that had gradually increased in size. An ultrasound and a CT scan of the neck showed an inhomogeneous and irregular lesion in the right laterocervical area. A biopsy of this lesion was performed, indicating a carcinoma ex pleomorphic adenoma of the right parotid gland.\nThe patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.\nAfter a staging CT scan and a total parotidectomy with ipsilateral laterocervical lymphadenectomy, a CXPA of the right parotid infiltrating the skin surface and the next muscle tissue of stage pT4a pN0 M0 was confirmed. Histologic examination showed a poorly differentiated malignant epithelial component originated from a pleomorphic adenoma. Immunohistochemically, cells were positive for p63 and a cocktail of cytokeratins. Moreover, Ki67 labeling index was 50% (Figure ).\nThe patient underwent adjuvant radiation therapy consisting of 1.50 Gy in 25 fractions and a boost of 2.10 Gy in 5 fractions to the right parotid area.\nIn March of 2011, during a surveillance CT of the neck an irregular and inhomogeneous lesion measuring 4 cm in the right supraclavicular region was detected. The patient underwent dissection of right supraclavicular lymph nodes with histopathological confirmation of a secondary localization of CXPA of salivary glands. The patient was subjected to radiation therapy consisting of 50 Gy in 25 fractions to the right supraclavicular region.\nFollow-up of the patient demonstrated no locoregional recurrence or distant metastases; however, in February of 2013 the patient underwent a surveillance CT scan showing a low-density nodular lesion measuring 1.2 cm in the apical segment of the upper lobe of the left lung and another similar lesion measuring 2.5 cm in the superior-medial portion of the spleen. Indeed, a PET scan confirmed the presence of two hypercaptant lesions in the left lung (SUV 4.1) and in the spleen (SUV 10.6) (Figure ).\nThe patient was referred to the Hematology Department, who performed a bone marrow biopsy and ruled out a hematological disease.\nIn April of 2013, the patient underwent a new CT scan showing a low-density nodular lesion measuring 1.7 cm in the apical segment of the upper lobe of the left lung that had increased in volume and a hypovascular lesion measuring 4.8 cm in the superior-medial portion of the spleen, which had also increased in volume (Figure ). The patient was referred to the General Surgery Department and underwent a laparoscopic splenectomy. This operation became hard due to the presence of metastasis displacing the hilar vessels. Histologic examination revealed that three out of four of the removed lymph nodes as well as the spleen were involved by atypical epitheliomorphic cells, arranged in solid nests and cords with a round or oval nucleus and a large eosinophilic cytoplasm. Few cellular monstrosities were present, while necrosis was not observed. Immunohistochemically, these CXPA cells were specifically positive for cytokeratin 7, S-100 protein, and p63, but were negative for cytokeratin 20, smooth muscle actin, and gross cystic disease fluid protein-15 (GCDFP-15). On the other hand, Ki67 labeling index was 50%.\nMorphology and immunohistochemical panels indicated splenic and lymph node localization of a poorly differentiated epithelial neoplasm, which was difficult to classify histopathologically, probably originating from the salivary glands (Figure ). |
The patient was a 57-year-old man with 6 months history of dysphagia and regurgitation. upper gastrointestinal (UGI) endoscopy was done which showed large wide mouthed diverticulum in lower oesophagus around 36 cm from the incisors. The mucosa within the lumen of diverticulum was normal and there was no other lesion in oesophagus, stomach or duodenum. Subsequently, barium swallow and Contrast Enhanced Computerised Tomography chest and abdomen were done which confirmed the diagnosis of epiphrenic diverticulum measuring 5 cm in maximum diameter arising from posterolateral wall of oesophagus around 4 cm above the Gastro Esophageal junction. Oesophageal manometry showed diffuse increase in pressure tracings with hypertensive Lower Esophageal Sphincter but normal peristalsis and LES relaxation with swallow. Twenty-four hour pH study did not reveal presence of preoperative reflux. The patient was taken up for surgery based on the severity of symptoms and objective findings. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy through single incision was planned.\nPatient was kept on liquid diet 1 day prior to surgery and was fasting overnight. Operation was performed under general anaesthesia with patient supine and legs apart with steep reverse trendelenberg tilt. A Ryle's tube was placed before induction. The surgeon stood between the legs of the patient with a camera assistant to the left and scrub nurse to the right of the surgeon. A 4 cm transverse skin incision was made within the umblicus and deepened upto the anterior rectus sheath. Pneumoperitoneum was created using Veress needle and a 10 mm trocar for laparoscope was placed in the centre of the incision. Two 5 mm trocars were placed on either side for the working instruments creating a mini triangulation effect []. Initial peritoneoscopy was done and then left lobe of liver was retracted by placing heavy double armed silk onstraight needle through a corrugated plastic drain and brought out through the liver parenchyma and the anterior abdominal wall []. This suture was kept on traction with help of small artery forceps. The dissection started with opening up of the avascular gastrohepatic omentum and division of phrenoesophageal membrane and gastrophrenic attachments of the fundus. The right crus of diaphragm was identified and dissected and retroesophageal space created. An umbilical tape was placed and tied around the GE junction after this dissection and brought out through the right trocar for traction during circumferential mobilisation of the oesophagus. The hiatus was opened anteriorly and lower end of mediastinal oesophagus was dissected. The diverticulum was visualised and peridiverticular adhesions were released. The left mediastinal pleura was carefully stripped off the diverticulum. The diverticulum was freed upto its neck, 5 mm right lateral trocar was replaced by a 12 mm trocar and the diverticulum was then divided with two firings of 60 mm linear stapler with a blue cartridge []. Intra operative endoscopy confirmed mucosal integrity and adequacy of lumen of the oesophagus. An anterior oesophageal myotomy was done starting from 6 cm above GE junction and extending 2 cm into the stomach. The mucosal integrity was once again confirmed with endoscopy and air leak test was done. Finally, the specimen was placed in a plastic bag and extracted and drain was placed. Fascial incisions were closed with No 1 loop nylon and skin with subcuticular absorbable suture []. |
A 42 year-old male patient was admitted to Incheon St. Mary's Hospital, The Catholic University of Korea to undergo surgery under diagnosis of SMT of GEJ by screening endoscopy. There was no symptom related to the tumor and there was no abnormality in physical examination and laboratory tests. The endoscopic finding revealed a 2.5 cm-sized SMT which involved the GEJ (), and this tumor was originated from the proper muscle layer by the finding of EUS (). The EUS-guided FNAB failed to get enough specimen for diagnosis, and a homogeneously enhanced SMT around the GEJ was observed by abdominal computed tomography (CT) scan (). The patient underwent laparoscopic gastric wedge resection.\nUnder general anesthesia, the patient was put in reverse Trendelenburg position with his legs apart. The operator was positioned on the right side, and the first assistant was positioned on the left side of the patient. The camera operator was poisoned between the legs of the patient. A 10 mm trocar was inserted through the umbilicus for the camera, and a 5 mm trocar was inserted just below the xiphoid process for liver retractor. One 5 mm trocar on right upper abdomen and one 12 mm trocar on left upper abdomen were used as working channels for the operator. Another 5 mm trocar on left upper abdomen was used for the first assistant. The lesser curvature of the cardia was dissected first as close as possible not to damage right and left vagus nerves and the lesser omentum including both vagus nerves was taped with an umbilical tape. After the tumor mass, which was located at antero-greater curvature side of cardia, was identified (), a small gastrotomy incision was made on the anterior gastric wall near the tumor by ultrasonic shears and wedge resection proceeded along with the tumor border. After the resection, about 2/3 of the circumference of the esophagus was detatched from the stomach with a large gastrotomy incision on the upper stomach (). The esophagus was reimplanted by intracorporeal 2-layered interrupted sutures with #3-0 vicryl. After reimplantation of the esophagus, a 4 cm length gastrotomy incision was remained along the lesser curvature side of cardia. This gastrotomy incision was repaired by intracorporeal 2-layered continuous sutures with #3-0 vicryl (). Two to three short gastric arteries were divided in order to mobilize the fundus and the mobilized fundus was sutured to anterior abdominal esophageal wall. Dor, anterior partial fundoplication was performed (). Crural repair was not performed because the size of esophageal hiatus of this patient was normal.\nAn upper gastrointestinal series was taken at the first postoperative day. There was no leakage nor stenosis in rebuilt, partially wrapped new GEJ (). Nasogastric tube was removed and oral feeding proceeded just after upper gastrointestinal series was taken. The final pathologic report revealed leiomyoma of GEJ. The result of immunochemical stain was that C-kit tyrosine kinase was not expressed and actin, desmin was expressed. The patient was discharged at fifth postoperative day without any complication. There had been no symptom of reflux or dysphasia on 5 months of postoperative follow up. |
A 39 year old female patient presented to our institute with instability on the pubic symphysis. On examination there was a palpable gap in the region of symphysis pubis. Initial mechanism of trauma was a motorcycle accident three years ago before the last admission to hospital. Initial fracture was classified as a combined mechanism according to the Young and Burgess' classification. The patient had undergone fixation with an external fixator (). Four months after the initial trauma, she reported no complaint other than insignificant leg length discrepancy which did not affect her. One year following injury she became pregnant. Gestation period proceeded in an uneventful manner. After childbirth (by caesarean section), the patient complained of pain on long distance walking and instability when she rolled to the lying position. When she was asked whether she had the same complaints during the last trimester, she stated that she had not noticed among pregnancy-related changes. Furthermore, she reported to be experiencing urinary incontinence during some activities such as sudden forward bending. Standard anteroposterior (AP) X-ray examination revealed SPD (). Additional radiographic evaluation was performed using inlet, outlet pelvic radiographs and three-dimensional computed tomography scanning (). There was not any significant residual displacement in the axial and coronal plane, only in the sagittal plane.\nAfter radiographic evaluation an operation was planned to close the gap by fixing with internal fixation. Operation was performed through a midline vertical rectus-splitting anterior approach after transverse skin incision. During surgery, the gap in the pubic symphysis was confirmed and closed to some extent when only firm, steady lateral compression was applied on the iliac crests; nonetheless diastasis still existed. It was decided to use corticocancellous autograft to both fill the gap and help with potential bony/fibrous fixation of pubic symphysis. The residual distance of the gap after maximum side to side compression of pelvis was measured. The bone graft which was 2-3 mm larger than this distance (to allow for some compression between the graft and symphysis pubis joint surface) was harvested from the contra lateral iliac crest of the patient. The fibrous tissue, which filled the separated symphysis pubis distance, was removed and both surfaces of the joint were decorticated to enhance bone healing. While the bone graft was compressed between the two articular surfaces of the symphysis pubis, the space was kept closed with bone clamp placed on both sides of the joint. In this position, the graft was temporarily fixed with K wire, which would not interfere with the placement of the plate. The pubic symphysis was fixed using a nine-hole 3.5 mm reconstruction plate (). The patient was allowed touch-down weight bearing for three months postoperatively. However, she discarded crutches one month post-operatively as she felt well in herself. Immediately after operation the urinary incontinence complaint improved and the pain also resolved shortly after.\nAlmost three years post-operatively patient was reevaluated and informed consent was obtained. At the 3 years follow-up, pelvis was considered stable after clinical and radiographic examination. The patient expressed no sexual dysfunction, urinary incontinence or instability. There was no complaint related to the iliac crest from which autograft had been harvested. However she was suffering from occasional mild pain on the sacroiliac joint. Supine AP, inlet, outlet and single leg stance pelvic radiograph was obtained to evaluate pelvic instability, re-displacement of symphysis pubis and/or fixation failure (). Radiographs revealed that, although the reconstruction plate remained intact, some of the screws were broken (). |
A 71-year-old male patient was transferred to our department due to soft tissue defect in the left lower leg and infected Achilles tendinitis. The patient underwent incision and drainage of both lower legs with necrotizing fasciitis, at another hospital two months ago. Continuous wound care was performed; however, the left leg open Achilles tendinitis and soft tissue defects were not resolved.\nPhysical examination revealed a 12 × 5 cm wound with exposed Achilles tendon over the posteromedial aspect of lower one-third of the leg (Fig. ). His wound culture grew methicillin-resistant Staphylococcus aureus (MRSA).\nWe performed an operation with the patient placed in the supine position. All infection associated with necrotic Achilles tendon in the proximal muscle tissue was excised (Fig. ). After debridement, the patient had a 16 cm tendon defect from the muscle with the ankle joint in neutral position. He had 2 cm of the distal tendon attached to the calcaneus. We extended the skin incision to the outside of the zone of injury in the anterior aspect of the ankle, dissected anterior tibial artery and vena comitantes to perform vascular anastomosis out of injury zone. We made a template with surgical glove, which included the vascularized fascia lata for the reconstruction of Achilles tendon (Fig. ). We used the already manufactured template on the ipsilateral thigh, centering the flap over the perforator and drew the flap larger than the recipient site (Fig. ). A 14 × 7 cm ALF flap with a large piece of fascia lata (bilaterally, approximately 2 cm extra fascia is taken) was harvested (Fig. ). The donor defect was closed primarily over a silicon drain. For the reconstruction of tendon, the fascia lata was repaired first using multiple figure-eight sutures and modified Becker method[ with 4–0 prolene sutures at the separated end-to-end of the Achilles tendon. An end-to-end microvascular anastomosis was performed between the anterior tibial vessels and the flap pedicle vessels using 9–0 sutures microscopically after inserting the flap into the defect (Fig. ).\nPostoperatively, the ankle and leg were wrapped in a bulky dressing and immobilized with an above-knee splint and the flap was monitored intensively for 7 days. Anticoagulation therapy with prostaglandin E1 (10 μg/day) and heparin (5000 units/day) were administered for 1 week and aspirin 100 mg once a day for 4 weeks after the surgery. The flap survived completely without complications. Passive and active exercise of the ankle joint was started at 6 weeks after surgery. Subsequently, the patient underwent a graduated rehabilitation program, from a non-weight bearing exercise to partial-weight bearing exercise. Twelve weeks after the surgery, the patient was permitted full-weight bearing with gait training.\nAt 12 months of follow-up, the patient was able to resume full daily activities, felt a little discomfort at the donor site after more than 2 h of hiking, but was able to walk without pain and without the need for support, also was able to squat, showed an ankle range of motion of 15° dorsiflexion and 45° plantar flexion, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 (Fig. ). |
A 68-year-old female was referred to our hospital due to habitual patellar instability. She had received a TKA without patella resurfacing at another hospital 15 years previously but had been suffering from severe knee pain and patella instability for 8 years. She walked lame due to pain. During her physical examination, the patella was found to have dislocated laterally towards the knee flexion and reduced the normal position to 30 degrees flexion during extension (Fig. ). The results of an apprehension test and posterior drawer test were positive and the knee was significantly laxed under both valgus and varus stress testing. An artificial mass was palpated at the medial side of the distal femur. X-rays of the knee revealed a tibial posterior sag, the femoral component had been installed at an extremely valgus position, and the patella surface was still native, but irregular and sclerotic. No implant loosening was evident (Fig. ). The FTA was measured at 159°, HKA at 9° and mLDFA at 80°, all of which were out of the normal range. CT analysis of the axial section confirmed that the femoral and tibial prosthesis had been adequately installed (Fig. ). TT-TG distance was 8 mm. We thus concluded that the habitual dislocation and polyethylene insert post failure were due to valgus mal-installation of the femoral component and a lack of insert thickness during the initial TKA despite proper rotational installation.\nWe conducted step wise surgery to preserve the prosthesis and avoid the bone loss and complications related to prosthesis removal. In the first step, we planned a varus biplanar CWDFO exposing the broken region of the polyethylene insert, and achieve medial plication and lateral release. According to Miniaci method [], we performed a 14 degrees of the biplanar varus medial CWHTO to achieve the weight bearing line passing through the center of the knee (Fig. a, b). The post of polyethylene insert was removed from fat tissues at medial part of distal femur (Fig. c). Although medial plication and lateral release after CWDFO, the patella still remained subluxated (Fig. d). Postoperative long leg standing X-ray revealed the weight bearing line almost passed through the center of the knee (Fig. e). Because the patella instability and femoro-tibial instability due to a lack of insert thickness were sustained, in the second surgery, we thus conducted patella resurfacing and an replaced a 14 mm thickness of polyethylene insert to 20 mm thickness (Fig. a, b). Subsequent MPFL reconstruction was then conducted to normalize the lateral subluxated patella tracking. Regarding MPFL reconstruction, a single-tailed hamstring tendon graft was fixed in 30° - 45° of knee flexion after the graft was placed both in Schöttle’s point [] of the femur using ACL TightRope® (Arthrex, Inc. Naples, FL, US) and oblique single tunnel in patella.\nAt the 24-month postoperative follow-up, the patient was able to use stairs without any support. The active range of motion (ROM) was now an extension to 0° and flexion to 130° without extension lag. Physical examinations revealed that the patella was stable in a lateral stress test with no apprehension signs. X-rays at 24 months after her second corrective surgery demonstrated good congruence of the patello-femoral joint (the tilt angle improved from 40° to 20°; the bisect offset improved from 121 to 86%, and finally to 60%), the disappearance of any tibial posterior sag, normal alignment of the lower extremity with an FTA of 172° and a HKA of 2° (Fig. ). There was no further patellar dislocation. The Kujala functional score and the Oxford knee score improved from 24 to 58, and from 28 to 40, respectively. |
A 61-year-old woman with diabetes and schizophrenia visited the thyroid-endocrine center at our hospital complaining of dysphagia and repeated vomiting. Furthermore, she experienced increasing dyspnea when lying down from the day before the visit. She was diagnosed with schizophrenia approximately 30 years ago. She had a history of hospitalization in a closed ward when her symptoms were severe, and received antipsychotic medications, including lithium (300 mg/day). She had a slowly growing goiter that began to develop approximately 10 years after taking lithium. She had never undergone any diagnostic tests, including ultrasonography and biopsy, because she had no specific symptoms or discomfort. At the time of admission, the patient’s guardian said that the size of the goiter had dramatically increased in the last 3 months.\nOn physical examination, a nontender and hard, huge anterior neck mass of approximately 10 × 12 cm in size was observed. A neck ultrasound and enhanced thyroid computed tomography (CT) examination revealed a multi-lobulated mass measuring 10.9 × 9.2 × 12.8 cm on the right thyroid gland. Moreover, a leftward deviation of the trachea due to internal calcification and mass was noted. Laryngeal examination with fiber optic endoscopy revealed an airway obstruction due to the anterior neck mass, however, the vocal cord mobility was intact (Fig. ). Laboratory examination showed serum triiodothyronine, free thyroxine, and TSH levels within the normal ranges.\nIn a multidisciplinary meeting, we discussed the options of whether to perform diagnostic confirmation procedures such as fine needle aspiration biopsy or emergency surgery. We consequently planned total thyroidectomy without additional diagnostic procedures considering the high risk of airway obstruction.\nDuring surgery, an approximately 11.5 × 9 cm mass in the right thyroid gland was removed, and no mass was found in the left thyroid gland. No other extra-thyroidal extensions were noted on gross examination, and recurrent laryngeal nerves were preserved on both sides. Microscopically, the tumor showed a trabecular, insular, and solid growth pattern with necrosis, hemorrhage, and ossification. Additionaly, atypical cells with hyperchromatic convoluted nuclei and increased mitotic figures were observed (Fig. ). Immunohistochemical staining was performed on formalin-fixed and paraffin-embedded tissues with antibodies against p53, TTF-1, and Ki-67. The tumor cells were diffusely immunopositive for p53, focally immunopositive for TTF-1, and the Ki-67 labeling index was more than 10% in the highest area (Fig. ). Mutation analyses for BRAF and the telomerase reverse transcriptase (TERT) promoter were performed. No BRAF gene mutations were detected, but the TERT promoter C228T point mutation was present in the PDTC.\nApproximately 6 h postoperatively, the patient complained of dyspnea and anterior neck swelling in the general ward. Emergency surgery was performed to remove postoperative hematoma and control bleeding. Postoperative 18F-FDG PET/CT showed no regional or distant metastases.\nThe patient received high-dose radioactive iodine therapy (150 mCi) 2 months postoperatively. At a recent follow-up 4 months postoperatively, she was taking TH replacement and remained in a relatively good health with a serum thyroglobulin level of 0.55 ng/ml. |
A 40-year-old, healthy man was referred to our clinic with acute painful visual loss in the right eye for 2 weeks. He suddenly developed acute blurriness in the right eye 2 weeks prior. He developed retrobulbar pain at the same time, which worsened on ocular movement. Over the course of 2 weeks, the blurriness in the right eye worsened. He did not experience any visual discomfort before the recent onset of unilateral vision loss. The patient had no significant social, past medical, past surgical, or trauma history. There was no current medication. He had one maternal uncle who was nearly blind in both eyes (unknown cause) and passed away. He also had a nephew (son of his younger brother) who had strabismus and decreased vision in one eye. A review of systems revealed no other symptoms except progressive visual loss with ocular pain. Upon ocular examination, visual acuity registered 20/40 in the right eye and 20/20 in the left eye. The Ishihara colour test score was 8/14 in the right eye and 12/14 in the left eye. The right pupil reacted slowly and weakly and the left pupil reacted normally to direct light. There was a relative afferent pupillary defect in the right eye. The ocular motility examination was normal. The anterior segments were normal. On fundus examination, there was optic disc swelling in the right eye with no abnormality in the left eye (Fig. -a). A visual field test showed there was a generalized visual field defect in the right eye and superotemporal visual field defect in the left eye (Fig. -a). Magnetic resonance imaging (MRI) revealed definite enhancement of the right optic nerve, consistent with optic neuritis. The optic nerve of the left eye showed normal MRI findings from the optic nerve head to the chiasm. No periventricular white matter lesion or brain parenchymal lesion was found (Fig. ). He was given 1 g of intravenous methylprednisolone daily for three days. His ocular pain resolved, and visual acuity improved to 20/20 within 2 weeks after the steroid pulse treatment (Fig. -b).\nSeven months later, the patient developed acute painless visual loss in the right eye. Visual acuity decreased to 20/200 in the right eye. He showed a central scotoma in the right eye, while visual acuity and the visual field in the left eye were normal (Fig. -c). On fundus examination, there was no optic disc swelling in the right eye, with mild temporal disc pallor. No macular or vascular change was observed (Fig. -b). MRI showed no enhancement in either optic nerve. The patient was given 1 g of intravenous methylprednisolone daily for three days again, but his visual acuity did not improve.\nEight months later, the patient developed subacute painless visual loss in the left eye. The visual acuity in the left eye deceased to 2/100 with central scotoma in the left eye (Fig. -d). MRI showed no enhancement in either optic nerve. Genetic testing for LHON was performed and revealed the pathologic mtDNA 11778 point mutation.\nFour years later since onset of bilateral visual loss, this patient’s final visual acuity was registered as 20/500 in the right eye and 20/667 in the left eye. On fundus examination, optic disc pallor was observed in both eyes.\nAt each episode, neuromyelitis optica immunoglobulin G was performed and every result was negative. |
Our second patient was a 46-year-old Caucasian woman who was being followed by a community neurologist, to whom she reported sudden onset bilateral numbness of her feet when walking. She had progressively worsening symptoms, including freezing/burning pain, and allodynia to bed sheets and when walking barefoot. She was initially referred to our tertiary neuromuscular clinic; however, she was admitted to the Keck Medical Hospital owing to the acutely progressive nature of her symptoms. During her hospital stay she had an unremarkable workup, including lumbar puncture, cervical and thoracic MRI, as well as chest, abdominal, and pelvic CT. Results from an additional laboratory workup, including testing for vitamin B12, folate, TSH, rapid plasma reagin, heavy metals, HbA1c, and homocysteine, and a serum electrophoresis were normal.\nShe presented to our clinic a month after being discharged from the hospital. She reported a 3-month history of sudden-onset numbness in both feet that had worsened and which she described as a frostbite sensation of freezing and burning. She had allodynia to bed sheets and walking barefoot that she described as a sensation of “walking on pegs.” Her social history showed heavy alcohol use of one bottle of wine daily. She had taken disulfiram at a dose of 500 mg daily but had stopped the medication a couple of weeks prior to her hospital admission when she developed symptoms of neuropathy. Since her discharge from hospital, she reported that she was no longer feeling pain and that the frostbite sensation had improved. Pertinent findings included normal results from a motor examination except for weaker bilateral ankle dorsiflexion. A sensory examination showed distal changes including absent position sense at the toes, significantly decreased vibration at the toes, and absent light touch and pinprick to the distal 5 cm of her feet. Electrodiagnostic testing was performed several weeks after her initial clinic visit and a nerve conduction study revealed severe motor axonal neuropathy in her lower extremity nerves with length-dependent characteristics. Her bilateral peroneal CMAPs were significantly decreased. By contrast, her upper extremity CMAP parameters were normal. There was sparing of her large fiber sensory nerves as evidenced by normal SNAPs. EMG showed 1+ positive sharp waves and fibrillation potentials in most of the sampled muscles of her lower extremities. There were slight to moderate increases in the amplitudes of the motor unit potentials as well as increased polyphasia.\nPlease see Tables and for electrodiagnostic data for both patients. |
A 56-year-old male patient sustained road traffic accident and presented to our emergency department with a history of pain in the thoracic spine and progressive weakness of both the lower limbs for 3 days. On examination, the thoracic spine was kyphotic and tender at the mid-thoracic region. The patient had spinal cord injury with ASIA–C neurological deficit. Patients’ medical records show that he had a history of spinal tuberculosis 25 years ago, which was treated conservatively by 9 months of anti tuberculosis chemotherapy (INH, rifampicin, ethambutol, and pyrazinamide) and bed rest. The patient had good recovery of symptoms and attained favorable status at 4 months of conservative treatment but had asymptomatic kyphotic deformity since then.\nRadiographic evaluation [Figures and ] of the patient revealed kyphosis of thoracic spine and fracture of the solidly fused thoracic fusion mass involving all three columns. The kyphotic fusion mass was extending from T7 to L1 with apex of kyphosis at T12. The fracture was noticed between vertebral segments between T10 and T11, and there was a gap in the fusion mass with breach in the anterior cortex with translation of the fractured ends of fusion mass. Magnetic resonance imaging showed the absence of intervertebral discs and complete fusion from D8 to L1 vertebral bodies. There was a hyperintense fluid collection at the ends of fractured fusion mass and separation of fractured ends. There was no significant cord compression resulting from internal gibbus deformity. The angle of global kyphosis was 57°, and local kyphosis at fracture site was 63° []. Kyphosis angles were calculated using Surgimap 2.2.7 version. The pattern favors that of traumatic fracture in view of sharp fracture margins without any adjacent sclerosis and symptoms being strongly associated with a history of trauma.\nThe patient was managed by stabilization of the fracture with posterior spinal instrumentation using pedicle screws and rods construct. Circumferential decompression of the spinal cord was done by posterior laminectomy and transpedicular approach. The anterior deficit between the fractured ends of fusion mass was freshened and 7-mm titanium interbody cage filled with bone grafts was inserted and compressed. No attempt was made to correct the deformity []. Postoperative period was uneventful, and the patient noticed a significant improvement in the neurological status and became ambulant within 4 months after surgery. The patient was pain free with thoracic kyphosis similar to his preinjury state. At 2 years’ followup, radiological images showed complete bony fusion at the fracture site []. |
Having the first intervention done at another health center, a 38-year-old male patient engaged in mining, presented to our emergency department (ED) with an isolated crush injury of the left leg 18 hours after lateral and medial sides of his left knee was temporarily squeezed at a high speed between a tree and an operative machine. The patient’s history revealed that he presented to the hospital 5 hours after the injury as the skin did not have a laceration. Investigation of the epicrisis reports and hospital records revealed that the patient underwent Doppler ultrasonography at the sixth hour. The Doppler examination revealed the presence of a probable thrombus\in the popliteal area. An embolectomy was attempted with a Fogarty catheter, but was unsuccessful as the catheter did not pass through the distal area. The patient presented to our ED at the 18th hour of the injury. In the immediate physical examination of the patient, the left knee level showed signs of paleness, coldness, anesthesia, hemorrhagic bullae, and ecchymosis posterior to the knee (). Tibialis posterior, dorsalis pedis, and popliteal arterial pulses were not felt. There was no motor function of the ankle and the toes. Successive tendon examination did not show any signs indicating a possible tendon injury. Radiographs of the leg did not show any bone pathology. The previously performed angiography revealed that the popliteal artery was totally occluded and there was no pathway to distal flow (). The patient was transfused 2 units of blood for hematocrit <27%, and as his general condition deteriorated an above-knee amputation was undertaken.\nUnder spinal anesthesia, the patient was placed in the supine position in a sterile field. Knee tendon examinations did not reveal any pathological finding under anesthesia.\nA fish-mouth incision was performed over the skin and the fascia. The bone was shortened 10 cm proximal to the femoral condyle. The popliteal artery and the vein were identified, tied, and cut. The proximal sciatic nerve was dissected, tied, and cut. The adductor magnus muscle was attached to the distal femur rudiment with ticron sutures. The amputation stump was sutured (). Following surgery, when the amputation was investigated, 3 cm of intimal damage to the popliteal artery was detected and necrosis of the muscle, tendon, and neurovascular structures was present at this level. During the post-operational period, no complications developed in the wound and the patient was followed-up on for 2 years. |
A 40-year-old man came to the casualty with a thoracic bullet injury. At presentation, he had loss of power in both the lower limbs and dyspnea. The supine plain radiograph of the chest taken in the casualty revealed a bullet in the left hemithorax and diffuse-increased opacity of the left hemithorax. An axial CT scan of the dorsal spine revealed a fracture of the sixth dorsal vertebra with comminution of fragments and canal compromise (not shown). The bullet was seen to lie in the left pleural cavity and a left-sided pleural effusion was present. The patient was taken for orthopedic procedure including posterior fixation and retrieval of the bullet from the pleural cavity. Following the surgical procedures he was kept in intensive therapy unit where in the post-op days he was detected to have reduced air entry on the left side of the chest. Once oral feeding was started, leakage of food material through the intercostals tube was noted and an esophago-pleural communication was suspected. A contrast-enhanced computed tomography of the thorax was performed after giving oral iodinated nonionic contrast. Axial section of mediastinal window at the level of carina showed left hydropneumothorax and compression collapse of the left lung lower lobe. Orally administered iodinated contrast was seen to accumulate in the left pleural cavity, suggesting an esophago-pleural fistula. The iodinated contrast was seen to follow a long irregular track in the mediastinum communicating the mid-thoracic esophagus to the pleural cavity and running in close proximity to the left main bronchus []. Cervical esophagostomy, cervical esophageal exclusion, and feeding jejunostomy were performed as a therapeutic procedure. In the postoperative period he was detected to have a continued air leak and bronchoscopy was performed with the clinical diagnosis of a bronchopleural fistula. Bronchoscopy revealed a rent in the anterior wall of the left main bronchus (2 mm in diameter) []. Considering the general condition of the patient a bronchoscopic closure of the fistula was planned for. Under general anesthesia, using a 4 Fr angiographic catheter, 0.5 ml of N-butyl-cyanoacrylate glue (NECTACRYL, Dr. Reddy's Laboratories, Hyderabad, India) mixed with 0.5 ml of iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) was injected in the fistulous tract []. Immediately after closure of fistula, the pneumothorax reduced. Follow-up imaging after 1 month revealed resolution of the hydropneumothorax and only small residual left lower lobe superior segment collapse. The glue was seen in the fistulous track to form a cast. A bronchoscopy done at this point of time revealed granulation tissue lining the mucosal aspect of the fistula, which had sealed. The contrast swallow study was normal and he was started on oral feed; esophagostomy and feeding jejunostomy were closed. The patient was discharged and kept on follow-up. Six-month follow-up imaging revealed complete resolution of the hydropneumothorax [] and good expansion of the left lung. |
A 37-year-old G2P1 female with a history of one prior cesarean delivery presented at 25 weeks gestational age for vaginal bleeding. She was noted to have a placenta previa and suspected placenta percreta on ultrasound (Figure ). MRI results were concerning for placental invasion into the bladder and surrounding vascular structures. Due to the severity of invasion, neovascularization, and the high likelihood of acute hemorrhage that would be challenging to control, a multidisciplinary team planned to perform a cesarean hysterectomy at 32 weeks gestational age with prophylactic REBOA placement.\nPrior to surgery, a massive transfusion protocol pack, rapid infuser, and intraoperative cell salvage device were on standby in the operating room. A right radial arterial line was placed prior to induction of general anesthesia, and a right internal jugular vein central line was placed atraumatically. Cystoscopy was not suggestive of placenta invasion through the entire bladder wall; however, it did reveal mass effect with vascularity just below the bladder mucosa. Femoral arterial cannulation for REBOA placement was challenging and attempts were performed on both common femoral arteries prior to the successful placement of a 7 French Cordis sheath in the patient’s right common femoral artery. Significant hemorrhage occurred from the hysterotomy site after delivery of the fetus requiring REBOA inflation for three minutes and blood transfusion via rapid infuser. There was found to be partial invasion of the placenta into the bladder, which resulted in significant hemorrhage, subsequent hysterectomy, and partial cystectomy during which the REBOA was re-inflated for 30 minutes. Bleeding from multiple sites was noted upon examination of the uterus, and TXA 1 gram was administered due to ongoing hemorrhage. Thromboelastography revealed normal coagulation parameters. The hysterectomy was completed, and surgical hemostasis achieved. The patient's mean arterial pressure was maintained at greater than 60 mmHg throughout the case. The total estimated blood loss was 4000 ml, and the patient received a total of 5 units of cell saver, 3 units of packed red blood cells, and 3 units of fresh frozen plasma. Bilateral quadratus lumborum blocks were performed for postoperative analgesia prior to extubation in the setting of a positive cuff leak test.\nAfter an uneventful post-anesthesia care unit (PACU) stay, the patient was transported to the ICU for serial neurovascular checks and the sheath of the REBOA was removed. Later that evening, decreased pulses were identified in her right lower extremity, prompting an emergent angiogram and thrombectomy of the right external iliac and common femoral arteries under general anesthesia. The remainder of her hospital stay was otherwise uneventful. At the time of discharge, the patient required a walker for ambulation due to right lower extremity pain with weight-bearing. At four weeks post-operatively, she was able to ambulate without assistance or pain. |
A 71 year old Caucasian female with a remote history of PTC presented with a 2-month history of palpable left-sided neck mass. Physical examination revealed a non-tender mass in the left lateral neck. There were no other abnormalities identified in a full head and neck examination. There was no palpable mass in the thyroid bed. Ultrasonography of the neck revealed an absence of normal thyroid tissue, consistent with patient’s history of distant thyroidectomy, and a solid mass in the left side of the neck superolateral to the expected location of the thyroid, in level III. This inhomogeneous mass appeared vascular and measured 2.8 cm in length by 1.7 cm in diameter. It was not felt to resemble a normal lymph node in ultrasonographic features. Nonetheless, from its appearance and anatomical location, this new mass was initially suspected to represent a lymph node or a carotid body tumour.\nComputed Tomography (CT) ruled out non-nodal neck pathology, and identified the mass as being consistent with an enlarged lymph node (Figs. , ). Again, this study revealed no evidence of recurrence in the thyroid bed, nor other evidence of neoplastic disease.\nTwo fine needle aspiration biopsies (FNAs) were performed. The specimens were cellular and consisted of groups of epithelial cells in flat sheets and papillary-like clusters. The cells showed enlarged nuclei with nuclear grooves and a few intranuclear inclusions. Immunohistochemistry on the cell block was positive for TTF-1 (thyroid transcription factor 1), consistent with cells of thyroid origin.\nA positron emission tomography (PET) study was performed to rule out distant metastatic disease. Apart from the known mass in the left neck, the PET study showed no other Fluorodeoxyglucose (FDG) avid lesions (Fig. ). Given these diagnostic findings, the patient was scheduled for a left lateral neck dissection after obtaining informed consent. The patient subsequently underwent an uncomplicated left level II-III neck dissection under general anesthesia. A timeline of events is presented in Table .\nTwo of the 10 nodes sent for surgical pathology in the lymphadenectomy specimen returned positive for metastatic papillary thyroid carcinoma of tall cell variant. The larger of the 2 nodes measured 3.5 cm with focal extranodal extension.\nThe patient recovered well from the operation and was seen for follow-up three weeks following the left neck dissection. Given the findings from surgical pathology, it was decided that the patient would benefit from radioactive iodine ablation and the patient was referred for adjuvant therapy. |
A newborn male child, less than one day old, was found to be leaking clear fluid from the skull one hour after birth whilst the mother was holding the child. The child was born at forty-one weeks through a normal vaginal delivery with forceps assistance and no immediate complications. Prenatal screening was unremarkable. The mother was from an indigenous background and in good health and there was no family history of any other similar illnesses. She denied smoking and alcohol use during pregnancy. At birth, no issue with the skull was noted. On further inspection of the child, after the mother raised concerns about the clear fluid leaking from the skull, a 1.5 cm circular defect was identified in the area of the posterior fontanelle with macerated skin edges and underlying membranes and evidence of clear fluid flowing from it. The child had normal haemodynamic parameters throughout and was otherwise examined normally. Further testing of the fluid for beta-trace protein was positive for cerebrospinal fluid (CSF). The neurosurgery team at the tertiary referral centre was contacted at this stage for a suspected encephalomeningocele and the child was transferred there for further management. Further examination at this stage showed a child who was otherwise well, feeding normally, and with normal system review.\nFurther imaging with computed tomography (CT) scan of the head, magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) identified a likely encephalomeningocele (Figures -). The defect was arising from the posterior fontanelle. Characterisation of the surrounding vasculature showed a persistent fetal vein and possibly an associated vein within the defect. An MRI spine to identify any associated NTD was unremarkable.\nThe child was booked in for emergent repair of the encephalocele. During the operation, a vertical incision with an elliptical extension around the defect was marked. Careful dissection from superior and inferior aspects of the incision to the pericranium and then working towards the defect identified the defect which appeared to consist of meninges. There were adjacent large venous structures visible beneath the defect and superiorly the superior sagittal sinus was identified in the midline. The defect was dissected from a peripheral direction towards a centre where the herniation appeared to arise from. At this stage, a small pedicle of tissue was holding the structure at the centre. This was tied off with absorbable sutures as there was a high possibility of vascular structures within the pedicle. Bipolar cautery was used to separate the defect. No obvious vessel injury was identified. A pericranial flap was mobilised inferiorly and was reflected around its pedicle from below and over the defect and sutured in place beyond the superior aspect of the defect to pericranium. A piece of synthetic dural graft material was secured over this repair. The wound was closed in two layers with braided absorbable sutures to the galea and then unbraided absorbable sutures to the skin. No further leak was identified at the conclusion of the operation. There was no obvious brain tissue on view during surgery, subsequent pathology also confirmed that no brain tissue was included in the specimen sent. This would support a diagnosis of a meningocele as only meninges were involved rather than an encephalomeningocele. The patient returned to the neonatal intensive care unit postoperatively and was extubated without issue. The child made an excellent recovery and was discharged six days after surgery. |
A 33-year-old pregnant woman in her 33rd week of gestation was admitted to our hospital’s emergency department in a dyspneic condition with perioral cyanosis accompanied by diaphoresis and sinus tachycardia. She had rheumatic mitral valvular stenosis and had undergone MVR with a mechanical prosthesis 11 years previously in another center. Transthoracic echocardiography revealed a thrombotic mass, leading to an obstruction of the prosthetic mitral valve and an immobile medial leaflet with a mean diastolic mitral transvalvular gradient of 23 mm Hg and a peak velocity of 3.36 m/s (). Transesophageal echocardiography confirmed the existence of the thrombus on the prosthetic mitral valve. The medial leaflet was immobile, and the mobility of the lateral leaflet was restricted deeply while there was also a 3° mitral regurgitation with 2° tricuspid regurgitation, demonstrating 60 mm Hg of systolic pulmonary artery pressure.\nThe patient’s anticoagulation procedure was changed from warfarin to enoxaparin upon confirmation of pregnancy. She was managed by an obstetrician and a cardiologist during her pregnancy period. A transthoracic echocardiographic examination had been performed 20 days before her current admission to our hospital, revealing no signs or symptoms of any size of a thrombotic mass. Inadequate anticoagulation therapy seemed to be the main reason for the thrombus according to the notifications of the patient. Based on these findings, the patient was transferred to our intensive care unit (ICU), where the preparation period for an emergent redo mitral valve surgery was started and continuous heparin infusion (1000 IU/h) was initiated until the operation time.\nEvaluation of the fetal conditions was performed meticulously, and there were no symptoms or signs of intrauterine gestational retardation. On the contrary, findings about fetal maturity demonstrated the 34th week of gestation. Fetal lung maturity was supported via surfactant administration, and our obstetricians permitted an emergency caesarean section (CS) concomitant with our procedure. The multidisciplinary team’s final decision in this case was to deliver the baby first by CS in order to prevent it from the adverse effects of CPB, responsible for the risks of high fetal mortality and morbidity rates.\nCS was performed via general anesthesia, and a 1540-g baby was delivered with an APGAR score of 9 in the 5th minute. There were no problems with the hemostasis, so the CS wound was closed rapidly by the obstetrician team. Subsequently, emergent redo mitral valve surgery was started with resternotomy, and then a densely adherent tissue to the heart was dissected as quickly and meticulously as possible. CPB was established by aortic and bicaval cannulation, and antegrade and retrograde cardioplegia was administered after the cross- clamping of the aorta. Moderate hypothermia (about 32 °C) was conducted. After left atriotomy, a disseminated and tensely adhesive thrombus on the prosthetic mitral valve was seen (); it was resected carefully () and redo MVR was performed with a mitral bioprosthetic valve (# 29 St. Jude) in accordance with the patient’s desire and her family’s request to have another child. CPB time was 58 minutes, cross-clamping time was 35 minutes, and the total operation time was 180 minutes. Weaning from CPB was uneventful; there was no need for support via either an intra-aortic balloon pump or a ventricular assist device. Nonetheless, 3–5 mcg/kg/min (+) inotropic support was necessary in the ICU. It was subsequently discontinued, and the patient was transferred to the ward 4 days after surgery. She was discharged on the 12th postoperative day, whereas her baby was discharged on the 15th postoperative day. They were both doing well 25 months after the operation. |
A 39-year-old woman was admitted to our department requesting a bilateral breast reduction after massive weight loss (). Past medical history was unremarkable and she underwent a previous gastric bypass as therapy to manage her severe obesity and a sequential abdominoplasty, without any complications. An inverted T-shaped reduction mammoplasty was performed in standard fashion removing 490 g of tissue from left breast and 520 g of tissue from right breast. The immediate postoperative course was uneventful. On postoperative day 4, patient developed a fever of 38°C, with severe pain (grade 7 of the visual analog scale) and swelling of both breasts. Breasts were unsymmetrically involved, both presenting rapidly expanding necrotic wound areas, surrounded by an erythematous zone, with undermined borders. Postoperative infectious cellulitis was suspected and a blind antibiotic intravenous treatment was given to the patient waiting for the microbiological results and blood cultures. On postoperative day 7 fever was still present and the breast ulcer deteriorated by 1 to 2 cm per day with an excruciating pain (visual analog scale 9), and rapidly developing a 10x5 cm of dimension cutaneous ulcer occupying the inferior half of the left breast but relatively sparing part of the areola and nipple. Along with the worsening of local conditions we assisted at a systemic drop with retro-nuchal pain, positive Lasegue’s sign and hemianopia of the right eye. All these signs were orienting us towards a septic state. The microbiological cultures and the blood cultures for aerobic and anaerobic bacteria came back negative, so we proceeded to obtain tissue biopsies. The patient underwent partial surgical debridement and a local negative pressure wound therapy (125 mmHg) was applied bilaterally. Two days after there was a new dehiscence in the surgical wound, with a large area of necrosis without secretion. Under analgesia the medications were changed.\nSeven days after the onset of symptoms histological examination identified a nonspecific acute inflammatory process and ulceration with necrosis and neutrophilic infiltration into the dermis. A diagnosis of PPG was made and a systemic corticosteroid therapy was started. Patient was treated at the time of diagnosis with IV metilprednisone (1.2 mg/kg/die) administration, according to international guidelines for PPG management, with a dramatic recovery. In the following days, the patient’s condition improved, and we were able to observe granulation tissue, the contraction of wound edges and an initial adherence between tissues. NPWT was applied for one month, and thirty-five days after the initial procedure some stitches were applied to increase improvements of the wound’s appearance (). The corticosteroids dose was gradually reduced.\nThe synergy of systemic steroid therapy and local negative pressure wound therapy led to an acceptable result, despite PSPG is a medical challenge. There has been a rapid response and wound areas significantly reduced. Wound bed showed an intensive vascularization, granulation tissue and a rapid contraction of wound edges, keeping the left nipple-areola complex vital and allowing a simple primary wound closure (). |
A 72-year-old female presented to the emergency room with the complaint of left thigh pain and the inability to walk after tumbling. She had been suffering from osteoarthritis of the left hip but was able to walk with a cane and sit on a couch. She had also received the diagnosis of osteoporosis and had been taking alendronate 35 mg weekly for six years. The initial radiograph in the emergency room showed a non-comminuted subtrochanteric fracture of the left femur with cortical thickness and the beaking of the lateral cortex at the fracture site. The fracture line was transverse on the lateral side and oblique on the medial side. The radiographic findings and the weakness of the force that caused the fracture satisfied the criteria for an atypical fracture of the femur. The radiograph showed Kellgren-Lawrence grade 4 osteoarthritis of the left hip as well, with superomedial migration, the external rotation of the femoral head, and the shortening of the femoral neck (Figure ).\nOsteosynthesis with intramedullary nailing was planned. However, the deformity of the hip joint appeared to preclude correct nail insertion. Furthermore, whenever we used a fracture table in the past, we often observed that the perineal post of the fracture table impeded the adduction of the proximal fragment of the subtrochanteric fracture while the whole leg was being adducted, resulting in varus malalignment. On the other hand, we were aware of easy access to the entry point via the standard lateral decubitus position without using the perineal post. For these reasons, we decided to fix the fracture with a nail in the lateral decubitus position. Total hip arthroplasty with fracture fixation was not chosen because of its invasiveness, which was inappropriate for the rather mild, pre-injury symptoms due to osteoarthritis, and because of the patient’s wish to preserve the femoral head.\nIn surgery, a flat, radiolucent operating table was used. The whole injured leg was sterilized and draped, and the hip was slightly flexed. The C-arm was placed at the ventral side of the patient. Although the proximal fragment was externally rotated, the entry point was located easily by adjusting the C-arm to obtain a correct A-P view. A guide pin was inserted in line with the long axis of the proximal fragment to the level of the fracture without any interference by the torso (Figure ).\nThen, the fracture was reduced with gentle manual traction of the thigh followed by the distal insertion of the guide pin. At this time, the fracture was perfectly aligned (Figure ).\nAfter reaming, a trochanteric-entry cephalomedullary nail (Trigen Trochanteric Antegrade Nail, Smith & Nephew, Massachusetts, \nUS), 11.5 mm in diameter, was inserted, again, without any obstruction by the torso. After assuring rotational alignment, two cephalomedullary screws and a distal interlocking screw were inserted. Accurate, non-varus reduction was confirmed by a postoperative radiograph (Figure ).\nThe operating time was 122 minutes. The total blood loss was 86 ml. Toe-touch weight bearing was initiated soon and full weight bearing was allowed in five weeks. A solid union was confirmed by radiograph after 10 months (Figure ). She was able to walk with a cane as she did before her injury without a worsening of the pain. Alendronate was discontinued after the injury and replaced with vitamin D supplements. No anabolic agent, such as teriparatide, was administered. |
A 36-year-old man was admitted to our hospital due to severe pain in his left eye. He mentioned that the pain had begun along with redness 2 days prior to his admission.\nOn admission, he presented with eyelid swelling, conjunctival erosion, and corneal filtrate at 6 o'clock of a size of 3/0 over 3.2 mm. The corneal abscess location was in the midperiphery making any future corneal graft attempt challenging. There were flare and cells in the anterior chamber and the pupil was hardly seen. Ultrasound examination showed a clear vitreous and no involvement of the posterior segment. The right eye was normal with no pathology.\nAnamnesis was taken in depth. It turned out that as part of his work, the patient was peeling plaster off of a wet wall that had fungi on it, and that a small piece of plaster had splashed into his left eye.\nHe was diagnosed as suffering from fungal keratitis, and further laboratory tests using PCR confirmed the infection to be caused by Fusarium solani. He was then treated with voriconazole, however without significant improvement (Fig. ).\nA couple of days later, a corneal melting process was observed and as the corneal melting continued, it was decided to try treatment with CXL. The patient underwent a CXL treatment and shortly thereafter, the abscess shrank, with significant improvement in symptoms and vision (Fig. ). The corneal melting stopped after the CXL treatment. The patient was treated for about 3 months with voriconazole.\nThe following year after the infection, corneal transplantation was done due to severe scarring of the cornea. Today, about 2 years later, best corrected visual acuity in the left eye is 20/80. The corneal graft is clear and shows good indentation with no signs of rejection. The anterior chamber is deep and clear, and other than a mild minimal nuclear cataract. The anterior segment is normal. The optic disc is normal and the C/D ratio is 0.4. The retina is attached and fundus examination revealed no pathology in the posterior segment. |
A 14-year-old female patient was hospitalized in our Cardiology Department for repeated episodes of PSVT which started at the age of 11. She was treated with Bisoprolol 2,5 mg but presented PSVT despite antiarrhythmic drugs. The 12-lead ECG showed minimal pre-excitation, with a small delta wave in leads V2–V3 but with a normal QRS complex of 100 ms and a normal PR interval in lead II of 160 ms. The three classical criteria for confirmation/exclusion of an accessory pathway were analyzed: there was a Q wave in lead V6, the precordial transition was after lead V1 and a R wave was present in lead avR. Therefore, the three criteria failed to confirm the presence of an accessory pathway. We measured the longest and the shortest PR interval and found a difference of 40 ms between leads II and V2. (Fig. ) Before the electrophysiological study, an echocardiogram showed normal ejection fraction and normal dimensions for the cardiac chambers, without any valvulopathy (Fig. ). During electrophysiological study 4 catheters were introduced through the right femoral vein: a quadripolar catheter at the level of the high right atrium, a quadripolar catheter at the level of the His bundle, a decapolar catheter at the level of the coronary sinus and the ablation catheter at the level of the right ventricle. During ventricular stimulation the retrograde conduction was through a left lateral accessory pathway, which was further confirmed by the activation through the coronary sinus catheter (Fig. ). As the accessory pathway was lateral, a trans-septal approach was performed using the Brockenborg needle for the septal puncture (Fig. ).\nAfter the puncture a sheath was introduced inside the left atrium and a 4 mm tip catheter ablation at the level of the left lateral ring (Fig. ). Catheter ablation of the accessory pathway was performed using 35 W and 55 C. After ablation there was no anterograde or retrograde conduction through the accessory pathway. After 30 min the procedure was stopped and the patient returned to her room. The 12-lead ECG performed after catheter ablation was compared with the ECG before ablation and the three classical criteria were once again insufficient to establish the presence or absence of an accessory pathway.\nOur criteria of PR variation of >30 ms confirmed the presence of the accessory pathway before ablation and the absence of the accessory pathway after ablation (Fig. ). Furthermore an adenosine test was performed to exclude the presence of the accessory pathway after ablation which produced a 2:1 AV block. After ablation the PR interval variation was 5 ms (Fig. ). |
A 47-year-old premenopausal woman, presented with a 3 month history of irregular vaginal bleeding. Ultrasonography revealed an endometrial thickness of 31 mm. Hysteroscopy, dilation and curettage was performed. Histology revealed Grade 1 endometrioid endometrial carcinoma. A CT scan of the chest, abdomen and pelvis was performed and demonstrated a 9.9-mm ground glass nodule in the upper lobe of the right lung. Histology of the nodule revealed adenocarcinoma arranged in a lepidic pattern with an immunoprofile consistent with primary lung cancer. An FDG-PET/CT was performed (), and there was intense FDG uptake in the uterus corresponding to the primary tumor. Moderate to intense FDG accumulation was also seen corresponding to a tubular mass located posteriorly to the uterus, thought to represent the fallopian tube and ovary. There was further moderate FDG accumulation in a right external iliac lymph node and in an aortocaval lymph node at the level of the right renal hilum () located behind the duodenum, and very mild FDG accumulation corresponding to an ill-defined ground-glass opacity in the upper lobe of the right lung laterally.\nAfter multidisciplinary discussion, gynecological surgery was planned first due to the low-grade nature of the lung cancer and acute vaginal bleeding symptoms. Because of the location of the high para-aortic lymph node, the patient underwent laparotomy rather than a laparoscopic approach. After discussion, the patient did not agree to a complete lymph node dissection due to concerns around lymphoedema, and consented to the removal of any clinically suspicious lymph nodes at the time of surgery with SLN identification enhanced by ICG. Intra-operatively, two SLN sites were located and removed.\nFinal histology revealed Grade 1 endometrioid adenocarcinoma, confined to the uterine body, invading the myometrium 10 mm through a wall 26-mm thick. No evidence of lymphovascular invasion was seen and the pelvic washings were negative. The right ovary contained a hemorrhagic corpus luteal cyst and the right fallopian tube showed features of an acute on chronic salpingitis and pyohydrosalpinx. The fallopian tubes and ovaries were benign. Both ICG-positive lymph nodes showed endosalpingiosis, which was CK7, ER and PAX8 immunopositive with an Ki67 proliferation index of less than 1%.\nThe patient’s diagnosis was stage 1A endometrial cancer with no further treatment indicated. She underwent excision of the lung lesion a few months later. Due to concerns around possible missed carcinoma in retained lymph nodes, PET/CT scan was repeated and was negative. There is no evidence of recurrence 18 months post-surgery. |
A 60-year-old female presented to the outpatient department of our tertiary care centre with a complain of progressively increasing swelling in the right gluteal region for 6 months associated with dull aching pain radiating to the right lower limb and urinary urgency. The swelling reduced completely and spontaneously on lying down. On clinical examination there was a 5 × 5 cm non-tender swelling in the right pararectal region, which was compressible with positive expansile cough impulse. Per vaginal examination revealed intact vault with swelling felt on the right side. Per rectal and proctoscopic examination was normal. She was a known hypertensive since 25 years on medication with no other comorbidities. Her past surgical history included lower segment caesarean section 25 years back, hysterectomy for uterine fibroids 10 years back followed by ventral hernia repair 9 years back.\nWith a differential diagnosis of sciatic hernia or posterolateral perianal hernia in mind the patient was investigated further. A local ultrasound scan was suggestive of an ischiorectal abscess herniating through the sciatic foramen (~130 cc in volume). Since the report did not correlate with the clinical scenario, a contrast-enhanced computerized tomography (CECT) of the abdomen and pelvis was performed which was suggestive of 4.2 × 5.7 × 7.9 cm ischiorectal abscess abutting the rectal wall on the right side with extension down posteriorly and a 3.5 × 4.5 × 3.9 cm cystic lesion posterior to the urinary bladder with a possibility of supralevator extension of the abscess ().\nIn view of a mismatch between the clinical and radiological findings, it was decided to go ahead with a diagnostic laparoscopy. The findings of laparoscopy were suggestive of an extraperitoneal lesion in the pelvis, ruling out a hernia.\nThe mass was removed by wide local excision through a pararectal incision maintaining a plane between the rectum and the swelling. The cavity was closed in layers with placement of a corrugated drain ( and ). Final histopathological report was suggestive of a spindle cell tumour and subsequent immunohistochemistry revealed an AAM. |
The patient is a 65-year-old female who initially presented with severe abdominal pain and was eventually found to have bowel obstruction. At that time, she had undergone sigmoidectomy and primary anastomosis to manage the bowel obstruction. However, it was complicated by an anastomotic leak which required exploratory lap and end colostomy. During the same hospital course after surgery, the patient developed acute onset dyspnea and hypoxic respiratory failure. Based on clinical features of developing pitting edema and orthopnea, a diagnosis of CHF was made. Two doses of IV Lasix 20mg were given with significant clinical improvement then patient got discharged. However, patient presented to ED with similar complaints of dyspnea, orthopnea and pitting edema after 4 days of discharge. On lab investigation, CBC showed leukocytosis and hemoglobin of 11 with normal peripheral smear. Electrolytes and renal function were within normal limits. Urinalysis was unremarkable. A CT angiogram was performed which excluded pulmonary embolism, but instead discovered an incidental filling defect that was present along the right side of descending thoracic aorta at 9 o’clock position opposite the carina and near the esophagus measuring 15.5 mm x 12.8 mm in size ()()(). Differential diagnosis for the filling defect at the time included a mural thrombus, primary arterial/aortic tumor, primary myxoma, or xanthogranulomatous sarcomas. Infection of the aorta was less likely as there was no irregular wall thickening elsewhere or any suggestion of plaque with ulceration. The difficulty in determining the etiology prompted an MRI of the chest which better visualized and aided in diagnosing a thrombus in the descending aorta. She had also undergone a transthoracic echocardiogram which showed ejection fraction of 3540%, no valvular vegetations, and no septal defects. As the patient was hemodynamically stable, pursuing conservative management rather than invasive surgery was decided. Intravenous heparin infusion was commenced in view of a more favorable diagnosis of descending aorta thrombus and was later bridged to oral anticoagulation with warfarin. After discharge, the patient had close follow-up with her primary care doctor and cardiologist. Follow-up CTA chest with contrast after 3 months showed the filling defect was no longer present in descending thoracic aorta. Instead, there was some calcification measuring 3 mm x 4 mm at the level of intima with no other filling defects seen to suggest any residual blood clot (). The second area of calcification was present posteriorly at the 10 o’clock position along the aortic margin in the intima at that level so there now is some calcific atherosclerosis where previously, there was a noncalcified blood clot and thrombus present. No dissection was seen in the descending thoracic aorta. No new areas of thrombus formation were seen along the walls of the vessel. The patient’s anticoagulation was discontinued after completing 3 months of therapy. Subsequent follow ups did not show any signs of recurrence of thrombus or signs of distal embolization. The patient was instructed to follow up for hypercoagulability work-up following completion of warfarin therapy. |
Our patient is a 55-year-old Ethiopian woman, gravida IV para III abortion 0, who gave birth to three children at home by spontaneous vaginal delivery. She presented to our hospital claiming she was carrying a dead fetus in her womb from a pregnancy that had been there for 22 years. The pregnancy lasted up to nine months uneventfully at which time the membrane ruptured and she went into labor. After 3 days of labor at home, she developed vaginal bleeding and visited a nearby hospital where she was informed that she had a uterine rupture which had to be operated on. However, she refused the surgery and went home. Over time she developed urinary incontinence.\nShe lost all her three children from an unspecified medical illness before their first birthday, although she claimed all the pregnancies and the labor were uneventful. Since the incident, she is divorced and lives alone supported by her sister.\nAt her current presentation, she had lower abdominal pain which had increased in severity, vaginal discharge, and urine per vagina since the onset of the condition. She had no other known medical illness.\nOn physical examination there was a gravid uterus of 20-week size and a non-tender, fixed, and firm abdominopelvic mass with no signs of fluid collection in her peritoneal cavity. There was a continuous leakage of urine through her vagina but a leak point was unidentified. Her vaginal canal was filled with a 4 cm by 5 cm, oval and stony hard mass.\nLaboratory findings, complete blood count, and organ function tests were in the normal range. An abdominal ultrasound was difficult to perform as there was only shadowing in her pelvis from the bony structures and our patient was incontinent, therefore, she was unable to retain urine.\nAbdominopelvic computed tomography (CT) findings: On the scanogram, multiple calcified tubular fetal parts were demonstrated in the pelvis of our patient (Fig. ). On the post-contrast images, the uterus was enlarged and the fundus extended up to the level of the umbilicus. Well-formed tubular bony parts were detected within the uterine cavity which had compressed and displaced the bladder. A diffuse pelvic and lower abdomen inflammation and focal adhesion of the uterus to the abdominal wall were additionally noted (Fig. a, b).\nIn January 2019, our patient underwent exploratory laparotomy. It was difficult to enter the peritoneal cavity because of the extensive adhesion of her uterus to the anterior abdominal wall. Her uterus was completely covered by the omentum forming a complex mass. Therefore, the peritoneal cavity was entered at the level of the epigastrium. Lysis of the adhesion and omentectomy were done starting from above to free her uterus from the anterior abdominal wall and the omentum which had gone into the uterine cavity through the anterior uterine wall rupture site.\nMultiple pieces of old necrotic fetal bones (Fig. a, b) were extracted from her uterine cavity and those that were difficult to separate from the complex mass were removed along with the mass, the uterus, and adnexa (Figs. b and ). Removal of the mass abdominally freed the fetal skull bones (Fig. b) in the vagina; the fetal skull bones were later easily removed transvaginally. A 3 cm defect was identified on the upper anterior vaginal mucosa and bladder wall that was obscured by the fetal skull. A Foley catheter was left in situ to drain urine but it could not prevent leakage through the fistula.\nShe had a fairly stable postoperative course and was discharged with a referral to a fistula hospital for repair of the VVF. |
A 64-year-old woman was admitted to our hospital with intermittent left upper abdominal pain for 3 months, and the pain increased after inhalation. One month ago, she went to the local hospital. Serum AFP was elevated at 1210 ng/ml. She tested negative for hepatitis b surface antigen. MRI scan at the local hospital showed a mass above the spleen.\nThe patient was then referred to our hospital as having a tumor above the spleen for surgical intervention. The patient had a history of partial thyroidectomy 40 years ago and hysterectomy 30 years ago. On physical examination, patient's blood pressure was 159/94 mm Hg, pulse rate of 72 beats per minute, respiratory rate of 20 breaths per minute, body temperature of 36.5 °C. She tested negative for both hepatitis b surface antigen and HBV DNA. Laboratory blood tests showed a slight elevation of alkaline phosphatase, gamma-glutamyl transpeptidase, blood glucose, and a slight decrease of serum calcium.\nEndoscopy of the upper gastrointestinal tract did not show any primary tumor. Ultrasound examination showed an irregular hypoecho mass above the spleen and below the left diaphragm. Abdominal contrast-enhanced CT scan (Fig. ) demonstrated an irregular mass that was mainly located between the left diaphragm and the spleen and was partially protruded out of the diaphragm, possibly connected to the left hepatic lobe and the spleen. There was nodule of calcification within the mass. MRI scan (Fig. ) revealed that the mass was slightly hypointensity on T1WI and slightly hyperintensity on T2WI, DWI showed the mass was hyperintensity with B value 1000 s/mm2.\nThe surgeon found the tumor located in the upper part of the spleen, the boundary was not clear. The mass adhered to epiploon and invaded left diaphragm. No connection was identified between the tumor and the edge of the left hepatic lobe. The mass, the spleen, and partial left diaphragm were removed. Partial left hepatic lobe was removed for better excision of lienophernic ligaments. The tumor had invaded the diaphragm; however, there was a clear boundary between the tumor and the spleen.\nHistological examinations confirmed the diagnosis of moderately to low differentiated HCC (Fig. ). The boundary between the solid carcinoma and spleen was clear. Immunohistochemistry analysis demonstrated that the specimen was positive for Hepatocyte, Glypican-3, Arginase1, AFP (weak), PCK (weak), EMA, CK8/18, CD34 (endothelial cells), and was negative for GATA, PAX8. The proportion of Ki-67 positive cells was about 30% to 40%. |
A 52-year-old woman experienced a blunt neck trauma due to a bicycle accident. After a car collision car the impact with the windscreen wipers caused the injury. At the time, the patient was suffering from Graves’ disease, positive for anti-thyroid-stimulating hormone receptor antibodies, with a multinodular goiter and was receiving long-term medical therapy with carbimazole 5 mg per day. Two hours after the accident, the patient presented to the emergency department with painful swelling of the neck, inspiratory stridor and increasing hoarseness. The clinical examination revealed a palpable mass on the right anterior part of the neck. Emergency tracheal intubation was performed due to progressive breathlessness and dyspnea. Subsequently, a contrast-enhanced computed tomography revealed a laceration of the right thyroid lobe with surrounding hematoma and tracheal deviation to the contralateral side (Fig. ). Therefore, the patient underwent emergency neck exploration with a 4-cm Kocher incision followed by a right hemithyroidectomy. Intraoperatively, the dorsal aspect of the right lobe of the thyroid gland was found to be ruptured with active arterial bleeding from branches of the inferior thyroid artery. The recurrent laryngeal nerve was macroscopically identified and preserved. Because of the bleeding into the surrounding tissue, it was particularly difficult to definitely identify the parathyroid glands due to anatomical complexity in this case. Even the location of the upper parathyroid gland, normally identified on the posterior surface of the upper pole of the thyroid gland, was not obvious, due to disturbed surrounding tissue caused by the bleeding. Postoperatively, the patient was monitored in the intensive care unit for 32 h. The patient was extubated after a further six hours, and the subsequent postoperative course was uneventful. Hoarseness disappeared spontaneously after two days. The histopathological analysis confirmed a multinodular goiter. Laryngoscopy was performed three days postoperatively and did not indicate any pathological alterations. Thyroid hormone levels were in the normal range directly after surgery and three weeks postoperatively. The one-month postoperative follow-up revealed normal thyroid function, consistent with full recovery of the patient. |
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