text
stringlengths 746
31k
|
|---|
The patient was a 64-year-old male with a past medical history of hypertension and coronary artery disease and is currently a 1 pack per day smoker and has been recently treated for transient ischemic attack 2 months prior. He presented with new onset aphasia and unsteady gait for 2–3 days. Upon arrival to the emergency department, he was found to be afebrile with a heart rate of 48–54 bpm, a respiratory rate of 18 bpm, and a blood pressure of 142/66 mm Hg.\nOn examination, the patient was awake, alert, and oriented. His speech was clear and slightly hesitant, but without dysarthria. He followed commands and was able to name objects. There was no facial weakness or asymmetry. Other than some mild right upper extremity ataxia on the finger-to-nose test, the rest of the neurological examination was within normal limits.\nOur stroke team was immediately called and they recommended imaging studies of the head. A computed tomography scan of the head without contrast showed no acute intracranial disease. Magnetic resonance imaging of brain showed multiple areas of restricted diffusion in the left middle cerebral artery territory in the medial and lateral left temporoparietal cortex and subcortical and periventricular white matter consistent with acute hemorrhagic infarcts, probably embolic. There were also multiple areas of restricted diffusion in the left frontoparietal periventricular centrum semiovale region consistent with acute watershed infarcts ( and ). The patient was immediately started on aspirin, high-dose statin, clopidogrel, and fluids to allow for permissive hypertension.\nAs part of the workup to determine the cause of his embolic stroke, the patient would have been sent for a trans-thoracic echocardiogram (TTE), but since he was recently worked up for a stroke just 2 months prior to this admission with a TTE, he was sent for a transesophageal echocardiogram (TEE). The TEE showed a fairly large (12×3 mm), bulky, and highly mobile mass on the aortic aspect of the aortic valve, consistent with a fibroelastoma ( and ). After completing the rest of the workup, it was determined that this was likely the cause of his stroke. Cardiothoracic surgery was consulted for removal of the growth. Because of recent Plavix® (Clopidogrel; Bristol-Myers Squibb, New York, NY, USA) use, the surgery was postponed for a couple of days while he remained on heparin. Surgery was able to remove the growth using a minimally invasive hemisternotomy approach with only 66 minutes of bypass time. The patient’s postoperative course was smooth with only some mild hypertension postprocedure. Otherwise, the patient’s neurological status returned back to normal and he continues to improve with intensive physiotherapy.\nThe Maimonides Medical Center (MMC) IRB decided that neither IRB approval nor a Health Insurance Portability and Accountability Act of 1996 (HIPAA) Waiver/HIPAA Authorization required for case report that involves no more than three patients, provided the presentation or publication does not have identifiable information and the activity is not considered FDA regulated research. |
A 47-year-old male patient underwent a work-related total amputation with a circular saw at the level of the wrist joint of the right hand. The patient was transported to the hospital and showed no other injuries. The otherwise healthy patient was then transferred to the operating theatre. The time from injury to operating theatre was 2:16 h. After debridement of the wound, a proximal row carpectomy and arthrodesis with a locking compression plate had to be performed. Microsurgical reconstruction of the ulnar and radial arteries and of the ulnar, median and radial nerves was performed. Then, all extensor and flexor tendons were sutured. The skin was left open on the volar side, and the hand was placed in a cast. The operation took 13:35 h. For the post-operative phase, the patient was transferred to the intermediate care unit and was given a catheter for axillary pain. On the third post-operative day, a skin graft was used to close the skin. Psychotherapy and physiotherapy were initiated on the fourth post-operative day. Intensive hand therapy was continued throughout the hospital stay. Wound healing was uneventful. The patient was discharged 21 days after the injury. Ambulatory rehabilitation was continued, and the patient showed good progress in reinnervation and motion of the fingers, but had restricted supination. Six months after replantation, resection of the ulnar head and tenolysis were performed. The patient returned to work as an office worker and farmer one year after sustaining the injury. The follow-up examination 53 months after replantation showed an excellent range of motion of the fingers (fingertip-palmar distance of under 1 cm), a sensitivity in all fingers close to normal (2-point distinction of 10 mm), and an almost normal rotation of the forearm compared to the contralateral side. The patient had a VAS rating of one and did not need analgesic medication. He appeared to be in good physical condition, competent and capable, and he declared his satisfaction with both the procedure and rehabilitation (Fig. ). |
A 25-year-old Caucasian female underwent a splenectomy which was performed through a vertical midline incision in 1994 for injuries sustained in a motor vehicle collision. Twelve years later, at age 37, she was diagnosed with stage IIA carcinoma of the left breast. She presented for bilateral mastectomies with immediate autologous tissue reconstruction. She had completed four cycles of neoadjuvant dose-dense adriamycin and cytoxan chemotherapy 2 months previously. Following her chemotherapy, her platelet counts ranged from 332 to 424 K/cmm. Her medical history was significant for obesity (BMI 40.4) and asthma. The patient had smoked 1 pack per day for 15 years, but had discontinued that practice during her chemotherapy treatment.\nIn 2006, she underwent a bilateral mastectomy with immediate bilateral ipsilateral single pedicle transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Venous thromboembolism prophylaxis was provided intraoperatively and during her hospital stay via sequential compression devices (SCD). Although not a routine component of our customary reconstructions, fluorescein was utilized intraoperatively to confirm the viability of the mastectomy flaps prior to final insetting of the TRAM flaps. The patient did well during the procedure and suffered no intraoperative or postoperative hypotensive episodes. On postoperative day 1, her wounds looked well and her platelet count was 374 K/cmm. She was discharged on postoperative day 4 with slight epidermolysis in the abdominal flap just cephalad to the mid-line sutures. Over the next 2 weeks, both the mastectomy and abdominal skin flaps underwent progressive necrosis as the platelet count rose to 1390 K/cmm. The patient's hematologist/oncologist was consulted at this point. The consultant's opinion was that this was a reactive phenomenon and required no additional testing or intervention. Even though the TRAM flaps remained completely viable, aspirin therapy was instituted empirically. The necrosis of the mastectomy and abdominal flaps continued to evolve and on postoperative day 18, the patient underwent operative debridement of her abdominal (Fig ) and chest wounds. The breast wounds were closed primarily and negative pressure wound therapy (NPWT) was applied to her abdomen. Intraoperative findings confirmed extensive skin subcutaneous necrosis in the mastectomy and abdominal flaps, whereas the TRAM flaps had minimal evidence of peripheral fat necrosis and no areas of skin loss. Her platelet count peaked at 1689 K/cmm 2 days later. Over the next several weeks, the wounds continued to deteriorate, but the patient elected to have them managed conservatively (Fig ). The patient was followed at weekly intervals in the outpatient clinic. Two months after her original surgery the platelet count had decreased to 758 K/cmm, and the first area of spontaneous healing in the form of healthy granulation and wound contraction was documented. Ultimately, the wounds healed by secondary intention (Fig ) as the platelet count returned to its postoperative nadir of 530. |
A 9 years old girl was admitted to a general pediatrics department and she showed symptoms of cough, vomit, abdominal pain, and twitching. The patient rapidly developed severe hypoxemia (SpO2: 45–70%), dyspnea, and heart failure on the next day. She was then transferred to the ICU (Intensive care unit), initial echocardiography at ICU showed enlargement of the left atrium and left ventricle, the magnitudes of ventricular wall motion was lower with an estimated 36% ejection fraction. A series of rescue treatment were implemented such as Continuous renal replacement therapy, large doses of dexamethasone impact therapy, and antibiotics. Most surprisingly is that the initial Chest CT (Computerized tomography) scan revealed extensive calcification of both ventricular walls and chordate on the 14th day (Fig. a.), which was confirmed by Cardiac Revolution CT scan subsequently (Fig. b). As her condition was improving, the follow-up echocardiography on the 16th day demonstrated that the ejection fraction of the left ventricular had recovered to 50%. A series of diagnosis was established including multiple organ failure (heart, lung, liver, and kidney), septic cardiomyopathy, systemic inflammatory response syndrome, pulmonary hemorrhage, viral encephalitis, myocardial calcification, bacterial pneumonia, electrolyte disorder (hyperkalemia, hyponatremia, hypocalcemia), metabolic acidosis, and disseminated intravascular coagulation.\nCompared to treatments in other case of myocardial calcification, there were negligible difference in standard treatments that were carried out in this case study. However, it is summarized that the favorable outcome in the patient was mainly attributed to the series of rescue treatments that were carried out when the MODS (Multiple organ dysfunction syndrome) appeared, the advantages and disadvantages for all the treatments that were implemented to protect the organs were took in account. During the intensive care unit admission, every vital signs were recorded every 1 h and the dose of antibiotics were calculated according to the weight of the child. The dose of antibiotics were used with half a dose of norepinephrine which was only used only one time. The dose of norepinephrine was given by the lowest amount which is 12 mg because when the patient is in hypotension shock, the norepinephrine can help avoid catecholamine-ranted ischemia. When considering that the current occurrence of MODS may be related to the storm of inflammatory factors, methylprednisolone pulse therapy (500 mg QD) was used. The dose was reduced and maintained after 3 days, and stopped when the vital signs were normal and stable.\nFurthermore, there was a follow-up on the patient for 18 months and the Magnetic Resonance Imaging images showed no changes in the myocardial calcification, showing that the patients didn’t have further extensive myocardial calcification. The cardiac function and the wall motion of the patient had also completely recovered in the 18 months follow-up. The follow-up echocardiography showed that the patient’s condition and cardiac function were completely normal. |
We present the clinical findings regarding a 64-year-old man, affected by arterial hypertension with heart and chronic renal failure.\nSix months before coming to our attention, the patient suffered weakness and nausea with weight loss. A computed tomography (CT) of the thorax and abdomen showed diffuse lymph node involvement, without spleen enlargement. The lymph node biopsy revealed that he was affected by CD. Viral infections commonly related with CD (HIV and HHV-8) were excluded, except for a previous Epstein–Barr virus and herpes simplex virus infection. The patient was treated with chemotherapy, and his hematologic conditions improved.\nA few days before the admission, he suffered from fever, headache, and gait imbalance. The patient was admitted to our Intensive Care Unit because of acute neurological deterioration with lethargy and unresponsiveness (Glasgow Coma Scale score 6). The head CT showed a hypodense lesion in the left cerebellar hemisphere with fourth ventricle and brainstem compression, upward cerebellar herniation, and triventricular hydrocephalus with trans-ependymal reabsorption of cerebrospinal fluid []. The lobulated lesion showed a marked enhancement, and the magnetic resonance imaging of the brain revealed the presence of a similar smaller lesion in the right parietal lobe []. The blood cell count showed 41,000 leukocytes/mm3. These findings were suggestive of abscess. We urgently positioned an external ventricular drainage in the right frontal horn, and the patient's neurological status improved after treatment of hydrocephalus. The following day, we performed a minimally invasive aspiration, by means of a navigated stereotactic puncture of the lesion. The diagnosis of suppuration was confirmed. Since no specific microorganism was isolated, intravenous broad-spectrum antibiotic therapy was administered (cefotaxime 2 g every 6 h and metronidazole 500 mg every 8 h). The neurological symptoms gradually resolved, the ventricular drainage catheter was removed after 9 days, and the CT scan showed a reduction of the lesion with reexpansion of the fourth ventricle and resolution of hydrocephalus []. The patient was discharged and advised physical therapy, and the antibiotic therapy was discontinued after 10 weeks. |
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 previously healthy 35-year-old Hispanic man with a remote history of mild performance anxiety in late adolescence presented to our family medicine residency clinic to establish and seek care for acute onset of anxiety. The patient was a manager at a large manufacturing firm and had received a master’s degree. At the time of presentation, he was married with two children. He had no family history of mental illness and was not taking prescription medications. At his initial visit at the clinic, he reported that 9 days prior, he had taken one dose of “molly” while at a gathering with friends. The friend who had supplied the drug stated that it was “pure crystal MDMA.” According to the patient, this was his first lifetime use of MDMA. He had also consumed several alcoholic drinks that night, reportedly reaching the level of intoxication. He described having a “fine” experience with the drug and returned to his normal baseline for the next 2 days. On the third day after ingesting MDMA, he began to experience an increase in worry and agitation; he reported having panicked thoughts and development of palpitations, blurry vision, flushing, increased thirst, and insomnia. He stated that these symptoms increased over the coming days, prompting him to seek medical care. Regarding substance use history, the patient reported occasional social alcohol use since his early 20s, rarely to excess. He had used cannabis several times while in college (ages 18–22) and found that this precipitated anxiety and therefore he did not continue using it regularly. He denied any regular use of other illicit substances.\nOn the initial day that the patient met with a medical provider in the clinic, he reported a score of 20 (maximum score of 21) on the Generalized Anxiety Disorder 7-item scale [], an anxiety screening and rating tool commonly used in primary care offices. This score was consistent with a severe level of anxiety. The patient was prescribed buspirone, a serotonin 1A receptor (5-HT1A) receptor agonist, with a plan to uptitrate to 15 mg twice daily over the coming weeks. The patient was also referred to the clinic’s behavioral health service for adjunctive treatment and was promptly seen by a behavioral health consultant for their first session the following day. This initial visit involved an assessment of his biopsychosocial history and mood, a functional analysis of his anxiety symptoms, and a collaborative discussion regarding his treatment goals. Using interventions informed by cognitive behavioral therapy, the patient and the behavioral health consultant aimed to increase his coping skills and management of his anxiety symptoms and to improve his overall quality of life (e.g., reduce distress, increase enjoyment at home, and increase productivity at work).\nThe patient was seen for follow-up every 7–10 days by his PCP for the next month (see Table ). Simultaneously, he received behavioral health treatment each week following his first month of medical treatment in the family medicine clinic. He then established a therapeutic relationship with a counselor outside the clinic, where they reportedly engaged in talk therapy weekly. The patient reported only a slight improvement in his anxiety and panic symptoms despite the therapeutic dose buspirone; therefore, he was prescribed a selective serotonin reuptake inhibitor (SSRI) and a benzodiazepine and was referred to the psychiatry department for additional consultation. The consulting psychiatrist was concerned for MDMA-induced anxiety disorder and recommended discontinuation of buspirone and initiation of low-dose sertraline with slow uptitration. The patient benefited from behavioral health treatment specifically aimed at enhancing understanding and controlling the sympathetic nervous system (i.e., cognitive behavioral modeling, psychoeducation on the cycle of panic, and relaxation skill training). Behavioral health treatment was especially important as he awaited the clinical effect of his psychoactive medications.\nOngoing evaluation by the PCP, a consulting psychiatrist, and the behavioral health consultant supported a diagnosis of substance-induced anxiety disorder. He experienced persistent anxiety (reporting daily worry, panic, racing heart, dizziness, restlessness, and catastrophic thinking), and all of his symptoms developed shortly after ingesting a single dose of MDMA. His symptoms caused him significant distress and impairment in his employment as well as his family life. The patient denied clinically significant anxiety directly prior to taking MDMA; his only history of anxiety was performance anxiety many years prior. Therefore, he did not meet criteria for panic disorder or generalized anxiety disorder, because his symptom onset followed substance ingestion. Simultaneously, the patient reported transdiagnostic depressive symptoms, including hopelessness, fatigue, maladaptive thinking, and low mood. These symptoms, which also began following the patient’s use of MDMA, were etiologically attributed to his anxious physiological symptoms and thoughts, in particular the catastrophic and generalized worries that this one-time drug use had “ruined” his life. Consequently, his symptoms appeared to be explained by the substance-induced anxiety, as opposed to representing a discrete depressive disorder.\nThe patient initially tolerated the sertraline well and experienced a relatively rapid improvement in anxiety symptoms while taking 25 mg daily. After 8 days of the 25-mg dose, the dose was increased to 37.5 mg. After 2 days at this dose, the patient developed abrupt onset of suicidal ideation with a resurgence of anxiety and panic symptoms. Given the gravity of these new symptoms, the PCP and behavioral health consultant worked together and with the patient to devise a plan for ongoing care. He was able to see the behavioral health consultant for an urgent visit. The dose of sertraline was reduced to 25 mg, and plans were made for intensive outpatient mental health treatment at a nearby hospital.\nWhile awaiting entrance into that program, his suicidal ideation and anxiety abated. As his symptoms improved, the behavioral health consultant supplemented sympathetic nervous system training with thought identification and cognitive retraining. These interventions served to address his reported catastrophic and demoralizing appraisals following the use of MDMA (e.g., “I am a terrible person for taking that Molly,” and “I have ruined my life forever”). He saw a second psychiatrist for additional recommendations. They concurred with the diagnosis of substance-induced anxiety disorder and the prescribed SSRI treatment. Eventually, the dose of sertraline was slowly increased to 50 mg with continued improvement in all symptoms and no further resurgence of suicidal ideation. The patient’s anxiety and panic were not well controlled until approximately 2.5 months after ingesting MDMA. At 6 months following his presentation, he was doing well with a plan to slowly taper the sertraline. He expressed gratitude for an interdisciplinary team approach and the unique benefits of skills training in tandem with psychopharmacological treatment. |
Our patient is a 47-year-old female who has been diagnosed with undifferentiated mucinous cervical adenocarcinoma a year and a half ago and had hysterectomy with salpingo-oophorectomy along with chemoradiation. She presented to the hospital with complaints of fatigue, nausea and reduced appetite for a week. Her examination revealed icterus and mild right upper quadrant tenderness but no ascites. She had no petechial rash and had no features of encephalopathy. Her initial workup revealed elevated liver enzymes with alanine transaminase (ALT) of 1891, aspartate transaminase (AST) of 600 and alkaline phosphatase (ALP) of 178. She had a total bilirubin level of 2.1 with the direct bilirubin of 1.9. Her electrolyte panel, renal parameters, and hemogram were normal.\nAt this point, we revisited history to inquire about the possibility of toxin or drug-induced hepatitis and viral hepatitis. She did not mention any recent addition of new medications. There is no recent acetaminophen intake or any other hepatotoxic medication. She does not consume any alcohol nor has she any history suggestive of a risk for viral hepatitis. Further workup included an ultrasound of the liver, viral hepatitis panel, and toxicology screening. Her viral hepatitis panel and the toxicology screening came back negative with normal serum acetaminophen levels. Ultrasound scan of the liver showed slight intrahepatic dilatation but normal common bile duct and no features of cholelithiasis. There was a 2.7-cm mass in the posterior segment of the right hepatic lobe and the same was confirmed in the CT scan (Figure ). Of note, there was hepatopetal blood flow seen during ultrasonography (USG)-Doppler and there were no features of portal vein thrombosis. The positron emission tomography (PET) scan which was done at this time revealed multiple new hypermetabolic metastatic lesions in the liver predominantly in the posterior right hepatic lobe (Figure ). There was increased hypermetabolic activity in the region of the vaginal cuff along with metastatic nodules in the left abdominal wall, left paracolic gutter and right para-aortic region. The previous PET scan done six months ago did not reveal any of the above-mentioned lesions (Figure ). Over the course in the hospital, she was given supportive and symptomatic treatment.\nHer symptoms resolved over the next couple of days. Her liver enzymes remained stable during the hospital stay with a slight downward trend and over the course of next few weeks, she was restarted on chemotherapy with gemcitabine and carboplatin. Two months later while on chemotherapy she developed septic shock and expired. |
A male patient, 26 years old, sought care at the dental clinic with fractures of the left maxillary central incisor resulting from a sudden strike three months earlier. The patient had no clinical symptoms during this period (Fig. ). A clinical examination revealed that the left maxillary central incisor was fractured in the middle third of the crown and that this fracture involved the enamel and dentin with no pulp exposure and no signs or symptoms of a concussion or contusion. A routine cold vitality test of the tooth revealed that it was associated with the same reaction as the reference tooth. Additionally, the patient had a defect in the incisal area of the right maxillary central incisor that resulted from eating melon seeds, and a routine cold vitality test of the tooth revealed a positive reaction. Finally, the relationship between the anterior teeth overbite and overjet was normal. A radiographic examination of the central incisors was conducted, and an analysis of radiography of the maxillary left central incisor revealed that there were fractures in the middle third of the crown, but no abnormalities, such as damage to the remaining roots, were observed (Fig. ).\nA 3D-printed template was fabricated using intra-oral scanning, CAD, virtual modeling and 3D printing. Briefly, a digital registration of the dentition was performed using a CEREC AC Omnicam intra-oral scanner (CEREC AC D3492, Sirona Dental Systems GmbH, Fabrikstr, Bensheim, Germany). The inlay in the machine was selected, and the system automatically generated a prosthesis using the contralateral tooth as a reference. From the analysis performed using the software, the occlusal contact of the intercuspal occlusion of the patient was concentrated in the middle third of the cervix, and it was therefore appropriate for composite resin restoration. An occlusal adjustment was made to eliminate anterior contact in the occlusion and to avoid contact with the prosthesis (Fig. ). We showed a picture of the result to the patient, and he was satisfied with it. The data were then imported into Freeform (Geomagic Freeform, 3D Systems, Morrisville, North Carolina, USA), a software program that is widely used to design 3D models. Using the Freeform program, a template can be designed through a process similar to drawing a picture, and a dentist can design a repaired palatal template in only minutes (Fig. ). The digitally designed template is prepared for export using the “stl check” command, exported as a stl-file and then sent to a 3D printer (3D System 3510HB, 3D Systems, Morrisville, North Carolina, USA). Finally, the 3D-printed template is fabricated (Fig. ).\nBefore treatment, the 3D-printed template was detached and soaked in disinfectant. Then, the template was positioned on the patient’s dentition, and a correct and reproducible fit was verified. Initially, the anterior teeth were isolated using a rubber dam (Hygienic Elasti rubber dam, Switzerland). The teeth were carefully cleaned using prophylaxis paste (SS white prophylaxis paste, England), dried, and submitted to minimal tooth preparation using a diamond bur (Mani SF-41, Japan) to produce an improved alignment for the bond. Both surfaces of the connection were etched using acid gel (Ultra-Etch® 35% Phosphoric Acid, Ultradent, USA), rinsed, and gently dried. Single bond (Adper™ Single Bond 2, 3 M ESPE, USA) was applied first. The surface was then air-dried for 5 s and exposed to light-activation for 10 s. Subsequently, the 3D template, which had been detached and soaked in disinfectant, was positioned on the back of the anterior teeth (Fig. ). It was convenient to construct the palatal surface using an opaque enamel shade (E2, Ceram*X duo, DENTSPLY, Germany) with the aid of a 3D printing guide. After polymerization, the palatal wall is sufficiently strong to support the next stratification steps. Reconstruction was performed using an opaque dentin shade (D2, Ceram*X duo, DENTSPLY, Germany) to construct the dentin body (Fig. ). The enamel shade E2 was used to match the superficial enamel, and each composite increment was light-cured for 20 s. Additionally, tooth 11 was restored using enamel shade E2 in the incisal area and on the buccal surface. The final step consisted of performing an additional 20 s of polymerization at each site. After excess composite material was removed, an occlusion test was performed using carbon paper, and the restorations were shaped to a proper anatomic morphology (Fig. ). Next, finishing and polishing procedures were performed using diamond fine coating burs and a polishing system (One-step diamond micro-polisher, Germany) (Fig. ). |
A 43-year-old female was admitted to our hospital complaining of numbness in the left limb for one week. Past medical history was notable for the diagnosis of NMO and intracranial hemorrhage. The patient was diagnosed with NMO ten years ago due to repeated episodes of blurred vision and numbness and weakness in the limbs. Brain and spinal magnetic resonance imaging (MRI) at that time indicated lesions in the brain white matter as well as spinal cord involving cervical and thoracic regions. AQP4 antibody test was not performed. Considering the potential diagnosis of demyelinating disease, steroid pulse therapy was initiated and the patient improved after the treatment. After discharge, corticosteroid was gradually tapered and the patient was maintained at a low-dose corticosteroid and azathioprine in the long term. The patient was also diagnosed with left basal ganglia hemorrhage three years ago, presenting as right-sided hemiplegia and confusion. Brain angiography was not performed at that time, and the patient recovered after symptomatic treatment. Family members exhibited no sign of the case pathology. Upon examination, the patient appeared lethargic and sluggish, with normal vital signs. Visual acuity was impaired in the right eye with a score of 20/200 on testing. Pupils were 3 mm bilaterally, round and reactive. Regarding motor function, muscle strength was decreased in the left extremities (Medical Research Council strength score, grade 3). Hypoesthesia of the left side was also observed. Babinski sign was present bilaterally. Further investigations revealed a positive AQP4 antibody in the serum, with an elevated titer of 1:32. An initial diagnosis of NMOSD was made considering her medical history and radiological findings. Other tests including complete blood count, basic metabolic panel, serum glucose, and anti-nuclear antibodies were all normal. Brain MRI after admission indicated lesions with restricted diffusion in the right thalamus and hemosiderin deposition in the left basal ganglia (Figure ). Unexpectedly, brain magnetic resonance angiography revealed severe stenosis of bilateral anterior and middle cerebral arteries, as well as stenosis of the right posterior artery and the intracranial segment of the right internal carotid artery. Radiological findings, as a result, strongly suggested the diagnosis of MMD. Digital subtraction angiography further confirmed this diagnosis with findings of bilateral occlusion of distal internal carotid arteries and rich collaterals near the skull base (Figure ). After antiplatelet and other symptomatic therapies, the patient improved. She refused further treatment with vascular reconstruction surgery and received physical therapy at a local rehabilitation center. |
A 40-year-old woman presented with continuous hematuria and discomfort in her right lumbar for 5 months. Previous medical history indicated that the complaint of right-side lumbago occurred at approximately 6 months of pregnancy, and the symptom of hematuria began 7 months after pregnancy. Taking her pregnancy into account, no additional imaging examination was carried out except an abdominal B-ultrasound scan, which revealed a palpable mass in the right lumbar region. A blood routine examination showed a mild anemia. Accordingly, urine detection described the presence of red blood cells (RBCs) as well as positive occult blood in the urine. Considering the pregnancy, she was required only to control relevant symptoms and check regularly with followups to monitor the course of the disease, until childbirth. During the pregnancy period, the volume of renal mass grew rapidly, from 26×21 mm to 47×39 mm in just 2 months. We could speculate that this kind of rare tumor might be related to hormonal changes associated with pregnancy.\nThe patient gave birth to a healthy baby when it was due. After delivery, abdominal CT was performed and revealed a right renal enhancing mass about 5 cm in length, accompanied by the parenchyma invasion and pelvis expansion of the right kidney (). Fortunately, there was no obviously abnormal density of the bilateral adrenal and left renal parenchyma. The morphology, size and density of liver, gallbladder, pancreas and spleen were found to have no obvious abnormalities. Subsequently, we performed robot-assisted laparoscopic nephrectomy for the patient and removed the entire right kidney successfully ().\nMicroscopically, histologic analysis of hematoxylin and eosin (H&E) staining revealed that the tumors were composed of a monotonous population of small round cells. Extensive necrosis was also observed in histologic sections (). For further confirmation, immunohistochemical staining showed positive expression for CD99, SYN, FLI1 and 30% positive staining for Ki67 (). FISH analysis demonstrated more than 10% of cells were positive, indicating EWSR1 gene rearrangement ().\nAfter surgery, the patient was given continuous anti- inflammatory and symptomatic treatments until gradually recovering. Moreover, no obvious complications occurred during the postoperative course of the patient who then received periodic reexaminations. Until now, no related recurrence or progression was found and the patient is still alive. Written informed consent was obtained from the patient for the publication of this case report and any accompanying images published. |
A 12-year-old male athlete with history of Osgood-Schlatter disease developed acute pain in his left knee while jumping during a basketball game. He was unable to ambulate following the injury and was originally seen at an outside hospital, where he was treated for a presumptive patellar dislocation. Two attempts at reduction under sedation were unsuccessful, and the patient was transferred to the authors’ institution for further management. Examination at this time revealed patella alta and diffuse swelling. No neurovascular deficits were noted.\nRadiographs showed a likely inferior patellar sleeve fracture with a possible concomitant tibial tubercle fracture. MRI confirmed avulsion fractures of both the patellar and tibial insertions of the patellar tendon, as well as a quadriceps strain at the patellar insertion and tears of the medial and lateral patellar retinaculum (–). Operative repair of the proximal and distal patellar tendon avulsions was undertaken.\nIntraoperative findings revealed a 75% avulsion of the tendon from its attachment at the medial tibial tubercle with the remaining lateral quarter of the tendon intact distally but detached from the inferior pole of the patella. Additionally, the fat pad and anterior capsule had also avulsed from the inferior aspect of the patella. The injury extended into the medial and lateral retinaculum at the level of the inferior patella. Repair of the patellar tendon at the distal avulsion site was performed with screw and ligament staple through the apophysis, and reinforced with Krackow sutures tied over a bone bridge in the anterior tibia. The proximal avulsion fracture was repaired with #2 non-absorbable sutures running from the tendon through patellar bone tunnels, and tied over the bone bridge at the superior patella. The retinaculum was repaired with absorbable suture.\nPostoperatively the patient was placed in a locked straight leg brace for one week ( and ). Following this initial week of recovery he began range of motion exercises and progression of weight bearing with physical therapy. At six weeks postoperatively he was tolerating full weight-bearing activity with the assistance of his brace. He was noted to have full range of motion in affected knee in 3 months follow up, when he was allowed to return to sport-specific activities in preparation for return to sport. |
We present a case of a 51 year-old white female with a 5-year history of ulcerative colitis. She has been taking mesalamine 1.2 gram (2 tablets two times a day) for 1 year with no complications that were reported. No history of allergies and no history of smoking or alcohol abuse were present. Past medical history was only remarkable for ulcerative colitis and there was no significant past surgical or family history. Around March 2018, she started having increased watery diarrhea with occasional blood (10-12 bowel movements per day from a baseline of 1-2 bowel movements per day) as well as cramping abdominal pain. She went to see her gastroenterologist in clinic. On physical examination, she had diffuse tenderness to palpation of her abdomen. Stool studies including stool cultures, stool ova, and parasites were sent which were negative. ESR and CRP levels were elevated. Therefore, she was thought to be in a moderate to severe ulcerative colitis flare based on the current criteria and was prescribed budesonide multimatrix (MMX) 9 mg once daily. Her abdominal pain improved but the diarrhea persisted. She then received a course of oral prednisone 40 mg daily for one month without any improvement of her symptoms and was subsequently started on infliximab therapy. Prior to initiating infliximab therapy, an interferon gamma release assay, hepatitis panel, varicella zoster antibody, and HIV tests were done which were negative. On 4/13/2018, she received her first dose of infliximab 500 mg based on her weight of 100 kg (5mg/kg). Her symptoms got better during the first week after the infusion; however during her second week, she complained of nonradiating chest pain located at the midsternal region, shortness of breath, and worsening fatigue. She went to a hospital where she was admitted. Her initial vitals were significant for low to normal blood pressure and a persistent tachycardia of up to 110. EKG was negative for any acute changes and a CT-PE was also negative for pulmonary embolism but showed a moderate size pericardial effusion. She was given fluids with no change in the blood pressure, and she continued to remain hypotensive and tachycardic and was eventually transferred to another hospital for concerns of a cardiac tamponade. At the other hospital, a transthoracic echocardiogram was done that showed an ejection fraction of 65-70% and a small to moderate size pericardial effusion that was present more anteriorly and less prominently on the apical, inferior, and subcostal views (Figures and ). There were no echocardiographic criteria for cardiac tamponade. Based on the difficult anatomical location of the effusion, decision was made to medically manage the patient.\nShe underwent extensive workup to evaluate the etiology of her pericardial effusion. Viral causes including HIV, monospot test were negative. T-spot was also negative. Due to concerns for a drug-induced lupus from infliximab, ANA and ds-DNA were checked, which were negative. Antihistone Abs were 1.9 (positive). ESR was 70 and CRP was more than 190. There were no signs of serositis, oral ulcers, photosensitivity, blood disorders (leukopenia, anemia, and thrombocytopenia), neurologic disorder, or rash (malar or discoid).\nThe clinical presentation was not compatible with any other pathology and based on the specified time frame of the presentation, a diagnosis of infliximab induced lupus was made and patient was taken off infliximab therapy.\nHer infectious workup for diarrhea including stool culture, stool ova and parasite, and clostridium difficile were negative. A procalcitonin level was also negative. She was in a moderate to severe ulcerative colitis flare and was therefore started on IV methylprednisolone 60 mg daily for 3 days and then transitioned to PO prednisone 40 mg daily. Her shortness of breath and fatigue got better and, after discharge, her diarrhea frequency went back to baseline. After she completed her prednisone taper, she was planned for vedolizumab (antagonist to α4β7 integrin) therapy for her ulcerative colitis. Vedolizumab is not shown to be associated with drug induced lupus [] and that is why it was chosen for our patient. She got induction therapy with IV vedolizumab 300 mg at weeks 0, 2, and 6 and was then continued on maintenance therapy with IV vedolizumab 300 mg every 8 weeks. She did not receive infliximab therapy in the future. Post discharge, serum anti-TNF alpha antibodies were checked which were negative. |
At 10:45 the 68 year old, male patient got injured after being attacked by a bull while working at a rural slaughterhouse. 10 minutes after the accident, an advanced life support team arrived on scene. Initially, the patient was in severe respiratory distress due to flail chest. He was able to communicate and to respond to given commands but had no measurable blood pressure. Initial ECG monitoring showed ST elevations in the aVR lead. Emergency endotracheal intubation was performed and as the breathsounds over the left side were impaired, a tube thoracostomy was performed via a Monaldi approach in the 3rd intercostal space midclavicular line and connected to a Heimlich flatter valve. Fluid resuscitation with cristalloids and colloids was initiated. Epinephrine and dopamine were then given as the response to fluid resuscitation was not sufficient. The patient was transferred in a critical condition 150 miles by helicopter from the rural district to the next level I trauma centre. At 12:10, during transport, the patient suffered from cardiorespiratory arrest with asystole. At 12:25 the patient was admitted to our trauma room undergoing manual external chest compressions with a massive subcutaneous emphysema despite the pre-hospital inserted chest tube, which had been inserted on the left side. Inspection of the tube and valve showed no obstruction through bending or clotted blood. Assuming a contralateral tension pneumothorax, a chest tube was placed on the right side while still on the gurney. Prior auscultation of the breath sounds was not possible due to the massive emphysema. An immediate chest film was taken the moment, when the patient was placed on the radiotranslucent trauma room table. Focused assessment with ultrasound in trauma (FAST) revealed neither pericardial effusion nor massive free abdominal fluid. A left side resuscitative thoracotomy was performed for direct cardiac massage and thoracic aortic occlusion. After opening the thorax it could be seen that the chest drain with the connected Heimlich flutter valve had been placed correctly in the pleural space.\nNow available developed chest film demonstrated correct tube positioning corresponding to the in situ findings. A subcutaneous emphysema but also a massive tension pneumothorax on the left side was visible, despite the inserted chest tube on scene [figure ]. Further exploration of the thorax showed an insufficient filling of the ventricles, an apical lung rupture and comminuted multiple rib fractures. Under manual cardiac massage, catecholamine adminstration and volume restoration, ventricular flutter occurred and was successfully defibrillated to a sinus rhythm with a blood pressure of 100 mmHg. Initial blood samples revealed hemoglobine concentration of 7,2 mg/dl, thromboplastine time of 31% and base excess of -22,5.\nThe apical lung rupture on the left side was sutured and 2000 ml of blood, resulting from multiple rip fractures, was drained via a chest tube on the right side. In the further progress celiotomy was performed and abdominal exploration showed no additional relevant findings.\nDespite the occluded thoracic aorta, high-dosage catecholamine medication and massive blood transfusion with 20 units of packed red blood cells, the patient remained hemodynamically unstable. Although supportive manual cardiac massage was performed, cardiac output detoriated and intermittent ventricular flutter episodes occurred. Resuscitative efforts were stopped at 13:45. Post mortem computed tomography and autopsy confirmed our major findings and revealed, except a pelvis fracture, no further relevant injuries. |
A 28-year-old female presented after sustaining multiple stab wounds to bilateral arms, and posterior right thigh. The patient was hypotensive with a blood pressure of 67/42 and tachycardic with a pulse of 140 in the emergency department with easily palpable carotid and radial pulses but intermittent dorsalis pedis pulses. She had a large posterior thigh wound with active bleeding. A tourniquet was placed at the thigh followed by initiation of massive transfusion protocol and she was promptly taken to the operating room (OR) for exploration of the right thigh wound.\nIn OR, a horizontal groin incision was performed with dissection carried down to the right femoral artery and vein. After proximal control was achieved, intra-operative Doppler ultrasound of the popliteal, posterior tibial and dorsalis pedis vessels yielded triphasic signals. An on-table angiogram through the right common femoral artery depicted flow through the SFA and profunda femoral arteries with no active extravasation (Fig. A and B).\nAlthough there was filling defect noted on Fig. B, contrast was shown flowing to the popliteal artery and thereby into the trifurcation of the right lower extremity (Fig. C).\nIt was noted that the posterior thigh wound was not actively bleeding and was packed with hemostatic agent.\nAs the patient was being prepared for extubation, right posterior thigh dressings were saturated and bleeding was identified from the wound. The patient became hypotensive. This wound was packed and second exploration was performed with patient in prone position to provide better exposure. When the packing was removed, active bleeding was seen and vascular clamps were applied to proximal and distal segments of a branch of the SFA. Doppler showed audible signals in the popliteal as well as posterior tibial artery. After the bleeding artery was suture ligated as well as clipped, hemostasis was obtained. A post-operative CT angiogram (CTA) of the right lower extremity was performed revealing occlusion of the SFA proximal to the adductor canal. Upon re-exploration and clearing a substantial amount of hematoma occluding the SFA, patient was found to have complete SFA transection with each end retracted. The injury was surgically managed with end-to-end anastomosis. Post-operatively, patient had Doppler dorsalis pedis and posterior tibial signals. Follow-up in clinic demonstrated palpable pulses in bilateral lower extremities. |
A 26-year-old male, not known to have NF1, presented with a 2-year history of pain in his left shoulder and an elbow swelling of six-month duration. He was initially diagnosed as having neurofibroma on the basis of tru-cut core biopsy of the mass done at a peripheral hospital. He underwent an excision of the tumor in October 2010 at another facility, and the histopathological diagnosis made there was MPNST. Six months later, the patient was referred to our hospital with a recurrent mass at the site of the previous excision, associated with pain that awakened the patient from sleep. On examination, there was a large surgical scar on the left elbow about 12 cm. in length and an underlying lobulated swelling extending proximally and distally with left radial nerve palsy (wrist drop).\nMagnetic resonance imaging (MRI) scans showed a large lobulated heterogeneous mass extending from the middle of the left arm down to the middle of forearm, measuring 29 × 9 × 9 cm. The lesion is predominantly in the volar aspect of both the left arm and the forearm, crossing the elbow joint, with no definite evidence of intra-articular or bony involvement. The radial neurovascular bundle cannot be separated from the lesion (). Two small subcentimetric pulmonary nodules at the upper lobe of the left lung of uncertain significance were seen.\nHistopathology slides from the referring hospital were reviewed, The tumor was predominantly composed of spindle cells arranged in interlacing fascicles, with a pattern of alternating dense and hypodense areas giving the so-called marbleized appearance (), with pleomorphic, hyperchromatic nuclei, and increased mitotic activity (). Large areas of necrosis were present with perivascular sparing of malignant tumor cells, with the so-called survival phenomenon noted. There were several foci of rhabdomyoblastic differentiation featuring large rhabdomyoblasts with abundant eosinophilic cytoplasm (). Some fields exhibit glandular differentiation featuring glands lined by malignant columnar epithelial cells, with mitotic figures and large pleomorphic nuclei ().\nImmunohistochemically, the spindle cell component showed patchy nuclear and cytoplasmic S100 protein expression (), while the rhabdoid cells were strongly positive for desmin (), and within the desmin-positive areas, there were cells showing nuclear myogenin expression (). The malignant epithelial cells of the glandular component were positive for pan-cytokeratin (pan-CK) (), but were negative for chromogranin and synaptophysin.\nOur revised diagnosis was MPNST with rhabdomyoblastic differentiation (MTT) that contained foci of malignant glandular epithelium.\nThe patient refused any surgical intervention which would require disarticulation. He received three cycles of chemotherapy (doxorubicin and ifosfamide) followed by radiation therapy 60 Gray (Gy) units over 30 fractions that ended in 2011, with marked improvement of his lesions (). At the time of reporting this case in January 2021, the patient had no evidence of clinical recurrence or residual disease or signs of metastasis. |
A 19-year-old male patient, with body mass index (BMI) of 8.45 kg/m [] and previous diagnosis of cerebral palsy, was admitted due to upper gastrointestinal bleeding Blatchford score of 10. Upon initial assessment, the patient required a blood transfusion due to hemoglobin level of 5.48 g/dl. The upper gastrointestinal endoscopy reported an esophageal ulcer Forrest IIC and esophagitis. Given the symptoms associated with chronic malnutrition and severe deconditioning, a gastrostomy was recommended. Initially an endoscopic gastrostomy was decided as the ideal approach, which was unsuccessful due to suboptimal translumination. Despite considering a new attempt to perform endoscopic gastrostomy at a later date, the patient´s nutritional and metabolic condition could worsen in case it failed a second time. Thus, an open gastrostomy was considered by the gastroenterology department to ensure an early start of the enteral nutritional route. The institutional anesthesiologist considered the patient’s high risk would be reduced once he was in adequate nutritional and metabolic so the surgery was performed without any initial complications. An upper gastrointestinal endoscopy on the third postoperative day revealed adequate positioning of the gastrostomy and enteral nutrition was initiated and well tolerated.\nTen days after surgery, patient in-hospital presented diffuse abdominal pain and multiple diarrheic episodes, of insidious origin, referring it began two days after surgical procedure and gradually increased its intensity. Laboratory results were within normal limits, and the abdominal computed tomography (CT) scan revealed extensive pneumatosis from esophagus, stomach, small intestine and partial colon. Additionally, moderate pneumoperitoneum and gas in the venous portal system were also reported (, ). The CT scan showed no evidence of an intra-abdominal collection or abscess that could otherwise explain the findings, as there was also no clinical or laboratory signs of systemic inflammatory response syndrome or infection. Medical management was initiated with intravenous fluids and nasogastric tube, while suspending the enteral nutrition. Patient showed improved outcome regarding symptomatology 24 h later. One month after the surgery, the patient was discharged in good conditions, with nutritional supplement via gastrostomy and integral rehabilitation. |
A 33-year-old Dutch Caucasian woman was referred to our clinic with signs of painful bony impingement of the left patellofemoral joint. One year before presentation, she underwent a trochlear osteotomy of the left knee for recurrent patellofemoral instability with signs of trochlear dysplasia (Figure ). There was no patella alta. Conservative treatment with physical therapy, activity modification, and taping had failed to relieve the patellofemoral instability. There was no history of any previous surgical procedures or trauma. In reviewing the operative records no complications during or directly after trochlear osteotomy were noted. Trochlear osteotomy was performed through a lateral parapatellar approach with the knee in full extension, allowing the patella to be retracted medially. After incomplete subchondral osteotomy of the anterior aspect of the lateral condyle with curved osteotomes, the articular cartilage of the anterior aspect of the lateral condyle was elevated in one piece to a height of 8 mm. Height was maintained by inserting a wedge shaped bone graft from the iliac crest and osteosynthesis with 2 screws. Patellofemoral stability was assessed through a full range of motion, and considered adequate. The synovial lining and lateral retinaculum were closed. No additional medial soft tissue surgery was performed. Direct postoperative partial weight bearing was advised with crutches, after 6 weeks full weight bearing was allowed.\nFive months later she still had persistent pain on the anterior aspect of the left knee without a history of trauma or patellar dislocation since the procedure. Radiographic examination demonstrated nonunion of the trochlear osteotomy with dislocation of subchondral bone resulting in an irregular patellofemoral joint (Figure ). Arthroscopy was performed with removal of the screws. Since patellofemoral joint preserving surgery was considered inadequate, she was referred to our hospital for further treatment.\nOn physical examination there was painful limited range of motion with 90 degrees of flexion. No signs of infection were observed. There was obvious quadriceps muscle wasting. Palpation of lateral retinaculum and lateral condyle was painful. Moving from flexion to maximal extension, the patella was found to wobble at approximately 30 degrees of flexion. A Computed Tomography (CT) scan of the left knee demonstrated the irregular condyle (Figure ).\nBecause of incapacitating pain, patellofemoral joint replacement was advised. Using a medial parapatellar incision, the knee joint was inspected. The anterior aspect of the lateral condyle was deformed with grade 4 cartilage degeneration. The remaining trochlea was dysplastic (Figure ). Inspection of the patella showed no clear medial and lateral facets, with only the odd facet readily visible. On the lateral side a 1 × 1 cm grade 4 lesion was present. The femorotibial compartments showed no degenerative changes. Patellofemoral arthroplasty was performed using the Journey PFJ (Smith&Nephew, Memphis, Tennessee) (Figure ). The irregular anterior femur was resected using the standard cutting blocks. Condylar support for the prosthesis was adequate. Postoperative rehabilitation was uneventful, and at last follow-up at 6 months the patient demonstrated good function of the left knee with 140 degrees of flexion. There were no signs of patellofemoral instability and she experienced only slight anterior knee pain. |
A 36-year-old female presented to the urology department with a two-month history of right-sided abdominal pain and backache. She denied haematuria or any other urinary or gastrointestinal symptoms. On retrospective review, she admitted to experiencing skin flushing once a week and palpitations and hot sweats but denied diarrhoeal symptoms. She was otherwise fit and well, and her only past medical history was of long-standing migraines for which she took zolmitriptan. She had never smoked and had no family history of renal or other neuroendocrine tumours. On examination, she had a palpable and minimally tender right-sided mass.\nAn ultrasound and subsequent computed tomography (CT) scan were arranged, which revealed a 14 cm mass arising from the upper pole of the right kidney (Fig. ). The tumour was abutting, but not invading the liver, and no evidence of metastatic spread was seen, either in the liver or elsewhere. Pre-operative blood workup revealed normal renal and liver function and mild normochromic anaemia.\nThe patient then underwent an open right radical nephrectomy. The operative findings were of a large 14 cm right upper pole tumour abutting the liver but with a clear plane between the liver and the kidney. After the removal of the right kidney with tumour, the liver was inspected and found to have more than 10 small lesions throughout the anterior surface occupying all of the visible liver segments. Most were less than 5 mm in diameter, but one was larger, measuring 3 cm in size. One liver lesion was sent for fresh frozen section, and an intra-operative diagnosis of liver metastasis was made. Owing to the large number of metastasis and their distribution throughout the liver, they were felt to be unresectable, and the operation was concluded with only the right radical nephrectomy performed.\nPost-operatively, the patient made a good recovery and was discharged after five days in the hospital without significant complications.\nHistopathological examination of the specimen found that the renal parenchyma had been largely replaced by a 144 mm haemorrhagic tumour displaying solid and cystic areas. The anatomy of the hilum had been grossly distorted, and foci suspicious for necrosis were seen.\nMicroscopy revealed tumour cells arranged in trabeculae, nests and ribbons, with focal attempts to form rosette-like structures (Fig. ). The tumour cells were monomorphic round to polygonal, with granular amphophilic to eosinophilic cytoplasm and uniform round nuclei with stippled (salt-and-pepper) chromatin (Fig. ). Immunohistochemistry was performed and showed tumour cells staining positive for synaptophysin (Fig. ), CD56 (Fig. ), CD57, chromogranin (focal) and alpha-methylacyl-CoA-racemase (AMACR) (weak). Staining with CK7, CD10, PAX8, Melan A, HMB45 and WT1 are all negative. The proliferation index (Ki-67) was 5%. The mitotic count was 1 per 10 HPF. The tumour was focally invading the wall of the renal capsule, but extra-capsular spread was not seen. At the hilum, the tumour appeared to have obliterated the normal sinus architecture; the tumour was seen within severely disrupted vascular structures with fragmented elastic fibres. Peri-capsular and intra-tumoural lymphovascular invasion was also noted.\nOverall, the morphological and immunohistochemical features were in keeping with a grade 2 well-differentiated neuroendocrine tumour pT3a. Further examination of the liver metastasis confirmed a grade 2 neuroendocrine tumour, with immunohistochemistry showing strong diffuse positivity with synaptophysin and CD56, and ISL-1 was also positive. The proliferation rate in “hot spots” was 5.9%.\nTwo months post-operatively, a Gallium-68 DOTATATE positron emission tomography (PET) scan was performed, which confirmed bilobar liver and pelvic skeletal metastases with variable somatostatin receptor expression. No alternative primary malignant site was identified. Subsequent blood tests for levels of gastrin, somatostatin, vasoactive intestinal peptide and chromogranin A, as well as a 24-hour urinary metanephrine collection, have all been normal.\nShe has now been started on monthly intravenous somatostatin analogue injections, which will be continued for six months. Clinically, she is experiencing gastrointestinal side effects related to these injections but is otherwise clinically stable at six months post-surgery. She will continue close follow-up within a specialist neuroendocrine tumour clinic with three-monthly blood tests and clinical review, and after six months of somatostatin analogue treatment, a follow-up PET scan and MRI liver will be performed to assess radiological response. |
A 38-year-old man was referred to our hospital for multiple gastric submucosal lesions after an annual medical checkup. The patient did not have a history of congenital or acquired immunodeficiency or symptoms of abdominal pain, weight loss, or fever. He was immunocompetent, as shown by a complete blood count with differential and the absence of serum viral markers, such as anti-human immunodeficiency virus (HIV) antibodies. Esophagogastroduodenoscopy revealed multiple protruding lesions covered with normal mucosa on the body and antrum of the stomach (). The lesions appeared as well-demarcated oval masses that varied in size from several millimeters to 1 cm. In addition, they were hypoechoic and originated in the submucosal layer without invasion into the deeper layers, as shown by endoscopic ultrasonography (). The Campylobacter-like organism (CLO) test was negative. No pathologic lesions were found by colonoscopy. Computed tomography also did not reveal any abnormal thickening of the gastric wall or regional lymphadenopathy. Three mass lesions were resected by endoscopic submucosal dissection and endoscopic mucosal resection.\nThe resected polyps revealed several well-defined submucosal nodules of dense lymphoid infiltrates mimicking ectopic lymph nodes (). These infiltrates had a diffuse and nodular architecture with primary and secondary lymphoid follicles (). A few lymphoid follicles also had a prominent mantle zone and small germinal center (). The lymphoid cells in the diffuse areas and primary follicles were composed predominantly of small cells, although there were a few multinucleated giant cells, which were considered to be Warthin-Finkeldey-type cells (). The infiltrate between the follicles was composed mainly of medium-sized lymphoid cells with abundant clear cytoplasm and indented or round nuclei with small nucleoli, admixed with a small number of plasma cells. In addition, a few large cells with vesicular nuclei and one or two prominent nucleoli were identified (). The gastric mucosa revealed multifocal lymphoid aggregates and some of the epithelial cells were infiltrated by small lymphocytes mimicking lymphoepithelial lesions ().\nImmunohistochemistry tests showed that the lymphoid infiltrates, including the medium-sized cells, in the interfollicular areas expressed CD2, CD3, CD4, CD5, CD8, and CD43, but the small cells in the lymphoid follicles and the large cells in the interfollicular areas did not express these markers (). However, the latter cell types expressed the CD20 antigen (). CD10 and bcl-6-positive B lymphoid cells were confined to small germinal centers (), but were negative for bcl-2. In addition, staining with CD21 and CD23 showed a normal reactive pattern in lymphoid follicles () and expanded follicular dendritic cell networks. CD30-positive large cells were rare. The plasma cells were polyclonal, as shown by kappa and lambda light chain immunohistochemistry.\nResults of in situ hybridization for Epstein-Barr virus-encoded RNA were negative. In addition, no evidence of a chromosomal translocation was found by using interphase fluorescence in situ hybridization analysis of paraffin sections using the API2/MALT1 dual-color, dual-fusion translocation probe, which revealed two orange and two green signals. However, polymerase chain reaction analysis of the immunoglobulin heavy chain and T-cell receptor gene rearrangements using the standard Biomed-2 PCR protocol, demonstrated a polyclonal pattern on Gene Scanning. The patient was followed for 1 year and the polypoid lesions remained unchanged without any additional treatment. |
A 43-year-old male patient with recently developed precordial Q waves on an electrocardiogram during a routine annual health check-up and with no previous history of acute coronary syndrome was admitted to our institution. He presented with mildly depressed left ventricular function (left ventricular ejection fraction, 48%) with hypokinesis of the anteroseptal wall on echocardiography and a positive exercise stress myocardial perfusion imaging result (summed stress score, 12 points); however, 64-row CCTA visualized patent coronary arteries, including the left anterior descending artery, without atherosclerotic plaque (). Considering the significant myocardial ischemia caused by exercise, moderately depressed left ventricular function, and professional requirement of physical fitness, we performed invasive coronary angiography and percutaneous intervention. His invasive coronary angiography revealed a unique coronary anatomy with a long lesion (>30 mm) in the middle of the left anterior descending artery (). The results of OFDI demonstrated the details of the lesion in the axial cross-sectional view (upper panels of ), longitudinal cross-sectional view (), and three-dimensional longitudinal view (). Simultaneously, we also performed IVUS imaging (lower panels of ). We observed the lesion by auto pullback system and identified it by locating the second diagonal branch and the second septal branch in each modality. The lesion comprised a proximal hazy portion (1 and 2 of : corresponding to , and ), middle slit portion (4 of : corresponding to , and ), and distal portion with a braid-like appearance (5 of : corresponding to , and ). In the proximal portion, an OFDI catheter was observed in the center of the vessel surrounded by multiple lumens, similar to a previously reported OCT observation in a patient with spontaneous coronary dissection (SCAD). In the middle portion, a double-barreled lumen was observed, similar to a previously reported observation during an autopsy in a patient with SCAD. Moreover, in the distal portion, multiple small channels communicating with each other were visualized, similar to previously reported observations using OCT and histology in patients with recanalization of organized thrombi. Furthermore, a dissection entry was identified (3 in , white arrows). However, IVUS revealed the absence of atherosclerotic plaque in the lesion. Based on the abovementioned findings of CCTA, invasive coronary angiography, OFDI, and IVUS, SCAD was diagnosed. Unfortunately, even with the use of OFDI, we could not clearly detect the disruption of “media” in the lesion. We postulated that we could have missed some findings because of the complexity of the lesion due to covering of the site of “disruption of media.” Thus, a drug-eluting stent was successfully implanted under the guidance of OFDI and IVUS that demonstrated an adequate expansion of stent struts without malapposition. |
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 77-year-old man visited an emergency department for chest pain that developed 1 hour before the hospital visit. The pain began when he washed his face after getting out of bed in the morning. The patient felt a tightening pain in the chest, through the back, and in the area between both the scapulae. The patient was taking aspirin 100 mg, clopidogrel 75 mg, and metformin 500 mg for hypertension and diabetes. He visited the hospital one year prior for a similar pain and underwent a stent insertion in the left anterior descending coronary artery for ST elevation myocardial infarction. When the patient visited the hospital this time, the pain was rated as an 8 out of 10 and continued even after sublingual administration of the patients own nitroglycerin. Vital signs were as follows: blood pressure, 166/88 mmHg; pulse rate, 72 beats/min; respiratory rate, 15 breaths/min; and body temperature, 36.7°C. Sinus rhythm and first-degree atrioventricular block were observed on electrocardiography. Bedside echocardiography showed similar results with the previous one, except for a decrease in ejection fraction to 38%. Laboratory data including hemoglobin, platelet count, white blood cell, blood chemistry, and cardiac enzyme test as well as urinalysis were normal. Thirty minutes after the hospital admission, the chest pain was relieved; however, the pain through the scapula remained. Therefore, aortic dissection was suspected and an aortic dissection computed tomography was obtained. The computed tomography showed multiple dissections at an infrarenal level. Since the patient had slipped and fallen 3 days prior, spinal radiography was performed and revealed an acute compression fracture at T8. Four hours later, he complained of numbness in the entire left leg below the knee. The numbness alternately occurred in the left and right leg during a neurological examination but the motor activity was measured as grade 5. Spinal magnetic resonance imaging (MRI) was obtained to check if a spinal cord injury was caused by the compression fracture, but there was no definite signal change in the spinal cord (). Six hours after the visit, the upper back pain increased in severity to the point that the patient was unable to lift his knee up, and the motor activity of the lower limb decreased to grade 3. A spinal cord infarction was suspected and the patient was admitted to the department of neurology. Nine hours after the hospital visit, a sudden sensory change–hypoesthesia (3/10)–occurred, loss of sensation progressed up to the T4 dermatome, the strength in both lower extremities deteriorated to grade 0, and a decrease in anal tone and deep tendon reflex was observed. The patient was numb to pain and temperature stimuli, but vibratory sensation was intact. Steroid pulse therapy (methylprednisolone 1 g/day) was initiated. Seventy-two hours after the hospital admission, no change in the neurological symptoms was observed. A follow-up spinal MRI showed a signal change with a diffuse pattern within the spinal cord at T2-T6 (T2 hyperintensity, T1 hypointensity without definite enhancement), and spinal cord swelling was observed (). Steroid pulse therapy was continued for 5 days. After a month of hospitalization, touch sensation in his right big toe had improved slightly, but the patient was still undergoing rehabilitation treatment while showing no improvement in the other neurological symptoms. |
A 41-year-old Caucasian woman was referred to eye casualty with a three-day history of a painful, red left eye. She had had similar episodes of bilateral anterior scleritis four years ago controlled by intravenous steroids and oral cyclosporin but had been off all immuno-suppression therapy for over three years. She was treated with oral flurbiprofen 100 mg t.d.s. This had no effect and after 48 hours she was commenced on 80 mg oral prednisolone. Two days later visual acuity reduced to 6/36 and she was placed on intravenous methylprednisolone 500 mg o.d. for three days. Haematological investigations excluded any systemic involvement. Ultrasound scan confirmed scleritis and MRI scan revealed no inflammatory orbital masses.\nThe inflammation and pain gradually settled and visual acuity improved to 6/6. She was discharged on oral prednisolone 80 mg daily as a reducing course. At 60 mg daily, she relapsed and required intravenous methylprednisolone 1 g stat followed by 500 mg o.d. for one week to control her inflammation. She declined cyclophosphamide because of the risk of side effects. Mycophenolate was started at 500 mg o.d., slowly increasing to 1 g b.i.d.\nShe developed weight gain and steroid-induced diabetes. She was an irregular attender at clinic and despite efforts to wean her off steroids she kept increasing the dose in order to control her ocular pain using between 60 and 70 mg prednisolone per day. There was a clear mismatch between the amount of ocular inflammation clinically and her symptoms of pain. Five months after presentation a trial of oral amitriptyline was commenced at 10 mg nocte increasing to 50 mg nocte over 1 week. This very rapidly controlled the pain and she was able to reduce her steroid dose from 60 mg to 15 mg prednisolone daily within fifteen weeks of starting amitriptyline. At this point her pain returned but this time with clear clinical evidence of her scleritis becoming more active. This flare up was controlled by briefly increasing her prednisolone to 40 mg daily and her mycophenolate to 1.5 mg b.i.d. She is now on 10 mg prednisolone o.d., mycophenolate 1.5 mg b.i.d. and amitriptyline 50 mg nocte without further relapse. |
In this article we present an unusual case of a 53-year-old male patient, who was referred to our department because of acute intestinal obstruction, presumably of malignant cause. Otherwise the patient had a diabetes mellitus type 2 on peroral therapy, smoker for 30 years (15 cigarettes per day) and occasional alcohol drinker. Prior to our treatment he was hospitalized at the internal clinic because of upper abdominal pain and vomiting. He did not pass any stool for 6 days. He was dehydrated, laboratory tests showed hyperkalemia, mild leukocytosis and renal insufficiency, C-reactive protein was mildly elevated (27 mg/L). Serologic examinations for viruses were negative, tyroid hormones were normal. The tumor marker carcinoembryonic antigen was elevated (717.2 µg/L), other tumor markers were normal. He was vomiting a dark brown fluid, therefore an urgent gastroscopy was rendered. Gastroscopy showed a soor oesophagitis and Helicobacter pylori erosive gastritis. The abdominal ultrasound showed dilated small bowel loops. Computed tomography (CT) of the abdomen showed small bowel obstruction, but the exact cause could not be determined. There was no free fluid nor free air in the abdomen. There were seen some changes of both adrenal glands, that were suspective for metastatic lesions (Fig. ).\nThe patient was sent to the operating theater for an emergency operation. He was placed in supine position. He already had inserted a nasogastric tube and a Foley catheter. Intravenous perioperative antibiotic prophylaxis was administered with gentamicin and metronidazole. The operative field was prepared in a sterile manner. A small median laparotomy was made and a thorough exploration of abdominal cavity was performed. During the abdominal exploration we found multiple metastatic lesions along the entire length of small bowel and also some lesions along small bowel mesenterium. One of the metastatic lesions was completely occluding the bowel lumen and was the cause of intestinal obstruction and ileus. The other lesion along the entire length of small bowel were at that time nonobstructive. We explored the entire abdominal cavity, but we did not find any other pathology, which would be suggestive as a primary tumor. There were also no other metastases. Liver and other peritoneal surfaces were without evident pathology. We took a sample of one metastatic lesion for definitive pathohistologic examination and then we created an intestinal bypass to relieve the intestinal obstruction. We created an entero–entero anastomosis with running slowly resorbable suture. Haemostasis was complete at the end of operation. We irrigated the abdominal cavity with saline and closed laparotomy with interrupted resorbable sutures without abdominal drain. The skin wound was closed with staples. The postoperative course was uneventful. On the second postoperative day patient started with liquid diet, the nasogastric tube and Foley catheter were removed, he started to pass stool spontaneously. On the fifth postoperative day he was discharged from hospital.\nA few days after the patient was already discharged from the hospital, we received the pathohistological report, which has spoken for a metastasis of poorly differentiated adenocarcinoma. According to imunophenotype it could be the metastasis from primary lung adenocarcinoma, less likely from stomach or tyroid gland adenocarcinoma (Fig. ).\nBecause of unknown origin of small intestinal metastases, the patient was referred to extensive diagnostics. Chest CT showed a large primary lung tumor in the left upper pulmonary lobe with pathological mediastinal lymph nodes. The patient was presented to multidisciplinary team and was later referred to oncology for further treatment. |
A 29-year-old male, while driving a car, sustained a closed head injury in a road traffic accident. The patient did not show any symptoms of a severe head injury immediately after the trauma and was treated symptomatically for other minor injuries. Computed tomography of the brain done then was suggestive of skull base fractures of greater wing of sphenoid, and there was no evidence of parenchymal injuries. The patient was discharged following symptomatic improvement. The patient reported to a tertiary care facility again 3 months after the injury with the complaints of progressive swelling of the left eye over the past 15 days with associated progressive loss of vision in the same eye for the past 10 days. Clinical examination revealed that the patient had severe periorbital edema and chemosis of conjunctiva with associated loss of vision (only perception of light) and restricted extraocular movements of the left eye with, as shown in .\nMagnetic resonance imaging (MRI) performed revealed a large, ill-defined lesion in the left supraclinoid and paraclinoid region with variable contrast enhancement. The patient was further investigated with a digital subtraction angiography (DSA), which showed a large 2.8 cm × 0.9 cm supraclinoid aneurysm which had ruptured inferiorly into the cavernous sinus forming a carotid-cavernous fistula (CCF) with an associated dilation of superior ophthalmic veins (SOVs) [Figure and ].\nThe patient was then planned for coiling of the supraclinoid pseudoaneurysm. Consent for procedure and have their data published was taken. A femoral microcatheter was passed to determine the origin of the aneurysm, which was observed to be proximal to the bifurcation of the ICA. The supraclinoid location of the aneurysm was confirmed as the aneurysm was deemed to be distal to the ophthalmic artery. Mild stenosis of the proximal portion of supraclinoid ICA was also observed. Complete obliteration of the CCF was achieved by coiling of the aneurysm alone [].\nThere were no observed procedural complications. During follow-up, the patient reported an improvement in the vision (6/36) in his left eye. The patient has been followed up for 1 year now. showing DSA performed 1 year postoperatively which is suggestive of completely obliterated aneurysm and fistula and no recurrence. |
A 25-year-old female, teacher by profession, with complaints of weakness and pain in left hand involving 3rd, 4th, and 5th digits associated with pain in wrist, elbow, and shoulder joint on the same side for 2 months. Over the next 15 days she started developing swelling and redness involving last three digits along with blackish mottling of the overlying skin on the dorsal aspect. She also had increased pain sensation in those digits to the slightest of touch such that she would keep her fingers flexed and avoid movements. She sought medical consultation at the dermatology clinic before consulting various other specialties and ultimately being referred to our rheumatology clinic.\nAt dermatology clinic, on clinical examination, ulnar nerve was found to be minimally thickened and palpable along with skin changes including hyperpigmented patches and hypoaesthetic plaques. There was reduced sensation to cold with preserved fine touch and pain sensations. Ulnar nerve biopsy was ordered which came out to be normal. Skin biopsy showed hyperkeratotic epidermis with large number of budding yeasts in stratum corneum and was prescribed fluconazole along with NSAID’S and topical ointments but to no relief.\nPatient visited neurology clinic for her complaints of excessive pain apparently in the ulnar nerve distribution. A possibility of mononeuritis multiplex was considered clinically. She underwent nerve conduction studies of all four limbs and MRI of cervical spine were revealed normal. Patient was started on Tramadol 50 mg twice daily, Gabapentin 150 mg twice daily, duloxetine 30 mg once daily, and Vitamin B-12 supplements but without any relief in her symptoms.\nMeanwhile, the patient consulted many orthopaedicians and physical medicine and rehabilitation centers but to no relief. With every passing day, her pain increased to the extent that she stopped venturing out in public places to avoid any touch on her fingers. Pain became so debilitating that she used to cry and could not sleep for weeks altogether.\nIn our rheumatology clinic, she denied history of recent or remote trauma to the left upper limb or any history of previous surgeries. On examination, there was flexion deformity at proximal and distal interphalyngeal joints involving left 3rd, 4th, and 5th digits []. There was associated soft tissue swelling and skin changes in the form of blackish discoloration and dryness and scaling but with no synovitis. Clubbing of digits with increased nail angle along with whitening and excessive shining of nails of 3rd, 4th, and 5th digits was also noticed []. Atrophy of thenar and hypothenar muscles of left hand was evident. Other proximal joints, namely elbow and shoulder, were normal on clinical examination. Pain was assessed with Visual Analogue Scale (VAS), the score of which was 9 at presentation.\nHer previous lab reports were reviewed. Blood counts were within normal limits. Liver function tests, lipid profile, thyroid profile, and renal function tests were all within normal limits. Her chest X-ray showed no abnormality. Serology for viral hepatitis, gonococcal, and HIV was negative. Rheumatoid factor, antinuclear antibody, and HLA-B27 were also negative. Radiograph of hand and wrist showed marked regional osteopenia with bone resorption involving mainly around the metacarpo-phalyngeal and interphalyngeal joints without any erosions or sclerosis []. A Technitium labeled MDP triple phase bone scan was advised that revealed increase in radiotracer accumulation in the region of left forearm and left wrist at inflow and pool phase images. Delayed whole body static images showed increased peri-articular radiotracer uptake in left shoulder joint, left elbow joint, and left wrist joint. Focal increased radiotracer uptake was also seen in metacarpophalyngeal joint and proximal interphalangeal joint of 3rd and 4th fingers of left hand.\nHence a diagnosis of CRPS type I was made according to Budapest criteria. As the patient did not respond to NSAIDs, amytryptiline, and pregabalin. Left stellate ganglion block was given []. After 5th sitting of stellate ganglion block, patient rated a score of 3 on VAS scale. With time, patient was able to do her routine day to day activities and is presently being followed up regularly. |
A 61-year old man presented with a left upper quadrant abdominal mass after experiencing several intermittent episodes of nausea, vague abdominal discomfort, and mild acid reflux. He also reported a nine kilogram weight loss over the prior six to eight months. Physical examination revealed a large mass in his upper abdomen.\nAbdominal computed tomography (CT) revealed a 21 × 12 cm heterogeneous mass occupying his mid and left upper quadrants (Figure ). Based on its location and imaging characteristics, the mass was hypothesized to be a GIST. The differential also included lymphoma, retroperitoneal sarcoma, and, less likely, a pancreatic neoplasm. To establish the diagnosis, an endoscopic ultrasound was performed and a core biopsy of the mass was obtained. The pathology of the core biopsy classified the mass as a spindle cell neoplasm that stained positive for CD117, consistent with a GIST.\nGiven the size and location of the lesion at the time of initial evaluation, resection of the mass would likely have necessitated a multi-visceral resection. Based on recent reports of effective preoperative imatinib therapy, a trial of neoadjuvant imatinib was felt to be the optimal treatment strategy to down-stage the tumor and minimize the extent of resection [].\nThe patient was treated with imatinib and tolerated the therapy well, with the exception of developing mild periorbital edema, the most commonly reported side effect of imatinib []. He was followed with CT scans performed at two-month intervals. The mass measured 21 × 12 cm on initial imaging. Subsequent measurements were 16.9 × 9.1 cm, 12.2 × 9.6 cm, and 10 × 8 cm (Figure ) at two, four, and six month intervals, respectively. Upon reviewing the patient's imaging and clinical course after six months of treatment, it was felt that resection was appropriate. Further, there was concern regarding the development of secondary resistance to imatinib.\nThe patient was counseled regarding a likely partial gastrectomy but also informed that a total gastrectomy and even a multi-visceral resection may be needed. At operation, he was found to have a softball-sized mass attached by a stalk to his stomach. He underwent a wedge resection of his stomach that included the stalk and tumor en bloc. Pathological analysis revealed a tumor of 15 cm in greatest dimension. There were extensive areas of ischemic necrosis. There were up to two mitoses per 50 high-power fields. The margins of the gastric resection were free of neoplasm.\nThe patient recovered from the operation. At least one year of adjuvant imatinib therapy is planned. |
A 34-year-old Liberian woman G2P2002 presented to us from the Obstetrics Department 9 days postpartum complaining of nausea, vomiting and epigastric discomfort. Her pregnancy was complicated by oligohydramnios and severe pre-eclampsia with reported systolic BP in the 200s. The patient was treated with magnesium sulfate, labetalol, hydralazine, nifedipine and underwent a Caesarian section delivery at 41.2 weeks. Prenatal care was split between the USA and Liberia. The patient denied any previous complications with the first pregnancy, which was delivered at term vaginally. Physical examination of the patient demonstrated uterine fundus at the level of the umbilicus but was otherwise benign.\nPatient's blood pressure remained uncontrolled and decision was made to perform a computed tomography (CT) scan of the chest and abdomen with contrast to rule out an aortic dissection. Imaging demonstrated the presence of a 14 mm × 11 mm × 11 mm VAA of the celiac trunk (see Figs and ).\nThe patient was educated on her elevated risk of aneurysm rupture due to her childbearing age, and also advised on the high risk of rupture should she become pregnant again. The decision was made to follow-up with the patient in outpatient vascular surgery clinic for ongoing aneurysm surveillance and planning for surgical repair.\nSurgical repair was performed approximately 8 weeks later. An upper laparotomy incision was performed extending from the xyphoid process to the umbilicus. The aorta and the celiac trunk were accessed and identified following division of the gastro-colic ligament and retraction of the stomach and small intestines. The celiac trunk was clamped using vascular loops at its bifurcation from the aorta, and the subsequent four branches were clamped using the same method at their branch points. Due to the ventral location and extension of the aneurysm sac on the celiac trunk as well as the lack of involvement of any branches, the decision was made to excise the aneurysmal sac in it's entirety and close the resultant defect using a patch made from a vascular graft (see Fig. ). After ensuring that the celiac trunk and it's branches were patent using Doppler ultrasonography, the incision was closed and the patient extubated.\nThe patient's postoperative course was uncomplicated and lasted a total of 3 days. Patient's bowel functioning returned within 24 h of the operation and she was able tolerate PO intake on postoperative day #2. No further complications were reported by the patient and she is to follow-up in clinic at 3 months postoperative. |
The patient was a 26-year-old Hispanic male diagnosed with AIDS who was being treated with a combination of oral tenofovir plus emtricitabine as well as lopinavir plus ritonavir in Mexico. Despite 2 months of highly active antiretroviral therapy, he continued to have a severely depressed CD4 cell count of six cells per microliter and an HIV viral load of 10,700 copies per milliliter. He then moved to the United States and presented at our hospital. He also reported purplish, hyperkeratotic lesions all over his body () over the previous 3 to 4 months. These lesions encompassed nearly 50% of his body-surface area. The worst lesion was involving his right foot and lower leg, which was a large 10 × 10-cm fungating purulent mass on the medial aspect of his right calf (). Along with the lesions, the ipsilateral foot had severe edema and dry gangrene. Surgical debridement was considered but not initiated because of fear that it would lead to an above-the-knee amputation, given a lack of viable tissue for closure.\nPunch biopsies from the right lower extremity and left upper chest confirmed the diagnosis of Kaposi's sarcoma (). A multidisciplinary team initiated a conservative approach to salvage his lower leg beginning with liposomal doxorubicin 20 mg/m2 once every 3 weeks to reduce underlying tumor (a total of 17 doses was given eventually). As the tumor burden improved on his face and torso (A), a continuing obstacle to the patient's progress (and ability to walk) was the large circumferential tumor on the patient's right lower extremity (B). Magnetic resonance imaging of right lower extremity 13 days after the first dose of liposomal doxorubicin showed extensive cellulitis and myositis of the foot with subcutaneous emphysema (possibly necrotizing) but no osteomyelitis, no communication of the plantar necrotic tissue and deeper viable tissue. Enzymatic debridement was determined to be of no benefit. Treating the patient with chemotherapy in the presence of this open, infected wound was considered extremely risky. Despite one chemotherapy treatment with liposomal doxorubicin, there was no improvement noted in the wound. It was felt that there was likely poor chemotherapy penetration in the highly necrotic tumor tissue. At this point the patient was facing potential death secondary to infection or an amputation of the involved extremity.\nThe decision was made to attempt two rounds of biologic debridement with MDT (C) before using amputation as a last resort. The two treatments of MDT were undertaken at 20 and 27 days after the initial dose of liposomal doxorubicin. For each round, one vial of medical maggots (Monarch Labs, Irvine, CA) was applied and removed after 48 hours by a wound nurse, according to the protocol provided by the manufacturer and Maggot Debridement Therapy Protocol at our institute (Protocol No. 46421 MT). In detail, DuoDERM dressing was applied around the wound and maggots were placed directly onto the wound at a concentration of 5 to 10 per square centimeter of wound base. The entire area was reinforced with moist 4 × 4 gauze squares and wrapped in Kerlix. The dressing was assessed every 6 hours by a bedside nurse and the gauze dressing on top of the maggots was kept moistened with normal saline. Forty-eight hours later, the dressing and maggot cage dressing were removed with saline-soaked gauze, and then the entire foot was irrigated with sterile normal saline. Dead tissue was removed from the plantar area of the foot with additional sterile saline washes. Red tissue was noted at the plantar aspect of the foot and at the base of the great toe. The foot was then placed in a basin with sterile saline to soak for 1 hour before being dressed with oil-emulsion/Vaseline from right ankle to midcalf in dry gauze and Kerlix wrap. During the treatment, the patient reported that his pain level was average at a level of 2 on a scale of zero to 10, which was tolerable.\nMDT profoundly decreased the necrotic burden surrounding the foot, allowing the viable tissue to arise. Repeat magnetic resonance imaging 3 days after the second round of MDT (also 11 days after the second dose of liposomal doxorubicin) showed decrease in myositis and cellulitis and stable cutaneous lesions. The patient was discharged home shortly after and continued to be observed through our multispecialty clinics. He continued with his chemotherapy regimen with continued response to his systemic lesions. Eight months later, the lesions on the patient's torso have melted away to less than 5% of their original presentation. The large lemon-size mass along the medial aspect of his right foot had completely resolved, and necrotic tissue on the plantar surface of the foot was replaced with viable tissue with intact sensation. One year later, his right leg remained intact (D) and he was able to walk on his foot, although some of the skin changes persisted. |
A 67-year-old female, who had undergone a transabdominal hysterectomy for uterine myomas 15 years earlier, but had no history of colon or urinary bladder disease, presented to the emergency department with a complaint of abdominal pain that had lasted for more than 3 hours after a screening colonoscopy. She showed stable vital signs without fever. She complained of mild abdominal pain in the left upper quadrant, periumbilical area, and lower abdomen, all of which began after the colonoscopy. Mild tenderness and rebound tenderness was checked on the left abdomen. Laboratory data showed normal leukocyte count and normal C-reactive protein level. Abdomino-pelvic computed tomography revealed a collapsed rectosigmoid colon with concentric wall thickening and surrounding fatty strands with a scanty amount of fluid collection. Small amounts of ascites existed diffusely along the subphrenic space extending to the pelvic cavity. However, no evidence of intraabdominal free gas was found ().\nThe patient was initially managed by using conservative treatment. However, she complained of worsening abdominal pain with growing tenderness upon physical examination. In addition, her leukocyte count was elevated. Therefore, we decided to perform an emergency operation. Laparoscopic examination showed that the greater omentum was adhered to the previous incision site and that dark brownish fluid was loculated in the left abdomen. Severe adhesion was found between the sigmoid colon and the urinary bladder. The urinary bladder wall was thin and weakened and had several perforation sites (). After urinary bladder perforation had been diagnosed, the surgery was converted to a laparotomy. The sigmoid colon was dissected from the urinary bladder. The Foley catheter was visible through the urinary bladder perforation site (). No evidence of any other injuries, including colon injury, was found in the abdominal cavity. After thorough examination, we performed primary repair of the perforation sites by using one-layer, interrupt suturing with Vicryl 3-0. An omentopexy was added using the greater omentum. After surgery, the Foley catheter was maintained in place for 12 days. On the 12th postoperative day, a cystogram was performed to check for urinary leakage, after which the Foley catheter was removed. After removal of the Foley catheter, the patient was able to urinate smoothly and was discharged in a healthy state. |
The patient is a 33-year-old woman gravida 5, para 3, abortion 1 with chronic hypertension and 3-year history of arterial thrombosis. At age 30, she underwent aortoiliac thrombectomy and bilateral femoral thrombectomies with repair, and was started on warfarin postoperatively. Fifteen months later, noncompliant with anticoagulation, she presented for severe back pain radiating down her legs bilaterally. A repeat CT angiogram revealed a left common iliac artery occlusion with thrombus in the infrarenal abdominal aorta with possible dissection flap above the bifurcation. She underwent aorta-left femoral and aorta-right iliac bypass with a bifurcated polytetrafluorethylene (PTFE) graft (). Repeat hypercoagulable testing was negative, and she was discharged on warfarin treatment. The patient continued anticoagulation inconsistently. She presented multiple times over the following year complaining of lower extremity pain. Repeat CT angiograms demonstrated complete occlusion of both arms of the graft with normal runoff and patent pelvic collaterals.\nThree years after her initial intervention, she was pregnant and established care with our maternal-fetal medicine practice at 13 weeks of gestation. Her obstetrical history included one prior spontaneous abortion, two term vaginal deliveries, and most recently a cesarean delivery at gestational week 28 due to preeclampsia with severe features. All previous pregnancies occurred prior to aortic reconstruction, and there was no history of thrombotic disease with any pregnancy. The risk of the patient's gestation was reviewed in detail and included discussion of her grafts, disease burden, and anticoagulation requirements. She was offered termination of pregnancy but declined. She was prescribed therapeutic dose enoxaparin (1 mg/kg twice daily) and aspirin 81 mg daily for anticoagulation.\nAt 18 weeks of gestation, she presented with left leg pain and decreased sensation in the left lower extremity. Repeat CT angiogram showed no interval changes with apparent diversion of some collateral flow to the pregnant uterus. Urine drug screen was positive for cocaine. Due to worsening symptoms likely secondary to increased vascular demand of the gravid uterus and cocaine use, the patient was admitted and started on an unfractionated (UFH) heparin infusion.\nAfter consulting vascular surgery, urgent surgical intervention was not offered as she had conserved sensation and motor function in lower extremities, there was increased likelihood that the gravid uterus would be a barrier to aortic reconstruction, and her occlusive disease appeared stable on repeat imaging. The vascular surgeons further assessed and recommended intervention only if worsening of blood flow, as defined by the loss of the patient's motor function in her lower extremities. If she reached that point, she would require axillofemoral bypass surgery. The goals of care were discussed, and the patient reported she was prepared to lose her leg before jeopardizing the pregnancy. She was discharged on therapeutic enoxaparin at 1 mg/kg twice daily and anti-factor Xa levels were followed monthly to adjust dose accordingly. Throughout the pregnancy, the patient was evaluated multiple times for increasing pain and required supportive care with wheelchair assistance and pain medications.\nThe patient presented at 31 weeks and 4 days of gestation with superimposed pre-eclampsia with severe features based on requirement of acute antihypertensives and persistent severe headache. Her CT head imaging was negative and she was transitioned to UFH. Her blood pressures stabilized and the headache resolved, but three days later the patient complained of a persistent headache refractory to medications and required increased dosing of her antihypertensive medications. Plans were made for delivery via repeat cesarean delivery. UFH was stopped 6 hours prior to delivery. The patient underwent an uncomplicated repeat cesarean delivery with bilateral tubal ligation with an estimated blood loss of 600 cc. She was managed in the intensive care unit in the immediate post-operative period and restarted on enoxaparin 1 mg/kg BID at 8 hours after delivery. The neonate weighed 1870 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.\nPostoperatively, the patient did complain of some worsening left lower extremity pain, which was evaluated by vascular surgery. However, they determined there was no need for acute surgical intervention as the patient had preserved motor function and her pain was adequately controlled. She was discharged home on enoxaparin 100 mg BID and aspirin 81 g daily. Despite anticoagulation, she was readmitted 11 weeks after delivery with flank pain and found to have a left renal artery infarct and extension of the infrarenal aortic occlusion up to the level of the renal arteries. She was acutely treated with intravenous UFH. Her flank pain resolved and renal function remained within normal limits. However, her left leg pain progressively worsened and required an open surgical juxtarenal aortic thrombectomy and redo aorta-right common iliac,-left common femoral reconstruction with a bifurcated cryopreserved allograft spliced to an autogenous left femoral vein conduit (). Prosthetic conduits were avoided because of her presumed hypercoagulable state and failure of previous prosthetic reconstruction. |
An 8-year-old female child reported as outpatient to the Department of Pediatric and Preventive Dentistry with the chief complaint of small growth in the oral cavity pertaining to upper right back tooth region which bleeds when interfered with eating and brushing.\nShe noticed the growth two months back which started as the size of peas and gradually increased to reach the present size. Her medical history and family history were non-contributory. No abnormality detected on extraoral examination and intraoral examination revealed a single growing exophytic lesion which was oval-shaped pedunculated with stalk, non-tender, reddish in color with smooth surface, which was measuring approximately 1.5 × 1 cm in upper right back tooth region, and it was attached to the alveolar mucosa in-between the right primary molars with no signs of lymph node enlargement ( and ).\nThese findings were confirmed by palpation of the lesion. Furthermore, there were no caries and absence of mobility of the involved teeth.\nOral hygiene status was fair. The blood picture showed that all the values are within the normal level. Based on the history and intraoral findings, provisionally it was diagnosed as pyogenic granuloma. Surgical excision of the lesion was planned and the excised sample was sent to the Department of Oral and Maxillofacial Pathology for histopathological analysis, where it is confirmed as pyogenic granuloma ( to ).\nThe patient returned only after 6 months with a recurrent swelling in the lower left back tooth region. On intraoral examination, a similar exophytic growth measuring approximately 2 × 1.5 cm, pedunculated, oval in shape, with a smooth surface, reddish in color which bleeds on probing, and it covered the buccal surfaces of the second primary molar and first permanent molar. Furthermore, there was a mild proximal caries with absence of mobility of the involved teeth. IOPA was taken to rule out if the swelling was related to caries, and finally the provisional diagnosis was pyogenic granuloma ().\nSurgical excision was planned at the new site and the excised tissue was sent for histopathological analysis to the Department of Oral and Maxillofacial Pathology ( to ). A diagnosis of pyogenic granuloma was confirmed.\nA possible list of differential diagnoses was as follows, irritational fibroma, peripheral ossifying fibroma, peripheral giant cell granuloma, soft tissue abscess, hemangioma, localized juvenile spongiotic gingival hyperplasia, pregnancy tumor, and post-extraction granuloma.\nThe given H&E stained section of both the samples showed stratified squamous epithelium which is hyperplastic and hyperkeratinized in nature, the underlying connective tissue, blood vessels proliferation noticed, associated with plenty of inflammatory cells infiltration noticed, the H/P consistent with the clinical diagnosis of pyogenic granuloma. |
A 14-year-old Asian girl residing on the north of Iran presented to our clinic with chronic low back pain from one year ago. She had a history of prolonged conservative treatment by home-made drugs and numerous bone setters. On plain radiograph, the only abnormal finding was a vertebral hamangioma of L3 that was confirmed by CT and MRI (). The patient was offered a classic course of conservative treatment and physiotherapy for about 2 months. The Pain did not decrease and finally due to tumoral size (fear of impending fracture) and preference of the patient’s father, the bone augmentation surgery was suggested and carried out.\nImmediately after percutaneous vertebroplasty (PVP) the pain was disappeared completely and the patient was discharged next day. After three days she returned to the school and did all her activities of daily living without any problems. This state lasted for 2 months. Then, gradually a radicular right leg pain was appeared and progressed unremittingly.\nAfter 12 months of the procedure, the severity of the pain was so severe that the patient has given up going to the school. She waked up on the average of 3 to 4 times a night. The pain was radiated to the right ankle area with no associated low back pain. Physical examination of the patient revealed a positive SLR at 30°, weakness of the left ankle dorsiflexion (3/5) but any paraesthesia or deep tendon reflex change was not noted.\nOn postoperative plain radiograph and CT scanning, right-sided cement leakage and L3-4 neuroforamen involvement were noted ( and ). Electrodiagnostic study was compatible with chronic moderate right L4 and L5 demyelinating radiculopathy.\nWith retrospective analysis of the preoperative images (), we got aware of a silent fracture through the vertebral body we injected cement. At first, we mistook it with a natural defect in the posterior vertebral cortex (blood vessels defect). Due to the severity and refractory nature of the symptoms, decompressive surgery was carried out with limited laminotomy and foraminotomy. The cement pieces extruded posterolaterally were excised completely and the L4 root was decompressed completely.\nImmediately after surgery the pain was omitted but muscular power took about 1 month to return to the normal state. Now, the patient is in her 6th month follow-up and symptom-free thoroughly. |
The first patient was a 63-year-old Caucasian male, smoker, and non-diabetic (Table ). His medical history included myocardial infarction, a cerebral insult, smoking-induced chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and a long-standing history of leg ischemia with rest pain when sleeping. He had undergone several surgical procedures over the past few years, including a femoropopliteal bypass with a Propaten graft above the knee in his right leg 2 years before the INP-treatment.\nWithin a few months following surgery, the patient experienced acute thrombosis of the graft and embolism distally in the leg arteries. Subsequently, a leg ulcer appeared on the patient's anterior tibia. The ulcer was treated unsuccessfully with a partial dermal skin graft from the patient's left thigh.\nThe patient regularly visited the wound clinic at the University Hospital to receive conventional wound care for 2 years prior to participating in the study. His maximal claudication distance was 100 m at a self-selected pace due to severe pain in his right calf. The main concern was his poor arterial leg inflow. Upon vascular examination, the patient had intact femoral artery pulses bilaterally, but no pulses in the arteries of his right foot. Duplex color scanning revealed an occluded popliteal artery. Distally, the only open artery was the fibular artery, which was open in two-thirds of the upper leg. The patient was informed that if the pain and wound worsened or failed to heal properly, amputation of the limb might be indicated.\nAfter 8 weeks of INP-therapy 2 h per day, the leg ulcer almost healed (Fig. ), and the SPP measured on the patient's right anterior and posterior tibial artery angiosomes on his right foot changed from 51 to 72 mmHg and 14 to 11 mmHg, respectively. The patient's distal ankle PVR increased from 6 to 8 mm in the leg exposed to INP, but remained unchanged in the control leg. We also measured acute changes in transcutaneous oxygen pressure (TcPO2) and blood flow velocity in the dorsal pedis artery in the lower limb exposed to INP. Laser Doppler flux was measured in the pulp of both big toes during a 10-min sequence of INP (Fig. ). |
A 52-year-old farmer was referred to us 7 hours after he had met with a high-velocity road traffic accident. He was resuscitated as per the ATLS protocol at the hospital where he was initially treated and when he arrived at the casualty department of our hospital, he was conscious and all his vital parameters were within normal limits. He also gave the history that he was under treatment for segmental myoclonus which was characterised by semirhythmic involuntary muscle contractions.\nHis radiographs showed a left-sided posterior acetabular wall fracture (AO type 6 2 A1). He also had an ipsilateral femoral neck fracture with the femoral head displaced anteriorly (Figures and ) and also an associated middle-third fracture of the shaft of the femur (). He also had an extra-articular distal femur fracture on the opposite side (AO type 3 3 A1). On arrival, his serum lactate level was 1.9 mmol/l indicating that he had been adequately resuscitated.\nHe was taken for definitive surgery 9 hours after arrival. The patient was positioned in the lateral position and a posterolateral approach was planned to address the acetabular and femoral head fractures. Upon dissection, the femoral head () was found to have buttonholed and displaced anteriorly through the capsule which was found to be torn. The posterior wall of the acetabulum was addressed using two contoured reconstruction plates (). Using the trochanteric flip osteotomy, better access to the femoral neck was achieved and the femoral head was reduced anatomically and secured with K-wires. Then the femoral shaft fracture was reduced by opening the fracture site and held with a clamp. The femoral head fracture and the shaft fracture were fixed with an antegrade femoral nail with two screws securing the femoral head (Figures and ). The flip osteotomy was fixed using a tension band wire and the joint was reduced. The torn capsule was sutured. Closure was done in layers. The operating time was 4 hours and the intraoperative blood loss was 600 ml. Three days following this surgery, the contralateral distal femur fracture was addressed using a titanium locking plate. The postoperative period was uneventful.\nThree weeks after the initial surgeries, the patient experienced an episode of rhythmic contractions of the lower limbs at his home. He presented to us with an anterior dislocation of the left hip joint (Figures and ). An open surgery was done to reduce the left hip joint (). Considering the displacement of the femoral head at the time of initial presentation, the chances of avascular necrosis of the femoral head was explained to the patient. The patient was also on follow-up treatment with a neurologist to manage the myoclonus problem.\nFour weeks after the surgery to relocate the femoral head, non-weight-bearing mobilization was initiated. As expected, avascular necrosis of the femoral head occurred () and we waited for union of the femoral shaft to occur as any procedure to address the femoral head would require removal of the intramedullary nail.\nEight months after the initial surgery and after union of the femoral shaft fracture, the patient was planned for total hip replacement surgery. Through a posterior approach, the antegrade femoral nail was removed. The acetabulum was reconstructed using a cage, and an uncemented hydroxyapatite-coated stem was used for the femur (). A ceramic on a polybearing surface was used. Postoperatively, there was no shortening of the limb. Immediate full weight-bearing mobilization was started using walker support. One year following the hip replacement surgery and 22 months following the initial trauma, the patient was ambulatory without any support and able to do all activities with an LEFS (lower extremity functional score) of 72. The radiographs showed complete union of all the fractures and there was no loosening of the femoral prosthesis. |
An 8-year-old African-American male with a history of asthma presented to his primary care provider for increasing exercise intolerance, shortness of breath, and cough for one day. He was started on methylprednisone and albuterol for possible exacerbation of his asthma. He returned to his pediatrician four days later for follow-up with increasing respiratory distress and shortness of breath and was referred to the ED for further evaluation.\nOn arrival to the emergency department, the patient was alert, awake, and cooperative. He walked into the room effortlessly, though did appear to have mild shortness of breath. His examination was notable for quiet heart sounds a possible holosystolic murmur and a quiet gallop. Although his liver edge was hard to feel, given the size of the patient, he was tender in the right upper quadrant. His extremities were warm and well-perfused, although radial pulses felt weak. He was placed on oxygen via nasal cannula. A chest radiograph showed an enlarged cardiac silhouette with pulmonary edema. An echocardiogram demonstrated a severely dilated left ventricle, severely depressed left ventricular function, moderate mitral and tricuspid regurgitation, and elevated right-sided pressures. He was noted to have a shortening fraction of 14%. Initial labs were unremarkable except a BNP 1150. He was admitted to the cardiac intensive care unit for further evaluation and treatment.\nThe patient was initially maintained on oxygen via nasal cannula but developed increased work of breathing that required CPAP and diuretic therapy. He was placed on milrinone captopril, and furosemide to improve cardiac function and decrease fluid overload. A cardiac catheterization confirmed a dilated cardiomyopathy and biopsy showed nonspecific acute inflammation. Prophylactic heparin anticoagulation was initiated due to his dilated ventricles and poor ventricular function. Viral studies and blood cultures were negative except for one culture that grew Streptococcus viridans. He was placed on ceftriaxone for possible bacteremia.\nDespite slow improvement in cardiac enzyme studies, the patient continued to require increasing amounts of milrinone and diuretic therapy. He developed increasing respiratory distress with increasing CPAP needs and sildenafil was initiated due to concern for pulmonary hypertension. His condition continued to deteriorate and the patient was placed on a waiting list for cardiac transplantation. |
A three year old male, known case of mild aortic stenosis, was referred to the paediatric respiratory physician with a seven month history of chronic productive cough and recurrent wheeze. The cough was resistant to regular inhaled corticosteroids and salbutamol. Physical examination was unremarkable (longstanding positive finding of a systolic murmur), with no respiratory compromise.\nOf note, in the past history, the child had been admitted to the Neonatal Intensive Care Unit at 16 hours of age with mild respiratory distress, which settled after minimal support and intravenous antibiotics.\nAt three years of age, there was one presentation to hospital with wheezing, resolving on nebulised salbutamol and oral antibiotics. A plain chest radiograph at the time reported “signs of right sided basal pneumonia associated with a small right sided pleural effusion” ().\nA repeat chest radiograph requested by the respiratory physician showed persistence of the above-mentioned abnormalities. A high resolution contrast enhanced computed tomography (HRCT) scan of the chest was performed, showing an elevated right hemi-diaphragm and a smaller right lung. The right basal lung parenchyma received its blood supply from an anomalous artery arising from the abdominal aorta at the level of the coeliac axis. The veins of the affected lobe drained directly into the pulmonary veins, implying a right-to-left shunt.\nThe lobe involved appeared inseparable from surrounding normal pulmonary parenchyma with a discernible reduction in the number of bronchi within the involved lung. The findings were suggestive of a diagnosis of intralobar pulmonary sequestration ().\nThe patient was referred to the paediatric cardiology team for further management. A diagnostic and therapeutic cardiac catheterisation was performed which confirmed the presence of the anomalous vessel, measuring 9mm in diameter, arising close to the coeliac axis (,). This vessel was embolised successfully using a 10 by 8 Amplatzer duct occluder device ().\nThe patient had an uncomplicated clinical course, with his symptoms having improved significantly. He continues to receive regular outpatient follow-up, and remains well to date. |
A 2-year-old Caucasian girl was brought for treatment at the Research and Clinical Center of Dental Trauma in Primary Teeth, where practice for the Discipline of Pediatric Dentistry (Faculty of Dentistry, University of São Paulo, Brazil) takes place. She presented total intrusion of the central lower right primary incisors. During clinical examination, tissue growth was detected on the lingual gingival mucosa of the lower right primary incisors teeth (). According to the mother, the lesion was asymptomatic and she had not noticed it before. The child did not have any medical complications.\nThe patient was referred for treatment of traumatized primary tooth, as well oral preventive measures, since oral biofilm and gingivitis were present. The patient failed to attend the following session and returned only 6 months later.\nOn clinical examination, a pedunculated fibrous lesion was observed. This lesion was nonhemorrhagic of firm consistency and covered by intact white mucosa of approximately 5 mm × 5 mm × 3 mm in size. The primary teeth adjacent to the lesion maintained their original position. The lesion partially covered the lingual surface of the central and lateral lower right primary incisors. No other alteration was present in the oral cavity (Figures and ).\nBased on the clinical appearance of the lesion, the differential diagnosis included primarily reactive and benign neoplastic lesions, such as fibroma, fibrous hyperplasia, peripheral ossifying fibroma, peripheral odontogenic fibroma, giant cell fibroma, and odontogenic hamartoma. As the procedure was simple, the lesion was excised under local anesthesia. The parents favoured less physical constraint; therefore, local anesthesia was used instead of general anesthesia. The young patient was sat on the dental chair. Her mother bent over her, holding her hands, whilst the assistant supported the child's head.\nA mouth prop was used to maintain adequate mouth opening. After topical anesthesia, local anesthesia was administered to the region of the incisors. Surgical removal was limited to the margins of the lesion in the gingival tissue. The excision was carried out using surgical scalpel blade number 15. Bleeding was very slight and was controlled using gaze compression. No suture was required ().\nExcised tissue was stored in 10% formaldehyde solution and submitted to the Oral Pathology Department of the Faculty of Dentistry, University of São Paulo, for histological analysis. The histological diagnosis revealed giant cell fibroma consisting of mucous tissue. This, in turn, was composed of parakeratinized stratified epithelium, which sent projections into the adjacent conjunctive tissue. Acanthosis, spongiosis, and exocytosis were also present. The lamina propria consisted of dense hyalinized connective tissue. Next to the juxta-epithelial hyalinization area, giant fibroblasts were found; they had two nuclei and stellate-form cells. In addition to the histological findings (Figures and ), extravasated red blood cells and often congested vascular spaces were found, which completed the findings.\nNo recurrence of the lesion was observed after a 20-month follow-up (). The patient maintained good oral hygiene throughout this period. |
A 13-year-old female of the Marshallese origin presented to the emergency department with complaints of nausea; nonbloody, nonbilious vomiting; and abdominal pain []. The patient denied any recent fevers, and no rash was reported. Review of systems was notable for the left ear drainage. Immunization status was unknown, and she was not reported to have been previously treated for any significant illness, though the history was limited by the patient's custodial circumstances. She lived in a small house in rural North Carolina with 21 other Marshallese immigrants and was cared for by relatives who had assumed care for her at the time of her immigration five years before.\nExamination during the initial hospital visit revealed dehydration and acute otitis media with rupture of the tympanic membrane. Laboratory results revealed leukocytosis, prerenal azotemia, elevated liver enzymes, and mildly elevated lipase (). Computed tomography (CT) showed scattered focal pulmonary infiltrates, splenomegaly, and a markedly distended stomach without an obvious focus of mechanical obstruction (). Cytomegalovirus and Epstein–Barr virus serology were requested with results suggesting prior exposure. She was admitted with a presumptive diagnosis of gastroparesis secondary to a nonspecific viral infection and possible mild pancreatitis. An NG tube was placed resulting in high volume output. Her symptoms gradually improved over several days with IV fluid support and bowel rest; her NG was successfully removed, and she was discharged home tolerating a regular diet.\nTwo days after discharge, the patient returned with recurrence of her prior symptoms. The patient appeared acutely ill with dehydration. On lung exam, scattered crackles were noted. She was also noted to have diffuse small nodular lesions most apparent on her hands, feet, lower legs, and face (). An advocate placed with the family reported her concern for additional symptoms of chronic weight loss and productive cough with posttussive emesis and reported the skin changes to have been present for months. Prior exposure to or testing for tuberculosis was unknown. The patient did not report symptoms of peripheral neuropathy.\nLaboratory results revealed a relatively increased white blood cell count (21.4 × 109 per liter) with significant worsening of her renal function (creatinine of 2.45 mg/dL which had previously been normalized with rehydration) and persistent mild elevation in liver enzymes and lipase. Respiratory viral screening was positive for rhino/enterovirus. Repeat CT imaging showed persistent gastric dilation and splenomegaly ().\nThe patient was placed on empiric antibiotics for community-acquired pneumonia and put on reverse isolation with concern for tuberculosis. Skin biopsies of multiple lesions were obtained and sent for pathology and culture (). Because multiple attempts to place an NG tube failed and vomiting failed to respond to conservative measures, endogastroduodenoscopy was pursued. The scope passed into the stomach and through the pylorus easily, reaching a normal-appearing proximal duodenum. However, a feeding tube could not be passed beyond the pylorus and was left just proximal to the pylorus for decompression. Stomach mucosa was described as having a “cobblestone” appearance in places, with one area of ulceration possibly due to prior nasogastric tube. Stomach biopsies revealed Helicobacter pylori and chronic active gastritis, but were negative for AFB.\nDue to persistent evidence of gastric outlet obstruction, an upper gastrointestinal study was performed which suggested gastric volvulus. The patient proceeded to gastropexy via open gastrostomy tube placement. The surgeons reported an extremely large and patulous stomach that had twisted mesenteroaxially. Gastric aspirates were negative for AFB.\nBiopsies of the skin lesions confirmed the presence of many AFB with changes consistent with lepromatous leprosy due to M. leprae (). Additionally, the serial sputum samples were positive for AFB, and culture of the skin sample for AFB showed evidence of growth within a few days, suggesting Mycobacterium tuberculosis (MTB) pulmonary infection and possibly disseminated MTB given selectivity of the culture medium.\nIn coordination with the health department and the infectious disease service, the patient was initiated on treatment for presumed disseminated MTB, noting that this would also provide coverage for M. leprae. However, polymerase chain reaction (PCR) testing from the sputum samples and skin samples failed to demonstrate MTB, while PCR testing performed at the Hansen's Disease Center of skin samples was positive for M. leprae. Retrospectively, it was felt that growth detected on the AFB culture was due to metabolism by an unusually large inoculum.\nGradually, the patient's oral intake improved. With hydration, her renal function again returned to normal. After several weeks of inpatient treatment, the patient discharged to complete therapy through the health department. Symptoms of gastric outlet obstruction have not returned. |
A 68-year-old male has a significant past medical history of severe aortic stenosis, peripheral arterial disease, chronic kidney disease, and an abdominal aortic aneurysm. He lives at home with his spouse and can independently perform routine daily activities of living. Nine years prior, he underwent an endovascular abdominal aortic aneurysm repair, which was complicated by an endoleak and required multiple graft revisions, eventual explantation of the endovascular graft, and placement of a bifurcated interposition aortobiiliac graft. The patient was admitted to the hospital for an elective one-vessel coronary artery bypass graft and placement of a bioprosthetic aortic valve. There were no intraoperative complications and the patient was extubated one day later. Four days after surgery, he developed worsening abdominal pain, leukocytosis, and inability to tolerate nutrition by mouth. Enteral nutrition was stopped, and a nasogastric tube on low intermittent suction was removed with over 1 L of bilious output daily. On postoperative day five, his abdominal pain progressed to focal peritonitis in the right lower quadrant.\nInvestigations\nComputed tomography with intravenous contrast on postoperative day five revealed thickened and moderately dilated loops of the proximal small bowel with a more prominent C-shaped loop of the small bowel and two transition points in the right lower quadrant, medial and posterior to the right iliac segment of the aortobiiliac graft (Figure ). The concern for nonviable or necrotic bowel prompted further investigation in the operating room.\nTreatment\nThe patient was taken emergently to the operating room for an exploratory laparotomy. Upon entering the abdominal cavity, extensive adhesions were encountered and lysed. While examining the small bowel, a jejunal loop was found fixed deep in the right hemi-pelvis. Upon further dissection, a 28-cm jejunal loop was entrapped behind the right iliac limb of the graft, causing a closed-loop jejunal obstruction and bowel necrosis (Figure ). Extensive adhesions to the prosthetic graft were divided sharply. The jejunum was transected proximally and distally to the obstruction using a linear stapler device, and the necrotic bowel was resected. The patient was kept intubated, and the bowel was left in discontinuity with an open abdomen and a negative pressure therapy device.\nHe returned to the operating room the next day for a second-look laparotomy, and the remaining bowel appeared viable and well perfused. The jejunum was anastomosed, and the abdomen was closed. Over the next several days, the patient had return of bowel function. His diet was advanced, and he was discharged home on postoperative day eight. At two-week follow-up, the patient was ambulating, eating a regular diet, and performing routine daily activities. |
We present a 43-year-old man with a past medical history only significant for a prior splenectomy who was admitted to the hospital due to right upper quadrant pain for two days. This was described as a dull “liver pain” in the right upper quadrant area. On physical exam, there was evidence of a midline scar, the abdomen was soft with mild tenderness to palpation of the right upper quadrant and the liver span was approximately 10 cm in the mid-clavicular line by percussion. A complete blood count and a basic metabolic panel were normal; however, alanine transaminase (ALT) and aspartate transaminase (AST) showed a mild elevation of 66 U/L and 51 U/L, respectively. Serum bilirubin levels and alkaline phosphatase levels were within normal limits. Due to the reported complaint of right upper quadrant pain and the associated abnormal liver function tests, an abdominal ultrasound (US) was ordered. This showed fatty liver disease and a left liver lobe isoechoic liver mass. A computed tomography (CT) triple phase abdomen scan was done demonstrating a 2.5 cm exophytic mass in the liver in segment 2 (Figure ). The next day of admission, the patient’s pain improved with analgesia. As no clear diagnosis was made, he was later discharged with an intention to perform an elective abdominal magnetic resonance imaging (MRI). This MRI revealed a single mass in segment 2 of the liver, with features of a hepatic adenoma (Figure ). The surgical team was consulted and evaluated the patient and an elective percutaneous liver biopsy was performed. Examination of hematoxylin and eosin (H&E) stained sections revealed histological evidence of splenic tissue with distinct red and white pulp areas, with evidence of passive congestion (Figure ). The red pulp included thin-walled venous sinusoids that were congested with red blood cells that were positive for CD8 stains (Figure ), with surrounding macrophages and few lymphocytes. The white pulp included thickened meshwork of cords showing arterioles sheathed by predominantly small T lymphocytes (CD3+) and scattered B-cell aggregates (CD20+), consistent with splenic Malpighian corpuscles (Figure ). On further questioning, the patient reported he had an exploratory laparotomy with subsequent emergent splenectomy at the age of 16 years due to a motor vehicle accident which caused a splenic rupture. As the patient was diagnosed with hepatic splenosis and was at this point asymptomatic, his benign diagnosis was explained, and no further workup was needed. |
Patient B was a 10-year-old girl with a history of scoliosis and hypothyroidism, whose family was living in Europe at the time of symptom onset. She was playing with a sibling and experienced significant pain when poked in the left clavicle. There was no fever or swelling, but the pain persisted, and her primary pediatrician referred her to orthopedics. Radiographs showed no evidence of fracture or dislocation, and she was prescribed ibuprofen. This did not provide relief, as she continued to have intermittent clavicular pain and occasional jaw pain.\nShe tolerated this discomfort into the next year when her endocrinologist decided to admit her for further workup. Lab evaluation showed elevated inflammatory markers, and she was given antibiotics, which did not lead to symptomatic improvement.\nHer family moved back to the United States and visited a hospital, where they were told that she had chronic osteomyelitis and that it would resolve with time. They sought a second opinion at another hospital, where a bone biopsy was performed, which showed no evidence of infection. Her inflammatory markers were still elevated, and she was again trialed on antibiotics. As with before, this did not yield improvement, and they were discontinued due to gastrointestinal intolerance.\nShe then visited a third hospital, where a rheumatologist clarified her diagnosis as CRMO (3 years after disease onset). She was initially treated with indomethacin but discontinued it due to headaches. Over the next few years, she controlled her flares with ibuprofen. Eventually she established care with a new rheumatologist who started her on sulfasalazine, but this was discontinued.\nOver time, her jaw pain worsened, and repeat MRI showed evidence of mandibular lesions. Etanercept (TNF-α inhibitor) was trialed and did not help, and after moving cities, her new pediatrician prescribed high dose steroids and referred her to our practice (7 years after disease onset).\nAt the time of initial visit, she continued to complain of jaw pain and swelling. Physical exam was positive for jaw edema, and tenderness over the left clavicle (). There was no loss in range of motion. WBMRI revealed an additional lesion in her right clavicle, and she was started on adalimumab, on which she has had improvement in inflammatory markers and pain level. |
A 78-year-old Caucasian male was diagnosed with a well differentiated squamous cell carcinoma (SCC) of the skin over the left ear. This was initially excised and treated with adjuvant radiation treatment using 12 MeV electrons between January and March 2008. An initial dose of 50 Gy was delivered to the external ear and the adjacent lymph node region, followed by a 10 Gy boost to the expanded GTV, and completed with an additional 6 Gy to a residual nodular area on the posterior surface of the ear. He later underwent excision of this nodular area with placement of a skin graft derived from the left supraclavicular area.\nIn Dec 2008, seven months following completion of his definitive therapy, the patient presented with a palpable swelling in the left upper neck which had been gradually increasing in size for two months (this was in the region that had received 5,000 cGy during the previous course of radiation). A fine needle aspiration biopsy revealed cells consistent with recurrent SCC. Computed tomography (CT) performed for staging showed a solitary 3.1 cm enhancing mass in the left post-auricular region, with infiltration of the left sternocleidomastoid muscle. No other disease was apparent.\nFollowing evaluations in both medical and radiation oncology, the clinical consensus was to proceed with re-irradiation with concurrent Cetuximab. He was therefore treated with 6 MV photons using an intensity modulated radiotherapy (IMRT) technique. Cetuximab was administered in standard fashion concurrently with his radiation therapy.\nApproximately two weeks into his treatment, he developed the anticipated papulo-pustular skin lesions on his neck. Surprisingly, however, there was no such skin reaction in the previously irradiated field which shared considerable overlap with the current re-irradiation field (Fig- & Fig-). During follow up appointments the Cetuximab-induced rash seen elsewhere gradually resolved but slight erythema persisted in the area previously covered by the rash.\nIn May 2009, approximately five months after his radiation treatment, he was found to have a second recurrence in the left neck, corresponding to a level Va lymph node, and he underwent resection of the involved node. In December 2009, he was diagnosed with dermal metastasis involving the left neck, recurrent lymph node involvement corresponding to the area of previous surgical resection in neck, as well as the development of a new node in the left parotid gland. At this point, he was deemed unresectable and was offered palliative chemotherapy. |
A 54-year-old Caucasian woman was referred to the gynaecology outpatient department by her GP for a 3 month history of lethargy, a 4 stone weight loss, and on examination a non-tender left pelvic mass was palpated. An ultrasound revealed a solid 4 cm mass in the left adnexa. Incidentally, the ultrasound also revealed an enlarged left kidney, with a solid mass occupying the middle and upper poles.\nA CT scan revealed a 10 × 8 cm intensely enhancing heterogeneous mass arising from the upper pole of the left kidney, consistent with renal cell diagnosis (). There was spread to the left para-aortic region at the level of the hilum, where a 1.5 cm lymph node was found. Also the left adnexal region, close to the left lateral margin of the uterus, revealed a 4 cm heterogeneous mass with fairly intense enhancement, which was initially thought to be a pedunculated fibroid ().\nThought to be an ovarian tumour, which metastasised to the kidney a joint gynaecological and urological operation was undertaken where she underwent a left nephrectomy & para-aortic clearance, with a total abdominal hysterectomy and bilateral salpingooophorectomy with peritoneal biopsies. Bone scan and chest CT showed no evidence of metastasis anywhere else in her body.\nThe histology report of the kidney was consistent with renal cell carcinoma of low grade and high grade transformation with sarcomatoid features (). The grade was a grade 4 of Fuhrman’s Classification system for nuclear grading. The report of the lymph node showed a sarcomatoid high grade metastatic renal cell carcinoma. The left ovary was entirely consistent with metastatic high grade renal cell carcinoma ().\nShe initially improved but 6 months after her operation during a routine follow ups she complained of left shoulder pain and further investigation found lytic lesions in her left proximal humerus and multiple pulmonary metastases. MDT decision was for further palliative radiotherapy and therapy with zoledronate for symptomatic relief. Unfortunately she died 3 months later. |
A 50-year-old male presented to the emergency department of a regional hospital with acute urinary retention. Two weeks earlier, he had been commenced on paracetamol and codeine for back pain and left leg sciatica which were troublesome since moving a refrigerator 3 weeks earlier. The patient’s medical history was notable for a renal transplant at 20 years of age, performed for end-stage renal failure secondary to childhood glomerulonephritis. He was also positive for factor V Leiden mutation and suffered from deep vein thrombosis 18 months earlier. Neurological examination was non-contributory. His urinary retention was initially attributed to opiate overuse and constipation and was relieved by temporary catheter drainage. Opiates were ceased and the patient was discharged from the emergency department.\nThe patient returned the following day with further urinary retention. An indwelling urinary catheter was placed and the patient was discharged and asked to return to perform a trial-of-void 3 days later. The trial-of-void was subsequently unsuccessful and given his ongoing back pain, CT of the lumbar spine was performed, demonstrating a protrusion of the L5–S1 intervertebral disc; however, it did not provide a conclusive cause for the patient’s urinary retention. He was observed overnight in the emergency department and again discharged the following day with a urinary catheter in situ.\nMRI of the lumbar spine was arranged the following week. It revealed extensive bony metastatic disease throughout the lumbar spine with associated soft tissue masses at the level of the lower sacrum extending into the sciatic notch. The bony metastases were not evident on the initial lumbar spine CT and the soft tissue masses were not within the coverage of the CT. On MRI, the vertebral lesions demonstrated low T1 and T2 signals, and a high STIR signal.\nThe patient was admitted to hospital and CT-guided biopsy of the low sacral soft tissue mass was performed. Histopathology concluded that the tissue was RMS with pleomorphic histology, the most common histological subtype encountered in adult RMS []. Staging scans performed at this time revealed widespread pulmonary metastases but no convincing thoracic, abdominal or pelvic primary mass.\nThe patient had previously had an MRI of a longstanding, right anterior leg mass performed several weeks prior to his initial presentation to hospital. The mass had been present for approximately 12 months. MRI findings were at that time thought to suggest a nerve sheath tumour. No tissue diagnosis was available on this mass but it was hypothesised to represent another RMS focus. The patient started palliative radiotherapy to the sacral mass and one of the pulmonary masses. Systemic chemotherapy was planned; however, the patient’s symptoms rapidly progressed and he died only one week after diagnosis (, ). |
The long-term treatment period of a Finnish, ethnically Caucasian, 21-year-old high school graduate and shop assistant, started when she was admitted to the acute ward of the local psychiatric hospital in August 2007 with a diagnosis of anorexia nervosa according to the criteria of the ICD-10. Her eating disorder had started in 2001, when she was 13 and began to exercise and avoid fattening food. Her weight dropped from 78 kg to 49 kg (her height is 178 cm) in a few months. At that time her parents were having severe marital problems. However, the parents did not separate or divorce. At the same time Ms. P.M. had started high school in a boarding school about 50 km away from her home, which was an exceptional choice as boarding schools are a rarity in Finland.\nDuring the first months of her eating disorder she had psychiatric outpatient treatment, but in summer 2002 her condition deteriorated as she started bulimic behaviour and vomiting, and also had symptoms of depression (depressive mood, loss of pleasure, low energy, insomnia). In September 2003 she was admitted to the Department of Adolescence Psychiatry, Tampere University Hospital and hospitalized for two months. During her hospital treatment she had no psychotropic medication. Her relationship to her parents was found to be exceptionally close and she had only one friend of her own age. There were many unsolved family problems but abuse was not among them. However, the eating disorder had brought the parents closer to each other, which pleased the patient.\nThe patient subsequently resumed psychiatric outpatient treatment until spring 2005. The outpatient treatment consisted of visits to a psychologist with CBT training once a week, psychotropic medication (fluoxetine 40-60 mg/day), and nutritional advising. She was able to complete her high school studies with good grades in May 2005. She then got a job as a shop assistant. She moved away from her parents' home with her only (female) friend as a room-mate. She also began occasionally dating a boyfriend of her own age and the relationship was a good one. In summer 2007 her room-mate moved to another town to work. Soon after that the patient's eating disorder became more severe and she had amenorrhoea. She also began to mutilate herself with a knife and to drink quite a lot of alcohol (cider). She was admitted to the acute ward of the local psychiatric hospital in August 2007. At that time her weight was 56.2 kg and Body Mass Index (BMI) 17.7. The patient's hospital treatment was then two months. After that there was an outpatient period of seven weeks, a new hospital treatment of one month, and again an outpatient treatment of six weeks. Poor compliance was the biggest problem in this outpatient treatment.\nSince the beginning of April 2008 she has been almost continuously hospitalised for more than a year (there was a short period of outpatient treatment in August 2008). She began her psychiatric inpatient treatment again in the local hospital. At the beginning of summer 2008 her weight was 40.0 kg and BMI 12.6. At that time she was admitted for two weeks for rapid nasogastric refeeding on the medical ward of the local hospital. Her weight rose to 49.6 kg in only two weeks, making her mood more and more anxious. Thereafter she was admitted to the psychiatric ward of the University Hospital, again for four days on the medical ward of the University Hospital, and then back to the psychiatric ward. Besides anorexia nervosa (F50.0), major depressive disorder (MDD; F32.2) was also diagnosed according to the criteria of the ICD-10. Her symptoms of depression were: lowering of mood, reduction of energy, decrease in activity, reduced capacity for enjoyment and interest, hopelessness, appetite diminished, feelings of worthlessness, agitation and suicidal acts. She had delusional thoughts about her body shape and weight. She totally refused to eat and regarded even water as a fattening foodstuff. She tried to vomit aggressively and exercise physically all the time. Mechanical restraints, nasogastric refeeding, and constant observation 24 hours a day were provided. She nevertheless managed to abuse herself by hysterical cutting and vomiting. At that time her medication included fluoxetine (60 mg/day) and olanzapine (30 mg/day) and also lorazepam (2 mg/day) before main meals. Later on fluoxetine was supplied in a combination of venlafaxine (150 mg/day) and mirtazapine (60 mg/day). Because the symptoms of MDD were not relieved with AD treatment, ECT was used. ECT was administered three times a week. Anaesthesia was induced with methohexital and muscle relaxation with succinylcholine. Physiological monitoring included pulse oximetry, blood pressure, ECG, four channel EEG and EMG. She had ten bifrontotemporal ECT sessions in July 2008. The psychotropic medication was continued during the ECT treatment. There were no anaesthetic complications. The respective Beck Depression Inventory (BDI) [] scores were 52 and 35 before and after the ECT treatment, meaning that her depression was not totally relieved. Clinically, the patient was satisfied with the outcome of the ECT, her behaviour continued to be self-destructive but her mood was better, she was more active, no longer hopeless, no longer delusional, and her appetite was no longer impaired. BMI had risen only slightly from 15.0 to 15.3. She continued exercising but the vomiting had diminished.\nIn August 2008 she first spent three weeks on the psychiatric ward of the local hospital and then returned to the psychiatric ward of the University Hospital with BMI only 13.8. She had started to exercise aggressively again. At the beginning of September 2008 her BMI was only 12.2. Two short treatment periods of nasogastric refeeding on the medical ward were initiated. She then requested a new series of ECT. Before the ECT her BDI was 35, her Montgomery-Åsberg Depression Rating Scale (MADRS) [], score 28 and BMI 14.2. After 12 bifrontotemporal ECT treatments BMI had risen slightly to 14.6, her mood was slightly better according to MADRS (scoring 24) and she began to smile, but she was acting out (lying and stealing) and the self-rated BDI was higher than it was before the ECT: 43. Vomiting and exercising had diminished quite a lot. In October 2008 she was transferred to a psychiatric ward specialized in treating refractory patients. At that time a decision was taken on mECT: bifrontotemporal ECT once a week or once in two weeks. The medication was again supplied: quetiapine (600-800 mg/day) was used instead of olanzapine and fluoxetine (60-70 mg/day) instead of other ADs. She had creative art therapy and physiotherapy in order to improve her body image of which physiotherapy was of some help by teaching the patient to relax. In December 2008 she was allowed to spend some days at (her parents') home. By the end of 2008 BMI was16.4 and she had no symptoms of depression. During the first weeks of 2009 mECT was only given once in 4 weeks. Very soon she became anxious again and started exercising, stealing sweets, binge eating, vomiting with the help of various hoses, and evacuating her rectum. Her mood became low and she was tired and hopeless. In the middle of February 2009 the frequency of mECT was then temporarily increased to twice a week for two months. Her mood improved and she was active and optimistic. Her weight remained at 50-51 kg (BMI about 16) until the beginning of April. The most aggressive exercising and vomiting faded away. Then quetiapine was changed to aripiprazole (20-30 mg/day), and at the same time the frequency of mECT was changed to once in 2 weeks. A new type of therapy was also initiated: the patient was given more responsibility for her own behaviour and the use of strict weight limits in order to obtain new benefits was abandoned. Her mood remained in balance and the acting out behaviour (stealing, lying, hysterical cutting) declined, but her weight dropped rapidly from 51 kg to 46 kg (BMI 14.5) in only eight weeks.\nMs. P.M. underwent a series of 10 ECT in the summer, a series of 12 ECT in the autumn, and a total of 23 mECTs during the winter and spring 2008-9. In order to control for possible side-effects of the mECT, a magnetic resonance image (MRI) of her head was taken and a psychologist's assessment was conducted in May 2009. The MRI was normal. Maintenance ECT was discontinued in order to get a psychologist's assessment of memory functions during a four-week time free of ECT. Soon depressive symptoms again became prominent: low mood, reduction in energy, difficulties in concentrating, but no hopelessness or suicidality. BMI remained low at 14.5. However, according to the psychologist's assessment in May 2009, the patient's cognitive capacity had been impaired during the last 21 months. A shorter psychological assessment had been conducted in August 2007 and at that time the patient's cognitive skills were clearly better (IQ was 116 in August 2007 and 102 in May 2009). Moreover, her memory functions three weeks after the latest ECT yielded a very uneven memory profile, indicating difficulties in verbal memory (word lists) possibly due to fluctuating attention. The psychologist's assessment even suggested that the patient's semantic memory might have deteriorated. As we did not want to expose her to possible difficulties with memory the idea of more mECT was abandoned.\nShe has now been 10 weeks without mECT. Her regular medication has been aripiprazole 30 mg/day, fluoxetine 60 mg/day and lorazepam 1 mg twice a day before main meals. At first her mood became depressive, but after 5-6 weeks she was no longer depressive but only feeling down once in a while. Her BMI has slightly risen from 14.8 to 15.3. |
A 41-year-old Asian female patient reported to the Department of Oral and Maxillofacial Surgery with a 4-month history of a gradually increasing swelling on the right side of the face. The swelling was largely painless with no other associated functional symptoms. On local examination, a diffuse swelling was observed measuring about 6 cm × 5 cm on the right side infraorbital region with regional lymphadenitis of the submandibular region of that side. The skin over the swelling appeared normal with no signs of infection or inflammation [Figure 1 ( and )]. The lump was diffuse, firm, and mildly tender. Fixation to the underlying structures was not present. Intraoral findings were unremarkable with no foci of infection. No other distant lymphadenopathy was elicited clinically. All her hematological investigation parameters were within normal limits. Chest X-ray confirmed the absence of any pathology including hilar lymphadenopathy. The clinical differential diagnosis comprised a wide spectrum of conditions such as lymphoma, fibrosarcoma, and neuroma.\nMRI scan of the head and neck showed a homogeneously enhancing infiltrative lesion seen involving the premaxillary space, buccal space, retromolar trigone, and lateral pterygoid in the masticator space on the right side. There was no significant bony destruction. Multiple enhancing solid lymph nodes were seen in the right submandibular, upper deep jugular group and the left submandibular group, largest measuring 18 mm × 12 mm in the right submandibular region. MRI report gave a differential diagnosis of neurofibroma [].\nFNAC was performed initially, but the result was inconclusive. Therefore, we proceeded with examination under anesthesia and biopsy. The incisional biopsy report suggested a nonspecific type of lymphoid hyperplasia. Hence, definitive surgery was planned with complete excision of the lesion. Intraoperatively, it was observed that the mass was well defined, capsulated, and firm. The histopathology showed dense fibrous connective tissue with some areas exhibiting sheets of numerous small well-differentiated lymphocytes interspersed along with reactive lymphoblasts that were infiltrating into the muscle tissue, blood vessels, and nerves, and in few areas, it formed germinal centers. Mixed type of inflammatory cells including plasma cells and macrophages were seen. The final histopathology report confirmed the diagnosis as reactive lymphoid hyperplasia with no evidence of malignancy.\nAdditional immunohistochemistry studies were performed to arrive at a more definitive diagnosis. It showed positivity for CD4, CD5, CD3, and CD20 and positivity for both kappa and lambda. This strongly suggested a pathology of inflammatory origin, ruling out malignancy. The patient was kept under close observation.\nOne year later, the patient reported with a recurrent swelling in relation to the right submandibular region. FNAC was performed again, this time from submandibular region. The cellular smear studies showed sheets of centrocytes, centroblasts, lymphocytes with epithelioid granulomas composed of round-to-oval cells with abundant cytoplasm, and sole-shaped nucleus admixed with necrosis and fibrous tissue suggesting granulomatous lymphadenitis.\nIn view of the earlier histopathological studies being inconclusive, persistent swelling, and FNAC showing granulomatous changes, we opted for a multidisciplinary approach to rule out other granulomatous diseases such as atypical tuberculosis and sarcoidosis. Fresh CT contrast studies were obtained. CT report suggested a diffusely enhancing soft tissue density lesion in the right buccal region involving upper and lower gingivobuccal space and retromandibular space. The region was closely abutting the right side of the mandible and obliterating the fat plane in the masticator space [Figure 3 ( and )]. Multiple enlarged lymph nodes were noted in the submandibular region and the upper deep cervical regions, the largest size being 2.1 cm in the submandibular region.\nLymph node biopsy was performed under general anesthesia, through a right submandibular approach. Intraoperatively, two huge solid lymph nodes, well encapsulated and firm in consistency, were removed []. The samples were sent for both histopathological studies and for microbiological tests. The culture test was negative for mycobacterium. The histopathology report this time suggested lymph nodes with multiple predominant follicles with prominent germinal centers with extensive fibrosis and inflammatory cells including multinucleated giant cells. Amidst these proliferating capillaries, prominent endothelial cells were evident. Based on the histopathology report, the patient was evaluated for serum immunoglobulin E (IgE) levels, peripheral eosinophils, and absolute eosinophilic count to rule out Kimura's disease. The IgE levels in this patient were considerably increased with 417 IU (reference value: <180 IU), absolute eosinophil count was marginally elevated with 445/cumm (reference value: <350/cumm), and differential count of eosinophils was 5%. The diagnosis of Kimura's disease was confirmed thereafter.\nBased on the available scientific evidence, the immunologist suggested that the patient is started on systemic steroid therapy with a loading dose of 60 mg of prednisolone in divided doses for 3 months. There was good response to steroid therapy, and the lump started to regress within 3 months which was confirmed by CT scan. Steroid dose was tapered to 2.5 mg OD over a period of 6 months. Complete remission of the lesion is observed for the past 18 months, and the patient is on a maintenance dose of 2.5 mg of oral prednisolone. |
Herein we report the case of a 50-year-old man, without past medical history, presented to our department of gastroenterology with abdominal pain and constipation for 3 months. The abdominal pain was not colicky but progressive and radiated to the epigastric region and relieved spontaneously without analgesics. No similar cases were mentioned in the family, neither any genetic syndrome nor malignancies. No drug history, nor professional exposure were noticed. There was no reported history of vomiting, diarrhea or passage of dark-colored stool and neither weight loss. At physical examination, there were no palpable masses and no collateral findings on the abdominal wall. Biological tests and blood tumor markers were normal. Endoscopy revealed a sessile polyp in the right colonic angle. Biopsy concluded to a tubular adenoma with low-grade dysplasia. The CT scan showed that the mass was measuring 4 cm in greatest diameter, polypoid with a large base (). No other polyp were identified. The patient was transferred to the general surgery department and underwent right hemi colectomy under general anesthesia, by a well-experienced surgeon specialized in operative management of colorectal carcinomas. The surgical procedure turned good without complications, such as hemorrhage, occlusion or peritonitis. On gross examination, the mass was polypoid with a white lobulated surface and large implantation base (). Microscopically, an invasive adenocarcinoma was identified occupying the colonic mucosal with an invasion of the submucosa (). The tumor showed a tubule-villous pattern on the surface and was made mostly of jagged crowded glands in the depth. Some region exhibiting Paneth cell differentiation characterized by an abundant cytoplasm (low nuclear: cytoplasm ratio) containing bright eosinophilic coarse granules and centrally located nuclei (). The transition between the two patterns was gradual with few glands featuring both Paneth cells and mucin secreting cells.There were no specific distribution of Paneth cells, which were observed both on the surface, and in the depth of the tumor. Masson’s trichrome stain highlighted the dense granules within the Paneth cells. At immunochemistry, the tumor show positive nuclear staining with b-catenin antibody () and a stable microsatellite profile (MSS). Surgical margins were free and no metastatic lymph nodes were found, thus the tumor was staged T1N0. The postoperative course was uneventful. The patient remained free of symptoms at the 6-month follow-up and had no evidence of recurrence. No adjuvant therapy was indicated. However, a close follow-up is planned based on endoscopy and radiologic examinations, to avoid any recurrence and to check new polyps raising. The patient was well informed about his pathology, outcomes and potential risks of recurrence for instance. |
A 37-year-old Caucasian woman with IPAH diagnosed in 2003, in WHO FC III, had dilatation of the main PA to 38 mm in CT. Sildenafil was started in 2003 and subcutaneous treprostinil was added in 2005 due to worsening of non-invasive prognostic markers. In October 2011, she started to complain of chest pain. CTA revealed compression of the LMCA, PA diameter increased to 49 mm without signs of dissection. A drug-eluting stent was implanted to the LMCA with resolution of chest pain. The patient remained in stable WHO FC III, but due to expanding PA aneurysm she was put on the active list for LTx. Over the next two years she remained stable, but CT revealed further PA dilatation: PA was 55 mm in February 2012, 55 mm in October 2012, 60 mm in June 2013, and 61.5 mm in September 2013. In January 2014, the patient moved to the UK and care was taken over by the National Pulmonary Hypertension Service Cambridge. In May 2014, CTA showed further PA dilatation to 66 mm, extending to both main branches. Over time, her treprostinil dose was increased to 54 ng/kg/min. In October 2016, her 6-min walk test (6MWT) improved to 354 m without desaturation while her exercise tolerance was limited by chest pain rather than dyspnea. Elective re-assessment of coronary arteries was considered. One month later she called an ambulance due to chest pain persisting for five days and she collapsed upon its arrival. She remained in cardiac arrest in spite of full life support with no obvious reversible cause. Autopsy revealed a massive 11-cm long fusiform aneurysm with a diameter of 10.5 cm involving the main pulmonary trunk and left main pulmonary artery. An intimal tear 7.5 cm long was noted at the junction of the main pulmonary trunk and left main pulmonary artery. There was a short dissection of the underlying wall as well as rupture into the pericardial cavity, causing massive hemopericardium with cardiac tamponade. |
A 70-year-old male patient was admitted to emergency service with complaint of abdominal pain. He had a history of diagnostic colonoscopy performed 2 days before. Colonoscopy was a diagnostic procedure for evaluation of his complaints of right lower quadrant pain and constipation. Gastroenterologist that had performed the procedure indicated that the colonoscopic procedure was not complex and was performed safely. Room air was used for inflating the colon. Abdominal complaints of the patient started after colonoscopy and increased significantly. Abdominal pain, distention, and rigidity were detected on physical examination.\nLaboratory findings were as follows: Leukocytes: 12000/mm3, Hb: 12 gr/dL, Hct: 35.4%, and CRP > 96 mg/L, fever: 37.8°C. Free air was detected on the plain films of the abdomen (). On the abdominal computerized tomography, free air was detected (). There was a 10 × 6 cm solid mass in the right iliac fossa. The border between the mass and iliac vein was not clear. There was another mass in the left iliac fossa 6.5 × 3 cm in dimensions. The prostate was hyperthrophic.\nThe patient went under emergent operation. During the exploration, no perforation was detected in the gastrointestinal system. The mass in right iliac fossa was so fixed to the adjacent structures that, we could not remove this mass. The mass next to left iliac vein was unrelated to any organ in pelvis and it was removed completely. Abdomen was closed in layers.\nThe postoperative course was uneventful. After the discharge of gas and stool, oral feeding was started in the postoperative 3rd day. No free air was seen in the plain film of the abdomen taken on postoperative 7th day and the patient was discharged from the hospital in health. The pathologic diagnosis of the mass was lymph node metastasis of adenocarcinoma. The result of the prostate biopsy taken in conjunction with transrectal ultrasonography was also adenocarcinoma. Upon these results, the patient was sent to medical oncology department for advanced treatment. Control tomography after oncologic treatment has not been performed yet. |
A 50-year-old woman was diagnosed with chronic kidney disease. An attempt was made to place a central venous catheter via the internal jugular vein with ultrasound guidance. A left-sided temporary double-channel hemodialysis catheter (Quintiles, Durham, NC, USA) was inserted by using the subclavian vein, but it did not work well. This may have been due to inability of the patient to cooperate because she shook her body repeatedly during the puncture process. After the procedure, the patient developed dyspnea and felt pain on the catheter insertion site. Oxygen inhalation was immediately supplied to the patient, and the hemodialysis catheter was secured in place and covered by a sterile dressing. Computed tomographic (CT) scans evaluated the upper mediastinal vascular structure. CT showed that the hemodialysis catheter had perforated the subclavian vein, and it terminated in the anterior mediastinum with pneumatosis and hemorrhage (). However, the middle of the catheter and the left brachiocephalic vein were not clearly observed, and we could not determine if there was damage to the aorta.\nTo prevent hemorrhagic shock, the patient had a blood transfusion, and her hemoglobin level increased from a baseline level of 56 to 75 g/L. After consultation with an interventional team, the patient was taken to the interventional radiology room for a contrast examination. Angiography through the venous channel showed that the catheter tip was located in the mediastinum with patency of the left subclavian vein, and contrast agent had regurgitated to the left brachiocephalic vein. The arterial channel was unobstructed. Finally, angiography confirmed that the aorta was not damaged by the catheter.\nThis case was discussed among the multidisciplinary team and we designed the following therapeutic strategy. (1) Continued attempts to securely tie and tape the tube in place should be made. (2) Blood pressure should be controlled to reduce the probability of hemorrhage. (3) Regional heparinization should be performed in an indwelling catheter to reduce thrombosis. (4) Surgical options were not considered because of the unsuitable injury site and the patient suffered from hypoproteinemia with uremia. (5) Surgical planning was as follows: infuse with thrombin regionally through a percutaneous catheter to patch the perforation and simultaneously pull out the catheter; a balloon would be used for hemostasis if necessary. Thoracic surgery, anesthesiology, and blood transfusion were on standby for thoracotomy hemostasis if the patient developed acute hemorrhage.\nInformed consent from the patient was obtained after explaining the steps, benefits, risks, and alternative of the procedure. Under fluoroscopic guidance, the guide wire was advanced into the channel of the hemodialysis catheter. When contrast agent was injected, slow flow accumulated in a false lumen, which was 2.2 × 7.64 cm, with delayed passage of the contrast to the main stream (). Approximately 500 units of lyophilizing thrombin powder (Hacon Pharma, Hangzhou, China) and prothrombin complex (Hualan Biological Engineering, Inc., Henan, China), which contained thrombin 200 IU per 1 mL, were dissolved in 3 mL saline and injected into the false lumen through the catheter. This was performed with real-time fluoroscopy guidance until the contrast agent vanished in the false lumen, but was present in an anonymous vein. The catheter was pulled out after this procedure. A venogram of the left internal jugular vein was performed, which showed an approximately 8 × 7-mm thrombus in the plane of the brachiocephalic vein with a focal stenotic segment (). A 16-mm balloon (MAXI LD 416-1640L LOT; Cordis, Miami, Florida, USA) was inserted along a guide wire into the brachiocephalic vein, and approximately four bars of pressure was pumped into the balloon catheter to compress the perforation. The signs of thrombosis and stenosis disappeared when angiography was repeated to assess the effect of the intervention and the degree of recanalization. After disinfection, the wound was compressed with a bandage and the patient was transferred to the intensive care unit for monitoring.\nPiperacillin-sulbactam was used for anti-infection and aggressive blood pressure-lowering therapy was applied after surgery. The patient’s hemoglobin concentration dropped to 66 g/L with no symptoms or signs of persistent bleeding, which may have been due to dilution by a large amount of rehydration. Her hemoglobin was stabilized at 112 g/L after blood transfusion. Femoral vein puncture and catheterization were performed 1 day after surgery with no accidents. After hemodialysis and symptomatic treatment, the patient’s edema, fatigue, and other symptoms had greatly improved.\nThe study protocol did not require approval by an ethics review committee. The patient signed informed consent. |
A 20-year-old male presented to us with pain in the right hip for 1 year with gradually developing limp over a period of 2 months. Initially, the pain was mild in intensity which gradually progressed to moderate intensity within a period of 1 year. Now, pain is continuous in nature, interfering with activities of daily living and relieved by taking pain medication. Since past 2 months, he noticed limp, which was progressive and associated with pain. He has been taking pain medication intermittently for past 1 year. He even took antitubercular treatment for 2 months which he stopped on its own. Previous magnetic resonance imaging scan reported synovial effusion with altered signal intensity at anteroinferior aspect of the right femoral head. He was diagnosed with monoarticular juvenile rheumatoid arthritis and referred to our center. Physical examination revealed tenderness in anterior aspect of hip joint. Movements were terminally restricted due to pain.\nBlood count and biochemical profile are within normal range. Careful evaluation of radiographs showed sclerosis in anteromedial aspect of femoral neck with nidus surrounded by radiolucent rim suggestive of osteoid osteoma (). Computed tomography (CT) scan clearly shows a small eccentric lytic lesion in inferomedial aspect of the right femoral head with subtle cortical breach and reactive bone sclerosis ().\nAn en blocopen surgical resection of the lesion was planned under guidance of image intensifier. Procedurewas done in supine position. Standard anterior Smith Peterson approach was used for the exposure of formal neck. Inferomedial part of femoral neck was clearly seen on abducting and external rotating the hip. Lesion was localized and marked using image intensifier. Drill holes were made along the margin of the lesion.\nA large chunk of abnormal bone was osteotomized and removed. Complete excision of the lesion was confirmed. Size of the defect created was measured. Slightly oversized tricortical bone graft was taken from the ipsilateral iliac crestand impacted into the void with cortical surfaces facing outside. The graft was quite stable and does not require any additional fixation. Since the bone was removed from inferomedial aspect of femoralneck; to prevent fracture prophylactic fixation was done using dynamic hip screw and plate from a separate lateral incision. Excised bone was sent for histological examination. Patient has significant pain relief immediately postsurgery. The limb was non-weight-bearing for 2 weeks, followed by gradual weight-bearing with crutches as tolerated over a period of next 4 weeks. Patient returned to his previous activities of daily living after 2 months. The pathology report shows fibrous dysplasia, which the authors were not convinced with. Hence, it was decided to send the tissue and slides for repeat histological examination at another laboratory, which revealed multi nidi osteoid osteoma. Diagnosis of atypical osteoid osteoma was established after discussing with the pathologist. Follow-up at the end of 1 year did not show the presence of any residual symptoms or recurrences. Radiograph shows good consolidation of the graft with implant well in place (). Patient regained full motion in the hip and was able to do squatting and cross-legged sitting comfortably (). |
A 35-year-old man was referred to our clinic for evaluation of a lesion that developed on his hard palate. The patient became aware of the lesion one month prior to his first visit. During consultation, he complained that the lesion became sensitive when it came in contact with hot and salty foods, but he experienced no other specific symptoms. The patient had a history of an unknown sexually transmitted disease, which he contracted one year prior to his first visit and completely recovered from by the time of consultation. In addition, the patient had a 20-year history of heavy smoking. No other specific general diseases or exceptional medical history were noted. During the clinical examination, which was conducted during his first consultation, a soft sessile mass with a verrucous, papillary surface resembling a strawberry was found on the palatal gingiva of the left maxillary second premolar and first molar. The lesion was 2.5×1.0 cm in size, well demarcated, and pinkish in color. It was not painful when palpated. He also had a normal response in the percussion, mobility, and vitality tests of his teeth, however; the palatal aspect of his left maxillary first molar showed mild gingival recession. The radiological examination, including periapical and panoramic radiographs, did not yield specific results. Further, there was no enlargement or induration of his bilateral neck lymph nodes on palpation. Though we could not obtain more information about his medical history in regard to his sexually transmitted disease, we suspected a relationship. We diagnosed the lesion with differentials that included syphilis and malignancies such as squamous cell carcinoma or verrucous carcinoma. An incisional biopsy for a definitive diagnosis was performed one week after the initial examination. During histopathologic examination, histology slides obtained from the biopsy showed a papillary squamous epithelial cell layer covered with parakeratotic surface () and xanthoma cells in the subepithelial connective tissue layer (), distinctive features of VX. Conservative surgical resection was performed after the results of the biopsy were confirmed. Postoperative follow-up examination showed a well-healed surgical site, and the patient had no complaints.\nFour years after this resection, the patient returned to our clinic for the recurrent appearance of the lesion at the same site. The lesion appeared to have grown to a similar size, and its shape was also similar to the one resected previously. Further, the recurring mass affected the same part of the buccal gingiva around his left maxillary second premolar and first molar. Once a clinical diagnosis of a recurrent lesion of the pre-existing VX was made, a wide surgical resection, which included seemingly normal tissues surrounding the lesion, was performed. The results of the histopathologic examination of the recurrent lesion were the same as that of the initial lesion. The patient has been followed-up at regular intervals of fewer than six months for the past ten years, and there has been no evidence of VX recurrence. |
A 45-year-old man was referred to hospital complaining of fatigue and extensive body pain. His medical history included stress-induced headaches that had been present for almost the entire previous year, for which he began using diclofenac at 50 mg/day as the frequency of headaches had increased during the prior month. He was referred to a physician for pyrosis, 1 week prior to presenting at the hospital, and was prescribed pantoprazole at 40 mg/day. He continued using diclofenac for the ongoing headaches. He started to experience pain in his leg muscles on the fourth day of the diclofenac and pantoprazole combination regimen and used two 50-mg doses of diclofenac to control the pain. The muscle pain became more widespread on the fifth day, and the patient also developed fatigue.\nAn examination revealed a blood pressure of 120/80 mmHg and a pulse of 76 bpm, full and rhythmic. Cardiac sounds were normal and the patient had no specific chest pain. Muscular strength was good; however, the patient complained of muscle tenderness upon palpation. Neurological and general system examinations were normal; no abnormal findings were seen in an electrocardiogram; and an abdomen ultrasound revealed no pathology, aside from an abdominal gas distention. A laboratory analysis revealed high levels of muscle destruction products, the foremost of which was creatinine kinase (Table ). Glucose, urea, creatinine, cholesterol levels, amylase, direct and indirect bilirubin, electrolytes, anti-streptolysin O, C-reactive protein, rheumatoid factor, and thyroid hormones were all within their normal ranges.\nA cardiac pathology was excluded because the electrocardiographic assessments and cardiac sounds were normal, and because the patient did not describe any pain that would indicate an infarct, and test results and findings were stable on the following days. Liver and biliary tract pathologies were excluded by ultrasound. AR was considered as a pre-diagnosis, as there was a chronologic alignment between the patient’s clinical representation and the medications he used, and this was supported by the laboratory parameters. Both medications were discontinued and the patient was followed up for 1 week, during which no medical interventions were carried out, aside from a recommendation of general hydration. The AR diagnosis was confirmed because his complaints disappeared, with his laboratory values returning to the normal range, a stable electrocardiogram, and other systemic examinations being found within normal ranges. |
44-year-old man had a history of trauma and splenectomy dating back to 2008 due to a high fall accident injury. The patient came to our hospital for routine follow-up health check for trauma. During the interview with the doctor, the patient had complaints of fatigue, flu-like symptoms and occasionally had the sense of thoracalgia for about a week. During the physical examination, a well healed laparotomy scar measuring about 10 cm in the upper left abdomen was identified. No spleen was palpable when palpation of left costal region was conducted by the doctor. No other significant findings were identified. All laboratory findings were within normal range. Hematology and biochemistry tests were within normal range. All other laboratory findings were within normal range too. Pulmonary function tests and cardiovascular examination showed the normal state. Plain chest computed tomography (CT) with an attenuation value 52HU was performed. There were multiple nodules under the left upper lobe tongue segment, lower lobe basal segment subpleural and right diaphragmatic, partial fusion showed wavy changes with uniform density. There were clear boundary and enhanced scanning lesions, measuring up to 18 mm, suggesting suspicious for primary lung cancer. There were old fractures of the left side 9th and 10th ribs, and no right sided pulmonary lesions or mediastinal lymphadenopathy were seen on CT. Contrast-enhanced CT scans showed obvious enhancement in soft tissue masses (Fig. ).\nBased on CT imaging, the surgery of left thoracic exploration and lumpectomy of the chest wall was planned to relief symptom, remove masses. After discussed with patient. Via video-assisted thoracic surgery (VATS) was performed to remove the masses. During the operation, we found mass on the surface of the upper lobe of the left lung, and a large number of nodules that scattered on the surface of left lung surface, diaphragm and mediastinal pleura. The largest nodule was tough in texture, regular in shape, and was measured about 1.82.0 cm on pleura. (Fig. ) We completely removed this biggest mass and other masses on left pleura through thoracotomy. After careful hemostasis, a chest tube was placed in the seventh intercostal space at the mid-axillary line and attached to an underwater seal. The left lung was re-inflated under direct vision. On the third day after surgery, the chest drain was removed after minimal drainage.\nThe patient had an excellent recovery after surgery and was discharged properly. Final pathological findings: (Fig. ) on H&E slide, the mass was consisted of red pulp and white pulp of spleen with splenic corpuscle and spleen trabecular structure, which showed viable splenic tissue. Immunohistochemically, cells of masses were CK(−)、CD3(T cell+)、CD20(B cell+)、TTF-1(−)、Syn(−)、Ki-67(+,5%)、CD34(sinusoid+)、CD8(sinusoid+)、CD1a(−)、S-100(−)、CD68(sinusoid+) (Fig. ). The final pathological diagnosis was splenosis without malignancy. |
We present a case of a 7.5-year-old boy admitted to our Pediatric and Allergology Clinic due to allergy to BL antibiotics for full diagnostics. The patient was born G1P1 with a birth weight of 3450 g and Apgar score of 9/10 points. His neonatal period was uncomplicated. The patient had a history of frequent respiratory tract infections (average once a month) since the beginning of preschool, usually requiring antibiotics. He was vaccinated according to the schedule. A family history of atopic diseases was negative. The boy was diagnosed with asthma and allergic rhinitis due to house dust allergy, and since 2016, he went under subcutaneous immunotherapy. Previously, he had been hospitalized several times due to pneumonia and asthma exacerbation (at the age of 5 and 6 years) and one time for orchitis (at the age of 2 years). According to the interview collected from his mother, due to infection in May 2017, the child had been given oral cefuroxime. About 15 minutes after the first dose of this antibiotic, a disseminated urticaria appeared, followed by edema of the face tissues. He was seen by a medical doctor and had been given intramuscular corticosteroids and antihistamines, achieving improvement of symptoms; the antibiotic had been changed to clarithromycin. After a course of 5 days of treatment, a similar situation developed—disseminated urticaria and difficulties in breathing. The boy had been hospitalized, and he had been treated with intravenous corticosteroids and antihistamines. Up to the date of first hospitalization for anaphylaxis, the patient had been treated with different BL antibiotics without any adverse reactions. The child was referred to our Allergic Department for drug allergy diagnostics. We performed this diagnostic in 3 months after the adverse event, according to the European Academy of Allergology and Clinical Immunology (EAACI) guidelines. Medical examination and laboratory findings confirmed no current infection. Skin prick tests were performed with amoxicillin, amoxicillin/clavulanate, and cefuroxime in concentrations as recommended in previous studies; skin prick test was strongly positive only for cefuroxime (wheal 6 mm + pseudopodium). Because of the boy’s medical history of severe anaphylactic reaction and a positive skin prick test for cefuroxime, we decided to abandon the oral drug provocation test (DPT) with cefuroxime, defining it as a culprit drug. We performed a provocation test with the alternative BL drug—amoxicillin. According to the EAACI guidelines, it was a 2-day blinded provocation test (placebo and the drug given in titrated doses up to the dispensable dose) performed under the control of spirometry parameters and vital signs (heart rate, respiratory rate). During the whole provocation test with amoxicillin, we did not notice any adverse reaction; thus, the parents were informed that oral amoxicillin may be used safely in case of infections needing therapy with antibiotics.\nThe parents were advised to come back to our department in 2 months for another diagnosis of clarithromycin sensitivity. In October 2017 (2 months after the first provocation), skin prick test performed with clarithromycin was negative. Intradermal test was not performed, because it is painful, time consuming, and its role has been widely debated in children. DPT with clarithromycin was performed as described previously (blinded and placebo-controlled oral provocation with titrated doses up to the dispensable dose) without any adverse events. The patient was discharged and referred to the Allergy Outpatient Clinic for further observation and immunotherapy continuation.\nBetween October 2017 and April 2018, the boy had been treated twice with amoxicillin and azithromycin (for pharyngitis and pneumonia); no adverse events were noticed. At the end of April 2018, the child was admitted to our department because of asthma exacerbation due to pneumonia. Treatment with amoxicillin/clavulanic acid was administered. Fifteen minutes after the first intravenous dose, the boy declared feet itching, followed by disseminated urticaria, face edema, bronchospasm, and drop in blood pressure. An immediate treatment with epinephrine, antihistamines, β2 agonists, and oxygen were given with rapid improvement in the boy’s general condition. The treatment was continued with intravenous aminoglycoside (biodacine) administered in a slow drip infusion for 5 more days. During the hospitalization, the boy developed a rota viral infection manifested by diarrhea, fever, vomiting, and general malaise. Because of the fever, our patient was treated with paracetamol followed by ibuprofen. About 5 minutes after an oral dose of ibuprofen, the patient developed an anaphylaxis; 2 doses of epinephrine were needed to achieve stabilization of vital signs. The patient was given drip infusions, dexamethasone, and inhaled budesonide. After 2 days, the patient presented disseminated urticaria and bronchoconstriction during the inhalation with budesonide. Several measurements of tryptase level were normal. A positive test for stool antigen Helicobacter pylori was found. |
A 43-year-old man sustained an injury to his left foot in a road side accident. He sustained this injury following his left foot entrapped in a deep pit followed by sudden twisting strain due to sudden inversion and plantar flexion. The patient presented with severe pain in left foot and was unable to bear weight in his foot. The initial clinical examination of his foot revealed swelling and tenderness on dorsomedial aspect of the right foot. There was no open injury on foot. There was no other associated injury aspect of the dorsum of foot. Plain radiographs including anteroposterior, oblique, and lateral were obtained with showed dorsal dislocation of the intermediate cuneiform bone and a displaced fracture at the medial cuneiform (). The patient was discussed regarding his injury and decision was made for surgical fixation.\nThe patient was operated within 6 h of injury. An attempt of closed reduction was attempted after putting patient under general anesthesia but it was not possible to maintain appropriate reduction. Hence, decision was made to put a JESS distractor, to create space between base of metatarsal and navicular with two proximal pins in talus and two dorsal pins in metatarsal head. On applying distraction with JESS assembly fracture of medial cuneiform fell back in place. Further on downward pressure reduction of intermediate cuneiform was achieved but it was very unstable as it came out on slight plantar stress. Therefore, it is further secured provisionally with 2.7 mm K-wire. Single 3.5 mm cortical lag screws were used for intermediate cuneiform with purchase of distal threads in medial cuneiform which was already being stabilized with K-wire. An additional intercuneiform K-wire was also applied ( and ).\nPost-operative radiographs showed good alignment with no distraction of fracture fragment of medial cuneiform with well aligned 2nd medial and middle column of midfoot. A below knee removable splint was given for 3 weeks. The patient was allowed non-weight bearing mobilization from 2nd post-operative day. K-wire and removable splint were taken out at 3rd week. Distractor and K-wire were removed after 6 weeks. The active range of ankle motion started at the same time. The patient was mobilized with weight bearing as tolerated and he started full weight bearing at 8 weeks following surgery. At 3 months of follow-up, plain radiographs revealed fusion of the medial cuneiform and no recurrence of the intermediate cuneiform dislocation. At the final follow-up 18 months after injury, the patient had painless foot with normal range of motion (). |
A 56-year-old female patient was transferred to our department of critical care medicine, Huashan hospital in Shanghai in June 2016 after she received treatment in a local hospital for productive cough, tachypnea and respiratory distress. She complained of recurrent fever and asymmetric edema of the lower extremities for over 1 month, as well as painful swelling both in the thyroid and labium majus for 2 weeks. In the previous hospital, due to the finding of multiple bilateral cysts which were palpable nodules in her thyroid gland by ultrasound examination, a left lobe thyroid puncture and drainage had been conducted and an aspergillus fumigatus infection was detected. She had a history of systemic lupus erythematosus (SLE) and lupus nephritis for 8 years, and received prednisone treatment for these diseases. But from November 2015, prednisone was switched to methylprednisolone, and hydroxychloroquine has been added because of lupus nephritis aggravation, and tacrolimus has also been added to the medications in the following month. She was also diagnosed with renal hypertension and diabetes induced by steroids, and received antihypertension and antihyperglycemic therapy. She had no history of pulmonary diseases such as chronic obstructive pulmonary disease (COPD), asthma, or any repeated infections, and had no addiction to drugs, smoking or alcoholism. Previous examinations showed no evidence of neutropenia. The ratio of CD4/CD8 was 0.33. Only one aspergillus test was positive in repeated sputum cultures. The galactomannan aspergillus antigen and culture tests in BALF were negative, so were blood and urine cultures including fungi. Our chest computed tomography (CT) imaging revealed bilateral patchy lung opacities in the middle and lower lobes, along with multiple shadows of fibrotic streaks, high-density nodules and mediastinal calcification of lymph nodes (Fig. ). The diagnosis of pulmonary infection was established, and pathogen was highly suspected of aspergillus according to the previous finding of thyroid puncture and drainage. An ultrasound examination showed thrombosis in the bilateral femoral veins and popliteal veins. In addition, a 51 × 16 mm hypoechoic lesion was detected in the left subcutaneous perineal region. We continued voriconazole therapy in a standard treatment dose (200 mg twice a day), but her body temperature was still up to 37.6 °C intermittently. Her white blood cells were 15.61 × 109/L (neutrophils 90.8% and lymphocytes 5.4%), hemoglobin was 93 g/L, and platelets were 295 × 109/L. Except hyperglycemia, proteinuria, and hypoproteinemia, other routine laboratory tests were unremarkable, which including thyroid hormone levels. A neck CT showed findings consistent with a fluid collection in the right thyroid lobe (Fig. ). Cultures of aspirated purulent fluid showed aspergillus fumigatus growth, which was obtained from fine needle aspirations in both thyroid and perineum. Five days after being transferred to our hospital, the patient’s thyroid drainage tube was removed because no further fluid was drained out. We continued the voriconazole dose 400 mg per day as anti-aspergillosis therapy with 16 mg methylprednisolone and 400 mg hydroxychloroquine per day as immunosuppressive therapy, along with a therapeutic 4100 iu q 12 h dose of nadroparin calcium. The patient’s fever was relatively controlled and white blood cells decreased to 10.74 × 109/L (neutrophils 91.7%, and lymphocytes 4.7%). Lesions in the thyroid and subcutaneous labium majus became significantly smaller, and the pain was greatly relieved. On the eighth day of hospitalization, the symptoms had improved and the patient was discharged from our hospital. She continuously took voriconazole orally (400 mg per day) for 6 months, combined with caspofungin for the initial 2 weeks (first day 70 mg, then 50 mg per day). After 1 month of antifungal treatment, she was afebrile and all the clinical symptoms were relieved. The patient is on a follow-up for 1 year and has been free of aspergillosis for 6 months. Hydroxychloroquine treatment ceased in April 2017, and methylprednisolone dose was reduced in a tapered manner. |
Female, 22 years old, was referred to a gastroenterology surgical team for evaluation following a history of vomiting over the past three months together with continuous, intense epigastric pain. In addition, the patient had an upper digestive tract endoscopy that revealed a tumor consisting of strands of black hair extending towards the antrum and blocking visualization of the pylorus.\nThe patient was slightly pale, this being the only abnormality found at physical examination. She had a history of slightly retarded neuropsychomotor development. The patient's mother admitted that she had a habit of pulling out her hair and secretly swallowing it. She was admitted to hospital for surgical treatment and psychiatric evaluation.\nA second endoscopy of the upper digestive tract was performed as part of the preoperative work-up, findings revealing a blackened, voluminous mass composed of strands of hair, fibrin and food residue in the stomach, located in the antrum and low body, extending towards the pylorus and blocking passage of the endoscope (Figures and ). A computed tomography scan of the abdomen was also performed and, in addition to identifying a hypodense intragastric mass, results showed hypodense circular areas in the small bowel and the presence of bowel intussusception (Figures and ), findings compatible with the Rapunzel syndrome [].\nSurgical treatment was initiated by videolaparoscopy, which was then converted to laparotomy due to the finding of a large intragastric mass that could not be removed by the technique initially selected. Gastrotomy was performed and the trichobezoar was removed together with strands in the shape of the stomach and the first portion of the duodenum, extending through the small intestine to a total length of 1.6 meters ().\nIn addition, bowel intussusception was found one meter from the angle of Treitz, which was unravelled manually, and a trichobezoar of two centimeters in diameter was found in the proximal ileum extending as far as the ascending colon.\nThe patient progressed with no complications and was discharged from hospital five days after surgery. She is currently being followed up as an outpatient by the gastroenterology, surgical and psychiatric teams. |
A 25-year-old woman with no medical illnesses presented to the hospital complaining of right upper quadrant pain and vomiting. The abdomen was soft and non-tender. An elective abdominal ultrasound confirmed the presence of cholelithiasis. The common bile duct was normal in caliber and liver function tests were within normal limits. She was scheduled for elective cholecystectomy.\nAfter induction of general anesthesia, an open technique was used to insert a 12 mm laparoscopic port at the umbilicus. Two 5 mm working ports were inserted in the right upper quadrant of the abdomen for surgeon dissection. Only three ports were used to perform the cholecystectomy. The choice of port placement was made to provide maximal surgeon ergonomics and no modification of our usual port placement was required to facilitate the use of the robotic arm.\nThe Freehand® robotic arm was secured to the operating table and used to fixate a 10 mm zero-degree laparoscope that was introduced into the umbilical port (Figure ). The Freehand® robotic arm was completely set up in approximately two minutes and did not consume a significant amount of operating time in this case.\nThe surgeon controlled the Freehand® robotic arm using an infrared communication device fixated on a headpiece (Figure ). This allowed the surgeon full control of the laparoscope using the robotic arm (Figure ). The working instruments were controlled by the surgeon and used to demonstrate Strasberg’s critical view prior to fixation of the cystic structures (Figure ). The operation was completed in 30 minutes. During this time, camera cleaning was required on two occasions. To facilitate this, the scope was easily disconnected from the robotic arm, cleaned in the usual fashion, and reconnected to the robotic arm. The procedure to clean the scope consumed less than one minute of operating time.\nAt the end of the operation, the robot was removed and the specimen was extracted using the umbilical port. There were no complications detected. The patient was discharged from the hospital within 24 hours and recovered uneventfully. |
An 18-year-old female presented to our unit with the complaint of a painless swelling on the left side of the lower jaw for the last 3 years that seemed to show a progressive increase in size. On examination, a firm, diffuse, nontender swelling of size 9 × 5 cm involving the left body of the mandible was observed []. On intraoral examination, a small hard tissue projecting over the posterior alveolus was present with normal surrounding mucosa. To our surprise, the left mandibular molars were missing []. There was buccal cortical expansion with an obliterated vestibular area. The orthopantomogram (OPG) showed a well-defined radiopaque mass of size 3 × 6 cm present over the left body of the mandible. An impacted third molar was present below the mass just above the inferior border []. The diagnosis of complex odontoma was made.\nWe planned surgical removal of the tumor along with the impacted third molar under general anesthesia. The tumor was approached via submandibular incision, followed by layer-wise dissection to reach the inferior border of the mandible. After reflection of the periosteal layer, the expanded buccal cortex was seen. With the help of a chisel and mallet, the outer cortical bone overlying the tumor was then removed. The tumor was excised with 0.5-cm bone margins, along with the impacted molar. The lingual cortical bone was found to be intact [Figures and ]. The defect was measured to be approximately 6 cm in length. The reconstruction of the defect was done with nonvascularized corticocancellous iliac crest bone, which was taken from the contralateral side []. The fixation of the graft was done with 2-0 Vicryl sutures to prevent any unnecessary hardware fixation or thermal injury to it. After achieving proper hemostasis, closure was done in layers. Postoperative recovery was absolutely uneventful. Postoperative antibiotics and analgesics were given for 1 week. One week post operation, healing over both the donor and recipient sites was found to be satisfactory, and the sutures were thus removed. To our surprise, histopathological examination revealed the tumoras an AFO []. The patient was kept under regular follow-up for 6 months and, to add to our delight, there were nosigns of graft failure or loco regional recurrence. |
A 32-year-old woman in her first pregnancy presented at 37 weeks gestation to the obstetric review centre in the late evening with a two-hour history of new onset right-sided leg pain and numbness. She was able to mobilise short distances and was otherwise well. Initially her symptoms were most suggestive of sciatica, a common complaint during pregnancy.\nHer symptoms progressed rapidly over the next two hours and she reported bilateral lower limb numbness and severe shooting midthoracic back pain and was unable to move her legs. Initially she had no urinary retention or faecal incontinence. She also reported no history of trauma or any similar symptoms in the past.\nShe had an otherwise low risk pregnancy and there were no signs of fetal distress on arrival. Her past medical history included asthma, allergic rhinoconjunctivitis, and depression. She was a smoker and migrated to Australia from England several years earlier.\nOn initial examination, vital signs were normal. She was afebrile. Cardiotocograph revealed no concerns for fetal wellbeing. Her neurological examination was inconsistent but nevertheless concerning. She was found to have patchy bilateral sensory loss up to a sensory level of T10. Lower limb examination revealed reduced power bilaterally (1-2/5) across all myotomes with hyperreflexia, clonus, and upgoing plantar reflexes. Upper limb neurological examination was normal. There was no bony tenderness on palpation of her spine. Insertion of a urinary catheter five hours after presentation drained 700 ml of urine. This was suggestive of urinary retention, particularly in the context of her advanced gestation. However, she reported normal perineal sensation on catheter insertion, again inconsistent with her other symptoms and examination findings.\nDue to her pregnant state, an urgent CT was not performed. An after hours MRI was not considered necessary as it was felt an acute surgical cause for the presenting signs and symptoms was unlikely. A kidney ultrasound ruled out renal stones as a cause for severe back pain.\nThe next morning an MRI spine was performed. This revealed a previously undiagnosed mixed intra- and perimedullary spinal cord AVM at T8 with surrounding spinal cord oedema from T6-T11 (see ). Her case was discussed with the neurosurgical team who felt she was not amenable to urgent surgical decompression or intervention based on MRI findings. A decision was made for urgent delivery to facilitate further investigation. A healthy baby girl was delivered that afternoon via caesarean under general anaesthetic. This was performed without complications.\nSubsequent angiography showed a predominantly perimedullary slow flow spinal cord AVM with intramedullary extension at T8 to a compact nidus (see ). The AVM received arterial supply from the radicular branches of the right T9 intercostal artery with a branch to the anterior spinal artery from the same level. The venous drainage of the AVM was via a single caudal draining vein that extended to the left internal iliac vein with attenuation at L5/S1.\nIn discussion between the radiology and neurosurgical teams, it was concluded the most likely aetiology for the patient's presentation was acute rupture of the AVM at T8 secondary to venous outflow compression from the enlarged uterus onto the draining vein at the level of L5 causing high pressure within the AVM and subsequent rupture. Given the lesion was partially within the spinal cord, treatment with surgical resection would risk potential permanent paraplegia. Additionally, she was considered not a good candidate for embolisation. As such, the patient was managed conservatively in the hope that she might have at least partial recovery of her neurological function. An inferior vena cava (IVC) filter was inserted at the time of initial angiography to prevent pulmonary emboli given the relative risk of anticoagulation in the setting of recent caesarean section and recent AVM rupture.\nOne month after admission, the patient developed left leg swelling and was diagnosed with a left leg extensive occlusive deep vein thrombosis extending to left external and common iliac vein as far as the IVC filter. There was concern about potential obstruction of venous outflow from the AVM precipitating further rupture as well as potential clot propagation above the IVC filter, so a decision was made for mechanical thrombectomy and removal of IVC filter. She was therapeutically anticoagulated on warfarin with clexane bridging and clot progression was monitored on weekly ultrasound scans.\nGiven the difficulties in finding a suitable discharge destination with a newborn baby, the patient's first few months of rehabilitation were as an inpatient in a private room on the neurosurgery ward. At the time of writing this article (six months after delivery), the patient remains paraplegic to the level of T8 with urinary and bowel incontinence. At this stage, she has a guarded prognosis for recovery. |
A male patient aged 32 years with a low-velocity gunshot wound was referred to the emergency room on August 28, 2012. Wound debridement, tetanus prophylaxis, and antibiotic treatment were initially administered for the management of the wound. Physical examination showed that entry wound was placed 1 cm lateral to femoral artery, 10 cm distal and 5 cm medial to spina iliaca anterior superior (). There was no exit wound. The patient had limited and painful hip joint movements. His neurovascular condition was intact.\nThe relation of the projectile lodged in acetabulum with the joint and its path through the femoral neck was seen at radiography and computed tomography (CT) scanning (). The patient was operated 2 days after the gunshot wound. Hip arthroscopy was performed using the supine position with the extremity in traction on a fracture table with general anesthesia. Traction weight of 30 kg was applied to the left hip joint of the patient. Hip joint was entered by making anterior and anterolateral portals. The projectile was found to be subchondrally located in posterior superior acetabulum, relating with the joint (). Exit point of the projectile was seen on the femoral side and chondral damage was treated with debridement. The surrounding of the projectile lodged in the acetabular side was enlarged with a probe for the removal of it. Projectile loosened with a probe was safely removed with a grasper ().\nFollowing the debridement of the chondral damage occurred in the femoral and acetabular sides and the application of microfractures for the appropriate areas, the joint was washed out and the procedure was terminated. No complication was observed post-operatively. Limited mobilization with double crutches was permitted for 6 weeks. Then, full weight bearing was initiated.\nIn the 2nd year of follow-up period, the patient appealed to hospital with groin pain. The patient had full range of motion but had hip pain, especially with weight bearing. Magnetic resonance images (MRIs) were taken and the path traversed by the projectile through the femoral neck and 4 cm × 2 cm chondral defect on the femoral head was apparent (). No signs of osteoarthritis were detected.\nThe patient was re-operated on March 2014. He was put on surgery table in lateral decubitis position with general anesthesia, and safe surgical dislocation of the hip was applied (). Dissolved cartilage was removed and microfracture was applied to subchondral bone. Acellular collagen scaffold (CaReS®-1S Arthro Kinetics, Esslingen, Germany) was implanted on chondral defect area and fixed with fibrin glue (). No complication was observed post-operatively. Passive motions were allowed after 2 days and weight bearing was prohibited for 6 weeks.\nOn May 2015, 1 year after second surgery, the patient had full range of motion and had no hip pain. |
A 47-year-old female patient was referred to our hospital due to sudden onset of headache (visual analog scale; VAS 8) and backaches (VAS 6) following a slip and fall two weeks prior to admission, resulting in periorbital swelling, bruising and a headache. The pain was aggravated by standing and walking and partially relieved by sitting. The patient showed no sensory and motor deficits in lower limbs and there were neither bladder nor bowel dysfunction. She was alert and well oriented, and her spine was aligned normally in the coronal plane with mild loss of lumbar lordosis. Lumbar spine movements in the sagittal plane were restricted by pain. Upon straight leg-raise testing, the patient's leg was able to be raised 60° while lying down, with no neurological deficits noted in the limbs. The cervical spine was normal. There was no evidence of cranial nerve palsy or lateralizing neurological deficits. She had no previous history of anticoagulant therapy and hematological coagulopathy. Her coagulation profiles including platelet count, prothrombin time, and activated partial thromboplastin time were all within the normal ranges. Cranial imaging studies revealed a small amount of acute SDH along the tentorium (). Magnetic resonance imaging of the patient's lumbosacral spine revealed spinal SDH at the anterior portion of the caudal thecal sac at the levels of L5-S2 with marked neural compression (). No definite contrast enhancement at the lesion site was observed. The remaining intracranial structures and cervicothoracic spine were normal. Based on radiologic findings, traumatic intracranial SDH at the tentorium with subsequent spinal SDH was diagnosed. Seven-day course of conservative management was uneventful, and the patient experienced no neurological deficits, without notable event. Her complaints of headache and back pain were nearly resolved, and the patient returned to normal daily activities. At one-year follow-up, the patient was free of leg pain, but complained of a sustained mild headache. Follow-up imaging studies showed no definite abnormalities in the cranium or spine. |
A 59-year-old man with a known left-middle cerebral artery infarction was newly diagnosed with right basal ganglia (BG) and thalamic intracranial hemorrhage (ICH). Emergency external ventricular drainage was performed (). He was referred to our hospital for comprehensive rehabilitation. Initially, he had zero grade in the left upper and lower limbs, according to a manual muscle test, and zero grade of spasticity by the Modified Ashworth Scale. The patient's Korean version of Modified Barthel Index score was 4 points and his Mini-Mental Status Examination score was 15 points. He required maximal assistance in mobility. In addition, he had neuropathic pain symptoms, such as numbness and tingling on the left hemiplegic side, suspected to be CPSP. He especially complained about neuropathic pain in the posterior thigh and lower leg. We performed a three-phase bone scan, confirming the presence of a complex regional pain syndrome involving the left arm. We therefore added 300 mg of gabapentin three times per day to the treatment to control neuropathic pain, which improved. He was discharged from our hospital at that time.\nHe was later readmitted to our department with persistent neuropathic pain in the left leg. We increased the dose of gabapentin to 600 mg twice per day, but the treatment did not relieve his neuropathic pain. He also suffered left hip pain and restricted ROM in the hip joint with flexion of 70° and could not maintain a sitting posture for ambulation with a wheelchair.\nLeft-hip radiography revealed an osteophyte of the left femoral head (). We performed a nerve conduction study (NCS) and electromyography (EMG); the findings were compatible with left L5 radiculopathy. Sensory NCS showed normal findings in both sural and superficial peroneal nerves. Motor NCS revealed slightly decreased amplitudes (by about 30%) of compound motor-action potentials in the left tibial and deep peroneal nerves relative to the right side, but showed normal onset latency and conduction velocity in those nerves. In needle EMG, tensor fascia latae, tibialis anterior, and tibialis posterior muscles showed positive sharp waves at rest. However, during the physical examination, the patient showed sign of the buttock () in the left hip. We performed lumbosacral (LS) spine magnetic resonance imaging (MRI) in addition to left-hip MRI. The LS spine MRI revealed a left foraminal protrusion at the L4-5 level that was compressing the nerve root (). We observed deep, soft tissue in the ischiofemoral space in the MRI of the left hip, measuring 4.0 cm×1.1 cm×2.2 cm around the sciatic nerve (), which we suspected to be a lipoma.\nThe patient was referred to the orthopedics department for surgical removal of the mass. An encapsulated fatty mass, 4 cm×4 cm×2 cm in volume, was discovered between the gluteus medius and maximus muscles; it was adhering to the sciatic nerve (). Immediately after surgery, the patient's left hip ROM was improved up to 110° in flexion, and neuropathic pain in the left leg was alleviated. His ROM after one week showed increments of up to 120° in flexion. Consequently, he could sit upright in a wheelchair without limitations and ambulate in this fashion. |
A 15-year-old boy with no past or family history of psychiatric illness presented to a tertiary care hospital with an illness of 4–5 months duration. His illness started with behavioral changes observed by his parents. He would be restless and would pace around in his home for a long period without any reason. After a few days, his sleep was also disturbed. He would be found standing in a particular posture for 1–2 h without getting tired for which he did not give any reason even after repeatedly being asked by family members. He also started remaining fearful for which he stated the reason that someone was coming to harm him. He would repeatedly check doors and windows and also ask his parents to do so. Despite repeated reassurances given by the parents, he would not get convinced of the fact that anyone was going to harm her. He also reported seeing “Bajrang Bali” (The Hindu God) in his clear consciousness during awaken state multiple times; however, he would not elaborate further. Parents also found him smiling and muttering to self on many occasions while he was alone as if he would be talking to someone. However, he did not give a history of hearing any voice. By now, he would also pass urine in his clothes (he would be aware of the urge but could not reach the bathroom). He became completely mute after 4–5 weeks of onset of illness. He was found doing some motor acts repeatedly in a specific manner (clapping continuously for 10–15 min with his hands kept above head). He used to maintain some unusual postures for a long period. He stopped taking a bath, taking food, and his mother had to assist him in daily activities of life.\nHe was taken to a private psychiatrist initially and was started on risperidone tablet 1–2 mg which led to some improvement in his psychotic symptoms. However, catatonic symptoms did not improve. After about 1½ months of treatment, he was referred to us for further management. A working diagnosis of schizophrenia – undifferentiated subtype versus organic psychotic disorder (ICD-10) – was kept. The dose of risperidone was optimized, and tablet lorazepam was added. It led to improvement in psychotic symptoms, however, as the catatonic symptoms and bladder dysfunction did not improve; a neurology referral was also sought. The patient underwent multiple investigations including computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, and electroencephalogram (EEG). His CT scan was normal. Brain MRI demonstrated periventricular white matter lesions. EEG reported typical findings suggestive of SSPE (i.e., high-voltage slow-wave complexes interspersed with short rhythmic waves) []. Considering this, antimeasles antibody titers were also performed which were found to be increased (blood - 1:32, cerebrospinal fluid [CSF] - 1:4). Serum creatine phosphokinase level was normal. Based on these findings, a diagnosis of SSPE was considered. In the follow-up course, the patient also developed myoclonic jerks and disorientation, and he was advised to follow-up at neurology outpatient department for long-term management. |
A 64 year old female of Chinese origin underwent uncomplicated mechanical mitral valve replacement in 2002. She was reviewed six weeks following discharge. The sternal wound was healing slowly, but there were no signs of infection.\nPast surgical history included sterilisation in 1962, haemorrhoidectomy in 1983 and hysterectomy for fibroids in 1985. None of these operations had resulted in scar hypertrophy. No other significant medical history was present.\nShe made an uncomplicated recovery from her mitral valve surgery and she was discharged back to her general practitioner (GP). In the next 9 months, she noticed increasing pain and thickness of the sternotomy and previous chest drain scars. She was initially treated by her GP with local anti-inflammatory agents with no noticeable improvement. She searched for other treatment options on the internet and chose to use Cica-Care™ (Smith & Nephew™), a silicone gel sheet for six months with little relief. At that stage her GP referred her to a plastic surgeon and a pain therapist who treated her with local steroid and lidocaine injections for approximately 4 years with no improvement. Eventually she was seen by her cardiologist who referred her back to our cardiothoracic unit.\nHer clinical examination confirmed a 12 cm long keloid scar at the site of the sternotomy and two other keloid scars inferiorly at the site of previous chest drains and pacing wires. (Figure )\nThese were extremely tender on light palpation, particularly over the site of the sternal wires. None of the wires were palpable. Following discussion on treatment options she agreed to have surgical excision of the scar and primary closure.\nIn November 2008, the patient underwent excision of the keloid scar with removal of the sternal wires and reconstruction of the wound with three layers of suture (1 Dexon™ Covidien UK™) under general anaesthetic. Mobilisation of the subcutaneous tissues was required for approximation of the skin edges. Skin was closed with Prolene™ (Ethicon™). Sutures were removed after ten days and a pressure dressing was applied. We were not sure if this patient was allergic to the Monocryl™ and we therefore chose to use a removable material such as Prolene™. The histology of the keloid scar did not show evidence of malignancy.\nThe hypertrophied scar at the pacing wire site was deliberately left untouched in order to compare any future scar formation. (Figure ) She was discharged home three days later. (Figure )\nThe patient was reviewed in the outpatients clinic six weeks later. The wound was healing well with minimal tenderness over the scar sites (Figure ). Nine months after excision there was evidence of recurrence of her scar, however this was of a lesser degree (Figure ). The patient felt that pain related to her scar had markedly improved and was satisfied with the overall result. |
A 62-year-old woman was referred to our neurosurgical outpatient service with abnormal sensation in her trunk, arms and legs. The patient had a past medical history of a gastric ulcer, a right ankle plating after fracture 20 years ago and a headlice infection 6 months before first presentation. She was a smoker, social drinker of alcohol and was not taking any regular medication. She lived alone and had been struggling to manage independently.\nSince her symptoms commenced 3 years previously, the patient had presented to emergency department (ED) on 11 occasions. Her primary complaint was of dysaesthetic sensory symptoms including a feeling of water retention and a gel infiltrating the skin of her face, trunk, arms and legs, feeling there was something stuck on her skin and feeling her hair was stuck down. In the weeks before the onset of her symptoms, the patient started using an olive oil moisturising cream, to which she attributed her symptoms.\nWhile dermatological examination was conducted, comprehensive neurological examinations were not documented during the first presentations to the ED, which focused on the patient’s facial dysaesthesia.\nThe patient was frustrated that her symptoms were repeatedly dismissed as delusional by the ED staff. She refused assessment by liaison psychiatry and mental health review by her general practitioner. The patient was felt to have capacity throughout all consultations. The patient was not taking any psychiatric medications.\nOver time her symptoms progressed. She started to complain of back pain, multiple falls and episodes of her right leg giving way which had progressed to severely compromised walking and coordination. The patient also complained of episodes of urinary and faecal incontinence. This led to a lumbar MRI which ruled out cauda equina syndrome. In her final presentation before referral, she also complained of stiff legs, difficulty walking, difficulty passing urine, reduced manual dexterity and neck pain. A neurology assessment was finally sought and an MRI for suspected myelopathy was organised.\nOn presentation to our neurosurgical clinic, the patient’s complaint remained sensory dysaesthesia from her neck down, particularly affecting her hands and groins. She complained of her body feeling like a ‘wet gel-like substance’. In addition to the above symptoms, the patient also complained of a 3-year medical history of numbness and tingling in her upper limbs.\nOn examination in the neurosurgical clinic, the patient had hyperaesthesia from the neck down, most prominent in the hands and groins. The patient had reduced grip strength of 3/5, finger extension and abduction of 3/5, wrist flexion and extension of 3/5, elbow flexion of 4+/5, elbow extension of 4/5 and shoulder abduction of 4+/5 on the Medical Research Council power scale. Hip flexion was 3/5, with all other muscle groups in the lower limb at 4+/5. The patient had very brisk reflexes with pathological spreading in the upper and lower limbs. There was self-limiting clonus in the ankle bilaterally. Hoffmann’s and Babinski reflexes were positive bilaterally. There was a severe loss of coordination and balance. Gait was impaired; the patient required a frame to mobilise. The severity of the patient’s cervical myelopathy was scored as 1 (upper limb motor dysfunction) +3 (lower limb motor dysfunction) +1 (upper limb sensory dysfunction) +1 (sphincter dysfunction) =6 (severe myelopathy) on the modified Japanese Orthopaedic Association scale (mJOA). |
A 27-month-old unimmunized girl presented with developmental regression and recurrent head drops for the past 1 month. She had language predominant global delay with a current developmental age of 15–18 months. Her perinatal period was uneventful. There was no past history of exanthematous illness. The child had repetitive myoclonic jerks every 9 s. Neurological examination revealed a normal fundus with central hypotonia and bipyramidal signs. The EEG and MRI were suggestive of SSPE which was confirmed by elevated anti-measles antibody titers in CSF. At 4-week follow-up, the child was in vegetative state.\nSSPE is frequently misdiagnosed or not suspected because of the variable presentation. Given the heterogeneous expression, accurate initial diagnosis of SSPE was made in only 21% cases presenting to a tertiary care center in South India.[] The first child in our report is exceptional for the early onset of SSPE and also for the short latent period of 14 months. The two cases highlight the fulminant nature of such an early presentation typified by a vegetative state within 3 months of onset.\nThe earliest description of SSPE in infancy and toddlerhood dates back to the late 1960s by Dayan et al. with histological and immunologically confirmed cases of 5-month and 15-month-old children at necropsy.[] Review of English literature identified 13 comparable cases in the past 30 years highlighting the rarity of this atypical presentation. Perinatally acquired measles were reported in 5 of the 13 cases []. Several important observations emerge on review of these children. First, the clinical course is atypical and does not follow the classic four stages of the Jabbour Classification. Second, the typical clinical picture of subacute mental deterioration with stereotyped generalized myoclonus is often preceded by a premorbid developmental delay with or without seizures in all five children as in our second child. On the other hand, in the primary measles group of 8 children, fulminant course of the disease is characterized by progression to a vegetative state within 3 months or fatal outcome within 6 months was the norm. The median latency in this group was 12.5 months with the shortest latency of 2 months.[] The exact reason behind this short latency and fulminant course is yet to be ascertained. Genetically determined immune dysfunction in the first 2 years of life preventing a successful cell-mediated immune clearance of measles virus has been implicated in the susceptibility to SSPE.[] Genetic polymorphisms of programmed cell death-1, Toll-like receptor 3, MxA, interleukin-4, and interferon-1 genes have also been hypothesized but not proven. Besides, the role of phylogenetic spectrum of the wild-type measles virus in the etiopathogenesis has to be considered.[] The wild-type measles D3 and D6 are the most prevalent genotypes identified in SSPE on nucleotide sequence analysis. However, D7 genotype with hypermutation in the M gene has been isolated in an adult with fulminant SSPE from autopsy in South India and its association is still speculative.\nThe other early presentations of SSPE include visual complaints, Balint's syndrome, dystonia, and ataxia. The diagnosis is usually established by Dyken's criteria with periodic electroencephalographic complexes and raised CSF measles antibody titers (100% sensitivity and positive predictive value). SSPE is essentially an incurable disease with limited treatment options inclusive of Isoprinosine, interferon, ribavirin, and flupirtine.[] Given the poor eventual outcome of the therapeutic strategies, prevention through vaccination is the only way to eradicate the disease. Hence, there is a need for intensification of the primary immunization and measles eradication program in India.\nMeanwhile, atypical presentation of SSPE should be considered in the differential diagnosis of any unexplained neurological illness irrespective of age, especially in endemic countries. A knowledge of the measles-like illness (also in the mother during the antenatal period), focused visual examination, and predominant white matter changes in MRI supplemented by an elevated CSF antibody titers are essential for an early diagnosis of this devastating condition.\nThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nNil.\nThere are no conflicts of interest. |
A 37-year old male patient visited outpatient clinic, with complaints of gradual cognitive decline which had started 3 years earlier. Working as an industrial researcher, he started to make serious calculation mistakes that made him quit the job and began working as a manager in a company. However, his frequent forgetfulness, along with aggravation in recent memory impairments hampered him from fulfilling his duties, making him change jobs frequently. Apraxia and apathy had started 2 years before his visit to our clinic, and disorientation to time and person was worsened to a degree which it became impossible to commute daily between his workplace and home. At time of his visit to our clinic, not only he was fired from his recent job, but also he needed frequent reminder from his family to maintain hygiene. His sleep disturbance became prominent, frequently waking up middle of the night self-talking.\nBefore his visit to our clinic, he had visited two hospitals for evaluation and management of his symptoms, but to no avail. For a thorough examination of his symptoms, he was immediately admitted to our psychiatric ward. His laboratory findings did not reveal any abnormalities, and his tests for human immunodeficiency virus, syphilis all turned out to be negative. Upon his psychiatric admission, a neuropsychological test battery was implemented to evaluate the patient's cognitive status. He scored 22 in Mini-mental status examination, 1 in Clinical dementia rating scale (CDR), and 4.5 in Clinical Dementia Rating-Sum of Box score(CDR-SB). In his cognitive tests, in contrast to his relatively preserved language function, he displayed serious impairments in free recall, 20-minute delayed recall and recognition.\nBrain magnetic resonance imaging demonstrated global cerebral atrophy of grade 1 by cortical atrophy scale and notable medial temporal lobe atrophy of grade 2 by medial temporal lobe atrophy visual rating scale (). Atypically early onset of dementia symptoms made the patient an eligible candidate for amyloid positron emission tomography (PET) imaging. 18-Florbetaben PET images revealed diffuse amyloid deposition with score 3 in brain beta-amyloid plaque load (BAPL), with predominant amyloid deposition in the striatum ().\nThe patient's history, along with neuroimaging results and cognitive test results all satisfied the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association Alzheimer's (NINCDS-ADRDA) criteria16 for probable Alzheimer's disease with high level of evidence. 5 mg of donepezil was prescribed, and the patient was discharged on the 10th day of his admission. To control his persistent cognitive decline even after the discharge, donepezil was increased up to 23 mg with combination of memantine, which was also increased up to 20 mg. His cognitive decline has been relatively plateaued, but we advised the patient and his caregiver to regularly visit the clinic for monitoring of his symptoms. |
A 23-year-old male came to our OPD with complaints of change of voice and noisy breathing. Examination revealed that the young man had inspiratory stridor and hoarseness of voice with portex tracheostomy tube in situ. History revealed that he was admitted previously for organophosphorus poisoning 3 years back, during that time he was intubated for 15 days. After extubation, he was kept in the ward for 5 days after which he was discharged. The patient developed dyspnea 1 month after discharge from primary hospital, and the patient was admitted and taken up for emergency tracheostomy, following which a clinical diagnosis of tracheal stenosis was made.\nCT neck revealed tracheal stenosis proximal to tracheostomy stoma involving length of 2 cm and transverse diameter of 6 mm.\nAfter which, the patient underwent 6 check bronchoscopies and 1 dilatation and followed stenting of the stenosis at the previous hospital, which did not relieve him of his complaints. He underwent a check bronchoscopy with dilatation of the tracheal stenosis at our hospital 1 year later.\nThe patient returned back to our ENT OPD 1 year after the dilatation with complaints of hoarseness of voice and stridor. 3D CT neck (Figures and ) revealed tracheal stenosis over approximately 11 mm length, noted at the level of cricoid cartilage. Transverse diameter measures 5.5 mm, and AP diameter measures 5.1 mm. There was grade III (90%) stenosis over the third tracheal ring with narrowing extending proximally up to the second ring. CT scan showed a stenotic segment of 2.5 cm. The patient and his relatives were explained about the condition and the procedure to be performed. They agreed for a reconstructive surgery, and a tracheal resection and anastomosis was planned.\nThe patient underwent surgery, and apron's neck incision was taken. Flaps elevated superiorly till the hyoid bone and inferiorly till the clavicle. Strap muscles were separated, and thyroid gland was dissected. Trachea was visualized, and stenotic portion of the trachea was resected, and end-to-end anastomosis was done with 3/0 Prolene suture material, and a Romo vac drain was kept in situ. A mentosternal suture with neck in flexion to restrict neck movement was placed with 1/0 Prolene. Postoperatively, the patient was kept in ICU with nasal intubation. Nasal intubation and Romo vac drain was removed on the 5th postoperative day. The patient was shifted out of ICU on the 8th postoperative day due to uneventful recovery and was discharged on the 14th postoperative day. At 1-month follow-up, the patient was asymptomatic with normal breathing and voice.\nCT neck 6 month postoperatively () suggested of no evidence of stenosis. Tracheal lumen and tracheal bifurcation were normal, and on 70 degree scopy, vocal cord mobility was normal. |
Mr. A is a 62-year-old male, married, retired, healthy, with no remarkable medical history. He was in his usual state of health until 2 months before his presentation in the clinic when he experienced an increase in body temperature with body ache, fatigue, and a dry cough. He went to his primary health care doctor, and a nose swab PCR test for COVID-19 virus was taken for him, which came back to be positive. He continued to manage his symptoms at home with only paracetamol and rest with no other medication, and all of his symptoms gradually subsided within 2 weeks. And on the third week, he repeated the nose swab PCR test, and the result came back negative. However, during the third and fourth week since the start of his symptoms, he started experiencing recurrent and persistent intrusive thoughts of doubts about his 20-year-old nephew being his own son. Even though he recognizes these thoughts as excessive and unreasonable, it makes him distressed, and in response to these thoughts, he would phone his nephew to ask about him indirectly. These thoughts were not going away and started to increase over time and to be followed by other recurrent and persistent thoughts about different things in his life, mainly on the theme of “doubts”, for example, going back repeatedly to check the car locks. In response, he started isolating himself, avoiding any family gatherings. His daily routine was disturbed. The patient denied having persistent and excessive worries about these thoughts; he denied having sudden periods of intense fear of dying or any other significant anxiety symptoms; he had no other significant mood symptoms nor apparent psychotic symptoms; the patient had no previous psychiatric history and no history of psychiatric illness in the family and the patient had no apparent cognitive impairment or changes before or after the infection. He presented to the clinic 2 months after the disappearance of his COVID-19 symptoms and the emergence of these new thoughts. A physical and neurological examination was performed with unremarkable findings. The patient had normal blood and chemistry results, including normal liver and renal function tests, but he never underwent a CT brain imaging. A formal diagnosis of obsessive–compulsive disorder with good insight was made.\nHe was started on escitalopram 10 mg daily and was referred for cognitive–behavioral psychotherapy and was given an appointment after 4 weeks.\nIn the fourth week, he self-reported that the recurrent and persistent intrusive thoughts were decreasing in intensity by approximately 60% on a scale from 0 to 100, but he still had them from time to time; the dose of escitalopram was increased to 20 mg, and he was given another appointment after 1 month at which he reported that most of these thoughts had disappeared and he started resuming his routine and daily living activity. Unfortunately, he dropped out of his psychotherapy sessions after the second visit, so he was advised to continue using the medication and was given a follow-up appointment. |
A 79-year-old female presented to the emergency room with confusion, agitation, and visual hallucinations after sustaining a fall. Although the patient was a poor historian, her family members did not report prior history of abdominal complaints including trauma, fever, weight loss, abdominal mass, or surgery. Abdominal examination revealed soft, nontender, palpable fullness in the paraumbilical region. Gastroenterology service was consulted for a nontender abdominal fullness on physical examination as well as laboratory findings of severe iron deficiency anemia. The rest of her laboratory findings were unremarkable.\nA supine and upright abdominal film showed bowel loops displaced to the left with a large amount of stool in the colon (\n). A noncontrast computed tomography (CT) of the abdomen and pelvis revealed a large right retroperitoneal cystic structure measuring at least 26.6 × 11.7 × 16.7 cm. The cyst was displacing the right kidney and right colon medially (\nand\n). These findings were consistent with a giant retroperitoneal cyst (RPC). Though her presenting complaints were attributed to her history of fall with possible concussion, the diagnosis of RPC was found via thorough physical exam revealing a large, palpable abdominal mass.\nThe patient was taken to the operating room with a high suspicion that the CT findings were consistent with a giant liver cyst. Upon entering the abdomen using a Hasson technique and placing a 12-mm trocar, a diagnostic laparoscopy revealed a large cyst with a blue hue. Given that the CT findings showed no evidence of nodularity, septation, or intracystic masses and the laparoscopic findings were consistent, the suspicion of malignancy was very low. Upon drainage of the cyst, it was clearly noted that it was easily separable from the posterior liver and was in fact retroperitoneal in origin. The posterior peritoneum was incised. The wall of the cyst was carefully dissected from the anterolateral wall of the kidney, adrenal, and the posterior wall of the ascending colon keeping in mind the significant distortions in anatomy secondary to its size. A plane between the cyst and the posterior peritoneum was established, and the cyst was separated using a combination of electrocautery and sharp dissection. The cyst was then placed in an endocatch bag and removed through the 12-mm port. Thus, the patient underwent a complete cyst excision using a laparoscopic transperitoneal approach. Intraoperatively, the retroperitoneal location of the cyst was confirmed as the cyst wall was separated from visceral peritoneum with ease (\n). Macroscopically, the cyst appeared to have thick walls and measured approximately 28 × 17 cm in size and containing 6 L of clear liquid (\n). Histopathology revealed a benign serous cystadenoma (\n). Should there have been a preoperative suspicion of malignancy based on imaging or, diagnostic laparoscopy, an open approach with en bloc resection would have been undertaken. A subsequent CT revealed interval removal of large RPC with properly repositioned loops of bowel. The patient followed up in 3 months with no further surgical complications or recurrence. We believe that the patient’s presenting symptoms were attributable to her fall, concussion, and dehydration that resolved with hydration and supportive therapy and not related to the findings of RPC or its surgical removal. |
We present the case of a 67-year-old female who had undergone an extended medial column and NC joint arthrodesis. The patient made an uncomplicated recovery; however, she was symptomatic of the prominent hardware due to a lateral NC joint screw. Twelve months following the index procedure, the hardware was removed percutaneously (see ). In both cases, the patient was prescribed 325 mg aspirin to be taken daily for 10 days for deep vein thrombosis (DVT) prophylaxis.\nOne month following this, she presented with increased pain and swelling in the dorsal midfoot. On careful examination, she had a pulsatile mass underneath the lateral percutaneous incision. Initial investigation with a Doppler ultrasound demonstrated a pulsatile aneurysm measuring 2.5 × 1.7 cm. A computed tomography (CT) angiogram confirmed this to be a branch of the dorsal metatarsal artery (see and ). Vascular surgery was consulted and agreed with our decision to excise the pseudoaneurysm.\nThe patient was taken back to the operating room for exploration, excision, and ligation of the pseudoaneurysm. Preoperative CT angiography confirmed adequate collateral flow. The pseudoaneurysm was located so close to the second metatarsal artery and vein that there was not sufficient length of the branch to ligate it individually. Therefore, the second dorsal metatarsal artery and vein were ligated. The tourniquet was deflated with a total time of 18 minutes at 300 mm Hg, and hemostasis was observed. The incision was closed in standard fashion, and a sterile compression dressing was applied. Of note, we did not use heparin at any point during this surgery. Postoperatively she was admitted to the hospital and observed. She was commenced on DVT prophylaxis with 325 mg aspirin per day for 10 days starting on day 1. The dressing was removed on day 1 without evidence of pseudoaneurysm or postoperative bleeding.\nAt 2-week follow-up, she was full weight bearing in a postoperative shoe. Her incision was healing well without recurrence of the pseudoaneurysm. |
This is a 50-year-old white male who originally presented in 2004 with complaints of epigastric abdominal pain. The patient's past medical history was significant for hypertension, 30-pack per-year history of tobacco use, occasional ETOH use, diabetes, hyperlipidemia, and regular marijuana use. Workup at that time revealed elevated amylase and lipase levels, a dedicated gallbladder ultrasound was unremarkable, and the final diagnosis of thiazide-induced pancreatitis was made. The medication was discontinued, laboratory values normalized, and the patient was discharged. The patient presented again in 2005 with similar complaints and lab abnormalities. Upon questioning, the patient stated he continued his thiazide medication since prior discharge; the thiazide was again discontinued. Following clinical improvement the patient was discharged and switched to an ACE inhibitor for blood pressure management. In the outpatient clinical setting, the patient continued to have unresolved epigastric abdominal discomfort despite unremarkable amylase and lipase values. In light of this, a computed tomography (CT) scan of the abdomen and pelvis was performed in early 2006 demonstrating a hypervascular retroperitoneal mass intimately related to the pancreas (Figures , , and ). A positron emission tomography (PET) scan performed 7/2006 demonstrated intense FDG uptake in the region of the pancreatic head without locoregional nodal or distant metastatic disease. Fine needle aspiration of the mass was suggestive of poorly differentiated carcinoma. These findings prompted surgical consultation and a Whipple procedure was planned for resection of the possible pancreatic head mass. In 8/2006 surgical exploration revealed a retroperitoneal mass situated inferior to the uncinate process which extended to the infrarenal abdominal aorta. The mass demonstrated close involvement with the inferior vena cava and superior mesenteric vessels. Direct involvement of the pancreas and adrenals was not appreciated. Given the unusual location of the mass as well as its aortic proximity, resection was deferred.\nA true cut biopsy was performed and sent for frozen as well as permanent section analysis. Histologic examination revealed a well-circumscribed neoplasm composed of epithelioid chief cells with eosinophilic cytoplasm arranged in a nested pattern and peripherally surrounded by more spindle-shaped sustentacular cells. These cell nests, referred to as “zellballen”, are characteristic of paragangliomas (). The neoplasm was histologically benign, with minimal pleomorphism, no evidence of invasion, and low mitotic activity. Frozen section diagnosis was rendered as “consistent with paraganglioma”. Immunohistochemical stains on the permanent section specimen, including chromogranin, synaptophysin, and S100, confirmed the neuroendocrine origin of this neoplasm (). As a result, a final pathologic diagnosis of “extraadrenal paraganglioma” was issued.\nThe patient underwent radiation treatment receiving a total dose of 3960 gray divided into 22 fractions from October 17, 2006 to November 16, 2006. Repeat CT imaging 2/2007 demonstrated no significant interval change of the paraganglioma. Follow-up CT 7/2007 showed continued stability. Repeat PET 7/2007 demonstrated the retroperitoneal paraganglioma minimally smaller compared to 7/2006. On surveillance CT imaging 5/2008 the patient was noted to have a solid left renal lesion without evidence of distant metastasis. After consultation with Urology the patient underwent a partial left nephrectomy in 7/2008. Frozen diagnosis was positive for renal cell carcinoma with a negative surgical margin. Surveillance CT imaging on 9/2009 demonstrated a mildly smaller retroperitoneal paraganglioma without evidence of recurrence or spread of either primary (). |
A 60-year-old female, South-Asian never-smoker presented in December 2011 with dizziness and nausea. A magnetic resonance imaging (MRI) scan of the head detected 25 brain metastases. The two largest metastases were in the right cerebellum measuring 38 mm and 22 mm in size; the remaining were < 10 mm with a diffuse bilateral cerebral and cerebellar distribution. The patient’s initial MRI is presented in Figure . Neurosurgical resection of the largest cerebellar metastasis showed poorly differentiated adenocarcinoma pathology, CK7 and TTF-1 positive, consistent with a lung primary. Genetic analysis did not detect the presence of an epidermal growth factor receptor (EGFR) exon 21 or exon 19 or ALK mutation. The primary tumour was identified in the left lower lobe lung and there were no other extracranial metastases on computed tomography (CT) imaging of the body.\nThe patient was treated with WBRT (20 Gy in five fractions). A CT scan of the head two months after WBRT showed an empty resection cavity, and definite intracranial lesions were no longer visible. The patient received platinum-based chemotherapy for four months with regression of the primary lung tumour. The patient did not receive further maintenance systemic therapy and was followed with chest and brain imaging every three to six months using both CT and MRI. At nine months, an MRI showed new asymptomatic brain metastases in the left frontal lobe (3 mm in size) and the left parietal lobe (8 mm) (Figure ). The two lesions were treated with SRS to a dose of 24 Gy in a single fraction (24 Gy/1). At 30 months, she developed a new metastasis in the right parietal lobe (16 mm) (Figure ). This was treated with SRS to a dose of 24 Gy/1. At 34 months, an MRI showed a new lesion in the left temporal lobe (5 mm) (Figure ), which was treated with SRS (24 Gy/1). At 44 months, brain imaging showed a fourth recurrence at new sites in the right parietal lobe (6 mm) (Figure ) and left temporal lobe (3 mm). The first lesion was treated with 24 Gy/1; the second lesion was treated with 18 Gy/1 because of the proximity to a lesion previously treated with SRS. The patient died at 56 months from the time of her initial pathologic diagnosis. At the time of her death, there was radiographic progression of the right parietal lobe lesion treated 26 months prior, while all other treated brain lesions were no longer visible. There was no recurrence of disease in the thorax. The only site of extracranial progression was lymphadenopathy in the neck in which there was a complete clinical response to palliative radiotherapy.\nThe SRS technique at our institution uses a frameless stereotactic mask system. Patients have a contrast enhanced CT and MRI scan to delineate the gross tumour volume and a 1.5 mm isotropic expansion for the planning target volume (PTV). Planning is performed on the BrainScan/iPlan stereotactic planning software (Brainlab AG, Germany) using multiple arcs and 3 mm multileaf collimation. The dose prescription is to the 80% isodose volume covering the PTV.\nClinically, the patient was asymptomatic and back to her normal baseline functional status by six weeks after WBRT. At 23 months, she reported bilateral hearing loss. Audiology showed profound bilateral sensorineural hearing loss in the 1000 Hz range. At 28 months, her family reported a decline in short-term memory. This was followed by a gradual progression of forgetfulness, anxiety, personality changes, and a lack of initiative, which did not coincide with the presence or absence of brain metastases. At the end of her life she suffered from a severe dementia. The specific cause of death was not known and an autopsy was not performed. |
A 60-year-old woman was addressed to our department for multiple inflammatory collections on the face 14 days after HA injections by her plastic surgeon in February 2016. She had received 1 ml of HA (Volbella®, Allergan, Dublin, Ireland) injections on each cheek for the treatment of wrinkles. It was her third HA injection and she reported satisfactory results without adverse events in the past. The patient was in good health and not known for any type of allergies. At day 1, the patient presented a sore throat without fever. At day 10, she observed pain, redness and oedema at multiple injection sites of the right cheek and consulted her injector physician. A swab test confirmed a streptococcal throat infection and the patient received a first treatment of amoxicillin and clavulanic acid. After 24h, the same inflammatory signs appeared on the left cheek and pustules were noted on the right cheek, allowing a bacterial sample analysis. At day 12, after 72h of antibiotic treatment, the patient developed multiple pustules over the entire body. An allergic reaction was suspected and the antibiotic regimen was switched to azithromycin. She was referred to our consultation at day 14 following worsening erythema and oedema of the face without fever. Physical examination showed warm and swollen cheeks with multiple painful indurations without collection. The antibiotic treatment was switched again to clindamycin following consultation with an infectiologist. Due to a worsening status with multiple palpable collections in both cheeks, the patient was hospitalised on day 16 (). The white blood cell count was 17.9 G/l and C-reactive protein was 29.1 mg/l. Incision and drainage performed at the bedside showed coagulated blood mixed with a sticky liquid like pus. Treatment with intravenous amoxicillin and clavulanic acid was started once again. Due to the occurrence of new collections, magnetic resonance imaging was performed and showed a diffuse infiltration of cutaneous and subcutaneous tissues with confluent subcutaneous collections in both cheeks (). Drainage under general anaesthesia was performed on day 20. The collections exuded approximately 5 ml of coagulated blood with a greyish viscous material. She presented other lesions that were indurated without collection at the time of operation. However, these lesions transformed to collections a few days later. Daily bedside collection drainage and antiseptic rinsing and antibiotic treatment were continued. All bacterial analysis and culture were negative. The clinical and biological evolution was favourable and the patient returned home after 11 days of hospitalisation. However, during the first 2 weeks backed to home, she continued to have new collections that needed drainage of the same type of liquid. After this period, she presented post-inflammatory induration on both cheeks that improved with daily physiotherapy and intense pulsed light therapy once a week. At 6 months, the patient presented aesthetic sequelae (). |
A 70-year-old male with a past medical history of aortic stenosis, hypertension, type 2 diabetes mellitus, dyslipidemia, and benign prostatic hypertrophy presented to the emergency room following a near syncopal episode and fall at home. He described the event as an episode of dizziness and denied any loss of consciousness, palpitations, or chest pain. Although the fall was unwitnessed, the patient’s wife claimed that the patient was fully alert and oriented upon assisting him within one minute of the fall. Of note, the patient did endorse increasing fatigue over the past month but denied any syncope or near syncopal events prior to this episode.\nThe patient was on semaglutide and glimepiride for diabetes and had experienced two hypoglycemic episodes in the past year, however, he stated that this event felt different, and he endorsed no resolution of symptoms after taking a glucose pill. The patient had been on doxazosin 4 mg for several years for the treatment of his benign prostatic hyperplasia without any complaints. Notably, the patient was not on any heart rate controlling medications.\nUpon further investigation, it was discovered that the patient had undergone a treadmill stress test two weeks prior as part of presurgical clearance for a noncardiovascular procedure. The patient experienced no angina during the test, and serial electrocardiograms (ECGs) revealed no ST or T wave abnormalities or arrhythmias. Previous echocardiograms were unable to be obtained as the patient endorsed not having seen a cardiologist in at least seven or eight years due to lack of cardiovascular-related symptoms. The patient did have a coronary artery catheterization performed in 2003 for a complaint of chest pain, which revealed a dominant circumflex system and a normal left ventricular function with no coronary artery disease. No further workup was done regarding this event.\nOn admission, the patient was hemodynamically stable with a baseline heart rate between 50 and 60 beats per minute (bpm). Physical exam was normal except for a 2/6 systolic ejection murmur at the right upper sternal border. The patient was awake, alert, and oriented during the admission interview. Initial electrocardiogram (ECG) showed sinus rhythm at 60 bpm with mild left axis deviation and no AV block. Laboratory testing revealed a troponin I of 0.01 ng/dl, pro-B-type natriuretic peptide (Pro-BNP) 54 pg/ml, thyroid-stimulating hormone (TSH) 1.0 mIU/l, glucose 117 mg/dl, and electrolytes within normal limits.\nDuring orthostatic testing of the patient, the nurse noticed the patient became lightheaded upon standing for a period of 10-15 seconds before returning to baseline. This period corresponded with a telemetry reading of asystole for nine seconds (Figure ). Upon further evaluation, the telemetry strip revealed the presence of P waves with total absence of corresponding QRS complexes. After this nine-second period, the rhythm spontaneously returned to a normal 1:1 P to QRS conduction with a normal P-R interval and a heart rate of 50 bpm. Cardiology was immediately consulted and diagnosed the patient with PVS. Repeat ECG at this time revealed sinus bradycardia at 53 bpm with no AV block. During cardiology’s evaluation of the patient, he underwent another five seconds of PVS, this time with the spontaneous return to sinus bradycardia at 30-35 bpm with no AV block (Figure ). At this point, it was decided that the patient should undergo an urgent dual-chamber pacemaker placement, following which he became asymptomatic with a heart rate of 70-80 bpm. |
A 15-year-old woman with no medical history was admitted to our intensive care unit (ICU) a few hours after a longboard fall without initial loss of consciousness or head trauma. The patient was not able to walk and she had to be transported to find help. When the medical team arrived, she was conscious, Glasgow coma scale (GCS) of 15, without hemodynamic or respiratory instability and with a left femur fracture. During the medical transport, she received analgesics medications and immobilization after the reduction of the fracture. The initial body CT scanner, performed 3 hours after the trauma, found a left femur fracture and an anterior left pneumothorax, without cerebral lesions.\nShe presented secondarily a neurologic status impairment with a GCS of 11, initially attributed to an excess of analgesic therapy. Anyway, she was operated with a left femoral nailing during which a prolongated hypotension without hypovolemia or other obvious causes occurred. At the end of the surgery, 7 hours after the initial injury a new brain scan was performed. It showed the appearance of a cerebral swelling ().\nPostoperatively, she was admitted to the ICU because of consciousness disorders requiring a drug induced coma to permit a mechanical ventilation. A cerebral fat embolism was rapidly suspected. Despite a hemodynamic stability and a normality of the PaCO2, the transcranial Doppler ultrasound found a bilateral high pulsatility index at 2.2 and low end-diastolic flow velocity below 20 cm/s. These Doppler profiles led us to suspect an intracranial hypertension. A new brain CT scan, performed 16 hours after the trauma, confirmed a diffuse major cerebral edema. No other organ dysfunctions, rash, or petechiae were noticed.\nThe patient was managed as a severe brain injury. An intracranial pressure catheter was inserted and found a very high intracranial pressure (ICP) of 75 mmHg. Despite a maximal medical treatment including osmotherapy, hypothermia, barbiturate sedation, and use of neuromuscular-blocking drugs, the ICP remained above 35 mmHg. Twenty-two hours after admission, the patient presented a bilateral reactive pupillary enlargement. The neurosurgeon immediately performed a decompressive right fronto-temporo-parietal hemicraniectomy. Afterwards, the intracranial pressure remained between 20 and 25mmHg and an external ventricular derivation was inserted. A control brain CT scan was performed ().\nOn the fourth day, the patient presented signs of brainstem injury with a bilateral unreactive mydriasis and loss of oculocardiac reflex despite the normalization of the ICP under 20 mmHg. The patient was still under sedative drugs. A cerebral magnetic resonance imaging (MRI) was carried out. T2-weighted, fluid-attenuated inversion recovery, and diffusion-weighted magnetic resonance imaging showed diffuse punctate hyperintense foci of restricted diffusion in both cerebral and cerebellar hemispheres, with susceptibility artifacts on susceptibility weighted MRI sequences in keeping with petechial hemorrhagic foci, in a starfield pattern ().\nProgressively, her consciousness improved with a GCS 9 (M4, V1, E4) ten days after the trauma. One month after her admission she was discharged to a rehabilitation center with a GCS 11 (M6 V1 E4). At two months, she was still improving with a GCS 15, but with persistence of few cognitive disorders evaluated by brain trauma scales: Montreal Cognitive Assessment scale at 26/30; Ranchos scale at VII. The cerebral MRI at three months showed a regression of the multiple punctate hypersignal lesions on diffusion sequences and a disappearance of the hypersignals FLAIR and diffusion of the striatum (). At 6 months after the trauma, she could reintegrate her school. She kept only some headaches and an asthenia one year later.\nWe have the patient's consent for publishing this case report. The ethic committee approval was not required according to French legislation. |
A 15-year-old female with a past medical history of obesity presented to the emergency department with a marked 90-degree flexion at the thoracolumbar region. She was able to walk only by using a walker in an unusual manner; she placed her axillae on the hand grips. The patient described constant back pain almost daily for which she took ibuprofen with moderate relief. These symptoms began three years ago following a sexual assault and have progressed significantly. As per the patient's mother, the only time the patient's spine straightened out was during deep sleep. She had no neurologic complaints, specifically denying any sensory or motor deficits, fatigue, ptosis, or any complaints consistent with any form of endocrinopathy. Her family history included siblings with epilepsy, ADHD, and mood disorders.\nThe patient denied any substance abuse, including use of alcohol or cigarettes, as well as being sexually active. She reported no history of mood or psychotic symptoms and no suicide attempts.\nDespite the pain, however, the patient was not concerned with her condition. The patient herself was not interested in physical therapy or additional diagnostic testing or counseling despite her mother's encouragement. She refused a gynecological examination due to anxiety following having been a victim of sexual assault; it was unclear the extent of counseling, if any, she received following the assault.\nThe patient was a seventh grader at a local school where she participated in extracurricular activities. She reported being well accepted by her peers. She stated having a good social support network including friends and family. Her parents were separated and she lived with her mother and brother.\nPhysical exam revealed an obese (BMI 39.2) Caucasian female, leaning forward with the spine nearly ninety degrees at the waist. Extremities showed normal strength, sensation, and range of motion. The patient was unwilling to attempt spinal extension. Tenderness to palpation of the paraspinal muscles was present. The rest of the physical examination was unremarkable.\nUpon Pediatric Neurology consultation, no evidence of neuromuscular disease was found. Plain radiography of the cervical, thoracic, and lumbar spine was limited due to her deformity, but no abnormalities were noted. Magnetic resonance imaging of the same was unrevealing. Psychiatric consultation was obtained; they concluded that the patient's symptoms were likely manifestations of Conversion Disorder, following exclusion of organic causes.\nWhile she is currently receiving social services support and physical therapy; she declines psychiatric outpatient care at this time. |
A 53 year old Pakistani lady presented to the Medicine clinic of a local hospital in 2004 with a history of heel pain and lower back pain for 5 months. In this period, the patient had sustained a rib fracture and left humeral fracture. There was no history of diabetes, hypertension or any other chronic disease. She had not been on any form of medication, including steroids and traditional drugs widely available and prescribed in the region, prior to the onset of pain. At the time of the fractures, she had been placed on non steroidal anti inflammatory agents, acetaminophen and tramadol. There was no history of illicit drug use and she was a non smoker. Family history was unremarkable, particularly in the context of bone disease, and malignancy.\nInitial laboratory investigations had shown a mildly elevated total calcium level of 10.8 mg/dL {2.7 mmol/L}-(no albumin level result available from that time for correction). Parathormone levels (PTH) had not been determined. There was no vitamin d or renal function report available from that time. X-Ray pelvis revealed lytic lesions in the right iliac bone (Fig. ). A magnetic resonance imaging (MRI) of the lumbosacral spine showed some signal changes. The differentials based on the MRI were metastatic bone disease or multiple myeloma.\nSerum protein electrophoresis was normal. The patient then got lost to follow-up. Her work up was resumed 4 years later when her bone pains had started flaring up. Bone marrow examinations done back in 2007, and later in 2009, were negative for multiple myeloma. A bone scan in November 2009 showed generalized increased tracer uptake over the skull and both the axial and appendicular skeletons- findings in favor of metabolic bone disease (Fig. a). An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the neck or superior mediastinum. No serum PTH report was available from this time either. Following this workup, the patient was treated empirically for bone pains with calcium supplements, an empiric vitamin d injection, and intravenous zoledronic acid 5 mg (without prior bone mineral density assessment via DXA scan). This empiric treatment was instituted by an orthopedic surgeon whom she had been referred to. The patient experienced only a slight improvement in bone pains with this treatment and also developed nausea, vomiting and anorexia. Subsequently, she sought care at the National Institute of Diabetes and Endocrinology, Dow University Health Sciences, Karachi, Pakistan.\nAt presentation, the patient was well oriented and of functional class 3 (wheel chair bound, able to walk only with support). Her blood pressure was 110/70 mmHg. Neck examination revealed no mass or lymphadenopathy. She had a significant proximal myopathy as well as curved thighs. She had shortened fingers, and spinal scoliosis was evident. Severe generalized bone tenderness was elicited. There was no focal deficit. Laboratory investigations at this time showed a calcium level of 15.1 mg/dL{3.775 mmol/L}, (corrected for albumin of 3.6 mg/dL{36 g/L}); Vitamin D3 level of 33.92 ng/mL{84.664 nmol/L}; phosphorus 2.3 mg/dL {0.743 mmol/L}and alkaline phosphatase of 1298 IU/L {21.633 µkat/L}. Her 24 h urine calcium was 155 mg/day {3.875 mmol/day}, with urine calcium to creatinine ratio of 0.02. Her creatinine level was 1.3 mg/dL {114.92 µmol/L}(Table ). The estimated glomerular filtration rate (calculated through Cockcroft-Gault equation) was 50 mL/min {0.835 mL/second).\nFollowing these tests, the patient’s PTH level was ordered and determined to be 2105 pg/mL {2105 ng/L} [Table ]. Ultrasonography of the neck showed a solid hypo echoic, well-circumscribed mass lesion, measuring 1.8 × 1.2 cm at the lower pole of the right lobe of thyroid. There were no calcifications or lymphadenopathy. Appearances were suggestive of parathyroid adenoma. Both lobes of the thyroid appeared normal. A repeat planar sestamibi scan, (requested from a different institute in the city), revealed areas of tracer retention over upper and lower poles of the right lobe of thyroid. The intensity of retained tracer was more over the right inferior parathyroid gland. The findings were highly suggestive of hyperparathyroidism (Fig. ).\nA bone mineral density scan showed a T score of − 2.9 in the spine, − 3.8 in the hip and − 4.5 in the distal forearm, consistent with severe osteoporosis. The Z scores at the spine, hip and distal forearm were − 2.0, − 3.1 and − 3.6, respectively (Table ).\nUltrasonography of the kidneys revealed a single renal stone (0.6 cm) and no neprocalcinosis.\nBased on the biochemistry results of hypercalcemia, associated with elevated PTH levels, a diagnosis of primary hyperparathyroidism was made. Subsequent sestamibi scan and neck imaging facilitated us to localize the abnormal parathyroid gland. The DXA scan was useful for evaluation of the bone mineral density. In view of the phenomenally high levels of parathyroid hormone, (more than 10 times upper limit of normal), the pre-operative suspicion of parathyroid cancer was high [, ]. The patient was rehydrated with intravenous fluids. Subcutaneous calcitonin injections at a dose of 4 units/kg every 12 h were administered to tide her over until the surgery. Once her calcium levels had come down to 10.5 mg/dL {2.625 nmol/L}L, she was operated upon. At surgery, right hemithyroidectomy and inferior parathyroidectomy with level six lymph node resection was done. The lymphadenectomy was performed as there was evidence of enlarged lymph nodes at neck exploration. The size of the lesion was measured as 2.5 × 1.5 × 1 cm. Histopathology showed features consistent with parathyroid cancer (Fig. a–d). Capsular invasion and focal vascular invasion were noted. However, margins of excision were tumor free. The excised lymph nodes did not show evidence of tumour infiltration. The patient was not given external radiation therapy postoperatively. Literature review revealed that post operative adjuvant radiation therapy may only have a role in the management of patients with a histologically positive margin following en bloc resection, or in those with lymph node metastases [, , ].\nPostoperative PTH level, performed on the second day of surgery, was 59 pg/mL {59 ng/L} (16–87). On the third postoperative day, the patient’s serum corrected calcium declined to 6 mg/dL {1.5 mmol/L}. This was associated with paresthesias around her mouth and carpo-pedal spasm. There were no seizures, although there was some confusion in terms of time and place. Intravenous calcium (2 g calcium gluconate, equivalent to 180 mg elemental calcium, in 50 mL 5% dextrose water) was infused over 20 min. Re-monitoring of calcium levels revealed persistent hypocalcemia. A slow infusion of calcium was initiated at an initial rate of 50 mL/h. This was prepared by adding 100 mL of 10% calcium gluconate (equivalent to 900 mg elemental calcium) to 1000 mL 5% dextrose water. The infusion rate was adjusted, with a goal to maintain calcium levels at lower end of normal range. On the fifth post-operative day, the calcium level had risen to 9.0 mg/dL {2.25 nmol/L}. Neurologic examination was normal and she was tolerating oral diet. Oral calcium supplementation was initiated (Qalsan D four times daily-equivalent to 2 g elemental calcium per day). She was discharged on oral calcium and vitamin D supplementation with active vitamin D, (calcitriol) 0.25 µg twice daily, in a stable condition.\nAt follow-up, her appetite and mobility had improved significantly, although she continued to experience bone pains. Corrected calcium was 9.5 mg/dL {2.375 nmol/L}. A repeat skeletal scintigraphy done 3 months after parathyroidectomy did not demonstrate a significant change in the lytic lesions (Fig. a, b). A repeat DXA scan 2 years down the line revealed a significant improvement in bone mineral density at all sites, though more so at the spine and hip, than at the forearm (Table ). Thereafter, we followed her clinically, as she was not keen to have further radiologic testing done. We have been monitoring her calcium and PTH levels on an annual basis. They have remained within their normal range till date (2018). She is now functional class 2, (no longer wheel chair bound), and on regular calcium and vitamin D supplements (patient perspective, attached as Additional file ). |
A 74-year-old man with neurofibromatosis presented with a new-onset forehead swelling and right eye deviation, which had been progressive over the past few months (). The patient had a history of surgical excision and full thickness skin graft for a forehead neurofibromatosis about two years ago. Subsequent to this, the tumor recurred and increased in size but was not associated with pain, headaches, epistaxis, nasal discharge or obstruction, or malodor. The patient did not report systemic symptoms such as fever or weight loss.\nOn examination, respective visual activity was 0.2 and 0.15 for right and left. His right eye deviation was to the inferolateral side with superior and medial gaze limitations. Diplopia was pronounced with upper gaze. The mass was about 5 × 6 cm in size, irregularly shaped, tender to palpation, and without overlying skin changes. On palpation, the mass was of mild tenderness, soft and fixed. No pulsation or bruits were observed (). He had café au lait spots and multiple neurofibromatosis throughout the entire body. The patient did not have any familial history significant for neurofibromatosis.\nComputed tomography revealed the mass to involve the right orbital cavity as well as the frontal and ethmoid sinuses. The 4 × 4.5 cm mass was found to have a locally expansile effect, with partial erosion of the anterior, posterior frontal sinus wall, lateral ethmoid wall, and compressive right orbit. The lesion did not extend into the nasal cavity or intracranium ().\nUnder general anesthesia, the patient underwent a mass resection through the forehead scar from the previous operation. The mass was removed along with the skull base and lateral nasal wall, using suction and curettage. In the orbital cavity, the mass was dissected sharply from the surrounding tissue to preserve the ocular muscles. After mass excision, defects of the medial orbital wall and nasal bone and frontal sinus anterior wall were reconstructed with Medpor. The postoperative course was complicated by necrosis of the skin flap over the right medial canthus and nasal dorsum (1.5 × 2 cm). The resulting defect was reconstructed with a left nasolabial fold island flap under local anesthesia 2 weeks after the mass resection.\nOn histologic examination, the excised specimen was identified as a cellular infiltration lesion made up of pleomorphic spindle-cells. The nuclei were pleomorphic and atypical. On immunocytochemistry, the tumor cells were found to express S-100 protein and were focal positive for Ki-67. Tumor morphology and immunocytochemical phenotype were consistent with a MPNST ().\nAfter surgery, the right eyeball position and movement was improved, but partial asymmetry and limitation remained (, ). The patient was followed up for 6 months without signs of recurrence or other complications. |
A 62-year-old woman suffered from severe low back pain after an accidental fall 10 days ago. Low back pain was obvious when turning over and getting out of bed. It was not relieved after bed rest and conservative treatment. Visual analog scale (VAS) of low back pain was 8 points and Oswestry Disability Index (ODI) score was 80%.\nPhysical examination showed that the patient with limited lumbar flexion and extension activities. There was severe slamming pain in L2 and L3 spinous process plane but no lower extremity radiation pain. Skin feel and muscle strength of lower lims were normal.\nX-ray, computer tomography (CT) and magnetic resonance imaging showed OVCF of L2 and L3 (Fig. ). The bone density T value was -4.8. OVCF and postmenopausal osteoporosis were diagnosed.\nWe performed modified extrapedicular kyphoplasty for the patient. The distance of skin puncture point and puncture angle were calculated according to preoperative CT (Fig. ). The midpoint of vertebral body was point a and the outer upper edge of pedicle was point b. The line connecting point a and point b was m. The intersection of line m and the skin was point c. The midline of the vertebral body was n. The intersection of line n and the skin was point d. The distance between point c and d was 62 mm. The angle between line m and n was 42°. So the distance of skin puncture point to the midline of the spinous process was 62 mm. Outreach angle of puncture needle was 42°.\nThe patient was placed in a prone position. An image of the vertebral body was adjusted under fluoroscopy with anteroposterior (AP) and lateral views (Fig. ). The midline of the spinous process was marked as line o. Parallel line p was marked with 62 mm on the right side of line o. The line connecting the upper edge of the right pedicle to the lower edge of the left pedicle was marked as q. The intersection of q and p was marked as point e which was the puncture point of skin. Local anesthesia with 1% lidocaine. A puncture needle was used to probe the entry point. The entry point of vertebral body was outer upper edge of pedicle in AP view and upper edge of pedicle in lateral view. The puncture direction was from the upper edge of pedicle to the lower edge of contralateral pedicle. Outreach angle of puncture needle was 42°. It was replaced with a tube when the needle entered vertebral body.\nA drill was used through the tube. The ideal position of drill tip should cross the spinous process in AP view and cross the center of vertebral body in lateral view. The balloon was used to restore vertebral height. Finally, bone cement was injected. The same technique was performed in L3 and L2. The amount of bone cement was 4 mL in L2 and 5 mL in L3. The distribution of bone cement was satisfactory and without bone cement leakage. The operation time was 20 minutes. The intraoperative blood loss was 5 mL.\nAfter the procedure, the patient was placed in the supine position and asked to remain flat for at least 2 hours. The patient was encouraged to ambulate from the next morning.\nVAS of low back pain was 2 points in 1 day after surgery. VAS of low back pain was zero point and ODI score was 10% in 12 months after surgery. Preoperative symptoms were significantly improved. Postoperative CT showed the satisfaction of bone cement was satisfactory. |
The subject is a 38-years-old woman living in Northern Italy. She smokes about 20 cigarettes per day and usually drinks 1-2 glasses of wine per day during meals. Her dietary habits are peculiar: since long time she has been having a marked preference for beef meat, while she does not like other types of meat or fish, nor vegetables or fruit. Accordingly her diet is substantially unbalanced, consisting mainly in grilled or roasted beef meat. As her family has long since had a cattle breeding, she is used to eating almost exclusively meat from the family farm.\nIn the winter of 2004 the family farm animals started to show various disorders, such as slowing growth rate, delayed sexual development, gastrointestinal tract disorders, increasing incidence of several infective diseases, abortions and increase of overall mortality. The veterinarians considered different causes and carried over various treatments, as antibiotic therapies, without significant results. Aflatoxicosis is a rare disease in the area, as a consequence the possibility of AFs intoxication was not considered at the time.\nFor years the animal feed had been supplied by the same producer, but in the late spring of 2007, among the attempts applied to find a solution, the feed supplier was changed.\nIn late summer of 2007 the cattle recovered and the disorders gradually subsided. Later on (autumn 2007) the patient's family acknowledged that some analyses performed on the animal feed back in 2006 had revealed AFB1 levels up to 25 µg/kg. The maximum level of AFB1 in animal feed permitted by the European Union (EU) is 5 µg/kg. Further data are missing, since the former supplier refused to produce records about other analyses in feed. Accordingly the possibility of higher concentrations of AFs in feed exists. After the finding of high AFB1 levels in feed, the symptoms and signs observed in the animals were reconsidered by the farm veterinarians, who agreed that an AFs intoxication was possible. Unfortunately it was not possible to perform specific laboratory tests in the animals since too much time had passed from the end of contaminated feed consumption. However a relation between the disorders observed in animals and AFs is supported by documented feed AFB1 levels exceeding the EU limit value, animal case history consistent with aflatoxicosis, temporal correspondence between onset of disorders and consumption of potentially contaminated feed, and submission of disorders after feed replacement, according to the temporality principle of causality.\nIn the subject under examination, previous medical history did not account for any relevant disorder nor hospitalization before winter of 2004, when episodes of nausea, abdominal swelling, constipation alternating with diarrhea and abdominal pain appeared. The frequency of symptoms increased during the following months including several episodes of intense abdominal pain.\nThe subject underwent several medical examinations to rule out major causes of abdominal pain. Repeated gastrointestinal X-rays and abdominal ultrasonography were performed from May to September 2005, along with a uterine ultrasound scan (November 2005), but they showed no apparent alterations. In September 2005 a stool examination was carried over and proved to be negative for pathological microorganisms or parasites, and no steatorrhea was observed. Antibody tests for celiac disease were negative. Repeated blood analyses were substantially normal, including pancreatic enzymes and liver function tests (serum glutamic-pyruvic and glutamic-oxaloacetic transaminases, alkaline phosphatase, gamma-glutamyl transpeptidase, bilirubin, albumin and total proteins). Blood viral hepatitis antibodies were negative.\nDuring 2006-2007 abdominal pain was so intense that the patient repeatedly attended the Emergency Department of the local area hospital. Twice "mittelschmertz" was diagnosed, other times a generic diagnosis of "acute abdominal pain" was made. Tramadol was effective in pain reduction.\nDuring the whole period the subject's diet remained substantially unmodified, and she has never ceased eating meet from the family farm. Nevertheless, after the animal feed supplier was changed in autumn of 2007, the meat was no more contaminated. The abdominal symptoms subsided by October 2007, and no further episodes of abdominal pain have ever since been reported.\nThe timing of signs and symptoms both in animals and in the case are described in Table . |
The patient described in this case report is a 34-year-old woman with the diagnosis of hereditary PAH. Several male family members on her father’s side had succumbed to the same disease around the age of 35 years. Her mother suffers from depression, and one brother has panic attacks. After finishing high school, the patient became a professional and worked in various physical health fields. She lives together with her boyfriend and in 2017 gave birth to her first child.\nThe patient reported dyspnea on exertion after giving birth to a healthy child in 2017. However, despite this fact and the above-mentioned family history, diagnosis of PAH was not made until December 2018 when she was admitted to our hospital as an emergency with right heart failure after pulmonary infection. She recovered with supportive measures and introduction of PAH treatment with macitentan, an endothelin receptor antagonist, and tadalafil, a phosphodiesterase-5 inhibitor. When she returned home, she continued to experience severe limitations in everyday situations. For example, she was not able to carry her child as she felt too weak. In addition, she was afraid of any illness her child could infect her with. She felt incapable of looking after her child on her own and was dependent on other people’s support. As soon as she experienced signs of being ill, she went to specialists for check-ups. She was very quickly physically exhausted and had an increased need to sleep. Her situation led to intensive worrying about her self-image, her future, and her health. She cried more than before and experienced panic attacks several times per week. She feared her death and felt guilt toward her family members. Further on she repeatedly kept comparing her current situation to how it was before she was diagnosed, which led to despair and hopelessness. Her everyday life was dominated by anxiety, safety behaviors, and despair. She could hardly be by herself and was dependent on reassurance from others. She was grateful for the internal specialist’s referral to the department of psychiatry to seek help.\nConsultation by the department of psychiatry resulted in the diagnosis of a severe adjustment disorder and she was registered for treatment.\nIn February 2019, she had a first appointment at the Department of Psychiatry, Social Psychiatry and Psychotherapy for a diagnostic assessment, and inpatient treatment started eventually in March. Treatment duration was 4 weeks. At both time points before treatment (T0a: diagnostic assessment, T0b: day of hospitalization) as well as at the end of treatment (T1) and 6 weeks after treatment ended (T2) she completed a set of questionnaires including the Hospital Anxiety and Depression Scale (), and the Metacognition Questionnaire (). At the start of treatment, she reported significant mental distress, indicated by a sum score of the anxiety subscale of the HADS of 13 points, and 7 points on the HADS depression subscale. These scores indicated that anxiety was severe and predominant. The scores of the MCQ-30 show that negative beliefs about uncontrollability and danger of worry were strongest. All scores are presented in . The patient gave written informed consent for the publication of this case report.\nFor the treatment with Metacognitive Therapy (MCT), the manual () was followed. During 4 weeks of inpatient treatment, the patient received weekly MCT sessions lasting 50 min each. In the first session, a personalized case formulation was developed using the generic model (), which is presented in . The patient was socialized to the model and the role of the cognitive attentional syndrome (CAS) was illustrated. Further, the patient was asked to rate the intensity of individual positive and negative metacognitive beliefs (). In the second session, Attention Training Technique (ATT; ) was introduced by using the German version of the audio file and the self-attention rating scale. Further, detached mindfulness was introduced by using the phone metaphor. For homework the patient was asked to do the ATT twice a day and practice worry postponement whenever her CAS was activated. In session number three, detached mindfulness was practiced again using the free association task several times. After the second repetition, subjectively difficult words were included in the task. In the beginning of the third session, the patient was also asked to rate the metacognitive beliefs formulated and rated in the first session (). The individual positive and negative metacognitive beliefs had already decreased to almost 0% and so no further challenging was undertaken. In the fourth session with the use of the “old plan – new plan” protocol was used to consolidate the change of strategies and attentional focus and metacognitive beliefs formulated in session 1 were again checked (). The patient was asked to repeat ATT after discharge for another 4 weeks.\nAssessment of metacognitive beliefs using the MCQ-30 () demonstrated a significant reduction in positive and negative metacognitive beliefs, and a significant reduction in maladaptive coping strategies including all elements of the CAS. This improvement was accompanied by a reduction in symptoms of anxiety and depression assessed with the HADS (). Interestingly, we also found an improvement in physical symptoms. As part of the routine assessment for patients with PAH, walking distance is regularly measured, and the patient had a 23% increase in walking distance after the end of MCT treatment (). At 6 week follow-up, results concerning metacognitive beliefs and maladaptive coping strategies remained stable, while assessment of anxiety and depression symptoms revealed further improvement ().\nIt can be reported that the treatment was well tolerated by the patient and no adverse effects could be identified. |
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 48-year-old female came to our observation due to a limitation in mouth opening range. She also reported crepitus sounds at the left TMJ as well as pain, exacerbated by function (e.g., chewing) and increasing in intensity over the past three months. Clinical assessment showed a limited mouth opening (i.e., 22 mm) and pain with palpation at the left joint and all the main masticatory muscles, more severe on the left side. At the first appointment (T0), mandible manipulation was performed to achieve a forced opening of about 40 mm. A magnetic resonance (MRI) was prescribed to assess the disc-condyle relationship as the possible source of limitation in mouth opening and to gather some pictorial evaluation of the presence of joint effusion (). Despite the clinical suspicion of TMJ arthritis, computerized tomography was not prescribed at this stage due to the expected low impact on treatment planning decisions.\nMRI showed a regularly shaped condyle, with an anteriorized disc at closed mouth. At the maximum mouth opening, the condylar translation is reduced and the disc is not recaptured. Joint effusion of severe entity is also present. A conservative approach to provide pain relief and to manage muscle tension was provided, based on counseling, a home program of self-exercise and a stabilization appliance to wear at night. After three months, symptoms improved only partially, with a reduction of pain with muscle palpation but a steady pain at the left joint.\nBased on that, a cycle of five arthrocentesis plus viscosupplementation with hyaluronic acid (Sinovial, IBSA) has been performed weekly. Clinical data has been recorded at each time point before each injection and 15 days after the last one ().\nAfter one month from the last arthrocentesis plus viscosupplementation, the patient still showed some pain and, more important, still felt a limitation in the unassisted mouth opening and right laterotrusion. A diagnosis of TMJ intermittent locking on the left side was thus performed, and given the difficulties to stabilize clinical symptoms and mouth opening with the usual conservative approaches, the patient was planned for a surgical removal of the TMJ disc with concurrent HAM positioning ().\nTMJ surgery provided condyle remodelling and discectomy (Figures –), after which a HAM patch is positioned within the intra-articular space (), and stratified stitching is performed to avoid postoperatory scars (Figures and ).\nThree months after the intervention, the patient showed no negative exitus or postsurgical side effects. Jaw range of motion was increasing, both as for unassisted mouth opening (38 mm) and right laterotrusion (8 mm). The patient reported an overall improvement in chewing efficiency as well as the absence of pain ().\nFive months after surgery, a new MRI was performed (). The images showed the physiological excursion of the TMJ condyle during mouth opening (). |
A previously healthy 25-year-old man was admitted to our hospital after a gunshot wound on May 1987. The bullet had entered the left side of his back at the 10th intercostal space and passed upward and laterally to exit at the fifth intercostal space three centimeters medial to the anterior axillary line. The patient had sustained colonic perforation, left diaphragmatic, splenic and lung lacerations and left bronchial rupture. A left thoracostomy tube was inserted and the gunshot entrance and exit wounds were sealed. While supportive therapy was ongoing, he developed tachycardia and fever and was found to have diminished breath sounds and dullness to percussion over the left lower thorax. A chest X-ray revealed left pleural effusion, which proved to be an empyema. With suspicion of esophageal perforation, he was taken to the operating room on the third day of admission. After exploration, fecal material and displaced stomach were noted in the left chest cavity. The lacerated diaphragm was repaired, and a loop colostomy was performed. A splenectomy was also performed due to the splenic laceration.\nTwo weeks after the operation, there was a significant bleeding episode through the left chest tube. A chest X-ray revealed left lung collapse and left pneumothorax and hemothorax. Upper gastrointestinal endoscopy and bronchoscopy did not reveal the bleeding site. Fiberoptic bronchoscopy revealed thick yellowish secretions in the left lower lobe bronchus. The chest bleeding stopped spontaneously. Later, a foul-smelling greenish secretion appeared in the chest tube and continued for two months. Aerobic culture of the secretion revealed Klebsiella, Escherichia coli and more than 15 species of Gram-positive bacteria (due to contamination). The patient was treated with a variety of antibiotics. Two months later, a window for drainage of the secretion was made on the left hemithorax at the eighth intercostal space. A second bronchoscopy was unremarkable. Patient’s general condition was improved but drainage of the purulent secretions from the left thorax continued for another month. The patient was discharged in a stable condition six months after the initial admission.\nIn the months following discharge, the patient had cough, hemoptysis, epigastric pain, vomiting, dysuria, hematuria and left costovertebral angle tenderness. A repeat bronchoscopy revealed no discernible pathology. The repeat upper gastrointestinal endoscopy reported two small ulcers in the lesser curvature and the duodenal bulla as well as bile reflux, which were treated with appropriate medications. A non-opaque renal stone was noted on radiology. Intravenous pyelography further showed a distorted lower renal pole and ultrasound examination revealed a decreased echogenicity at the same area. Urine exam revealed microscopic proteinuria but was negative for acid-fast bacilli. One month later, a bronchography was performed owing to continued hemoptysis. This revealed the leakage of the contrast material into the left pleural cavity through a communicating port from a branch of the lateral segmental bronchus of the left lower lobe and progression of the contrast down to the stomach (Figure ). A diagnosis of GBF was made. A surgical repair was under consideration, but the patient’s condition improved with antacids treatment administered for a prolong period. Hemoptysis and melena gradually ceased without any significant pulmonary complications. In a 20-year follow-up, the patient had no recurrence of fistula. He was intermittently suffering from urolithiasis, urethral stenosis, occasional dysphagia, esophageal hiatal hernia, and intestinal adhesions. |
A 61-year-old man with a medical history of chronic neck and back pain secondary to a motor vehicle accident presented to the clinic with a 1-month history of worsening neck pain. The x-ray of the cervical spine showed evidence of degenerative disk disease, and he was prescribed hydrocodone. One week later, the patient returned with progressive worsening of pain associated with upper extremity weakness, decreased grip strength, numbness, and paraesthesias of bilateral upper extremities. Range of motion was impaired secondary to pain. Activities of daily living were reported to be severely limited as the patient was unable to dress or bathe himself without assistance. Social history was significant for a several year history of construction work and negative for tobacco or alcohol use. On examination, temperature was 36°C, blood pressure was 140/88 mm Hg, and pulse was 75 beats per minute. Point tenderness was noted on palpation of the cervical spine, and strength and range of motion testing were limited by severe pain.\nMagnetic resonance imaging (MRI) of the cervical spine ordered by the primary care physician showed extensive vasogenic edema of the brain and spinal cord as well as a single nodular lesion at the C4-C5 level (). The patient was subsequently admitted to the hospital and had an MRI of the brain, cervical, thoracic, and lumbar spinal cord. Imaging revealed innumerable ring-enhancing lesions throughout both cerebral hemispheres, basal ganglia, and cerebellum concerning for metastases. There was also evidence of a 6 mm × 14 mm × 9 mm-enhancing nodule in the right lateral ventral spinal cord at the level of C4-C5. No other spinal cord lesions were noted. Computed tomography (CT) of the chest, abdomen, and pelvis was ordered, revealing a dense consolidation of the left lower lobe (). Other CT findings concerning for metastases included mediastinal and periportal lymphadenopathy, a low-density lesion in the posterior spleen, and a nonspecific small sclerotic lesion of the left iliac bone. Although there was initially concern for an infectious process, blood cultures and infectious workup were negative. Transbronchial biopsy of the lesion confirmed the presence of a moderately differentiated adenocarcinoma of the lung with evidence of lymphovascular invasion. In the setting of wide metastases noted on CT, the disease was found to be consistent with stage IV adenocarcinoma of the left lung.\nPromptly after diagnosis, the patient was started on palliative whole brain radiation therapy and spinal radiation therapy. The tumor was found to be anaplastic lymphoma kinase (ALK) gene positive, and the patient was subsequently started on crizotinib, an oral tyrosine kinase inhibitor targeting ALK. Due to central nervous system (CNS) involvement, dexamethasone was initiated with plan for a long prednisone taper.\nThis patient’s disease course was complicated by steroid-induced psychosis and acute hypoxic respiratory failure which was believed to be multifactorial. He was found to have a left-sided pleural effusion for which a thoracentesis was performed. One liter of serosanguinous fluid was drained with cytology confirming a malignant effusion. Unfortunately, the patient experienced a prompt reaccumulation of loculated fluid, and his respiratory status continued to decline. He was ultimately discharged on home hospice. |
A 48-year-old woman was admitted to our clinic with the complaint of sudden and painless vision loss in her right eye for one day. She had no previous medical history and no history of neck pain, dizziness, or fever and drug usage. On ophthalmologic examination, there was just the light perception in the right eye and best corrected visual acuity (BCVA) was 20/20 in the left eye. Relative afferent pupillary defect (RAPD) was detected in the right eye. Anterior segment examination was normal bilaterally. Intraocular pressure was measured to be 16 mmHg and 17 mmHg in the right eye and in the left eye, respectively. Fundus examination in the right eye revealed pale retina with cherry red spot and left eye was normal. These findings supported the diagnosis of central retinal artery occlusion (). Ocular massage was done; oral acetazolamide was administered to the patient. To establish the etiology of central retinal artery occlusion (CRAO), consultations were sought with the cardiovascular surgery, hematology, and rheumatology experts. In the systemic examination, the patient's upper extremity pulses were not palpable. Magnetic resonance (MR) angiography revealed segmental stenosis of the left carotid artery, brachiocephalic truncus, and the left subclavian occlusion (). The patient was clinically diagnosed with TA and was referred to the rheumatology clinic. The patient received intravenous methylprednisolone 4 × 250 mg/kg per day for two days and continued with oral prednisone 48 mg per day and methotrexate 10 mg per day over four months. But there was no improvement in visual acuity of the right eye of the patient ().\nAfter 3 years, in ophthalmologic examination, there was no light perception in the right eye and BCVA was 20/20 in the left eye. Anterior segment examination was normal bilaterally. Intraocular pressure was measured to be 16 mmHg and 12 mmHg in the right eye and in the left eye, respectively. Fundus examination in the right eye revealed a pale optic disc. |
The case patient was a 40-year-old man with a cystic lesion on his right adrenal gland, as confirmed by CT, who had been observed in our hospital for several years. We decided to remove the cyst because it exhibited a growth tendency and we could not rule out the possibility of malignancy. The cyst measured 10 cm in diameter on CT just before the surgery was performed (Fig. ).\nThe patient was placed in the left lateral position. Figure shows the positioning of the ports intended for an intraperitoneal approach. First, a 20-mm transverse incision was made below the right costal margin on the midclavicular line; the endoscopic port was placed on this incision. Subsequently, other ports were placed with the use of an endoscope: 12- and 5-mm surgeon ports on the line parallel with the border of the rib arch and two 5-mm assistant ports on the superior part of the iliac crest and the right side of the umbilicus.\nAfter performing a Kocher maneuver to expose the inferior vena cava, we incised the peritoneum from the caudal side of the liver through the surface of the inferior vena cava to the caudal edge of the cyst. Lifting the liver and upper pole of the kidney allowed us to identify the central adrenal vein and to control it with metal clips. Detaching the cyst from the psoas muscle and the surface of the liver revealed that we could not observe the cranial aspect of the cyst because of the cyst itself. To address this difficult situation, we inserted a SAND balloon catheter (Hakko Shoji, Tokyo, Japan) through an assistant port. After puncturing the cyst (Fig. ) and aspirating some inner fluid through the inner needle of the SAND balloon catheter to prevent overflow, we inflated the distal balloon inside the cyst and the proximal balloon outside the cyst in sequence to hold the cyst wall with these balloons. Removing the inner needle led to complete discharge of the inner fluid of the cyst (Fig. ). This procedure allowed us not only to externally collect the fluid from the cyst, for which malignancy had not been ruled out, without any leakage to the operative field but also to pull out the cyst so as to easily perform adhesiolysis with a good field of view (Fig. ). Finally, the adrenal gland, including the cyst, was placed in a retrieval bag and extracted from the 20-mm endoscopic port incision without additional excision. The operating time was 220 min, and the calculated blood loss was 10 mL. The pathological finding showed lymphangiomatous endothelial cyst without malignant features. |
In February 2019, a 55-year-old man was referred to our department for further evaluation and treatment of a gallbladder mass. He had a history of nephrectomy for clear-cell RCC of the left kidney. Contrast-enhanced computed tomography (CT) performed just before the nephrectomy revealed a tumor measuring 9 cm at the upper pole of the left kidney that exhibited exophytic growth and had a heterogeneous solid and cystic consistency. Simultaneously, a small enhancing polyp measuring 5 mm in diameter was identified at the liver side of the gallbladder body (Fig. ). In December 2015, the patient had undergone an open radical nephrectomy, and the pathology report at that time revealed clear-cell RCC Fuhrman grade 3, and that pathological stage was T3 Nx.\nThe patient was followed up with CT scanning in an outpatient clinic, which indicated no suspicious lesions suggesting the recurrence of RCC except for the gallbladder polyp, whose diameter grew progressively by 5 mm in the following 34 months. The last CT scan performed before the patient's cholecystectomy in February 2019 showed that the polypoid gallbladder mass had grown and had a maximum diameter of 22 mm (Fig. ). Endoscopic ultrasonography showed a 24 mm smooth-surfaced, heterogeneously echogenic, polypoid mass. After contrast injection with Sono-Vue (Bracco, Milan, Italy), the lesion was shown to be well enhanced and the gallbladder wall under the lesion was intact (Fig. ). A chest CT and bone scan for evaluation of metastases were negative.\nWe performed a laparoscopic cholecystectomy in April 2019. Gross examination of the specimen showed a pink–red polypoid mass measuring 23 mm in the largest dimension that was detached from the inner mucosal layer. To decide on the extent of surgery needed, we checked an intraoperative frozen biopsy, which showed an RCC metastasis without involvement of the muscular layer. The final pathology diagnosis was gallbladder metastasis of clear-cell RCC. Microscopically, the lesion comprised malignant clear cells that were confined to the polyp and a negative margin (Fig. ). Immunohistochemistry was positive for CK and CD10, and Ki-67 expression was 20%.\nTo detect other possible metastases, we requested positron emission tomography after the cholecystectomy, which showed no lesions of the metastasis. The patient is free from disease and is in a satisfactory condition 10 months after the cholecystectomy. The patient provided written informed consent for publication of this report. |
A 25-year-old male presented at our clinics for a right shoulder pain related to a dorsal scapular mass first observed 4 months earlier. The main symptom was a shoulder discomfort when lying on his back, sometimes compromising the sleep. The patient also complained of some weakness when using his right arm under the shoulder level. The medical history consisted in a unique kidney and past treatments for a nodular sclerosis-subtype Hodgkin lymphoma (chemotherapy and radiotherapy, last treatment twelve years ago and no recurrence).\nThe physical examination revealed a nonmobile 3 cm T × 3 cm AP × 2 cm CC hard mass on the posterior superomedial angle of the right scapula, sensitive to palpation (). Muscle trophicity was symmetrical. The right shoulder presented a full range of motion in all directions without scapulothoracic dyskinesis. Weakness and pain were observed when raising the right shoulder or during active abduction (at all levels).\nA right shoulder radiological series including AP, lateral, and Neer views was described normal and conducted additional investigations. A thoracic computed tomography was performed and described a 2.6 cm T × 2.6 cm AP × 2.2 cm CC solid bone mass at the posterior aspect of the superomedial angle of the scapula. The diagnosis of an osteochondroma without signs of malignancy was stated (). No adenopathy or recurrence of the past Hodgkin lymphoma was observed. Retrospectively, the mass was apparent on the shoulder Neer view. A magnetic resonance imaging (MRI) including the right shoulder and scapula confirmed the benign character of the osteochondroma. The accessory nerve (XI) was compressed between the osteochondroma and the deep layer of the trapezius; no muscle atrophy was described ().\nThe osteochondroma was surgically removed under general anesthesia. The patient was prone, and a 10 cm incision was centered on the mass. The trapezius muscle was split at its superior part at the level of the scapula spine. The accessory nerve was visualized and protected in the deep layer of the trapezius muscle. The osteochondroma was exposed and resected from the supraspinatous fossa with an osteotome. The mass was perfectly smooth and measured 3 cm T × 3 cm AP × 2 cm CC (). The integrity of the accessory nerve was checked before closure. The histopathologic analysis confirmed the diagnosis of a benign osteochondroma ().\nThe shoulder was immobilized in a sling 10 days for wound care. Free mobilization was then granted. No physiotherapy was needed.\nThe patient was followed annually up to 3 years. He regained full shoulder range of motion and complete symmetric trapezius and rotator cuff strength. The patient has no clinical and radiological recurrence of the osteochondroma. |
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 7-year-old boy underwent the Nuss procedure at the age of 5 years for funnel chest wherein bar displacement occurred, and the Nuss method was performed a second time at the age of 6 years at the same hospital. However, even after the second surgery, the bar displaced, and he visited our hospital. The preoperative photograph showed strong depression on the left, centering on the solar plexus from the lower end of the sternum, and the ends on both sides of the bar protruded subcutaneously [Figure and ]. The pretreatment radiograph taken at the previous hospital showed a depression below the sternum []. The bar was placed horizontally immediately after the first surgery []. In the radiograph obtained 5 months after the first surgery, there was displacement toward the foot side []. The angle of the bar relative to the sternum was 23°. The second surgery was performed 1½ years after the first operation. However, the reinserted bar caused displacement to the head side. The patient visited our hospital 2 years after the initial surgery. During radiography at our hospital, the central part of the bar rotated toward the head side, and the displacement of the bar with respect to the sternum was 27° []. The computed tomography (CT) index was 4.1 [Figure and ].\nIn this case, we considered that double bars should be used because the chest deformity is extensive depression and performed the third Nuss procedure using a new stabilizer. The new stabilizer was constructed based on the conventional stabilizer developed by Lorentz, and the stabilizers were fixed by connecting the two bars []. We planned to insert bars in the fourth and fifth intercostal spaces and set the interval between the two bars to 3 cm. Lifting of the sternum by the Nuss method was carried out as expected. We confirmed that the morphology of the thorax was corrected adequately. A new stabilizer was placed under the skin of the right chest on the surface of the ribs, and the bar was fixed. The stabilizer and thorax were fixed with sutures.\nThe postoperative course was good, and no bar displacement occurred [Figure and ]. On the postoperative radiograph, the two bars were connected and fixed, retaining a stable shape []. The CT index, which was 4.1 at our hospital, improved to 2.7 after the surgery [Figure and ]. |
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. |
The female patient, of white race, now 28 years of age, suffered sudden loss of consciousness in March 2004, when she was 15 years old. When she reached the hospital, she was scored in Glasgow Coma Scale 3; computed tomography (CT) scan showed a large intraparenchymal cerebellar hemorrhage from rupture of an arteriovenous malformation supplied by the posterior circle. The patient underwent surgery to remove the hematoma and malformation. The operation was complicated by repeated hemorrhage at the operation site, requiring multiple blood transfusions, and by 2 cardiocirculatory arrests. A second operation was necessary 3 days later to enlarge the craniotomy in the posterior cranial fossa due to increased intracranial pressure. Post-operative recovery was complicated by many infections and ventriculoperitoneal shunt obstruction, requiring repeated replacements. The patient remained in vegetative state with eyes fixed in central position, showing severe spasticity and repeated generalized epileptic seizures. The extent of the disorder of consciousness (DoC) was confirmed by the scores attributed to the patient through the assessment scales used in Italy in those years: Los Amigos Levels of Cognitive Functioning (LCF), Level II, Disability Rating Scale (DRS), Score 25, Glasgow Outcome Scale: vegetative state, Modified Barthel Index (MBI) Score 0/100, Category 1.\nFor about 7 years, she stayed in a nursing home near where her parents live. The score obtained in the evaluation scales and the clinical judgment were confirmed in 2 successive formal evaluations performed by a neurologist expert in the field of DoC in March 2006 and October 2010, confirming the apparent stability of the neurological picture. Her parents continued to care for and stimulate her, with the support of the staff. The first signs of recovery of consciousness were observed in February 2011: the patient was wakeful, did not respond to simple instructions but followed the examiner with gaze, first evidence of transition to minimally conscious state (MCS). In March 2013, after resolution of ongoing cranioplastic complications, the patient was admitted to our rehabilitation center where a first multidimensional assessment of her motor, visual, and cognitive status was made.\nOn admission, the patient was wakeful, conscious, and able to perform simple and complex requests. Severely impaired vision in both eyes, nystagmus in all directions of gaze, convergence insufficiency, exotropia and hypertropia of the right eye with deficit of adduction and depression of the right eye and deficit of elevation with slight abduction restriction of the left eye, left homonymous hemianopia, right homonymous upper quadrantopsia, dysarthria, mnestic deficit, and executive functions deficit with reduced illness awareness were recorded. Neuromotor status showed severe left spastic hemiparesis and right cerebellar hemisyndrome with dysmetria and kinetic tremor, reduced antigravity control of trunk, total dependence for basic activities of daily life. The Percutaneous Endoscopic Gastronomy (PEG) tube had previously been removed and the patient was able to feed without risk of inhalation, but she needed assistance because she could not bring food to her mouth. Full sphincter control had not been achieved yet, and episodes of incontinence were present.\nConsidering the exceptional conditions and the young age of the patient, we decided to apply immediately the rehabilitative intervention, sacrificing a possible research design (eg, A-B-A-B), that could have ensured, with high reliability, the link between the effects of the training and the possible improvement. The patient underwent a program of intensive multi-professional rehabilitation from April 2013 to December 2014, first as a full-time inpatient and then on a day hospital basis. After discharge the patient returned home, where she lives with her mother, and regularly attends a day center for brain injury patients. The family then activated a basic daily life autonomy support program and a socialization program in stimulating extra-family contexts, with the support of a peer tutor. |
A 19-year-old male patient, with body mass index (BMI) of 8.45 kg/m [] and previous diagnosis of cerebral palsy, was admitted due to upper gastrointestinal bleeding Blatchford score of 10. Upon initial assessment, the patient required a blood transfusion due to hemoglobin level of 5.48 g/dl. The upper gastrointestinal endoscopy reported an esophageal ulcer Forrest IIC and esophagitis. Given the symptoms associated with chronic malnutrition and severe deconditioning, a gastrostomy was recommended. Initially an endoscopic gastrostomy was decided as the ideal approach, which was unsuccessful due to suboptimal translumination. Despite considering a new attempt to perform endoscopic gastrostomy at a later date, the patient´s nutritional and metabolic condition could worsen in case it failed a second time. Thus, an open gastrostomy was considered by the gastroenterology department to ensure an early start of the enteral nutritional route. The institutional anesthesiologist considered the patient’s high risk would be reduced once he was in adequate nutritional and metabolic so the surgery was performed without any initial complications. An upper gastrointestinal endoscopy on the third postoperative day revealed adequate positioning of the gastrostomy and enteral nutrition was initiated and well tolerated.\nTen days after surgery, patient in-hospital presented diffuse abdominal pain and multiple diarrheic episodes, of insidious origin, referring it began two days after surgical procedure and gradually increased its intensity. Laboratory results were within normal limits, and the abdominal computed tomography (CT) scan revealed extensive pneumatosis from esophagus, stomach, small intestine and partial colon. Additionally, moderate pneumoperitoneum and gas in the venous portal system were also reported (, ). The CT scan showed no evidence of an intra-abdominal collection or abscess that could otherwise explain the findings, as there was also no clinical or laboratory signs of systemic inflammatory response syndrome or infection. Medical management was initiated with intravenous fluids and nasogastric tube, while suspending the enteral nutrition. Patient showed improved outcome regarding symptomatology 24 h later. One month after the surgery, the patient was discharged in good conditions, with nutritional supplement via gastrostomy and integral rehabilitation. |
In 2010, a 52-year-old female patient complained of nausea present for more than 6 months, vomitus, intermittent vertigo, loss of appetite with B-symptoms, and weight loss of 10 kg. The initial diagnostic workup consisted of gastrointestinal imaging and a thorax X-ray, which were normal. However, a cranial magnetic resonance imaging (MRI) showed a tumor mass within the fourth ventricle (3 cm × 2 cm of size [Figures and ]); the differential diagnosis included an ependymoma, a plexus papilloma, and an intraventricular meningioma. A suboccipital craniectomy with tumor resection was performed at the University Hospital Basel with histopathological evidence of an atypical CPP WHO Grad II. One day postoperatively, the patient developed a hydrocephalus due to the fourth ventricle outflow obstruction secondary to a blood clot. For immediate treatment of the elevated intracranial pressure, a ventricular drainage was placed. The hematoma was subsequently removed to restore the physiological dynamics of the CSF. A few days later, the patient presented with diplopia and paralysis of the left-sided glossopharyngeal nerve and the hypoglossal nerve requiring an emergent tracheotomy. Nine days after the initial tumor resection (i.e., 7 days after external ventricular drain placement and evacuation of the hematoma), the patient developed double vision and nystagmus. A computed tomography (CT) head showed a new epidural hematoma at the site of the suboccipital craniotomy. The hematoma was subsequently removed with resolution of the symptoms. At this point of time, the ventricular drainage was still in place. CSF analysis revealed an elevated cell count, and after consultation with the infectious disease team, IV antibiotic treatment with rifampicin and ceftriaxone was initiated. Due to the absence of bacteria in the CSF (negative gram stain and cultures) and normal white blood cell and CRP findings, the antibiotic treatment was stopped after 5 days. Three days postoperatively, the patient developed a left-sided hemiparesis due to ischemia in the right parietal lobe as diagnosed by MRI scan. Since subsequent cardiologic workup (transesophageal echocardiography with contrast agent), an extra- and intracranial Doppler ultrasound, and blood chemistry were unremarkable, the diagnosis of a cryptogenic stroke was made. The left-sided hemiparesis persisted. After a period of inpatient surveillance, the patient was referred to our rehabilitation center and underwent an intense neurorehabilitation program. After several weeks, she was able to be discharged from our rehabilitation center, walking independently. Brain imaging during the 2 following years did not show any new pathological findings.\nSeven years later (2017), the patient complained again of two episodes of paroxysmal vertigo. Ophthalmological examination revealed a bilateral upbeat nystagmus. In addition, the patient reported a mild headache and bilateral pulse-synchronous tinnitus. Neurological examination showed a mild left-sided limb ataxia. She continued to ambulate without a walking aid. In September 2017, a cranial MRI showed a localized, inhomogeneous contrast-enhancing tumor mass in the middle left cerebellar peduncle (circa 17 mm × 17 mm) []. On a follow-up MRI in February 2018, a further increase in size to 22 mm was noted, without any evidence of obstruction of the ventricular system. There were no signs of a metastatic disease detectable on the thoracoabdominal CT scan. After detection of the new lesion on the MRI, the patient initially refused surgical intervention and opted for MR follow-up. After 3 months, with increasing symptoms and further growing of the new lesion on the follow-up MRI, she decided for surgical treatment. In March 2018, a left retrosigmoid craniectomy with tumor resection was performed. Histopathological examination revealed an atypical CPP (WHO Grade II). Post-operative irradiation was recommended. Due to the patient’s wish (i.e., fear of worsening of neurological deficits), post-operative irradiation was not performed and is planned in case of progression of the remaining contrast-enhancing area on MRI. After the surgical intervention, the patient re-entered our rehabilitation clinic for the 2nd time. The follow-up examination in June 2018 showed a satisfactory course. Improvement was seen in coordination, trunk-stability, balance, and gait, resulting positively in a reduced tendency to fall; only for outside walks, she had still to use a stick. The clinical improvement translated equally into objective assessment scales. The Functional Independence Measure test improved from 96 to 112 points (maximal score possible 126), and on the Mini-Balance Evaluation Systems Test, she scored 22 of 28 possible points. On the Functional Ambulation Categories test, the patient scored 5 out of 5 points. In the 6-min walk test, she achieved 451 m (reference 700–800 m). |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.