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A 39-year-old Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.\nPhysical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().\nIn this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement using the single-incision anterior approach. The finding was a soft tissue mass involving the distal biceps tendon with complete tendon rupture. There was also a small focal cortical defect at the radial tuberosity. The ruptured distal biceps tendon was debrided. The tendon was repaired to the long-head tendon insertion, which was proximal to the focal defect by about 5 mm, using a TWINFIX Ti 2.8 mm Suture Anchor with one #2 ULTRABRAID Suture (Smith & Nephew Inc.). Antituberculosis chemotherapy started one day after the surgery, following a positive test of the fluid for acid-fast bacilli and a positive polymerase chain reaction for Mycobacterium tuberculosis. The patient received a total of 6 months of a rifampin-based regimen, which is recommended for musculoskeletal tuberculosis []. The patient initially received isoniazid 300 mg, rifampicin 600 mg, ethambutol 800 mg, and pyrazinamide 1500 mg daily for two months and then reduced to isoniazid and rifampicin for the remaining four months. The elbow was immobilized in a posterior elbow slab with the forearm supinated for four weeks. Mycobacterium culture revealed Mycobacterium tuberculosis. Microscopic examination of the soft tissue revealed granulomatous inflammation with multinucleated Langhans giant cells and caseous necrosis.\nAt the 1-year follow-up, erythrocyte sedimentation rate was 10 mm/hr, and C-reactive protein was 2 mg/L. Motor power of supination and flexion showed grade V and the hook test was negative. This study was approved by the Khon Kaen University Ethics Committee for Human Research (KKUEC) in which the study ID was HE611179. |
A 65-year-old man with known history of asthma presented to another tertiary hospital with a history of bleeding per rectum for a few days. He underwent a colonoscopy which revealed an irregular thickening with a slightly raised area at the proximal transverse colon. Biopsies taken were reported as neuroendocrine carcinoma. An abdominal CT scan was done at the same hospital and revealed a mass in the proximal part of the transverse colon. No other lesions were seen. No significant lymph nodes or omental deposits were noted.\nPatient underwent resection of the transverse colon. The colonic segment showed a disc shaped slightly raised ulcerated mass measuring 23 × 20 mm. An infiltrating high grade malignancy was detected. It was reported to be positive for CD56 and focally positive for NSE and negative for other immunohistochemical stains including cytokeratins (AE1/AE3, CK20, and CK7), synaptophysin, chromogranin A, TTF-1, HMB45, Melan A, S100, and CDX2. The lesion was reported as grade 3 neuroendocrine carcinoma by the primary pathologist.\nThe patient was referred to the oncology centre in our hospital for further management. He had a whole body scan which showed no lesions anywhere else and was advised with follow-up. After a period of 9 months, he developed right shoulder pain and bleeding per rectum again. A whole body CT scan showed multiple osteolytic lesions involving rib, clavicle, and bilateral femoral shafts. A 11 × 10 cm mass was also noted in the retroperitoneum posterior to head of pancreas, attached to posterior wall of stomach and involving the duodenum. It was diagnosed as a recurrence of the initial colonic mass. Colonoscopy was done and showed a raised lesion at the anastomotic site from which biopsies were taken. The colonic biopsies showed small to medium sized, oval to round neoplastic cells infiltrating the lamina propria without crypt destruction. The cells had round nuclei and prominent nucleoli. No grouping or glandular pattern was noted. Immunohistochemical stains were done on this biopsy and showed negative staining for cytokeratins (AE1/AE3, CK8/18), chromogranin A, NSE, and synaptophysin. As the tissue in the small biopsy was exhausted without confirmation of the original diagnosis of neuroendocrine carcinoma, we requested for the original blocks of the tumor from the primary hospital. We reviewed the slides, which showed a malignant neoplasm similar to that seen in the biopsy involving all layers of the colonic wall. These tumour cells were seen in the lamina propria in between the preserved crypts and infiltrating the muscularis propria and beyond, but confined to the bowel wall (). The tumour cells had plasmacytoid morphology with marked pleomorphism and many intranuclear and intracytoplasmic inclusions (Figures and ). Additional immunohistochemical stains were performed. The tumor cells were negative for the cytokeratins, lymphoid markers, and all mesenchymal markers except vimentin (). This immunohistochemical reaction pattern along with the plasmacytoid appearance of the tumor cells led us to think about plasma cell neoplasm. The plasma cell markers CD138, MUM-1, and CD56 were positive along with positivity for kappa light chain and negativity for Lambda light chain staining (Figures –). Ki-67 proliferation index was 30% ().\nIn correlation with the multiple lytic lesions in the bone and with the above morphologic and immunohistochemical findings in the colonic mass, we made a diagnosis of multiple myeloma. Serum electrophoresis showed a monoclonal band of beta globulins. Immunofixation electrophoresis depicted IgA kappa type. Bone marrow trephine biopsy revealed trilineage haematopoiesis with increased plasma cells.\nPatient was then referred to the hematooncology department for further management of multiple myeloma, but he expired before proper treatment could be started. |
Our patient was a 23-month-old Japanese girl. She was born full-term after a normal pregnancy and delivery. At 6 months of age, she presented at a nearby hospital with a mass on the popliteal side of her lower right leg, which was diagnosed as a benign adipose tumor; the diagnosis was made via magnetic resonance imaging (MRI) because she had no symptoms. The mass gradually increased in size, and she had difficulty in walking.\nAt 1 year and 11 months of age, she was referred to our hospital. A physical examination revealed a subcutaneous mass on the popliteal side of her lower right leg (Fig. ). The mass was soft, smooth, painless, immobile, and 13 × 10 × 7 cm in size. Knee movement was restricted because of the tumor, but there were no neurological symptoms. Laboratory parameters including tumor marker levels were within normal ranges. Radiography showed a localized mass on the popliteal side of her lower right leg, with compression of the mass causing proximal tibia deformity (Fig. ). MRI showed a giant circumscribed subcutaneous mass that was hyperintense on T1-weighted and T2-weighted images but not fat-saturated on T2-weighted images (Fig. ). The mass had numerous internal fibrous partitions that were visible on gadolinium-enhanced fat-saturated images. Based on these findings, she was diagnosed as having an LBS.\nSurgical resection was considered but deemed risky and technically challenging because the mass surrounded her popliteal artery and vein and part of the popliteal nerve, as revealed by MRI. We decided to observe only, as the mass was not expected to grow. However, it grew rapidly (Fig. ) and her symptoms worsened within the year after our initial examination; hence, she underwent complete resection at 2 years and 6 months of age (Fig. ). Because the mass surrounded her popliteal artery and vein, we divided it at these vessels, which allowed us to remove it without leaving any observable tumor tissue and without sacrifice of her neurovascular structures.\nA histological examination of the tumor showed that it mainly consisted of mature fatty cells, fibrous partitions that created lobular cysts, immature lipoblasts, primitive mesenchymal cells, and stroma (Fig. ). These findings confirmed the preoperative diagnosis of LBS. Our patient was discharged from our hospital 3 days after surgery without any residual symptoms. She could walk without pain at the 6-month follow-up, and no local recurrence was observed on magnetic resonance images. |
A 52-year-old man was admitted to our hospital for PEG tube placement. The patient's body mass index was 19.0 kg/m2. He had previously been treated for acute aortic dissection of the aortic arch and descending aorta under thoracotomy. A cardiologist had replaced the aortic arch and descending aorta. After the operation, he experienced a disturbance in swallowing because of cerebral infarction. For 2 years, he had been experiencing occasional vomiting. Blood examination and laboratory serum tests did not reveal any abnormal findings.\nX-ray and computed tomography (CT) scan images did not show a distended stomach (Figures and ). The CT examination revealed that the transverse colon was on the entire surface of the stomach, and therefore PEG insertion would be difficult.\nWe first attempted PEG under gastrointestinal fiberscope (GIF) inspection. The GIF findings indicated no remarkable abnormalities. The gastric folds were smooth and not tortuous. We failed to place a PEG tube while using a GIF because the abdominal wall could not be transilluminated. Therefore, we believed that the transverse colon was covering the stomach.\nWe then attempted PEG insertion by using a colon fiberscope to move the transverse colon down to the caudal side; however, this procedure was unsuccessful (). The reasons for the unsuccessful PEG tube insertion were that we failed to move the transverse colon down and we could not detect transillumination of the abdominal wall. We subsequently attempted LAPEG to observe the stomach and other organs because we believed some abnormalities around the stomach might have existed.\nLaparoscopic surgery was performed under general anesthesia. Based on laparoscopic observation, we determined that the stomach was twisted and the transverse colon was not on the stomach. By using laparoscopy, we found a greater curvature of the stomach on the head side (i.e., the stomach was twisted 180 degrees). We diagnosed the patient as having the organo-axial type of gastric volvulus. During the endoscopy procedure, we were unable to derotate the stomach to its original position although the stomach had no adhesions to neighboring organs and paraesophageal hernia. We easily corrected gastric volvulus by using laparoscopic forceps and derotating the stomach. We then sutured the anterior wall of gastric body to the abdominal wall at four sites by using the Funada-style gastropexy kit []. We finally inserted the PEG tube safely at the anterior wall of the gastric body (). The operative time was 62 minutes.\nAfter the PEG tube insertion, the patient recovered smoothly and was discharged from the hospital without any complications. The patient has not had a recurrence of gastric volvulus. We were able to place the tube safely without interfering with organs surrounding the stomach by using the laparoscopy procedure. |
A female patient aged 29 years, who was single, accompanied by her parents, was referred by a psychiatrist for dental implantation and prosthetic rehabilitation for her edentulous state. A detailed history was elicited from her parents, and it was gathered that the patient, a graduate, developed psychiatric symptoms following family issues. A psychiatric consultation was sought earlier and she was under treatment for the past 6 years.\nAt the time of admission to the present mental health clinic, she presented with cardinal symptoms of schizophrenia such as auditory hallucination, delusion of reference, delusion of persecution, obsessive-compulsive features of frequent bathing, and repeatedly doing same jobs. She had disorganized behaviors such as stripping off her clothes in the public, wandering behavior, restlessness, excessive talk, and abusive and assaultive tendencies with no insight. She had also attempted suicide more than once. All these odd behaviors forced the parents to bring her to the present psychiatrist.\nThere is no family history of any other psychiatric illness. During the course of treatment, her mood and ideas fluctuated on and off. One such instance being she insisted on tooth extraction and threatened to commit suicide if not obliged. The patient claimed that she has been commanded by some voice to go for removal of teeth and was also deluded that her mouth was infested with worms. Meanwhile, she visited many dentists, more than ten dental surgeons, and had 7–8 healthy upper teeth extracted first, by forcing the dentist in spite of assurance by the dentist that her teeth were normal. And finally, she had all her teeth extracted over a period of 6 months [Figures -].\nShe still had another somatic delusion that her nose was being drawn inside and sinking. Later in the course of illness, she said that she got all her teeth removed in response to the voice of the person. Hence, it was clear that she had communicating and commanding auditory hallucinations to which she responded.\nShe has been treated with antipsychotic drugs and was not administered electroconvulsive therapy as her parents were not willing for the treatment.\nAfter total extraction of the upper teeth, she tried having dentures but she refused to wear and threw it away. At present, the patient is getting better and symptoms are under control by treatment but still she is under counseling for denture or dental implantation.\nA review of various literature reveals documentation of patients with a known psychiatric disorders who were hospitalized and the effects of psychotropic medication on oral health, for example, temporomandibular joint disorders. Mental health problems may be manifested as the only symptom or the first one relating to oral mucosa such as facial pain, preoccupation with dentures, increased erosion, and self-inflicted injury.[]\nSelf-inflicted lesions that cause mutilation are observed in schizophrenic patients. An interdisciplinary approach to self-mutilation due to psychiatric disorders was emphasized. An interaction between the two teams, dentistry and psychiatry, is very important for the improvement of the patient's condition.[]\nIn addition, many patients complain of halitosis and get recurrent cleaning and scaling done, thinking their teeth are full of dirt. This sort of false belief of having a bad odor which none can perceive, neither the clinician nor the other person, is called delusional halitosis. A study was done by Akpata et al. which shows significant correlation of patients associated with oral factors and delusional halitosis.[] Screening can be done in dental patients with comorbid mental disorders and simultaneously both can be treated.[]\nAmong patients presenting for cosmetic treatments, up to 15% suffer from body dysmorphic disorder, a psychiatric condition characterized by an imagined defect in appearance with references to nose and teeth. Definitely, this proves that the preformed ideas associated with one's physical appearance is a motivating factor for undergoing certain types of cosmetic dental procedures.[]\nA proper history taking and physical examination is a must for any patient and obviously includes even noninstitutionalized psychiatric patients. Drug history is also a must. The knowledge of various side effects of the drugs should be known which commonly include dryness of mouth.[] |
A 25-year-old male presented to us with complaints of painful swelling of his right knee joint with inability to bear weight. He had undergone surgery (done elsewhere) for GCT of lateral condyle of femur 22 months ago in the form of curettage and bone grafting from iliac crest (: Pre-operative and : 3-month post-operative radiograph). The patient did not relieve his pain in knee joint (which he had before surgery) throughout the course of the treatment. He consulted the primary surgeon for the same and advised active range of motion exercises. The pain kept on increasing, especially in last 6 months, and on examination, he had tenderness over lateral and posterior aspect of knee joint with diffuse swelling and limited range of motion (10—°) when presented to us. Investigation in the form of radiograph () depicted diffuse osteolysis and cortical destruction in lateral femoral condyle. Magnetic resonance imagingMRI of the lesion illustrated the heterogeneous decreased signals on T1 sequences and areas of hyperintensities on T2 sequences with overall picture suggestive of recurrence ( and ). Complete surgical excision of the tumor and articular surface reconstruction was planned as described by D’ Aubigne []. A 15-cm long vertical incision was made over anterolateral aspect of distal thigh and right knee and quadriceps tendon, patella and patellar tendon exposed. A 3-cm wide, musculovascular pedicle separated at inferior border of vastus lateralis muscle, approximately 10-cm proximal from lateral border of patella. Patella was then enucleated from rest of its attachments, releasing quadriceps tendon all around except the pedicle, leaving a rim of 4-mm soft tissue to spare vascular supply. Lateral condyle of femur was exposed and excised en bloc with whole tumor mass with the help of saw and osteotome. The deep articular surface and medial aspect of patella were freshened. The anterior surface which was to be used as articular surface was rotated inferiorly, brought at the level of medial condyle and the patella was fixed with two lag screws as depicted in . The rest of the condylar defect was filled with fibular strut graft and bone chips from iliac crest. The extensor mechanism repair was done by turning down the aponeurotic flap of rectus femoris and suturing it to patellar tendon and vastus expansion. Wound closure done after hemostasis achieved. Bulky dressings with a long posterior plaster of Paris (POP) slab applied which were changed on the 2nd post-operative day. Knee was kept in posterior POP slab for immobilization up to 6 weeks and active mobilization exercises started subsequently. Patient was kept non-weight-bearing till adequate radiological strength achieved, i.e., 16 weeks () and a knee brace was worn while walking with a stick support up to 1 year. Patient recovered uneventfully and at the end of 2 years there was no sign of recurrence or deformity with good function as he walks without support and performs his routine activities with fair range of movements (0—°). Radiological evaluation suggested good healing of lesion without any evidence of osteolysis or collapse of reconstructed lateral femoral condyle (). The quadriceps strength was found to be of Grade 4/5. There was no laxity or instability. Musculoskeletal tumor society score [] was found to be 25 suggesting gratifying outcome. The patient is to be followed up for the long-term results. |
A 32-year-old female presented to the emergency department with a few hours' history of shortness of breath and weakness associated with chest tightness, congestion, hoarseness of voice, and difficulty swallowing. The patient had presented 24 hours earlier with the complaint of diplopia for one day. The patient denied any ingestion of exotic food, shellfish, raw meat, raw fish, or other foods generally associated with botulism. The patient also denied traveling to any exotic place or recent camping trips. The general workup, including biochemical and hematological investigations, came out to be normal except for a mildly decreased serum calcium (7.9 mg/dl). The magnetic resonance imaging (MRI) scan of the brain was also normal. That day, she was discharged with an outpatient consultation with neurology, but she continued to have persistent diplopia. After a few hours of admission, her breathing started to get worse, she was intubated, placed on mechanical ventilation, and was admitted to the intensive care unit (ICU). On examination, she had a symmetrical weakness in all four limbs, with more in the upper limbs compared to the lower limbs. The tensilon test was performed, which was negative. A lumbar puncture was performed, which also came out to be normal. Blood was sent to be tested for botulinum toxin. In the meantime, symptomatic treatment was started and disease control authorities were involved. Her weakness progressively increased and while she was being treated, another case arrived at the hospital with a very similar presentation. Four days later, the botulinum toxin test came positive and the patient was started on botulinum antitoxin and the rest of symptomatic treatment was continued. The Centre for Disease Control (CDC) tracked the events related to both these patients and found out that they both had eaten nacho cheese from a gas station the day before the appearance of their symptoms. A total of 10 cases were associated with this source within days and one death was reported. |
Case 1 was a 65-year-old woman who reported continuous left hip pain and limited range of motion. She was referred to our hospital in June 2013. During the first consultation, physical examination revealed limited range of motion of her left hip due to pain. Her Merle d'Aubigné-Postel score was 9 points, with the following distribution: pain, 2 points; walking ability, 3 points; and mobility, 4 points.\nAn anteroposterior plain radiograph of the hip indicated enlargement of the acetabular fossa of the affected hip (). Upon magnetic resonance (MR) imaging, coronal and axial images of the left hip joint revealed a large lesion with heterogeneous signal intensity that extended to both the intra-articular and extra-articular joint spaces. A large extra-articular tumour-like lesion appeared to be connected to the inferomedial joint capsule (). Arthrography and computed tomography (CT) images of the left hip joint also revealed a honeycomb appearance of the lesion (). These examination findings suggested that the tumour was a synovial osteochondromatosis forming a herniation sac. Therefore, our treatment goals were to confirm the diagnosis, extract intra-articular loose bodies, and perform a synovectomy using arthroscopy. Histopathological examination confirmed the diagnosis of a synovial osteochondromatosis (). After examining the CT and MR images, we determined that a complete arthroscopic resection would be difficult and that an open anterior approach would be more suitable for manually reaching the herniation sac. Therefore, we performed open surgery using an anterior approach 2 weeks after the initial diagnostic arthroscopy.\nThe surgical procedure of this case was succinctly reported previously [], and the salient components of the procedure were as follows. The patient was placed in a supine position, and a 13 cm straight skin incision was made just lateral to the anterior superior iliac spine, extending distally. The lateral femoral cutaneous nerve was identified beneath the fascia and was gently retracted medially. The joint capsule was exposed between the tensor fascia latae and the rectus femoris muscle, and the head of the rectus femoris was transiently detached, with the attachment portion left intact to secure the repair. Near the joint capsule, the ascending branch of the lateral femoral circumflex artery was detected and ligated for capsular exposure. The anterior capsule was opened and the head of the femur was dislocated anteriorly using an external rotation maneuver of the hip. Osteochondromas near the femoral head, including those on the back of the zona orbicularis, were easily removed. Osteochondromas on the acetabular fossa were removed with a curette. Arthroscopic assistance was useful for providing clear visualisation of the acetabular fossa. Osteochondromas in the herniation sac were easily and completely removed manually (). After lavage and joint reduction, the head of the rectus femoris was reattached, which was followed by fascia reattachment and skin closure.\nThe patient began partial weight-bearing gait 2 weeks after surgery and progressed to full weight-bearing at 4 weeks after surgery. MR imaging performed 1 month after surgery revealed no sign of avascular necrosis of the femoral head. The herniation sac diminished in size, with no apparent contents (). At follow-up 3 years after surgery, there was no evidence of tumour recurrence or of osteoarthritic changes. The patient was symptom-free, with full range of motion of the left hip. Her Merle d'Aubigné-Postel score had improved (18 points). |
A 20-year-old female presented to the emergency department with a 5-day history of fever, pain and lump in the right hypochondrium. The laboratory examination was unremarkable except for mild leukocytosis. This was followed by an ultrasound examination that revealed a well-defined, round-to-oval, heteroechoic, part solid and part cystic lesion with internal vascularity in the subhepatic region, with loss of planes with the anterior abdominal wall muscles. The mass was seen separately from the gallbladder, which showed multiple intraluminal calculi with normal wall thickness. No other significant finding was seen in the abdomen. This was followed by a contrast-enhanced CT scan of the abdomen that revealed a large (approximately 7 × 6 cm sized) solid cystic mass lesion in the right subhepatic region showing intensely enhancing solid areas with peripheral cystic non-enhancing areas (,). The mass showed loss of fat planes, with focal infiltration of the adjacent anterior abdominal wall muscles. Arterial supply to the mass was from a branch of the right gastroepiploic artery, while venous drainage was via the superior mesenteric vein through the right gastroepiploic vein (). Owing to its drainage into the omental veins (“omental vascular pedicle sign”), the origin of the mass was ascertained to be from the greater omentum. Loss of fat planes with the anterior abdominal wall muscles suggested a possible malignant aetiology. Based on the imaging findings, a primary diagnosis of malignant omental mass was suggested. The patient was operated on and underwent wide local excision. Intraoperative appearance confirmed the omental origin of the mass with other findings being similar to those suggested by the CT scan. Gross pathological examination showed a fleshy mass with white tan surface and areas of haemorrhage measuring approximately 7 × 6 cm. Histopathological examination of the mass showed the typical appearance of alternating hypercellular and hypocellular areas, with cells arranged in a fascicular pattern within the hypercellular areas. Immunohistochemistry of the tumour cells showed positive staining for S100 and negative results for α-smooth muscle actin, desmin, c-kit, and cluster of differentiation 34, which was suggestive of a MPNST. The margins of the resected specimen were negative on microscopic examination. As the patient belonged to the reproductive age group, she was kept under regular follow-up. and after a short period of 6 months, she developed local recurrence in the abdominal wall. The patient subsequently underwent chemoradiotherapy and is on follow-up. |
A 52-year-old man, after a fall on the ground, suffers from an intertrochanteric fracture of the left hip, and during the operation, a biopsy was performed from the area. In the description of pathology, evidence of metastatic lesions from prostate or kidney or thyroid gland had been reported. During the whole-body bone scan, there were other lesions in the T8–T9 and ankle and left knee areas []. Two months later, the patient had deep-venous thrombosis (DVT) of the left leg, and 1 month after the DVT, he had an atrial fibrillation rhythm that was detected after thyroid tests that revealed T3-thyrotoxicosis. In the thyroid examination, thyromegaly and the left lobe nodule were touched. After performing thyroid ultrasonography, a heterogeneous hyperechoic nodule was reported at a size of 78 × 50 × 42 mm that occupied the entire left thyroid lobe. The right thyroid lobe was large but without a nodule. The laboratory data are summarized in . The thyroid scintigraphy with technetium-99m showed a large cold nodule in the left lobe of the thyroid gland []. The patient was treated with methimazole, and after endocrinology consult and performing fine-needle aspiration from the left lobe of the thyroid nodule, pathology report showed follicular neoplasm. And then, the patient underwent total thyroidectomy. The pathology report was that there was no specific lesion in the macroscopic examination of the right thyroid lobe, but the left thyroid lobe occupied a mass of 6.5 cm in diameter with relatively distinct margin, which seems to remain a narrow rim of the thyroid tissue. In a microscopic examination, the thyroid specimen was that sections of the capsular mass composed of follicular cells, mainly with a microfollicular and trabecular arrangement. In some areas of the cytoplasm, these cells were acidophilic and in some areas clear. The nucleus of the cells is usually round and sometimes has a nucleus of prominence, and localized necrosis was seen. In limited areas (<4 locations), evidence of malignant cell invasion of FTC, to the tumor capsule and vessels, was seen, and follicular carcinoma was diagnosed [], and the patient was introduced to receive radioactive iodine. A month later, when he was referred to the Nuclear Medicine Center to get radioactive iodine, he complains of nausea and vomiting, bone pain, abdominal pain, constipation, anorexia, and back pain; thus, they avoided radioactive iodine administration and sent him to a hospital for medical care. On physical examination, the patient was alert with dry mucosa, blood pressure 160/90 mmHg, pulse rate 100 beats/min, number of breaths 20 times/min, sublingual temperature 37.1°C, lower and upper extremity force lowered (3 from 5), and positive tenderness of the thoracic spine; in neck examination, there was no palpable mass or nodule in the thyroid bed, and left thigh had a scar due to past intertrochanteric surgery, and the rest of physical examinations findings were normal.\nIn laboratory data, serum calcium was 14 mg/dl, and in thyroid tests, T3-thyrotoxicosis was found.\nFinally, due to hypercalcemia and T3-thyrotoxicosis and pathological results, the diagnosis of functional follicular metastatic carcinoma was performed. The result of the patient's tests is summarized in . Ultrasound and computer tomography (CT) scan of the kidneys were normal. In the CT scan of the abdomen and pelvis and the thorax without contrast, except for a few lytic lesions in the vertebrae body, no other point was reported. Magnetic resonance imaging (MRI) without and with the contrast of the brain and the lumbar spine was normal, but in the thoracic MRI, there were several metastatic lesions in the vertebral cortex and pedicle of T4, T5, T8, T9, and T12. To treat dehydration and hypercalcemia, fluid therapy began to reduce the serum levels of calcium, calcitonin, and zoledronic acid infused, and for treatment of T3 toxicosis, oral methimazole was prescribed. Then, to prevent cord compression, the patient underwent spinal fixation surgery. Several days after surgery and 7 days after taking zoledronic acid, the patient suffered from hypocalcemia, hypomagnesemia, hypophosphatemia, and hypokalemia, which required calcium gluconate and potassium chloride and magnesium sulfate and oral calcitriol. Finally, after stabilizing the patient with oral calcium, calcitriol, and methimazole, he was discharged and introduced to receive radioactive iodine.\nNow, 1.5 years after FTC metastases diagnosis, the patient has recurrent hip metastases and is candidate for local radiotherapy. He is able to walk with a walker, and the symptoms of thyrotoxicosis are controlled by radioactive iodine, and there is no any evidence of recurrence of hypercalcemia. The latest patient's serum levels of T3, T4, thyroid-stimulating hormone (TSH), corrected calcium, phosphor, and 25-hydroxyvitamin D were, respectively, 2.1 ng/ml, 1.49 μg/dl, 0.01 m IU/L, 9.6 mg/dl, 3.5 mg/dl, and 37 ng/ml. Kidney function was normal, but he complains of low back pain. The latest whole- body scan after radioactive iodine intake was indicative of extensive bone metastases []. |
A 4-year-old boy presented to the pediatric emergency department with symptoms of cerebellar ataxia and gait disturbances. Sixteen days prior to that, his parents had consulted a primary care physician due to left earache and fever. No purulent discharge from the ear was evident at the time. Then, the patient was diagnosed with otitis media and was prescribed oral amoxicillin-clavulanic acid. Due to symptoms persistence, treatment was subsequently switched to oral cefuroxime.\nUpon presentation to our emergency department, a complete blood count showed leukocytosis and neutrophilia. The prominence of cerebellar symptoms raised suspicion for an intracranial pathology and thus an emergency contrast-enhanced CT scan was performed. The scan revealed a multilobular cystic lesion with peripheral contrast enhancement, located in the subdural space of the posterior fossa, in contact with the tentorium cerebelli superiorly []. The lesion was compressing the left cerebellar hemisphere, which appeared edematous and the cerebellar midline was displaced by 9 mm. Moreover, the left middle ear cavity, ipsilateral mastoid air cells, and partially the left ethmoid air cells were occupied by fluid. The left transverse sinus could not be recognized in the scan. Subsequently, in order to evaluate more accurately the extent of the posterior fossa collection and to address the CT findings suggesting left transverse sinus thrombosis, a magnetic resonance imaging (MRI) scan and a magnetic resonance venography (MRV) were conducted. MRI confirmed the presence of extensive infratentorial subdural empyema over the left cerebellar hemisphere, accompanied by displacement and edema of the left cerebellum. MRV revealed diminished flow through the left transverse sinus and no flow through the left sigmoidal sinus [], and these findings were consistent with sinus thrombosis. Consecutively, an emergency operation was scheduled. A left suboccipital craniotomy was performed. The transverse sinus was recognized and the dura was incised. Following traction of the cerebellum, the subdural space was expanded and the purulent collection was encountered. Cultures from the purulent fluid were obtained and the empyema was evacuated.\nIntravenous antibiotic treatment with piperacillin-tazobactam and teicoplanin was initiated. After 4 days the patient had no fever, no neurological deficits, and was ambulatory. Follow-up MRI scan documented the successful evacuation of the empyema and subsiding inflammation []. Three weeks into the treatment, a morbilliform skin rash was developed on the patient's trunk, face, and limbs consistent with drug allergic reaction. The antibiotic treatment was then switched to oral clarithromycin, which was administered for 3 more weeks, for a total of 6 weeks of antibiotic treatment. The patient was discharged from the hospital 4 weeks after the operation. |
On January 4th, 2018, a 57-year-old woman was hospitalized in the department of Psychiatry, Sir Run Run Shaw Hospital because of pain and acid bilge in multiple sites of her upper body for more than 1 year. Over a year ago, the patient started feeling pain and discomfort in the upper left abdomen, and the pain got worse when coughing but with no other discomfort. Two months later, the upper left abdomen pain and acid bilge extended to the front chest, back, abdomen, and upper limbs. The symptoms persisted for months, and aggravated when changing body posture. Test results including cervical MRI, chest CT, abdominal B ultrasound of upper abdomen in a local hospital showed no abnormalities. Treated with Chinese medicine for more than 3 months, there was no significant improvement. About 6 months ago, the patient came to our hospital, expressing the symptoms above and worries about them, with weight loss of about 1–1.5 kg, but denying continuous depression, anxiety, and other symptoms (the score of 24 items of Hamilton Rating Scale for Depression was 12, and Hamilton Anxiety Rating Scale score was 11), and was diagnosed as “somatic symptom disorder.” After 4 months of treatment with 60 mg of duloxetine enteric-coated capsules twice daily and hypnotic drugs, the symptoms were obviously alleviated but not completely relieved and there was a significant weight loss of about 5 kg. Therefore, medication was adjusted to escitalopram tablets 20 mg once daily. Two months later, the patient felt no further improvement.\nWith hypertension history of more than 10 years, the patient claimed that it's not necessary for her to take any antihypertensive drugs to control blood pressure in recent 1 year. She had bronchitis for 12 years but no medicine was needed. She denied any history of diabetes, heart disease and other diseases and claimed there was no history of surgery and trauma. Also, the patient denied long-term chemical substances, drug or poison exposure history and had no history of smoking and drinking alcohol.\nAfter admission, due to long-term poor efficacy of the patient, we re-evaluated the patient's physical condition to rule out organic diseases. However, through Blood routine, Blood Biochemistry, Stool Routine, Urine Routine, Chest Film, Electrocardiogram, and so on, no specific abnormality was found. We found that the patient's tumor marker CA-153 was 61.2 U/mL (< 25.00 U/mL) and ferritin was 198.70 ug/L (13.00–150.00 ug/L), with no specificity. There was another finding of patient suffering from cholecystitis and gallstones through abdominal ultrasound examination; however, the surgeon suggested that it could not explain the patient's symptoms. When perfecting cranial MRI, we unexpectedly discovered below result: diffuse thickening of the skull and increasing signal intensity. Metastasis? Multiple myeloma? (Figure ).\nAnd lumbar MRI prompted lumbar vertebra, attachment and right iliac bone multiple bone changes, multiple myeloma? Transfer? (Figure ). Skull and pelvis plain radiographs prompted skull, maxillofacial bone, pelvis, and femoral bone changes, multiple myeloma? Transfer? (Figure ).\nAfter perfecting corresponding blood examination, the patient eventually underwent bone marrow aspiration and the results suggested that the patient was suffered from multiple myeloma (Figure ). The patient was finally referred to the hematology department and received appropriate treatment.\nHere we report on a case of a 57-year-old woman with pain and discomfort in multiple sites of upper body who was diagnosed as somatic symptom disorder after completing a partial examinations of relevant parts which turned out to be negative. Finished imageological examinations of all painful parts, she was eventually diagnosed with multiple myeloma after 6-month being misdiagnosed as somatic symptom disorder. This case highlights the importance of completing imageological examinations of all the painful parts of the patient to exclude the possibility of multiple myeloma especially when symptoms are associated with objective signs and treatment has been ineffective; and it is as well as significant to notice characteristics of symptoms and to pay excessive attention directed toward the symptoms in the diagnosis of somatic symptom disorder.\nMM is a disease which is characterized by the neoplastic proliferation of immunoglobulin-producing plasma cells. Most patients with MM present with signs or symptoms related to the infiltration of plasma cells into the bone or other organs or to kidney damage from excess light chains. MM accounts for ~1–2% of all cancers and slightly more than 17% of hematologic malignancies (). Worldwide, there are ~154,000 cases and 101,000 deaths per year attributed to MM (). MM is also slightly more frequent in men than in women (~1.4:1). The risk of developing MM increases with body mass index (, ). MM is a disease of older adults. The median age at diagnosis is 66 years; only 10 and 2% of patients are younger than 50 and 40 years, respectively (, ).\nMost patients with MM present with signs or symptoms related to the infiltration of plasma cells into the bone or other organs or to kidney damage from excess light chains. As an example, a retrospective analysis of 1,027 sequential patients diagnosed with MM at a single institution found the following symptoms and signs at presentation: Anemia-73%, Bone pain-58%, Elevated creatinine-48%, Fatigue/generalized weakness-32%, Hypercalcemia-28%, Weight loss-24%, one-half of whom had lost ≥9 kg ().\nIn American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition (DSM-5) (), SSD is characterized by one or more somatic symptoms that are accompanied by excessive thoughts, feelings, and/or behaviors related to the somatic symptoms. It is estimated the prevalence in the general population is 4% (, ) and that among primary care patients is 17% (, ). An analysis of individual patient data from nine community studies (total n > 28,000) found that the most frequent burdensome symptom was pain (). SSD is not defined by the number of distressful physical symptoms that are present; however, patients who complain about multiple symptoms are more likely to have the disorder. In this case, the patient had a number of pains and acid bilge in multiple locations which are typically present in somatic symptom disorder, with no other symptoms of MM, for instance, anemia, elevated creatinine, fatigue/generalized weakness, hypercalcemia. These enhance the possibilities of misdiagnosing MM as SSD. The percentage of underlying somatic diseases in patients previously diagnosed with SSD is relatively small but unneglectable. A meta-analysis () reviewed six diagnostic evaluation studies (total N = 1,804 patients), 16 follow-up studies (total N = 2,440 patients), and the percentage of misdiagnosis with SSD was 8.8% (95% CI 1.0–22.2, p = 0.007) in diagnostic evaluation studies, 0.5% (95% CI 0.01–1.5, p = 0.03) in follow-up studies, while the correct diagnosis shall be diabetes mellitus, duodenal ulcer, Crohn's disease, polymyalgia rheumatica, carcinoma, herniated disc, and so on.\nImaging is a key part of the evaluation of all patients with suspected MM. In this case, we found some related negative imaging test results like cervical MRI, chest CT, abdominal B ultrasound of upper abdomen from another hospital, however, neglected to do examinations of other important parts where the patient reported discomfort, such a lumbar and pelvis imageological examinations. Pain and acid bilge in multiple sites are usually associated with musculoskeletal and nervous system disease, and MRI is the best imaging choice for the early stage of these diseases. In the diagnosis procedure of SSD, thorough physical examination, laboratory tests and imageological examinations are necessary to help clinicians and patients build confidence and ensure that no important diagnosis will be missed (–). Moreover, criteria for selective use of tests include objective signs rather than the volume of the concerns expressed by the patient, the presence of complex symptoms, and persistence of symptoms (). For instance, in our case, the pain of the patient aggravates when the body posture is changed or coughing. This characteristic probably points to a physical disease which is ignored during the early processes of out-patient treatment.\nSSD patients always have excessive thoughts, feelings, or behaviors associated with the somatic symptoms. The patient was also anxious because of her symptoms which now we can consider it as healthy anxiety. Clinicians taking a history should determine whether somatic symptoms trigger healthy anxiety or not, in addition, determine whether the patient manifests persistent thoughts and anxiety related to the somatic symptoms, and whether the patient devotes excessive time and energy to the somatic symptoms (–). In International Classification of Disease-10 (ICD-10) () which is currently widely used in the world, somatoform disorders are defined on the basis of failure to find physical causes rather than the presence of definite psychological and behavioral features. The notion of taking medically unexplained symptoms as the defining feature of ICD-10 somatoform disorders creates a major hindrance to the clinical utility of the diagnosis. There is evidence that the decision about whether symptoms are medically unexplained is unreliable and lacks validity. The inherent dualism in the notion of a lack of medical explanation for somatic symptoms that are cross-sectionally assessed is simplistic and ultimately unhelpful to patent care (). In ICD-11 (), excessive attention directed toward the symptoms is highlighted in the diagnosis of Bodily distress disorder.\nThere is evidence that antidepressants are effective for SSD (, ). However, SNRIs could relieve pain by inhibiting reuptake of serotonin and norepinephrine, and suppressing painful sensation uploading regardless of physical disease or psychiatric disorders. Therefore, pain of the patient was obviously alleviated after 4 months of treatment with 60 mg of duloxetine enteric-coated capsules twice daily. This phenomenon also could perplex the revision of the diagnosis.\nThis case indicates that imageological examinations of all the painful parts of the patient should be completed to exclude the possibility of MM, especially of those whose symptoms are associated with objective signs and treatment has been ineffective. Furthermore, diagnosis of SSD requires not only the elimination of somatic diseases, but also excessive thoughts, feelings, or behaviors associated with the somatic symptoms. |
A 27-year-old woman, gravida 2, para 1, had undergone aortic valve replacement (mechanical) for aortic regurgitation at the age of 10 years. Since then, she had been receiving anticoagulation with warfarin, 5 mg/day. During the previous pregnancy, she received a combination of warfarin and heparin for anticoagulation, and the pregnancy and delivery were uneventful for both mother and infant. As with the previous pregnancy, oral administration of warfarin was switched to continuous intravenous infusion of heparin in the fifth week of gestation. In the 12 weeks of gestation, oral administration of warfarin was resumed at a dose of 3 mg/day, and then, the dose was increased to 4.5 mg/day. The activated partial thromboplastin time (APTT) was maintained between 50 and 60 sec during heparin use, and prothrombin time by international normalized ratio (PT/INR) was maintained between 1.5 and 2.0 during oral administration of warfarin. On the fifth day of the 31 week of gestation, ultrasonography revealed mild enlargement of the left lateral ventricle of the fetus, measuring 1.0 cm, and it was found to have further enlarged to 1.5 cm on the fifth day of the 33 weeks of gestation (Fig.). Magnetic resonance imaging (MRI) performed on the first day of the 35 week of gestation revealed bilateral intracranial subdural hematoma in the fetus, and the left ventricle was found to have enlarged due to compression by the hematoma (Fig.). We determined that the fetal intracranial subdural hematoma had been caused by fetal intracranial hemorrhage associated with warfarin administration to the mother. On the same day, warfarin was discontinued and replaced with continuous intravenous infusion of heparin. Cardiotocography (CTG) showed that the fetal conditions were favorable and no anemia was observed based on the measurement of middle cerebral artery peak systolic velocity (MCA-PSV). On the second day of the 36 weeks of gestation, the mother underwent elective induction of delivery with oxytocin in response to her desire for a vaginal delivery. A male infant of 2648 g, with Apgar scores of 8 and 9 at 1 and 5 min, respectively, was delivered and umbilical arterial blood pH was 7.266. He had good muscle tone with no apparent paralysis of the limbs. Both respiration and circulation were well maintained. Because the infant had a hemoglobin level of 7.0 mg/dL, PT/INR of 4, and APTT of 105 sec, showing anemia and abnormal coagulation parameters, red cell concentrate and fresh-frozen plasma were transfused. At 3 days of age, he underwent cranial surgery with bilateral subdural hematoma removal. At present, 4 months after birth, he remains asymptomatic with no motor deficits or growth problems restriction. |
A 30 year old G2P1001 sub-Saharan African female teacher at 11 weeks amenorrhea, presented to the Nkwen Baptist Health Center (Bamenda, North West Region of Cameroon) on the 15th of May 2016 with bilateral lower limb swelling and pain of 5 days duration. She had no known chronic illness and denied having a family history of VTE.\nShe reported being well till 2 weeks prior to presentation when she started experiencing abdominal pains; the pain was mainly in her lower abdomen, dull in nature, non-radiating, mild in intensity, was initially intermittent then became constant. It was associated with intermittent low grade fever. This prompted her to consult at a remote health center, where a urinalysis and malaria parasite test was done but their results were inconclusive. She was then cautioned to be having early pregnancy symptoms and placed on acetaminophen 3 g per day in three divided doses which she took for a week with no regression of symptoms. The persistent and progressively worsening pain now localized at the right lower quadrant prompted a second consultation at another health facility. This pain was still associated with low grade fever and now included; loss of appetite and intermittent postprandial vomiting. The attending physician on examination remarked right iliac fossa tenderness and rebound tenderness with a positive Rovsing’s sign. Presumptive diagnosis of acute appendicitis and differential of ovarian cyst in pregnancy were retained. An emergency surgery was booked. However, intra-operative findings revealed a normal appendix and ovaries.\nFollowing surgery, lower abdominal pains persisted and she complained of a sudden onset of crampy constant pains in her right thigh. She was told to be having post surgery pain, for which she was then given analgesics. On day 3 post hospitalization she was discharged on analgesics, antibiotics and progesterone suppository. While at home, the pains persisted and 2 days later involved her left calf area. This was associated with bilateral lower limb swelling that was more on the right lower limb. The pain increased in severity making it difficult for her to walk. This prompted consultation at our health facility.\nOn arrival she was ill-looking and in painful distress. Her blood pressure was 122/76 mmHg, heart rate 94 beats/min, respiratory rate of 22 breaths/min, temperature 37 °C, O2 saturation at 97% and weight 58 kg. Her conjunctivae were pink and sclera anicteric, heart sounds were normal and lung fields clear. On examining the abdomen, a clean midline incision was seen and there was tenderness on deep palpation of the lower abdominal quadrants marked on the right. There was bilateral lower limb pitting oedema extending to the thighs with right lower limb more swollen than left. The limbs were mildly erythematous but there was no area of cracked skin or wound on both limbs that could have served as portal of entry for skin infection. Both lower limbs were warm tender.\nBased on these we made a tentative diagnosis of bilateral lower limb deep venous thrombosis in early pregnancy with a possible pelvic vein thrombosis that was misdiagnosed for acute appendicitis. Our health facility was not equipped with the necessary tools and personnel to confirm our diagnosis and manage the patient. She was therefore referred to a tertiary care center about 40 km from our facility.\nAt the tertiary center compressive doppler ultrasound of the pelvis and lower limbs revealed pelvic and bilateral lower extremity veins seen with echoes in the right common iliac vein (Fig. ), right femoral vein, left femoral vein and left popliteal vein. There was decreased colour flow in these veins and decreased compressibility. These suggested DVT of the right common iliac vein, right femoral vein, left femoral vein and left popliteal vein and thus confirmed our diagnosis of bilateral lower limb and pelvic DVT.\nFurther laboratory testing showed the following: normal white cell count of 8100/µl, mild anaemia with haemoglobin of 9.8 g/dl, thrombocytosis of 532,000/µl, normal kidney function test (serum creatinine of 0.64 mg/dl and urea of 12.7 mg/dl), glycaemia of 85.9 mg/dl and normal serum electrolytes of: (Sodium 134 mmol/l, Potassium of 4.17 mmol/l and Chloride of 103 mmol/l). Cardiac echography and electrocardiogram done were all normal.\nThe patient was immediately started on low molecular weight heparin (LMWH) 80 mg subcutaneous route daily. After 5 days of treatment the patient’s symptoms had subsided and she was discharge and counter referred for continuation of care. We continued her daily LMWH injections and scheduled her for a repeat of the pelvic and lower limb ultrasound. Six weeks later there were no more echoes in the pelvic and lower limb veins (Fig. ). She continued daily LMWH till 12 weeks postpartum. |
A 51-year-old male patient visited the hospital for a left femoral neck fracture that resulted from a fall (). He was receiving neurological treatments for epilepsy, alcohol dependence and behavior disorder, and had suffered from several falls and syncopes in the past. Moreover, there was a medical history of four episodes of seizures and syncopes for the past one year. A dual mobility acetabular component was used for this patient to reduce the risk of hip dislocation and to improve the range of motion of the hip joint, because he was a young patient and had a vulnerable condition for hip dislocation (). We used cementless acetabular component (Active Articulation™ E1® Hip System; Zimmer Biomet, Warsaw, IN, USA) and cementless femoral stem (Taperloc® Hip System; Zimmer Biomet). A physical examination carried in an operation room revealed normal range of motion; the joints showed no impingement on the neighboring tissues and no instability. No unusual signs were observed in an imaging test as the anteversion and inclination angles of an acetabular cup were 17° and 43°, respectively. The patient visited the hospital 10 weeks after the surgery in a drunken state, complaining of pain of the left hip joint that had occurred after seizure. In the plain radiograph conducted in the emergency department, a left hip dislocation was observed and reduced with closed reduction (). However, plain radiograph and computed tomography after reduction showed a dissociation of the PE liner that was not observed before closed reduction and eccentric location of femoral head against acetabular cup (). Therefore, we performed revision of acetabular component. During reoperation, the PE liner was found in the gluteus maximus muscles, and the acetabular cup, liner and femoral head were replaced because the acetabular cup and head were injured (). The femoral stem was not replaced since it was stable (). At the moment, he is under observation through the outpatient treatment with no unusual signs apparent. |
A 64-year-old woman presented due to chronic progressive gait disturbances that had started approximately 1 month after concluding a 4-cycle docetaxel-based chemotherapy for breast cancer 2 years ago. Prior to chemotherapy, the patient was able to walk normally. Almost at the same time, the patient reported to have started with a light numbness of the extremities, accentuated distally, a symptom that had remained stable during those 2 years. She did not complain about other neurological symptoms like headache, dizziness, speech, attention or concentration difficulties, memory or sight loss, abnormal movements or bladder/bowel disturbances. The patient was regularly followed by her oncologist and up to the present there had been no evidence of cancer relapse.\nIn the first instance, the gait disorder was assumed to be due a docetaxel-induced polyneuropathy, given the high frequency of this side effect associated with the treatment with this drug and the accompanying extremity numbness []. Electrophysiological studies were performed later on and, although inconclusive, confirmed the presence of polyneuropathy. However, despite the clinical stability of the sensory deficits, the patient had experienced a continuous and dramatic progression of her gait disturbance and was therefore referred to a neurologist.\nAt the moment of consultation, the patient presented a gait disorder characterized by small steps, rotation instability, and an increment in sustentation base. The Romberg test was negative, although there was objectively a light impairment of deep and superficial sensory input in both feet and hands. The patient had otherwise normal cranial nerve function and deep muscular reflexes, there were no signs of pyramidal tract affection, and urinary or bowel sphincter function was retained. There was no evidence of tremor, freezing or cogwheel phenomenon. Regarding cognitive performance, Mini-Mental State Examination and verbal fluency tests revealed normal scores.\nBrain MRI revealed a marked hydrocephalus with a dramatic enlargement of the supra- and infratentorial ventricular system and no cortical atrophy (Fig. ). Furthermore, there was no evidence of malignant brain or meningeal seed.\nWe decided to perform a lumbar puncture to drain 30 mL of cerebrospinal fluid (CSF) and gait performance was assessed prior and 24 h after the puncture. A 10-m walking test revealed a clear reduction in the number of steps as well as time required to complete the task between the pre- and post-puncture measures. Additionally, the patient reduced the number of steps needed for a 360° rotation after puncture (Table ). Cytology of CSF was otherwise inconspicuous.\nBased on these results, we decided to place a ventriculoperitoneal shunt. The surgery was performed following a standard technique using a pro-GAV® system with an adjustable valve (labeled at 8 cm H2O) and a gravitational component fixed at 20 cm H2O. The patient recovered successfully from the surgery and did not experience postoperative complications. Improvement on gait performance observed after CSF drainage remained stable immediately after surgery and during the follow-up (at the moment 38 months), despite the unchanged numbness of arms and legs. |
A 14-year-old girl, presented to our clinic with left knee pain, especially on full extension of the knee, for duration of 6 months. There was no trauma involved. Examination showed lateral joint line tenderness without any ligamentous laxity. Plain radiographs of the knee were normal. Further imaging with magnetic resonance imaging (MRI) scan revealed discoid lateral meniscus with a horizontal tear (\n). Diagnostic scope was done and we found an incomplete discoid lateral meniscus with complex vertical tear involving anterior horn with horizontal extension into the midbody (\n). Arthroscopic all-inside repair was done without any implant. Postoperatively, the patient's knee was protected with a brace. Postsurgery, 6 weeks, the brace was discontinued and the patient started full weight bearing without pain. At 6 months postsurgery, the patient was pain free and without any mechanical symptoms.\nThe position was supine, with the leg hung freely at the end of the table. A tourniquet was used to secure hemostasis. A standard anterolateral portal was used for diagnostic arthroscopy. The finding was an incomplete discoid lateral meniscus with peripheral vertical tear of the anterior horn and partial horizontal tear involving the mid body but not breaching the inner peripheries (\n). A standard anteromedial portal was made and the tear was further assessed using a probe. The tear site was prepared for repair. An additional far medial portal was made to allow arthroscopic instrumentation. A suture passer loaded with synthetic monofilament absorbable suture, introduced through far medial portal, while viewing through anteromedial portal (\n). The torn central fragment and the peripheral rim of the meniscus were penetrated and the tip of suture was pulled through using an arthroscopic grasper through anterolateral portal. The suture passer was reversed out of the far medial portal, leaving the suture inside. Then, a suture retriever was introduced through anterolateral portal and used to retrieve the suture tip bringing both suture-ends out through one portal. Both the suture ends were tied using a sliding knot technique. This whole process was repeated for a second suture repair (\n). The stability of the repair was assessed using a probe. Initially, we planned to saucerize the discoid meniscus together with meniscus repair. However, intraoperatively we decided not to saucerize the meniscus in view of the tear configuration. Due to the complex nature of the tear pattern (peripheral vertical tear with extensive horizontal tear through the meniscus body), saucerization would have made the articular surface of the meniscus a loose fragment or created a flap tear, which is more difficult to repair. |
A 94-year-old male was transferred to our hospital due to malaise, loss of appetite, and bradycardia with a heart rate of 30 beats per minute. He experienced syncope a few months prior to presentation. He had been treated with an angiotensin II receptor blocker for hypertension by his family doctor. At the age of 70 years he underwent a gastrectomy for gastric cancer. He received an operation for lumbar spinal stenosis at an age of 90. An electrocardiogram (ECG) demonstrated 2:1 atrio-ventricular block with a ventricular rate of 34 bpm (Figure ). Chest radiography and computed tomography (CT) revealed the existence of dextrocardia with situs inversus (Figure , ).\nThe patient received an emergency cardiac catheterization since the cardiac troponin T was positive. Coronary angiography showed no significant stenosis in the coronary arteries. A temporary pacemaker was inserted from the right internal jugular vein for treatment of symptomatic bradycardia. His symptoms and pulmonary congestion improved after VVI pacing at 70 bpm, and an elective implantation of the permanent pacemaker was scheduled. Echocardiography demonstrated a normal left ventricular function and no significant valve dysfunction or other cardiac anomalies. On the next day after admission, the patient removed the pacing lead of temporary pacemaker unintentionally due to delirium during the daytime. His daily cognitive ability was normal. We discussed the treatment option as to whether to insert a temporary pacemaker again and implant a transvenous pacemaker electively or to implant a leadless pacemaker directly. The medical team explained the family members about the possible repetition of removal of the temporally pacemaker before implantation of transvenous pacemaker. Although, in patients with atrio-ventricular block lacking atrial fibrillation, dual-chamber pacing, not single-chamber pacemaker, is recommended, his family requested to implant a leadless pacemaker.\nThe implantation of a leadless pacemaker was performed under fluoroscopy after the right ventriculography (Figure , ). The procedure was performed according to the manufacturer’s standard recommendations. Due to the existence of dextrocardia and situs inversus, the procedure required additional time. To obtain a stable fixation and an adequate pacing threshold on the mid-septum of the right ventricle, we had to deploy and retract the device 6 times. The risk factors for the cardiac injury were advanced age, low body mass index, and absence of atrial fibrillation. Finally, we could successfully implant it on the septum close to the apex of the right ventricle, and obtain a good sensing parameter and pacing threshold (Figure , ). In the pull-and-hold test, at least two tines were firmly fixed. The final parameters at the end of the procedure were an impedance of 570 ohms, R-wave sensing of 4.3 mV, and right ventricular pacing threshold of 1.0 V at 0.24 ms. The pacing threshold further improved to 0.38 V at 0.24 ms on the next day. The clinical course after the implantation was uneventful and the patient was discharged without any complications. The chest radiograph (Figure ) and ECG (Figure ) after the implantation are shown in Figure . |
A case of 14-month-old boy was referred to our center due to retention of a BB which was accidently ingested 3 weeks ago. The baby was playing with his toys when the mother noticed that a toy was broken and one of the batteries was missing (size 8 mm). She went to the nearest hospital where an abdominal X-ray was done nearly 2 h after the accident and showed that the battery is beyond the esophagus and stomach (shown in Fig. ). So, the decision was made for outpatient management and to repeat the abdominal X-ray after a week as long as the boy is asymptomatic. Follow-up X-rays were done at 1, 2, and 3 weeks later, and the battery was detected in different positions within the abdominal cavity (shown in Fig. ).\nThen, the boy was referred to our center. On examination, the child was vitally stable, abdomen was lax with mild distension, and normal stool could be detected in PR examination. Laparoscopic exploration failed to detect the site of the battery and an evident discrepancy in the jejunum with hugely dilated proximal segment up to the duodenojejunal junction was identified and brought out through a longitudinal umbilical incision (shown in Fig. ). On palpation of the site of this discrepancy, a membrane-like thickening was felt with retained food particle proximal to it containing the battery (shown in Fig. ). After opening the dialed segment through the antimesenteric side, the battery was taken out, revealing a web obstructing the intestinal lumen with a pinhole opening in its center (shown in Fig. ). We resected the segment containing the discrepancy with 10 cm of the proximal ectatic segment, followed by end-to-end anastomosis in 2 layers.\nHistological examination revealed that the web was covered with normal intestinal mucosa without a proper muscle layer between the 2 mucosal surfaces confirming the congenital nature of the web. The patient recovered uneventfully, started oral feeding on the third postoperative day, and was discharged on the sixth postoperative day. He is now doing well and free of symptom for more than 6 months after his operation. |
A 63-year-old man came to the clinical observation because of a rapid onset of dyspnea and dysphonia along with the development of a bulky node in the left side of the neck. He had been working as an interventional cardiologist in an angiographic room for 15 years at the local Hospital. Family history was negative with regard to malignancies and thyroid disease.\nThe relevant medical history included hypertension treated with valsartan and hydrochlorothiazide and non-insulin-dependent diabetes mellitus treated with metformin. There was no previous history of thyroid disease. Two years before the admission, he was treated with warfarin because of a deep venous thrombosis of the left leg occurred after a short bed rest for prostatitis. He was a heavy smoker.\nThe iodine status of the patient was not known; however, he was from a non-Alpine region and he was still living in the same area which is considered as a mildly iodine insufficient [].\nOn physical examination, the patient had a 8 × 10-cm firm left-sided neck mass with a right-sided shift of the larynx. On ultrasound examination, a nodule of the left thyroid lobe was found measuring 5 and 6-cm in its antero-posterior (AP) and transverse (T) diameters, respectively. The nodule was hypoechoic but inhomogeneous, with no vascularization; at the strain elastography, the nodule ranged from a medium elasticity to a hard pattern. The volume of the right thyroid lobe was reduced with a small hypoechoic nodule. No enlarged lymphnodes were found at the neck ultrasound. Computed tomography (CT) of the neck confirmed a 7 × 5 × 13-cm (T × AP × Long diameters) large, inhomogeneous neck mass originating from the left lobe that caused displacement of the trachea, the left common carotid artery and the left internal jugular vein. No evidence of primary malignancies or suspicious for secondary lesions was found at the CT of the head, abdomen, and pelvis. The chest CT showed a 6-mm round-shaped nodule not suspicious for malignancy close to the parietal pleura at the lower lobe of the right lung.\nA fine needle aspiration cytology (FNAC) of the mass was performed which yielded hemorrhagic smears with few groups of large, epithelioid cells, with vesicular, severely atypical nuclei and eosinophilic dense cytoplasms. A diagnosis of malignancy was given (Category 6 according to Bethesda 2010) with a suggestion for an anaplastic carcinoma (Figure ).\nThe patient underwent a total thyroidectomy and lymphadenectomy of central and left lateral cervical nodes. At the gross pathology examination, the tumor measured 6 × 6 × 12 cm (T × AP × Long diameters) and was partially circumscribed by a fibrous pseudocapsule. The mass had a gray, tan and red cut surface, with areas of hemorrhagic necrosis. Histology showed a vasoformative high grade neoplasia characterized by large epithelioid cells growing in sheets and lining abnormal vascular spaces; some cells showed intracytoplasmic lumina. There were areas of spontaneous necrosis and hemorrhage and a brisk mitotic activity; angioinvasion was noted. The tumor immunostained for vascular markers (CD31, ERG, CD34, factor VIII and vimentin), whereas epithelial differentiation markers were negative (cytokeratins, thyroid transcription factor 1, thyroglobulin, and EMA). The final histologic diagnosis was primary epithelioid angiosarcoma of the thyroid, grade 3 according to FFCCS (Figures ). This diagnosis was confirmed at a second opinion from a different institution. The tumor was restricted to the thyroid with free surgical margins. The mass had substernal extension and displaced the surrounding structures but it did not infiltrate the thyroid capsule, the strap muscles, or other neck tissues. The remaining thyroid tissue had nodular colloid goiter. No lymphnode metastases were detected.\nFifteen days after the thyroidectomy, the patient was operated to prevent rupture of an aneurysm of the abdominal aorta. One month after thyroidectomy, the chest CT showed multiple pulmonary nodular lesions some of them with a solid pattern surrounded by a ground-glass halo, 12 mm in maximum diameter. There was no consensus as to the oncologic relevance of these lesions, therefore, no biopsy was performed. A bone scintigraphy yielded negative results.\nChemotherapy with Epirubicin, Ifosfamide, and Mesna was administered but it was discontinued after 4 cycles because of pancytopenia and infection by Klebsiella Pneumoniae, treated with piperacillin/tazobactam, and by Clostridium difficile, treated with vancomycin. The patient recovered from the infections and, at a 6-month follow-up, the chest CT showed a reduction of the number and volume of the lung lesions with only three of them remaining in the medial lobe of the right lung.\nAt a further 18-month control, the chest CT was unchanged. The 6 mm round-shaped nodule close to the parietal pleura at the lower lobe of the right lung was also found to be stable. One year later, the patient developed pneumonitis and recovered after antibiotic therapy. At that time, he was investigated by neck, chest, abdomen and pelvis CT as well as with FDG-PET without any evidence of disease recurrence.\nAfterward, a 6-month CT follow-up program was started which is still ongoing. At present, the patient is alive with no evidence of disease after 62 months from initial diagnosis. |
A 78-year-old woman was involved in a motor vehicle collision while traveling approximately six weeks before presenting to our institution. She initially had high cervical neck pain at the time of the event but no other neurologic symptoms. She was brought to a local trauma center at the time of the event, and a computed tomographic angiography (CTA) of the neck revealed a Levine and Edwards Type II fracture with bilateral C2 pars and pedicle fractures extending into the vertebral body with anterolisthesis of C2 on C3 (see Figure ). Also seen was a tortuous right dominant vertebral artery that filled a large C2 transverse foramen with a congenitally small pedicle (see Figure ). Her vertebral artery on the left appeared to contribute very little to her posterior circulation. There was no evidence of radiographic vascular injury. She was advised to undergo surgical fixation at the time of her injury, however, she elected to wait until she returned home. She was discharged from the outside hospital with a hard cervical collar and presented to our institution for further evaluation over a month later. After discussing the possible treatment options, including continued conservative treatment with continued external orthosis vs. surgical intervention, the patient elected for surgical intervention. The risks and benefits of the surgical options were discussed with her in detail, including an anterior approach at C2-3, or a posterior C1-3 fusion. The patient elected to have a posterior fusion to avoid the possible swallowing complications of a high cervical exposure and other possible risks of an anterior approach..\nInformed consent was obtained and the patient was brought to the operating room. Neurophysiologic monitoring was utilized to establish baseline motor and somatosensory evoked potentials. After application of cranial pinions, the patient’s neck was brought into a neutral and slightly flexed position under live fluoroscopy. A post-positioning film showed the patient’s anterolisthesis had reduced and the fractured pedicle showed improved alignment (see Figure ). Motor-evoked potentials and somatosensory-evoked potentials showed no change from baseline. A cranial reference frame was attached to the head clamp for CT-guided intraoperative navigation (see Figure ). Attachment of the cranial reference frame to the head clamp was a key step to ensure maximal accuracy of the optical system during instrumentation, as the posterior elements of C2 would not be stable enough to accept the spinous process clamp after exposure.\nAfter exposure of the posterior elements from C1-3 and the C1 lateral masses, an O-arm spin was performed for navigation registration. The left C2 pedicle was accessed using a navigated drill. The fracture line in the middle of the pedicle was crossed with the drill bit into the vertebral body. Careful palpation of the drill track with a ball-tipped probe did not show any breaches. The hole was tapped with a navigated 3.5-mm tapered tap. A 4.0 mm x 24 mm screw was slowly advanced across the fracture into the C2 vertebral body. Care was taken during screw placement to ensure purchase across the fracture so that the tip of the pedicle screw did not push the vertebral body anteriorly. Bilateral C1 and C3 lateral mass screws were then placed. The right C2 pedicle was skipped due to her congenital abnormality and the risk of vertebral artery injury. An intraoperative CT scan showed excellent hardware placement (see Figure ). A cortico-cancellous piece of iliac crest was harvested and contoured to an appropriate dimension for placement between the C1 and C2 lamina. The laminae were decorticated and a piece of iliac crest graft was placed in between. Bilateral titanium rods were cut and placed. The wound was closed in layers and the patient awoke with no complications. She was placed in a hard cervical collar post-operatively. Postoperative X-ray images were obtained after the patient mobilized and showed stability of the construct (see Figure ). |
A 53-year-old Hispanic man with past medical history significant for coronary artery disease, habitual intravenous heroin abuse, chronic untreated hepatitis C without cirrhosis, bipolar disorder, tobacco abuse of 80 pack-year, and degenerative disc disease presented from home to our hospital with chief complaint of left scrotal pain, diffuse abdominal pain, back pain, and chest pain. Four days prior to presentation, he was seen in the emergency department for chronic back pain and was discharged with naproxen and instruction to follow up with his primary care physician. Since then, he developed acute onset of sharp constant pain of his left testicle and his abdomen. He admitted to using ten bags of heroin intravenously daily. He underwent an incision and drainage one month prior for a skin abscess. He reported no new sexual partner and is only sexually active with his current girlfriend. Family history was significant for heart disease in both his parents and maternal grandparents. His vital signs on admission were within the normal range. Physical exam revealed a man, with cachexia and temporal muscle wasting, in moderate distress from pain. He had jaundice with icteric sclera. His lungs were clear to auscultation. His heart sounds had regular rate and rhythm without any audible murmur. He had a soft abdomen that was mildly distended and tender in all four quadrants. His genitourinary exam was significant for bilateral scrotal erythema and swelling, which was worse on the left and was tender to light touch. He had diffuse tenderness to his back including paraspinal muscles, but no tenderness to the spinal processes. He was alert and oriented to person, time, and place and could answer questions appropriately. He had no facial asymmetry or deviated tongue, and he displayed normal proximal and distal strength. Laboratory findings were significant for WBC of 12.1 K/mm3 with a neutrophil predominance of 90%, microcytic anemia with hemoglobin 7.7 g/dL and MCV 75.6 fL, and thrombocytopenia of 47 K/mm3. His direct bilirubin level was elevated (3.0 mg/dL), as were his alkaline phosphatase (282 U/L), AST (87 U/L), ALT (33 U/L), and LDH (393 U/L). His albumin was 1.7 g/dL and lactic acid was normal at 1.2 mmol/L. His HIV-screening test was negative, as were his gonorrhea and chlamydia molecular amplification tests. He was subsequently admitted to internal medicine service/floor for further management.\nHis initial work up included a urinalysis that was significant for 10–20 RBC per HPF, 5–10 WBC per HPF, and positive urine nitrite; an EKG that showed normal sinus rhythm; and a chest X-ray which was negative for cardiomegaly, pleural effusions, or lung consolidations. A computed tomography (CT) of his head did not show any intracranial abnormalities. A CT of his abdomen and pelvis without contrast was performed which revealed hepatosplenomegaly with multiple large wedge-shaped areas of hypoperfusion in the spleen, concerning splenic infarctions (). The scrotal ultrasound showed no torsions, but revealed left epididymo-orchitis, large complex left scrotal hydrocele, and bilateral testicular microlithiasis. A limited bedside transthoracic echocardiogram by the emergency department physicians revealed a small pericardial effusion with no observable valvular vegetations. Blood and urine cultures were collected, and he was initially started on the broad-spectrum antibiotics of vancomycin, piperacillin-tazobactam, and azithromycin considering his risk factors and clinical presentation.\nOvernight, he remained afebrile, but his leukocytosis worsened to 14.6 K/mm3, and he developed dyspnea and tachypnea with 24 breaths per minute. He became disoriented and was not answering questions appropriately. On exam, new findings of splinter hemorrhages, toe infarctions, and subconjunctival hemorrhaging were noted. Urine culture grew Serratia marcescens 50,000–100,000 CFU. Blood cultures also later grew the same organism, susceptible to all tested antibiotics including amikacin, aztreonam, cefepime, ceftriaxone, ciprofloxacin, gentamicin, ertapenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole. On hospital day 2, a formal transthoracic echocardiogram (TTE) revealed an ejection fraction of 60% (unchanged from three years prior) with a large echodensity on the aortic valve consistent with vegetation. Mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation were also noted. Antibiotics were subsequently changed toertapenem 1 g daily and ciprofloxacin 750 mg twice daily in consultation with infectious disease.\nThe patient continued to deteriorate the following day. He became more disoriented and agitated. He remained afebrile, but his tachypnea worsened to 30 breaths per minute, and new rales were now audible on lung auscultation. An arterial blood gas (pH 7.51; pCO2 21 mmHg; pO2 70 mmHg; HCO3 16 mmol/L; O2 saturation 93%) showed a respiratory alkalosis. A repeat chest X-ray showed new interstitial pulmonary edema and vascular congestion. A CT of the head without contrast was performed due to his altered mental status, which showed two areas concerning embolic infarcts in the left parietal lobe and the left cerebellum (), compared to the one obtained on admission. On hospital day 4, an urgent transesophageal echocardiogram (TEE) was performed which again demonstrated the large aortic valve vegetations (), but it now demonstrated acutely deteriorating moderate to severe aortic regurgitation, which was different from the TTE findings a few days prior that only showed mild-moderate aortic insufficiency. In addition, it also revealed a mildly dilated left ventricle. The aortic valve leaflet had prolapsed motion. Due to the presence of large aortic valve vegetations, multiple embolic phenomena, and a progressively worsening of his clinical condition, decision was made to perform an urgent aortic valve replacement.\nPostoperatively, he was managed in the surgical intensive care unit, where he developed a moderate-sized left pneumothorax requiring a chest tube placement. Slowly, his mental and clinical status began to improve. By hospital day 19, the patient was no longer agitated or disoriented. He displayed good appetite, and his chest tube was removed. His leukocytosis significantly improved to 8.0 K/mm3, and his repeat blood cultures did not grow any organisms for 5 days. Throughout his hospital course, he remained afebrile and did not receive any antipyretics. The lack of fever was concerning for an immunocompromised state, but he tested negative for HIV. He was ultimately discharged to a skilled nursing facility to complete his antibiotics, ertapenem 1 g daily with ciprofloxacin 750 mg twice daily, for a total course of 6 weeks, and to continue physical therapy. |
A 21-year-old Asian male presented to the clinic with a history of increased paranoia, irrelevant talk, self-talk, and decreased sleep for the last two years. He has no family history of any psychiatric or medical illness. He had attained all his milestones on time, and he was an active student in his school. According to his parents, the patient's symptoms had started nine years ago when he had started to show inattentiveness, impulsivity, and hyperactivity. He was diagnosed with attention deficit hyperkinetic disorder (ADHD). His parents were counseled on behavioral therapy and the need for medications. His parents refused medications and agreed to behavioral therapy. They changed his environment. But he became more irritable and aggressive by the age of 16 years and his symptoms kept worsening.\nAt the age of 18 years, he consulted a psychiatrist due to his symptoms of auditory and visual hallucinations, indifferent attitude, increased sexual desire, and aggressiveness. After excluding any illicit drug abuse and other causes, he was diagnosed with schizophrenia. He was given risperidone 2 mg and procyclidine hydrochloride 5 mg twice a day orally. He was regularly followed-up in the clinic. He remained symptom-free when he was taking his medications. After two months, he had an acute episode of seizure which lasted less than five minutes. On mental state examination, the patient was sitting comfortably, but his mood was anxious. He had decreased attention span and his thoughts and perceptions were distorted due to auditory and visual hallucinations. His judgment, abstract thinking, and memory were also distorted. According to his history, he had decreased appetite and sleep for the past two months since he had stopped taking his medication. He was observed in the hospital and a head computed tomography (CT) scan was ordered, which showed bilateral calcification in basal ganglia as can be seen in Figure .\nComplete blood count, erythrocyte sedimentation rate (ESR), urinary analysis, basal metabolic panel, urinary copper level, total plasma parathyroid hormone (PTH) level, and electroencephalogram (EEG) got done. All his lab results were evaluated to be normal, including the urinary copper level of 71 mcg and ceruloplasmin levels of 0.28 mcg. Both sleep and wake EEG came back normal. Complete physical examination revealed no other significant findings. After ruling out any metabolic causes, electrolyte abnormalities, infections, and toxic or traumatic etiology, the patient was counseled for Fahr's syndrome. As there is no well-known treatment for Fahr's syndrome, the patient was managed with risperidone and procyclidine. The patient has been responding well to his medications for the last six months. |
A 23-year-old woman presented with complaints of gradually enlarging painless lump in the left breast for 3 years. She had also noticed a new lump which had developed next to the previous lump for 6 months. She did not give history of any nipple discharge or cyclical mastalgia. Her menstrual cycles were regular and she did not have any other known comorbidities. She did not have any family history of similar illness or breast malignancies. On physical examination, there was an 8 × 10 cm firm lump with nodular surface, occupying the left breast between 2 and 6 o’clock position. A 2 × 3 cm firm mobile lump was also felt at 7 o’clock position on the same side. The skin overlying the swellings was normal. There was no palpable axillary or supraclavicular lymph nodes. A firm, mobile painless lump of 2 × 2 cm was palpable at 8 o’clock position in the contralateral breast. She was clinically suspected to have bilateral fibroadenomas. Due to the history of progressive enlargement of the left-sided lesion, she underwent an excision biopsy of both the lumps in her left breast. The patient opted not to have the surgery on the right side in the same setting. Postoperatively, her recovery was uneventful.\nTwo encapsulated fibro-fatty masses were excised measuring 9.5 × 8.5 × 5 and 4 × 2 × 1 cm. Cut section of the larger mass showed grayish white and grayish yellow solid areas, while the smaller one had a grayish white surface with slit like areas. Under the microscope, the larger mass had closely packed tubular structures lined by single layer of secretory cells and few flattened myoepithelial cells, with scanty connective tissue stroma between the tubules. The smaller mass showed a biphasic tumor with proliferation of both glandular and stromal components. Based on their characteristic features, the larger swelling was identified to be a tubular adenoma while the smaller one was reported as a fibroadenoma.\nThis case is being reported in view of the rarity of occurrence of both tubular adenoma and fibroadenoma together. To the authors’ knowledge, there has been only one other case reported to date where both the histologies have been reported in close proximity []. |
A 78-year-old woman was involved in a motor vehicle collision while traveling approximately six weeks before presenting to our institution. She initially had high cervical neck pain at the time of the event but no other neurologic symptoms. She was brought to a local trauma center at the time of the event, and a computed tomographic angiography (CTA) of the neck revealed a Levine and Edwards Type II fracture with bilateral C2 pars and pedicle fractures extending into the vertebral body with anterolisthesis of C2 on C3 (see Figure ). Also seen was a tortuous right dominant vertebral artery that filled a large C2 transverse foramen with a congenitally small pedicle (see Figure ). Her vertebral artery on the left appeared to contribute very little to her posterior circulation. There was no evidence of radiographic vascular injury. She was advised to undergo surgical fixation at the time of her injury, however, she elected to wait until she returned home. She was discharged from the outside hospital with a hard cervical collar and presented to our institution for further evaluation over a month later. After discussing the possible treatment options, including continued conservative treatment with continued external orthosis vs. surgical intervention, the patient elected for surgical intervention. The risks and benefits of the surgical options were discussed with her in detail, including an anterior approach at C2-3, or a posterior C1-3 fusion. The patient elected to have a posterior fusion to avoid the possible swallowing complications of a high cervical exposure and other possible risks of an anterior approach..\nInformed consent was obtained and the patient was brought to the operating room. Neurophysiologic monitoring was utilized to establish baseline motor and somatosensory evoked potentials. After application of cranial pinions, the patient’s neck was brought into a neutral and slightly flexed position under live fluoroscopy. A post-positioning film showed the patient’s anterolisthesis had reduced and the fractured pedicle showed improved alignment (see Figure ). Motor-evoked potentials and somatosensory-evoked potentials showed no change from baseline. A cranial reference frame was attached to the head clamp for CT-guided intraoperative navigation (see Figure ). Attachment of the cranial reference frame to the head clamp was a key step to ensure maximal accuracy of the optical system during instrumentation, as the posterior elements of C2 would not be stable enough to accept the spinous process clamp after exposure.\nAfter exposure of the posterior elements from C1-3 and the C1 lateral masses, an O-arm spin was performed for navigation registration. The left C2 pedicle was accessed using a navigated drill. The fracture line in the middle of the pedicle was crossed with the drill bit into the vertebral body. Careful palpation of the drill track with a ball-tipped probe did not show any breaches. The hole was tapped with a navigated 3.5-mm tapered tap. A 4.0 mm x 24 mm screw was slowly advanced across the fracture into the C2 vertebral body. Care was taken during screw placement to ensure purchase across the fracture so that the tip of the pedicle screw did not push the vertebral body anteriorly. Bilateral C1 and C3 lateral mass screws were then placed. The right C2 pedicle was skipped due to her congenital abnormality and the risk of vertebral artery injury. An intraoperative CT scan showed excellent hardware placement (see Figure ). A cortico-cancellous piece of iliac crest was harvested and contoured to an appropriate dimension for placement between the C1 and C2 lamina. The laminae were decorticated and a piece of iliac crest graft was placed in between. Bilateral titanium rods were cut and placed. The wound was closed in layers and the patient awoke with no complications. She was placed in a hard cervical collar post-operatively. Postoperative X-ray images were obtained after the patient mobilized and showed stability of the construct (see Figure ). |
A 13-year-old female Motswana student, who is the first born in a family of two children and being raised by a single unemployed mother, was referred to a psychiatric hospital by her local facility. She presented with a 1 week history of calling out for people who were not there as if she were conversing with them and seeing things other people could not see. She was also reported to often appear anxious and was not sleeping well at night. The symptoms appeared to worsen daily, prompting the caregivers to seek help. There have been no preceding life events that may have precipitated the symptoms, and she had never been admitted or been on treatment for any psychiatric disorder before the current presentation.\nMs K was born via a normal vaginal delivery at 32 weeks gestational age, with a birth weight of 2.1 kg. The mother was Gravida 2, Para 2, and antenatal history was unremarkable. Her mother highlighted that the patient had delayed developmental milestones as she did not walk and talk until after age two. Regarding social development, Ms K was reported to prefer solitary activities, and if she interacted with others, she would choose children younger than her. She reportedly attended a normal stream school for 2 years but was transferred to a special needs school (i.e. school for children with learning difficulties) because of academic difficulties.\nOn medical history, she has been diagnosed with a complex congenital heart disease: pulmonary atresia, large ventricular septal defect, pulmonary regurgitation, right ventricular hypertension and failure. She underwent corrective surgeries for the cardiac conditions at ages 6 years and 12 years, an umbilical herniorrhaphy at 3 years and clubfoot repair at 2 years.\nTypical features of DGS on physical appearance were a broad flat nose, small ears and a thoracolumbar scoliosis, whereas the typical long face, hypertelorism and micrognathia were absent. Physical examination revealed a mediastinal scar and a pansystolic murmur. Her blood pressure was 113/83 mmHg, pulse rate was 114 beats/minute and temperature was 35.8 °C. Investigations such as full blood count, liver function test, urea and electrolytes were within normal ranges. A chromosomal analysis was positive for chromosome 22 deletion syndrome.\nMental status assessment on the index consultation revealed a well-nourished adolescent. She was very restless, pacing up and down the interview room, thus making it difficult to establish a rapport. There was no eye contact. She had a labile affect. She was socially inappropriate as she kept undressing during the interview. Thought process was mostly tangential. She had fixed belief that her family members were bewitching her. She reported that God was commanding her to take her clothes off and she admitted to seeing a short man in the interview room.\nA working diagnosis of acute schizophrenia-like psychotic disorder was made using the International Classification of Diseases-10 (ICD-10) diagnostic criteria. The patient was admitted on haloperidol 3 mg at night. Four days post admission, she was noted to have increased motor activity, restlessness and sialorrhea, whereas the psychotic symptoms persisted. Manic symptoms such as elated or irritable mood and increased energy were absent. On suspicion of akathisia, haloperidol was stopped and she was started on olanzapine, 5 mg once daily at night. The extra pyramidal side effects (EPSE) symptoms reduced after 2 days. Psychotic symptoms subsided on day nine post admission. She stabilised 2 weeks after admission and was discharged on olanzapine 5 mg once daily at night. She was reviewed in an outpatient clinic after 2 weeks and remained stable. She continued reviews as an outpatient for 4 months and medication dose was reduced to 2.5 mg nocte. A month later, she presented to OPD with history of poor sleep at night, laughing inappropriately and isolating self. Medication was reviewed upwards to olanzapine 5 mg nocte as it was on discharge. For long-term management, patient was to be enrolled in vocational training and behavioural therapy. A definitive diagnosis of early-onset schizophrenia in a patient with DiGeorge syndrome was made. |
A 53-year-old man with a 13-year history of Type 2 diabetes mellitus presented to our foot clinic with an ulcer over the plantar aspect of his right second metatarsophalangeal joint and right dorsal second toe. He was known to have a Charcot (neuroarthropathic) foot on the left, diagnosed four years previously. Three months prior to presentation, he had undergone a third metatarsal ray amputation for ulceration and osteomyelitis. On examination, the wound appeared clean and a small piece of bone was removed. Radiographs of the foot showed new bone destruction centred on the neck of the second metatarsal with dislocation of the second metatarsophalangeal joint, in keeping with osteomyelitis (). In accordance with our local antibiotic protocol, he was started on a course of oral co-amoxiclav. Despite this, an magnetic resonance imaging scan done three weeks later showed extensive osteomyelitis within the second metatarsal with bone fragmentation of the metatarsal head and involvement of the metatarsophalangeal joint. In addition, there was extensive periosseous phlegmon formation around the second metatarsal shaft (). Despite these radiological findings, the patient was reluctant to pursue surgical options, opting for another course of broad spectrum antibiotics. Another magnetic resonance imaging scan performed 6 weeks later showed persisting osteomyelitis involving the second metatarsal, with an increasing larger concentric soft tissue mass along the shaft of the second metatarsal associated with bony destruction. However, clinically his foot had no swelling or erythema. Over the subsequent two months he had ongoing debridement and offloading of his foot ulcer. Sequential radiographs showed ongoing exuberant bone formation, bony erosion and periosteal reaction of the right second metatarsal (). His ulcer persisted and a further magnetic resonance imaging scan suggested ongoing osteomyelitis in the second metatarsal. Nevertheless, on examination, his foot showed no evidence suggestive of underlying infection. After discussion with the specialist soft tissue radiologist, it was felt that the images of the second metatarsal represented Myositis ossificans with concurrent osteomyelitis. |
A 22-year-old female was admitted to the Jilin Cancer Hospital (Changchun, China) in May 2013. In January 2009, a 2.0×3.0 cm painless mass was surgically removed from the left parotid gland of the patient. Postoperative pathology characterized the mass as a lymphocytic hyperplasia; however, parotid duct cells were also detected within the lymphocytes. Morphological results and immunohistochemical staining supported the diagnosis of a BLEL.\nAfter six months, the left parotid gland became locally swollen again and intermittent management with traditional Chinese medicine was unable to achieve remission. In October 2010, the size of the mass reached 5.0×6.0 cm. A computerized tomography (CT) scan of the parotid gland indicated a soft tissue mass in the left neck area without uniform density or a clear border with the left parotid gland, and evident infiltration in the surrounding tissue. The mass was considered to be a recurrence of the BLEL in the left parotid gland; however, the patient did not agree to further surgical therapy. The mass in the left parotid gland area became gradually enlarged, and was more evident when the patient became ill with a cold; however, the mass was slightly reduced following anti-infective treatment (mainly with cephalosporins). The patient also received traditional Chinese medicine for six months and local acupuncture therapy for 40 days. However, the mass in the left parotid gland area was continually increasing in size and reached a diameter of 15 cm. On April 27 2013, the patient developed a fever of up to 40°C, accompanied with shivering, weakness and a loss of appetite, which was more severe in the afternoon and at night. Remission was observed following self-medication with oral ibuprofen; however, the temperature of the patient increased after several hours and a light yellow, clear liquid was discharged from the ulceration on the skin surface of the left parotid gland mass. On May 4 2013, the patient visited the Jilin Cancer Hospital, where the local ulceration and infection of the left parotid gland mass was managed with anti-infective treatment for three days; however, the high temperature of the patient did not decrease and the mass did not reduce in size. The patient was admitted to the hospital for further therapy on May 8 2013, and physical examination identified a large mass of 17×14 cm on the left side of the patient’s face, a red and swollen skin surface and multiple ruptures in the middle of the mass with a light yellow liquid discharge. The peripheral skin of the mass was tenacious and swollen, and the skin temperature was high. A blood routine examination and liver and renal functions were found to be normal. Color ultrasound revealed a visible 18.2×8.5-cm low-echo area with strong-echo stripes under the skin on the left side of the patient’s face, without the appearance of a clear margin. Color Doppler flow imaging revealed an abundant blood flow in the mass and the absence of normal parotid gland tissue, indicating a solid space-occupying lesion on the left parotid gland. A CT scan of the left parotid gland revealed an abnormal mass in a low-density image and an undefined margin of the lesion, with the superior border extending towards the orbit, the inferior border at the submaxillary level, the inner border at the left parapharyngeal space and the outside border at the skin of the left-side of the face. The mass reached 13.4×9.7 cm in an axial view, showing uniform density and a CT value of 47 HU (), with the left parotid gland unable to be distinguished. The lesion was wrapped around the left sphenoid bone and mandible. In addition, morphological changes were observed, indicating recurrence of the BLEL in the left parotid gland with bone resorption of the sphenoid bone and mandible. A bacterial culture of the mass discharge indicated a Staphylococcus aureus infection, which was sensitive to levofloxacin. The body temperature of the patient returned to normal levels following the administration of levofloxacin for one week. A biopsy was not performed due to the weakness, high fever, local swelling and infection of the patient, as well as the abundant blood flow detected in the mass with color ultrasound. No consensus was reached with regard to further surgical intervention. Drugs inhibiting vascular endothelial growth (Endostar and Shenyi capsules) were administered for five days, but were discontinued by the patient due to local pain and swelling. Chemoradiotherapy was subsequently considered; however, due to the young age of the patient and the examination results not indicating malignance, the patient did not agree to the therapy.\nFollowing failed conservative treatment, DC-CIK therapy was initiated based on the immune index result of the patient, which found the percentage of inhibitory T cells to be 32.2% (CD8+CD28−; normal range, 9.8–21.8%) and the CD4+/CD8+ ratio to be 0.42 (), indicating low immunity. The patient signed informed consent for the treatment protocol, which was approved for tumor patients by the Health Department of Jilin Province (Changchun, China) and the Ethics Committee of the Jilin Cancer Hospital.\nAntigen-presenting DCs and CIK cells were produced using heat shock protein-70, extracted from a head and neck squamous carcinoma cell strain supplied by the Jilin Cancer Hospital, and cocultured with cord blood DCs.\nThe duration of the first treatment session was 10 days, after which the treatment was discontinued for 10 days. Following the initial treatment course, the lesion in the left parotid gland area was reduced, while the local infection and skin ulceration were soothed. Biotherapy was continued for three months (four sessions of treatment), after which the left parotid gland lesion disappeared and the skin ulceration was healed.\nParotid gland CT scans () indicated that the primary lesion of the left parotid gland area disappeared gradually and the bone destruction was completely recovered. The patient was discharged from hospital and the condition remained stable without signs of recurrence during a follow-up period of 10 months; however, the patient remains under close observation. |
A 59-year-old male was transferred to our hospital presenting with a headache after falling backward. No neurological deficit was observed. The brain computerized tomography (CT) at the first hospital showed a small amount of ASDH in the right side of posterior fossa (). The patient was admitted to our intensive care unit for careful observation of his neurological status without operation. Several hours after the admission, the patient's condition got worse to drowsy from alert mentality. The follow-up brain CT revealed a newly developed intraparenchymal haemorrhage in the right cerebellar hemisphere and an increased amount of the right subdural haematoma (). The right intracerebellar parenchymal haemorrhage was considered to be the main cause of the deterioration of mentality.\nAfter informed consent, the patient was transferred to an operation room. A midline incision and right suboccipital craniotomy were performed in a prone position under general anaesthesia. Most of the intraparenchymal hemorrhage was smoothly removed. However, as soon as we removed the haematoma located around the right lower lateral corner covered with unresected bone, a sudden excessive blood poured into the operation field. Due to the huge amount of bleeding and the bone, which had not been resected at the beginning of the operation, concealing the bleeding point, the location of the bleeding point could not be determined. The bleeding seemed to be from a venous sinus at the far lower lateral corner of right posterior fossa. To stop the bleeding, TachoSil (Baxter, Deerfield, IL, USA) was used, but to no avail. The amount of bleeding was increasing and became rampant and uncontrollable. The blood pressure decreased so rapidly that we did not have enough time to use another way of hemostasis. Eventually a cardiac arrest occurred in 2 or 3 minutes. For the immediate cardiopulmonary resuscitation, we promptly packed a 4×8-inch gauze into the bleeding site for the bleeding control and closed the wound by suturing of the skin directly without dura or subcutaneous closure, with one-third of the gauze remaining in the epidural space. During the closure, only a small amount of blood oozing was observed through the packed gauze. The patient's heart rhythm recovered soon after an injection of epinephrine and the gauze packing while closing the skin.\nWe quit the operation at that point and transferred the patient to the intensive care unit. He was relatively stable; the blood pressure was around 100 mmHg, the pupils were isocoric and showed a prompt light reflex. On day 2 after the operation, the brain CT showed no significant intraparenchymal hemorrhage around the gauze, ischemic lesion, and brain stem compression except the hyperdense shadow of the gauze (). In the next several days, the patient gradually recovered to drowsy mentality without significant motor weakness. The patient became febrile over 38°C from the second post-operation day.\nOn day 10 after the operation, the patient got the second operation to remove the previously packed gauze. The enhanced preoperative brain CT showed occlusion of the right transverse sinus at the distal end, and we confirmed that again with transfemoral cerebral angiography for a safe surgery (). While reviewing the images before the second surgery, we found that there was a diastatic fracture of right occipitomastoid suture around the subdural hematoma (). The fracture might have caused the sigmoid sinus injury and the development of the subdural haematoma. During the removal of the gauze, no recurrent haemorrhage from the sinus, which had been expected through the enhanced preoperative CT and the cerebral angiography, was observed. There was no intraparenchymal hemorrhage inside and around the gauze. The patient improved to the light drowsy status on day 2 after the operation and became afebrile immediately after the second operation. He was getting better over time and became alert. On day 26 after the second operation, he was transferred to the rehabilitation department for the management of gait difficulty. |
A 42-year-old male presented in emergency with history of sudden onset palpitations and chest discomfort. Half an hour before presentation in the emergency department, the patient was doing his normal routine work in kitchen garden where he was bitten by a flock of wasps over his head, back, and arms. He developed sudden pain and redness at the site of wasp bites. Thereby, he applied some oil as a home remedial measure to the local site. After about 15 min of the wasp bite, he experienced palpitations and chest discomfort which was sudden in onset and but persistent. He described them as fast and regular thumping in the chest that he had never experienced before. The episode was not associated with loss of consciousness, sweating, or chest pain. Within half an hour of the episode, he presented to the emergency department of our hospital. He also had one episode of vomiting while coming to hospital. He had no history of ischemic heart disease, hypertension, diabetes, and any other autoimmune disease. The patient was not taking any herbal or allopathic medications. On examination, patient was conscious, well oriented to time, place, and person. His pulse was 180/min regular, blood pressure of 164/86 mmHg, respiratory rate of 16/min, and oxygen saturation of 98% at room air. He was anxious and restless. His cardiovascular examination was normal except for tachycardia. His electrocardiography was done which showed wide QRS tachycardia with loss of P waves fitting into sustained VT of right bundle branch block type according to the Brugada criteria for VT (as shown in ). The patient was given a slow intravenous bolus of injection amiodarone 150 mg after which tachycardia improved and rhythm became sinus. The patient was put on tablet metoprolol 25 mg twice a day. The patient was also given injection chlorpheniramine and dexamethasone followed by tablet cetirizine 10 mg in once a day. Patient was kept for observation for next 48 h during which his vitals gradually improved. Transthoracic echo was normal with no regional wall motion abnormalities and normal ejection fraction. Serial electrocardiograms were normal. Further investigations such as electrophysiological studies, cardiac magnetic resonance imaging (MRI) were planned, but the patient refused for the same. The patient was discharged in satisfactory condition. |
A 39-year-old lady was referred to a rheumatology clinic with a history of recurrent febrile illness. The patient was enjoying her usual life till the age of 35 years when she developed fever associated with aphthous ulcers, stomatitis, and tonsillitis. The patient was also having severe myalgia, arthralgia, and generalized body aches to an extent that she was unable to carry out her daily activities. This episode resolved after five days. Thereafter, the patient had recurrent similar febrile episodes every 4th week. The patient was seen by her physician, and initially, she was managed as having viral infection and then as tonsillitis with antibiotics. She continued to have similar episodes at regular intervals. The attacks were so regular that the patient and her family could foretell the exact day when an episode will occur. The patient underwent tonsillectomy as she was having regular febrile episodes with tonsillitis and stomatitis for almost 2 years. After tonsillectomy, she continued to have similar febrile episodes at regular intervals but with less intensity and less frequency for almost 6 months. Six months after surgery, the patient started to have similar attacks with increase in severity. At her last febrile episode, the patient was admitted to a hospital and extensively investigated as a case of pyrexia of unknown origin. The following set of investigations were all normal during her stay in hospital: full blood count, renal function, liver function, urine and blood cultures, swab culture from throat, ASO titers, and CT imaging of neck, chest, abdomen, and pelvis. The patient was discharged with outpatient referral to the rheumatology department.\nIn the rheumatology outpatient clinic, the patient was initially seen between the attacks when she was completely asymptomatic. A detailed history was taken from the patient. There was no history of joint swelling, skin rash, hair fall, Raynaud's phenomenon, and genital ulceration. Systemic review was unremarkable. There was no history of headache, recurrent chest pain, shortness of breath, recurrent abdominal pain, or urinary symptoms. Between the episodes, the patient was completely normal and living a healthy life. Febrile episode was not related to the menstrual cycle of patient.\nThere was no history of similar recurrent febrile episode in any of the first- or second-degree family member.\nOn examination, the patient was not in any apparent distress and looked well built.\nHer weight was 68 kg, temperature 37°C, blood pressure 114/70, and pulse 82/min (regular).\nThe patient was not pale and not jaundiced. There was no cervical and axillary lymphadenopathy. Ear and nose examination were normal. Oral cavity examination was completely normal. Lung and heart examination revealed normal vesicular breathing and normal heart sounds, respectively. Abdominal examination was also normal with no evidence of organomegaly. Further investigation revealed negative ANA, rheumatoid factor, and negative antibodies against extractable nuclear antigen (ENA).\nClinical diagnosis of PFAPA was made, and the patient was started on colchicine 0.5 mg orally twice daily and later on ranitidine 150 mg once daily as prophylaxis, but she continued to have similar attacks every 4 to 5 weeks.\nThe patient was advised to take prednisolone 60 mg orally with one dose at the start of episode.\nThe patient responded to the single high dose of steroid with resolution of symptoms within 1 day. On regular follow-up, the patient did report of more frequent attacks every 2 to 3 weeks after starting steroid. Currently, the patient is advised to take a single high dose of prednisolone at the start of febrile illness. The patient lost follow-up as she moved to a different country. |
A 60-year-old male with a past medical history significant only for benign prostatic hyperplasia presented to our Emergency Department (ED) with chief complaints of gradual onset of progressively worsening speech difficulty (predominantly word finding with stuttering) and confusion (inability to recognize his family members).\nHis symptoms started four weeks priorly, beginning with constitutional symptoms of headache, fatigue, and vertigo. This slowly led to intermittent confusion, slurred speech, and intermittent spasms of his right upper and lower extremities. His spasms and weakness resulted in a fall from a tractor one week into the course of his symptoms fortunately without significant trauma nor loss of consciousness. His family gave additional potentially relevant information of a recent visit to Mexico where he stayed for four months before returning home. He was asymptomatic upon return to the USA, but symptoms started approximately four weeks later. Interestingly, while in Mexico, he worked in the cattle manure industry which he does locally as well. He was relatively healthy at baseline without any previous surgeries and no family history of diabetes, seizure, dementia, nor neurodegenerative conditions.\nHe initially visited an urgent care center with these complaints ten days prior to this hospital encounter. At that time, he was found to have a normal neurological examination, brain MRI, and carotid Doppler. He was discharged home with a working diagnosis of transient ischemic attack. His symptoms continued to worsen however, thus motivating him to present to the ED for further evaluation.\nUpon arrival to the ED, he complained of photophobia, neck pain, and vertigo but was afebrile. His initial physical examination included vital signs: pulse 85 beats per minute, blood pressure 135/78 mmHg, temperature 98 F, and a respiratory rate of 18 per minute. Initial neurological examination was unremarkable except for persistent word finding difficulty. Initial lab work is summarized in table format (). A noncontrast head computed tomography (CT) scan was negative for any acute intracranial pathology. Initial CSF analysis was inconclusive for any acute infectious etiology although he had a mildly elevated protein level of 65 mg/dl (). He was admitted to the neurology unit and diagnosed with a complex migraine and treated with intravenous (IV) ketorolac, sumatriptan, and promethazine. A neurology consult was obtained and an EEG ordered.\nInitial EEG on his second hospital day showed focal seizures emanating from the left frontal region () and he was started on oral levetiracetam (loading dose of 1 gram followed by 750 mg PO twice daily thereafter). He started complaining of right upper extremity weakness and on repeat physical exam was found to have diminished deep tendon reflexes of his right upper extremity (RUE) with weakness in pronation and fine motor activity. On hospital day #3, he developed intermittent myoclonic jerking of his RUE with a fine, persistent tremor. At this point intermittent focal seizure activity was thought to be precipitated from his minor head trauma related to his fall. Differential diagnoses, though less likely, included an infectious etiology which was excluded with negative microbiology, a stroke despite a normal MRI, or other common metabolic causes including electrolyte abnormalities, ammonia, toxins, and liver and kidney dysfunction. Medications were also considered which could potentially lower seizure threshold, and tramadol and diphenhydramine were discontinued.\nOver the next few days he gradually became drowsier and confused with worsening of his expressive aphasia and development of cerebellar dysfunction on exam. His dose of levetiracetam was increased to 1 gm twice daily. Initial MRI of brain during this hospital encounter was performed which did not show any acute intracranial lesion except mild cerebral and cerebellar substance loss ().\nHis cognition and right upper extremity shaking/tremor rapidly worsened and, on hospital day #4, EEG was significant for persistent focal seizures in left hemisphere despite being on levetiracetam (). He was started on lacosamide 200 mg twice daily in addition to the ongoing levetiracetam increased now to 1 gm three times daily. Continuous EEG was started at this point to closer monitor effectiveness of therapies. A repeat MRI brain with contrast on hospital day #5 showed developing cytotoxic edema in the left frontal and parietal lobe with punctate calcified lesions in right cortex () which was considered likely due to persistent seizure activity. Given the initial CSF result showing elevated proteins (65 mg/dl), ongoing myoclonus, and the newly developed vasogenic edema on MRI, the decision was made by neurology at this point, to start a 3-day course of pulse dose steroids (solumedrol 1 gm IV/daily) for possible autoimmune encephalitis (AE) while awaiting the finalized autoimmune workup [, ].\nUnfortunately, despite the increasing doses of antiepileptics and the high dose steroids, the patient continued to decline neurologically. Continuous EEG revealed persistent epileptogenic activity with bilateral hemispheric discharges (left > right) (). Valproic acid (500 mg orally three times daily) was added to his regimen and lacosamide increased to 200 mg three times daily. His initial CSF (collected on the first hospital day) was sent for oligoclonal bands and infectious encephalopathies which all eventually came back negative (). Acyclovir was started empirically for possible viral encephalitis but subsequently discontinued two days later when CSF resulted negative.\nDuring the next few days (hospital days nine to eleven) he remained globally aphasic with RUE flaccidity. He would awaken but was unable to follow commands. A repeat MRI showed persistent ribboning in the left hemispheric region () and EEG () showed “diffuse epileptiform discharge suggestive of encephalopathic state with presence of continuous left frontal and sometimes synchronized bifrontal sharps spikes with a more generalized appearance, which was concerning for nonconvulsive status epilepticus.” Perampanel was added to his antiseizure regimen at dose of 4 mg twice daily. Efficacy of perampanel has been established as an adjunct treatment for partial-onset seizures with or without secondary generalization and primary generalized tonic-clonic seizures in idiopathic generalized epilepsy as well as for treatment of refractory seizures. This patient was having refractory seizures; therefore, this medication was added [].\nAt this point CJD was considered among other possible etiologies such as paraneoplastic encephalitis, meningeal carcinomatous, infectious cerebritis, and primary CNS angiitis given his continued deterioration and refractory status epilepticus. Computed tomography angiogram (CTA) excluded the primary central nervous system (CNS) angiitis. A repeat lumbar puncture was performed with additional CSF tests ordered including Epstein-Barr virus (EBV), acid fast bacilli (AFB), fungal culture, Zika virus, 14-3-3 protein, neurocysticercosis antibodies, and an autoimmune and paraneoplastic panel.\nEventually phenobarbital (16.2 mg twice daily) was started yet he continued to deteriorate remaining aphasic with flaccid paralysis in RUE and lost his ability to protect his airway requiring intubation on hospital day #11. His EEG remained without any significant improvement. On hospital day #13, while awaiting results from his repeat CSF analysis, neurology felt it was prudent to again trial high dose steroids (solumedrol 1 gm IV daily) for potential AE which continued for the next 5 days without obvious efficacy.\nHe remained in a persistent coma at this point and lost reflexes to even deep painful stimuli while cEEG showed continuous episodic sharp wave from left frontal and synchronized bifrontal discharge was obvious on lowering his sedation (). Seizures were refractory to extensive antiseizure medication regimen including keppra 1500 mg twice daily, lacosamide 200 mg three times daily, perampanel 4 mg twice daily, phenobarbital 120 mg twice daily, and valproic acid 1 gm twice daily.\nOn hospital day #23, his course was complicated by development of ventilator associated pneumonia, for which he was started on vancomycin and cefepime. Cultures from bronchoalveolar lavage were negative.\nHis neurological condition did not improve with EEG persistently showing frequent generalized epileptiform discharges (). Repeat MRI brain () showed extensive and persistent worse cortical ribboning particularly around the left hemisphere, and involving right frontal, and limited involvement of the basal ganglia without any acute infarct on diffusion weighted imaging (DWI) (suggestive of cytotoxic edema from prolonged seizure activity and early CJD). Tissue diagnosis from brain biopsy was discussed but, given hospital policy and limitations, deemed not possible.\nOn hospital day #26, his CSF finally resulted from the national laboratory positive for 14-3-3 protein, tau protein, and Real-Time Quaking-Induced Conversion (RT-QuIC) proteins, confirming prion disease. Before giving his family the news of the results, and for prognostication purposes, his sedation was held for several hours. On physical exam, he lacked any withdrawal response to painful stimuli but maintained cough and gag reflexes with a minimal, sluggish pupillary reflex. EEG () at that time showed a worsening seizure activity pattern which initially started as focal left frontal lobe diffuse spike-wave complexes but now had progressed into generalized epileptiform discharges with development of nonconvulsive status epilepticus (NCSE).\nA family conference was held discussing the patient's terminal diagnosis and a decision was made to transition the patient to comfort care with compassionate extubation. He died shortly after extubation with family at bedside. The county health department was involved in his case and investigations were performed at the local manure plant to test for potential cow involvement, usually seen in variant (vCJD), which was unremarkable. However, our patient's age of disease onset, typical EEG (PSWC), absent pulvinar sign on MRI as well as lack of past medical/surgical and family history was not consistent with vCJD. Thus, he was diagnosed with probable sCJD. His remains were cremated, and his ashes taken to Mexico by family preventing final genetic testing to be performed. |
A 2-year old girl was referred to the Jos University Teaching Hospital in north central Nigeria, with complains of progressive cough and difficulty in breathing in the preceding six months. She was treated at several health facilities for pneumonia and asthma without resolution of symptoms. Patient had no fever or features suggestive of tuberculosis. Pregnancy, delivery, neonatal and infant periods were uneventful and patient had received all immunization appropriate for her age. Examination at presentation showed a child in severe respiratory difficulty necessitating oxygen administration, with Spo2 89–90% at room air and 96% on oxygen by nasal prongs. There was bulging of the right side of her anterior chest wall and markedly reduced breath sounds on the right hemithorax. No features suggestive of congenital heart disease. Chest X-ray showed homogenous opacity continuous with the cardiac silhouette, involving almost the entire right thoracic cavity with a shift of the mediastinum to the left (Fig. ). Echocardiography confirmed a very large well defined mediastinal cyst compressing the right atrium, left atrium and right ventricle (Fig. ). Contrast-enhanced computed tomography scan of the chest showed a well defined large cyst of the anterior mediastinum compressing the right main bronchus (Fig. ). Blood investigations were all normal. A diagnosis of anterior mediastinal cyst was made and the patient had right posterolateral thoracotomy through the fifth intercostals space. Intraoperatively a large tense cyst measuring 20 × 16 × 3.5 cm was noted adjacent to the pericardium and attached loosely to the thymus compressing but not attached to the bronchus. The cyst was unilocular with a thick wall and contained serous fluid (Figs. & ); the cyst was excised en bloc. There was moderate pericardial fluid which was drained by a pericardiostomy. Histopathological sections showed ectopic pancreatic tissues in the wall of the cyst (Figs. , and ). The post operative course was uneventful; the patient has been asymptomatic after a followed-up period of twenty four months. |
A 58 year-old male with end stage renal disease due to IgA nephropathy who had previously undergone a renal transplant which had failed was declined for redo renal transplantation. He had progressive dyspnoea and a history of syncope on exertion. The transthoracic echocardiogram confirmed severe stenosis of a BAV with a peak velocity of 3.9 m/s (peak gradient 61 mmHg, mean gradient of 39 mmHg and area of 0.89 cm2). There was also the presence of moderate aortic regurgitation. Coronary angiography revealed non-flow limiting coronary artery disease. MSCT confirmed a Sievers Type 1 bicuspid valve with a partial raphe between the right and left cusps. The aortic annulus was large with a perimeter measuring 98 mm, mean Sinus of Valsalva diameter of 40 mm and an inter-commisural distance of 29 mm (Figure ). Both common femoral arteries were of large caliber and measured 8 mm on the left and 9 mm on the right. Following discussion by the Heart team and careful analysis of the MSCT it was felt that TAVI was technically possible if deployed at the inter-commisural space.\nTAVI was performed under local anesthetic and the right femoral artery was cannulated and a 20 Fr sheath was inserted. The left femoral artery was cannulated and a 7 Fr sheath was inserted. The left femoral vein was used for insertion of a temporary pacemaker lead. The bicuspid aortic valve was crossed retrogradely using a Amplatz Left 1 diagnostic catheter and a hydrophilic coated straight tipped Glidewire. This was exchanged for a pre-shaped Safari wire and placed in the left ventricular apex. A balloon valvuloplasty was performed using a 25 mm balloon and a simultaneous aortogram was performed. The aortogram revealed a leak of contrast into the left ventricular cavity during balloon aortic valvuloplasty and felt to be an inadequate seal. A 34 mm Evolut CoreValve was deployed at the level of the leaflet tips, with hemodynamics and echocardiography confirming a good result with no significant PVL. The peak velocity across the TAVI valve was 1.8 m/s, peak gradient of 14 mmHg and area of 1.11 cm2. |
A 63-year-old male patient was transferred to the emergency department of the first affiliated hospital of Nanjing Medical University for esophageal foreign body. Two weeks ago, he swallowed fish bone and it got stuck, after attempt of pushing downward by bolus, the foreign body sensation aggravated gradually in the next few days, and the local community hospital initiated antibiotics therapy on the 3rd day without laryngoscope and gastroscopy examination for local poor medical condition. Until referral on the 12th day, symptoms showed no signs of decreasing. On admission, the patient couldn’t lie down due to a swollen neck with activity limitation, and body temperature was 39 °C; blood pressure, 139/82 mmHg; hemoglobin 11.5 g and white blood cell count 20,200. Contrast-enhanced CT results showed an abscess confined to right mediastinal pleural with two high density foreign bodies in the abscess at the level of the sternum angle, one located the medial margin of the carotid artery and the other at outside of the esophagus wall (Fig. ).\nSurgical scheme was made to adopt a single lumen intubation, a horizontal position, with upper back elevated to suitable height avoiding neck overextension and possible injury of fish bones to the adjacent carotid artery. After anesthesia, the location and diameter of perforation was explored by a gastroenterologist with endoscopy, which showed a rim of compressed fibrous tissue protruding from the esophageal mucosa 24 cm from the incisor. Nasogastric decompression tube and nasointestinal feeding tube were placed, while stent was needless since no obvious crevice was found. Subsequently, the thoracic surgeons probed the abscess with an incision anterior to the border of sterno-mastoid muscle. After exposing the deep layer of cervical fascia, the abscess wall with high tension was palpable. After abscess cavity decompression and pus drawing for a bacteriological examination with injector puncture, the abscess wall was cut and the pus was cleared with further suction. In consideration of the sharp fish bone adjacent to the carotid artery and the deep abscess extending to the mediastinum, which caused huge risk of bleeding and difficulty of exposure, video-mediastinoscopy was applied via the abscess wall incision. Two fish bones with locations coincident to preoperative CT results were displayed clearly on the screen (Fig. ). With a grasper through the wide operating channel of the video-mediastinoscopy, fish bones were removed carefully, then,the abscess septations were debrided completely and flushed with diluted iodine, hydrogen peroxide and saline in sequence. Three drainage tubes were embedded at the top, center and bottom of the abscess.\nPostoperative comprehensive therapy included anti-infection and nutrition support. Pus culture was positive for pseudomonas aeruginosa, which is sensitive to sulperazone. The patient received intravenous drip for 7 days until the body temperature and blood routine returned to normal. Continuous irrigation with diluted iodine lasted for 7 days until liquid drainage disappeared. On postoperative day 14, after upper gastroenterography and CT confirmed satisfactory closure of the abscess cavity without contrast agent leakage and all routine examinations recovered to normal, all indwelling tubes were removed. Enteral feeding was then initiated and the patient was discharged without any problems on postoperative day 16. Follow-up results on postoperative day 30 showed no problem. |
A 23-year-old Indonesian female presented with a bend of the second to fifth fingers of both hands. She had been suffering from multiple joint pain, swelling, deformities, and fever as well as red patches on her face and erythematous nodules on both arms and legs for 4 years. She was initially diagnosed with systemic lupus erythematosus in the Internal Medicine Department, but after being treated, there was no improvement of her condition. She was then transferred to our department. We found a bacterial index of 4+ and a morphological index of 59.7% from the slit skin smear examination. The patient was then diagnosed with lepromatous leprosy with second-grade deformity and erythema nodosum leprosum reaction. She received multidrug therapy based on the World Health Organization multibacillary regimen for 12 months along with prednisone for 6 months. One year after release from treatment, multiple erythematous nodules reappeared, and she was diagnosed with erythema nodosum leprosum and received prednisone for 3 more months.\nIn the current examination, we found bilateral madarosis and hyperextension of the PIP joints and flexion of the DIP joints of the second to fifth fingers of both hands (Fig. , ). Neurological examinations showed ulnar nerve thickening by palpation and hypoesthesia without motor impairment of the fourth and fifth fingers of both hands. Bacteriological examination found no acid-fast bacilli. Radiograph examination revealed resorption of the end of the distal phalanges, cupping form deformity of the base of the proximal phalangeal joints of the second, third, and fifth fingers of the left hand and of the second and fifth fingers of the right hand. In addition, narrowing of the metacarpophalangeal joints of the second, third, and fifth fingers of the right hand and sclerosis of the second and fifth fingers of the right hand were also observed (Fig. , ). These results indicated abnormalities due to leprosy. Assessment performed by the Department of Physical and Rehabilitative Medicine showed no motor impairment, and the patient was diagnosed with swan neck deformity of the second to fifth fingers of both hands. |
The third case was of a forty two year old gentleman who again had been dancing the ‘Jerusalema’ with his daughter at home and felt a sudden pop at the back of his left leg. He described the injury occurring in a similar fashion to our last patient following a small jump and push off the floor with his left leg.\nHe presented to the emergency department in MRHT where he was clinically diagnosed with a ruptured Right TA with a clear loss of tendinous definition and a palpable tendinous gap approximately 4–6 cm from its calcaneal insertion (). His past medical history was unremarkable except for an elevated Body Mass Index (BMI) of 32 and he is a non-smoker.\nAll three patients recalled the injury occurring at a specific part of the dance with one gentleman having caught it on video ().\nOf note none of our patients had recently taken any class of antibiotics or steroids prior to their injury.\nUpon review, all three gentlemen were offered either an operative or a non-operative management approach and were counselled on the risks and potential benefits of each. All three of them opted for an operative approach.\nEach one of our three patients was operated on the day after presentation to the emergency department on a scheduled trauma list.\nIn all three cases they were given a general anaesthetic, prophylactic antibiotics in accordance with local guidelines and were positioned prone for the operation.\nThe TA was approached via a 5-7 cm incision medial to the tendon with care taken to avoid damage to the soft-tissue envelope by utilizing only gentle traction of the skin edges for exposure.\nIntra operatively all three gentlemen were seen to have a complete TA ruptures.\nEach patient underwent an open end to end modified Krakow repair of the tendon with a 5 Ethibond suture and 2/0 Vicryl circumferential suture with the foot in plantar flexion. The posterior compartment was decompressed in all 3 cases. The contralateral extremity was used as a guide for the restoration of proper tendon length.\nThe subcutaneous tissue was closed with 3/0 Vicryl interrupted sutures and the skin was closed with 3/0 Quill. The wounds were dressed in the operating theatre and all three patients were put in a walking boot with a one inch heel raise putting them in approximately 20 degrees of plantar flexion.\nThere were no intraoperative complications in any of the surgeries.\nAll patients were given one more dose of intravenous antibiotics on the ward, analgesia as required and were also placed in an Unna compression bandage prior to discharge on post-operative day one.\nThey were educated on the walking boot, weightbearing status, symptoms of lower limb venous thrombosis and were given follow up dressings clinic and outpatients clinic appointments.\nAll three gentlemen were seen back in our outpatients dressing at 12 days for wound review of which there were no post-operative wound complications. Subsequently at their outpatients clinic review at three weeks post-operative, all patients were clinically well. The one inch heel raise was removed from the walker boot. Weightbearing instructions were given, and controlled ankle range of movement exercises limiting dorsiflexion to neutral was employed.\nSubsequent outpatient clinic visits have been uneventful with all three gentlemen progressing with no issues. They are currently in phase 3 of our accelerated rehabilitation programme (see ) and are attending the outpatient physiotherapy clinic for gait retraining. |
A healthy 17-year-old male patient was referred to our hospital for treatment of CO poisoning that had occurred while he was bathing near a gas heater. Half an hour after the poisoning, he was found foaming at the mouth, delirious, and cold to the touch, but he had no physical tics or incontinence. He was admitted to a local hospital 1 hour after the poisoning, where he recovered consciousness. Approximately 2 hours after the poisoning, he was transferred to the intensive care unit of a local traditional Chinese medicine hospital. Upon admission, he felt dizziness, chest tightness, chills, and shortness of breath. His blood pressure could not be measured, and laboratory examinations revealed dysfunction of the heart, liver, kidney, pancreas, and blood coagulation. Computed tomography of the brain showed normal findings, but computed tomography angiography (CTA) of the pulmonary arteries suggested multiple embolisms in the bilateral pulmonary arteries, upper and lower pulmonary artery trunk, and various blood vessel branches (). Computed tomography of the chest showed the same results as pulmonary CTA, and computed tomography of the abdomen suggested thrombosis in the inferior vena cava near the liver (). Cardiac echocardiography indicated an enlarged right atrium and right ventricle, moderate tricuspid regurgitation, and mild hypertension in the pulmonary artery. Bilateral lower extremity arteriovenous color Doppler imaging showed no obvious abnormalities.\nAfter these examinations, the patient’s vital signs again became unstable. He was immediately intubated and mechanically ventilated and sent to the emergency department for urokinase therapy (600,000 IU) together with norepinephrine to maintain his blood pressure. CTA after thrombolysis showed improvement in the right lower pulmonary artery branches, but not in the right pulmonary artery trunk (). The patient’s hemodynamics remained unstable, suggesting ineffective thrombolysis. At 18 hours after poisoning, he was transferred to the cardiac surgery intensive care unit of our hospital. He arrived in a coma and was given noradrenaline (0.7 µg/kg/min) to maintain stable blood circulation. The patient’s laboratory findings are shown in . His Acute Physiology and Chronic Health Evaluation (APACHE) II score was 22, and his Sequential Organ Failure Assessment (SOFA) score was 15.\nThe patient was diagnosed with acute massive pulmonary embolism combined with multiple organ dysfunction syndrome. His condition was critical, so we conducted multidisciplinary consultations to guide further treatment. Clinicians from cardiac surgery considered that the embolisms should be removed through emergency surgery with the aid of extracorporeal membrane oxygenation because the patient had massive pulmonary embolism, poor oxygenation, and hemodynamic instability. Clinicians from the medical intensive care unit considered that the patient’s previous thrombolytic treatment had been insufficient and that given the indications for repeat thrombolysis, he would benefit from repeat venous thrombolytic therapy. After comprehensive evaluation and careful consideration, we decided to repeat the thrombolytic therapy. On the following afternoon, we treated the patient with actilyse (50 mg intravenously, 25 mg/h) together with nitric oxide, sildenafil, and treprostinil to reduce his pulmonary artery pressure. We also administered drugs to reduce his intracranial pressure and performed continuous renal replacement therapy for acute renal failure to alleviate whole-body edema. After all of these treatments, his blood gas analysis results indicated significant improvement in his oxygenation index (), and his hemodynamics gradually stabilized.\nOn day 2, we administered the anticoagulant drug enoxaparin, and the patient woke up on day 3. On day 4, we administered the oral anticoagulant drug warfarin (1.5 mg), and by day 5 his hemodynamics had stabilized completely without the need for booster drugs. He was extubated after the blood gas findings were satisfactory. One week later, the patient’s laboratory findings indicated significant improvement (), and he was transferred out of the cardiac surgery intensive care unit. Twenty-five days later, he was discharged from our hospital with stable vital signs and a normal urine volume. Computed tomography of the chest and abdomen indicated a residual thrombi in the left pulmonary artery trunk, in basal segments of the lower lobe of the left lung, and in the inferior vena cava near the liver-filling defect ().\nBoth verbal and written informed consent was obtained from the patient described in this case report. Because consent was obtained and this was a clinical case report, ethical approval was not required for this study. |
A 43-year-old female patient visited the emergency department 4 days after the abrupt onset of a headache (numeric rating scale 8), nausea, and tinnitus, which began following a session of heavy lifting. She complained that the headache extended from the left parietal to the frontal areas. Her symptoms were not affected by posture and she had no notable past medical history. Laboratory analysis and a brain computed tomogram showed no remarkable findings. She was discharged with a diagnosis of migraine after symptom improvement following simple analgesic administration. She returned to the emergency room 6 days after discharge due to horizontal diplopia on right gaze that developed with improvement of the headache. Intraocular examination was normal. She was admitted to the neurology department for further tests. The physical examination revealed limited abduction in the right eye. Other cranial nerves and systemic examinations were unremarkable. A diagnostic spinal puncture showed the cerebrospinal fluid (CSF) opening pressure was 6 cmH2O and CSF analysis was normal. In general, the normal range of CSF opening pressure measured at lumbar puncture is 10–18 cmH2O, with the patient lying on the side. Brain magnetic resonance imaging (MRI) without contrast enhancement showed diffuse pachymeningeal enhancement, with thickening and venous sinus engorgement (). Mild obliteration of the basal, prepontine, and suprasellar cistern was also observed. There was no other abnormality on the MRI. Furthermore, radionuclide cisternography revealed multiple CSF leakages in mid to lower thoracic spine levels, notably T9 and T10 (). The patient was diagnosed with SIH and secondary right sixth cranial nerve palsy.\nAlthough conservative treatment management, including bed rest and hydration, relieved the headache, double vision in the right gaze was not fully relieved. The department of anesthesiology and pain medicine was consulted for consideration of EBP treatment. Fourteen days after developing diplopia, an EBP was applied. At this time, the headache had completely resolved. With the patient lying in prone position, 14 ml of autologous blood was injected aseptically into the epidural space at the T9-T10 level using an 18G Tuohy needle under fluoroscopic guidance. Because the patient complained of back pain, only 14 ml of epidural blood was administered. After EBP application, the patient maintained the supine position overnight. Decreased diplopia was reported the day after EBP treatment.\nThe patient was discharged 3 days after the procedure. One month after discharge, symptoms of diplopia and headache were resolved. Furthermore, follow-up examination revealed complete resolution of sixth cranial nerve palsy without any neurologic deficit. A follow-up MRI also showed decreased extent of the diffuse pachymeningeal enhancement with thickening and venous sinus engorgement (). In addition, although it was not clinically significant, a small subacute subdural hematoma was observed. |
A 25-year-old female with end-stage kidney disease was referred by a nephrologist for the purpose of transplantation. She had a history of recurrent urinary tract infection. A urine analysis was showed microscopic pyuria and a urine culture showed traces of the E. coli organism. After treatment with antibiotics, a voiding cystourethrography was performed showing bilateral Grade IV vesicoureteral reflux []. A ultrasonography had detected an empty left renal fossa; an echogenic irregular kidney with an abnormal shape was present in the right lumbar region. A three-dimensional computed tomography (CT) scan with contrast showed a left to right crossed fused renal ectopia with right kidney malrotation. The ectopic fused kidney was situated anterior and lateral to the orthotopic kidney [].\nAfter discussing the risks and benefits of open and laparoscopic surgery with the patient, and with consent for open conversion if required, the patient was subjected for retroperitoneoscopic nephrectomy for fused kidneys.\nAn endotracheal intubation was performed after general anesthesia. The patient was positioned in a flank position and the retroperitoneum was accessed by open technique. The retroperitoneum was accessed by a 1.5 cm long incision at the tip of the 12th rib. Balloon dilation of retroperitoneum was created and a 10 mm port was placed for laparoscope. 10 mm working ports were placed at the angle between the erector spina muscle and the lower border of the 12th rib and a 5 mm port was placed at the anterior axillary line under the guide of a 30° laparoscope. Gerota's fascia was opened by sharp dissection and a dissection on the posterolateral aspect of the inferior vena cava was carried out to find renal vessels. A total of 6 renal arteries and 4 renal veins were identified. The arteries were clipped separately by hem-o-lok clips and divided. The fused kidneys were mobilized completely and both ureters were identified. After mobilization of the fused kidneys and confirming that no additional blood supply was present, the renal veins were clipped and divided. The ureter going to the left side was divided after clipping it with hem-o-lok clips. The specimen was delivered intact by making a small incision (5 cm) in the inguinal region and a complete ureterectomy was carried out on the right side. The wound and port sides were closed.\nThe operative time was 148 minutes and blood loss was 35 ml. The patient resumed liquids orally 8 hours after surgery and remained in the hospital for 4 days. She is now on maintenance hemodialysis. |
An 84-year-old woman with hypertension presented to the emergency department with epigastric pain, nausea, and dizziness for 3 hours. A 12-lead electrocardiogram showed a junctional rhythm at rate of 40 and 2 mm inferior ST-elevations with lateral ST depressions. High-sensitivity troponin-I level was 0.01 ng/mL. Initial management included aspirin, clopidogrel, and intravenous heparin, and she was subsequently taken emergently to the catheterization laboratory. Attempts to engage the right coronary artery (RCA) were unsuccessful despite using multiple guide catheters. The left coronary system showed no angiographic evidence of coronary artery disease with left to right collaterals. Contrast injection in the right coronary sinus suggested ostial total occlusion of the RCA (). Probing with a coronary wire near where the RCA ostium was presumed to be located was associated with an increase in the heart rate with an idioventricular rhythm and resolution of inferior ST-elevation. The RCA was then easily engaged with a guide catheter. Angiographic evaluation of the RCA showed a smooth vessel with no evidence of coronary artery disease except for abrupt termination of the distal PL2 branch (). A computed tomography angiogram was then done to explore the cause of the right ostial occlusion and revealed an aortic root thrombus (21 × 16 mm) with extension into the right coronary sinus, together with near complete obliteration of the left atrial appendage with another large thrombus ( and ). Serial electrocardiograms demonstrated paroxysmal atrial fibrillation with complete resolution of inferior ST-segment elevation. Subsequent troponin-I levels peaked at 74 ng/mL. A transthoracic echocardiogram showed inferobasal septal hypokinesis and ejection fraction of 45%. A brain magnetic resonance imaging obtained secondary to mental status changes that occurred a few hours after the procedure showed multiple embolic cerebral infarcts and complete occlusion of the left internal carotid artery. The patient was treated with intravenous heparin and bridged to warfarin therapy. She was discharged home in good condition on hospital day 5. Follow-up 6 months after the index hospitalization revealed no symptoms or signs of disease recurrence. |
A 58-year-old woman underwent a partial cholecystectomy at a local hospital for gall bladder perforation following acute cholecystitis. As per the postsurgical notes, the surgeons were unable to perform a cholecystectomy and so they drained the abscess and sutured the rest of the gall bladder. Her recovery was uneventful and she was discharged after a month. Three months later she was readmitted to the same hospital with abdominal pain, nausea, and vomiting. Physical examination was unremarkable, apart from mild abdominal tenderness. She had mild leukocytosis of 11,000/μl. On review, we found that her first plain abdominal radiograph showed a linear, curved radiopacity resembling the marker of a sponge in the right side of the abdomen at the level of the second lumbar vertebra []. Another radiograph obtained later on the same day showed slight displacement of the marker to the level of the twelfth thoracic vertebra []. This was not considered significant at the time. Six days later the patient was referred to our clinic after a third plain abdominal radiograph showed displacement of the marker to the left upper quadrant []. USG revealed a curvilinear hyperechoic structure within the intestinal lumen, with intense posterior acoustic shadowing []. A single-contrast barium enema study showed that the transverse colon on the left side was dilated and the faint relative opacity of the marker could be distinguished within [], though an obvious filling defect was not seen. It was not easy to exclude bezoar or a calcified mass and so MRI was ordered after the enema. We did not opt for CT because barium had just been used. On MRI [], we detected a 25 × 6 × 5.5-cm well-circumscribed ovoid mass located in front of the left kidney and within the descending colon. It was hypointense on both pulse sequences, with some scattered and wavy intensities within. Surrounding the mass, there was an irregular hyperintense rim on the T2W images, which turned hypointense on T1W images and enhanced after intravenous gadolinium administration. This may have been due to the inflammation around the hypointense sponge. A radiograph obtained the same day after the MRI showed a mass coated with barium and containing the marker within, the marker having reached the rectosigmoid junction []. We decided to extract the mass endoscopically and, the next day, a mass containing a 30 × 30-cm laparotomy towel was extracted with a sigmoidoscope. |
A 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broca’s aphasia, identified by loss of speech and writing capabilities, with no impairment of comprehension. A neurological examination found no signs or symptoms of hemiparesis or hemiplegia. Cerebrovascular ischemia was suggested, and the patient’s daughter became fairly angry about the diagnosis of ischemia, which she considered exaggerated. Both mother and daughter left the clinic and refused a neurological consultation. Two days later, the patient came to the office, reporting that she was almost recovered and reaffirming her belief that she had suffered an allergic reaction. After an appropriate explanation, 1 week later, a normal transthoracic echocardiogram was obtained and magnetic resonance showed a recent cerebrovascular ischemia in Broca’s area ( ). A transesophageal bubble study echocardiogram performed a few days later revealed a patent foramen ovale ( ). The patient’s daughter’s became very upset again, and, despite a complete recovery by the patient, the doctor-patient relationship broke down almost completely. It wasn’t possible to continue investigations. More explanation and discussion followed, in which the intention to publish this complication was decisive to achieving greater comprehension about what had occurred. Both the patient and her daughter gave permission for publication in writing. |
A 23-year-old man presented to our outpatient clinic with painless gradually enlarging mass in the upper part of the neck below the angle of the mandible. Computed tomography (CT) scan of the lesion demonstrated homogenous, hyperdense, lesion at the mandibular angle which was diagnosed as aparaganglioma. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach. After manipulation of the lesion, severe pulsatile bleeding was encountered and a vascular lesion was suspected. Thus two vascular clamps were placed proximal and distal to the lesion and the bleeding was controlled. Vascular surgeon was consulted immediately. A CT-angiogram revealed a huge (8×4 cm) aneurysm located at the distal part of the right internal carotid artery (ICA) aneurysm which was injured (). Anticoagulation and wide spectrum antibiotic was administered to the patient and he was admitted to the intensive care unit (ICU) with the clamps in place ().\nAfter 2 days with available neurovascular surgeon for possible intracranial bleeding control and craniotomy, the patient was transferred to operating room. The previous skin incision was re-opened and the two gauzes were removed (). Appropriate irrigation was performed and the two vascular clamps were removed one by one. There was just small back bleeding from distal neck of right ICA aneurysm, therefore packing by means of small segments of fibrillar Dacron was done for 15 minutes and bleeding was stopped completely. Then Dacrons were covered with muscle flaps and the wound was closed in layers. The patient had an uneventful postoperative course and was discharged on the 6th postoperative day. The postoperative angiogram revealed the patent internal carotid artery without any aneurysm residue. The patient received anticoagulation for 3 months and was followed in outpatient clinic. After 1 year of follow-up he was completely asymptomatic and the angiogram revealed patent parent vessel without residue. The patient and his family provided their informed written consent for publication of the case and the images. |
The patient was a 47-year-old man who was brought to the emergency department of Shahid Beheshti hospital with chief complaints of dyspnea and dry cough but no respiratory distress for two days before the admission. The patient had an amputated left leg and knee due to the previous trauma since childhood and was a heavy smoker (1 pack-year) and had inhalational opium addiction for more than 20 and 10 years respectively. The patient had no family history of any specific disease. The patient’s upright chest radiography and Chest spiral CT scan revealed bilateral primary spontaneous pneumothorax (Figs. , ), and the patient underwent bilateral chest tube insertion (After local anesthesia, a conventional large-bore chest tube (32 French) was placed into the pleural space in the bilateral 5th-6th intercostal space in the posterior axillary line (Fig. ).\nTwo days after the insertion of the chest tubes, as there was no development of bullae within the lung parenchyma as the bullous lung disease, and after obtaining an informed consent from the patient, the patient underwent chemical pleurodesis with talc slurry at the right side, and on the next day chemical pleurodesis with bleomycin was done at the left side (Bilateral pleurodesis was done in two consecutive days). For talc slurry and bleomycin pleurodesis, 2 g of talc and 60 units of bleomycin were dissolved in 50 ml sodium chloride 0.9% respectively and were shacked to ensure the thorough mixing before flushing it with a 50 ml syringe into the chest tube and then the intercostal tube was clamped for 4 to 6 h. During this time, the patient was told to rotate to prone supine and left and right lateral decubitus positions for every 20 min to make sure good spread of the talc slurry or bleomycin in the pleural cavity, and then the chest tube was unclamped, and was removed within 48 h. The patient received heart monitoring and pulse oximetry during and after the administration of talc or bleomycin until the chest tube was removed. The patient was discharged and was followed afterward. He developed again with severe dyspnea and respiratory distress 14 month after the first presentation of the disease, so was admitted and the patient’s upright chest radiography revealed recurrent left-sided spontaneous pneumothorax (Fig. ). In Table , comparing of talc slurry and bleomycin pleurodesis is shown according to the side effects, complications, and pneumothorax recurrence. Left sided chest tube was inserted again for him, but unfortunately the lung was not expanded afterward, moreover, the patient intervention adherence and tolerability in using incentive spirometry was very poor, so the patient was candidate for surgery. Figures and show that the pneumothorax didn’t resolve.\nThe patient underwent posterolateral thoracotomy, pneumolysis, and wedge resection of apical segment of left upper lobe (bullectomy), apical pleurectomy, and scarification. We found an accidental and surprising finding in left lung during thoracotomy and that was that the left lung had 4 lobes with 3 developed fissures (Fig. ). Figure shows chest radiography after the operation.\nThe patient was then discharged with a good recovery after 7 days. Figure shows the chest radiography on the time of discharge from the hospital. There was no report of the recurrence afterward in follow-up visits. |
A 32-year-old male with no significant medical history presented to the St. Joseph’s University Medical Center after sustaining multiple gunshot wounds to the abdomen. On arrival at the trauma bay, the patient complained of abdominal pain. On admission, his vital signs were notable for a heart rate of 90 beats per minute and blood pressure of 169/85 mmHg. On examination, the patient was neurologically intact, and cardiac and pulmonary exams were normal. Abdominal examination was notable for peritonitis and a gunshot wound to the anterior right abdomen, and a second wound approximately 4 cm to the left of the midline at the level of L1. Peripheral pulses were intact. The initial chest radiograph showed no abnormality. The abdominal radiograph showed a bullet overlying the right cardiophrenic angle as well as subtle fractures of L1 and L2. The initial focused assessment with sonography in trauma (FAST) exam was negative. On clinical examination, due to peritonitis along with the suspected trajectory of the gunshot wound, the patient was taken to the operating room for further exploration.\nThe patient underwent an exploratory laparotomy with right and left medial visceral rotations. There was a wound through the anterior right lobe of the liver just to the right of the falciform ligament for which Floseal® (Baxter International. Deerfield, IL) was applied. Otherwise, there was no evidence of hemorrhage, and no other visceral or vascular injury in the peritoneal or retroperitoneal cavity was noted. An upper endoscopy was also performed, which showed no injury. The patient was stable and there was no apparent presence of any intra-abdominal or immediately visible retroperitoneal injury; hence, the patient was taken for a CT scan of the chest, abdomen, and pelvis. This imaging was notable for dissection of the abdominal aorta at the level of the SMA extending to just below the renal arteries with a posterior pseudoaneurysm of the aorta of ~1.9 x 1.5 x 2.5 cm without active extravasation (Figures , ). Additionally, there was multifocal retroperitoneal hemorrhage as well as a comminuted fracture of the L1 pedicle and transverse process fracture of L2.\nThe patient was brought back to the operating room for evaluation of the aortic pseudoaneurysm. An aortogram was performed, which identified the aortic pseudoaneurysm at the level of the L1 vertebral body, and it was also noted that the SMA was coming off of the celiac trunk (Figure ). The patient was heparinized and the SMA, as well as the right common iliac artery, were dissected out circumferentially and isolated. A right common iliac to SMA bypass with a 7-mm ringed polytetrafluoroethylene (PTFE) graft was created. The celiac trunk was then ligated after retrograde perfusion of all of its branches was confirmed. A repeat aortogram confirmed that the bypass graft had retrograde filling into the SMA along with celiac branches (Figures , ). Next, through the 22-French right groin sheath, a thoracic endograft stent (Cook Medical, Bloomington, IN) measuring 22 x 58 mm was inserted at the level of the thoracic aorta just above the renal arteries and deployed. A second stent measuring 22 x 39 mm was deployed just superior to it, with a 17-mm overlap. A repeat aortogram was performed, which confirmed that the pseudoaneurysm was obliterated (Figure ), with continued and adequate blood flow to the aorta, visceral and iliac arteries, as well as retrograde flow into the bypass graft. Closure of the abdomen was not possible due to bowel edema, and an ABThera™ wound vac device (3M, Maplewood, MN) was placed. Postoperatively, the patient had normal and palpable distal pulses throughout.\nThe patient was evaluated by orthopedics and a decision was made for the nonoperative management of the L1 pedicle and L2 transverse process fractures. The patient had a prolonged hospital course including multiple returns to the operating room for staged abdominal closure, with a partial closure of the abdomen with the placement of VICRYL® mesh and eventual split-thickness skin graft over the abdomen. A Follow-up CT scan of the abdomen and pelvis performed one month postoperatively was notable for a 6 x 8.8 x 16.5-cm collection surrounding the superficial femoral artery (SFA) to the right common iliac artery graft causing a mass effect resulting in right hydronephrosis, along with intestinal ileus. A CT angiogram was also performed to confirm that there was no extravasation from the bypass into the collection. The patient was treated with IV antibiotics for the peri-graft collection and total parenteral nutrition (TPN) with a nasogastric tube (NGT) for intermittent intestinal ileus. A repeat CT scan two months postoperatively redemonstrated the peri-graft collection, which was increased in size to 11 x 7.7 cm, a possible fistula between the small bowel and sigmoid colon, and worsening right hydronephrosis where the distal ureter was no longer visualized. The patient had interventional radiology (IR) drainage of the peri-graft collection; serous fluid was drained and cultures grew Enterobacter cloacae. He was started on daptomycin 500 mg intravenously once every 24 hours for 30 days and meropenem 1000 mg intravenously every eight hours for 30 days. In addition, he was provided ciprofloxacin 500 mg one tablet every 12 hours and Bactrim double strength containing 800 mg sulfamethoxazole and 160 mg trimethoprim in tablet form with one tablet every 12 hours, along with Fluconazole 100 mg tablet once a day. All three medications were administered orally. A repeat scan showed persistent peri-graft collection despite the initial drainage. The second drainage was attempted; however, pulsatile blood was aspirated and there was a concern for a leaking aneurysm of the bypass graft, and hence the procedure was aborted.\nRepeat CT scan again showed the persistent peri-graft collection, as well as an enterocutaneous fistula (ECF) from the small bowel in the center of the skin graft. On hospital day 94, the patient underwent operative exploration in an attempt to drain the peri-graft collection. The patient had retroperitoneal exploration; once the surface of the suspected peri-graft collection was exposed, a Doppler ultrasound was used and the collection was noted to have increased vascularity with dense fibrotic adhesions, it was deemed unsafe for further exploration and the procedure was aborted. An Eakin pouch (6.9 x 4.3 inches; TG Eakin, Comber, UK) was placed over the fistula, which covered the skin graft and extended onto his native skin. There was a small amount of slightly thick, mustard-colored drainage present in the bag. When fistula output became minimal, the Eakin pouch was replaced with Convatec one-piece cut-to-fit ostomy pouch (ConvaTec Group, Deeside, UK). His WBC trended down, and he was placed on a regular diet with boost supplement and his fluid balance and electrolyte were carefully monitored. The patient was eventually started on an enteral diet and continued on TPN for malnutrition; he required an IR-guided nephrostomy tube for the right hydronephrosis and was continued on antibiotics as mentioned above for the peri-graft collection. The ECF remained to have low output and was treated with local wound care. A repeat CT scan showed an interval decrease in the peri-graft collection. In summary, the patient had a prolonged hospital course complicated by a peri-graft collection, and intestinal ileus along with an enterocutaneous fistula, but ultimately became stable and his fistula resolved upon discharge. On hospital day 117, under the custody of law enforcement, he was discharged and instructed to take the three previously mentioned oral antibiotics at home. |
The patient is a 58-year-old male residing in the city of Philadelphia, Pennsylvania, USA. He lives by himself in an apartment. He is currently disabled but was working at an appliance repair store up until a few years ago. He carries a history of hypertension, type 2 diabetes mellitus, hypertriglyceridemia and lumbar spondylosis. He is an active smoker and smokes approximately a pack of cigarettes daily. He reported compliance to all his medications (25 mg hydrochlorothiazide and 80 mg valsartan that he takes every day for hypertension; 500 mg twice daily of metformin and 50 mg daily sitagliptin for type 2 diabetes mellitus; 20 mg daily pravastatin and over the counter fish oil for the hypertriglyceridemia). Other than smoking, he denied any concern in terms of the complications from these comorbidities. Urine toxicology screen was negative for any illicit substances. He denied peripheral vascular disease (PVD), cardiovascular or neurological conditions though he did not recall getting tested for PVD or diabetic neuropathy as such.\nHe was also diagnosed with OCD at the age of 26 years but reported compulsive behavior from his adolescence. As an adolescent, he first developed compulsive squeezing of his acne and picking of his facial hair. A few years later, he had to compulsively pick the hair, the acne and skin in his entire body, more so in his legs. At times, he reported severe anxiety associated with these skin-picking episodes and even reported a couple of visits to the emergency room with the symptoms of OCD. He was taking quetiapine 50 mg daily for his OCD.\nOver the last few months or so, he reported he became more and more compulsive in picking the skin on his toes and his feet. Though he was not able to specify the exact times he was picking his skin every day, he did report that the picking would get worse whenever he gets nervous and anxious. He described his picking as constant on a daily basis, sometimes that episode could last for minutes. This compulsive behavior started off with picking the skin around his nail beds and slowly got worse. He reported few occasions of having painful sores and wounds due to the skin picking when he applied topical over the counter antibiotic and antiseptic creams. However, he could not resist picking the scars over these wounds and the wounds would never heal. Over time, he reported that “he gave up” on his skin picking behavior as he noticed that the left leg wound was gradually getting worse. Due to the worsening pain and foul-smelling discharge from the wound, he decided to come to the emergency room (ER).\nWhen he presented to the ER, he was found to have an extensive wound on distal left foot with exposure of the underlying muscle tissue, oozing of blood and surrounding erythema (Figure ).\nHe had a low-grade temperature of 100.2 F, heart rate of 103 beats/min and blood pressure 133/82 mm Hg. Systemic examination was normal other than sinus tachycardia and the above-described wound. The patient’s initial baseline laboratory data at the time of admission showed a leukocytosis with a white cell count up to 13,400 per microliter. The patient’s thyroid, renal, electrolyte, acid base and liver function tests were within normal limits. He was referred to admission to the general medicine service along with broad-spectrum intravenous (IV) antibiotic coverage (vancomycin and piperacillin/tazobactam) to empirically treat methicillin-resistant Staphylococcus aureus (MRSA), other gram-positive, gram-negative and anaerobic organisms that might be causing the wound infection. The IV antibiotics were given for about 72 hours till the wound cultures were finalized and the blood cultures resulted negative. The wound was also evaluated by general surgery service who recommend topical wound care and management with antibiotics.\nWith the intention to treat the underlying disease, we investigated his psychiatric history in detail. He was under the care of a few psychiatrists for a diagnosis of OCD over the last 30 years or so. He was on a variety of different medications for his OCD including aripiprazole, risperidone and fluoxetine. He did not report a great benefit from any of these medications. Apart from the history of smoking, he denied alcohol or substance abuse. He denied any suicidal attempts. He noticed that his skin picking would get worse whenever he gets nervous or anxious. He reported that his mother and sister also had similar obsessive compulsive traits. When he started realizing that his symptoms were getting worse of late and when the medications did not seem to help, he decided to join a few online support groups on the internet. He felt relieved talking to others with similar symptoms and dedicated some time every day talking and listening to them and understanding what medications and therapies helped them.\nOnce he was ready for discharge from the hospital, he was sent home with prescriptions of a seven-ay course of trimethoprim/sulfamethoxazole double strength and a higher dose of quetiapine (200 mg oral daily). He was referred to the hospital's CBT program that specializes in treatment of OCD and anxiety disorders. |
A healthy 20-month-old boy was brought to the emergency department of our hospital with history of FB inhalation and respiratory distress. In the past 12 months, he already had two similar episodes of FB inhalation (peanut and plastic bead) and was treated at a regional hospital before being referred to us on the third occasion. The hospital notes of the past interventions mentioned the FBs lodged in the right main bronchus. In the past, the child had received treatment for asthma with corticosteroids.\nThe patient was born at term by a non-complicated delivery, and was in good condition with an age-appropriate development. On examination, the child had dry cough, inspiratory stridor, hoarseness, and hypoventilation of the right lung. The chest X-ray showed an air trapping phenomenon. Due to the past history of recurrent FB inhalation, a dynamic airway endoscopy was performed before the extraction of the FB. Under general anesthesia and the child breathing spontaneously the flexible transnasal laryngoscopy showed a right vocal cord paralysis with the cord lying in an intermediate position (). Subsequent ventilating rigid bronchoscopy showed complete obstruction of the right main stem bronchus by a peanut (). The FB was removed using dedicated rigid peanut grasping forceps. The distal airways were normal. In the following days, the child had an uneventful recovery.\nIn the past history, the child presented with dysphonia and breathy voice since birth. There was no history suggestive of viral infections and surgery. The parents did mention of him occasionally chocking especially with liquids. To complete the investigation for his unilateral vocal cord paralysis, an MRI of the brain, and CT-scan of the neck and chest were performed. They did not show any abnormalities.\nSubsequently, the child was given intensive speech and swallow therapy and the parents were educated regarding modifications during feeding. The endoscopy after 1 year showed a complete recovery of the vocal cord paralysis, without any repeat history of FB inhalation. |
A 68-year-old, 179 cm, 108 kg man presented to the authors’ preoperative anesthesia clinic for evaluation before anticipated removal of infected total knee arthroplasty hardware, placement of antibiotic spacers, incision and drainage procedures, and revision arthroplasty. The patient had undergone a right total knee arthroplasty for osteoarthritis eight years before the current evaluation, but he subsequently developed a draining sinus tract in the operative joint consistent with a chronic infection that had not responded to conservative treatment. The patient’s past medical history was notable for obstructive sleep apnea, tobacco abuse, moderate to severe chronic obstructive pulmonary disease (documented with pulmonary function tests; responsive to inhaled bronchodilators), and squamous cell carcinoma of the right true vocal cord (stage T2N0) for which he had previously undergone a right vertical hemilaryngectomy nine years before current evaluation. A tracheostomy that was performed as part of the hemilaryngectomy had been allowed to spontaneously close as he recovered from the operation. The patient was not treated with head and neck radiation therapy nor did he receive adjuvant chemotherapy. The patient reported that he was chronically short of breath and had been intermittently since the tracheostomy closed. He was unable to tolerate continuous positive airway pressure equipment for treatment of his obstructive sleep apnea. He described dyspnea on exertion with minimal exercise. Indeed, he was noticeably short of breath after walking from the waiting room to the clinic office (a distance of less than 50 feet). Reduced breath sounds with inspiratory and expiratory wheezes were heard during auscultation of his lungs. Intermittent inspiratory stridor was also present. The patient’s voice was coarse and soft in character. A Mallampati class 3 upper airway was present, the thyromental distance was approximately 5 cm, and cervical osteoarthritis limited the patient’s ability to extend his neck. These findings suggested that endotracheal intubation may be somewhat more difficult using direct laryngoscopy, but based on this standard assessment, the authors felt that the patient’s airway could be easily secured using a videolaryngoscope. Nevertheless, the previous hemilaryngectomy, closed tracheostomy, obstructive sleep apnea, and mild inspiratory stridor, prompted the authors to perform a transnasal videoendoscopy examination of the upper airway. Topical local anesthesia [consisting of 4% lidocaine mixed with phenylephrine (200 mcg)] was applied into the right nares and upper oropharynx using an atomizer with the patient in sitting position. A videoendoscope (Olympus ENF-VH, Tokyo, Japan) was then gently passed through the right nares and advanced through the oropharynx to a position immediately above the glottis. Absence of the right arytenoid complex was noted consistent with the previous hemilaryngectomy (). The left vocal cord moved normally with phonation, but supraglottic scarring narrowed the glottic opening. Subglottic airway narrowing was also observed beyond the glottic opening (); the authors did not attempt to further examine the proximal trachea as a result. A large amount of redundant tissue was also noted in the lower oropharynx that caused partial airway obstruction with the patient breathing spontaneously. This latter finding was consistent with the established diagnosis of obstructive sleep apnea. The videoendoscope was removed after the examination was completed. The patient tolerated the procedure well.\nBecause of the patient’s symptoms and the authors’ videoendoscopy findings, the patient was referred to the otolaryngology clinic for further evaluation. Computed tomography revealed tracheal stenosis; a segment of the proximal subglottic trachea was narrowed to a diameter of approximately 4 mm (). Computed tomography also showed cartilageous erosion consistent with tracheomalacia. The otolaryngology consultant initially proposed tracheal reconstruction, but this option was not feasible in the short term because of the urgent need to address the infected knee arthroplasty. The otolaryngologist concurred with the authors who were concerned that repetitive endotracheal intubation and extubation was not an option for this patient with a substantially narrowed glottis and subglottic stenosis. As a result, the patient underwent an elective permanent tracheostomy under conscious sedation (intravenous midazolam and fentanyl) to obtain definitive control of his airway immediately before the infected knee arthroplasty was removed and antibiotic spacers were placed after induction of general anesthesia. A subsequent incision and drainage procedure was also performed. The patient eventually underwent a revision total knee arthroplasty several months later after the infection had been successfully treated. The patient made an uneventful recovery after each operation. |
A 72-year-old female presented to the emergency department with chest pain and shortness of breath. Her history was significant for prior CABG surgery with a left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, a saphenous vein graft (SVG) to the obtuse marginal artery, and an SVG to the RCA. On initial workup the patient was found to have a non-ST elevation myocardial infarction with an elevation in cardiac enzymes and nonspecific ST-segment changes on electrocardiogram. We proceeded with a left heart catheterization and coronary angiogram.\nThe patient’s coronary angiography revealed 90% stenosis in the proximal SVG to RCA. Her angiogram also demonstrated a CTO of the native RCA, which was previously known based on prior coronary angiograms (, ). During the initial contrast injection, where 7 - 8 mL of contrast was injected at 3 mL/s into the native RCA, a dissection occurred at the location of the CTO ( and , ). Unfortunately, the development of the dissection was unnoticed, and a second 7 - 8 mL of contrast was administered at 3 mL/s into the RCA. The second contrast injection into the RCA resulted in progression of the coronary dissection causing a CAVF with the middle cardiac vein distally ( and , ). Additionally, there was a right coronary cusp dissection proximally ( and , ). Initially, there was concern that the second contrast injection had caused a perforation of the mid segment of the RCA. However, upon further review of the angiogram images, contrast could be seen flowing distally into the middle cardiac vein and emptying into the right atrium ( and , ).\nThe decision was made to manage the patient conservatively as we believed the CAVF would spontaneously close within 4 - 8 weeks as the RCA CTO dissection healed. She was closely monitored following her procedure in the cardiovascular unit. Two days after her initial coronary angiogram, she successfully underwent PCI of the SVG to RCA. The presence of the CAVF did not interfere with the PCI of the SVG to RCA.\nFollowing successful PCI of the SVG to RCA, the patient was observed overnight in the cardiac observation unit. She had no complications following her procedure and was therefore safely discharged home in stable condition. She is regularly seen in our clinic and has not reported any new concerns or adverse events following the initial hospitalization. Repeat angiography of the native RCA to evaluate for fistula closure was deferred due to the risk of worsening or repeat dissection and/or fistula. |
A 19-year-old woman was referred to our clinic for further evaluation of cardiomegaly on chest radiography. She had no chest pain, shortness of breath, or other specific signs and symptoms. Her past medical history and family history were unremarkable. She had not taken any medications and denied use of illicit drugs and tobacco or alcohol abuse. On cardiac examination, a regular heart rhythm was heard without heart murmur. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm, with a heart rate of 62 bpm and right deviation of the heart axis (). The chest radiograph revealed that the heart had bulging contour of the left superior cardiac border and leftward shift (). The echocardiography showed a globe-shaped heart and bulbous ventricle due to suspension of the heart from its basal pedicle (). It also revealed mitral valve prolapse. The estimated left ventricular ejection fraction was 65%. Chest computed tomography (CT) revealed outpouching of the right ventricle (RV), which contacted the left chest wall, and interposition of the lung between the aortic arch and prominent pulmonary trunk (). The patient was diagnosed with congenital absence of the left pericardium.\nA 56-year-old man was referred to our clinic for ECG abnormality. He had no chest pain, dyspnea, or other specific signs and symptoms. His past medical history and family history were unremarkable. He neither took medications nor used tobacco or alcohol. On examination, his blood pressure was 126/76 mmHg. A systolic ejection-type murmur was present with regular heart rhythm. A 12-lead ECG showed sinus rhythm with a heart rate of 59 bpm, an incomplete right bundle branch block, and a slight increase in left ventricular voltage (). Chest radiography revealed flattening of the left heart border and a lucent area between the aorta and pulmonary artery due to lung interposition (). The patient underwent an echocardiogram and chest CT because of the abnormal chest radiography, murmur, and ECG. The echocardiography showed a left laterally displaced left ventricle (LV) apex with a swinging motion that was highly suggestive of congenital absence of the pericardium (). The RV cavity was enlarged as 38 mm and demonstrated paradoxical septal motion. LV systolic function was normal. The chest CT revealed nonvisualization of the pericardium and leftward displacement of the entire heart with mild RV dilatation (). The patient was diagnosed with congenital absence of the pericardium.\nA 71-year-old male patient presented with a history of dyspnea on exertion. He reported atypical chest pain and shortness of breath. He suffered from asthma and was taking medication. Medical and family histories were otherwise unremarkable. He was a current, 100 pack-year smoker. On examination, his blood pressure was 120/70 mmHg. Regular heart rhythm without murmur and clear breath sounds were heard on auscultation. A 12-lead ECG showed normal sinus rhythm, with a heart rate of 73 bpm and left deviation of the heart axis (). Q-waves were seen in leads II, aVF, V1, V2, and V3. Chest radiography showed bulging contour of the left superior cardiac border (). Due to his symptoms, abnormal chest radiography, and ECG, the patient underwent an echocardiogram and heart CT. The echocardiography revealed a laterally displaced LV apex that was highly suggestive of congenital absence of the pericardium (). It also showed an enlarged LV cavity with mild global hypokinesia without regional wall motion abnormality. Valvular morphology and function were normal, and the estimated LV ejection fraction was 47%. The cardiac CT revealed absence of the pericardium at the left side of the heart without evidence of associated anomaly such as atrial septal defect or ventricular septal defect (). The patient was diagnosed with congenital absence of the left pericardium. |
A 25-year-old single Nigerian man was admitted via the surgical outpatient clinic with a two-year history of scrotal swelling which was initially small in size, non-painful and not associated with fever. The swelling gradually increased in size to the extent of impairing free movement of the patient both because of its weight and size in between the lower limbs. The swelling made sexual intercourse and voiding in the standing position impossible. The skin was intact without associated ulcerations, and there was no difficulty in voiding though the penile shaft was buried in the swelling. There was no history of chronic cough suggestive of pulmonary or disseminated tuberculosis. He had no problems with his eyesight and no other swellings on his body were known.\nHe had a history of surgery to the two inguinal areas about 10 years before presentation; surgical details were not available nor was any histology available. He was from a polygamous home and took neither alcohol nor any other substance of abuse. There was no history of a similar lesion in his relatives or his acquaintances at his place of abode.\nPhysical examination showed a healthy looking young man with a giant scrotal swelling of a size greater than that of his head. There were hyperpigmented giant ruggae in otherwise intact skin with the penile shaft buried in the scrotal wall skin (Figure and ). The swelling was non-tender, non-pitting and non-reducible with the cord barely discernible at the neck. Bilateral inguinal scars were seen with significant lymphadenopathy.\nHemogram, serum electrolyte, urea and creatinine, urinalysis, urine microscopy culture and sensitivity were all within normal limits. Scrotal ultrasound showed a thickened scrotal wall but the scrotal content was normal.\nHe subsequently underwent a modified Charles' procedure with a primary penile shaft split-thickness skin graft (Figure ) performed by a team of general surgeons and plastic surgeons. His immediate postoperative condition was satisfactory (Figure ). On the postoperative day seven, the penile skin graft showed good skin take and some good granulation tissue over the exposed testicles.\nThe patient continued to have wound dressing until the perineal wound had healed and contracted appreciably leaving about a 3 cm raw area of the wound at the six postoperative week (Figure ). He had an uneventful postoperative course with the scrotal wound healing completely by the eighth postoperative week (Figure ). He is now about one year post-surgery and doing well. The patient is physically and socially satisfied with his improved quality of life. |
A 32-year-old woman, prime para, came at the obstetric department at Kibaha Tumbi Referral Hospital, after an onset of progressive abdomen distention with a history of amenorrhea of one year and two months. Her medical history was unremarkable. However, her past obstetric history was prime para with previous history of prolonged obstructed labor which took three days to be in labor and she had difficult attempted vaginal deliveries of fresh stillbirth male baby at term. On the 14 days after removing the catheter, she started to experience a continuous uncontrolled urine leakage. Before being seen at our obstetric clinic, she had been already having three consecutive obstetric fistula surgical repairs, whereby the third one was done one year and two months prior to this admission. The third fistula surgical repair went successful whereby she could not notice urine leakage and resume her normal sexual life without using any unprotected gear but she could not get a normal menstrual flow throughout the all period, when later she started to notice a progressive abdomen distended and amenorrhea contradict herself as if she had a full-term pregnancy ().\nDue to the distended abdomen she was thought to have pregnancy despite the fact that she had never seen her normal menstruated blood. Therefore, she was decided to return to the hospital seeking for further evaluation and obstetrics care at our clinic.\nPhysically she looked healthy with significant normal body weight. Afebrile with her blood pressure measured 120/70 mmHg and pulse rate measured 78 beats/min. Her abdomen was distended with approximated fundal height corresponding to the gestational age of 39 weeks, tense abdomen and tympanic sound, no palpable fetal part, no fluid thrill, and no shifted dullness with the marked tenderness of the lower abdomen.\nOn speculum examination, a normal cervix could be clearly visualized, and adhesive scared tissue was visualized filling the lateral fornix and the upper part of the vaginal vault. The bimanual examination was performed which revealed that the mass was originated from the uterus with bilateral adnexal difficult to be appreciated.\nHaematology laboratory findings revealed a hemoglobin level of 9.6 g/dl, the haematocrit value was 35.7%, and complete blood count was 4.5 billion cells/L with a platelet count of 125 billion/L. Other hematological findings include serum creatinine, BUN, electrolytes, prothrombin time, and partial thromboplastin time appearing in the normal range and biochemistry panel: ALAT-26.71 IU/L ASAT-24.48 IU/L.\nTransabdominal ultrasound revealed echogenic opacification with free fluids filled in the uterus, endometrial thickening which measured 10 mm, and markedly thinned elongated closed cervix with free fluid.\nThe ultrasonography conclusion was a presence of lower genital tract occlusion with haematometra and bilateral haemosalpinx secondarily to acquire obstruction of the lower female genital tract. Detailed examination and planned dilation of the endocervical canal to allow egress of the depicted fluid and subsequent menstruation were attempted under general anesthesia, yet no dimple indicating the external cervical os could be visualized or palpated.\nThe patient was informed to have explorative laparotomy and the possibility of undergoing abdominal hysterotomy.\nPeritoneal cavity was exposed and found a huge haematometra with distended bilateral haemosalpinx and blood debris leaking at the end of ampulla ().\nThe urinary bladder was identified and the lower uterine segment was not obviously formed, hysterotomy was done, and menstruated blood debris was suction which was approximately 10 liters (). Using Hegar dilator numbers 6 and 9 repeated alternatively to dilated uterine cervix through abdominally were performed until successful cervical dilatation has been observed and Hegar pass was allowed through the internal os of cervix to the vaginal canal, respectively. Finally, hemostasis was achieved and hysterotomy incision repaired in layers using Vicryl number 2 and abdomen wall closed successfully.\nPathologic assessment of the surgical menstrual blood debris specimen showed the recently evacuated blood clots and endometrial tissues, respectively. The approximate blood loss was one liter and intraoperatively she was transfused one unit of blood. Postoperative period was unremarkable and she was discharged on the seventh day in good condition and advised to continue with cervical dilatation using Hegar at GOPD whereby she was lost to follow-up. |
A 57-year-old male patient was transferred to the emergency department after a road traffic accident. He had a fall from his bike and his right arm was crashed by the following car. On clinical examination, he had pain and obvious deformity in the shoulder while he was unable to move his arm in any direction, especially in external rotation. He had numbness in the regimental badge region of the axillary nerve and normal radial pulse at the wrist. Radiological examination showed an anterior shoulder dislocation with impaction of the humeral head underneath glenoid and associated fracture of the greater tuberosity (Fig. ). He had no other skeletal or visceral injuries. After conscious sedation, an effort for closed reduction (3 attempts) was performed in the emergency room but was unsuccessful. For reasons unrelated to the patient or the disease a CT-scan of the shoulder was not possible to be performed at that time. The patient was transferred immediately to the operative theatre for closed manipulation under general anaesthesia in order to reduce the dislocation and avoid further neurological compromise; a CT-scan and/or MRI has been scheduled for the next morning. Despite prompt sedation and muscle relaxation the shoulder was still unable to interpose. Open reduction was accomplished thereafter using the deltopectoral approach; the biceps tendon was found entrapped posterolateral between the humeral head and the tuberosity fragment preventing once again reduction of the glenohumeral joint. (Fig. ). Tenotomy and tenodesis of the frayed biceps at the level of pectoralis major was performed using a bone anchor; the transverse ligament at the bicipital groove had been torned. Next, the subscapularis was incised, 1 cm medial to its insertion at the lesser tubercle, and retracted medially after separated from the capsule. The latter was incised and the labrum was clearly visualized and was found to be intact inferomedially. Using longitudinal traction and finger manipulation in an anterior direction the humeral head was finally reduced revealing a large triangular Hill-Sachs lesion at its posterior part. The greater tuberosity was fixed back to its bed using heavy transosseous sutures (Fig. ). The capsule and subscapularis tendon were repaired anatomically with sutures and the shoulder joint was found stable through a full range of motion of internal rotation and external rotation with the arm in adduction and at 90° of abduction. The patient had an uneventful postoperative recovery without neurovascular compromise. Pendulum exercises initiated from the second postoperative day followed by passive assisted forward flexion and limitation of active internal rotation for 4 weeks. At the last follow up, one year postoperatively he had a stable joint, full range of motion and a Constant score of 90 (Fig. ). |
A 78-year-old woman was involved in a motor vehicle collision while traveling approximately six weeks before presenting to our institution. She initially had high cervical neck pain at the time of the event but no other neurologic symptoms. She was brought to a local trauma center at the time of the event, and a computed tomographic angiography (CTA) of the neck revealed a Levine and Edwards Type II fracture with bilateral C2 pars and pedicle fractures extending into the vertebral body with anterolisthesis of C2 on C3 (see Figure ). Also seen was a tortuous right dominant vertebral artery that filled a large C2 transverse foramen with a congenitally small pedicle (see Figure ). Her vertebral artery on the left appeared to contribute very little to her posterior circulation. There was no evidence of radiographic vascular injury. She was advised to undergo surgical fixation at the time of her injury, however, she elected to wait until she returned home. She was discharged from the outside hospital with a hard cervical collar and presented to our institution for further evaluation over a month later. After discussing the possible treatment options, including continued conservative treatment with continued external orthosis vs. surgical intervention, the patient elected for surgical intervention. The risks and benefits of the surgical options were discussed with her in detail, including an anterior approach at C2-3, or a posterior C1-3 fusion. The patient elected to have a posterior fusion to avoid the possible swallowing complications of a high cervical exposure and other possible risks of an anterior approach..\nInformed consent was obtained and the patient was brought to the operating room. Neurophysiologic monitoring was utilized to establish baseline motor and somatosensory evoked potentials. After application of cranial pinions, the patient’s neck was brought into a neutral and slightly flexed position under live fluoroscopy. A post-positioning film showed the patient’s anterolisthesis had reduced and the fractured pedicle showed improved alignment (see Figure ). Motor-evoked potentials and somatosensory-evoked potentials showed no change from baseline. A cranial reference frame was attached to the head clamp for CT-guided intraoperative navigation (see Figure ). Attachment of the cranial reference frame to the head clamp was a key step to ensure maximal accuracy of the optical system during instrumentation, as the posterior elements of C2 would not be stable enough to accept the spinous process clamp after exposure.\nAfter exposure of the posterior elements from C1-3 and the C1 lateral masses, an O-arm spin was performed for navigation registration. The left C2 pedicle was accessed using a navigated drill. The fracture line in the middle of the pedicle was crossed with the drill bit into the vertebral body. Careful palpation of the drill track with a ball-tipped probe did not show any breaches. The hole was tapped with a navigated 3.5-mm tapered tap. A 4.0 mm x 24 mm screw was slowly advanced across the fracture into the C2 vertebral body. Care was taken during screw placement to ensure purchase across the fracture so that the tip of the pedicle screw did not push the vertebral body anteriorly. Bilateral C1 and C3 lateral mass screws were then placed. The right C2 pedicle was skipped due to her congenital abnormality and the risk of vertebral artery injury. An intraoperative CT scan showed excellent hardware placement (see Figure ). A cortico-cancellous piece of iliac crest was harvested and contoured to an appropriate dimension for placement between the C1 and C2 lamina. The laminae were decorticated and a piece of iliac crest graft was placed in between. Bilateral titanium rods were cut and placed. The wound was closed in layers and the patient awoke with no complications. She was placed in a hard cervical collar post-operatively. Postoperative X-ray images were obtained after the patient mobilized and showed stability of the construct (see Figure ). |
A 38-year-old lady who was otherwise healthy presented with 6-month history of intermittent diarrhoea since her trip to Vietnam 2 weeks before the onset of symptoms. She had no fever, vomiting or abdominal pain. Her stool was watery with no blood or mucus. Her symptoms did not subside despite treatment prescribed by general practitioners. She also had severe weight loss of 5 kg over 6 months. She claimed that she had taken some homemade salad during her stay in Vietnam for her holiday. She worked as a dental nurse in Hong Kong while her husband stayed in Vietnam and used to visit her twice yearly. She did not take any long-term medications before the onset of symptoms nor have any sign and symptoms suggestive of hyperthyroidism. Her blood counts including hemoglobin, white blood cells and platelet counts were normal when she presented to us 6 months after onset of symptoms. The renal and liver functions tests were also unremarkable expect for a low albumin level of 33 g/L. Her thyroid function tests, fasting glucose, calcium and phosphate levels were all normal.\nMicroscopic examination and culture on repeated stool samples collected within 6 months’ time did not yield any bacteria, virus, or parasites initially. In view of the prolonged diarrhoea, an upper gastrointestinal endoscopy (UGIE) and a colonoscopy were performed. The UGIE only identified mild gastritis and the duodenum appeared normal. The colonoscopy showed only a small area of erythema over the descending colon with normal terminal ileum and other parts of colon. However, numerous intracellular protozoa could be identified at the apical half of the enterocytes of both the terminal ileum and the duodenum. Villus blunting with non-specific inflammatory cells infiltration of the terminal ileum was also noted (Figure ). The electron microscopy of the parasite demonstrated a typical morphology of an Apicomplexa organism. The merozoites were surrounded by layers of thick parasitophorous vacuoles (Figure , Panel A). A binucleated schizont could be seen inside a parasitophorous vacuole (Figure , Panel B). Mature merozoites could also be identified (Figure , Panel C). Further stool samples using modified acid-fast staining showed typical Cyclospora oocyst (Figure , Panel A). An unstained oocyst, the “ghost” cell, could also be found (Figure , Panel B).\nFurther history revealed that her husband had multiple sexual partners in Vietnam. The lady was subsequently diagnosed to be HIV positive and the baseline CD4 count was only 98 cells/μL with HIV ribonucleic acid (RNA) of 420,000 copies/mL. She was initially treated with 2 weeks of ciprofloxacin 500 mg twice daily. However, her response was suboptimal. Trimethoprim/sulfamethoxazole (TMP-SMX) 960 mg twice daily was then introduced and her symptoms totally subsided after two weeks. Anti-retroviral therapy (ART) was also prescribed and her CD4 count went up to 153 cells/μL in half-year’s time. Her HIV RNA had become undetectable after 3 months of ART and she remained well. She also had weight gain of 5 kg after 6 months of ART. |
A 29-year-old woman with a history of asthma (on intermittent inhaler use) came in with one episode of unarousable loss of consciousness. She was noted to have irregular breathing that alarmed the mother who was sleeping next to her. She called for help and the brother then tried to wake her up but she was not arousable. According to the account, she was sweating profusely and had labored breathing. She spontaneously started breathing normally and started coming around. At this point, she felt very weak, experienced nausea and vomiting, and felt like her “stomach was upset”. Her post-event recovery was less than five minutes. She was brought to the hospital. She is a nurse by profession and was doing her normal ward duties and reports no remarkable event in her history that would have suggested volume loss or prolonged hemodynamic stress. Her examination was unremarkable and there was no postural drop in blood pressure (BP). She was admitted under neurology; her blood and electrolyte work-up was normal and she underwent a complete neurological work-up. She was then referred to cardiology at which point it was noted that she had pre-excitation on the electrocardiogram (ECG). She was taken to the catheterization lab where she underwent an electrophysiological (EP) study that induced an orthodromic atrioventricular tachycardia. Atrial fibrillation was induced through rapid atrial pacing but could not be sustained and no ventricular arrhythmias were inducible without or with dobutamine provocation. Ablation of a left posteroseptal pathway was carried out. The earliest ventricular signal was tracked during tachycardia and ventricular pacing but ablation at the earliest position suppressed accessory pathway conduction only to recur every time. After extensively mapping the right side and the coronary sinus, the ablation was stopped. She was put on flecainide and calcium channel blockers and was discharged. After a few weeks, she had a similar episode and was brought to the hospital. She then underwent a head-up tilt (HUT) test on suspicion of vasovagal mechanism of syncope, which came out positive with nitrate provocation. Her post-ictal phase was reported by her to be an exact replication of her clinical symptoms. The flecainide and calcium channel blockers were discontinued as the mechanism of her fainting was identified to be vasovagal and not a cardiac arrhythmia. She was prescribed hydration, counter-maneuvers (which she practiced inconsistently), and preventive measures. Since the last episode, she has done well but experiences recurrences. |
A 54 year old male, with no comorbidities or significant social history presented to the emergency department with a three day history of intermittent generalized abdominal pain radiating to the back. He did not endorse a history of constitutional symptoms. Upon presentation to the emergency department he was hemodynamically stable. Physical examination revealed a soft abdomen with generalized tenderness particularly in the epigastric region. Initial lab results showed a WBC 6.77 × 109/L, serum amylase 79IU/L, urinary amylase 738IU/L, CRP 73.88 mg/L, D-dimer 13.66ug/ml, and a Lactate of 1.87 mmol/L. The patient was subsequently admitted under the gastroenterology service with the diagnosis of pancreatitis.\nPreliminary CT Abdomen with oral and IV contrast showed acute pancreatitis with superior mesenteric and portal vein thrombosis and no evidence of mesenteric small bowel involvement (). He was managed conservatively on the ward by means of heparin Infusion and thereafter switched to LMWH and warfarin. A week later he developed sustained tachycardia and sudden drop in WBC with associated increase in lactate to 5.31IU/L. A follow up CT abdomen with IV contrast revealed diffuse wall thickening involving multiple loops of jejunum highly suspicious of bowel ischemia (). A decision was made to proceed with an exploratory laparotomy which revealed no evidence of full thickness necrosis but characteristics of small bowel edema secondary to SMV thrombosis. Additionally, the pancreas appeared inflamed and edematous with evidence of intraperitoneal calcification within the lesser sac. An ABthera vacuum dressing was applied in anticipation of a second look laparotomy. The patient was shifted to the ICU where he showed evidence of progressive acute hepatic failure with rising INR, bilirubin, and serum ammonia level. On re-evaluation of the bowel within 48 h, we noted viable but dusky appearing jejunum. An access sheath was inserted retrograde from the middle colic vein into the superior mesenteric vein and portal vein where a catheter was placed for the direct thrombolysis (). A bolus of Heparin 1000 IU followed by 500 IU/hr infusion was delivered through the sheath along with Altepase 1 mg/hr for a 24 h period.\nFollowing the 24 h period, a third look exploratory laparotomy was performed where the vascular catheter placed was removed. An Intraoperative venography showed patent portal veins (). However, 100 cm segment of proximal bowel was found ischemic and therefore a resection and side to side anastomosis was done.\nThe patient had an uneventful post-operative course. A week after his final laparotomy, an ultrasound abdomen was performed showing resolved portal and superior mesenteric vein thrombosis. The patient was discharged in a satisfactory condition on Warfarin 3 mg PO OD. |
This is a case of a 73-year-old Hispanic male with past medical history of hypertension, dyslipidemia, diabetes mellitus type 2, and former nicotine dependence. The patient presented to our ED brought in via Emergency Medical Services (EMS) as a ST elevation myocardial infarction (STEMI) alert. The patient was transferred to our emergency department (ED) from a nearby urgent care center, where he presented with complaints of chest pain. The patient stated that he woke up with midsternal chest pain, 3 hours prior to arrival. He described the chest pain as a pressure-like, non-radiating and constant, 7 out of 10 in severity initially on arrival to urgent care. He stated the pain was worsened by deep breathing and movement and that nothing alleviated it. He also endorsed feeling short of breath and having dyspnea on minimal exertion, for example, by walking a few steps. The patient denied palpitations, diaphoresis, nausea, vomiting, headache, dizziness, syncope, weakness, fever, chills, abdominal pain, or other complaints.\nThe patient stated that approximately 6 to 8 weeks prior, he was admitted in another hospital and was in critical condition due to COVID-19 infection complicated by pneumonia. The patient stated that he was discharged from the hospital less than 1 month ago and that he was feeling well after discharge until waking up this day with chest pain.\nThe initial vital signs were within normal limits except for heart rate fluctuating between 100 to 110 beats per minute. The patient reported the chest pain was still present, although it had slightly improved compared to the onset. The initial 12-lead electrocardiogram (ECG) in our ED is depicted below (figure ).\nThe interventional cardiologist was consulted and upon evaluation of the ECG and because the patient was still experiencing chest pain, the decision was made to take the patient immediately for an emergent diagnostic left heart catheterization and coronary angiography. This study showed non obstructive coronary artery disease; thus no interventions were performed. A transthoracic echocardiogram was significant for a small pericardial effusion grade I diastolic dysfunction, with ejection fraction of 40% to 50% and increased wall thickness as well as concentric hypertrophy. Shortly after the coronary angiography, the serum troponin I levels came back within normal limits and the complete blood count was remarkable for a neutrophil-predominant leukocytosis (WBC of 20.63 K/mm3). Chest radiograph was negative for acute cardiopulmonary process. Given these findings, the diagnosis of acute myopericarditis was confirmed and the diagnosis of STEMI was ruled out. |
An 11-year-old girl from North-eastern part of India presented with 2 year history of progressive painless swelling at the root of nose. She had left sided nasal obstruction for one year and had occasional blood stained nasal discharge. Her vision was normal and had normal eye movements. There were no skin lesions/pigmentation over her any body part and had no signs of focal neurological deficits. Local examination revealed a smooth 4 × 3 cm swelling at the root of nose and bony nasal dorsum causing nasal deformity and telecanthus. The skin over swelling was normal and on palpation it was firm, non- tender and non compressible. The nasal bones appeared to be splayed and thinned out in the middle through which tumor was palpable. Anterior rhinoscopy revealed a pinkish mucosa covered mass filling the upper half of left nasal cavity and nasal septum was pushed to the opposite side.\nContrast enhanced high resolution computed tomography (HRCT) of the paranasal sinuses revealed soft tissue expansile lesion of 42 × 36 × 20 mm size in left nasal cavity, left frontal sinus and bilateral anterior ethmoid area causing widening of nasal cavity and leading to thinning and erosion of right nasal bone. The mass was reaching upto but not eroding the cribriform plate. There were scattered areas of increased attenuation and mild post-contrast enhancement. Magnetic resonance imaging (MRI) showed a mass lesion of intermediate intensity on T1-weighted images and the T2-weighted signal without the cystic characteristics of the lesion (Figure ). Based on clinical and radiological findings a differential diagnosis of dermoid, mucocoele or rhabdomyosarcoma was made. Fine needle aspiration cytology showed only blood. Endoscopic surgery under general anaesthesia was planned for tissue biopsy and if found cystic, marsupalisation would be done. On incision it was a solid encapsulated greyish mass. Tissue was sent for histopathological examination and reported as schwannoma. The patient was taken up for excision of the tumor mass using external approach since such a large tumor was not possible to remove by endoscopic approach.\nA left sided modified lateral rhinotomy incision with lateral extension into the eyebrow was made (Figure ). This was joined superiorly with butterfly incision to have good access. On flap elevation papery thin nasal bones which were deficient in midline seen. The nasal bones were gently reflected off the tumor. A well circumscribed, lobulated mass occupying left frontal sinus, ethmoid sinus and the nasal cavity was seen. The tumor was removed piece meal and was found to be adherent in the area of bony septum. Complete removal of the tumor mass was achieved and confirmed using nasal endoscopy. Intraoperatively bleeding was minimal. Skin flaps along with nasal bone replaced back and sutured after securing hemostasis. Final histopathological and immunohistochemical examination was consistent with sinonasal schwannoma (Figure ). Postoperative recovery was uneventful and pack was removed on third postoperative day. At 4 months follow-up there is no evidence of disease and skin incision is well healed (Figure ). |
A 23-year-old woman presented to our hospital with involuntary movement attacks, which she had exhibited for about 20 years. The patient has an unremarkable family history, and her antenatal and perinatal histories and postnatal development were uneventful. At the age of 2, she underwent her first non-febrile generalized seizure. She was administered sodium valproate for 1 year. While another seizure occurred at the age of 12, the patient had since remained seizure-free. At the age of 3 years, involuntary movement attacks without impairment of consciousness began to occur after prolonged exercise or fasting. Attacks were characterized by intermittent dystonia of right unilateral limbs, manifesting as elbow joint, wrist joint, knee joint alternating flexion, twist, and adduction, especially the upper limb. Left limbs were involved occasionally. The involuntary movements lasted from 3 to 5 min. The episodes occurred only one or two times every month. She was diagnosed with dystonia, but no drugs were prescribed. The attacks often occurred before menstruation since her adolescence. At the age of 21 years, the pattern of attacks did not change, but it occurred more frequently than before, about once a week. The patient received a prescription for oxcarbazepine; while the drug helped to control the symptoms at first, it gradually became unhelpful. Four months before admission, the patient's manifestations became less associated with exercise or fasting, and the frequency increased to two to three times weekly. Oxcarbazepine was replaced with carbamazepine. Two months before admission, the symptom worsened after a trip to the seaside: the patient experienced continuous attacks, presenting as involuntary movements of the right upper and lower limbs, with affected limbs becoming painful. The degree of movement was similar to previous attacks; however, the episodes lasted from 3 to 30 min with intervals of 15–20 min; carbamazepine combined with Madopar could not relieve her PDs. Her head circumference was normal. Psychomotor development did not show any abnormalities according to her parents. The timeline of the patient's symptom is shown in .\nNeurological examination revealed positive bilateral Hoffman signs and decreased muscle tone. Cranial nerves, motor strength, and sensory examination were normal. Brain and spine magnetic resonance imaging, lung computed tomography, and laboratory blood exams (including the assessments of ceruloplasmin and erythrocyte sedimentation rates) were unremarkable.\nProlonged electroencephalogram monitoring showed sharp-slow and delta waves in the bilateral frontal area (). Considering the worsening of her symptoms after her travels and a low fever of under 38.0°C, which had begun 4 days before admission to our hospital, we supposed that the worsened dyskinesia could be attributed to infectious factors. After written informed consent was obtained from the patient, lumbar puncture was performed, which showed a white blood cell (WBC) count of 20 × 106/L and a glucose concentration of 1.9 mmol/L (reference value: 2.3–4.1 mmol/L) in CSF; before the lumbar puncture, the patient's blood glucose concentration was 4.39 mmol/L. The CSF:blood glucose ratio was 0.43 (normal range: 0.62–0.68) [3]. These findings informed a speculative diagnosis of intracranial infection. However, antibody testing for M. tuberculosis and viruses in the blood and smear tests for M. tuberculosis and Cryptococcus in CSF showed negative results. A second lumbar puncture was performed 6 days later, showing a WBC of 2 × 106/L and a glucose concentration of 2.0 mmol/L in CSF. Tested the same morning, the patient's blood glucose concentration was 4.50 mmol/L; the ratio of CSF to blood glucose concentration was 0.44. Though the WBC in the CSF decreased to normal levels, the patient's symptoms did not abate fully. Her symptoms, medical history, and persistent reduced CSF:blood glucose ratios together suggested a neurometabolic disorder. We therefore subjected the patient and her parents to genetic analyses and identified a heterozygous point mutation (c.940G>A) in exon 7 of the SLC2A1 gene, which causes a substitution of amino acid 314 from glycine to serine (p.Gly314Ser). The mutation was not found in her parents. Ultimately, the genetic analysis informed a diagnosis of Glut1-DS. The patient began a ketogenic diet (KD), and the PDs disappeared within 3 months. |
The patient is a 43-year-old female who developed end stage renal disease following an ANCA positive rapid progressive glomerulonephritis, for which she received a living donor renal transplant six years ago. The donor tissue was negative for Epstein Barr Virus (EBV serologies, while the recipient was positive for EBV IgG Antibodies only. She was managed on chronic immunosuppression with a combination of azathioprine and prednisone.\nThe patient presented initially after an exacerbation of chronic lower back pain following a non-traumatic injury while dancing. Radiographs and MRI of the lumbar spine were performed as part of the initial work-up. Radiographs were negative for acute injury. MRI of her L-spine incompletely captured irregular marrow signal at her left ischium and right sacral ala. This raised the concern for a primary or metastatic marrow replacing process and prompted further imaging work-up. MRI of the pelvis and sacrum performed at this time demonstrated multiple T\n2-hyperintense and enhancing osseous lesions involving the lumbar spine, sacrum, pelvis, and proximal left femur. Several lesions demonstrated aggressive features, including periosteal reaction and large extra osseous soft tissue components (). The multifocal nature of the bone involvement and the presence of lytic and aggressive features raised concern for osseous metastatic disease from a distant primary.\nCT of the chest, abdomen, and pelvis was performed at this time in attempt to locate a primary site of disease. The CT scan again demonstrated multiple bone lesions with areas of marked cortical destruction (). Numerous round pulmonary nodules measuring up to 1.8 cm, as well as a few enlarged axillary lymph nodes, the largest measuring 2.1 cm in the short axis, were also noted. However, there was no conclusive primary site of malignancy. Fluo-D-glucose positron emission tomography revealed markedly fludeoxyglucose (FDG) avid bone lesions with maximum standardized uptake value up to 35.8 (). Additionally, the rounded pulmonary nodules and prominent thoracic lymph nodes were found to be FDG avid as well, with the SUVmax of the nodules and lymph nodes measuring 23.6 and 30.9, respectively ().\nCT guidance was utilized in the biopsy of the large destructive sacral bone lesion. Pathological analysis revealed an EBV negative, diffuse large b-cell lymphoma with a high proliferation rate. confirming the diagnosis of PTLD. The additional thoracic findings were then presumed to be from PTLD given their rounded, mass-like appearance and marked FDG, and therefore biopsy of these lesions was not pursued. |
A 9-year-old boy complained of malaise, just a few minutes after his first summer swim in the sea; soon after, he presented generalized urticaria, dyspnea, conjunctival hyperemia, blurred vision and faintness. When first aid arrived, since anaphylactic shock was suspected, intramuscular steroids, intravenous antihistamine and nebulized salbutamol were administered, with rapid improvement on the part of the patient. The only thing of note in the child’s medical history was allergy to dust mite, and no other allergies were reported. There was no evidence of any insect bite or drug ingestion; an hour before the swim, the child had eaten his usual breakfast, with hot chocolate. Apparently, there was not contact with fish during the swim. The child had never complained of similar symptoms before and had never had urticaria after contact with water, be it seawater or tap water. No familiarity for allergic disease or chronic urticaria was reported. The child was referred to the local Allergy Department and in order to identify the offender, skin tests and specific IgE assays were performed. In detail, they tested allergy to milk, due the history of milk intake before the appearance of symptoms, and to insect venom and fish, because of the possibility of contact with insects and fish during the bath; all the tests were negative. Although the patient developed no symptoms on contact with tap water, an aquagenic urticaria was suspected, but the specific test was negative. Finally, a cold urticaria was suspected but the cold stimulation test (CST) was negative too. Given the severity of the reaction, prophylactic antihistamine therapy was commenced, but in spite of this, throughout the summer the patient continued to develop wheals all over his body after every swim in the sea (Fig. ), even in places where there had been no direct contact between the skin and the water. The child then came to our attention, at the Burlo Garofalo Institute for Maternal and Child Health in Trieste (Italy), the referral centre for allergic diseases in the north-east of Italy. There, based on the child’s clinical history, a diagnosis of an atypical form of cold urticaria (ACU) was formulated. The specific diagnostic test of ACU involves keeping the lightly clothed patient in a cold room (at a temperature of 4 °C) for 30 min; in our case, it was avoided because of the past patient’s severe systemic reaction. In any case, the boy’s history was fairly characteristic enough to confirm the diagnosis of this rare and often unrecognised chronic physical urticaria: typical diagnostic features of ACU are in fact the appearance of wheals after exposure to various sources of cold (such as seawater at the beginning of summer), also in areas not directly in contact with water and the negativity of the CST. Antihistamine therapy was continued for the whole summer with fair control of symptoms and self-injectable epinephrine was prescribed but the child has never used it. |
A 64-year-old male with a past medical history of hypertension presents to our facility with complaints of worsening abdominal pain for the last week. The patient reported that he had been experiencing abdominal discomfort that he initially attributed to gastric reflux, for which he was prescribed anti-reflux medications by his primary care physician, without improvement of symptoms. He stated that the abdominal pain was initially intermittent but subsequently progressed to persistent and constant abdominal pain. He also reported associated abdominal distension during the past week, with nausea and vomiting that began one day prior to presentation. The patient additionally reported not having a bowel movement for the past three weeks. The patient denies previous abdominal operations as well as ever undergoing a colonoscopy or upper endoscopy. He denies any family history of cancer. He reported denied a history of tobacco, alcohol or illicit substance use. He reported his occupation as a mechanic.\nThe patient’s vitals were stable on first encounter, apart from mild tachycardia of 103 beats per minute that normalized with intravenous crystalloid resuscitation. A complete blood count as well as chemistry panel were within normal limits. Lactic acid level was 1.2 mmol/Liter.\nThe patient’s physical exam was significant for abdominal distension that was tympanic to percussion in all four quadrants. The patient’s abdomen was diffusely tender to palpation, with increased tenderness in the epigastrium, but without peritonitis. No hernia was palpated in the bilateral inguinal regions. There were no prior surgical scars on the abdomen or pelvis.\nComputed tomography (CT) of the abdomen and pelvis with intravenous contrast only demonstrated a high-grade obstruction with dilated, fluid-filled loops of small bowel and a transition point in the right lower quadrant (Figure ). The transition point demonstrated a segment of circumferential wall thickening without fat stranding (Figure ). There was no free air or fluid noted.\nThe patient underwent an exploratory laparotomy where an 8 cm stenotic segment of proximal ileum was noted with decompressed small intestine distally (Figure ). The stenotic segment was palpated and noted to be hard and fibrotic. No intestinal contents were able to be milked through this stricture distally. We decided to resect the stenotic segment and perform a primary anastomosis, which was performed without issue using staples. The remaining small bowel as well as the large bowel were inspected, and no further lesions were noted. The abdomen was closed in a standard fashion. On the backtable, the resected segment of small bowel was inspected and a thick fibrotic submucosal layer was noted with mucosal ulceration (Figures , ).\nThe patient’s post-operative course was rather unremarkable. The patient was ambulating on post-operative day #1, with bowel function returning on post-operative day #3. The patient was started on a liquid diet, which he tolerated well and was advanced accordingly. The was subsequently discharged on post-operative day #5. Histopathology of the resected segment of bowel demonstrated circumferential tubulo-villous adenoma with ulceration and fibrosis. No foci of carcinoma were noted. |
A 68-year-old Caucasian male with a history of hypertension, hypercholesterolemia, coronary artery disease status post five vessel coronary artery bypass grafting presented to the emergency room with chest pain for four days which radiated to his jaw and along the left arm (Figure ).\nElectrocardiogram (EKG) showed old Q waves in inferior leads and new ST depression in leads I, AVL, V5 and V6 and troponin peaked up to 15.8. At the time of presentation, the patient was also short of breath with initial chest plain, a radiograph (X-ray) showing pulmonary edema is depicted (Figures and 3).\nThe patient was electively intubated before urgent cardiac catheterization, which was performed within 12 hours of patient’s arrival, and revealed 100% occlusion in right coronary, left main coronary, and the proximal portion of the circumflex artery as well as diffuse disease of the grafted vessels to circumflex. Furthermore, during catheterization, the patient was also noted to have hemodynamic compromise with blood pressure observed to be 86/63 mmHg and a heart rate of 115 beats per minute, which prompted emergency echocardiography (ECHO) showing partial disruption of medial papillary muscle with severely flail posterior MV leaflet and severe MR. He subsequently underwent venoarterial extracorporeal membrane oxygenation (ECMO) pump placement by cardiothoracic surgery for hemodynamic support accessing through the right common femoral artery and right femoral vein (Figure ).\nHeart team specialists thus discussed the possibility of performing an MV clipping, and it was decided in favor of proceeding with the transcatheter procedure as the patient had a history of median sternotomy and previous bypass surgery. The patient remained intubated and was taken to cath lab on the fifth day of hospitalization. The femoral vein was accessed using ultrasound guidance, and the transseptal puncture was performed using intraoperative transesophageal echocardiography. This was then followed by prepping the MitraClip using standard technique and positioning it across the interatrial septum and above the atrial valve. For this procedure, two clips were used, one was on the posterior segment P2 and just beside it to cinch up P2 and A2, and the second one for P2 and P1 laterally. Once the resulting MR reduction was regarded as adequate, clips were deployed (Figures and 6).\nThe only complication noted was the transient Wenckebach heart block for which the patient subsequently received a pacemaker later in the hospital course. Thus, the patient underwent two successful MitraClip placements, and the severity of MR went down from 4+ to no more than 1+. The patient’s left ventricular function improved postprocedure and ECMO was subsequently followed by extubation later on. Repeat ECHO on third postprocedure day showed mild MR and normal left ventricular ejection fraction. At the 30th day, the patient was followed up in the clinic and repeat ECHO at that time showed mild MR only. |
The patient was a 73-year-old Chinese woman with osteoarthritis in both knees. In the recent half year, she had been suffering from intractable right knee pain with failed conservative treatment and prepared for right side TKA. She had a 27-year history of hypertension and her blood pressure was controlled well by medication. She had no other medical history, including smoking history. Her BMI was 24. The physical examination showed a limited range of motion (ROM) of 0°–120° without varus or valgus deformity. Preoperative X-ray showed narrow medial knee joint space and osteophyte formation without vascular calcification (Fig. ). The peripheral pulses and capillary refill were normal, although the preoperative Doppler ultrasound showed arteriosclerosis with plaque formation in the arteries in both legs.\nThe right side TKA with a posterior stabilized design (LPS, NexGen, Zimmer, Warsaw, USA) was performed under general anesthesia. A tourniquet was applied for 70 min at a pressure of 250 mmHg. The whole surgery was completed without any complications and there was normal intraoperative bleeding at the surgical site. The postoperative X-ray showed successful implantation for the right knee (Fig. ).\nHowever, immediately after the surgery, routine peripheral pulse check in the operating room found absent dorsalis pedis artery pulse in the right foot. The patient was closely monitored in the recovery room. After approximately 2 h, there was no improvement in peripheral pulses, capillary refill, and oxygen saturation. In consideration of the high possibility of arterial occlusion, the vascular consultant recommended using 1000 U heparin for anticoagulation and immediate evaluation by arteriography for diagnosis. An emergency arteriography under local anesthesia showed that there was a short segmental occlusion of the popliteal artery (Fig. ). Then the angioplasty was performed with a balloon with a diameter of 5 mm for 3 min. Follow-up imaging showed excellent blood flow although vascular stenosis was still observed in popliteal artery (Fig. ). There was a return of palpable pulses and a normal capillary refill and oxygen saturation.\nAfter the patient returned to the ward, 12 500 U heparin in 50 mL saline was pumped 1 mL/h and activated partial thromboplastin time (APTT) was controlled around 40 s. The peripheral pulses were closely monitored. On postoperative day 2, the patient was allowed to walk with aids. On postoperative day 6, the anticoagulation plan was changed to rivaroxaban 10 mg two times a day and aspirin 100 mg one time a day for 3 weeks orally. The patient was discharged home 2 weeks after surgery without any complaints.\nAt the most recent follow-up in the orthopaedic clinic (3 months after surgery), there were no orthopaedic or vascular complaints. The patient had an ROM of 0° to 125° with excellent muscle strength and could walk without aids for 1 km. |
A 64-year-old female presented to her primary care physician with a tender right breast lump that had been present for 4-5 days. Additionally, she had been feeling feverish and fatigued. Further history indicated that she recently moved to the United States from Bangladesh. Her primary care physician proceeded to perform an ultrasound needle guided biopsy. Biopsy showed abscess formation and necrotizing granulomatous inflammation. Ziehl-Neelsen and Gram stains were negative for any organisms. Patient diagnosed with an abscess and prescribed a course of oral antibiotics. Several weeks later, cultures from the site grew tuberculosis. The patient was travelling abroad at this time and was unable to follow-up. Upon returning to the United States, the patient was informed of the diagnosis of tuberculosis but was unable to obtain an appointment with an infectious disease specialist in her city of residence. A couple months later the patient presented to our infectious disease clinic complaining of daily fevers and a nonhealing lesion on her right breast. She was not complaining of any other symptoms at that time.\nPhysical exam revealed that she was afebrile but tachycardic. Breast exam was significant for a 1-inch movable mass on the right anterior axillary line without overlying skin changes, warmth, erythema, or nipple changes. Physical exam was otherwise unremarkable. The patient was prescribed oral antituberculosis therapy and was counseled on the need for her family members to be tested for tuberculosis as well. However, the patient's condition worsened over the next couple days and required admission to the hospital. During her hospital admission, her creatinine was found to be elevated from her baseline and she was started on IV fluids. A chest X-ray was obtained and did not reveal any cavitary lesions. A CT scan of the chest revealed nonspecific enlarged axillary, mediastinal, and breast lymph nodes; evidence of prior granulomatous disease of the lungs; no evidence of consolidation, pleural effusion, or pneumothorax; and a diffusely enlarged thyroid with multiple nodules. We were unable to obtain sputum cultures during this admission as the patient was vomiting.\nThe patient was started on oral pyrazinamide, isoniazid, and rifampin in the hospital. Over the course of three days, the patient showed marked improvement in her symptoms and was discharged on antituberculosis therapy. |
A 73-year-old woman was referred to a ‘Sarcoma’ clinic suspected of having a soft-tissue malignancy. The woman had noticed a slow-growing lump on the left side of her abdomen, which had been present for 2 months. The abdominal lump was her primary complaint and she had no significant past medical history. On examination she was noted to have a soft swelling in the left upper quadrant of the abdomen, which felt as if it was arising from the anterior abdominal wall.\nAn ultrasound scan of the abdomen wall demonstrated a complex mass lying within the fatty layer. The lesion extended to 3.5 cm in diameter with a central lobular, heterogenous portion surrounded by fat, which demonstrated marked internal vascularity on Doppler study. This was suspicious of liposarcoma, and 3 core biopsies of the lump were taken which revealed extensively necrotic moderately to poorly differentiated carcinoma. There were both glandular and focal squamous differentiation histologically with keratinisation. illustrates histology from the core biopsy obtained from this abdominal wall lesion. The photomicrograph shows part of a malignant epithelial tumour exhibiting both squamous (left side) and glandular (right side) differentiation. Immunohistochemistry showed focal expression of cytokeratin 20 and a rare cell showing cytokeratin 7. TTF1 (a marker of primary thyroid and non-small cell lung carcinoma), oestrogen receptor and neuroendocrine markers was not expressed. At this stage, the differential diagnosis included a primary skin adnexal carcinoma, for example, a sweat gland carcinoma; however, the histology did not show the classical pattern of the best-recognised subtypes. Therefore, the more likely diagnosis was that of metastatic carcinoma with a number of potential primary sites. A computed tomography (CT) scan and upper gastrointestinal (GI) endoscopy were therefore arranged.\nThe CT scan showed widespread metastatic disease. Beginning cranially, within the lungs there were multiple rounded nodules of varying size, the largest measuring 23 mm, consistent with metastases. In the right superior mediastinum there was an enlarged node measuring over 2 cm. This node was separated from the right lobe of the thyroid by the jugular vein but posteriorly shown to be inseparable from the upper thoracic esophagus. The distal esophagus and gastro-esophageal junction was noted to be abnormally circumferentially thickened and irregular; however, there was no proximal dilatation of the esophagus. There were further metastatic deposits in the liver, kidneys and omentum. A number of subcutaneous and intramuscular lesions were identified throughout the thorax and abdomen, but no lytic bone lesions. The original left abdominal mass was identified as originating from the anterior abdominal wall and extending into the subcutaneous tissue: illustrate CT images of multiple lung metastases (the largest measuring 22.50 mm), of the circumferential esophageal wall thickening consistent with the primary tumour, and of the anterior abdominal wall lesion, respectively.\nAn upper GI endoscopy revealed an extensive, friable and bleeding carcinoma of the esophagus at between 25 cm and 31 cm. Biopsies of the lesion revealed squamous cell carcinoma. The biopsies of the abdominal wall and the esophageal lesion were compared and confirmed as showing identical pattern.\nThe patient was subsequently referred to the upper GI cancer team and at the time of writing, despite the substantial tumour burden, remains well awaiting esophageal stenting and palliative chemotherapy. |
A 31-year-old woman was admitted to our department in order to undergo a laparoscopic cholecystectomy. She had a medical history of symptomatic cholelithiasis with an episode of acute cholecystitis 6 months before and several other episodes of biliary colic before and after this. The rest of her medical history was unremarkable. No preoperative assessment of patient's biliary anatomy with magnetic resonance cholangiopancreatography (MRCP) had been performed. The operation started laparoscopically with division of adhesions between the gallbladder and the greater omentum. During the dissection of the cystic duct and the cystic artery in the hepatocystic triangle, a transected bile duct with small caliber was noticed. The operation was converted to open. It proceeded with retrograde dissection of the gallbladder from the liver bed, identification, dissection, ligation and division of the cystic duct and the cystic artery and removal of the gallbladder from the operating field. During the cholecystectomy, it was recognized that the initially transected bile duct, which was 2 mm in diameter, came out of the hepatoduodenal ligament, ran along the common hepatic duct (CHD) and drained into the cystic duct, in proximity to the neck of the gallbladder. In order to identify the exact nature of the injury, an intraoperative cholangiography was performed by injecting an iodine-containing contrast medium through the common bile duct (CBD). The intraoperative cholangiography revealed that the aberrant bile duct was originated from the right posterior sectoral duct (RPSD). The RPSD continued its typical course up to its confluence with the right anterior sectoral duct (RASD) and the formation of the right hepatic duct (RHD) (Fig. ). The small caliber of the aberrant bile duct and the fact that it drained less than a liver segment led to the decision of its ligation (Fig. ). A drain was placed under the surface of the liver. The postoperative course was uneventful and the patient was discharged on the third postoperative day and remains free of symptoms 6 months later. The histopathological examination of the gallbladder revealed the presence of stones and chronic inflammation of its wall. Figure depicts the patient's biliary tree along with the part of the extrahepatic biliary tree that was removed during the operation (the gallbladder, part of the cystic duct and part of the aberrant duct). An informed consent was taken from the patient in order to publish the aforementioned information. |
A 40-year-old European woman presented with a 1-year history of a palpable anterior neck mass. Physical examination revealed a 1 × 1 cm indurated mass in the right thyroid lobe without palpable lymphadenopathy. Fine-needle aspiration confirmed a papillary thyroid carcinoma. She underwent a total thyroidectomy with cervico-central and cervico-lateral lymphadenectomy. Intraoperative histopathological examination revealed a bilateral papillary carcinoma pT1 pN1b. Laryngeal nerves and thoracic duct were identified and not harmed, and administration of cream via gastric tube showed no leakage. Two suction drains were left behind.\nOn the second postoperative day, the patient complained of dyspnoea and chest discomfort. In absence of neck swelling or suggestive fluid in her drains, a computed tomography of the chest for suspected pulmonary embolism was performed. Massive bilateral pleural effusions were detected; bilateral thoracic drainages were inserted and about 2 L of milky white fluid with a triglyceride level of 17 mmol/L were evacuated. Total parenteral nutrition with total enteral rest and octreotide were initiated. The output of both pleural drains was over 2 L a day. The patient was re-operated on post-operative day (pod) 4 due to the persisting thoracic discharge of over 2 L a day. Again, no chyle leak or injury to the thoracic duct was found. The thoracic duct was ligated. This resulted in a dramatic decrease in the drain output. The thoracic drains were removed on pod 9 and a regular diet was started again. The patient was discharged on pod 11.\nThe thoracic duct arises from the cisterna chyli at the level of the second lumbar vertebra. It enters at the base of the neck and curves to the left to cross the scalene anterior muscle and the thyrocervical trunk. From here it enters the internal jugular, left subclavian, left external jugular or right jugular vein with a high variability []. Injury to the duct usually occurs with thorough dissection of lymphatic tissue in this region. It is commonly recognized by milky effusion in the drain.\nChylothorax in absence of direct injury to the thoracic duct and therefore without chylous effusion however is rare. Bilateral chylothorax is even more uncommon. The pathophysiology is not completely understood; two pathologic mechanisms are discussed in the literature. First, direct leakage of the thoracic duct with subsequent drainage into the mediastinum leads to an inflammatory reaction that causes effusion to both thoracic cavities. Even though in this case no obvious injury to the thoracic duct was found intraoperatively, there has been reports of a few cases in which the suction drains in the thyroid cavity drained chyle. This has been thought to be an indirect sign of injury to the cervical lymphatic vessels.\nThe second pathologic mechanism is thought to be the inadvertent ligation of the thoracic duct which leads to a rise of the intraductal pressure intrathoracically. This rising pressure and in combination with the negative intrapleural pressure generated during inspiration is thought to be severe enough to result in the rupture of the thoracic duct. In our case study, we were not able to identify any injury to the large lymphatic vessels. In both initial and in the revision procedure, cream was administered and the thoracic duct was inspected. Furthermore, the thoracic duct was only ligated in the revision operation. Therefore, exact pathophysiology of chylothorax in our case study remains unknown.\nManagement of chylothorax is mostly conservative and is focused on decreasing the amount of chyle production and preventing concurrent nutritional, immunologic and cardiopulmonary complications.\nThe first measure is to drain the bilateral effusions by inserting chest tubes to relieve respiratory and circulatory distress. Diet comprising of middle chain fatty acids or even total parenteral nutrition without oral intake is recommended.\nAdministration of octreotide to reduce thoracic duct flow remains controversial [].\nOperative treatment is recommended for chyle leaks of more than 1 L per day persisting for more than 5 days or chylothorax remaining longer than 4 weeks, or in a case which results in severe metabolic complications.\nHowever, some surgeons prefer early operative intervention to reduce hospital stay and morbidity secondary to long time nutritional restriction and drainage tubes []. Due to the paucity of cases, definitive treatment guidelines are still lacking.\nAnother aspect is the delay in treatment. This is particularly significant in oncologic patients where lymphadenectomies are being performed. In our patient, a computed chest tomography was performed due to a high clinical suspicion of a pulmonary embolic event. Due to iodide exposition, radioiodine therapy followed with a delay of 4 weeks. |
A 34 year old middle eastern lady with a spontaneous conception presented at 13 weeks of gestation for a routine 1st trimester ultrasound and screening. Her booking weight was 79 kg and her height 165 cm. She was a housewife with three previous uncomplicated pregnancies delivered vaginally. She was on no medication except for iron supplement. The past medical and surgical history was unremarkable and the patient was neither a smoker nor an alcohol drinker. The family history of her partner and herself was unremarkable as well.\nOn 1st trimester ultrasound, the fetus was noted to have bilateral anterolateral neck cysts around 5 × 5 mm in size (Figures and ) suggestive of either 'non-septated cystic hygromas' which are congenital malformations of the lymphatic system characterized by fluid-filled jugular lymphatic sacs of the fetal neck [,] or, the much rarer bilateral branchial cleft cysts. No other abnormalities were noted and the nuchal translucency measured 2.3 mm. The patient was counselled for the high possibility of spontaneous regression and good fetal outcome awaiting the results of the integrated 1st trimester screening test. At 16 weeks, integrated screening gave a 1 in 2 risk for trisomy 18 and therefore fetal ultrasonograpy was repeated. The fetal growth and amniotic fluid volume were normal and the bilateral neck cysts were stable in size. No other abnormalities could be detected despite a careful sonographic assessment and an amniocentesis for fetal karyotyping was offered and accepted. PCR on the amniotic fluid revealed trisomy 18 which was confirmed by cytogenetic analysis.\nThe couple decided to opt for termination of pregnancy which was completed medically at 17+4 weeks with no complications. Pathologic examination of the fetus revealed a dysmorphic face with low-set ears, both legs fixed in extension and clenched fists. At autopsy the neck cysts could not be identified, but there had been considerable trauma to the scalp during delivery. Internally the kidneys and adrenals were of normal size and shape but there was dysplasia on microscopy. There was abnormal placental villous morphology, of a pattern consistent with aneuploidy. There were no internal gross structural anomalies that had been missed on the scan. |
The informed consent was provided by the patient, and ethical approval was warranted by the First People's Hospital of Huaihua.\nA 49-year-old man presented with a 5-month history of back pain who was diagnosed with fourth thoracic vertebral body fracture caused by tumor cells based on pathology results. The tumor cells in the fourth thoracic vertebral body originated from hepatocellular carcinoma. The preoperative thoracic magnetic resonance imaging (MRI) showed a minor intraspinal space-occupying lesion in the fourth thoracic vertebra canal and found pathological fractures of the fourth vertebrae (). Back pain as the only clinical symptom without any weakness, numbness, or other symptoms of spinal cord injury in both lower extremities was reported to the physician. And then, he accepted the percutaneous vertebroplasty (PVP) plus interstitial implantation of 125I particles (10 particles) at a local county hospital (). Back pain was relieved postoperatively, 3 days after he received PVP combined with interstitial implantation of 125I seeds. However, back pain, bilateral lower extremity weakness, and loss of bladder control reoccurred on day 3 after surgery and got worse. A general physical examination and central nervous system examination upon patient admission revealed abnormal findings. The majority of symptoms encompassed pain and hypoesthesia below the processus xiphoideus. The abdominal reflex, the crissum and cremasteric reflex, and the knee and ankle reflex could not be induced. No pathological reflection of Babinski's sign was induced. The strengths of the major muscle of both lower limbs were 3 grades and progressively decreased in the postoperative period. The opiate drugs were used to control pain originating from the surgical site. He was admitted to our hospital after 44 postoperative days because of serious back pain. The postoperative transverse computed tomography (CT) revealed bone cements and metallic implants in T4 without any bone cement leakage, but the MRI showed the left intraspinal space-occupying lesion in the T4 vertebral body (). And the enhanced CT indicated the possibility of tissue tumor, which was also confirmed by thoracic vertebra magnetic resonance imaging (). However, no powerful evidences could be used to confirm that the intraspinal space-occupying lesion was a tissue tumor (). In fact, the results of MRI showed the high signal intensity in T2-weighted and fat-suppression images in the T5 body level (). Notably, there are several particles located in the vertebral posterior wall without appropriate distribution (). The above clinical symptoms may be caused by delayed radiation-induced myelopathy or spinal cord compression. This patient died after 5 months of surgery because of multiple organ failure. |
A 10-year-old girl was referred to our pediatric orthopedic department for treatment with RF ablation of an osteoid osteoma of the right knee. Her past medical history was a 6-month duration of severe pain, localized on the right knee, exacerbating during the night, making her unable to sleep. She was a normally developing girl, participating in sports activities until the appearance of pain. She had a series of blood test investigations (Hb, Ht, WBC, ESR, CRP, alkaline phosphatase) that were all in normal ranges.\nTwo X-ray examinations of the right knee were taken in an attempt to define a diagnosis for the knee pain. An area of a small subperiosteal lucency of the lateral femoral condyle was reported. The right knee was further investigated with MRI. A consultant pediatric radiologist reported that there was minimal edema, possible small nidus, and absence of bone sclerosis. She suggested a diagnosis of a subchondral osteoid osteoma. The girl was provided with paracetamol and ibuprofen but the pain remained unchanged. Figure .\nThe girl was obviously suffering and was continuously grasping the right knee. She could walk normally without signs of limping and was able to hop bilaterally without discomfort. A clinical examination of the right knee revealed a full range of movements, without effusion. Both hips were also normal. Her spine was straight and with full movements of flexion and extension. She had normal bilateral tendon reflexes, a normal sensation in both of the legs and feet.\nUpon review of the X-ray and MRI documents, we could not support the diagnosis of an osteoid osteoma (OO). Therefore, an MRI and a CT examination were undertaken with slices of 5 mm, but a nidus or sclerosis could not be identified. A bone scan was performed that had no increased uptake in the right knee. The bone scan had normal uptake throughout the body. We informed the patient's family that we would not precede to ablation. Figure .\nWe further examined her with an X-ray of hips and pelvis, and lumbar spine AP and lateral, with normal findings. On the next day, we performed an MRI investigation of the right femur, pelvis, and lumbar spine in an attempt to find possible pathological signs.\nIn the lumbar spine an oval, intradural extramedullary, tumefactive lesion was observed in the thecal sac, at the level of L1 vertebra. The lesion consisted of a cystic central part (showing a high signal in T2W and STIR sequences) and a solid peripheral part, with intense enhancement of the latter. There is no evident extension of the lesion in the foramina. The mass measured 27.5 mm (craniocaudal diameter) X 17.5 mm (transverse diameter) X 13 mm (anteroposterior diameter) Figure .\nThe lesion appeared to be mainly located in the central and left part of the thecal sac, causing pressure to the roots of cauda equina. The imaging findings were mostly consistent with a tumor of neurogenic origin (schwannoma). With the diagnosis of schwannoma of the spine, we informed the family about the need for surgical treatment of the tumor. We have not performed biopsy for a tumor with benign characters. Our neurosurgical team performed the operation. After posterior laminectomy of L1 and L2, a well-defined capsulated tumor was resected after clear separation from the nerve roots.\nHistopathological and immunohistochemical analyses confirmed the diagnosis of a cellular neurilemmoma. The tumor showed increased cellularity and the cells were spindle-shaped and arranged in fascicles. The tumor cells are without nuclear atypia or mitosis. Some show nuclear palisading. The tumor cells were strongly positive for S100 and negative for GFAP and EMA. The positivity for Ki67 in “hot spots” was about 5% of the nuclei. Figure .\nThe patient showed impressive recovery, feeling completely relieved. Peripheral neurological examination remained normal. We performed a new MRI of the spine in 6 months, with no elements of recurrence. The girl 8 months after the operation has not experienced any pain. The MRI examination of the brain was normal and we excluded neurofibromatosis. |
A 41-year-old man suffering from the bilateral knee and ankle arthralgia for several months was transported emergently to our hospital owing to acute respiratory distress and hemoptysis. Upon arrival, he was in a shock state. Chest roentgenography revealed severe pulmonary congestion; cardiac echogram revealed a large mass in the LA that incarcerated into the mitral valve. Additionally, chest computed tomography (CT) revealed a tumor in the LA; thus, he was diagnosed with acute left heart failure caused by the mass that obstructed cardiac blood flow (Fig. ).\nAn emergency surgery was performed under cardiac arrest with extracorporeal circulation, which was established in the usual manner with bicaval direct cannulation. Because of the dimensions of the tumor and its pedicle attachment, we could approach through both the wall incisions on the right-side LA from the right upper pulmonary vein and atrioseptostomy from the right atrium. The tumor pedicle widely and irregularly originated from the right upper and posterior LA wall and extended to the lateral LA wall, which included the right upper pulmonary vein. The tumor was visibly extirpated and invaded the LA wall (Fig. ). The shape and function of the mitral valve were intact, and the large defect in the LA wall was reconstructed using a bovine pericardial patch. It was 159 min under extracorporeal circulation, and the aortic cross-clamping time was 123 min.\nExtracorporeal circulation weaning and post-operative course were uneventful, and arthralgia in both lower limbs disappeared immediately after surgery. The pathological diagnosis was UPS with clear resection margins (R0 resection), which invaded the atrial muscular layer (Fig. ). Subsequently, as imaging studies soon and 3 months after surgery did not reveal tumor presence, we decided to adopt a more suitable treatment strategy without involving adjuvant therapy after surgery if UPS relapse or metastasis occurred. Specifically, we planned to perform re-surgical resection or proton radiotherapy for recurred or metastatic tumors. In addition, we planned to initiate systemic chemotherapy using a target organ drug or other anti-malignant tumor agents for distant metastasis depending on the local and general conditions of the patient. He was discharged 20 days after surgery without additional treatment and was able to work 2 months after discharge.\nHowever, local recurrence in the LA was observed on positron emission CT (PET) and other imaging studies 7 months after surgery (Fig. a). A tumor was detected on the posterior LA wall adjacent to the incision line of previous surgery. He again experienced arthralgia in both lower limbs. Thus, we selected radiotherapy with proton beam as treatment, and a dose of 75 Gy was delivered to the recurrent tumor in 30 fractions for 45 days. No tumor was observed in the LA on imaging performed 2 months after radiotherapy as an outpatient (Fig. b).\nAfter 6 months, the second local recurrence at a different site in the LA and distant metastasis to the left adrenal gland were simultaneously observed on the results of several imaging tests. In the left adrenal gland, a large solid tumor with an irregular surface and abundant blood flow was observed on enhanced CT scan (Fig. a), and remarkable fluorodeoxyglucose (FDG) uptake was found on positron emission tomography/CT scan (Fig. b). Proton beam radiation for both tumors was selected to conserve the left kidney function. A dose of 60 Gy was delivered to the tumor in 30 fractions in the LA and 46 Gy in 23 fractions in the left adrenal gland. Moreover, chemotherapy with pazopanib hydrochloride (800 mg/day), a tyrosine-kinase inhibitor (molecularly targeted drug), was used in combination radiotherapy. At the end of the second radiotherapy, a larger but cystic and non-enhanced mass in the left adrenal gland was observed on CT (Fig. c). While the patient was receiving chemotherapy for 8 months after the completion of the second radiotherapy, the size of the left adrenal mass apparently reduced. Moreover, neither blood flow nor fluorodeoxyglucose (FDG) uptake of lesions in both the LA and left adrenal gland were revealed on positron emission CT scan (Fig. d, e).\nTwenty-seven months after surgery, no active tumor was noted on any imaging result, and he returned to work without symptoms, including arthralgia of the lower limbs. |
A 31-year-old white male presented with dyspnea associated with generalized weakness and lethargy for the past 4 months. In the past month, his breathing had further worsened with episodes of syncope with exertion. He also reported an intermittent fever and had lost 40 pounds in 2 months. He smokes cigarettes and drinks alcohol regularly along with intravenous (IV) methamphetamine once or twice per week.\nOn presentation, he was febrile, tachycardic, and hypotensive and was admitted to the hospital for the management of septic shock. The examination showed a Grade 2 systolic murmur in the mitral area and tenderness of the upper abdomen. He was treated with IV fluids and broad-spectrum antibiotics as per protocol. Computed tomography (CT) of the abdomen showed geographical enhancement of the spleen suspicious of infarction, along with multiple small renal infarction. On the basis of these findings, infective endocarditis with embolization was suspected. Echocardiogram confirmed 2.5 cm × 1.5 cm vegetation in both mitral leaflets with evidence of severe mitral regurgitation [].\nWhile being worked up for mitral valve replacement, he suddenly developed numbness of his left arm. On examination, the left arm was pale with an absent radial pulse. Bedside, arterial Doppler revealed a possible obstruction of the proximal brachial artery with maintained blood flow distally. Meanwhile, his blood cultures grew A. defectiva (nutritionally deficient Streptococcus [NVS]) from both of the bottles []. Vascular surgery was consulted, and CT angiogram of the left upper extremity was performed, revealing an occlusion of the left brachial artery distal to the deep brachial branch point []. There was a reconstitution of flow distally within the ulcer artery, which was patent to the level of the wrist, and the radial artery did not become opacified until just proximal to the wrist joint, suggesting extension of the thrombus into the radial artery. The patient was initiated on anticoagulation therapy and underwent left brachial artery balloon embolectomy with extraction of two clots/vegetation, one approximately the size of a cashew nut and another the size of a peanut. The patient later underwent mitral valve replacement under pump. Both mitral valve leaflets appeared mushy and destroyed and the vegetation extended into the chordae tendineae closest to the papillary muscle and also into the left atrial wall []. The native valve was successfully replaced with an On-X33-mm prosthetic valve. A. defectiva was pan-sensitive to ceftriaxone, gentamycin, penicillin, and vancomycin; hence, treatment was tailored to IV penicillin G at 4 million units every 4 h and IV gentamycin at 1 mg/kg every 8 h for a total of 6 weeks. He improved symptomatically and was discharged home along with home antibiotics and anticoagulation therapy. At the follow-up appointment, he reported well-being and had gained 10 pounds of weight. |
A 36-year-old Asian man was referred to our hospital with cardiac tumor metastases from ASPS. In July 2005, he underwent surgical resection for a tumor in his right lower extremity; pathological examination indicated ASPS. Postoperative care included radiotherapy, although the radiation dose was unclear. In August 2007, follow-up CT scans showed multiple lung metastases, for which the patient received systemic chemotherapy. Despite treatment, the metastases gradually increased and so the patient underwent lung metastasis resection of the left and right lung in June and September 2013, respectively. In June 2014, follow-up CT scans indicated double kidney metastases; the patient consequently underwent right renal tumor resection and, 3 months later, left renal tumor resection. In January 2015, left lung metastases were again found, and the patient underwent cryoablation. In June 2015, metastases were found in the right adrenal gland and pericardium, leading to treatment by CyberKnife. The patient was then admitted to our hospital for further treatment of cardiac metastasis.\nPhysical examination was almost normal. CT examination of the right ventricular wall showed a localized metastasis of about 4.9 × 3.8 × 3.4 cm (fig. ) with large amounts of pericardial effusion. Electrocardiogram examination was normal, and there was no detectable valvar abnormality. Transthoracic echocardiography revealed a 43 × 40 mm low echogenic tumor that was invading the myocardium of the apex of the right ventricular wall, and the border of the tumor was poorly defined.\nAlthough we recommended a surgical or transvenous biopsy, the patient did not wish to undergo this procedure and so the metastasis was not histologically confirmed. However, given the echocardiographic and CT features and the patient's past history, we suspected the tumor to be a metastasis from ASPS. After multidisciplinary discussion, we considered cryoablation combined with iodine seed implantation to treat the cardiac metastasis. We obtained the patient's informed consent and undertook the operation on August 3, 2015. The procedure was carried out as follows: a 10-cm-long incision was made along the midline of the sternum in the lower one-third to cut the skin and subcutaneous layers. Next, the xiphoid was removed and the sternum split 5 cm longitudinally. A transverse apical incision was made to enter the chest and expose the pericardium. The pericardium was cut, and about 350 ml of red bloody fluid in the pericardial effusion was aspirated. After exploration, a gray-white lump of approximately 5 × 4 × 3 cm was seen in the lower wall of the right ventricle. The surface was uneven and hard, and there was no sense of myocardial contractility. Under ultrasound guidance, a 1.47-mm cryoprobe in stick mode was inserted into the tumor to administer a small amount of freezing gas (fig. ).\nNext, we implanted iodine seeds in the tumor target area and administered D90 of iodine-125 seeds at 110 Gy, according to the preoperative treatment planning system program. Total radioactivity was 21.0 mCi, and the half-life was 60.1 days. After the iodine seeds have been implanted, the cryoprobe was used in freezing mode to administer two freeze-thaw cycles given as follows: freezing at −120°C for 5 min then thawing at 1°C for 1 min. An ultrasound scan showed that the size of the ice ball was about 2.5 × 2.5 × 3.0 cm. After rewarming, the cryoprobe was removed.\nSurgery proceeded smoothly with a blood loss of approximately 50 ml; the patient's vital signs were stable. One 8-Fr drainage tube was inserted into the pericardial sac to allow culture of the drainage fluid for bacterial and cancer cells.\nWe performed a CT scan 1 day after the operation to assess any initial changes in the ablated lesion and monitored procedural-related side effects (fig. ). |
A 39-year-old Thai male patient presented with progressive pain and swelling of seven-month duration over the antecubital fossa of the right elbow. Initially, there was only slight swelling. Three months later, he complained of dull pain. The patient went to a private clinic where the diagnosis was distal biceps tendinitis. The first doctor gave a local steroid injection, but the symptoms recurred about one month later. Four months later, the patient complained of pain at night and weakness on supination of the forearm and flexion of the elbow. He had no underlying disease, chest symptoms, fever, weight loss, or history of contact with patients suffering from pulmonary tuberculosis.\nPhysical examination of the right elbow when patient visited the hospital in Thailand demonstrated swelling at the antecubital fossa, mild tenderness at the distal biceps, and muscle weakness or pain when attempting to supinate the forearm and flex the elbow. All other systemic examinations were normal. There was a high white blood cell count (12,710 cells/mcL); neutrophil count was 72% and lymphocyte count 17%. Erythrocyte sedimentation rate was 17 mm/hr, and C-reactive protein was 6.69 mg/L. Radiography of the right elbow showed swelling at the antecubital fossa, and chest radiographs showed infiltration of the left upper lung. Magnetic resonance images showed disruption of the distal biceps tendon with an associated ill-defined soft tissue mass (about 2 × 2 cm). A less enhanced area was observed at the inferior part, which was likely to be necrotic or cystic. An abnormal marrow signal was detected at the proximal radius with focal cortical erosion at the radial tuberosity ().\nIn this case, we suspected that the patient had disseminated tuberculosis because preoperative chest radiographs demonstrated left upper lung infiltration, which was likely pulmonary tuberculosis, and there was a soft tissue mass at the distal biceps tendon. We performed an open excisional biopsy and debridement using the single-incision anterior approach. The finding was a soft tissue mass involving the distal biceps tendon with complete tendon rupture. There was also a small focal cortical defect at the radial tuberosity. The ruptured distal biceps tendon was debrided. The tendon was repaired to the long-head tendon insertion, which was proximal to the focal defect by about 5 mm, using a TWINFIX Ti 2.8 mm Suture Anchor with one #2 ULTRABRAID Suture (Smith & Nephew Inc.). Antituberculosis chemotherapy started one day after the surgery, following a positive test of the fluid for acid-fast bacilli and a positive polymerase chain reaction for Mycobacterium tuberculosis. The patient received a total of 6 months of a rifampin-based regimen, which is recommended for musculoskeletal tuberculosis []. The patient initially received isoniazid 300 mg, rifampicin 600 mg, ethambutol 800 mg, and pyrazinamide 1500 mg daily for two months and then reduced to isoniazid and rifampicin for the remaining four months. The elbow was immobilized in a posterior elbow slab with the forearm supinated for four weeks. Mycobacterium culture revealed Mycobacterium tuberculosis. Microscopic examination of the soft tissue revealed granulomatous inflammation with multinucleated Langhans giant cells and caseous necrosis.\nAt the 1-year follow-up, erythrocyte sedimentation rate was 10 mm/hr, and C-reactive protein was 2 mg/L. Motor power of supination and flexion showed grade V and the hook test was negative. This study was approved by the Khon Kaen University Ethics Committee for Human Research (KKUEC) in which the study ID was HE611179. |
A 15-yr-old man had a chief complaint of a palpable neck mass for 4 months. He had no family or past medical history. The patient first recognized the neck mass 4 months before, and it rapidly increased in size during the latter 2 months. All laboratory tests, including thyroid function tests, were unremarkable. The neck computed tomography revealed a relatively well-demarcated solid mass at the superior and lateral portion of the left thyroid gland (), suggesting that this lesion may be either a primary thyroid mass with exophytic growth or a soft tissue tumor pushing the thyroid, in particular, a neurogenic tumor. The fine needle aspiration cytology disclosed moderate cellularity with a predominance of bipolar spindle-shaped cells having oval- to spindle-shaped nuclei and finely granular chromatin without nucleoli. The plump spindle cells in the clusters were arranged in a fascicular or streaming pattern with a mild degree of pleomorphism. The cytoplasm of the spindle and oval cells was moderate and pale eosinophilic. These cytologic findings were initially regarded as a benign follicular lesion and could not lead to a definitive diagnosis ().\nThe patient subsequently underwent total thyroidectomy and left cervical lymph node dissection. The mass was encapsulated and covered by the same capsule as the thyroid, measuring 6×5×5 cm in dimensions. The cut surface showed a well-demarcated, lobulated and grayish tan solid mass with rubbery consistency ().\nMicroscopically, the tumor was separated from the thyroid parenchyme by a thick fibrous capsule and showed a biphasic growth pattern, which was an admixture of spindle and epithelial cell components in almost equal proportions (). The spindle cell component consisted of fascicles of atypical fibroblast-like spindle cells, and the epithelial component was composed of solid nests of plump epithelioid cells with well-formed glandular structures (). The periphery of the tumor showed focal calcification and more densely packed spindle cells without an epithelial component (). Focal areas of hemangiopericytic pattern were also present (). The glandular structures were lined by round or cuboidal cells with round to oval nuclei and abundant eosinophilic cytoplasm. Some glandular lumens are filled with pale basophilic materials, which were periodic acid schiff and alcian blue positive. The intervening spindle cells were slightly plump and had elongated, vesicular nuclei with a scant amount of eosinophilic cytoplasm. On average, 15 mitotic figures were seen per 10 high-power fields both in epithelial and spindle cells.\nOn immunohistochemical staining, the glandular elements were diffusely and strongly stained with cytokeratin, whereas the spindle cells were diffusely stained with vimentin and focally with epithelial membrane antigen (). The tumor cells were diffusely positive for CD99. Stains for muscle specific actin, smooth muscle actin, S-100, carcinoembryonic antigen, synaptophysin, chromogranin, thyroglobulin, and thyroid transcription factor-1 (TTF-1) were all negative in the tumor cells.\nOn ultrastructural examination, the tumor was composed of solid nests of epithelial cells and fascicles of spindle cells, which were partially covered by basal lamina. The epithelial cells had desmosome-like cell junctions, whereas the spindle cells had no cell junctions. No tonofilaments, granules, microvilli, or other specific organelles were found ().\nThe SYT-SSX fusion gene transcript was identified in the paraffin-embedded tumor tissue using the reverse transcriptase-polymerase chain reaction method (). |
A six-year-old boy was referred to our hospital after a traffic accident. He presented with decreased mentality (Glasgow Coma Scale score of 6), with an endotracheal tube and mechanical ventilation. Pupils were isocoric but sluggish to light. Computed tomography (CT) scans showed bilateral TBGH, about 30 cc in the right side and 20 cc in the left side (). Intraventricular hemorrhage (IVH) was present. We decided to remove bilateral TBGH to reduce increased intracranial pressure (ICP); this was done by bilateral stereotactic hemorrhage aspiration (). Surgery lasted 6 hours and draining catheters were inserted in both operation sites. Postoperatively, he was transferred to the intensive care unit where he was sedated and ventilated. Immediate postoperative brain CT confirmed the appropriate location of both draining catheters and the persistence of hemorrhage, with more hemorrhage on the right side (). We started irrigation via a draining catheter with 8,000 IU of urokinase dissolved in normal saline every 8 hours over 2 days on the right side. After the administration of urokinase, 3 cc normal saline was injected into the clot. At total of 5 cc of diluted urokinase and normal saline were administered. The catheter was then clamped for 30 minutes. The amount of drain was about 110 cc dark-colored blood mixed with cerebrospinal fluid on the right side and less than 5 cc on the left side during the first 24 hours postoperatively. On the second day after operation, brain CT follow-up demonstrated diffuse low density around the previous hemorrhage and severe brain swelling (). Shortly after brain CT, the patient's right pupil size suddenly became dilated and unresponsive to light. Decompressive huge craniectomy and duroplasty were performed (). At postoperative day (POD) 11, brain CT showed further reduction in bilateral TBGH and IVH and enlargement of ventricle size associated with scalp bulging at the operation site (). At POD 39, ventriculoperitoneal shunting and cranioplasty using autologous bone were done (). Currently, he remains in a chronic vegetative condition. |
A 59-year-old male presented for pancreaticoduodenectomy for T3N1 Pancreatic Adenocarcinoma. He was induced with 200 mg propofol, 70 mg lidocaine, 100 mcg fentanyl, and 60 mg rocuronium. Induction was completed successfully without any major hemodynamic instability facilitating endotracheal intubation. Following induction, the patient was easily masked without the need for an oropharyngeal airway. Upon initial attempt at intubation, a Macintosh size 4 laryngoscope blade was inserted successfully without obvious damage to oropharyngeal structures. Obtaining the view of the vocal cords was difficult as it was anteriorly displaced, and there was limited mobility of the larynx. Additional anterocaudal force was applied to the laryngoscope to attempt to improve view and laryngeal manipulation was required for a final best view of glottis structures to achieve a Cormack/Lehane score of grade 2B. At this time, the decision was made to abort direct laryngoscopy and proceed with video laryngoscopy for improved view.\nThe video laryngoscope size 4 blade was inserted without dental or oropharyngeal trauma and laryngeal manipulation was required for a final best view of glottis structures to achieve a Cormack/Lehane score of grade 2A. A 7.5 mm internal diameter, and a cuffed endotracheal tube was inserted without any mucosal trauma or bleeding and was placed posterolateral to the tongue and secured with tape at 22 cm at the teeth.\nThe intraoperative course was complicated by prolonged duration and excessive blood loss requiring large volume resuscitation to maintain hemodynamic stability. The surgery duration was 10 hours 55 minutes with an estimated blood loss of 1500 cc requiring a transfusion of 3 units of packed red blood cells, in addition to infusion of 8000 cc of crystalloid and 1000 cc of 5% albumin. There were no adjustments made to the positioning of the endotracheal tube of cuff pressure during the procedure. The patient was hemodynamically stable at the end of the surgery and was successfully extubated and taken to the general postanesthesia care unit where he was awake, responsive, and reported that his pain was adequately controlled. Upon waking up the following day, the patient first noticed slurred speech accompanying a swollen tongue and when examined by the bedside nurse was noted to have dysarthria and deviation of the tongue to the left. As the day progressed, the patient did notice improvement in his symptoms. Neurology was consulted and performed a complete neurological exam which was significant only for the findings described above. There was no word-finding difficulty, aphasia, weakness, or other cranial nerve or focal neurological deficits. The patient was alert and oriented to person, place, time, and situation. A MRI of the brain without contrast was performed to investigate possible cerebral infarction, which was ultimately negative. The neurology team concluded the deficit was likely hypoglossal nerve palsy related to prolonged orotracheal intubation.\nFollow-up with the patient on postoperative day 2 showed improvements of approximately 75% in swelling, dysarthria, and deviation, although the symptoms were still present. Postoperative day 6 and day 17 showed similar symptoms as postop day 2, with the patient noting no additional improvements during these intervals. Working with speech pathology mildly improved speech; however, tongue deviation and pronunciation of specific letter sounds still proved difficult. Approximately 2 months after the procedure, the patient's symptoms completely resolved spontaneously. |
Agenesis of the infra-renal aorta is very uncommon anatomical variation; the presence of which can complicate significantly the accurate interpretation of the sonographic assessment of the aorta, leading to false initial differential diagnoses such as extensive aortic thrombosis or even contained rupture.\nComplete agenesis of the infra-renal aorta is an extremely rare anatomical variation, with only few cases reported in the international literature to date., Herein, we present a case in which this rare condition was sonographically diagnosed as possible complete aortic thrombosis or contained rupture, highlighting the need for considering this anatomical variation as a potential explanation in similar cases of unconventional initial sonographic findings of the infra-renal aortic segment.\nA 48-year-old Caucasian female patient presented to our emergency department with features of new-onset, mild bilateral calf edema. Her past medical history was unremarkable. A vascular consult was sought to rule out the presence of ileo-femoral or more proximal venous thrombosis as part of the initial diagnostic work-up. Her admission blood tests (full blood count, renal and liver function tests, and coagulation profile) were within normal range; bedside lower limb venous triplex did not demonstrate any signs compatible with proximal venous thrombosis; however—despite multiple attempts—the infra-renal part of the aorta could not be visualized till the level of common femoral vessels. As the latter raised the possibilities of extensive thrombosis or even contained rupture of the aorta, an urgent computed tomography angiogram (CTA) was performed. The later demonstrated complete agenesis of the aortic trunk distally to the level of the renal arteries, with substitution of the undeveloped part of the aorta by a pair of significantly enlarged lumbar arteries, along with significant prominence of the superior-inferior epigastric anastomotic circuit bilaterally, as an adjustment to the absence of developed aorto-iliac axes (Figure ). The patient was reassured from the vascular point of view and a note was sent to her general practitioner, highlighting the need for clear documentation of this rare anatomical variation in the patient's medical records; particularly, should she require any vascular intervention in her future life. Of note, the patient remains completely asymptomatic at 30 days’ follow-up. |
A previously healthy 26 year old male presented to the emergency department (ED) with chest pain for 1 hour. The patient stated the substernal pain was 10/10 in severity, non-radiating and worse with deep inspiration. He experienced intermittent left arm numbness that started after the onset of the chest pain but denied heart palpitations, diaphoresis, shortness of breath, hemoptysis, cough or recent fevers. On physical exam, vital signs were unremarkable, and he was cooperative and able to speak in full sentences. Chest auscultation did not detect any abnormalities. An electrocardiogram was read as normal. A chest radiograph revealed a lung lesion in the left lower lobe. A computed tomography (CT) of the chest showed a 11 cm × 9 cm × 10.5 cm round, well-defined, heterogeneous mass consistent in location with the lesion noted on the chest radiograph. The patient’s chest pain was well controlled on oral analgesics, and after consultation with the surgical service he was scheduled for an outpatient appointment for follow up and treatment. The patient was discharged and prescribed acetaminophen-hydrocodone 500 mg-5 mg oral tablets to be taken as needed for pain 1–2 tablets every 4–6 hours with a maximum of 8 tablets per day. He was advised to return to the ED if symptoms persisted or worsened.\nThe patient returned to the ED 1 day later with recurrent chest pain that was now more localized around his left lower ribs and rated as 8 out of 10 in severity. His vital signs remained within normal limits and his physical exam was unchanged from discharge. A repeat chest CT showed no changes. His pain management therapy was changed to acetaminophen-oxycodone 325 mg–7.5 mg oral tablets to be taken as needed for pain 1 tablet every 4 hours with a maximum of 6 tablets per day. This adjustment resulted in symptomatic relief of his chest pain. With improved symptoms and unchanged imaging, he was discharged with strict follow-up instructions.\nThe patient returned 3 days later for his scheduled outpatient appointment. The surgical service obtained a chest magnetic resonance angiogram with contrast that revealed a cystic lesion measuring 108.7 mm by 104.0 mm (). A thoracotomy with resection of an extralobar pulmonary sequestration (PS) was completed without intraoperative or post-operative complications. The non-communicating lung parenchyma was being supplied by an artery arising from the abdominal aorta. The patient was discharged home on post-operative day 4.\nAt a follow-up outpatient appointment 1 week after discharge, the patient remained asymptomatic, and a repeat chest radiograph showed resolution of the PS. The patient did not require further outpatient follow-up. |
A 26-year-old Chinese Han female patient with a sudden onset of massive vaginal bleeding was transferred to our department by the emergency service. She had delivered a healthy female baby at 39 weeks of gestation by primary cesarean due to the large vulvovaginal varicosities in the local hospital 10 days before. And the referral letter of the regional hospital wrote that there had been postpartum hemorrhage of about 1500 mL (general anesthesia, without telling any other details of the operation). By blood transfusion and the use of uterine contraction medicines, the patient had recovered well and been discharged with her newborn. On the 10th day after delivery when she was at home, there was a sudden heavy vaginal bleeding as mentioned above. On the way to referral, there had been ∼1500 mL of vaginal bleeding. The regional hospital gave her three units of red cell suspension and some drugs to promote uterine contraction and then transferred her to our hospital by emergency.\nWhen she was a little girl, she limped and her left leg was sweaty. She was diagnosed as “acromegaly” in her childhood without any special treatment. She conceived spontaneously without preconception counseling. She was first diagnosed with KTS by one of the dermatologists of the local hospital at the last trimester of pregnancy. There had been no history of thrombosis. During pregnancy, neither low-weight heparin nor low-dose acetylsalicylic acid had been given to her. Her medical history was otherwise uneventful. She denied family history of KTS or any other familial genetic diseases.\nAt the time of admission, physical examination was remarkable for blood pressure of 89/56 mm Hg, heart rate of 125 per minute, respiratory rate of 22 per minute, and a temperature of 37.3°C. She appeared pale and diaphoretic. Cardiopulmonary examination was unremarkable. The lower abdomen was bulging and tender, with scattered subcutaneous ecchymoses. The bottom of the uterus was palpable at the level of navel with tenderness. A Pfannenstiel incision scar with old blood scab was seen. And there was a palpable mass of 16 × 18 cm around the incision. Multiple subcutaneous hemangiomas, varicosities and port-wine capillaries distributed over the left buttock and the whole left lower extremity (Fig. A–C). No bruit or thrill was present. Massive hypertrophy of the left lower extremity was obvious, and the difference in leg length was 4 cm. The left labia majora contained a large complex of varicosities (Fig. D). Bimanual examination showed massive bleeding from the vagina without blood clot.\nLaboratory studies showed white blood cell (WBC) 9.01 × 109/L (normal 3.69–9.16 × 109/L), hemoglobin (HGB) 75 g/L (normal 113–151 g/L), hematocrit (HCT) 23.6% (normal 33.5–45.2%), mean corpuscular volume (MCV) 91.3 fL (normal 82.6–99.1 fL), platelets (PLT) 91 × 109/L (normal 101–320 × 109/L), prothrombin time (PT) 14.4 seconds (normal 10.4–12.6 seconds), activated partial thromboplastin time (APTT) 37.7 seconds (normal 21.1–36.5 seconds), plasma fibrinogen level (FIB) 0.5 g/L (normal 1.8–3.5 g/L), plasma fibrinogen degradation product (P-FDP) 386.3 Ug/mL (normal 0.0–5.0 Ug/mL), INR 1.24 (normal 0.96–1.16), and d-dimer (normal 0.0–0.55 mg/L FEU) could not be measured out for several times. The ultrasound showed that there was a mixed echo of 10.5 cm × 5.1 cm in the uterine cavity with a dark liquid area of 3.8 × 1.8 cm. The spleen was enlarged with an intercostals’ thickness of 4.6 cm. Ultrasound of the liver, gallbladder, pancreas and the kidneys, etc. revealed unremarkable. Cardiovascular ultrasound showed no evidence of cardiomegaly, abnormal cardiac structure, or arteriovenous fistula of the left lower extremity.\nBased on these findings, the patient was first diagnosed as: late puerperal hemorrhage, KTS, DIC, and hemorrhagic shock. Despite the blood transfusion, the massaging of the uterus as well as the use of hemostatics, there was still heavy vaginal bleeding of 1700 mL since admission. And the second laboratory tests showed HGB 70 g/L, PLT 78 × 109/L, PT 13.4 seconds, APTT 38.9 seconds, FIB 0.5 g/L, P-FDP 330.3 Ug/mL. d-Dimer could not be measured out either. And then emergency hysterectomy was performed. There was abdominal incision hematoma of about 250 g, and pelvic hematocele of 900 mL. The inert uterus looked like a big pocket. There was nothing special about the uterine vessels and the bilateral adnexa. Old blood clot of about 500 g was found in the cavity of the uterus. The postoperative course was complicated with intraperitoneal hemorrhage, disseminated intravascular coagulation (DIC), peritonitis and sepsis. Thirty-nine hours after the hysterectomy, the peritoneal drainage was bloody about 1800 mL and the HGB dived to 46 g/L with a heart rate of 160 per minute. So, she underwent another emergency laparotomy because of the hemoperitoneum. There was diffused blood oozing in the pelvic and the bleeding site could not be clearly found. So, four conjoint long ribbon gauzes were packed in the pelvic before abdominal closure with the terminal outside. The gauzes were removed, respectively, 36 and 48 hours after the second laparotomy. Then, bilateral internal iliac artery embolization was carried out with the consideration of KTS and the risk of bleeding again. The angiography showed the hypervascularity of bilateral internal iliac artery branches with patchy exudation. The bilateral internal iliac artery was embolized successfully. The intraperitoneal hemorrhage was controlled gradually. Meantime, the correction of coagulation disorders, the improvement of anemia, and the anti-infection treatment, etc was carried out. Then, she was sent to the operation room again for wound dehiscence closure. Given her refractory coagulopathy, a diagnosis of Kasabach–Merritt syndrome was considered. Low molecular weight heparin therapy (2000 IU IH qd for 2 days, then 2000 IU IH q12 hour for 2 days, then 3000 IU IH q12 hour for 2 days, followed by 4000 IU IH q12 h) was started at the 13th day after the second laparotomy. And warfarin (2.5 mg orally qn for 3 days followed by 3.75 mg orally qn) was added at the 31st day. The therapy was continued until the 37th day after the second laparotomy, when the patient's hemoglobin and hematocrit were stable and her thrombocytopenia was resolved. Totally, she required transfusion of a total of 43 units of red cell suspension, 9850 mL of fresh frozen plasma, 9 therapeutic doses of platelets, 94 units of cryoprecipitate, 5.5 g lyophilized human fibrinogen, and 300 IU of human prothrombin complex. She was discharged after 42 days of hospitalization with medical elastic stockings. She was followed up for nearly 5 years with nothing remarkable and her baby was healthy. |
A 26-year-old Caucasian woman suffering from congenital absolute UFI underwent a deceased donor UTx. In the first year of the post-transplant period, 4 episodes of mild acute cellular rejection were diagnosed by cervical biopsy. They were treated with pulses of glucocorticoids and the addition of azathioprine to a maintenance immunosuppressive regimen of tacrolimus. In the further course, the patient developed secondary neutropenia, which was addressed by withdrawal of azathioprine and administration of several pulses of granulocyte colony-stimulating factor.\nApart from congenital uterine agenesis which was treated with UTx, the patient was healthy with no history of further operations. Family history was negative for inherent diseases.\nFive months after the UTx, the patient’s compliance was suboptimal. She decided to go on vacation to Egypt despite clear physician recommendation not to do so considering the high risk of acquisition of infectious gastroenteritis.\nAfter her return from Egypt, the patient presented with nausea, abdominal discomfort, and diarrhoea. She was hospitalized to receive rehydration therapy and to run necessary tests.\nUpon admission, there were no signs of acute abdomen. The abdomen was mildly tender in all quadrants; there were no signs of peritoneal inflammation.\nUpon admission, her abdominal ultrasound (US) was normal, although the appendix was not differentiated on baseline US. There was no suspicion of acute abdomen, and thrombosis of the uterine graft was excluded using Doppler ultrasound (Figure ).\nC-reactive protein was 27 mg/L on day 0; the level of leukocytes was within the normal range. However, tests proved to be positive for Clostridium difficile colitis. Due to lack of signs of acute abdomen and verified colitis, we felt it was not necessary to run computed tomography (CT) of the abdomen. A therapy of perorally administered vancomycin 125 mg 4 times a day was started. Viral and parasitic colitis were excluded. Additionally, cytomegalovirus (CMV) polymerase chain reaction was negative. In the course of the next few days, there was a steady progressive elevation of the level of C-reactive protein up to 83 mg/L on day 4. Although the differential blood count showed a normal level of leukocytes, it was considered pathologic because the patient had been leukopenic chronically and there was a new finding of neutrophilia. On day 4, the abdominal discomfort changed to pain and became localized to the right hypogastrium. |
A 52-year-old female with bipolar disorder and a past medical history of hypothyroidism was admitted to the psychiatric unit for the treatment of a manic episode. She had first been diagnosed with bipolar disorder in early adulthood and had taken lithium for most of the following 3 decades along with adjunctive mood stabilizers and antipsychotics. Prior to admission, she had been taking lithium carbonate CR 900 mg nightly, quetiapine 50 mg twice daily, and levothyroxine 125 mcg daily. She expressed deep ambivalence regarding psychiatric medications. While she initially agreed to increase quetiapine to target her worsening symptoms, on hospital day 4 she stopped taking the medication. On hospital day 8, she agreed to take carbamazepine—a medication which she had taken for several years previously. The medication was started at 200 mg twice daily and incrementally increased over 4 days to a dose of 400 mg twice daily starting on hospital day 12. During this period, she self-discontinued lithium, which left carbamazepine as her only scheduled psychotropic medication.\nOver the hospitalization, the patient's mania worsened: she became more talkative, her affect became more irritable, and her thought process became characterized by a worsening flight of ideas. On hospital day 16, a carbamazepine trough level was ordered and accidentally drawn twice by the phlebotomist. It was measured as 11.5 μg/mL and 12.1 μg/mL. The patient had been taking carbamazepine 400 mg twice daily for 4 days, except for the evening dosage on hospital day 13 that she refused. Blood was drawn 10 hours after the last administration of the medication. That evening, she complained of a headache and was given acetaminophen. On hospital day 17, 9 days after initiation of carbamazepine, she developed a fever (see the and for details) and the medical service was consulted for further evaluation. She complained of no other symptoms; a complete metabolic panel including liver function tests, complete blood count, urinalysis, and creatine kinase were all unremarkable, a COVID-19 PCR assay was negative, and c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were mildly elevated. She refused carbamazepine that evening and overnight was given acetaminophen.\nOn hospital day 18, the patient took her scheduled morning carbamazepine and her fever increased to 104.4°F. She complained of headache and jaw pain, but her complaints were difficult to interpret given her increasing disorganization. She refused a repeat COVID-19 test, and the decision was made to transfer her to the medical floor. Inflammatory markers including d-dimer and lactate dehydrogenase were elevated as was a repeat CRP. A chest x-ray was notable for “minimal increase in the interstitial markings in both lungs and minimal linear atelectatic areas at the bases,” according to the radiologist's report, but was otherwise unremarkable. A CT scan of the face, chest, and abdomen was ordered but the patient refused. She also refused her evening dose of carbamazepine but accepted acetaminophen. That night, her measured oxygen saturation level decreased from 100% to 91% before returning to 94% over a 12-hour period.\nOn hospital day 19, the patient again refused her morning carbamazepine dose. Her measured oxygen saturation level normalized, but her fever continued, and she refused a repeat COVID-19 nasal swab, prompting the medical service to transfer her to a dedicated COVID-19 unit. Additional blood work was notable for an elevated procalcitonin level as well as an elevated antinuclear antibody with strongly positive anti–Sjögren-syndrome type A and B antibodies. She refused empiric antibiotic therapy. That evening, the on-call psychiatrist in consultation with the on-call pharmacist elected to hold carbamazepine to rule out medication side effect as the etiology of the fever. This decision left the day 18 morning dose of carbamazepine as the final dose administered to the patient. The patient accepted additional doses of acetaminophen.\nOn hospital day 20, she remained febrile and agreed to a repeat COVID-19 PCR swab, which was negative. On hospital day 21, her fever resolved, and on hospital day 22 she was transferred back to the psychiatric unit. The rheumatology service was consulted and noted that the patient had complained of dry mouth during their evaluation; they recommended she be reevaluated in 3 to 6 months for possible Sjögren syndrome once her mood stabilized given the presence of elevated anti-Sjögren-syndrome type A and B antibodies. However, they advised that this condition was unlikely to explain her fever. The allergy and immunology service was also consulted. They noted no evidence of rash on the patient's chest, back, abdomen, or extremities and advised that drug reaction was the most likely etiology.\nThe patient developed a mild lymphopenia which resolved within 2 weeks. She subsequently agreed to restart lithium and initiate olanzapine, and her psychiatric symptoms improved. |
A 55-year-old man, a social drinker and a technical officer by profession presented to the Teaching Hospital, Peradeniya (THP) in the Central Province of Sri Lanka with a history of headache, gradual alteration of level of consciousness (LOC) and behavioral changes of 3 weeks duration. He was apparently well 7 weeks back and experienced headache, faintishness and vomiting at 2 am while doing a night shift in his work place. After the patient has lost consciousness and become unresponsive. The following day morning, other workers who came for the morning shift found him drowsy and less responsive and took him to the nearest hospital after 6 hours of initial symptoms. On admission, his Glasgow Coma Scale (GCS) was 9/15 and there were no any focal neurological signs. He was haemodynamically stable and respiratory examination was normal with normal pulse- oximeter finding. He continued to have vomiting and diarrhoea over the next 48 h. His full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and renal profiles were normal. He was treated with 6 L of oxygen via a face mask and was managed as food poisoning. He was gradually improving and was discharged from the hospital on the 4th day of admission and he was totally normal on discharge. After discharge he was asymptomatic and was doing day to day activities normally.\nAfter 1 month of initial episodes, he developed reduced self-care, a lack of interest of work in which he was interested before the illness. He found it difficult to work as a technical officer due to low energy, lethargy, poor concentration and reduced memory. He was withdrawn at times and was less communicative. He endorsed poor sleep and had a low mood. His condition deteriorated over the next 2 weeks and developed episodic inappropriate talking, confusion, generalized rigidity of the body and urinary and fecal incontinence. He was unable to identify his family members and developed reduced level of consciousness. He was admitted to the THP 7 weeks after the initial incidence. On admission to the THP, he was haemodynamically stable with blood pressure of 140/90. On neurological examination, he was drowsy with GCS of 11/12 (E3, V3, M5). Pupils were normal in size and well reacting to light, both optic fundi were normal, and all cranial nerves were normal. He had generalized rigidity with hyperreflexia and bilateral extensor plantar response. He gradually developed masklike face, positive glabella sign and primitive reflexes (grasp reflex). Mini-Mental State Examination (MMSE) was unable to take because of his demented status. His full blood count, blood picture, ESR, CRP, serum magnesium and calcium levels, liver and renal profiles were normal (Table ). He had normal electrocardiogram with normal 2D echocardiogram and troponin I was negative. His EEG showed marked generalized slowing of background with multifocal high amplitude waves and delta waves suggestive gross cerebral dysfunction without epileptiform discharges (Fig. ). Non contrast computer tomography (CT) of brain showed prominent cerebral white matter with obliterated sulci with preserved gray-white demarcation and normal ventricular system with no evidence of intra cerebral haemorrhage (Fig. ). His cerebrospinal fluid (CSF) report was normal and CSF was negative for both bacterial studies (light microscopy examination and culture) and viral studies (HSV/Entero/Flavi). The MRI brain showed diffuse high signal intensity involving subcortical white matter, globus pallidus on FLAIR and T2W images (Fig. ). These areas showed high signals in DWI images with no significant changes appreciated on ADC map (Fig. ). There was no abnormal contrast enhancement appreciated in the above areas. Rest of the cerebral hemisphere, ventricular system, brain stem and cerebellum were normal. While investigating this patient (index case) we came to know that another person (2nd case), who did a night duty with our patient and slept in the same room, also had been admitted with our patient to the same local hospital with the initial incidence. He (2nd case) too has experienced vomiting, diarrhoea, faintishness and unsteady gait, but no changing sensorium. On admission to local hospital his (2nd case) unsteady gait improved, and he had vomiting and few more episodes of diarrhoea. He was totally normal on next day and was discharged from the hospital with a diagnosis of food poisoning. Since then he was asymptomatic.\nFurther inquiry revealed an another incidence happened in the same place after 2 weeks of initial incidence when 8 workers who came from their main office (Colombo) slept in the same room and all of them became ill after being there for about 3 hours. The most common symptoms were headache and faintishness which were experienced by all 8 workers. Six of them had unsteady gait and four of them fallen on ground when they attempted to walk. Five of them experienced lethargy and nausea and two had vomiting. Loss of consciousness was experienced by three patients and duration of loss of consciousness (LOC) was less than 5 minutes in two of them and around 20 min for the other one. Even though, it was impossible to recall the associated seizure by others, one had urinary and fecal incontinence at the time of LOC. Three people had diarrhoea and two experienced burning sensation of throat. All of them were taken out and two became totally normal within 30 min. Another two became normal within 2 hours. Two patients out of three who developed LOC became asymptomatic after 12 h and they were treated with face mask oxygen and other supportive care at the same local hospital. All the symptoms except headache experienced by the person who had LOC of around 20 min settled after 24 h and his headache lasted for 3 days. The remaining patient had headache for 3 days even though his initial symptoms were mild. All of them were discharged from the local hospital on the same day evening.\nAfter this incidence, the work place was examined by the authorities and found to have newly implanted petrol driven generator, in the ground floor of the two-story building in which all victims (patients) slept. It was found that mal functioning generator emitting carbon monoxide when it was on. In both incidences, there had been a power failure requiring power to be generated by this offending generator. Subsequently, we traced all exposed victims and examined them, including the person who developed symptoms in initial incidence with our patient (index case), after 8 weeks of initial exposure. All of them were neurologically normal and all had normal MRI brain imaging.\nDepending on the available history, examination, epidemiology of the incidence and the MRI brain finding, the diagnosis of Carbon Monoxide-induced Delayed Neuropsychiatric Sequelae was made. Supportive management was offered to him. He was started on Sinemet (carbidopa levodopa) up to maximum dosages with no clear therapeutic benefit. Dexamethasone was also tried without obvious effect. He was gradually deteriorated over next 2 weeks, exhibited athetoid movements of his feet, and hands and went to rigid akinetic mute state. He could not respond to any stimulation and even displayed decorticate-like posture. His illness was complicated with aspiration pneumonia and died nearly after 3 weeks of admission. His post mortem examination showed evidence of pneumonia mainly in right lung and punctuate haemorrages in the sub cortical white matter of the brain. Histological examinations of all the organs were normal including brain.\nAll the others who had exposure history were followed up for 1 year and they were totally asymptomatic at 1 year of initial incidence. |
We report the case of a Caucasian male patient aged 34 without an irrelevant past medical history that presented with unexplained weight loss. Imaging studies revealed the presence of a left renal mass of 10 × 12 cm (Fig. ). The patient underwent a left radical nephrectomy and the pathology was consistent with an EAML (Fig. ) with poor prognosis features (size > 7 cm, vascular and renal sinus invasion, necrosis, and severe atypia). Immunohistochemical profile revealed diffuse and intense expression of HMB-45 and Melan A (Fig. ), along with expression of smooth muscle actin and CD68 (KP-1, Ventana), and negativity for CD-31, CEA, CK-pan, desmin, EMA, Ki-67, myogenin and S-100. After nephrectomy the patient did not receive adjuvant therapy and started follow up in urology clinics. Seven months after primary surgery the patient developed 3 liver metastases (two in segment VIII of 6 cm and 1.5 cm, respectively, and one in segment IV of 2 cm). All these lesions were completely resected through a right partial hepatectomy with extension to segment IV through a split in situ technique. Again, adjuvant therapy was not administered. Five months later a new single metastasis developed in the first lumbar vertebrae, and was managed through a total L1 corpectomy. Six months after the spine surgery liver recurrence was observed, surgical resection was incomplete leaving positive margins and within 12 weeks a new liver lesion of 1.7 cm was detected. A new surgical attempt was considered not feasible and after reviewing the scarce existing literature, it was decided to start systemic treatment with sirolimus 6 mg/day []. After starting sirolimus treatment the patient presented a very unusual and favorable response (complete response after 13 months of treatment; Fig. ). Tolerance was excellent with grade 1 intermittent diarrhea and acne along with grade 1 hypophosphatemia. At the time of publication, after 36 months of treatment and about five years of the initial diagnosis, the patient remains free of disease and with an excellent performance status. Genetic testing was performed and ruled out TSC (no TSC1 or TSC2 germline mutations detected).\nTargeted NGS of MTOR, TSC1 and TSC2 genes was performed on DNA extracted from formalin-fixed paraffin-embedded primary tumor and hepatic metastasis, and the patient’s peripheral blood (TruSeq Custom Amplicon Low Input; Illumina). Primary tumor failed NGS due to poor DNA quality, however, the liver metastasis and the blood were successfully sequenced by NGS, with a mean coverage of 184× and 1643×, respectively, and single nucleotide variants and indels were identified. One TSC2 variant resulting in a premature stop codon (c.2739dup; p.K914*) was found in heterozygosity in the metastasis while it was absent in blood (Fig. ). Sanger sequencing validated this finding, and detected the TSC2 mutation also in the primary tumor (Fig. ). IHC revealed absence of TSC2 expression in the liver metastasis (Fig. ), in agreement with inactivation of TSC2. Phospho-ribosomal protein S6 staining was positive in the primary tumor and liver metastasis (Fig. ), indicating activation of the mTOR pathway in the patient’s tumors. |
A 36-year-old Asian-Indian woman presented to our Oral and Maxillofacial Clinic with a complaint of persistent swelling present bilaterally over the parotid region which had been present for more than 12 years along with dry eyes and dry mouth. Initially, the swelling was present only over the left side. A serology study for rheumatoid antibodies done previously was positive, and she was prescribed corticosteroid for same. She had then developed another swelling on the left side of her neck. At the time, the evaluating physician noted some cervical lymphadenopathy for which an excisional biopsy of the lymph node was then determined to be “nonspecific inflammation.”\nHer symptoms of dryness of eyes and mouth persisted and swelling over the right side began to appear 5 years prior. She had consulted many physicians who were of the opinion of secondary SS and was prescribed 10 mg of methotrexate tablets once daily. A handful of biopsies had been done before presentation to us, most of which were suggestive of a benign lymphoepithelial lesion (one was suggestive of Castleman's disease). A history of chronic salpingitis and ovarian cystectomy done 5 years before the presentation was also noted. She had no comorbidities at the time of her initial presentation.\nA clinical examination revealed dry eyes, dry mouth, and large 16 cm2 diffuse swelling of the left and moderate 8 cm2 swelling of the right parotid region []. The skin over both swellings was normal in appearance and nontender and soft in consistency. She also had 3 purpuric/ecchymotic areas, of 1 cm2 each, over her left upper calf region and lower back. Intraoral examination revealed a grossly carious upper left third molar which required extraction, and the saliva was thick and sticky in consistency.\nHer laboratory evaluation included a complete blood count, comprehensive metabolic profile, and urinalysis which were within normal values, along with tests for salivary flow and tearing which revealed markedly lower than normal values. Antinuclear antibody and rheumatoid arthritis antibodies results were negative.\nA plain and contrast MRI scan of the bilateral parotid region was taken which reported two well-defined homogeneously isointense soft-tissue density mass on T1-weighted and hyperintense on T2-weighted images, in the markedly enlarged superficial lobe extending to the deep lobe of the left parotid gland and one in the superficial lobe of the right parotid gland. The perilesional planes were well maintained, and no infiltration into surrounding structures was seen. There was also the enlargement of level 1, 2, and 3 lymph nodes which were considered only reactive. A lip biopsy was also performed and showed nonspecific inflammation of the minor salivary glands. Based on these findings, a provisional diagnosis of SS was given according to the AECG criteria even though autoantibodies were negative. The refractory nature of her condition was explained, and the option of superficial parotidectomy was suggested along with continuation of the medical management for the sicca symptoms. After obtaining informed consent, the patient underwent a superficial parotidectomy of the left parotid gland under general anesthesia []. The superficial lobe was excised through a lazy S approach. Postoperatively, the wound healed uneventfully, and the patient is on regular follow-up.\nThe histology showed chronic inflammatory cell infiltrate, especially lymphocytes, of the left parotid gland, correlated clinically as Sjogren's syndrome. |
A 10-year-old overweight Hispanic female (BMI > 28) complaining of abdominal pain for 2 days was brought to our emergency department (ED) by her mother. The pain reportedly started in the periumbilical area and later localized to the right lower quadrant. She also reported left lower quadrant pain, anorexia, and nausea but denied vomiting. She had no fever. Upon arrival to the emergency department, her vital signs were within normal limits for her age, but physical exam revealed generalized lower abdominal tenderness with rebound and guarding.\nHer laboratory investigation was positive for elevated white cell count of 12.10 per microliter of blood with a left shift. The rest of her laboratory results were within normal limits. Abdominal and pelvic CT scan were done which showed hyperemic appendix and hazy anterior mesentery and a small amount of free fluid (Figures –).\nBased on the history, physical exam, and CT scan findings, a diagnosis of acute appendicitis was made and the patient was taken to the operating room for laparoscopic appendectomy. Intraoperatively, a tortuous retrocecal appendix with free fluid was found, and appendectomy was performed without any complications. After performing the appendectomy, the omentum was noted to be adherent to the anterior abdominal wall and on careful examination, it was noted to be hemorrhagic and necrotic as shown in Figures and . The necrotic omentum was resected and sent for histopathological examination. Although the infarcted omentum was mostly in the midline anterior abdominal wall, we did not have the necessity to place additional ports and were able to successfully resect the omentum with standard laparoscopic appendectomy port placements (umbilical port, left iliac fossa port, and suprapubic port). The patient had an uneventful postoperative course and was discharged on the second operative day.\nHistopathological exam of the appendix revealed focal superficial acute mucositis and recent hemorrhage suggesting early acute appendicitis. Examination of the omental mass showed fragments of adipose tissue with hemorrhage, fat necrosis, and granulation tissue formation consistent with omental infarction (Figures –). |
A previously healthy 14-year-old female presented to the office with sharp, generalized abdominal pain and dark brown urine since the previous night. Additionally, the patient noticed that her whole body ached after running for two hours that same day. She was afebrile and had a cough and runny nose for the past three days. All of these symptoms were not preceded by trauma or Streptococcus infection within the past month. Her last menstrual period was 20 days earlier.\nOn observation, the patient looked well. All vital signs were normal. Physical examination findings were unremarkable (non-tender abdomen, no edema noted on extremities). Urine sampling demonstrated light yellow clear urine. A urine dipstick was not performed because it was unavailable in the office. Consequently, the patient was advised to call the office or go to the emergency room should she have the reemergence of abdominal pain or brown urine. Shockingly, the office was notified that the patient had been admitted to a hospital with acute renal failure the following day. She was in the hospital for three days before finally being discharged home to be followed up by the renal clinic.\nFour months later, the patient presented to the office with diffuse back pain of one day's duration. The pain did not radiate anywhere. She also presented with chest pain that had been going on for five months. The pain occurred mainly in the left lower breast area, and it typically increased with inspiration. It occurred roughly one to three times per week and, along with a cough, was associated with recreational sports. The patient stated that the last time she had any chest pain was the previous week. An electrocardiogram (EKG) taken four months earlier was unremarkable. She denied any palpitations, nausea, vomiting, and any dizziness during exercise or rest. Upon further questioning, it was discovered that her throat had felt ‘tight’ for the past year when running, and she often tried to cough because it hurt to swallow. This did not negatively affect her ability to participate until the end of the run, however. In general, she didn’t experience any fever, changes in weight, muscle weakness, or swelling of extremities. She denied having any episodes of dark brown urine ever since being discharged from the hospital. Consequently, the patient was diagnosed with exercise-induced asthma and back muscle strain.\nAt a follow-up visit four days later, the patient felt well, but her creatine phosphokinase (CPK) was 2,439 U/L (reference range: 26.0 - 192.0 U/L). This was observed even eight days after she played kickball for one hour. At that time, she was advised to avoid sports and to do a weekly CPK test for three weeks. Table shows the results.\nOn further questioning, the patient disclosed that eight months earlier, she had presented to a clinic with dark brown blood in the urine of three days duration (four days after the completion of her menses). The patient reported starting a strenuous exercise regimen on the day she started seeing the brown urine and had generalized exercise-related soreness. She mentioned having been in school sports (mainly basketball), which she had been doing for three years now. The basketball practice and games lasted up to a maximum of two hours, with the first 15 to 30 minutes generally being running. She did not participate in any weightlifting. On average, she drank two bottles of water and half a bottle of Gatorade a day. Urine dipsticks showed the presence of protein and blood in the urine. She was sent home with a diagnosis of dehydration due to strenuous exercise and not drinking enough fluids.\nThe patient’s past medical history was unrevealing. Occasionally, she took acetaminophen for pain as needed. The patient had been performing really well in school, honoring in all of her classes. She denied any smoking, alcohol consumption, or recreational drug usage. Her mother has attention deficit hyperactivity disorder (ADHD), hypertension, and arrhythmias. Her maternal grandfather suffered from a heart attack, and her maternal grandmother had melanoma three times. One of her second cousins suffered a cardiac arrest and was found to have a prolonged QTc (it was unclear whether this developed before or after the cardiac arrest). Her half-brother has an autism spectrum disorder and ADHD. Her full biological brother is very healthy.\nAt the time of the follow-up visit in the office, the patient weighed 132 lbs (59.9 kg, 74th percentile) and was 67 inches tall (1.7 meters, 92nd percentile). Her percentiles for weight and height have been the same since the age of three. Her body mass index (BMI) was 20.7 (62nd percentile). Muscle tone, strength, and mass were normal. There were no signs of calf muscle hypertrophy. Gower’s sign was negative (which was performed because the CPK levels were greater than 100 times the upper normal limit when she was previously hospitalized). In the hospital, the following were also unremarkable: CT scan, antineutrophil cytoplasmic antibodies (ANCA), C3/C4 complement, antistreptolysin O titers, Streptococcus A direct probe, and a pregnancy test. Erythrocyte sedimentation rate and liver function tests were also normal. Table compares various measurements taken at the time of hospitalization to the time of follow-up.\nThe patient’s history of recurrent rhabdomyolysis related to sports, acute renal failure, absence of weakness, and persistently elevated CPK levels with low exercise threshold raised suspicion for metabolic myopathy. She was consequently referred to a geneticist for evaluation. The geneticists performed lactic acid and acylcarnitine panels, both of which were normal. Whole exome sequencing (WES) revealed a pathogenic partial gene deletion in the DMD gene. Pathogenic variants in this gene are associated with Duchenne/Becker muscular dystrophy (DMD/BMD). This was surprising because DMD is X-linked. It was traditionally thought that only males developed this condition.\nOn recent subsequent evaluations, she tended to present with calf muscle pain and cramping during exercise, muscle twitching all over (although mostly on extremities), and weakness with climbing and trying to get up from a chair. She was still able to participate in sports after school with frequent drinking and resting as needed. She was advised to drink enough fluids and monitor her urine color so that it remained clear. |
A 55-year-old female presented to the out patient department of our hospital with a history of a fall from height. The patient had experienced immediate pain and swelling in the knee and ankle area of the limb. On removing the splint used to transport this patient and examining the patient, swelling of the knee, upper tibia and heel were noticed. Palpation produced crepitus of the upper tibia. Significant tenderness was elicited on palpation at the knee as well as the heel.\nRadiographs of the knee in the anterioposterior and lateral plane showed a type VI Schatzker fracture of the tibial plateau. Radiographic examination of the calcaneum showed a tongue type fracture of the calcaneum with complete loss of the Bohler angle ( & ).\nThe patient's limb was placed in a well padded splint and observed for compartment syndrome. Over a period of three days the patient developed significant ecchymosis around the upper tibia.\nIn view of the compromised soft tissue envelope, age of the patient and complexity of the trauma, it was decided to manage both the fractures in a ring fixator ().\nThe patient was anaesthetised and placed on a traction table. The proximal fragments were approximated with manual pressure under image intensifier control. Ilizarov wires were placed to obtain compression in the coronal plane. A cancellous transverse lag screw was placed to obtain further stability. An additional ring was placed and affixed to the bone, below the metaphysiodiaphysial comminution. This ring was affixed to the diaphyseal bone with two Schanz pins placed at right angles to each other. The foot was immobilised with a Schanz pin attached to this fixator. This Schanz pin was placed in the first metatarsal ( & ).\nA Schanz pin was placed into the tongue shaped calcaneal fragment, starting posteriorly. This pin was attached to the second ring by means of a plate and two threaded rods. By gradual distraction and lateral pressure under image intensifier control, the Bohler angle was restored. The Schanz pin was kept in this position in the distraction mode. The patient was allowed range of motion exercises of the knee from the first post operative day. At 10 weeks the fixator was removed and patient allowed partial weight bearing crutch walking. 12 weeks post fixation full weight bearing was allowed ( & ). At final follow up of 40 weeks, the patient had a range of motion from 10 degrees to 125 degrees. The ankle range of motion at was 15 degrees dorsiflexion to 30 degrees of plantar flexion. The patient is able to ambulate without pain, and is able to do light activity. However, heavy activity causes mild discomfort around the knee. |
A 74-year-old Caucasian female was diagnosed with primary cutaneous melanoma of the right plantar toe in 2014. She underwent surgery followed by an anti-PD-1 agent (Pembrolizumab) immunotherapy resulting in complete resolution. No evidence of metastatic disease at other locations was noted. Three years later, in February 2017, she was found to have a mass in the right ascending colon. She underwent a right hemicolectomy with lymph node dissection and remained disease-free. In May 2017, a CT scan of the chest showed a large heterogeneous mass centered on the lateral wall of the right atrium communicating with another mass inferiorly. She had complaints of slowly progressive fatigue, malaise, and weight loss. Her exam was significant for pallor, increased vitiligo on both hands as well as the forearms and persistent right lower extremity lymphedema. Cardiac magnetic resonance (CMR) (Figure ) further characterized the mass as a bilobed mass in the right atrium occupying a significant portion of the chamber. One lobe was attached to the right atrial wall with another component that was mobile in the right atrium cavity. The mural component was a solid, enhancing mass. The mobile lobe appeared to be a combination of a mass and thrombus. Both of these masses were homogenously hyperintense to myocardium on T1 and T2 weighted imaging; the mobile component was slightly more heterogeneous on T1 than the mural component. The mass was impinging on the tricuspid valve with the suggestion of tricuspid inflow turbulence and tricuspid regurgitation. The superior vena cava appeared slightly dilated but without involvement. The 3D TEE (Figure ) revealed the mass and its site of attachment on the lateral wall of the right atrium. Echocardiographic contrast demonstrated enhancement of the mass, indicating vascularity.\nThe patient underwent TEE-guided biopsy. Two biopsy specimens were obtained and sent for histopathological examination. The procedure was complicated by transient hypotension and development of a small pericardial effusion without echocardiographic features of tamponade. Repeat TTE four days later showed a stable pericardial effusion. Biopsy of the mass was consistent with metastatic melanoma with the tumor being positive for S100, HMB45, and Melan A on immunohistochemistry stain. Given her good functional status and isolated metastasis, she underwent tumor resection from the right atrium with the reconstruction of the right and left atrium, interatrial septum, and left-sided pulmonary veins with bovine pericardial patches. A pacemaker was also placed. |
A 58-year-old male presented with left-sided headache after inadvertently colliding with a door and hitting the left side of his face. The patient's past medical history was significant for mechanical mitral valve on anticoagulation, HLA-B27 associated uveitis, and bilateral retinal detachments. Four years ago, he underwent prosthetic replacement of the right eye and silicone oil (SO) endotamponade on the left, however this maneuver was ultimately unsuccessful, and he had no vision in either eye at baseline. Physical exam was notable for an irregular and non-reactive left pupil with no light perception; clean prosthetic within the right orbit; and a small abrasion on the left forehead and nose with minimal ecchymosis. His neurological exam was otherwise unremarkable.\nThe patient's initial CT head was misinterpreted as favoring intracranial metastasis which led to further work up with MRI head, CT chest, abdomen and pelvis. He was found to have a 13 mm spiculated nodule in the right lower lobe of the lung with low uptake on a positron emission tomography scan that also revealed other nonspecific findings in the gastrointestinal tract.\nThe patient was admitted to the intensive care unit where his anticoagulation, warfarin with therapeutic level at the time of admission, was held for concern of intracranial hemorrhage. He underwent an esophagogastroduodenoscopy and colonoscopy given the abnormal positron emission tomography scan findings.\nHe was seen by multiple services. While there were initial plans to obtain a surgical biopsy of his lung nodule, image review with radiology led to a prone CT head which confirmed the mobile debris in the ventricular system was in fact SO. Supine CT head revealed new (compared to a prior imaging two years earlier performed when he was presented to an outside emergency room with dizziness) hyperdense nodules in the anti-dependent portions of the lateral ventricles. MRI head with and without contrast showed the hyperdense lesions in the anti-dependent portions of the lateral ventricles demonstrated no appreciable enhancement but did demonstrate significant chemical shift artifact consistent with intraventricular migration of intraocular silicone. A prone CT head confirmed that the hyperdense intraventricular debris was mobile, supporting the suspicion of intraventricular migration of silicone.\nWhile the patient was largely asymptomatic, misdiagnosis of intracranial SO migration triggered the unnecessary use of resources such as specialist consultation, intensive care admission, further imaging in addition to exposing the patient to potentially life-threatening complications by withholding anticoagulation. There was also a plan for lung resection, assuming the lung nodule represented a neoplastic process. After successful diagnosis, the patient's subsequent hospital course was uneventful. |
A 37-year-old male presented with a laceration to the dorsal aspect of his right hand and 4th digit. Six days prior to admission, the patient was involved in an altercation where he struck an individual in the mouth. Over several days, the patient developed severe, constant pain, limited mobility of the 4th digit, swelling, erythema, and purulent drainage.\nSix days after the injury, the patient presented to the emergency room and had a 2 cm laceration to the dorsum of the right hand at the level of the 4th MCP joint with gross purulence and a foul odor. The patient was unable to extend the 4th and 5th digits from the flexed position. Extensors and flexors of the thumb appeared intact along with the intrinsic muscles of the hand. Sensation to light touch was intact in the distributions of the axillary, radial, ulnar, and median nerves, and all digits had brisk capillary refill.\nThe patient underwent surgery for irrigation and debridement, as well as exploration and potential repair of damaged structures. The traumatic laceration was extended proximally and distally to approximately 7 cm. Once in the 4th MCP joint, purulent fluid was noted and cultures were taken. There was necrotic tissue, and the infection had eroded through the extensor tendon causing rupture in Zone V (). The patient was started on broad spectrum IV antibiotics, and a second surgery was planned in 48 hours.\nAfter further irrigation and debridement, the compromised tissue was resected back to reveal a 10 cm gap in the extensor tendon, which would necessitate reconstruction. Intraoperative cultures grew Streptococcus anginosus and Eikenella corrodens.\nSix days after initial presentation, the patient was taken to the operating room for a third time. At this time, there was no progression of the infection, and the wound bed appeared to be stable with minimal need for debridement. Given the 10 cm gap, the decision was made to use palmaris longus autograft. This was harvested using standard technique with two transverse incisions at the proximal and distal ends of the forearm. The graft was connected to each end of the ruptured extensor tendon using a Pulvertaft weave.\nA 3 × 6 cm piece of AVIVE® Soft Tissue Membrane was wrapped around the tendon reconstruction and secured with a chromic suture (Figures and ). The wound was closed with chromic sutures and staples (), dressed, and the patient was placed in a volar resting splint for the entire hand to the PIP joints. This provided support and prevented flexion and/or extension beyond what the repair could sustain within the first week. |
A 41-year-old man suffering from the bilateral knee and ankle arthralgia for several months was transported emergently to our hospital owing to acute respiratory distress and hemoptysis. Upon arrival, he was in a shock state. Chest roentgenography revealed severe pulmonary congestion; cardiac echogram revealed a large mass in the LA that incarcerated into the mitral valve. Additionally, chest computed tomography (CT) revealed a tumor in the LA; thus, he was diagnosed with acute left heart failure caused by the mass that obstructed cardiac blood flow (Fig. ).\nAn emergency surgery was performed under cardiac arrest with extracorporeal circulation, which was established in the usual manner with bicaval direct cannulation. Because of the dimensions of the tumor and its pedicle attachment, we could approach through both the wall incisions on the right-side LA from the right upper pulmonary vein and atrioseptostomy from the right atrium. The tumor pedicle widely and irregularly originated from the right upper and posterior LA wall and extended to the lateral LA wall, which included the right upper pulmonary vein. The tumor was visibly extirpated and invaded the LA wall (Fig. ). The shape and function of the mitral valve were intact, and the large defect in the LA wall was reconstructed using a bovine pericardial patch. It was 159 min under extracorporeal circulation, and the aortic cross-clamping time was 123 min.\nExtracorporeal circulation weaning and post-operative course were uneventful, and arthralgia in both lower limbs disappeared immediately after surgery. The pathological diagnosis was UPS with clear resection margins (R0 resection), which invaded the atrial muscular layer (Fig. ). Subsequently, as imaging studies soon and 3 months after surgery did not reveal tumor presence, we decided to adopt a more suitable treatment strategy without involving adjuvant therapy after surgery if UPS relapse or metastasis occurred. Specifically, we planned to perform re-surgical resection or proton radiotherapy for recurred or metastatic tumors. In addition, we planned to initiate systemic chemotherapy using a target organ drug or other anti-malignant tumor agents for distant metastasis depending on the local and general conditions of the patient. He was discharged 20 days after surgery without additional treatment and was able to work 2 months after discharge.\nHowever, local recurrence in the LA was observed on positron emission CT (PET) and other imaging studies 7 months after surgery (Fig. a). A tumor was detected on the posterior LA wall adjacent to the incision line of previous surgery. He again experienced arthralgia in both lower limbs. Thus, we selected radiotherapy with proton beam as treatment, and a dose of 75 Gy was delivered to the recurrent tumor in 30 fractions for 45 days. No tumor was observed in the LA on imaging performed 2 months after radiotherapy as an outpatient (Fig. b).\nAfter 6 months, the second local recurrence at a different site in the LA and distant metastasis to the left adrenal gland were simultaneously observed on the results of several imaging tests. In the left adrenal gland, a large solid tumor with an irregular surface and abundant blood flow was observed on enhanced CT scan (Fig. a), and remarkable fluorodeoxyglucose (FDG) uptake was found on positron emission tomography/CT scan (Fig. b). Proton beam radiation for both tumors was selected to conserve the left kidney function. A dose of 60 Gy was delivered to the tumor in 30 fractions in the LA and 46 Gy in 23 fractions in the left adrenal gland. Moreover, chemotherapy with pazopanib hydrochloride (800 mg/day), a tyrosine-kinase inhibitor (molecularly targeted drug), was used in combination radiotherapy. At the end of the second radiotherapy, a larger but cystic and non-enhanced mass in the left adrenal gland was observed on CT (Fig. c). While the patient was receiving chemotherapy for 8 months after the completion of the second radiotherapy, the size of the left adrenal mass apparently reduced. Moreover, neither blood flow nor fluorodeoxyglucose (FDG) uptake of lesions in both the LA and left adrenal gland were revealed on positron emission CT scan (Fig. d, e).\nTwenty-seven months after surgery, no active tumor was noted on any imaging result, and he returned to work without symptoms, including arthralgia of the lower limbs. |
The patient is a 56-year-old female with a past medical history of hypertension, morbid obesity, and uterine fibroids. She had a history of abdominal surgery with two cesarean sections, total abdominal hysterectomy, and bilateral salpingooophorectomy. Five months after her last surgery in 1996, the patient was re-admitted with a large incisional hernia. She had open hernia repair with inlay polypropylene mesh under general anesthesia. Her post-operative course was uncomplicated. In general, polypropylene is cheap, available readily and is usually first choice for most hernias. It causes intense scarring, which is what is desired for repair of hernias.\nApproximately 14 years (June 2010) after hernia repair, the patient presented to the Emergency Department complaining of intermittent abdominal pain rated 6/10 starting at right lower quadrant and migrating upwards and diffusely over the entire abdomen, associated with 2-3 episodes of nausea/ week. She had felt this pain on and off for the past 2 years but came to the Emergency Department because she felt it was worsening. She denied any other complaints. She was passing gas and having bowel movements. All lab work was normal. Computed tomography (CT) scan of abdomen and pelvis was unremarkable. Physical exam showed moderate tenderness at right lower quadrant but was otherwise benign. Prior screening colonoscopy showed diverticulosis but was otherwise unremarkable. Repeat colonoscopy was performed on this admission which showed mesh in the cecum. In light of the patient’s past history of incisional hernia repair with polypropylene mesh, this finding was consistent with partial migration of the previous surgical mesh into the cecum and mesh was intact. The mesh appeared to have eroded into the lumen, but there was no enterocutaneous fistula or any other enteric fistula. This would have been evident by clinical exam and CT scan. The patient had no external leakage of stool or gas to suggest an enterocutaneous fistula, and she did not have peritoneal signs to suggest an enteric leak into the abdomen ().\nMesh migration often results in significant bleeding or a fistula and requires operation. However, based on the patient’s minimal symptoms, morbid obesity, and probability of significant surgical morbidity (postoperative wound infection, recurrent hernia, fistula, etc.), we elected to observe. The patient was discharged with instructions to return in case of significant bleeding or increased, disabling pain. Surgery would be a better choice but the operation would be complicated; she was morbidly obese and had had multiple hernia repairs in the past. Her mesh migration was in the right lower quadrant, a difficult area to repair hernias because mesh fixation around the iliac bone is difficult. After initial presentation, she was advised to be followed up as she was minimally symptomatic from it and had no bleeding. The operation would have involved removing the mesh, removing the cecum, re-anastamosing the bowel and then repairing the hernia with a biologic mesh, so that the mesh would not get infected. A two-stage operation might have to be done since bowel resection would have contaminated the field. |
A 61-year-old woman with no history of TSC1/TSC2 mutation or symptoms of TSC presented to the emergency department after a fall from standing level. She subsequently developed hemodynamic instability from a retroperitoneal bleed secondary to hemorrhage of a massive left lower pole perinephric mass containing few small vessels, as well as mixed fatty and soft tissue elements as seen on computerized tomography ().\nThe normal appearing portions of her left kidney were displaced superiorly, but hydronephrosis was not appreciated. After IV fluid resuscitation and stabilization in the emergency room, her care was transferred to the intensive care unit.\nShe required transfusion of 5 units of packed red blood cells initially, and her hemoglobin continued to drop slowly while in the hospital. Therefore, her care team decided to proceed with SAE of her AML. This would stop the immediate bleeding, but still allow an attempt at a partial nephrectomy.\nFour days later, she underwent an open exploration of her left renal AML, with plan for intraoperative evaluation and consideration of a partial versus radical nephrectomy based on the extent of bleeding and inflammation in the retroperitoneal space. Her preoperative hemoglobin was 7.8 g/dL with creatinine of 0.66 mg/dL and eGFR of 74 mL/min/1.7 m2. She received four additional units of packed RBCs intraoperatively. Surgical exploration revealed two left renal arteries, including one artery to the AML emanating directly from the aorta, which was ligated and divided, and a second to the main portion of the normal kidney. This artery was clamped for a total of 20 minutes of warm ischemia time. Intraoperative ultrasound was used to identify the transition of normal kidney to kidney tumor. The mass was isolated and excised with successful partial nephrectomy, and the patient left the operating room in stable condition.\nPathologic examination revealed a 3818.3 g, 30.0 × 26.5 × 18.0 cm tumor that was grossly well circumscribed and appeared to be attached to the kidney by a stalk. The cut surface revealed a heterogeneous pink-tan to yellow mass with extensive hemorrhage. The microscopic sections showed an unencapsulated, circumscribed triphasic tumor arising from the kidney, composed of prominent, irregular, thick-walled dystrophic blood vessels, interspersed with mature adipose tissue and smooth muscle fascicles, typical of an AML. The smooth muscle cells were oval to spindle with pale eosinophilic cytoplasm, round to oval regular nuclei, and small nucleoli. They appeared to be emanating from the wall of the blood vessels, characteristic of the PEComa family of tumors ().\nTen-month postoperative radiological surveillance revealed no evidence of recurrent mass lesion or other postoperative complications (). Renal function was virtually unchanged at this time with a creatinine of 0.83 mg/dL and eGFR of 70 mL/min/1.7 m2. |
A 53-year-old male with a history significant for alcohol abuse presented to our facility with a 3-week history of nausea, vomiting and abdominal pain. Patient had been discharged from our facility approximately 7 weeks earlier after initially being transferred from another facility after respiratory failure secondary to aspiration pneumonia; at the time of transfer from the outside facility patient was found to have elevated amylase and lipase; however, CT did not show any signs of pancreatitis at that time.\nUpon readmission to our hospital another CT was done which showed numerous fluid collections surrounding the pancreas with enhancing rims, representing numerous pseudocysts. It was noted that several of these pseudocysts interconnect. One was noted to measure 8.7 × 10.1 × 12 cm in the undersurface of the body and tail of the pancreas, another measuring 7.8 × 5.9 cm extending towards the lesser curvature of the stomach, and another measuring 9 × 5 cm lateral to the head of the pancreas. CBD was also enlarged at 12.5 mm. Because of the enlarged CBD an MRCP was then ordered which showed some narrowing in the intra-pancreatic portion of the CBD, likely secondary to the inflammatory process secondary to pancreatitis.\nPatient then underwent EUS/ERCP with cystogastrostomy. EUS evaluation confirmed what was seen on prior imaging. We then proceeded with ERCP. After introducing the ERCP side-viewing scope into the stomach, pus was seen coming out of a fistula in the antrum. We then passed a jag wire into the cyst using a hydratome. A cystotome was then introduced to form a tract. A 15 mm × 6 cm balloon was then introduced and the tract was dilated. Finally a 10 mm × 4 cm fully covered SEMS was placed. The pseudocyst was irrigated with 200 cc of saline. Large amount of pus drained into the stomach during the procedure. The patient’s pain improved the following day, patient was started on a clear liquid diet and his diet was advanced. He was discharged 6 days after the procedure ().\nHe followed up in 2 weeks for an ERCP. The stent was in good position; contrast was injected into the cyst cavity through the stent. The cyst was inspected under fluoroscopy and by passing the endoscope directly through the stent. No necrotic tissue was noted. The stent was removed using a rat-tooth forceps. Patient was discharged home and follow-up was scheduled on outpatient basis.\nPatient continued to follow up on outpatient basis. Approximately 1 month after the last endoscopy patient reported weight gain with the ability to further tolerate a low fat diet with minimal abdominal discomfort. |
A 44-year-old Malay lady presented to our clinic with a progressive central scotoma in her right eye that she experienced since past 1 month. She had previous history of recurrent episodes of weakness in both of her lower limbs from past 8 months. She was admitted to a center for investigations; however, a proper diagnosis could not be established. She was treated conservatively. This was the first ocular presentation.\nOn examination, visual acuity in her right and left eye was 6/9 and 6/6, respectively. The relative afferent pupillary defect in the right eye was positive. The optic nerve functions such as light brightness, red saturation and color vision of the right eye were affected. Visual field showed a central scotoma in the right eye. Her extraocular muscle movements were full. Both anterior segments were unremarkable. Fundoscopy of her right eye showed a pale optic disc. Her left eye fundus was normal. Neurological examination showed bilateral lower limb weakness with intact sensation. Other examinations related to cranial nerves were normal. Magnetic resonance imaging of the brain and spine showed syringomyelia at the level of T3–T6 ( and ). However, both optic nerves were normal.\nShe was diagnosed with syringomyelia with right optic atrophy. She was started on intravenous methylprednisolone at a dosage of 250 mg four times a day for 5 days, followed by oral prednisolone at a dosage of 40 mg (1 mg/kg/day) once daily for 9 days. Her condition improved after 2 weeks of treatment, with reduction in the right eye central scotoma. However, due to the preexisting optic atrophy, visual acuity in her right eye was 6/9. Her optic nerve functions persistently reduced compared to her left eye. She was continued with oral prednisolone with tapering dose weekly. Subsequent follow-up at 1 month after diagnosis showed that her ocular condition was stable. Her limb weakness improved slightly, but she remained wheelchair bound. There was no complication of treatment. Her condition was stable at 6 months follow-up. |
The patient is a 46-year-old female with morbid obesity but otherwise no past medical history who presented to an outside hospital with right-sided weakness and inability to communicate. She suddenly collapsed at home and was found to be unable to speak or answer questions. The patient was brought to a local emergency department where she was noted to be globally aphasic with right hemiparesis. Her initial NIHSS was 25. CT of the head showed no acute intracranial hemorrhage. She was given intravenous tissue plasminogen activator within 2 h of symptom onset and was subsequently transferred to our tertiary care facility for a possible endovascular intervention.\nUpon arrival to our facility, the patient had full strength in all extremities but persistent global aphasia. Follow-up NIHSS was 11. CT angiogram of the head and neck at the time of her arrival to our institution revealed patency of all large intracranial and extracranial vessels.\nMRI of the brain (Fig. ) revealed restricted diffusion in the left middle cerebral artery territory. The patient had a normal complete blood count without evidence of anemia. A lipid panel test showed an LDL level of 132. Her HgbA1c level was 5.3. EKG and telemetry for 4 days showed no evidence of atrial fibrillation. Echocardiogram (transthoracic initially, then transesophageal) showed a patent foramen ovale with an associated atrial septal aneurysm and no left atrial appendage thrombus. Hypercoagulable workup was negative. She was not on hormonal contraceptive therapy. Venous Doppler ultrasounds of the lower and upper extremities were negative for acute deep vein thrombosis. MRV of the pelvis (Fig. ) revealed an enlarged fibroid uterus causing compression of the right common iliac vein.\nThe most likely explanation for her cerebral infarction was secondary to paradoxical emboli in the setting of right common iliac vein compression due to uterine fibroids. She was started on dual antiplatelet therapy with aspirin 81 mg/day, clopidogrel 75 mg/day, and atorvastatin 80 mg/day for stroke prevention. |
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