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A 21-year-old female college student presented to the emergency department (ED) with severe pain in her left hip, thigh, and calf. The pain started suddenly when she was playing basketball a few hours earlier. She twisted her torso to shoot the ball and heard a “pop” in her left hip with immediate onset of pain, and she subsequently fell to her knees. She was initially able to ambulate but had worsening pain and rapid progression of swelling and mottling in the left leg from her hip to her ankle. She denied any pain or swelling in that extremity prior to the injury during the basketball game. With the exception of oral contraceptive use, she had no significant medical or family history.\nOn examination her left extremity was mottled, dusky, and cool to the touch from the hip to the toes and she had decreased dorsalis pedis and posterior tibial pulses when compared with the right extremity. The leg was markedly tender to palpation and sensation to light touch was diminished. Passive range of motion of the hip, knee, and ankle elicited severe pain.\nPOCUS was performed at the bedside to evaluate for arterial blood flow and deep venous thrombosis. This demonstrated normal color flow in the femoral and popliteal arteries (), but echogenic material was noted within the left common femoral vein extending distally to the popliteal vein and the veins were non-compressible (). Vascular surgery was immediately consulted, and while awaiting their arrival to the ED the patient was sent for an emergent computed tomography (CT) angiogram, which confirmed arterial patency and extensive deep venous thrombosis in the left popliteal, femoral, and iliac veins (). A heparin bolus was given and the patient was then taken to interventional radiology where she underwent partial thrombectomy, catheter-directed tissue plasminogen activator (tPA) treatment, and placement of an inferior vena cava (IVC) filter. By the next morning her leg was noted to be well-perfused, non-tender, and without swelling, and her pain had resolved. A workup for hypercoagulable states revealed heterozygosity for the Factor V Leiden mutation. She was discharged one week later on warfarin after bridging from enoxaparin.
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A 60-year-old gentleman who was previously diagnosed with type 2 diabetes mellitus, hypertension, and a cerebrovascular accident, which he suffered two years prior to presentation, which left him with residual right-sided upper and lower limbs weakness, for which he is undergoing physiotherapy with continuous improvement, presented with a history of right eye sudden painless drop in the vision of one-day duration. He denied any history of trauma to the eye or head and gave no history of previous eye symptoms or surgeries. Apart from the right-sided upper and lower limb weakness, his general and systemic examination was unremarkable.\nHis ophthalmic examination showed visual acuity of hand movement in the right eye and 6/6 in the left eye, with normal intraocular pressure in both eyes (18 mmHg in the right and 12 mmHg in the left). Slit-lamp biomicroscopy showed grossly normal anterior segments of both eyes with immature cataracts. Fundus examination of the right eye by binocular indirect ophthalmoscopy showed no view of the retina due to a grade 4 vitreous hemorrhage, while fundus examination of the left eye was unremarkable.\nB-scan ultrasonography of the right eye showed a large mushroom-shaped mass invading the choroid and retina, and protruding into the vitreous cavity in the inferior aspect of the posterior pole (Figure ) with a shallow exudative retinal detachment observed in the peripheral rim of the mass, with dense vitreous hemorrhage (Figure ).\nMagnetic resonance imaging (MRI) of the orbits was also done and showed a small mass suggestive of a choroidal melanoma along the posterior aspect of the right globe extending into the vitreous and measuring 8 x 6 mm. The lesion appears of high signal intensity on T1-weighted images and low intensity on T2-weighted images and shows mild contrast enhancement in the post-contrast images. The vitreous body shows an abnormal V-shaped appearance with abnormal high signal intensity on T2-weighted images mostly suggestive of vitreous hemorrhage with posterior vitreous detachment (Figures -).\nAdditional testing included positron emission tomography (PET) scan, chest X-ray, and laboratory studies, which included complete blood count (CBC), serum electrolytes, and liver function test (LFT), which were all within normal limits, excluding the possibility of metastasis to the lungs and liver, and confirming that the choroidal mass is a localized primary ocular mass.\nAfter discussing the treatment options with the patient, and due to the unavailability of plaque brachytherapy and the concurrent presence of a vitreous hemorrhage, which would already mandate a pars-plana vitrectomy, a decision was made to book the patient for an early surgical transretinal endoresection via the pars plana route.\nUnder local anesthesia (peribulbar block), routine phacoemulsification complicated by a posterior capsular rent was first done with the implantation of a sulcus intraocular lens. Then, a standard 23-gauge three-port pars plana vitrectomy was performed to clear the vitreous hemorrhage, after which a mushroom-shaped mass measuring approximately 6 disc diameter in size (Figure ) was seen protruding into the vitreous cavity inferior to the fovea (the base of which was 1 disc diameter inferior to the inferior vascular arcade). Micro scissors were used to obtain two biopsy specimens from the mass. After that, complete tumor transretinal endoresection using the vitrector was performed, during which endodiathermy was used frequently to stop bleeding from the mass to ensure adequate visibility at all times. Perfluorocarbon liquid was injected for foveal protection, drainage of subretinal fluid, and stabilization of the retina, while the edges of the resultant retinotomy were carefully cauterized using endodiathermy (Figure ). This was followed by argon laser photocoagulation peripheral to the endodiathermy marks, placing three rows of laser photocoagulation around the retinotomy (Figure ). Finally perfluorocarbon liquid/air exchange was performed and 1000cs silicone oil was injected as a tamponade.\nBoth solid biopsy specimens and diluted vitreous samples from the aspirated fluid were sent to the lab for histopathological examination. However, the pathologist report showed that there was not enough sample for adequate histopathological grading, with mainly melanocytes in the slide.\nAt one week post-operation, the best-corrected visual acuity of the right eye had improved to 6/36 with remaining anterior uveitis and fundus examination showed a flat retina with white laser marks around the retinotomy. At one month post-operative, the visual acuity had further improved to 6/9 with a flat retina and silicone oil tamponade in situ. Optical coherence tomography (OCT) of the macula (Figure ) and fundus photography (Figure ) at one month post-operative are shown below.\nPost-operative MRI, which was done at one week post-operative to ensure complete resection, showed no evidence of residual tumor, and complete resolution of the exudative retinal detachment was seen pre-operatively, with a visible silicone oil bubble in the globe (Figure ).\nThe patient was also referred to the oncology department to continue monitoring tumor control in liaison with the ophthalmology department with regular follow-up appointments, and he will be posted for silicone oil removal after six to nine months.
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In February 2016, a 78-year-old man presented with an enlarging mass on the right side of the neck in relation to the submandibular space. The mass was painless and had been enlarging for the previous month. An immobile soft tissue mass was noted at the submandibular space on the right side. Ultrasonically, a 16 × 19 mm hypodense tumour was visualised in relation to the posterior pole of the submandibular gland on the right side (Fig. ). A fine needle biopsy and Tru-cut biopsy was performed which showed cells from adenocarcinoma, but it was not possible to classify the tumour further (Fig. ). MRI showed a 19 × 17 × 12 mm process in the lateral part of the right submandibular gland, growing into the platysma muscle, and there was no lymphadenopathy. The patient underwent a neck dissection of level I, II, and III and removal of the submandibular gland on the right side. Surgical pathology revealed a 30-mm SDC with perineural invasion and 1 lymph node was positive for tumour cells. Postoperatively, the patient received radiotherapy at a total dose of 70 Gy delivered to the right submandibular area and level I, II, and III of the neck.\nIn January 2017 the patient presented with a skin tumour on the right side of his forehead (Fig. ). Clinically, the tumour resembled a basal cell carcinoma and was treated with curettage by a dermatologist. The pathology report described islands or nests of basaloid cells associable with basal cell carcinoma. However, the wound never healed and the patient developed a 10 × 8 mm superficial ulcer at the site. An excision of the tumour with a 3-mm margin was performed and this time the pathology report described metastases from SDC arising from the submandibular gland. The specimens from the first curettage biopsy were examined and it was concluded that even this biopsy showed cells from an SDC and not basal cell carcinoma.
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A 70-year-old Caucasian female with a history of peripheral vascular disease and perforated peptic ulcer disease presented to the emergency room with chronic left upper quadrant abdominal pain of 7–8 months duration which had acutely worsened over the previous 4–5 days. She described the pain as ‘stabbing’ pain that radiated to her back. She reported that the pain was exacerbated by oral intake. Although the patient was having regular bowel movements without gross blood, she was noted to have microscopic blood in her stool and was sent for evaluation in the ER. Computerized tomography (CT) with contrast demonstrated evidence of fatty liver, diffuse gallbladder wall thickening, an 8 mm common bile duct, diverticulosis and a normal appendix. Lipase level was found to be within normal limits and there was no leukocytosis. The patient was subsequently transferred to our hospital for further workup.\nPrevious workup for the patient’s abdominal pain included a CT which demonstrated medial insertion of the cystic duct and a positive hepatobiliary iminodiacetic acid scan suspicious for cystic duct obstruction. Esophagogastroduodenoscopy (EGD) with biopsy demonstrated mild inflammation of the gastric antrum but showed no evidence of dysplasia, malignancy or Helicobacter pylori infection.\nMRCP performed during the patient’s hospital stay confirmed the patient’s aberrant ductal anatomy, showing a cystic duct coursing parallel and medial to the common bile duct before anastomosing just proximal to the ampulla. CT angiogram did not show evidence of bowel ischemia.\nAlthough the location in the left upper quadrant was not typical of gallbladder pain, cholecystectomy was offered to the patient given the evidence of gallbladder wall thickening. Additionally, workup for alternative etiologies of the abdominal pain, including mesenteric ischemia, had been negative. Patient elected to undergo open cholecystectomy with awareness that her aberrant anatomy put her at increased risk of common bile duct injury as well as the fact that her pain may not be improved by the surgery.\nPatient successfully underwent EGD with stent placement in preparation for surgery. During surgery, laparoscopic examination revealed adhesions between the colon, colonic mesentery, the underside of the liver and the gallbladder due to prior surgery for her perforated duodenal ulcer. Following extensive lysis of adhesions, a top-down dissection of the gallbladder was performed. The cystic duct was once again seen coursing posterior to the common bile duct within the porta hepatis. Intraoperative cholangiogram confirmed low insertion of the cystic duct and dilation of the common bile duct. The surgery was performed without complications.\nThe patient’s post-operative course was without complication, with the patient tolerating oral intake and with pain managed on oral medications. However, the patient continued to complain of left-sided abdominal pain despite surgery.
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A 32-year-old male was hospitalized in the parent institution in November 2016, due to general symptoms of infection accompanied by pain in the left lumbal region, when duplex collecting system of the left kidney was diagnosed. CT urography, performed during the hospitalization indicated the existence of a duplex pyelocaliceal system of the left kidney with a duplicated ureter, dilation of the pyelocaliceal system of the upper pole of the left kidney grade 4, with the kidney parenchyma reduced to 1 mm, as well as the left ureter dilated (12 mm) and curved throughout its length, with ectopic ostium in prostatic urethra ( and ).\nDuring the hospitalization, the patient was treated conservatively with a positive clinical effect. After the inflammatory parameters were stabilized and the pathogenic microorganism was eliminated from urine, the prophylactic antimicrobial therapy ensued, supplemented by further diagnostic procedures. Renal radionuclide imaging, as an integral part of nuclear medicine, provides substantial information on the actual renal function. Static kidney scintigraphy with Tc99mm (DMSA) indicated the absence of accumulation of radiopharmaceuticals in the upper third of the left kidney, except for the slightly preserved function of cortical activity in the marginal area of the upper pole of the left kidney. Dynamic scintigraphy was performed with Tc99mm (DTPA) and it indicated a lower amplitude of the renal curve above the left kidney (lower functional mass), with a relative left-kidney function of 35.3%, while the relative right-kidney function was 64.7%.The patient was surgically treated at the Urology Clinic of the University Clinical Centre of the Republic of Srpska in Banja Luka, in July 2017. Control Ultrasound examination indicated the existence of a duplex pyelocaliceal system of the left kidney with a duplicated ureter, dilation of the pyelocaliceal system of the upper pole of the left kidney grade 4, with the kidney parenchyma reduced to 1 mm, as well as the dilatation of the left ureter (). Taking into account the clinical perspective, the degree of damage to the renal parenchyma of the upper pole of the left kidney which was not functional, the indication for nephron-sparing surgery was set, that is, for the partial nephrectomy and ureterectomy. Optimal renal perfusion provided by a hydration regimen of approximately 200 mL/h or more of crystalloids overnight was beneficial. Before positioning the patient for lumbar incision, an urethrocystoscopy was performed, detecting no ectopic ureter orifice in prostatic urethra. Afterwards, JJ stent was placed through the orthotropic left orifice, in order to accurately preserve the ureter for the distal two-thirds of the left ureter. After the patient was adequately positioned, a standard left side lumbar approach was performed, which provided excellent and rapid exposure to the kidney and the hilum. Optimal renal exposure is the key to a successful outcome. We identified the renal pedicle and defined the vasculature and ureter. Then, we isolated the renal artery and placed a vascular loop. After that, we excised the hydronephrotic upper pole with sharp dissection and put suture on the edge to ligate any bleeding vessel with 3-0 absorbable sutures with in situ techniques. Then, the ureter was released with blunt and sharp dissection to the distal third of it, as far as possible from the lumbar incision, the ureter was cut and preparations of the resected upper pole of the left kidney were removed continuously from the proximal 2/3 of the ureter. After that, the aspiration of the contents of the unresected distal third of dilated left ureter was performed and ligature was placed on it. The resected surface of the upper pole, approximately max 20x20 mm, was additionally cauterized with argon, covered with the Gerota’s fascia, the drain was placed, and the lumbar incision was closed by layers. The patient had a neat post-surgery course. PH findings indicated that there was a renal parenchymal dysfunction, nephritis interstitial chronica and ureteritic chronica. A control ultrasound performed after six months showed a regular post-surgery finding for the remaining distal two thirds of the left kidney, without the accumulation of fluid in the retroperitoneal space.
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In January 2013, an 11-year-old female patient with a chief report of swelling in the left mandibular molar region was referred to our medical center. Two weeks before the first visit, the patient was prescribed antibiotics by a local family medical clinic because of swelling in the left side of the jaw and tenderness of the mandibular angle. For these reasons, she was referred from a local dental clinic and consulted our center. The patient had no systemic health conditions. Extraoral examination revealed swelling in the left mandibular angle area, and intraoral examination revealed mucosal swelling that extended from the lower first molar to the retromolar region, mixed dentition, and an unerupted left mandibular second molar.\nA panoramic radiograph revealed a well-circumscribed, unilocular radiolucency in the region of the left mandibular molars, extending from the distal root of the first molar area to the left ascending ramus, with an unerupted second molar, and the dental follicle of the third molar (Fig. ). The impacted left mandibular second molar presented with incomplete root formation and displacement up to the inferior border of the body. The left mandibular third molar was located on the coronoid process of the mandible. Considering the clinical and radiographic findings, a provisional differential diagnosis of UA, dentigerous cyst, and odontogenic keratocyst was considered. With the patient under local anesthesia, an incisional biopsy was conducted; after histopathologic evaluation, the lesion was diagnosed as UA. The parents were informed of the condition, proposed treatment, recurrence, and benefits, after which they provided their informed consent for the conservative treatment. Marsupialization of the gingiva and cystic wall was performed using a silastic drain to maintain continuity between the marsupialized lesion and oral environment and to ultimately reduce the lesion size. The patient was scheduled for follow-up and daily management for the first month, followed by weekly management. The parents were instructed to maintain overall proper hygiene of the oral cavity through self-irrigation after marsupialization. After 1 month, a propensity of the lower left second molar toward eruption was observed (Fig. ). After confirmation of epithelization of the cystic wall, the drain was removed. Three months after marsupialization, the lesion diminished in size, new bone formation was observed, and the lower left second molar was in a more advanced phase of eruption (Fig. ). Radiographs obtained 6 months after marsupialization showed that the lesion margin had lost clarity and that the regenerated bone was replaced by normal trabeculae. The radiolucent area was significantly reduced (Fig. ). Twelve months after marsupialization, a part of the lower left second molar was observed in the oral cavity (Fig. ). Thirty months after marsupialization, the lower left second molar erupted on the same occlusal plane as the lower right second molar. The lower left third molar was impacted. In the following month, enucleation of the lesion was performed to completely remove the lesion along with the impacted third molar with the patient under general anesthesia (Fig. ). The second molar was preserved. The patient began orthodontic treatment for reduction of mild crowding. At 36 months after marsupialization, radiographs showed complete eruption of the lower left second molar, whereas a mild interdental space was observed between the first and second molars. At 48 months after marsupialization, complete occlusion was observed. This tooth was eventually preserved and did not require a root canal (Fig. ). To date, no evidence of tumor recurrence has been observed on examinations during the 49-month follow-up.
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An otherwise healthy 30-year-old female patient from our hospital was hospitalized because of neck pain and weakness of left leg for 2 days 6 weeks after cesarean delivery of a second baby. Physical examination showed the muscle strength of the left lower limb of grade 4, with the tendon reflex ++. Blood routine, hemagglutination, D-dimer, liver and kidney function test, electrolyte, blood homocysteine, 12 items of immunity, 3 items of vasculitis, thyroid function, glycosylated hemoglobin and C-reactive protein were all normal. The systolic blood pressure was 125 mm Hg, and the diastolic blood pressure was 83 mm Hg. The body mass index (BMI) was normal (21), and no connective tissue disease was present. Magnetic resonance imaging (MRI) revealed multiple acute cerebral infarcts in the right frontal and parietal lobes and right watershed cerebral infarction (Fig. ) and occlusion of the right internal carotid artery (Fig. C). Carotid artery ultrasound (Fig. A) revealed a moderate-echo membranous structure pulsating with blood flow in the lumen of the right common carotid artery. Low echo could be detected in the lumen of the lesion, resulting in local severe stenosis of the common carotid artery and distal occlusion of the internal carotid artery. Transcranial Doppler ultrasound (Fig. B & C) showed low pulsation of bilateral middle cerebral arteries, especially on the right side, and low velocity blood flow signal was detected in the left vertebral artery, with relatively high resistance changes. Cervical MRA (Fig. A & B) demonstrated crescent-shaped signal in the lumen of bilateral internal carotid arteries and right inferior occipital segment of vertebral artery, indicating severe stenosis of bilateral internal carotid arteries. Different signal intensities of the intramural hematomas were shown (Fig. B), which indicated that these dissections probably occurred at different time points rather simultaneously, and the only symptomatic dissection was most probably that of the right internal carotid artery. Combined head and neck CTA (Fig. C & D) revealed wall thickening of C1 segment of bilateral internal carotid arteries with severe stenosis and multiple aneurysms in the left V1 and V2 segments and right V2 segment of vertebral artery. DSA (Fig. ) demonstrated a long tubular stenosis with wavy appearance in the right extracranial segment of internal carotid artery (carotid sinus not involved) and a severe stenosis at C1/C2 junction with slow blood flow velocity at the distal end. Multiple stenoses and dissecting aneurysms were also shown in the V2 segment of bilateral vertebral arteries. The initial diagnosis was myofibrous dysplasia because of long stenoses and dissections in bilateral C1 and V2 segments.\nAfter admission, the patient was treated with antiplatelet medications (aspirin enteric coated tablets 0.1 g qd combined with clopidogrel bisulfate tablets 75 mg qd). Neck pain and left lower limb weakness were relieved at discharge 1 week later. Follow-up transcranial Doppler ultrasound 2 months later (Fig. A) revealed increases of the middle cerebral artery velocity and pulsatility index and improvement of the spectrum of intracranial artery. Six months later, there was no abnormality in color Doppler ultrasound (Fig. B) or MRA of head and neck (Fig. A & B). The final diagnosis was postpartum cerebral arterial dissections. Followed up for 3.5 years, the patient was well recovered, with no presence of cerebral arterial dissections on head and neck CTA (Fig. C).
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A 10-year-old overweight Hispanic female (BMI > 28) complaining of abdominal pain for 2 days was brought to our emergency department (ED) by her mother. The pain reportedly started in the periumbilical area and later localized to the right lower quadrant. She also reported left lower quadrant pain, anorexia, and nausea but denied vomiting. She had no fever. Upon arrival to the emergency department, her vital signs were within normal limits for her age, but physical exam revealed generalized lower abdominal tenderness with rebound and guarding.\nHer laboratory investigation was positive for elevated white cell count of 12.10 per microliter of blood with a left shift. The rest of her laboratory results were within normal limits. Abdominal and pelvic CT scan were done which showed hyperemic appendix and hazy anterior mesentery and a small amount of free fluid (Figures –).\nBased on the history, physical exam, and CT scan findings, a diagnosis of acute appendicitis was made and the patient was taken to the operating room for laparoscopic appendectomy. Intraoperatively, a tortuous retrocecal appendix with free fluid was found, and appendectomy was performed without any complications. After performing the appendectomy, the omentum was noted to be adherent to the anterior abdominal wall and on careful examination, it was noted to be hemorrhagic and necrotic as shown in Figures and . The necrotic omentum was resected and sent for histopathological examination. Although the infarcted omentum was mostly in the midline anterior abdominal wall, we did not have the necessity to place additional ports and were able to successfully resect the omentum with standard laparoscopic appendectomy port placements (umbilical port, left iliac fossa port, and suprapubic port). The patient had an uneventful postoperative course and was discharged on the second operative day.\nHistopathological exam of the appendix revealed focal superficial acute mucositis and recent hemorrhage suggesting early acute appendicitis. Examination of the omental mass showed fragments of adipose tissue with hemorrhage, fat necrosis, and granulation tissue formation consistent with omental infarction (Figures –).
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A 14-year-old boy was admitted to our institution for elective PTCA to relieve stenosis of the coronary arteries. At 4 years and 7 months of age, the patient presented to our institution with typical signs and symptoms of KD (persistent fever up to 39℃ for 10 days accompanied with conjunctival injection and a strawberry tongue). Consequently, the patient received intravenous gamma globulin and aspirin, which resulted in a prompt resolution of the fever and improvement of symptoms. Two-dimensional echocardiography performed during the acute phase of the illness demonstrated fusiform aneurysms of the right coronary artery (RCA) (10 mm in diameter), left anterior descending (LAD) branch (7 mm), and left circumflex (3.7 mm), as well as dilatation of the left main coronary artery (LMCA) (4 mm). However, there was normal systolic ventricular function without regional wall motion abnormalities. The patient was given low-dose aspirin and discharged from the institution. After discharge the patient was free of symptoms. An echocardiogram performed 15 months after the onset of illness demonstrated mildly improved fusiform aneurysms of the RCA (8.4 mm) and LAD (5 mm), as well as improved dilatation of LMCA (3.4 mm). However, there was no change in the left circumflex lesion. The patient was continued on a therapy of low-dose aspirin and remained asymptomatic. A 24 hour Holter monitor at 20 months, 40 months, and 68 months after presentation indicated normal heart rhythm with no evidence of ischemia. A treadmill test performed 9 years after presentation revealed no arrhythmias or ischemic changes. Nine years and 5 months after disease onset, selective coronary angiography revealed two saccular aneurysms in the proximal portion of the LAD, and in the proximal portion of the RCA as well as stenosis (minimal lesion in the proximal portion of the LAD, discrete lesion in the left circumflex, and total obstruction in the RCA with collateral arteries supplying blood to the distal portion of the RCA.)(). The patient retrospectively reported symptoms of intermittent chest discomfort for 5 months prior to catheterization. On admission, his blood pressure was 120/80 mmHg. His heart rhythm was regular and his heart rate was 76 bpm. The patient looked well and his physical examination and laboratory results did not reveal any abnormalities. Accordingly PTCA was performed at 9 years and 6 months after the onset of illness. The procedure employed a 3.5 mm balloon catheter in the stenotic lesion of the proximal portion of the left circumflex. The balloon was then inflated with diluted contrast medium to a pressure of 10 atm. The area of stenosis was 80% before PTCA and there was no residual stenosis after PTCA (). An intravascular ultrasound (IVUS) study was performed immediately after PTCA. The IVUS imaging revealed a calcified lesion and atheroma at the site of the left circumflex coronary artery (). The patient tolerated the procedure well with no electrocardiographic changes. He was discharged home on aspirin, ticlopidine, and isosorbide dinitrate. To date, he has been well. Currently, the patient is following a regimen of low-dose aspirin.
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A 40 years old male visited our out-patient department with the chief complaints of lower back pain and right buttock pain, along with difficulty in falling asleep because of the severe pain. For the past history, he was operated on twice in different hospitals since he was injured at work where he was carrying heavy materials and he slipped with his back bent forward. Thos occurred about 18 months before he visited the other hospital and he was operated on for the first time via endoscopic micro-discetomy. A year after that surgery, he underwent another posterior open discetomy operation in a different hospital because of his constant lower back pain. On the physical examination, it was determined that the motor and sensory nerve functions were normal and the straight leg raising test was also within the normal limits. Simple radiography of the lumbar spine was nonspecific. After being diagnosed with post-operative syndrome in the lumbar spine and being admitted into our hospital, he started exercise and physical therapy, and he received medication (anti-inflammatory drugs, analgesics and antidepressant) for three months, but he did not show any improvements. So we performed posterior interbody fusion using pedicular screws and an interbody cage (Diapason®, Stryker®, Bordeaux, France) after the removal of the L4/5 disc and lamina (L4/5) ().\nThere was some improvements of the symptom until five days after the surgery, but then the patient complained of a progressive tingling sensation in both legs and difficulties in micturition and defecation with a saddle sensory decrease and a decrease of the anal sphincter tone. He showed some mild change in his symptoms several days after the surgery, but he suffered from constant neurogenic pain along with the difficulty in micturition and defecation and he was unable to walk normally because of the weakness and tingling sensation in both legs. Thus, we performed electromyography of the lower extremities and the results showed diffuse bilateral lumbosacral radiculopathies. The 3-phase bone scan showed non-specific findings. However, there was no evidence of focal disc herniation and compression of the thecal sac or nerve root, and the fixation device was in good position according to the contrast enhancement lumbar MRI findings (). We carried out various treatments with taking adhesive arachnoiditis, a battered nerve root or scar adhesion and the psychological compensation from the labor injury into account as the cause of the post-operative syndrome in the lumbar spine. We administered oral corticosteroid (Dexamethasone®; Pacific Pharmaceuticals, Seoul, Korea) due to the neurogenic symptoms for a fixed period, and the patient continued his exercise and physical therapy, and he received medication (anti-inflammatory drugs, analgesics, and gabapentin [Neurontin®; Pfizer, New York, USA]) at the same time. We also administered medication for the difficulty of micturition along with conducting uro-dynamic and bladder examinations at the urology center and we provided psychological consultation and antidepressants at the neuropsychology center. Furthermore, the patient received local injection therapy that included epidural block at the pain clinic, but he did not show any satisfying improvement of the symptoms.\nSo we diagnosed the patients as having CRPS type 2 under the diagnostic criteria, because patient showed a spontaneous tingling sensation with continuing pain in the lower back and both lower extremities (not in a specific dermatome) that was disproportionate in degree to the usual course after lumbar fusion surgery. The patient showed hyperesthesia, allodynia and dystrophic change in his feet, including saddle sensory decrease, and the motor dysfunction (weakness, tremor) of both lower extremities (below the knee joint and especially the feet). The physical examination showed edema, swelling and warmth in the feet, a decreased range of motion of the knee and ankle, and trophic change of the toenail and skin. At another pain clinic, a permanent spinal cord stimulator was implanted after a successful trial of stimulation with a temporarily (1 week) implanted electrode on the lower thoracic area (). According to the visual analogus scale, there was a 50% decrease in the intensity of the spontaneous tingling sensation with decreased continuing pain on a scale from 70/100 to 30~40/100, along with being able to fall asleep easily. Yet the difficulty in micturition and defication, and the lower extremity tremor, weakness and hyperesthesia still existed.
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A 59-year-old male patient, from Peru, with no relevant medical history, presented in September 2019 with a history of back pain, weight loss of about 5 kg, early feeling of fullness and night sweating of 8 months of evolution. His physical examination revealed a mobile mass without defined margins, located 12 cm from his left ribcage. The results of his routine haematology and biochemistry laboratory blood tests revealed moderate anaemia with a haemoglobin of 9.0 g/L and hyperkalaemia with a serum potassium of 5.8 mmol/L.\nHe had computed tomography (CT) scan of abdomen which showed a left renal mass of heterogeneous density of 19 × 12 × 9 cm, which had defined borders and contours and which was not associated with any nodal or vascular involvement (). Kidney cancer presumptive diagnosis was considered.\nIn October 2019, he underwent a surgery (left radical nephrectomy plus para-aortic lymphadenectomy), and during the procedure he was noted to have a left kidney dependent tumour that measured 20 × 19 cm with associated hilar and para-aortic lymph nodes.\nMacroscopy pathology examination of the specimen was reported to have identified a left renal tumour that measured 23 × 12 × 10 cm which was noted to have a solid component, and which was soft in consistency, and which was light brown in colour and which contained areas of myxoid and haemorrhagic necrosis of 30% and 10%, respectively (). Microscopy pathology examination of the specimen detected a cell proliferation of tumour cells that were arranged in a storiform pattern which infiltrated the renal sinus, capsule and the perirenal fat, with pleomorphic nuclei and high mitotic index (). These findings were reported to be consistent with an undifferentiated liposarcoma of high histological grade, with 35 mitoses per ten high-power field (35/10 high-power field mitoses) and 30% of necrosis.\nThere was no evidence of metastatic spread to the Gerota’s fascia, renal pelvis, adrenal glands as well as there was no evidence of lymphovascular invasion by the tumour.\nImmunohistochemistry staining study of the tumour with MDM2 showed that the tumour had exhibited positive nuclear immunostaining expression within the neoplastic cells (), which did confirm the proposed diagnosis. A definitive final diagnosis of renal liposarcoma of the left kidney was made and this tumour was classified as clinical stage IIIB (T4N0M0 G3) for he had undergone radical surgical excision (radical nephrectomy and lymph node excision) as a primary treatment with negative surgical resection margins (R0). The patient has been undergoing regular follow-up assessments with clinical examination, laboratory tests and radiology imaging assessments.\nAfter 15 months of follow-up, the patient has remained well with no evidence of local recurrence or distant metastases based upon the results of his clinical examination, laboratory blood tests and CT scan images. He will continue to have regular follow-up assessments.
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A 24-year-old native Arabian lady, mother of four, from the high mountainous area who was managed by a local primary healthcare centre as a case of essential hypertension, was referred to the medical outpatient department of our secondary care facility for uncontrolled hypertension for the last few months. After primary assessment, the medical team put her on antihypertensive medication and sent back home. On the next visit, her BP remained high despite combined antihypertensives with ACE inhibitor, beta-blocker, and Ca-channel blocker and complaining of right hypochondrial pain, for which ultrasonography was requested along with basic laboratory workup.\nU/S shows a large cyst in the liver for which the patient was referred to surgical OPD for consultation. The surgical team decided for elective surgical exploration.\nOn admission, the patient vitals were stable except high BP of 155/91 mmHg and high ALP (221 U/l).\nUltrasonography showed a maternal right liver lobe hydatid cyst measuring 14 × 16 cm, and CT scan revealed a large sizable hypodense cystic lesion of about 150 × 150 × 200 mm in AP × TS × CC dimensions, respectively, with multiple septations inside, being mainly in the right lobe, with peripheral calcific wall seen laterally with normal liver parenchyma (), occupying almost the whole right lobe of the liver, exerting a mass effect in the form of right kidney, right renal vasculature, and IVC compression with no invasion in addition to medial displacement of the duodenum and midline structures. Exploratory laparotomy was done, and evacuation of a large hydatid cyst with deroofing was done by the standard protocol (). Postoperatively, the patient had a spike of high BP in the postoperative holding area, which was managed by the medical team. On the 1st postoperative day, the patient was recovering well with BP findings of 130/80 mmHg for which antihypertensive medication was withhold on the 2nd postoperative day. The patient discharged on the 8th postoperative day, and on subsequent visit to the surgical OPD, the patient was doing well with normotensive findings without antihypertensive medications.
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A 47-year-old male patient fell from the second floor while he was working on a construction site, which led to his left upper limb trauma. The first doctor on the scene diagnosed a dislocation of the left elbow. He practiced a closed reduction as the injury was very painful. The patient was then directed in a medical ambulance to our trauma center. On his arrival at the emergency room, the patient was conscious and had no respiratory distress. His vital signs were stable. He was unable to move his left upper limb due to intense pain. The left elbow was swollen. The forearm seemed shortened. Distal pulses, fingers motility, and sensitivity were normal. Radiographs showed a reduced elbow with a displaced fracture of the radial head () and a dorsal perilunate dislocation of the wrist (). Computed tomography scan showed Mason type 2 radial head fracture associated with Regan and Morrey type 1 coronoid apophysis fracture (). There were no carpal bone fractures. The diagnosis of floating forearm with terrible triad injury of the elbow was assessed. Then, the patient underwent primary surgical treatment on the same day. As closed manipulation did not succeed, an open reduction of the wrist was performed through a dorsal approach. Then, the reduction was fixed by the mean of three K-wires. The first K-wire passed from the scaphoid into the lunatum, the second from the scaphoid into the capitatum, and the third from the triquetrum into the lunatum ( and ). The scapholunate and triquetrolunate ligaments were ruptured. They were primarily repaired. Then, a lateral approach to the elbow was performed, the radial head was reduced and fixed with screws, the capsule was tied through drill holes, and the lateral collateral ligament was repaired with transosseous sutures ( and ). The elbow was stable when testing. An elbow immobilization using a cast at a joint angle of 90° was maintained for 3weeks. It was followed by a below-elbow cast for 3 other weeks. Elbow rehabilitation started in the 3rdpost-operative week. Shoulder mobilization and active-assisted flexion/extension of the elbow were performed 2times a week to reestablish non-painful range of motion and to prevent muscular atrophy. In the 6thweek, casting and K-wires were completely removed and rehabilitation of the patient’s wrist began. Resisting active exercises and handgrip training were introduced gradually, which helped to reduce pain and edema. Then, range of motion activities was performed for all planes of the elbow and the wrist. The patient was motivated to accomplish further home exercises. He was followed up regularly. There has been no septic complication or wound dehiscence. At 12-month follow-up, the patient only complained of moderate pain on heavy lifting and had resumed his job as a construction worker. At 18 months, the extension of the left elbow was limited at 10° while flexion was limited at 110°. The palmar and dorsal flexion of the wrist was each 70° (, , , and ). The grip strength was 75% of the contralateral side. It was measured using a hand dynamometer. The disability of the arm, shoulder, and hand score was 20, which assessed mild impairment and good functional outcome.
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A 36-year-old female visited the Postgraduate and Specialized Conservative Dentistry Clinic of the Dental School, Prince of Songkla University, due to concern about a space between her front teeth (). The patient presented clinically with a midline diastema of 1.5–2 mm. She reported that she had lost two maxillary central incisors due to trauma when she was a teenager. Ten years later, she received orthodontic treatment that moved the lateral incisors into the central incisor positions and the canines into the lateral incisor positions. The right lateral incisor also received an endodontic treatment followed by a casting post and core with porcelain fused to a metal crown (PFM). The left lateral incisor was built up with a direct resin composite (Figures and ). The mesiodistal width dimension of left and right lateral incisors was increased by 1 mm each in order to transform the lateral incisors into maxillary incisors. Gingival recession of about 0.5 mm was presented at the distolabial aspect of the left lateral incisor, resulting in gingival level disharmony (). A shine-through effect in a metal ceramic crown and cast metal post was also observed (). Orthodontic treatment and all restorations were completed in a private clinic more than 13 years ago. A periapical radiograph showed that both lateral incisors had horizontal bone loss at cervical 1/3 of the roots. The distance from the estimated contact point to the alveolar bone was about 8 mm (Figures and ). This suggested that it was unlikely that a restorative technique alone would completely close the space.\nThe primary treatment objective was to restore a normal appearance of both “white” and “pink” esthetics to the maxillary anterior teeth. Based on the objective and given the clinical and radiographic features, two treatment options were proposed to the patient. The first option consisted of an orthodontic retreatment for diastema closure and papilla reconstruction with a surgical technique for correction of the open gingival embrasure. With orthodontic tooth movement, appropriate crown-root angulation, incisal level, and gingival zenith position for final restorations can be achieved. However, there is a longer time and higher cost of treatment compared to the second option. In addition, an outcome of papilla reconstruction is unpredictable. The second option consisted of the esthetic reconstruction of the anterior teeth without orthodontic movement by increasing the mesial emergence profile and the additional mesiodistal width of the lateral incisors (0.75 mm each) with HA injections to treat the interdental papilla loss. To correct the gingival level disharmony of the two lateral incisors, gingival sculpting of the left lateral incisor with a diode laser was carried out. This option is less invasive, fast, and low-cost solution to treat the midline diastema and the open gingival embrasure. However, HA retreatment may be required in long term. For both options, all-ceramic crown and veneer were used for esthetic reconstructions of the lateral incisor substitution for the missing central incisors. Esthetic reshaping of canines with direct resin composite build-ups would be substituted for the lateral incisors. As far as the esthetic outcome was concerned, the risks and benefits of replacing the metal post with an esthetic post were discussed with the patient; however, she declined the metal post replacement and decided on the second option.\nA study model and a diagnostic wax-up were used for esthetic evaluation and fabricating provisional restorations. In addition, the diagnostic wax-up and photograph were used to facilitate communication with the patient, periodontist, and laboratory technician. shows a final restorative plan including the all-ceramic crown for the right lateral incisor, the ceramic veneer for the left lateral incisor, and the direct resin composite build-up of both canines. Injection of HA fillers was planned to fill the deficient interdental papilla, because there was an excessive distance from the alveolar bone crest to the approximal contact in this case.\nIn the first treatment visit, after removal of the PFM crown and previous resin composite restoration, a provisional crown made with Protemp™ (3M ESPE) and a provisional veneer made with direct resin composite (Filtek Z350 XT, shade A2B, 3M ESPE) with a spot etching technique were placed (). At this point, the mesiodistal width of the lateral incisors had increased a total of 1.75 mm each. The tip of the interdental papilla was blunt and lay between the interdental contact points at the labial cementoenamel junction (CEJ) level. There was about 1.5–2 mm of the open gingival embrasure remaining between teeth, measured from the tip of the interdental papilla to the contact point ().\nIn the following visit, a gingivectomy with a diode laser of the left lateral incisor and direct injection of HA (JUVÉDERM® Ultra XC) of 0.2 cc into the middle of the papilla using a 30-gauge needle were done under a topical anesthetic (10% xylocaine). The HA injection was repeated at 21 days with a dose of 0.2 cc and then at 48 days with a dose of 0.05 cc. Gentle massage of the treatment area for about 1 minute was done. After each treatment session, the patient was given postoperative instructions that included using a soft toothbrush and 24-hour abstinence from mechanical plaque control in the treatment area []. The patient reported postoperative discomfort experienced at the last time of injection. At a 1-month follow-up after the last injection, about 1 mm open gingival embrasure or black triangle space in the cervical region remained. Subsequently, the proximal contours of the provisional crown and veneer were added with a flowable resin composite (Filtek Z350 XT flowable, 3M ESPE) and the contact area was lengthened and located more apically to close the remaining open gingival embrasure. One month later, final tooth preparation and impressions were done. The material used for the crown of the right lateral incisor was zirconia with IPS E-max veneering, while the veneer of the left lateral incisor was IPS E-max. After checking for suitability, the all-ceramic crown was fixed with RelyX Unicem (3M ESPE) and the veneer was fixed with RelyX veneer shade WO (3M ESPE). During the same visit, the reshaping and direct resin composite build-up of the canines (Filtek Z350 XT shade A3E, 3M ESPE) to substitute for the lateral incisors were completed (). The esthetic appearances of the restorations and soft tissue were reevaluated at 2 weeks, 3 months, 6 months, 12 months, and 18 months after completing treatment. Routine scaling and polishing were done during the 12-month follow-up. shows intraoral photograph of adhesive tooth-colored restorations and the interdental papilla from baseline, 2 weeks, and 18 months after completing treatment. The length of lateral incisors that were substituted for missing central incisors was about 0.5 mm longer than incisal edges of the adjacent teeth and the interdental embrasures were shaped as inverted “V.” Gingival contours of the restored anterior teeth were not ideal as they were at the same height. However, gingival contours of the restored anterior teeth were considered as acceptable, provided there was no gingival margin exposure at smiling. The overall final clinical results of restoring the maxillary anterior teeth in this patient were satisfactory, even though the esthetic outcomes were compromised by a shine-through effect from the metal post and compromised gingival contour.
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A 30-year-old male with no significant past medical history presented to his primary care physician in early 2019, with a painless right neck swelling in addition to multiple palpable masses in the area. A neck ultrasound showed multiple irregular and enlarged lymph nodes on the right side of the neck (Figures and ) along with a calcified right thyroid nodule measuring 17 × 20 × 13 mm. The left lobe of the thyroid was normal. The TSH value was 1.04 mIU/ml, confirming a euthyroid status. The patient reported no history of ionizing radiation exposure and no family history of thyroid cancer or other familial cancer syndromes.\nFine-needle aspiration (FNA) from the palpable lymph node revealed rare atypical epithelial cells and histocytes. Fine-needle aspiration from the right thyroid nodule was performed at an outside facility before referral, and the results were benign (presumably Bethesda class 2). We suspected a sampling error.\nBecause of the high index of suspicion for thyroid cancer, he underwent total thyroidectomy with central neck dissection and right lateral lymph node dissection at the end of July 2019.\nIntraoperative findings showed the presence of extensively involved cervical lymphadenopathy at multiple levels (IV–VI), mainly on the right side. The right cervical level IV and V lymph nodes were tightly adherent to the internal jugular vein and the other large blood vessels. Abnormal paratracheal lymph nodes were dissected from both sides. Postoperatively, the patient developed right recurrent laryngeal nerve paralysis as there was local invasion around the nerve. However, there was no evidence of postsurgical hypocalcemia.\nThe histopathology of the resected thyroidectomy specimen showed multifocal follicular variant papillary thyroid cancer (FV-PTC) infiltrating both lobes and the isthmus with angioinvasion, lymphatic invasion, and microscopic extrathyroidal extension (). The right superior and left superior lobe margins were also positive for the tumor. The largest tumor sizes were 3.5 and 1.5 cm in the most significant dimension, and the smallest tumor size was 0.1 cm. The Delphian lymph node and 4/4 right level VI lymph nodes had tumor involvement. Left paratracheal nodes (4/4) also had tumor involvement. A total of 5/9 lymph nodes from the right lymph node dissection at levels IV and V had metastatic tumor involvement. The largest metastatic tumor size was 4.0 cm, and this tumor showed an extranodal extension ().\nOn the initial visit to the endocrine clinic four weeks after surgery, a physical exam was remarkable only to develop hoarseness of voice. No palpable lymphadenopathy was noted. The patient was not on thyroid replacement therapy. The thyroglobulin level was 294 ng/ml (TSH 52.9 mIU/ml). Antithyroglobulin antibodies were undetectable.\nBecause of the patient's DTC's aggressive nature, next-generation sequencing was performed on the tumor tissue (OmniSeq; Integrated Oncology Lab) using multiplexed PCR-based DNA and RNA sequencing. The results showed EML4e13-ALKe20 fusion, a relatively common fusion described in non-small-cell lung cancer, which creates a more tumorigenic ALK kinase domain receptor by partnering with echinoderm microtubule-associated protein-like 4 (EML4) []. No other molecular alteration was found. Because of the high thyroglobulin level (294 ng/ml; TSH 52.9 mIU/ml), which was suggestive of persistent structural disease or distant metastasis, an FDG-PET/CT scan was performed. It showed two hypermetabolic lymph nodes in the upper cervical chain posterior to the internal carotid artery (SUV of 4.9 and 4.4). There was another hypermetabolic lymph node in the left supraclavicular area (SUV of 3.9). There was no significant uptake in the thyroid bed and no evidence of distant metastasis ().\nThe patient underwent a second surgery (bilateral neck dissection for residual disease), and as per the surgeon's description, there was no macroscopic disease left in the explored area. Pathology showed metastatic papillary thyroid cancer in 2 out of 12 right level II lymph nodes and 6 out of 13 left level III lymph nodes. The size of the largest metastatic tumor was 1.3 cm on both sides. There was evidence of extranodal extension on both sides.\nThe thyroglobulin level was reduced to 28 ng/ml 10 weeks after the second neck dissection (TSH 83.70 mIU/ml). The patient received 150 mCi I-131 therapy for the treatment of remnant tissue and residual disease.\nThe posttreatment scan showed localized uptake in the neck area ().\nFour months after posttreatment with radioactive iodine, the thyroglobulin level decreased to 0.19 ng/ml with undetectable antithyroglobulin antibodies (TSH 0.261 mIU/ml). There was no evidence of local recurrence by physical examination.
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The patient is a 50 year old male who received a LURT 8 years prior to presentation. He had previously undergone bilateral native nephrectomies 2 months prior to transplant for PKD. His early course was complicated by biopsy-proven acute cellular rejection, vascular type, 5 days after transplant, which was effectively treated with anti-thymocyte globulin and intravenous immunoglobulin. He subsequently went on to enjoy excellent graft function. Initially, he was maintained on standard triple immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and prednisone.\nTwo years prior to presentation, he developed numerous squamous cell carcinomas of the skin treated with resection and radiation. One of these lesions was an invasive poorly differentiated SCC (Bowen’s type) of the left auricle, requiring auriculectomy and reconstruction. Tumor margins were negative. His immunosuppression was reduced by stopping his MMF.\nOne year prior to presentation he developed a parotid mass found to be SCC by fine needle aspiration. It was felt that this was a metastatic lesion from the auricular tumor. At this time, he was switched from a dual immunosuppressive regimen of tacrolimus and prednisone to sirolimus (SRL) and prednisone. He underwent a left parotidectomy and neck dissection with pathology showing invasive keratinizing squamous cell carcinoma, poorly differentiated. The tumor was 4.6 cm with lymphovascular and perineural invasion. Surgical margins were negative, but 5 out of 23 periparotid and cervical LNs were positive for metastasis with focal extranodal extension. He underwent radiation therapy and cetuximab. A surveillance PET CT performed 6 months after treatment revealed 5 bilateral pulmonary nodules, which grew over 2 months from 6 mm to 10 mm. He initiated systemic treatment with carboplatin, paclitaxel and cetuximab with minor improvement initially, followed by disease progression in the lungs and mediastinum after 7 months of treatment. He was then treated with gemcitabine, and imaging after 2 months of therapy revealed tumor growth.\nA complex discussion was then held regarding symptom-focused palliative care or consideration of novel therapies. Next-generation tumor sequencing was performed on his lung biopsy specimen. Although no clear primary tumor driver was found, 16 genetic abnormalities of possible oncogenic effect were demonstrated, including an EGFR amplification event and a ROS1 mutation of uncertain significance. He enrolled in a clinical trial of the ROS1 inhibitor, entrectinib, but had clinical and radiographic progression within 6 weeks. Other clinical trial options were limited by his history of solid organ transplantation.\nWith his young age and active lifestyle, the patient opted to proceed with nivolumab 3 mg per kg therapy, understanding the high risk of alloimmune kidney transplant rejection. In preparation, sirolimus was tapered off and prednisone was tapered to 5 mg daily, after which his allograft function remained stable with a creatinine of 1.4 mg/dL. His sirolimus level prior to discontinuation was 6.9 ng/mL.\nThirteen days after receiving the first dose of nivolumab, he presented with low-grade fevers, oliguria and fluid retention. The physical exam demonstrated an enlarged and tender renal allograft and significant lower extremity and peri-orbital edema. Laboratory testing revealed marked acute kidney injury with a creatinine of 4.4 mg/dL. His sirolimus level was noted to be 1 ng/mL and he was treated empirically for acute rejection with a 3 day methylprednisone pulse but without improvement. A renal biopsy was deferred, as he was not a candidate for T-cell depleting therapy with his active malignancy and hemodialysis was initiated for volume overload and electrolyte disturbances. Given the life-threatening nature of his metastatic SCC, the graft was sacrificed and he continued on nivolumab therapy every 2 weeks. Imaging after 4 weeks demonstrated a partial regression in tumor burden and lymphadenopathy. For continued fevers, hematuria and marked allograft pain, an allograft nephrectomy was performed 2 months after stopping his immunosuppression. Histologic evaluation revealed hemorrhagic infarction with features of acute and chronic vascular rejection (Fig. ).\nNow, he continues treatment with nivolumab and most recent imaging 18 months after treatment initiation shows stable tumor regression. He has been maintained on hemodialysis, but has been able to travel and return to an active lifestyle.
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A male famer aged 68 years old was admitted to our institute for a tumor in his lower lip. This patient has a history of smoking (30 pack-year) and consuming alcohol for more than 30 years (approximately 200 ml per day). He was diagnosed as systemic lupus erythematosus (SLE) 20 years ago and had been treated with methylprednisolone for 17 years. For the last three years, his SLE status has been stable and thus, he discontinued the SLE treatment.\nThe patient reported that the tumor in the middle of his lower lip had appeared for a year and gradually increased in size without any pain or bleeding. He did not receive any treatment because of his financial issue. For the last few months, the tumor had rapidly grown, bled and become painful, so that he could not eat or clean his teeth.\nOn examination, there was a 3 x 4 cm, raised, ulcerous, and bleeding tumor, developing in the lower lip and expanding to 1/3 external upper lip (). The submental lymph node was around 2 cm in diameter, firm, and hardly moveable. Ultrasound revealed a suspected metastatic submental lymph node with absent echogenic hilum. MRI Scan demonstrated a lesion in lower lip with size of 13 x 31 mm, which increased in T1W signal and T2W signal, strongly enhanced after contrast and did not invade surrounding tissue. A 2 cm and round lymph node was also identified (). The fine needle aspiration (FNA) result of the lymph node presented a metastatic squamous cell carcinoma and the biopsy result of the tumor confirmed squamous cell carcinoma (SCC). No abnormality was detected by a metastatic work-up. Therefore, the clinical staging of this patient was cT2N1M0. In addition, other para-clinical tests including full blood count, biochemistry profile, ds-DNA, ANA were normal, which indicated a stable status of SLE.\nThe patient underwent surgery including a complete removal of the lower lip and 1/3 external of upper lip, and dissection of the bilateral cervical lymph nodes. The lower lip was reconstructed with V-Y advancement flap (). This operation, performed by a team of head and neck surgeons, was proceeded within 4 h. Patient was discharged after 14 days without any complications. Final pathology presented SCC ().
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A 40-year old Chinese male non-diabetic, non-hypertensive patient presented at our hospital with precordial and back pain that started 5 h earlier, and chest pain lasted for only a few minutes. Vital signs were recorded on admission with normal blood pressure in arms and legs. Blood pressure in the right arm was 138/74 mmHg, heart rate was 108 beats per minute and body temperature was 37.3 C degree. The patient received computed tomography angiography (CTA) and it revealed aortic dissection of the descending aorta without pericardial effusion or significant coronary disease. No dissection was found in ascending aorta, and the arterial bifurcation of the limbs and organs were not involved. The false lumen of descending aortic showed crescent-shaped with a thickness of 5 mm (Fig. a, b). As no poor perfusion, aneurysm, or uncontrolled pain complicated, the patient deemed not to be in need of emergency surgical repair. On this basis, conservative medical therapy was given together with blood pressure and heart rate tight control, as well as hemostasis. The blood pressure was kept less than 110/70 mmHg and the heart rate was maintained below 70 bpm after administration of calcium channel blocker (nifedipine started with 10 mg, three times a day) and beta-blocking agent (metoprolol started with 47.5 mg, once a day), the medicine dosages were adjusted according to the level of blood pressure. The patient did not experience any recurring chest pain after resolution of the original attack, which lasted a few minutes only.\nCTA was performed after 6 days of conservative treatment, RTAD was detected in the absence of typical thoracic pain. Ascending aortic false lumen was 5 mm thickening in a crescent shape, as well as the thickness of false lumen in the descending aorta wall was expanded to 9.5 mm (Fig. c, d). Subsequently, a CTA scan was followed by another 6-day medical treatment due to the patient’s refusal to open surgical therapy at the beginning. The thickness of false lumen in the walls of ascending and descending aorta was 13.1 mm and 12.9 mm respectively (Fig. e, f). Moreover, a cardiac ultrasound indicated pericardial effusion, together with an anechoic liquid area, 5 mm thickness behind the posterior wall of the left ventricle. It showed that type B aortic dissection progressed into RTAD without any symptom. Flowchart for management of our case was shown in Fig. .\nOn day 12, as the high risk of aortic rupture and cardiac tamponade, open surgical repair was performed under the permission of the patient. Total replacement of the aortic arch combined with elephant trunk implantation through a median sternotomy under hypothermic cardiopulmonary bypass (CPB) was proceeded as explained in earlier studies [, ]. Cannulation for CPB was carried out through the right femoral artery and the right atrium. Cardiac protection was done through cold-blood cardioplegia perfusion. Cerebral effective protection was done using bilateral antegrade cerebral perfusion combined with deep hypothermic circulatory arrest in aortic arch surgery. After that, the aortic arch and ascending aorta were opened and inspected closely. The primary tear of aortic dissection was observed in the descending aorta. Sleeve anastomosis was performed to suture the root of the aorta. We implanted a 100 mm long stent-graft (Shanghai MicroPort Medical Corporation, China) into the descending aorta compressed as an elephant trunk and sealed off the descending aorta intimal tear. The sutural margins were then fixed using the 4–0 Prolene suture. Besides, fenestration was performed in the stented elephant trunk to simplify the procedure of anastomosis to the left subclavian artery. Then, a four-branched prosthetic graft (Terumo Corporation, Japan) replaced the ascending aorta and aortic arch. Bilateral antegrade cerebral perfusion was discontinued after anastomosis of the innominate artery and common carotid artery. CPB was gradually returned to normal flow and started to rewarm. After the reconstruction of all aortic arch vessels, the proximal anastomosis was carried out during rewarming. The CBP time was 190 min, aortic cross-clamp time was 114 min, and double cerebral perfusion time was 35 min.\nThe patient was sent to the intensive care unit (ICU) for further monitoring after the operation was done, weaned from ventilator 14 h after the surgery. After mediastinal drainage tube removed on the third day, postoperative total aortic CTA was performed and revealed no aberrant changes in the position, profile or size of the artificial blood vessel and the stent. The pathological examination showed that elastic fibrous tissue hyperplasia and semi-mucoid degeneration of aortic wall, there was massive hemorrhage between the aorta walls, and the results were consistent with aortic dissection. The patient was discharged with satisfactory conditions two weeks after operation, continued to take medicine (nifedipine 30 mg per day; metoprolol 47.5 mg per day) to control blood pressure and heart rate, avoid heavy physical work, and follow-up regularly. At 6 month follow-up, no obvious abnormality was detected in the implanted prosthetic graft or stent as evident by CTA.
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A 38-year-old female with no past medical history came to the hospital with complaints of episodic chest discomfort, mild dyspnea, and occasional non-productive cough. On physical examination, she was hemodynamically stable without any pathological finding. A chest x-ray was done and it showed mass-like opacities abutting the right heart (Figure ).\nTo have a better idea of the cause of opacity, a further assessment with computed tomography (CT) chest with contrast was ordered and it showed a large, well-circumscribed, heterogeneously enhancing mass of 10 cm with peripheral calcification in the right mediastinum. Also, there was a dilated vessel along the posteromedial and inferior of the mass (Figure ).\nAfter the chest CT findings, the patient was admitted to the hospital for further evaluation and cardiac consult was called. In order to differentiate if the mass was due to some tumor or some anomaly of the coronary vessel, coronary CT angiography with contrast was ordered. A subsequent coronary CT angiography (CCTA) showed a 9.7 cm aneurysm and an anomalous vessel emanating from the left coronary artery and the proximal circumflex, fistulizing into the right atrial appendage. CCTA also showed a dilated right atrium likely due to fistula formation (Figures -).\nWhen the right heart catheterization was performed, a rise in saturation was noted in the right side of the heart due to shunting of blood from the left side to the right side of the heart as a result of coronary cameral fistula formation between the right heart and the anomalous vessel originating from the left coronary artery and proximal circumflex artery. On transesophageal echocardiogram (TEE), an enlarged right atrial chamber was noted due to the fistulous tract draining into the right atrium. The cardiothoracic department then scheduled the patient for surgery. Sternotomy was performed to repair the coronary artery aneurysm with ligation and resection of the coronary cameral fistula and repair of the right atrium. Surgery went well and no intra-operative and postoperative complications were noted.
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A 31-yr-old woman underwent barium enema examination as part of a medical checkup. She had been healthy without specific complaints and had no significant past medical or family history. The patient was 161 cm in height and weighed 44 kg; she appeared well and the physical examination showed no abnormalities. The complete blood cell count and the biochemical analysis of the blood for hepatic and renal function, urine analysis, and fecal occult blood test were all within normal limits. The tumor markers for CEA and CA 19-9 were also normal. No lesions were observed on the upper endoscopy and the abdominal ultrasound.\nOn the air contrast barium enema, multiple thumbprint-like lesions ranging from 7 to 20 mm in diameter were observed from the cecum to the hepatic flexure, mainly in the ascending colon (). The colonoscopy revealed clusters of round submucosal tumors with a gentle slope and smooth surface from the cecum to the hepatic flexure (). The color and surface characteristics of the lesions did not differ from those of the surrounding normal mucosa; however, they were noted to be pale to transparent. The lesions had a positive cushion (pillow) sign, and there were no ulcerations or erosions.\nThe EUS was performed with a radial scanning catheter probe (12 MHz, Fujinon Inc., Saitama, Japan) that showed each of the submucosal lesions as an echo-free cyst, with a clear border, in the submucosal layer (). The inner structure was uniform and some of the cysts had septal walls (). Some of the lesions were punctured and aspirated, and a transparent yellowish, serous liquid resembling lymphatic fluid was collected. The submucosal lesions easily caved in during aspiration. The endoscopic biopsy revealed a submucosal cyst with occasional multinucleated cells; however, there were no fat or blood cell components (). The D2-40 immunostaining, which is a specific lymphatic endothelial marker, showed positive reactivity for lining endothelial cells of the lymphatic spaces ().\nBased on the above colonoscopy and EUS findings, the diagnosis of lymphangiomatosis of the colon was made. Further therapy was not provided, because these lesions are benign and the patient had no symptoms associated with them.
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A 53 year-old White male presented to the emergency department with dysphagia to liquids and solids for 1 day. He reported eating boneless chicken the night prior when he felt the food get lodged in his throat. In the emergency department, his vital signs were stable and physical examination was unremarkable. Food impaction was suspected and gastroenterology was consulted.\nEsophagogastroduodenoscopy (EGD) was performed and impacted meat, approximately 6 cm in diameter, was visible in the lower third of the esophagus at 35 cm from the incisors (). Attempts were made to gently push the soft bolus into the stomach with the endoscope but were unsuccessful. Multiple attempts, over the course of several hours, to relieve the food bolus with Roth Net retrievers, biopsy forceps, tripod forceps and dilation balloons were also unsuccessful (). The patient remained intubated in the intensive care unit with recommendations to give glucagon 0.5 mg intravenously (IV) once every 6 h overnight and repeat EGD in the morning. Of note, the patient also received benzodiazepines while intubated for sedation.\nRepeat EGD performed the following day showed that the food bolus had spontaneously passed (). The esophagus appeared normal and multiple biopsies were taken from the proximal and distal esophagus to rule out eosinophilic esophagitis (EoE). The biopsy results showed features suggestive of reflux in the proximal and distal esophagus. There was no histological evidence suggestive of EoE. We postulate that the patient did not finish the oral phase of digestion, causing the partially chewed meat bolus to reach the esophagus where it was lodged. This likely caused significant esophageal spasm in a physiological attempt to push the bolus into the stomach, rendering the complete endoscopic removal a challenge. He was discharged with a proton pump inhibitor twice daily and told to follow up with GI in the clinic. The patient was called 1 week after his procedure and he was doing well without repeat episodes of dysphagia.
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A 48-year-old male was taking out the trash from his home when he lost his footing and fell on his right side resulting in significant pain and shortness of breath. Upon arrival to our institution, he was found to have displaced right 6th through 9th rib fractures without pneumothorax or pulmonary contusion (). Physical exam revealed significant tenderness to palpation over the right chest wall as well as a “clicking” sensation upon deep inspiration. His breathing pattern was rapid and shallow due to severe pain, and his oxygenation saturation was 90% on room air. Initial incentive spirometry measurements were recorded at 500 milliliters (mL), which is only 16% of his predicted value.\nThe patient was admitted to the intensive care unit (ICU) for pain control and pulmonary hygiene. On hospital days 1 and 2 he continued to experience significant pain despite being given an aggressive multi-modal pain regimen. His incentive spirometer measurements barely improved and he continued to have marginal oxygen saturations requiring oxygen supplementation. On hospital day 4, he was found to be severely tachypneic, hypoxic, and tachycardic, requiring BiPAP support to maintain adequate oxygenation. Pulmonary embolus was ruled out, and he had an epidural placed for better pain control (he initially refused upon admission). Incentive spirometry measurements were still only 32% of his predicted value. Given the slow progression of recovery and the amount of pain the patient was experiencing, the decision was made to proceed with surgical stabilization of the rib fractures. Initially, he was hesitant to undergo surgery but given the amount of pain he was experiencing the continued respiratory compromise, he eventually decided to undergo SSRF on hospital day 8. He was deemed an excellent candidate for stabilization using a minimally invasive intrathoracic approach. After an extensive discussion with the patient regarding the risks and benefits of surgical fixation, he consented to the procedure.\nThe patient was taken to the operating room for right sided SSRF of ribs 6 through 9. He was intubated with a dual-lumen endotracheal tube, placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. Initially, a small incision (4 cm) was made in the middle of the palpable rib fractures for exposure from the outside. Next, the pleural space was entered through a 12-millimeter (mm) counter incision in the 8th intercostal space posteriorly. The right lung endotracheal tube portion was then clamped allowing the right lung to collapse for better visualization of the fractures from the inside. Holes were then drilled through non-fractured rib at least 1 cm on either side of the fracture site to allow for rubber guide tubes to be passed through from the inside of the chest cavity outward. The fixation plates were then inserted into the chest via the 12 mm thoracoscope incision and guided to the fractures via cables fed through the rubber guide tubes. Using the cables attached to the plate, we were able to adequately reduce each fracture. The plates were fixated from the outside using bolts and nuts, allowing for both anterior and posterior cortical engagement. Of note, the bolts are fixated to the intrathoracic plates but are able to fold into the plate, allowing for ease of placement into the chest through the 12 mm incision. The bolts are what is attached to the cables which are then pulled through the previously drilled holes, allowing for the nut and washer to secure to the external portion of the rib.\nOnce all four ribs were reduced appropriately and plated, the right chest was much more stable (). The chest cavity was then irrigated thoracoscopically and a 14 French pigtail catheter was placed for further drainage. Cryoablation of the concomitant intercostal nerves was also performed for further pain management. The incisions were copiously irrigated and closed in layers. The patient was extubated and returned to the ICU in a stable condition. A post-operative chest x-ray was obtained and demonstrated in .\nPostoperatively, the patient resumed working with respiratory therapy on an aggressive pulmonary hygiene regimen. He immediately expressed his satisfaction that he could no longer feel his ribs “clicking” on inhalation and that he was pleased with his decision to undergo fixation. On post-operative day (POD) 1, he was out of bed and ambulating the halls, something he had not desired much since admission. His incentive spirometry measurements and oxygenation requirements began to improve, and they improved each day throughout the remainder of his hospital stay. On POD 2, the pigtail catheter was removed without issue and he continued to ambulate even more. By POD 3, his incentive spirometry measurements were 81% of his expected amount and his breathing mechanics had greatly improved (). He no longer required the use of supplemental oxygen was deemed fit for discharge. He was discharged home with support without any issues or complications. Eleven days later, he was seen in clinic and reported a significant improvement in pain and was happy with the progress he had made so far. He was actually requesting to be released back to work at this time, which he was granted.\nThe patient did follow-up one additional time in the clinic 3 months after his surgery. At that time, his chest pain had completely resolved, he denied any clicking or popping of his rib previous rib fractures and he had no shortness of breath, all of which suggested his ribs had healed. Furthermore, he was back to full work capacity and was sleeping well. Given his significant improvement, no additional imaging was necessary and he was instructed to follow-up in the clinic as needed.
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A 2-year old boy without significant past medical history presented to the pediatric emergency department of this hospital following extreme irritability, crying, abdominal pain, and shortness of breath that occurred during bath time. Initial blood pressure was 90/50 mm Hg, pulse rate and respiratory rate were 161/min and 50/min respectively, temperature was 37.3°C and oxygen saturation was 88% to 91% on room air, so he was given oxygen by mask. He had wheezing on the right side of the chest with reduced breath sounds on the left side. The white blood cell count was elevated at 38,450/uL, and his chest x-ray showed air shadowing in the whole left thorax and mediastinal shift (Fig. ).\nThe pediatric emergency team suspected a large bulla or tension pneumothorax in the left lung, so the patient was referred to our department for opinion. Based on the chest x-ray, we did not feel that it was a bulla or pneumothorax so the patient underwent chest computed tomography (CT) for more accurate diagnosis. The chest CT showed a herniated stomach that was distended with large amount of food and gas, leading to significant shifting of the heart and lung to the right side, as well as right-sided pneumonia (Fig. ). Based on these findings we diagnosed tension gastrothorax and nasogastric tube (NGT) was inserted for gastric decompression, but the patient was irritable and did not tolerate it so it was soon pulled out.\nThe oxygen saturation level of the patient could not be maintained despite high flow oxygen through a mask and the patient had high fever with ipsilateral pneumonia. It was deemed unsafe for the patient to have NGT reinsertion while awake, so a decision was made to put the patient under general anesthesia for NGT insertion followed by operation. However, the patient had cardiac arrest immediately after starting general anesthesia in the operating room. Although the circulation returned after resuscitation, the vital signs were unstable. Considering the risk of another cardiac arrest during NGT insertion, we decided to proceed to operation without reinserting the NGT. As gastric decompression could not be achieved, we thought that laparotomy approach would be difficult so proceeded to thoracotomy approach.\nPosterolateral thoracotomy showed a significantly distended stomach that filled the entire thoracic cavity. In order to aid the recovery of the cardiorespiratory function, there was a need for immediate gastric decompression to relieve the pressure on the heart and lungs from the distended stomach. The stomach was; therefore, deliberately perforated to suction the gas and food contents filling the stomach, to relieve the pressure on the lungs and the heart. Once patient vitals were stabilized, the stomach perforation site was closed and the herniated stomach was examined which did not reveal ischemic changes or other abnormalities.\nThe diaphragmatic defect was found on the posterolateral side. The stomach that had herniated through the defect was reduced, and as the defect was not very large, we decided that patch reconstruction was not necessary. The defect was treated by primary repair.\nPostoperative chest x-ray showed full expansion of the left lung, with normal diaphragm. There was normal stomach gas in the intraperitoneal region (Fig. A). The chest tube was removed on day 3, and the patient was discharged on day 8 when the right-sided pneumonia had improved (Fig. B). At 1-year postoperative follow up, the patient was well with normal chest x-ray findings (Fig. C).\nThis case report was approved by the Institutional Review Board of Soonchunhyang University Hospital (SCHCA 2020-07-010). The patient has provided informed consent for publication of this case.
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A 25-year-old female with a known diagnosis of epilepsy presented to the emergency department with complaints of fever, anorexia, and uncontrolled convulsions for the last one month. The convulsions were generalized, tonic-clonic, and were associated with tongue biting, fecal and urinary incontinence as well as postictal confusion. The seizures lasted for about ten minutes. They were recurrent with episodes occurring on a monthly basis. The fever was of gradual onset, high grade, intermittent in pattern, relieved temporarily by medications and cold sponging. There were no associated rigors or chills. She was reported to be having poor appetite and sleep. She had a history of multiple previous admissions in different hospitals for the management of her seizures. However, no brain imaging had previously been done. Her past medical history was significant for delayed motor, language, and cognitive functions. She was bedridden and needed nursing care since childhood. She had a skin lesion on her face since her birth. There was no significant past surgical history. She was on anti-epileptic medications, but there was no available record.\nOn inspection, a young female of average height and build was lying in a drowsy state. She had a dark, pigmented skin lesion on the midline of her face. The lesion was dark brown in color, extending from the submental region to the lower lip and then extending from her nasal bridge to her forehead in the same midline plane (Figure ).\nThe lesion was greasy on touch. She was pale and dehydrated. Her temperature was 102o F, pulse was 106 bpm, and her BP was 90/60mm Hg. Her right eye showed many raised dark pigmented lesions on the temporal sides of the optic discs. Both the corneas were hazy in the periphery. She had poor oral hygiene with shallow oral ulcers. Her neurologic examination showed a GCS of 6/15. Her neck was supple with no signs of meningeal irritation. Her pupils were reactive to light. Her plantars were upgoing. Her tone and reflexes were normal. She was aphasic. Her power, sensory system, and cerebellar systems could not be assessed. The rest of her systemic examination was unremarkable. She had a urinary catheter in place.\nLaboratory investigation revealed a hemoglobin of 13.4 mg/dL, platelet count of 182,000/mcL, and white blood cell count of 13,000/mcL. The urinalysis showed 8-10 WBCs/HPF and 1-2 RBCs/HPF. Her serum electrolytes, renal function tests, and liver function tests were in the normal range. The urine culture was not reported due to a laboratory error. Her serum calcium was 9.9 mg/dl, and her serum blood glucose level was 120 mg/dL. An ultrasound of the abdomen and pelvis was normal. A skin histopathology was not performed due to the patient's preference. An MRI of the brain with contrast showed congenital cerebral malformations with cortical dysplasia and multiple hamartomas in the medial temporal lobe, thalamus, and periventricular region on right side and cerebellar atrophy with Dandy-Walker variant (Figures -).\nOn presentation, the differential diagnosis included meningitis, encephalitis, tuberous sclerosis, neurofibromatosis, and Von Hippel-Lindau disease. However, there was no associated neck stiffness, and a lumbar puncture showed no pleocytosis, hyperproteinemia, or hypoglycemia. Furthermore, there were no cafe lait spots, adenoma sebaceum, ash leaf spots, cardiac anomalies, abdominal mass, or eye findings suggestive of the above-mentioned differential diagnosis, and the MRI findings and typical nevus suggested ENS as the most likely diagnosis.\nThe patient was started on intravenous ceftriaxone and valproic acid for the treatment of the urinary tract infection and seizures, respectively. Her urinary tract infection and seizures resolved by the third day of her hospitalization. She became afebrile, and her GCS score improved to 10/15. The patient was sent home on oral valproic acid, and the family was counseled about hygiene and safety measures to avoid aspiration pneumonia and other complications such as bed sores.\nAt follow-up after one month, the patient had no change in her cognition, and she still had occasional episodes of tonic-clonic seizures; however, her fever was completely resolved.
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A 42-year-old female reported to our outpatient department with complaints of left flank pain for 10 days. There was no documented history of hypertension, diabetes mellitus, or any other significant illness in the past.\nShe had no complaints of weight loss or weight gain, nausea, vomiting, or dyspnea. Plain X-ray of the kidney-ureter-bladder region showed a small 6 mm left upper ureteric calculi, and the ultrasonography showed an incidental finding of right suprarenal mass. The intravenous urography showed left upper ureteric calculi along with displacement of the right kidney (due to the suprarenal mass) []. Both the kidneys showed normal function on the intravenous pyelogram. The computed tomography (CT) scan showed large well-defined lesion of size 126 mm × 146 mm × 180 mm in the right suprarenal region with fat density showing areas of calcification, necrosis producing mass effect over adjacent abdominal viscera []. Lesion was abutting right posterolateral abdominal wall, also producing compression over inferior vena cava, pancreatic head, and aorta shifted toward the left side. The perilesional fat planes were found clear, and there was no lymphadenopathy. General examination of the patient showed hypertension. After admitting the patient at our center, the hormonal and urinary parameters were tested along with other routine investigations. Although all the other parameters were normal, the dexamethasone suppression test was found positive and also the patient was diagnosed with diabetes mellitus but the patient had no overt external clinical features of Cushing syndrome. The patient was started on antihypertensives and insulin. Left upper ureteric calculi were managed conservatively because of its small size and no backpressure changes.\nAfter controlling the blood sugar and blood pressure of the patient, the patient underwent an open right adrenalectomy. Perioperative period was uneventful. The gross specimen consisted of a capsulated fibrofatty soft-tissue mass weighing 1.758 kg and measuring 24 cm × 17 cm × 15 cm in size []. Histopathological examination of the specimen revealed almost whole of the adrenal gland to be replaced by mature adipose tissue and trilinear hematopoietic elements composed of myeloid cells with few clusters of erythroid cells and megakaryocytes. Areas of osseous metaplasia were also seen [Figures and ].
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We present the case of a 62-year-old woman, admitted to a local hospital following a short episode of loss of consciousness related to physical effort, with subsequent generalized tonic-clonic seizures. The patient had features of Hunt and Hess Grade III SAH which was confirmed by CT scan and was referred to the Bagdasar Arseni Emergency Hospital for further management. An angio-CT scan [] and a four-vessel DSA [] were performed, which showed a ruptured ophthalmic artery aneurysm.\nDuring the diagnostic angiography, the interventional radiologist also attempted endovascular treatment, but embolization had to be aborted due to the anatomic particularities of the case. In addition to the multilobulated aspect of the left ophthalmic artery aneurysm, the left ICA was intensely atheromatous, and the right ICA was hypoplastic. These findings related a high thrombo-embolic risk and rendered the endovascular treatment impossible.\nGiven this particular anatomical setting, we decided to perform an early surgical intervention, hoping to offer the patient the best chance of avoiding subsequent vasospasm. The intervention proved challenging, as the aneurysm size and location provided a very narrow working space. The surgical procedure was performed in a classic fashion, beginning with a left pterional flap. The proximal sylvian fissure was dissected after brain relaxation was obtained by having inserted an external ventricular drain into the frontal horn of the lateral ventricle. The ICA was then followed from the bifurcation to the emergence from the cavernous sinus, and additional CSF leakage provided further brain relaxation. We did not need to use a temporal clip, as the proximal ICA was adequately exposed. The base of the left anterior clinoid process was subsequently drilled and the aneurysm was dissected from its adherences. A 10 mm Yasargil titanium clip was applied on the neck of the aneurysm, parallel to the ophthalmic artery. Previously, the artery had been carefully dissected from its adherences to the neck of the aneurysm, to make sure it remained under the clip. The clip positioning was inspected to make sure the aneurysm was well clipped and there was no kinking.\nAn angio-CT performed on the first postoperative day proved the integrity of the circle of Willis and the integrity of the flux in the left ophthalmic artery. The aneurysm has been excluded from circulation [].\nPostoperatively, the patient was in good condition with a GCS of 15 and no neurological deficits. During the postoperative course, a calcium channel blocker (nimodipine) was administered. Her vision was completely preserved. At 6 months follow up, she was assigned maximum scores of 5 and 8 on the GOS and Extended GOS (GOS-E), respectively.
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A 53-year-old Hispanic man with past medical history significant for coronary artery disease, habitual intravenous heroin abuse, chronic untreated hepatitis C without cirrhosis, bipolar disorder, tobacco abuse of 80 pack-year, and degenerative disc disease presented from home to our hospital with chief complaint of left scrotal pain, diffuse abdominal pain, back pain, and chest pain. Four days prior to presentation, he was seen in the emergency department for chronic back pain and was discharged with naproxen and instruction to follow up with his primary care physician. Since then, he developed acute onset of sharp constant pain of his left testicle and his abdomen. He admitted to using ten bags of heroin intravenously daily. He underwent an incision and drainage one month prior for a skin abscess. He reported no new sexual partner and is only sexually active with his current girlfriend. Family history was significant for heart disease in both his parents and maternal grandparents. His vital signs on admission were within the normal range. Physical exam revealed a man, with cachexia and temporal muscle wasting, in moderate distress from pain. He had jaundice with icteric sclera. His lungs were clear to auscultation. His heart sounds had regular rate and rhythm without any audible murmur. He had a soft abdomen that was mildly distended and tender in all four quadrants. His genitourinary exam was significant for bilateral scrotal erythema and swelling, which was worse on the left and was tender to light touch. He had diffuse tenderness to his back including paraspinal muscles, but no tenderness to the spinal processes. He was alert and oriented to person, time, and place and could answer questions appropriately. He had no facial asymmetry or deviated tongue, and he displayed normal proximal and distal strength. Laboratory findings were significant for WBC of 12.1 K/mm3 with a neutrophil predominance of 90%, microcytic anemia with hemoglobin 7.7 g/dL and MCV 75.6 fL, and thrombocytopenia of 47 K/mm3. His direct bilirubin level was elevated (3.0 mg/dL), as were his alkaline phosphatase (282 U/L), AST (87 U/L), ALT (33 U/L), and LDH (393 U/L). His albumin was 1.7 g/dL and lactic acid was normal at 1.2 mmol/L. His HIV-screening test was negative, as were his gonorrhea and chlamydia molecular amplification tests. He was subsequently admitted to internal medicine service/floor for further management.\nHis initial work up included a urinalysis that was significant for 10–20 RBC per HPF, 5–10 WBC per HPF, and positive urine nitrite; an EKG that showed normal sinus rhythm; and a chest X-ray which was negative for cardiomegaly, pleural effusions, or lung consolidations. A computed tomography (CT) of his head did not show any intracranial abnormalities. A CT of his abdomen and pelvis without contrast was performed which revealed hepatosplenomegaly with multiple large wedge-shaped areas of hypoperfusion in the spleen, concerning splenic infarctions (). The scrotal ultrasound showed no torsions, but revealed left epididymo-orchitis, large complex left scrotal hydrocele, and bilateral testicular microlithiasis. A limited bedside transthoracic echocardiogram by the emergency department physicians revealed a small pericardial effusion with no observable valvular vegetations. Blood and urine cultures were collected, and he was initially started on the broad-spectrum antibiotics of vancomycin, piperacillin-tazobactam, and azithromycin considering his risk factors and clinical presentation.\nOvernight, he remained afebrile, but his leukocytosis worsened to 14.6 K/mm3, and he developed dyspnea and tachypnea with 24 breaths per minute. He became disoriented and was not answering questions appropriately. On exam, new findings of splinter hemorrhages, toe infarctions, and subconjunctival hemorrhaging were noted. Urine culture grew Serratia marcescens 50,000–100,000 CFU. Blood cultures also later grew the same organism, susceptible to all tested antibiotics including amikacin, aztreonam, cefepime, ceftriaxone, ciprofloxacin, gentamicin, ertapenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole. On hospital day 2, a formal transthoracic echocardiogram (TTE) revealed an ejection fraction of 60% (unchanged from three years prior) with a large echodensity on the aortic valve consistent with vegetation. Mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation were also noted. Antibiotics were subsequently changed toertapenem 1 g daily and ciprofloxacin 750 mg twice daily in consultation with infectious disease.\nThe patient continued to deteriorate the following day. He became more disoriented and agitated. He remained afebrile, but his tachypnea worsened to 30 breaths per minute, and new rales were now audible on lung auscultation. An arterial blood gas (pH 7.51; pCO2 21 mmHg; pO2 70 mmHg; HCO3 16 mmol/L; O2 saturation 93%) showed a respiratory alkalosis. A repeat chest X-ray showed new interstitial pulmonary edema and vascular congestion. A CT of the head without contrast was performed due to his altered mental status, which showed two areas concerning embolic infarcts in the left parietal lobe and the left cerebellum (), compared to the one obtained on admission. On hospital day 4, an urgent transesophageal echocardiogram (TEE) was performed which again demonstrated the large aortic valve vegetations (), but it now demonstrated acutely deteriorating moderate to severe aortic regurgitation, which was different from the TTE findings a few days prior that only showed mild-moderate aortic insufficiency. In addition, it also revealed a mildly dilated left ventricle. The aortic valve leaflet had prolapsed motion. Due to the presence of large aortic valve vegetations, multiple embolic phenomena, and a progressively worsening of his clinical condition, decision was made to perform an urgent aortic valve replacement.\nPostoperatively, he was managed in the surgical intensive care unit, where he developed a moderate-sized left pneumothorax requiring a chest tube placement. Slowly, his mental and clinical status began to improve. By hospital day 19, the patient was no longer agitated or disoriented. He displayed good appetite, and his chest tube was removed. His leukocytosis significantly improved to 8.0 K/mm3, and his repeat blood cultures did not grow any organisms for 5 days. Throughout his hospital course, he remained afebrile and did not receive any antipyretics. The lack of fever was concerning for an immunocompromised state, but he tested negative for HIV. He was ultimately discharged to a skilled nursing facility to complete his antibiotics, ertapenem 1 g daily with ciprofloxacin 750 mg twice daily, for a total course of 6 weeks, and to continue physical therapy.
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An 86-year-old woman presented with massive rectal bleeding, severe anemia (Hb 6 g/dL), and hemodynamic stability. The patient had a body mass index of 22 and arterial hypertension. A computed tomography with contrast enhancement showed a right colon carcinoma with active bleeding; no distant metastases were found. The patient was admitted in the intensive care unit (ICU) for resuscitation and blood transfusion, requiring 4 packed red blood cells unit in 24 hours. Laboratory tests showed that PT, creatinine, and urea levels were within the normal ranges. A colonoscopy did not show bowel lesions other than the right colon carcinoma. The constant bleeding from the right colon mass was temporarily arrested by endoscopic argon coagulation. After 12 h surveillance in the ICU, no other bowel bleeding was found and we decided upon an urgent right colectomy without primary anastomosis due to the patient’s poor nutritional status (serum albumin 2.7 g/dL; pre-albumin 112 mg/L) and the important previous body weight loss (>10%), which are recognized risk factors for anastomotic leak and mortality in elderly patients [-]. Although the patient was stable, the risk of re-bleeding and related complications was considered high, which led us to decide upon an urgent colectomy. A radical resection was considered achievable with a minimally invasive approach, namely, robotic surgery. The robot present in our department is the da Vinci Intuitive Surgical System®. It consists of a vision cart and a surgeon’s console, with the option of a second console for the first assistant surgeon. The patient was placed in a supine position with the legs open. The patient was secured to the operating table with the help of a bean bag, with both arms on the bedside. The robot was on the right side of the patient and the first assistant and the scrub nurse were situated to the patient’s left side. Once the robot is docked, there can be no change to the robot’s or the patient’s position without first undocking the robotic arms. We routinely use only two robotic arms with a third one for the camera (in order to contain surgery-related costs), although three robotic working arms can be used if needed. Robotic trocars were placed on the left mid-clavicular line, and the assistant’s trocar was placed in the hypogastric region below the camera for traction (Figure ). The first trocar was placed with the Hasson open technique.\nThe robot was brought from the right side of the patient and docked onto the ports. We routinely use a vessel sealer on the right hand and a bipolar fenestrated grasper on the left robotic arm. The procedure began as any other laparoscopic procedure, with the inspection of the abdominal cavity to evaluate the feasibility of the robotic resection or the presence of other contraindications. The patient was placed in the Trendelenburg position, with a left inclination of 30 degrees. This allowed for good vision of the operating field, exposing the caecum and the terminal part of the ileum, while the small bowel and the omentum were pushed into the upper quadrants. A medial to lateral approach was used. The caecum was grasped and retracted laterally, and the peritoneum was incised in the ileo-caecal fold. The ileo-caecal artery and vein were then dissected and stapled with a vascular stapler. This helped to open the avascular retroperitoneal plane of dissection. The entire right colon was mobilized up to the hepatic flexure. The transverse colon was retracted inferiorly, and the gastrocolic ligament was divided with the help of vessel sealer. The dissection was continued toward the hepatic flexure and the final attachments of the colon to the retroperitoneum were divided. This completed the mobilization of the entire right colon and the robotic part of the procedure. Once completed, the robot was undocked and the site of the double-barreled ileocolostomy was prepared in the right iliac region. The double-barreled ileocolostomy consists in the creation of an ostomy site were both the proximal ileum stump and the transverse colonic stump are tacked together by interrupted 4–0 Vicryl sutures (Figure a). The mobilized right colon was entirely exteriorized through the ileocolostomy site (approximately 5 cm) and resected extracorporeally (Figure b). No drain was left in the abdomen. The whole procedure took 150 min and the estimated blood loss was 50 ml. The post-operative period was uneventful. The patient was discharged on postoperative day 6 after a re-alimentation and normal bowel transit (achieved at post-operative day 1). The nutritional status improved with specific diet and progressive re-alimentation. The tumor was a moderately differentiated mucinous adenocarcinoma of the colon, classified as pT3N0 (on 17 lymphnodes); no adjuvant chemotherapy was indicated, and surveillance was decided after a multidisciplinary meeting. The ileocolostomy closure was performed three months later with a local approach. Stoma closure was simply achieved by local mobilization at the mucocutaneous junction and extracorporeal anastomosis. At the 5 month follow-up, the patient was well, asymptomatic and without signs of recurrence.
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Our patient is a fifty-one-year-old woman who was initially admitted to our facility in July 2007 with complaints of malaise, intermittent subjective fevers, and bilateral breast pain. She admitted undergoing soft tissue augmentation of her breast and buttocks with unknown “silicone oil” in 2001 by an untrained practitioner in Mexico; mammography showed calcifications in both breasts from 2004 (). Physical examination revealed multiple subcutaneous tender “stony consistency” masses with erythema involving her breast, buttocks, thigh, and back. Areas of thickened skin were also noticed in multiple areas involving sternum and thighs. Laboratory workup revealed moderate leukocytosis with left shift. Abdominal and pelvic computed tomography (CT) revealed extensive infiltration of the soft tissue planes involving breast, back, and gluteal areas (Figures and ). She was treated with ibuprofen 400 mg every 8 hours and a short course of corticosteroids prednisone 40 mg daily with tapering dose for 4 weeks without significant improvement.\nFor the next few years, she had multiple admissions due to chronic pain involving breasts, buttock, and back. In 2009, she underwent bilateral mastectomy. The histopathological examination of biopsy specimen of breast showed foreign material reaction with microscopic and macroscopic fibrous loculation, giant cell reaction, and fibrosis (). However, she continued to have silicone migration to her neck and anterior chest leading to multiple debulking surgeries in 2011 and 2012, and CT chest still showed extensive infiltrative even after multiple debulking procedures (). The histopathological examination of biopsy specimen from anterior chest revealed muscle tissue with fibrosis, fat necrosis, giant cell reaction with chronic inflammation, and calcifications as shown in .\nShe continued to have multiple admissions for pain in her chest and back and swelling in her neck. She was intubated electively in 2015 for airway protection due to increased swelling. CT neck revealed increased edema in submandibular and anterior cervical spaces with increased soft tissue swelling along the musculature. There were numerous scattered calcifications and fatty lesions throughout soft tissue ().\nShe eventually started to develop progressive dysphagia and was admitted to hospital in 2017 for not able to swallow solid food. Esophagram shown in and esophagogastroduodenoscopy revealed a food bolus impaction at 20 cm with severe narrowing of the esophagus due to external compression by granulomatous mediastinitis. She underwent percutaneous endoscopic gastrostomy tube placement.\nPatient was evaluated by rheumatology services for the treatment of chronic granulomatous inflammation in October 2015. Rheumatologic workup was negative for rheumatoid factor (RF), antinuclear antibodies (ANA), and anti-dsDNA antibodies, anti-SSA and anti-SSB. Given the signs of extensive systemic inflammation, she was started on oral hydroxychloroquine (HCQ) 200 mg twice daily dose with progressive improvement in her symptoms of pain in next few months and she was kept on HCQ 200 mg twice a day with significant decrease in number of emergency room visits and hospital admissions since 2016 after initiation of hydroxychloroquine. The imaging remained stable with no further progression of granulomatous inflammation to other organs. Also there was a significant improvement in inflammatory markers given below in .
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A 51-year-old Chinese female presented at the inpatient section of the medical breast center at Zhejiang Cancer Hospital on July 21, 2016, complaining of chest pain and dyspnea that had persisted for a week. The Eastern Cooperative Oncology Group performance score was 2. She had previously received modified radical mastectomies in both breasts, one for ductal carcinoma in situ in the left breast 7 years prior, and another for LPS in the right breast in 2014. She experienced menarche at the age of 14 and had regular cyclical periods. Menopause age was 49 years old. She had her 1st child at 26 years old and the child had been breastfed. There was no history of oral contraceptive use, and she had no family history of breast cancer.\nThe endocrine adjuvant therapy for her left breast ductal carcinoma in situ was tamoxifen for 5 years, and no radiotherapy had been given. The LPS mass was 1.8 cm × 1.5 cm × 1.5 cm in her right upper quadrant breast. No postoperative adjuvant therapy was administered after the surgery.\nAfter physical and imaging examinations, bulk pleural effusion and multiple masses in the pleura were discovered by computed tomography (CT) scan when the patient came to our inpatient department. Core needle biopsy of the pleural mass identified a metastatic LPS (Fig. ). Immunohistochemistry was positive for S100 proteins (Fig. ).\nAfter discussion in a breast cancer multidisciplinary team meeting, considering the relatively milder side effects of pegylated liposomal doxorubicin (PLD) than doxorubicin, we decided to treat the patient with a regimen of PLD, ifosfamide, and pleural cavity infusion of recombinant human interleukin 2. The body surface area of the patient was 1.55 m2, the dose and frequency of chemotherapy in detail was PLD 40 mg day 1, ifosfamide 2 g day 1 to 3, q3w. The patient responded well to palliative therapy for 6 cycles (3 weeks/cycle); the response was confirmed by CT scans (Fig. ). The CT images showed solid masses with low densities representing fat and multiple masses in the pleura covered up by the bulk pleural effusion which resulted in the difficulty in measuring the solid masses directly. Nonetheless, the clear decrease in pleural effusion confirmed the good response to palliative therapy (Fig. ). Although regular biological tumor marker detecting is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines for soft-tissue sarcoma, we did find some change of serum tumor markers during the treatment. Carbohydrate antigen 125 had declined from 309 U/mL to normal level and neuron specific enolase from 21 ng/mL to normal level after the completion of 6 cycles of chemotherapy. This patient developed grade 1/2 gastrointestinal reaction and hematologic toxicity during chemotherapy. The side effects could be satisfactorily managed in our case. She later underwent regular follow-up for 2 months. She was recently seen at the medical breast cancer clinic with no active complaints, and her dyspnea had been relieved. Informed consent was obtained from the patient for publication of this case report and all accompanying radiographic images and pathological sections.
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A 22-year-old lady at the 26th week of pregnancy was referred to our clinic for fetal echocardiography; the indication was pericardial effusion detected during routine obstetric ultrasonography. She was previously healthy and this was her first pregnancy; her medical history was uneventful; however, her obstetric follow-up was not regular. Fetal echocardiography revealed pericardial, pleural, abdominal free fluid and skin edema. Intracardiac anatomy seemed to be normal despite poor echocardiographic images. However, cardiothoracic ratio was increased (heart was 1/2 times as large as the thoracic cavity), and significant holosystolic tricuspid regurgitation was observed; coronary sinus was found to be dilated (Figures , , and ). Severe bradycardia was present during the entire examination. Since these findings suggested hydrops fetalis and severe fetal heart failure, the patient was immediately referred to obstetrics and gynecology clinic where an emergency cesarian section was performed. She gave birth to a premature boy weighing 1050 grams with no spontaneous respiration, his heart rate was below 60/minute, and he was hypotonic. Based on these findings an emergency cardiopulmonary resuscitation was started; the patient was intubated and admitted to the neonatal intensive care unit. His skin was pale, cold, and a generalized edema was present. Lung auscultation revealed bilateral equal aeration and fine rales. Heart sounds were muffled but rhythmic and bradycardic with a rate of 100 bpm without any murmur. Peripheral pulses were weak; blood pressure could not be measured. During abdominal examination, the liver was 3 cm palpable and spleen was not palpated. Heart failure treatment was started under the support of mechanical ventilation. Blood gas analysis showed severe metabolic acidosis. Medication included dopamine and dobutamine infusion as inotropic agents. Transthoracic echocardiography was performed in order to identify the cause of congestive heart failure. A large arteriovenous fistula connecting the left coronary artery with the apex of the right ventricle was found (); left ventricular contractility was acceptable; and other structures of the heart were normal. No intervention was possible because of the poor clinical condition of the baby. Correction of the acidosis and maintaining the blood pressure were not possible and the patient was lost at the 4th hour of life in spite of aggressive inotropic and ventilatory support.
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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.
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A 17-year-old male with history of neuromyelitis optica (NMO) and seizures presented to the pediatric pulmonology clinic for evaluation of recurrent pneumonias. He had been diagnosed with NMO with positive antibodies at 9 years of age after acute vision loss in the left eye. At that time, he was started on azathioprine and chronic steroids. At 2 years after initial presentation, he was initiated on rituximab after his condition worsened and he developed blurry vision in the contralateral eye. All other immunosuppressive medications were discontinued following initiation of rituximab. He was receiving rituximab 1000 mg every 6 months for 6 years before evaluation by pediatric pulmonology. At his pulmonary evaluation, he presented with a history of four pneumonias over the past 2 years, two of which required admission for intravenous antibiotics and two of which were treated as an outpatient with oral antibiotics. There was no previous history of tonsillitis, ear infections, sinusitis, or recurrent pneumonias.\nIn between his recent episodes of pneumonia, he would improve briefly but continued to have daily productive cough with yellow phlegm. He also had recurrent rhinitis and sinusitis despite multiple antibiotic courses. Additionally, he had a history of positive respiratory Mycobacterium avium-intracellulare (MAI) polymerase chain reaction (PCR) test at the time of his initial pneumonia that was not treated because it was a single positive test. His physical exam was notable for normal vital signs, erythema and opacity of the right tympanic membrane, nasal congestion, and decreased breath sounds on the right side with crackles. Review of previous chest radiographs revealed localized right middle lobe and right lower lobe infiltrates. An extensive workup was subsequently initiated.\nA chest computed tomography (CT) scan revealed localized bronchiectasis and mucoid impaction, as shown in Fig. . Flexible bronchoscopy with bronchoalveolar lavage (BAL) showed normal anatomy with thick mucus secretions in the right lower lobe. BAL fluid cell count was notable for 100% neutrophils. BAL bacterial culture was positive for Streptococcus viridans but negative for acid fast bacilli. BAL cytology was negative for lipid-laden and hemosiderin-laden macrophages.\nQuantitative immunoglobulin panel revealed low levels of IgA, IgG, and IgM. Prior labs revealed a gradual decline of immunoglobulins over the past few years (Table ). This decline was attributed to secondary hypogammaglobulinemia following rituximab administration. Baseline immunoglobulin levels prior to initiation of rituximab were normal, which indicated against a primary immunodeficiency. Lymphocyte subset testing was remarkable for high cluster of differentiation (CD)-8 count (1622 cells/µl [54%]) and low CD19 level (1 cell/µl [1%]).\nBecause of the CT findings and clinical symptoms, airway clearance was initiated. He was then referred to allergy and immunology and was started on intravenous immunoglobulin replacement therapy (IGRT) for acquired hypogammaglobulinemia secondary to rituximab. Marked clinical improvement of his upper and lower respiratory disease was noted after initiation of IGRT.
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A 59-year-old female presented to Acute Medicine via the Emergency Department because she was concerned about her fast heart rate. Her smartwatch had alarmed several times during the preceding night that her pulse rate exceeded 120 beats per minute (bpm) whilst she was inactive and indicated a fluctuating rate of 130–140 bpm. The smartwatch (Apple Watch Series 2, Apple Inc.) had been used without any medical or diagnostic intention and did not have any specific features to diagnose arrhythmias. The patient remained tachycardic the following morning but felt well and was asymptomatic. She denied palpitations, dizziness, chest pain, shortness of breath or infective symptoms. She gave a past medical history of type 2 diabetes mellitus, arterial hypertension, hypercholesterolaemia, obesity, temporal lobe epilepsy and osteoarthritis. She was a non-smoker and drank alcohol only very occasionally. Two months prior she had suffered a TIA which had been managed in accordance with the locally implemented national stroke guidelines. One day before her TIA she had a brief episode of diaphoresis and palpitations, her smartwatch had then indicated a heart rate of 144 bpm. When reviewed by the stroke team, she was found to be in sinus rhythm, computed tomography of her brain was normal, bilateral carotid dopplers showed no evidence of atheroma. She was also found to be in sinus rhythm throughout during an outpatient 24 hour ECG that was recorded a fortnight after her presentation. Myocardial perfusion imaging in the past had shown no evidence of ischaemia and a normal ejection fraction. On examination, she was comfortable but had an irregular pulse and a heart rate that was fluctuating between 130 and 140 bpm. The rest of her observations were normal. ECG showed AF with a fast ventricular response. There was no evidence of heart failure, valvular disease or an infection clinically. Blood tests including urea and electrolytes, liver function tests, full blood count, thyroid function tests and troponin were unremarkable as was her chest X-ray and urine dip. She was started on Bisoprolol which controlled her heart rate. Her CHA2DS2-VASc Score was five, equating to an annual stroke risk of 7.2%. She was hence anticoagulated with a direct oral anticoagulant. Clopidogrel, which had initially been started at her presentation to the TIA clinic, was stopped. She is currently awaiting outpatient transthoracic echocardiography.
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A 59-year-old female with a history of non-anticoagulated paroxysmal atrial fibrillation, dyslipidaemia, and tobacco use was admitted with anterior ST-elevation myocardial infarction. Her chest pain started 2 days before she sought medical advice. ECG showed sinus rhythm with ST-elevation in the anterolateral leads with established deep Q waves in leads V1–V4. She was taken directly to the catheterization laboratory where diagnostic coronary angiogram revealed occluded mid left anterior descending artery (LAD) with otherwise unobstructed vessels. Revascularization of LAD was attempted with balloon angioplasty several times but with no restoration of flow. Due to resolution of symptoms and a relatively small-calibre vessel, the procedure was abandoned. Routine post-acute myocardial infarction (AMI) transthoracic echocardiography showed akinesia of the apex and apical walls with moderately impaired left ventricular systolic function. Following stabilization, she was discharged with optimal medical therapy. After 2 months, cardiac magnetic resonance imaging (MRI) was performed to assess for myocardial viability to guide the need for further revascularization attempts and this showed transmural myocardial infarction in the mid to apical LAD territory. There was a large left ventricular apical septum pseudoaneurysm measuring ∼ 80 × 55 mm with laminar thrombus and markedly increased left ventricular volume (Figure ). The pseudoaneurysm was contained within the pericardial space with the pericardium forming its walls. Despite the large pseudoaneurysm, 13 segments of the left ventricle were viable. A routine repeat transthoracic echocardiography with contrast demonstrated a large apical myocardial rupture and apical pseudoaneurysm (Figure ).\nTo guide the optimal intervention strategy and for better anatomic delineation, cardiac computed tomography (CT) was performed and this confirmed a large apical pseudoaneurysm measuring 95 × 64 mm with significant increase in the size of thrombus occupying more than half of the cavity (Figure ). The patient underwent urgent surgical repair at which time a huge friable clot was found within the pseudoaneurysm (Figure ). She had an uneventful postoperative recovery and continued to do well at 6-month follow-up. Histology of the resected aneurysm showed organizing fibrin and blood clot on a base of thick collagenous fibrous tissue, consistent with a contained rupture of the left ventricle. Repeat cardiac MRI showed good surgical result with normalization of left ventricle volume for age and body surface area and left ventricular ejection fraction of 47%.
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An otherwise healthy 18-year-old female was referred to the orthopedic unit of Dr. Ruth KM Pfau, Civil Hospital Karachi (CHK) for a non-healing fracture of the distal shaft of left humerus, sustained five months prior after falling on an outstretched arm. She was taken to the nearest hospital then, for left arm pain, where anteroposterior (AP) and lateral plain X-rays of left humerus showed a minimally displaced transverse fracture at the distal third shaft of the humerus (Figure ). The patient was managed conservatively with a Plaster of Paris (POP) back slab that was replaced by a POP full cast. However, X-ray performed after a period of six weeks showed no callus formation indicating delayed union along with the disappearance of the bone. (Figure ). Serial X-rays taken thereafter showed the persistence of fracture and bone resorption at the site along with generalized osteopenia in the shaft (Figure ). Hence, she was diagnosed with osteomyelitis and treated accordingly. Following no significant improvement of her symptoms and increased bone resorption at the fracture site as seen on X-rays, she was referred to our setup and was admitted for a detailed workup. A thorough evaluation was undertaken at our institution. A careful examination of the patient's left upper limb revealed global decreased muscle strength and limited motion of the left forearm. All active movements in the affected limb were mildly painful and limited at the shoulder and elbow joint, most notably flexion and extension. Wrist movements including gripping were normal. No neurologic deficits were found. A gap of nearly 3 cm was palpable in the distal part of the arm with palpable non-tender bony ends. Soft tissue swelling was absent and no lump was palpable along the length of the humerus. The skin overlying the fracture was normal. X-ray of the left arm was repeated, which showed marked disappearance of bone at fracture site resulting in a gap of 2-3 cm with tapering of bone ends and generalized osteopenia (Figure ).\nThere were no enlarged lymph nodes or any other abnormalities on the rest of her body. A complete blood workup ruled out hyperparathyroidism, renal osteodystrophy, osteomyelitis, vasculitis, etc. as secondary causes of bone resorption. Bone scintigraphy performed next with technetium 99m-methyl diphosphonate (99mTc MDP), showed mildly increased tracer uptake at distal 2/3rd of the shaft, ruling out our suspicion of malignancy. MRI scans revealed cortical and medullary erosion at left humeral shaft and complete resorption of the distal shaft with tapering of bone, indicating GSS. Consecutively, an incisional bone biopsy was sent for histopathologic evaluation, which demonstrated the increased proliferation of thin-walled vessels with no evidence of inflammatory or neoplastic cells, confirming GSS of the left humerus. The non-healing nature of the fracture, laboratory and radiological findings and histopathology exam fulfilled the criteria for Gorham disease suggested by Heffez et al. (Table ).\nConsistent with the present literature on suitable treatment of upper extremity GSS, we planned to undertake a reconstructive surgery of left humerus using a fibular graft.
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A 23-year-old male patient with chronic kidney disease underwent live renal transplant in May 2014 from his mother as the donor. The surgeons performed prophylactic DJ stenting of the ureter to protect ureteroneocystostomy anastomosis. As per the protocol of our institute, the patient was called for cystoscopic removal of DJ stent after 4 weeks. The procedure was accomplished under local anesthesia taking all aseptic precautions. However, the stent could not be removed even after two consecutive attempts made by experienced urologists. The reason for failure was thought to be inadvertent suturing with biodegradable suture through the lower end of the DJ stent at the vesicoureteric anastomotic site. Considering the nature of biodegradable suture, patient was again called for the stent retrieval after 6 weeks of initial attempt. During the removal attempt, there was inadvertent fracture of the lower J part of the stent. The subsequent limited acquisition of plain computed tomography of the pelvis showed partially fractured distal end of the stent []. No evidence of calcification or encrustation was seen along the stent. Transplant kidney was normal in size, outlines with decompressed pelvicalyceal system. Proximal loop and distal part of the stent was seen within the renal pelvis and urinary bladder, respectively. Then, the patient was referred to us for percutaneous removal of the impacted stent. The patient was shifted to the angiography suite for the stent retrieval procedure, which was performed under local anesthesia taking all aseptic precautions and informed consent. The transplant kidney pelvicalyceal system was distended by giving intravenous frusemide and subsequently upper pole anterior calyx was punctured under ultrasound (USG) guidance with micropuncture needle [] from anterolateral approach so that the ureter could be negotiated easily through the approach. It was followed by advancement of 5 French multipurpose angiographic (MPA) catheter over 0.035 inch terumo J tip guide wire into the renal pelvis proximal to the tip of DJ stent under intermittent fluoroscopy guidance. The hydrophilic terumo guide wire was exchanged with 145 cm 0.035 inch superstiff Amplantz guide wire with subsequent slow stepwise pushing of the stent distally under fluoroscopic guidance [] by the stiff guide wire. The free delivery of the stent into the urinary bladder was achieved in approximately 15 minutes. Subsequently, cystoscopy was performed and the stent was successfully removed. Anterograde pyelography [] with nephrostomy tube in situ showing the opacification of pelvicalyceal system and ureter without any filling defect. No periprocedure complication was encountered.
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A 66-year-old male patient, with a history of smoking (30 pack-years) and no known medical or surgical history, was admitted in our department for a spontaneously resolved inferior ST elevation myocardial infarction (STEMI). The intra-hospital treatment included enoxaparin 0.6 ml twice a day, clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day. The coronary angiogram (performed at day 3 through the right radial artery) showed a severe thrombotic lesion of the distal circumflex. The patient underwent an ad-hoc successful angioplasty of the circumflex with a drug eluting (everolimus) stent. Initial laboratory tests at admission were normal except elevated troponin. Echocardiography showed a 65% left ventricular ejection fraction. The patient was discharged after 5 days of anticoagulation by low molecular weight heparin (enoxaparin). Laboratory tests were not controlled during the hospitalization. The discharge treatment included clopidogrel 75 mg once a day, aspirin 100 mg once a day, bisoprolol 2.5 mg once a day and atorvastatin 40 mg once a day.\nOne week later, the patient was referred again to our department for both chest and right lower limb pain. The electrocardiogram showed an inferior STEMI and the physical exam of the right lower limb found ischemic signs with absence of the femoral pulse. There was no history of aspirin or clopidogrel discontinuation. An urgent coronary angiogram (performed through the left femoral artery) showed total thrombosis of the circumflex stent (\n). The patient underwent a successful primary angioplasty of the circumflex by simple balloon (\n). Urgent lower limb contrast-enhanced computed tomography was performed immediately after the angioplasty, revealing total acute thrombosis of the right common femoral artery (\n). The patient underwent an urgent successful thrombectomy with Fogarty catheter. Immediate evolution was favorable with total regression of coronary and right lower limb ischemic signs. Laboratory tests showed a marked fall in the platelet count (68,000/L) which was normal (364,000/L) in the previous hospitalization. A diagnosis of concomitant coronary stent and femoral artery thrombosis due to HIT was strongly suspected (4T score = 8). Our therapeutic strategy was immediate discontinuation of low molecular weight heparin (enoxaparin), aspirin and clopidogrel with strict daily control of platelet count. During this period, no alternative anticoagulation was initiated because of the unavailability of direct thrombin inhibitors in our center. Anticoagulation with a vitamin K antagonist (acenocoumarol 4 mg once a day) and dual antiplatelet therapy with aspirin 100 mg once a day and clopidogrel 75 mg once a day were initiated at day 3 once platelet count had recovered. The in-hospital outcome was favorable and the patient was discharged after 15 days on acenocoumarol 4 mg once a day, aspirin 100 mg once a day and clopidogrel 75 mg once a day. The 3-month follow-up, with controlled blood tests and lower limb contrast-enhanced computed tomography showing total reperfusion of the right femoral artery (\n), was unremarkable.
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A 32-year-old male patient reported at the dental office with a chief complaint of receding gums and visibility of root portion of teeth with generalized sensitivity to hot and cold food stuff. The patient was healthy with no systemic disease and no adverse habit such as smoking. The patient had Class II recession with cervical abrasions in relation to (irt) 14.15 and 16 and Grade II furcation irt 16. Recession irt 14 and 15 was 5 mm, and irt 16, it was 7 mm, there were no pockets, all the measurements were done with UNC 15 probe. After 1 month of completion of phase I therapy, abrasion was filled with glass ionomer cement irt 14.15 and 16. The use of the pedicled buccal fat pad flap was planned to cover the recession and augment the final width of the keratinized mucosa coronal to recession.\nBefore starting with the surgical procedure, surgical area was anesthetized, glass ionomer cement (GIC) restoration was planed [], and a full-thickness flap was raised []. There are three approaches to harvest BFP. A horizontal incision through the mucosa on the buccal aspect of the vestibule in the molar region will readily expose the BFP []; second approach is to give a vertical mucosal incision slightly lateral to the anterior margin of the ascending ramus, this will result in a forward bulging of the fat pad []; a third approach to the fat pad is elevation of a mucoperiosteal flap in the molar region on the lateral aspect of the maxillary alveolar process and then a horizontal incision of the periosteum at the level of the buccal sulcus [].[] The choice of exposure depends on the requirements of the specific situation in which the flap is used. For this clinical procedure, third approach was used. Using blunt dissection through the buccinator and loose surrounding fascia, BFP was exposed into the mouth. The body of the BFP and the buccal extension were gently mobilized by blunt dissection, taking care not to disrupt the delicate capsule and vascular plexus and to preserve as wide a base as possible []. BFP was easily spread over the maxillary roots of 14, 15, and 16, 1–2 mm apical to cementoenamel junction (CEJ), acknowledging possible wound contraction. BFP was first stabilized using horizontal mattress suture, over which mucogingival flap was placed which was not covering BFP completely and was sutured with Vicryl 3-0 [] (Polyglactin 910, Ethicon, Johnson and Johnson).\nPatient was prescribed with capsule amoxicillin 500 mg TDS for 5 days, tablet ibuprofen 300 mg + paracetamol 325 mg SOS, chimeral forte, chlorhexidine (0.12%) mouthwash twice daily for 2 weeks. The patient was instructed to eat a soft diet. Among other oral hygiene instructions and methods, the patient was asked to use a soft brush and brush very gently over the surgical area even after suture removal and not to exert too much pressure during brushing. His brushing habit was changed to modified bass method, and every time, he would come for check he was asked to bring his brush along so that his method of brushing could be checked. He was asked to use floss and rinse mouth with warm saline rinse 2–3 times daily. Furthermore, patient's scaling was done at every 6 months.
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We describe the case of a 54-year-old Japanese woman.
She went to a nearby clinic to get a check-up for abdominal distension. A large quantity of pleural and ascitic effusion was recognized and a blood test showed high CA125 (209 U/mL), and she was suspected to have a malignant tumor. She was admitted to a cancer center in our hospital, and we carried out a close examination. We found a tumor in her right breast and we performed a core needle biopsy. A diagnosis of primary breast cancer (solid tubular carcinoma) (Fig. ) was made; estrogen receptor (EgR) and progesterone receptor (PgR) were positive, and human epidermal growth factor receptor 2 (HER2) was negative. Cytology of pleural and ascitic effusion revealed cells similar to the breast cancer, and she was diagnosed as having inoperable breast cancer, stage IV, according to TNM classification: T2 N1 M1, pleura, peritoneum. After these results, weekly paclitaxel therapy was started for our patient. The protocol of this therapy, as a cycle, was that paclitaxel (90 mg/m2 based on body surface area) was intravenously infused every week for 3 weeks followed by 1 week for rest. After three cycles of weekly paclitaxel, the primary tumor had reduced and subsequently the pleural effusion disappeared but the ascites did not change. Because only the ascites did not decrease, other cancers such as a peritoneal carcinoma were suspected and we performed diagnostic laparoscopy. A large amount of transparent and viscous ascites was detected in her abdominal cavity. Her small intestine, omentum, and transverse colon had become grouped into a dumpling form, and the whole peritoneum was thickened and hyperplasic. We excised a peritoneal sample and submitted it to histopathological examination. The histopathological examination revealed that the peritoneum was not the primary peritoneal cancer but the peritoneal dissemination of breast cancer because the peritoneal cells were similar to the cells of the primary breast cancer and there was no Wilm's tumour
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The patient was a 55-year-old African American male with a significant past medical history of known breast cancer, who presented to an academic teaching hospital in February of 2018 after a surveillance computed tomography (CT) scan of his chest, abdomen, and pelvis showed incidental acute appendicitis. The patient was asymptomatic on his original presentation but subsequently developed nausea and vomiting along with right lower quadrant abdominal pain in the following days resulting in admission to the general surgery service for treatment of appendicitis. The patient did not have any contributory family, drug, or psychosocial history.\nOn chart review, the patient had an extensive past oncological history dating back to 2014 after resection of an enlarging, exophytic, ulcerating chest mass on the right side just lateral to the midline. Pathology from the wide local excision of this mass demonstrated estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2/neu negative metastatic adenocarcinoma with an unknown primary source at the time. He underwent esophagogastroduodenoscopy (EGD) and colonoscopy to rule out a primary gastrointestinal malignancy, however, both were normal. He was followed closely by medical oncology and treated with tamoxifen for hormone therapy. Due to an enlarged anterior mediastinal wall lymph node discovered on routine CT surveillance in May of 2017, the patient underwent CT-guided biopsy and positron emission tomography (PET). The biopsy was negative for malignancy, however, the PET demonstrated abnormal, hypermetabolic activity within a retrosternal nodule, intense activity in a mixed focus in the manubrium, and several hypermetabolic nodes within the mediastinum. It also showed an abnormal hypermetabolic focus in the cecum suspicious for a colon primary (, ). An attempt was made to complete a colonoscopy at the time, but the gastroenterologist could not advance the colonoscope past the transverse colon due to technical reasons. Medical oncology elected to continue close surveillance.\nIn January 2018, the patient was noted to have right axillary lymphadenopathy and an ultrasound-guided biopsy of a 1.5 cm right axillary lymph node was performed. Pathology results showed an infiltrating, moderately-differentiated ductal carcinoma. This specimen was also ER and PR positive as well as HER2/neu negative.\nA CT scan of the patient’s chest, abdomen, and pelvis was completed on February 15, 2018 for further monitoring. At this time, the patient was incidentally found to have a dilated appendix with no wall thickening or periappendiceal stranding. He did not have a leukocytosis and clinically he did not have any fever or any symptoms including pain, nausea, or vomiting at this original presentation. However, he returned two days later with nausea, vomiting, and right lower quadrant pain consistent with appendicitis. On a repeat CT of the abdomen and pelvis with IV and oral contrast, the appendix was dilated to 1.8 cm with appendiceal wall thickening and periappendiceal stranding. In addition, a 2.3 × 1.9 × 2.3 cm bowel mass was identified in the right lower quadrant either adjacent to or within the wall of the cecum that correlated with the previous PET-CT scan performed in May 2017 (). He was therefore admitted and treated with IV antibiotics for acute appendicitis with plans for appendectomy during his hospitalization along with further workup of the cecal mass.\nBecause of his oncological history, a colonoscopy was performed on hospital day one to evaluate the cecum to rule out metachronous colon tumors given his CT imaging findings and previous PET-CT. The colonoscope was advanced to the cecum without issue. Cecal inflammation was noted and several biopsies were taken of this area, however, no discernable tumors were noted. Pathology returned with no significant pathologic changes to the biopsied tissue.\nThe following day after receiving intravenous antibiotics and fluid resuscitation, the patient underwent laparoscopic appendectomy. The procedure was converted to open due to the extensive inflammatory process in the right lower quadrant and retrocecal position of the appendix. The appendix was divided from the cecum using a GIA stapler and the appendiceal vessels were suture ligated and divided with electrocautery. The specimen was removed from the field and sent to pathology for evaluation. Prior to abdominal closure, the colon was run from the terminal ileum to the rectum and a large walnut-sized mass was discovered in the cecum proximal to the area of the appendiceal orifice. It was hard, mobile, and suspicious for a primary colon lesion. A right hemicolectomy was then performed including adequate mesenteric lymph node resection. The operation was performed by a general surgeon and a chief resident. The patient tolerated the procedure without complications and was returned to the surgical floor postoperatively. His post-operative course was unremarkable, and he was discharged five days after the procedure.\nPathology from the surgical specimen returned shortly after the surgery. The appendix showed findings suggestive of acute appendicitis with organizing periappendicitis. The right colon specimen returned as metastatic breast carcinoma involving cecal submucosa clear of margins with overlying benign colonic mucosa (). Twenty lymph nodes were harvested and were all negative for disease. The specimen stained strongly and diffusely for GATA3 which was consistent with metastatic breast carcinoma and negative for CDX2 (A–D).\nAfter discharge, the patient had close surveillance with medical oncology. He was transitioned to anastrazole secondary to the ER/PR + receptor status of his tumor and its refractory response to tamoxifen. Prior to his first outpatient appointment in April 2018, he complained of worsening skeletal pain at multiple sites. Bone scan showed left posterior rib and sternal involvement for which zoledronic acid was initiated. He also underwent CT scan of his chest, abdomen, and pelvis to monitor progression of his metastatic disease which showed no significant changes. During his appointment in June 2018, he was noted to have an enlarging left lateral neck mass. Ultrasound-guided biopsy of this mass returned positive for metastatic carcinoma consistent with breast origin. No significant changes to his treatment regimen have occurred since this time.
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A 62-year-old woman with a history of hypertension, type 2 diabetes, and end-stage renal disease was admitted to the hospital with bleeding from her arteriovenous (AV) graft and was found to have methicillin-resistant Staphylococcus aureus bacteremia. The source of her bacteremia was thought to be her AV graft, which was excised for source control. Her initial electrocardiogram (ECG) showed sinus rhythm (, but her hospital course was complicated by the development of complete heart block with a narrow junctional escape rhythm and paroxysmal atrial fibrillation. Further workup with a transesophageal echocardiogram demonstrated a small mobile echo density measuring 4 × 5 mm attached to the coumadin ridge. She was placed on prophylactic and not therapeutic anticoagulation due to a high bleeding risk. Cardiac computed tomography ruled out the involvement of the aortic root, ie, aortic root abscess or pseudoaneurysm. No other reversible causes of her complete heart block could be identified. Subsequently, a transvenous pacing wire was successfully placed within the right ventricle.\nGiven her diagnosis of infective endocarditis and need for a prolonged course of antibiotics, the decision was made to proceed with the implantation of a permanent pacing system. The patient decided to undergo Micra™ transcatheter LP implantation, due to her recent history of extraction of her potentially infected left upper-extremity AV graft and previously documented right subclavian vein occlusion. Subsequently, the patient underwent Micra™ implantation through the right femoral vein. After the device was deployed, the pull-and-hold test was performed to ensure adequate fixation. The postfixation electrical testing of the device demonstrated an R-wave sensing value of 6.5 mV, an impedance of 550 Ω, and a pacing threshold of 1.3 V at 0.24 ms. The latter improved to less than 1 V at 0.24 ms before the end of the case. Hence, the decision was made to cut the tethering suture and release the Micra™ device. Postprocedure, the patient remained stable and was transferred to the medical floor.\nApproximately five hours following Micra™ insertion, she developed VF cardiac arrest. The telemetry strip for the event is shown in . She did not have hyperkalemia and was not on any concomitant proarrhythmogenic or QT-prolonging medications. She received seven shocks and eight ampules of epinephrine in addition to intravenous amiodarone and lidocaine boluses. Return of spontaneous circulation was subsequently achieved, and she was transferred to the cardiovascular intensive care unit.\nIn the cardiovascular intensive care unit, she was started on norepinephrine and vasopressin for hemodynamic support. Her Micra™ interrogation showed normal device function with stable impedance, sensing, and slightly higher pacing threshold values. The latter, however, remained below the programmed pacing output of the device. A post–cardiac arrest ECG showed a ventricular-paced rhythm with occasional premature ventricular complexes (PVCs). Transthoracic echocardiography did not show any evidence of pericardial effusion, and her chest X-ray showed stable device positioning from implantation and diffuse infiltrates as seen in . However, the chest X-ray was obtained after the VF arrest and she was not in respiratory distress or hypoxia prior to the arrest. Her serum electrolytes, including potassium, and blood counts were within the normal limits and unchanged from admission. Given the lack of a clear explanation for her VF arrest and given the temporal association with the Micra™ device implantation, her VF was presumed to be secondary to myocardial irritation from the Micra™ device. Unfortunately, she developed worsening shock with increasing vasopressor requirements and was later transitioned to comfort care following a family discussion and subsequently expired within 18 hours of the original procedure.
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A 33-year-old female patient at 31 weeks of gestation presented to our emergency department complaining of sharp constant upper abdominal pain that had grown progressively worse over the preceding 24 h period. She denied fever, chills, changes in her appetite, nausea or vomiting. Her past medical history was significant for unspecified inflammatory bowel disease and chronic urinary tract infections. She was confirmed by ultrasound to have a 31-week intrauterine pregnancy that until presentation had been largely uneventful. She was admitted to the maternal–fetal medicine service and was found to have a white blood cell count of 18.700/mm3 with 87% neutrophils and frequent contractions. The obstetricians administered Mg2+ for tocolysis and steroids for fetal pulmonary maturation, and the patient underwent an amniocentesis that was negative for chorioamnionitis. Her urinalysis was unremarkable and urine culture was sent and her workup had been otherwise unrevealing including ultrasound imaging of the right upper quadrant, which did not show any pertinent biliary pathology.\nThe patient underwent an MRI, which demonstrated a single fetus in cephalic vertex position, but could not completely visualize the appendix and was negative for inflammatory changes in the right lower quadrant or surrounding the terminal ileum. Initially, the patient improved clinically, however over the following 2 days her severe upper abdominal pain returned. A repeat MRI was obtained that now showed no appendix, but a multilobulated cystic mass complicated with an abscess measuring up to 13 mm and free fluid tracking along the right paracolic gutter and a small amount of perihepatic free fluid (Fig. ). Interestingly, the study also showed small rounded hypodensities in the base of the cecum that were initially interpreted as fecalith or intraluminal gas, but in retrospect might have presented ectopic endometrial glands. These findings in conjunction with her rising white blood count (21 000/mm3) and worsening physical examination were concerning for an acute perforated appendicitis and the patient was brought to the operating room for an open appendectomy in the presence of the obstetric team for fetal monitoring. Upon entering the abdomen abundant free fluid and a grossly inflamed, necrotic and perforated appendix were noted. Frozen section of the tissue came back as grossly inflamed perforated appendicitis and transmural intestinal endometriosis with extensive dezidualization (Fig. ). Given the extensive nature of the perforation, likely secondary to endometriosis at the base of the appendix, an ileocecetomy was performed. The patient tolerated the patient well and fetal monitoring did not show any signs of distress at the conclusion of the case.\nApproximately 5 h postoperatively the patient experienced painful contractions and fetal heart monitoring showed late decelerations. Pelvic examination showed an 8-cm dilated cervix. Subsequently the patient's membranes ruptured and she delivered a viable male infant who required 36 h of mechanical ventilation and newborn special care unit (NBSCU) admission. The patient made a full recovery in a few days and the infant did well in the NBSCU.
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A 27-year-old lady in her 2nd pregnancy was referred to the Obstetrics & Gynaecology Department, Hospital Kemaman, at 32-week pregnancy for further assessment of disparity between the fundal height measurement and gestational age, noted during her routine antenatal care. The previous pregnancy was uneventful, resulting in a birth of a healthy 2.8 kg baby at term and the patient had no significant medical problem.\nUltrasound examination was performed using a Voluson S6 (GE Healthcare Ultrasound, Milwaukee, WI, USA) equipped with a 3–5 MHz curvilinear 3D abdominal probe which showed a single fetus with parameters corresponding to 32-week gestation with normal liquor volume. The fetal heart was pushed to the right with the left hemithorax filled with fetal liver and part of the small intestine. There was a defect in the left anterolateral part of the 3rd and 4th rib which was identified on 2D mode, with herniation of the stomach, intestine, and part of the left lobe of the liver (). Using the 3D ultrasound probe, a volume was acquired and a mixture of surface mode and transparent maximal rendering was used to show the bony ribs, the absence of the anterior part of the involved ribs, and also the size of the defect on the chest (). There was also absence of left radius with concurrent curved ulna. Other structures were normal. The subsequent visits to our centre revealed slowing of the fetal growth but no changes seen on the thoracic defect or the herniated organs.\nThe delivery was planned to be completed at a tertiary centre with paediatric surgical service but the patient went into spontaneous labour at 36 weeks of gestation. It was an uncomplicated event resulting in delivery of a 1500 gm boy. The neonate had Apgar score of 9 and 10 at the 1st and 5th minutes of life, respectively, with good, spontaneous breathing effort.\nExamination after the delivery showed herniation of the stomach, small intestine, part of the left lobe of the liver, and spleen through a 3 × 3 cm defect on left thorax, at the anterior axillary line (). There was polydactyly with fused interdigits of the left hand, overlapping fingers of the right hand, bilateral rocker-bottom foot, and bilateral cryptorchidism. A nasogastric tube was inserted with tip located outside the thoracic cavity while an echocardiogram showed normal heart structures. Radiographic examination revealed absence of anterior part of left 3rd and 4th rib with left type IV (Bayne and Klug classification) [] radial aplasia with bent and short radially bowed ulna ().\nIn the first few hours of life, the baby was stable and breathing on his own while the preparation is made for transfer to a tertiary hospital with paediatric surgical expertise. Despite the initial promising outcome, the boy developed respiratory distress 12 hours after delivery requiring intubation and mechanical ventilation. He was on the respiratory support for the next 2 days but the condition worsened with evidence of sepsis and passed away at day 3 of life. The parents declined postmortem examination.
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A 72-year-old female presented to the emergency room with the complaint of left thigh pain and the inability to walk after tumbling. She had been suffering from osteoarthritis of the left hip but was able to walk with a cane and sit on a couch. She had also received the diagnosis of osteoporosis and had been taking alendronate 35 mg weekly for six years. The initial radiograph in the emergency room showed a non-comminuted subtrochanteric fracture of the left femur with cortical thickness and the beaking of the lateral cortex at the fracture site. The fracture line was transverse on the lateral side and oblique on the medial side. The radiographic findings and the weakness of the force that caused the fracture satisfied the criteria for an atypical fracture of the femur. The radiograph showed Kellgren-Lawrence grade 4 osteoarthritis of the left hip as well, with superomedial migration, the external rotation of the femoral head, and the shortening of the femoral neck (Figure ).\nOsteosynthesis with intramedullary nailing was planned. However, the deformity of the hip joint appeared to preclude correct nail insertion. Furthermore, whenever we used a fracture table in the past, we often observed that the perineal post of the fracture table impeded the adduction of the proximal fragment of the subtrochanteric fracture while the whole leg was being adducted, resulting in varus malalignment. On the other hand, we were aware of easy access to the entry point via the standard lateral decubitus position without using the perineal post. For these reasons, we decided to fix the fracture with a nail in the lateral decubitus position. Total hip arthroplasty with fracture fixation was not chosen because of its invasiveness, which was inappropriate for the rather mild, pre-injury symptoms due to osteoarthritis, and because of the patient’s wish to preserve the femoral head.\nIn surgery, a flat, radiolucent operating table was used. The whole injured leg was sterilized and draped, and the hip was slightly flexed. The C-arm was placed at the ventral side of the patient. Although the proximal fragment was externally rotated, the entry point was located easily by adjusting the C-arm to obtain a correct A-P view. A guide pin was inserted in line with the long axis of the proximal fragment to the level of the fracture without any interference by the torso (Figure ).\nThen, the fracture was reduced with gentle manual traction of the thigh followed by the distal insertion of the guide pin. At this time, the fracture was perfectly aligned (Figure ).\nAfter reaming, a trochanteric-entry cephalomedullary nail (Trigen Trochanteric Antegrade Nail, Smith & Nephew, Massachusetts, \nUS), 11.5 mm in diameter, was inserted, again, without any obstruction by the torso. After assuring rotational alignment, two cephalomedullary screws and a distal interlocking screw were inserted. Accurate, non-varus reduction was confirmed by a postoperative radiograph (Figure ).\nThe operating time was 122 minutes. The total blood loss was 86 ml. Toe-touch weight bearing was initiated soon and full weight bearing was allowed in five weeks. A solid union was confirmed by radiograph after 10 months (Figure ). She was able to walk with a cane as she did before her injury without a worsening of the pain. Alendronate was discontinued after the injury and replaced with vitamin D supplements. No anabolic agent, such as teriparatide, was administered.
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A 31-year-old Caucasian male with a history of lumbar disc herniations identified on an MRI of the lumbar spine one year ago presented to the emergency department (ED) for radicular back pain to the right lower extremity. Three weeks prior to presentation, the patient went on a jet ski trip where he incurred repetitive axial loading forces. Since that time, the patient noted increasing back pain with radiation to right lower extremity including the foot. The pain was intermittent and diffuse without a clear dermatomal distribution. The pain was described as electric, exacerbated with extension of his back, and relieved with flexion. No loss of bowel or bladder control was reported. On exam, the patient was 5/5 in the bilateral upper and lower extremities. Rectal tone and bulbocavernosus reflexes were intact. The patient underwent an MRI of the lumbar spine without contrast demonstrating a herniated L5-S1 disc as shown in Figure . The patient was prescribed a Medrol dosepak and gabapentin with instructions to follow up in clinic with plans for outpatient conservative management.\nAt follow-up clinic visit, review of the MRI scout image included in the lumbar spine series demonstrated a thoracic abnormality as shown in Figure . MRI of the thoracic spine with and without contrast was ordered. It demonstrated T4-5 epidural mass as shown in Figure .\nThe patient was contacted and advised to go to the ED for evaluation. After examination, the images were reviewed with the patient. After a discussion of alternatives and the patient’s slowly progressing symptoms with an unidentified mass, the recommendation was for surgical resection.\nThe patient underwent a thoracic four and five laminectomy for resection of the mass. Intraoperative images are shown in Figure and Figure . Intraoperative pathology was read as angiolipoma with final pathology slides shown in Figure . Surgery carried on until complete resection was achieved. Post-operatively the patient was extubated and recovered well with improved lower extremity paresthesias and transient urinary retention that resolved by post-operative day 2. Post-operative MRI demonstrated gross total resection as shown in Figure .
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The patient was a 55-year-old African American male with a significant past medical history of known breast cancer, who presented to an academic teaching hospital in February of 2018 after a surveillance computed tomography (CT) scan of his chest, abdomen, and pelvis showed incidental acute appendicitis. The patient was asymptomatic on his original presentation but subsequently developed nausea and vomiting along with right lower quadrant abdominal pain in the following days resulting in admission to the general surgery service for treatment of appendicitis. The patient did not have any contributory family, drug, or psychosocial history.\nOn chart review, the patient had an extensive past oncological history dating back to 2014 after resection of an enlarging, exophytic, ulcerating chest mass on the right side just lateral to the midline. Pathology from the wide local excision of this mass demonstrated estrogen receptor (ER) positive, progesterone receptor (PR) positive, and HER2/neu negative metastatic adenocarcinoma with an unknown primary source at the time. He underwent esophagogastroduodenoscopy (EGD) and colonoscopy to rule out a primary gastrointestinal malignancy, however, both were normal. He was followed closely by medical oncology and treated with tamoxifen for hormone therapy. Due to an enlarged anterior mediastinal wall lymph node discovered on routine CT surveillance in May of 2017, the patient underwent CT-guided biopsy and positron emission tomography (PET). The biopsy was negative for malignancy, however, the PET demonstrated abnormal, hypermetabolic activity within a retrosternal nodule, intense activity in a mixed focus in the manubrium, and several hypermetabolic nodes within the mediastinum. It also showed an abnormal hypermetabolic focus in the cecum suspicious for a colon primary (, ). An attempt was made to complete a colonoscopy at the time, but the gastroenterologist could not advance the colonoscope past the transverse colon due to technical reasons. Medical oncology elected to continue close surveillance.\nIn January 2018, the patient was noted to have right axillary lymphadenopathy and an ultrasound-guided biopsy of a 1.5 cm right axillary lymph node was performed. Pathology results showed an infiltrating, moderately-differentiated ductal carcinoma. This specimen was also ER and PR positive as well as HER2/neu negative.\nA CT scan of the patient’s chest, abdomen, and pelvis was completed on February 15, 2018 for further monitoring. At this time, the patient was incidentally found to have a dilated appendix with no wall thickening or periappendiceal stranding. He did not have a leukocytosis and clinically he did not have any fever or any symptoms including pain, nausea, or vomiting at this original presentation. However, he returned two days later with nausea, vomiting, and right lower quadrant pain consistent with appendicitis. On a repeat CT of the abdomen and pelvis with IV and oral contrast, the appendix was dilated to 1.8 cm with appendiceal wall thickening and periappendiceal stranding. In addition, a 2.3 × 1.9 × 2.3 cm bowel mass was identified in the right lower quadrant either adjacent to or within the wall of the cecum that correlated with the previous PET-CT scan performed in May 2017 (). He was therefore admitted and treated with IV antibiotics for acute appendicitis with plans for appendectomy during his hospitalization along with further workup of the cecal mass.\nBecause of his oncological history, a colonoscopy was performed on hospital day one to evaluate the cecum to rule out metachronous colon tumors given his CT imaging findings and previous PET-CT. The colonoscope was advanced to the cecum without issue. Cecal inflammation was noted and several biopsies were taken of this area, however, no discernable tumors were noted. Pathology returned with no significant pathologic changes to the biopsied tissue.\nThe following day after receiving intravenous antibiotics and fluid resuscitation, the patient underwent laparoscopic appendectomy. The procedure was converted to open due to the extensive inflammatory process in the right lower quadrant and retrocecal position of the appendix. The appendix was divided from the cecum using a GIA stapler and the appendiceal vessels were suture ligated and divided with electrocautery. The specimen was removed from the field and sent to pathology for evaluation. Prior to abdominal closure, the colon was run from the terminal ileum to the rectum and a large walnut-sized mass was discovered in the cecum proximal to the area of the appendiceal orifice. It was hard, mobile, and suspicious for a primary colon lesion. A right hemicolectomy was then performed including adequate mesenteric lymph node resection. The operation was performed by a general surgeon and a chief resident. The patient tolerated the procedure without complications and was returned to the surgical floor postoperatively. His post-operative course was unremarkable, and he was discharged five days after the procedure.\nPathology from the surgical specimen returned shortly after the surgery. The appendix showed findings suggestive of acute appendicitis with organizing periappendicitis. The right colon specimen returned as metastatic breast carcinoma involving cecal submucosa clear of margins with overlying benign colonic mucosa (). Twenty lymph nodes were harvested and were all negative for disease. The specimen stained strongly and diffusely for GATA3 which was consistent with metastatic breast carcinoma and negative for CDX2 (A–D).\nAfter discharge, the patient had close surveillance with medical oncology. He was transitioned to anastrazole secondary to the ER/PR + receptor status of his tumor and its refractory response to tamoxifen. Prior to his first outpatient appointment in April 2018, he complained of worsening skeletal pain at multiple sites. Bone scan showed left posterior rib and sternal involvement for which zoledronic acid was initiated. He also underwent CT scan of his chest, abdomen, and pelvis to monitor progression of his metastatic disease which showed no significant changes. During his appointment in June 2018, he was noted to have an enlarging left lateral neck mass. Ultrasound-guided biopsy of this mass returned positive for metastatic carcinoma consistent with breast origin. No significant changes to his treatment regimen have occurred since this time.
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The patient was a 73-year-old Chinese woman with osteoarthritis in both knees. In the recent half year, she had been suffering from intractable right knee pain with failed conservative treatment and prepared for right side TKA. She had a 27-year history of hypertension and her blood pressure was controlled well by medication. She had no other medical history, including smoking history. Her BMI was 24. The physical examination showed a limited range of motion (ROM) of 0°–120° without varus or valgus deformity. Preoperative X-ray showed narrow medial knee joint space and osteophyte formation without vascular calcification (Fig. ). The peripheral pulses and capillary refill were normal, although the preoperative Doppler ultrasound showed arteriosclerosis with plaque formation in the arteries in both legs.\nThe right side TKA with a posterior stabilized design (LPS, NexGen, Zimmer, Warsaw, USA) was performed under general anesthesia. A tourniquet was applied for 70 min at a pressure of 250 mmHg. The whole surgery was completed without any complications and there was normal intraoperative bleeding at the surgical site. The postoperative X-ray showed successful implantation for the right knee (Fig. ).\nHowever, immediately after the surgery, routine peripheral pulse check in the operating room found absent dorsalis pedis artery pulse in the right foot. The patient was closely monitored in the recovery room. After approximately 2 h, there was no improvement in peripheral pulses, capillary refill, and oxygen saturation. In consideration of the high possibility of arterial occlusion, the vascular consultant recommended using 1000 U heparin for anticoagulation and immediate evaluation by arteriography for diagnosis. An emergency arteriography under local anesthesia showed that there was a short segmental occlusion of the popliteal artery (Fig. ). Then the angioplasty was performed with a balloon with a diameter of 5 mm for 3 min. Follow-up imaging showed excellent blood flow although vascular stenosis was still observed in popliteal artery (Fig. ). There was a return of palpable pulses and a normal capillary refill and oxygen saturation.\nAfter the patient returned to the ward, 12 500 U heparin in 50 mL saline was pumped 1 mL/h and activated partial thromboplastin time (APTT) was controlled around 40 s. The peripheral pulses were closely monitored. On postoperative day 2, the patient was allowed to walk with aids. On postoperative day 6, the anticoagulation plan was changed to rivaroxaban 10 mg two times a day and aspirin 100 mg one time a day for 3 weeks orally. The patient was discharged home 2 weeks after surgery without any complaints.\nAt the most recent follow-up in the orthopaedic clinic (3 months after surgery), there were no orthopaedic or vascular complaints. The patient had an ROM of 0° to 125° with excellent muscle strength and could walk without aids for 1 km.
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The patient was a 16-year-old female high school student who actively played basketball. Initially, she complained of right knee pain especially on the medial side when she visited her family doctor. On the first visit, radiographs were taken and the knee was considered intact as shown in . On physical examination, there was no evidence of increasing synovial fluid. In spite of the right knee pain, she kept playing basketball. Three months later, her right knee pain aggravated and she took a week off from practice before resuming basketball. One more month later, when she played basketball in a competition, she felt her right knee cracking but continued playing in the game. Two days later, she visited the family doctor and from the radiographs, she was diagnosed with a displaced fracture of the patella with sclerosis at the margin of the fracture site as seen in . At that time, she was able to stretch out her right knee.\nConsidering her high activity level and >3 mm displacement of the distal fragment, open reduction and internal fixation were determined to be performed. An anterior transverse incision was made over the distal patella, and we found the extensor mechanism was not ruptured. By splitting the patella retinaculum longitudinally, the surface of the fracture was exposed. The sclerotic fracture edges were also directly observed intraoperatively. The sclerotic fracture margins were debrided and the bone fragment and the patella were longitudinally penetrated with a 2 mm K-wire for making 2 holes. Non-absorbable suture ligatures, No.2 Ethibond (Ethicon, Somerville, NJ, USA), were passed through with suture passers and tied down over the top of the patella as displayed in .\nPostoperative care included full weight bearing with knee extension supported by an extension knee brace, knee flexion restricted to 45° until three weeks and then to 90° until eight weeks, after which full flexion was allowed. Three months postoperatively, the patient was allowed to return to training. Six months postoperatively she regained her preinjury activity level without any subsequent symptoms.
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The patient was a 14-year-old refugee boy from Syria who had been playing outdoors in his hometown at the age of 10 years. A battle begun during his play, and after the cessation of fire, he was found lying on the street unconscious. After admission to the local hospital, a low-resolution CT scan was taken. A bullet was seen intracranially close to the inner surface of the bone in the area of the sinus confluence. Due to high complication risks, it was decided not to remove the bullet. The patient gained consciousness within a couple of days and was discharged in approximately 10 days. Thereafter, the patient’s family sought their way to the refugee camp in Turkey and 3 years later to Finland.\nIn Finland, the patient suffered from headaches and mental health problems. He had short-lasting headache attacks several times a week ever since the accident. The episodes usually lasted 5–20 min with pain starting in the occipital region and radiating behind the right eye. During these headaches, the patient usually went supine due to the devastating pain. In clinical investigation, no neurological deficiencies were found. Neither were there any abnormal findings on skull palpation. On ophthalmological investigation, myopia, requiring correction with glasses, as well as borderline reduction of an upper medial visual field were found. The later finding was interpreted as a possible result of the damage to the occipital cortex. A 3D skull CT scan was performed. According to the scan, the bullet seemed to be preserved in one piece and located close to the inner surface of the skull bone near the lambdoid suture, in contact with the tentorium just above the sinus transversus. Compared to CT scans 4 years earlier, the bullet had moved approximately 29 mm laterally (Fig. ).\nThe patient and his parents wished the bullet to be removed because of the pain located precisely at the bullet area, in the hope of headache cessation after successful surgery. The decision to remove the bullet, in addition to the wishes of the patient and his parents, was based on the following considerations. At first, the removal of the ferromagnetic foreign object would allow performing MR imaging whenever needed. Second, the bullet had already moved almost 3 cm away from primary location during the follow-up time, and further dislocation of the bullet risked causing new damage. Third, the relatively superficial location of the bullet supported the decision to proceed with operative treatment.\nPrior to the operation, up-to-date images of the bullet’s location and vascular structures in its proximity were necessary. The 3D CT scan done previously in a central hospital was not suitable for navigation due to slice thickness (Fig. ). In addition, preoperative images revealed the movement of the bullet, leading to the decision to use neuronavigation with intraoperative O-arm imaging and automatic direct registration to the navigation system.\nWe used the StealthStation S7 (Medtronic Inc., Louisville, CO, USA) with optical localization method for navigation. Due to the lack of O-arm navigation implementation in Cranial software, we used the Spine software to allow an automated registration of the O-arm images.\nThe intraoperative imaging was done with O-arm (Medtronic Inc., Louisville, CO, USA) and 3D images (slice thickness was 0.833 mm, tube voltage 100 kV, tube current 80 mA and imaging time 13 s) were automatically transferred into navigation system.\nThe patient was set in a prone position with his head fixated using the carbon fibre frame (Fig. ). After the O-arm imaging and navigation (Fig. ), an L-shaped skin opening was made in the midline extending to the right side. After opening of the soft tissues, the lambdoid suture and the bullet were located using navigation (Fig. ). Craniotomy was done in a conventional way with its lower line going just above the sinus transversus edge. The dura was preserved intact during the bone removal and its appearance was normal. After opening of the dura the encapsulated bullet was found lying on the surface of an apparently normal-looking cortex. The capsule was opened sharply, and the bullet was removed (Fig. ). The capsule wall was calcified, and it was adherent to the venous sinus wall and to the cortex. For this reason, it was decided not to remove this fibrotic capsule. The dura was sutured with continuous suture. Hemocoagulate patch (Tachosil, Takeda Austria GmbH, Austria) and tissue glue (Evicel, Omrix Biopharmaceuticals Ltd., Israel) were used to ensure watertight closure. The bone was fixated with Matrix low-profile titanium alloy plates and screws. The skin was closed in a conventional way.\nPostoperative testing of the removed bullet showed that it was not ferromagnetic. The bullet appeared to be a 9 × 19-mm Parabellum pistol cartridge (Fig. ). The calcified residual of the capsule was seen in the postoperative CT images. The postoperative CT showed no signs of any complications. The recovery after surgery was uneventful and the patient was discharged on the 5th postoperative day. After 1 year of follow-up, the patient had made a full recovery and had neither headaches nor any other symptoms.
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A 54-year-old Caucasian woman presented to the emergency department (ED) of our institution with uncontrolled hypertension and new-onset seizures. Two weeks prior to this admission the patient's hypertensive medication had been switched in a tapered fashion from clonidine to lisinopril because of a reported intolerance in the form of general malaise, sinus headache and non-productive cough. Five days before presentation she had developed generalized headache, blurred vision and nausea, and she decided to visit her closest ED, an outside facility in Northwestern Massachusetts, which found her hypertensive with systolic blood pressure of 260 mmHg. At that time, she was treated with analgesics and parenteral antihypertensive medications, which led to partial improvement of her symptoms and subsequent discharge to her home in rural western Massachusetts. Twenty-four hours before her hospital admission, she again visited the ED of the same outside facility complaining of recurrent, severe headaches accompanied by blurred vision. Her blood pressure recorded at that time was 260/160 mmHg. She was again treated with intravenous narcotics and antihypertensive's; however, while being treated, she developed confusion, and the decision was made to transfer the patient to our hospital. En route to our hospital she had an episode of tonic-clonic seizure activity lasting three to four minutes. In our ED, she received a dose of 1000 mg intravenous fosphenytoin once upon arrival and was subsequently intubated for airway protection because of unresponsiveness. Her admission blood pressure was 194/115 mmHg, and she was given two doses of 10 mg of intravenous labetalol.\nHer medical history was notable for hypertension, systemic lupus erythematosus (SLE), end-stage renal disease (ESRD) secondary to lupus nephritis on daily ambulatory intermittent peritoneal dialysis, with a history of good dialysis compliance and blood pressure control. Her most recent peritoneal dialysis treatment had been the day preceding admission. She had also had a mechanical aortic valve replacement for a history of aortic stenosis and underwent chronic anticoagulation treatment. She was no longer on any immunosuppressive therapy for lupus. She did not use alcohol, tobacco or recreational drugs. There were no reported sick contacts, recent travel or outdoor exposures.\nHer initial laboratory data were relevant for leukocytosis of 16,500 cells/mm3. No thrombocytopenia or schistocytes were noted on peripheral blood smear. Her liver panel was normal. Her blood urea nitrogen was 68 mg/dl with serum creatinine of 5.6 mg/dl. Her baseline serum creatinine was 5.2 mg/dl. Continuous cycling peritoneal dialysis was initiated in the Intensive-Care Unit (ICU). She underwent computed tomography of the brain, which showed subtle evidence of a possible acute abnormality in the right occipital lobe in addition to an unusual pattern of calcifications in the cerebral hemispheres (Figure ). The patient underwent lumbar puncture for cerebrospinal fluid (CSF) analysis, which showed clear fluid, a white blood cell count of 99 cells/mm3, a protein level of 9860 mg/dl and a glucose level of 53 mg/dl. Her chest X-ray was unremarkable. Empiric treatment for viral and bacterial meningitis with intravenous acyclovir, vancomycin and ceftriaxone followed. Her blood and CSF cultures ultimately showed no growth, and her CSF venereal disease research laboratory, herpes simplex and varicella virus polymerase chain reaction results were negative.\nIn our ICU, the physical examination revealed an afebrile patient with a blood pressure of 145/92 mmHg while sedated on propofol and intubated on assist control ventilation, tidal volume of 550 ml, positive end-expiratory pressure of 5 cmH2O, oxygen saturation of 100%, fraction of inspired oxygen of 50% and heart rate of 85 beats/minute. She had a noticeable generalized fine maculopapular rash not reported on admission. Her head and neck examination revealed no signs of trauma, with equal and reactive pupils without subconjunctival hemorrhage. Her neck was supple without lymphadenopathy. Her neurological examination showed no obvious posturing or asymmetry; however, she had bilateral lower-extremity hyperreflexia accompanied by the presence of a coexistent Babinski sign. Her lungs were clear to auscultation bilaterally, and her cardiac examination showed a regular pulse with normal S1 and S2 and an audible systolic click. No rashes on her palms or soles were noted. No embolic or immunologic phenomena of endocarditis were encountered.\nOn ICU day 2, the patient developed a fever of 102°F, and a nasopharyngeal direct fluorescent antibody test was positive for parainfluenza virus, which was confirmed by viral cultures for parainfluenza virus type 3. Lupus activity studies showed normal C3/C4 levels and elevated complement 50 levels > 60 U/ml. Her anti-nuclear antibody titer was 1:800 with a homogeneous nucleolar pattern. Transesophageal echocardiography showed normal prosthetic valve function and no evidence of vegetations. MRI of the brain without contrast enhancement was also performed on ICU day two. The image revealed multifocal T2-weighted hyperintense lesions present within the parasagittal white matter and both cerebellar hemispheres (Figure ).
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An 80-year-old Japanese man was referred from another hospital presenting with altered mental status, loss of appetite, and urinary retention. He had been in a long-term care facility for 10 years due to mild sequelae after measles, which he had contracted when he was young. He was able to ambulate with the aid of a walker and independently perform all activities of daily living. Two and a half months prior to his visit to our hospital, surgical treatment was performed for a left femoral neck fracture resulting from a ground-level fall. Since then, the patient had needed a wheelchair due to his inability to cooperate and difficulty with rehabilitation. One week before his visit, he had fallen when he got out of his wheelchair independently. Three days after the fall, he was taken to a local clinic because of fever and urinary retention and was diagnosed with a urinary tract infection. On the day of his visit to our hospital, he presented with progressive altered mental status and loss of appetite over 3 days, which brought him to the psychiatric hospital, where no abnormal findings were revealed by head computed tomography (CT). Thereafter, he was referred to our hospital for further evaluation.\nOn arrival, he appeared lethargic, poorly responsive to questions, and unable to follow commands, which did not allow us to acquire an informative history and perform a thorough physical examination. The patient’s vital signs were as follows: Glasgow Coma Scale score of 13 (E4V4M5), 24 breaths per minute, heart rate of 70 beats per minute, blood pressure of 107/70 mmHg, oxygen saturation of 98%, and temperature of 36.7°C. Lower abdominal distention was evident without any remarkable findings on chest exam. Apparent weakness in his bilateral lower extremities was noted. The patient denied back pain. Blood test results showed elevated blood urea nitrogen of 63 mg/dL and creatinine level of 2.93 mg/dL. CT scan of the torso identified transverse fracture and dislocation of the T10 vertebra with extensively ossified anterior longitudinal ligament in the thoracic and lumbar spine region (). Bilateral hydronephrosis was also detected (). A limited physical examination revealed the absence of bilateral lower extremity reflexes and a decrease in anal sphincter tone. Active lower extremity motion was observed bilaterally; however, we were unable to administer a manual muscle test or assess skin sensation to touch in his torso or lower limbs.\nBased on his history of falling from the wheelchair and examination, the patient was diagnosed with a T10 fracture associated with DISH, which due to its unstable nature had developed into a secondary neurological impairment, leading to urinary retention and subsequent kidney injury. The patient was immediately transferred to a tertiary care hospital where posterior fixation of the spinal fracture was successfully performed on the same day (). The patient developed delirium and aspiration pneumonia, which was treated with antimicrobial therapy. He was discharged to a rehabilitation hospital on the 16th post-operative day, when it was observed his neurological deficits had not improved. Persistent delirium prevented the patient from performing rehabilitation. Postoperative treatment including lumbar brace or teriparatide were therefore not applied. When the patient was transferred to a long-term care facility 2.5 months following the surgery, persistent neurological impairment was observed.
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The patient is a 21-year-old previously healthy male brought to the trauma bay after sustaining a gunshot wound to the left upper back scapular region. His primary survey was remarkable for a zone 2 non-expanding hematoma of the left neck without a wound in the neck, requiring prophylactic intubation for airway protection. Chest X-ray demonstrated a hemopneumothorax, for which a chest tube was placed. Secondary survey was notable for the previously mentioned gunshot wound. Computed tomography (CT) angiogram of the neck and chest was then performed, showing the left neck hematoma mentioned previously along with bullet fragment artifact that interfered with image interpretation at the level of the left distal common carotid (CCA) and proximal internal carotid arteries (ICA) (). No pseudoaneurysm was observed. The contralateral cervical vessels and intra-thoracic vasculature were intact. Vascular surgery was consulted to evaluate this lesion. At that point, the patient was following commands and moving all four extremities; however, he was intubated and a comprehensive assessment of his cranial nerve function was not feasible. A carotid angiogram was performed. This did not reveal any traumatic injury to the cervical or intra-thoracic vasculature, namely the absence of pseudoaneurysm, dissection, thrombosis, or fistula. The patient was then managed conservatively post-procedure. He was initially in the intensive care unit (ICU) for neurovascular checks until he was extubated. His chest tube was subsequently removed, and he was discharged home without any antiplatelet or anticoagulants.\nA total of 3 months later, the patient presented to the Emergency Department with an enlarging pulsatile mass on his left neck. He was doing well until 3 days prior, when he developed pain and dysphagia. On evaluation, he was also found to have hoarseness, and tongue deviation to the left. The patient admitted to these symptoms being present over the past months but had worsened over the past 3 days. He was hemodynamically stable and underwent repeat CT angiogram of the neck (see ). This showed a 6-cm pseudoaneurysm arising from the proximal left internal carotid artery (ICA). Secondary to the proposed mass effect by the hematoma/pseudoaneurysm complex on the neighboring nerves and hypopharynx, decision was made to manage this with an open procedure to evacuate the hematoma (). The patient underwent an end-to-end left CCA to left ICA bypass with reversed great saphenous vein, and ligation of the left external carotid artery (). No shunts were used. The patient was hemodynamically normal throughout the case, and there were no concerning electroencephalography (EEG) changes during carotid clamping. He was extubated immediately post-operatively. No new neurological deficits were noted. He was discharged home 3 days later and seen in clinic 2 weeks afterwards with improved hoarseness and left tongue deviation, an intact surgical incision, and no clinical evidence of a recurrent pseudoaneurysm or hematoma.
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A 62-year-old man referred to our facility for the management of abnormal computed tomography of the chest identified during investigation for atypical chest pain. His past medical history was significant for chronic hepatitis C complicated by liver cirrhosis and hepatocellular carcinoma (HCC). He underwent chemoembolization and radiofrequency ablation of the liver as bridging therapies prior to uneventful orthotopic liver transplantation (OLT), a curative treatment for HCC. The explanted liver was cirrhotic and contained two 4.5 cm extensively necrotic lesions consistent with poorly differentiated HCC on pathological examination. There was an extensive intravascular invasion, and tumor was presented within an intracaval thrombus, which was removed during surgery. After the OLT, he was maintained on immunosuppressive therapy with tacrolimus and prednisone. Unfortunately, he was diagnosed with prostate cancer a few months later and underwent prostatectomy as curative treatment. At this time, his immunosuppressant was changed from tacrolimus to sirolimus, which had shown to delay HCC recurrence when compared to regimens that use tacrolimus in retrospective study.\nPhysical examination of his chest revealed normal breath sounds. Cardiovascular examination was unremarkable for abnormal heart sounds or murmurs. The rest of his physical examination was normal. Cardiac workup was negative for myocardial injury. Computed tomography of his chest images is shown in . The patient subsequently underwent endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) of right paratracheal lymph node station 4R ().\nPathological examination revealed highly cellular and clusters of large, loosely cohesive sheets of tumor with thin-walled traversing blood vessels. The tumor cells had a moderate amount of granular cytoplasm containing occasional hyaline globules. Nuclei were round to oval in shape and moderately pleomorphic, with prominent nucleoli and scattered intranuclear pseudoinclusions. Bile pigment was not identified. Numerous nuclei stripped of cytoplasm were present in the background of the smears (). The specimen did not contain appreciable lymphoid tissue, but small aggregates of macrophages with anthracotic pigment were present; these macrophages indicate that the tumor was located within a mediastinal lymph node (). Immunohistochemical stains were positive for hepatocyte paraffin 1 (HepPar1) () and alpha-fetoprotein (AFP), and stains for cytokeratin (CK)-7, CK-20, thyroid transcription factor-1 (TTF-1), and monoclonal carcinoembryonic antigen (CEA) were all negative.\nRecurrent metastatic HCC in mediastinum.
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A 70-year-old man had a 5-year history of bilateral knee pain, which had gradually worsened over the last one year, along with reduced walking distance secondary to bilateral osteoarthritis of the knee. He had no difficulty in daily life activities during childhood or adulthood. He had worked as a barber and had no history of trauma. There was no relevant family history. He walked with two crutches since developing bilateral knee pain and could not negotiate stairs. Conservative therapy at another medical clinic, including injection of hyaluronic acid into both knees, was not effective.\nWhen he first visited our institution, physical examination revealed conspicuous bilateral quadriceps atrophy. Both quadriceps were rated as having strength 3 on a muscle testing scale of 0–5. The patellas were palpable at the lateral side of the bilateral femoral condyle and had no mobility during flexion and extension. The proximal tibiae were rotated outward. Preoperatively, the passive range of motion in both knees was −10° to 130°. There was an extension lag of 45° at both knees. Effusions were present in both knees. The knees showed no signs of instability or ligamentous deficiency.\nRoentgenograms and computed tomography (CT) showed patellar dislocation and severe osteoarthritis of the bilateral knees with complete loss of the lateral compartment joint space (Figures –). Valgus deformity of 10° was observed in each knee on standing with the lower extremities aligned. The patient had more pain in the left knee than the right knee. TKA with correction of the extensor mechanism was planned first for the more painful left knee.\nA midline longitudinal skin incision was made under tourniquet control and lateral parapatellar arthrotomy was performed. The patella was located in the lateral gutter of the knee; the femoral condyle was hypoplastic. The medial retinaculum was thin. The vastus medialis oblique muscle was found to be located over the anterior aspect of the femur. For realignment of the extensor mechanism, we performed extensive medial and lateral retinacular release and distal realignment by tibial tubercle transfer. A posterior stabilized prosthesis (NexGen LPS-Flex; Zimmer, Inc., Warsaw, IN) was implanted and held in place with cement. Patellar resurfacing was not performed. The femoral component prosthesis was placed in 9° external rotation with reference to the posterior condyle line to facilitate patellar tracking. The iliotibial tract was partially detached from Gerdy's tubercle subperiosteally. The lateral collateral ligament and the popliteus tendon were also partially released from the lateral femoral condyle. The rotational alignment of the tibial component was based on the locations of the femoral components. After cementing the selected implants, the dislocated patella could not be reduced, so a proximal realignment procedure was performed as described by Insall et al. [], and the rectus femoralis tendon was lengthened by Z-plasty. Thereafter, the patella was in the groove during extension, but passive flexion angle was limited to 90° of flexion of the knee with the hip flexed to 90°. The lateral side of the arthrotomy could not be closed. Medial plication was performed as possible as we could. Finally, the patella could not be reduced fully and did not track centrally, but more laterally, in the patellofemoral groove throughout the full range of movement ().\nFull weight-bearing walking was allowed 7 days postoperatively with a brace for 0° angle restriction for 2 weeks. Range of motion (ROM) exercise using a continuous passive motion device was started 1 week after the operation. At 4 weeks after the operation, ROM was 0°–90° in the left knee and the patient was discharged with one crutch.\nAt 5 weeks after the operation, the patient slipped at home and fractured his left tibia. He was readmitted and conservative therapy was performed with a brace against the fracture. Three months later, his fracture was healed and he was discharged walking with one crutch ().\nOne year after the operation on the left knee, he had hoped to undergo right knee surgery because of pain. He was not satisfied with the restriction of flexion angle of the left knee and was concerned about future fractures. Therefore, he asserted that it was not necessary to reduce the dislocated patella and realign the extensor mechanism in the right knee.\nWe performed TKA using the same prosthesis in the right knee without realignment of the extensor mechanism and reduction of the patella. A midline longitudinal skin incision was made under tourniquet control, and medial parapatellar arthrotomy was performed. The femoral component prosthesis was placed in 3° external rotation with reference to the posterior condyle line. The right patella was located on the lateral side of the femoral component.\nAt the final follow-up one year after the right knee operation, the patient had full extension and 90° flexion in the left knee. There was an extension lag of 45° and flexion angle was 125° in the right knee. Left side quadriceps strength was improved to a rating of 4 on the muscle testing scale of 0–5, but that on the right side was not improved as before surgery. His walking ability was improved and he was satisfied with pain relief in both knees and walked with one crutch ().\nThe preoperative Knee Society score and functional scores were 40 and 15, respectively, which improved to 83 and 60, respectively, at the final follow-up.
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A 45-year-old male patient presented to us who required extraction of tooth #8 due to symptoms of gingival inflammation, oral fistula with exudate underpressure, pain, and discomfort for weeks before. On clinical examination, there were swelling, redness, and deep probing of 10 mm in the vestibular zone with purulent liquid originating from the crevicular sulcus; a scar area was observed along the attached gum, which is the product of a previous surgery. Periapical X-ray showed an enlargement of the periodontal ligament in the apex. Apical filling with an alloy metal was observed without relief of symptoms. Imageology examination was complemented with cone-beam computed tomography of the zone, showing a huge zone of bone loss in three-dimensional (3D) aspects of tooth #8. In addition, severe bone loss was observed. Tooth #8 was diagnosed as a chronic periodontal abscess,[] with a bad prognosis []. After the patient signed the informed consent, the surgical intervention was carried out. A Newman flap was designed for the extraction of # 8, the area was detoxified with tetracycline after tooth extraction and irrigated with saline solution to eliminate remaining infected tissue. Once it was confirmed that the buccal wall presented a perforation accompanied by bone loss, the area was filled with particulate xenograft of with particulate xenograft (LuminaBone by Criteria Inc) and a platelet-rich fibrin membrane was placed. A suture with nylon 6-0 was allowed to close the socket, and a hemostatic was used, followed by a aesthetic temporary restoration []. The extracted tooth showed signs of apical corrosion due to retrograde filling and multiple lines of fracture at the root. Finally, the patient was prescribed oral capsules of amoxicillin 500 mg and nimesulide tablets 100 mg. Control at 8 days and 6 weeks showed good stability of the tissues around the graft and good functional and esthetic condition of the temporary bridge []. The cone-beam tomography showed a bone neoformation at 4 months, with an increase in vestibular bone volume even with the immature bone. The clinical findings accompanied the results in the tomography []. After 8 months of follow-up, there is no relapse of abscess or inflammation in the surgical zone. The gingival tissue showed good healing and the regenerated bone volume was confirmed with CBT.
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A 34-year-old, otherwise healthy Caucasian male patient was referred to our clinic with the complaint of swelling in the right TMJ for more than 2 years. The last few weeks before presentation, the swelling, discomfort and limitation of mouth opening increased significantly. No pain was present at rest or with mouth opening. Mouth opening was limited to an interincisal distance of 35 mm (). His personal medical history revealed chronic bronchial asthma and periodic sinusitis and an inconspicuous family history.\nOn computer tomogram (CT) examination, a mixed radio-lucent and radio-opaque tumor was seen that appeared as an enlarged condylar head () and an interrupted cortical margin was evident, especially in the anterior aspect of the condyle. On MRI examination, a large inhomogeneous mass was seen expanding the condyle with cortical perforation in some areas and pronounced hemosiderin content ().\nA benign tumor was considered as first option due to the slow growth pattern and fairly well demarcated tumor without evidence of infiltration.\nA transcutaneous fine needle aspiration (FNA) was performed that led to a provisional diagnosis of a hemorrhagic, giant cell containing lesion with a comment that the precise diagnosis was unclear. Due to the predominantly intraosseous growth, an osteoblastoma, an aneurysmal bone cyst and a brown tumor of hyperparathyroidism were considered in the differential diagnosis. Open biopsy followed via an intra-oral route to the anterior component of the condylar tumor with uneventful post-operative healing. Histopathological examination revealed myofibroblastic proliferation with a marked inflammatory component containing giant cells and abundant hemosiderin () and the diagnosis of intraosseous growth of a TSGT of diffuse type was suggested. Although the main mass of the tumor was intraosseous, some extracortical components could be verified on the pre-operative imaging (, ).\nAfter discussing the treatment options in detail, the patient opted for our second choice, a free vascularized costochondral graft and decided against a custom total joint replacement. Access to the tumor was via a pre-auricular and submandibular incision. After the low condylectomy bony incision the tumor was mobilized and removed laterally as well as inferiorly. Removal of the antero-medial portion was difficult due to the attachment of the lateral pterygoid muscle and a very brittle tumor component in this area that resulted in removal in several fragments.\nAfter tumor removal, the vascularized costochondral graft was harvested. The patient was partly positioned on his side (30°). The thoracodorsal artery was identified and followed until the branches to the serratus muscle. A 7 cm costochondral graft of the seventh rib was raised, covered by the serratus muscle laterally and raised in a subperiosteal plain medially ().\nThe graft was positioned with lag screws and the occlusion and mouth opening was checked. Vascular anastomosis followed with anastomosis on the superior thyroid artery and external jugular vein. One year post-operative follow-up MR () depicted the total removal of the TGCT and a well remodeled bone graft adjacent to the glenoid fossa. Clinically the patient regained a normal, symmetrical mouth opening with translation movement on the right ().
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A 20-year-old unmarried female presented a well-circumscribed mobile lump in the upper outer quadrant of her left breast. The lump had gradually increased in size over the last six months and had started to be painful in the last few days. On clinical examination, the lump measured 5.5 cm × 4 cm, and the skin over the lump was not attached to the mass and showed no signs of inflammation. The patient presented this for the first time to the surgery outpatient department. Moreover, there was no history of trauma and no previous fine needle aspiration cytology (FNAC) had been performed. The lump was diagnosed clinically as a fibroadenoma, and the FNAC was carried out with a 5-ml syringe using a 24-gauge needle. Smears were dried, fixed, and stained with hematoxylin and eosin and then evaluated by the pathologist. The smears were highly cellular; most of the cells were scattered individually and had hyperchromatic round/oval nuclei with smudged chromatin and eosinophilic cytoplasm. There were only a few tight clusters of ductal epithelial cells with myoepithelial cells, and a few focal areas of fibromyxoid stroma ( and ). There was no evidence of any necrosis, and no inflammatory cells or red blood cells were present. A diagnosis of fibroadenoma with secondary squamous metaplasia was reported after the FNAC, and an excision biopsy was carried out. The removed tissue was fixed in 10% buffered formalin overnight. On macroscopic inspection, the specimen was found to be an encapsulated grey white mass measuring 5.2 cm × 4 cm × 3.5 cm. A grey brown area measuring 4 cm × 4 cm × 3.5 cm with small cystic areas was evident in the cross-sectional view of the specimen. The remaining part of the specimen was firm, grey white with a single small cystic area. Representative multiple sections were prepared from the grey brown areas, the cystic areas, and the firm grey white area. Tissue samples, measuring 4–5 mm in size, were fixed in the 10% neutral buffered formalin, processed under standardized conditions for paraffin embedding. Sections of 3–4 µm were cut and stained with hematoxylin and eosin using the standard procedures. On microscopic examination, sections from the grey white area indicated an intracanalicular type of fibroadenoma with cleft-like spaces. In addition, sections from grey brown areas revealed areas of ischemic hemorrhagic necrosis within the fibroadenoma. The outlines of the intracanalicular pattern were still retained along with congested small vessels and areas of haemorrhage (). The epithelium lining the cleft-like spaces was desquamated and lying as individual cells in the cleft spaces (). Few lobules showed complete disintegration of ductal and stromal cells. The ductal cells were round to polygonal in shape, and stromal cells were spindle shaped. Both these cell types were lying singly in a cystic space lined by the ductal epithelial cells (). No inflammatory cells were evident. The histological diagnosis was fibroadenoma with subtotal infarction.
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A 51-year-old woman with a one-month history of redness and swollen left knee joint was transferred to our general intensive care unit (ICU) due to persistent high fever (up to 39.5°C) and sudden hypotension. After being diagnosed with dermatomyositis 2 years ago, she continued medication treatment on prednisone tablets with a 25 mg daily dose and cyclosporine capsule with a 75 mg dose twice per day. Last month, the results of blood culture and bacterial culture of joint cavity pus as obtained from other medical institutions were shown to be negative, with no special microbiological examination performed.\nWhen the patient visited the rheumatology department for appointment with a doctor, she coughed up sputum intermittently and her body temperature reached up to 40°C. Physical examination revealed that the left knee was red and swollen with positive floating patellar test, along with red rash in the V area of face and neck. The right dark yellow pleural effusion displayed exudate and negative bacterial culture. Vancomycin was thus prescribed to reduce infection, and 20 mg of methylprednisolone was applied twice a day. Four days later, she was transferred to ICU due to hypotension (the detailed clinical course is shown in ). The patient exhibited low blood pressure and high heart rate, which was accompanied by elevated procalcitonin and multiple organ failure. Broad-spectrum anti-infective therapy (imipenem/cilastatin + linezolid) was initiated within the first hour of highly suspected septic shock. ECG suggested cardiac infarction and high myocardial enzyme index. In order to rule out the occurrence of acute cardiovascular event, no infarction was detected immediately after coronary angiography. Given the EF value of 30% for the patient, septic heart disease was suspected. At the same time, the patient suffered acute liver injury, acute renal injury and thrombocytopenia.\nAfter the patient was transferred to ICU, joint cavity pus was also taken for culture in addition to blood culture samples (ultrasound: , MRI: ). Considering that the patient had negative culture multiple times in the previous month, the NGS examination was conducted for joint cavity pus and blood samples at the same time. Subsequently, NGS results indicated that the pathogen was “M. tuberculosis,” with acid-fast bacilli unexpectedly visible in articular cavity effusion. After an inquiry made about her medical history, it was known that the patient had a history of contact with pulmonary tuberculosis, and such symptoms as night sweating, coughing and expectoration were manifested since around the last month. Thus, the septic shock associated with M. tuberculosis was suspected. Five combinations of anti-tuberculosis drugs (HRZEO: Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Ofloxacin) were prescribed, while imipenem/cilastatin was downgraded to piperacillin/tazobactam and vitamin B6 was prescribed as a supplement. The bronchoalveolar lavage fluid was found negative for acid-fast staining. The T-SPOT results of the patients remained negative. The T lymphocyte count of the patient was shown to be extremely low. After about 10 days of anti-tuberculosis treatment, the body temperature improved, the ST segment of ECG decreased, myocardial enzymes returned to normal, shock was alleviated, and the count of platelets increased. Unfortunately, liver function deteriorated for the patient gradually. Five days after the adjustment made to anti-tuberculosis drugs, the patients showed such tuberculosis poisoning symptoms as high fever and shock, norepinephrine of 1.2 ug/kg/kg·min, which was accompanied by a decline in the count of platelet again. Afterwards, both liver function and cardiac function further deteriorated. Re-examination of blood NGS remained suggestive of M. tuberculosis. Our advice against further treatment was rejected by her family members.
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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. ).
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A 58-year-old male with hypertension without regular medical control was presented to our emergency department for the complaint of left side chest pain that lasted for an hour with concomitant hypotension. He had no cold sweating, radiating pain, or claudication. The 12-lead electrocardiogram suggested inferior wall and right ventricle STEMI, including ST elevation in leads III, and aVF, lead I with reciprocal ST depression, and right side V4R elevation (Fig. A). Under the impression of an inferior wall STEMI, antiplatelet medications and inotropic agent were administrated, and the patient was sent promptly for a primary PCI.\nEmergent primary PCI was approached through right radial access. After the insertion of radial sheath, the radial systolic blood pressure was 82 mm Hg. When the diagnostic catheter was advanced to the ascending aorta, the systolic aorta pressure became 20 mm Hg higher (ie, 102 mm Hg). Due to the abnormally large pressure differential between the peripheral radial artery and central ascending aorta, TAAD was suspected. After a short trial that failed to locate ostium of the right coronary artery, we withdrew the diagnostic catheter from the ascending aorta back to the innominate artery and there, we found the maximal pressure damping site around the junction of aorta arch and innominate artery (Fig. B). Through the diagnostic catheter, the injection of contrast medium was performed and subsequent imaging results showed a stenosis near the injection site and irregularly narrowing of the ascending aorta (Fig. C and D, Video 1). TAAD was finally diagnosed. The bedside echocardiography also conducted to visualize a dissection flap located over the ascending aorta together with a moderate aortic valve regurgitation. Computer tomography of the aorta further verified the TAAD with extensive dissection involving innominate artery, left carotid artery, and bilateral iliac arteries. Imaging results provided evidence of a false lumen compromising the innominate artery that had caused the pressure damping (Fig. A–D). The cardiovascular surgeon was consulted right away and the patient received aortic root and aortic valve replacement combined with bypass surgery thereafter. Due to the severe dissection and profounding shock, the patient passed away 2 days after the surgery.
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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 ().
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Case 1 is a 63 years old male patient, under follow up in our hospital, with a grade IV glioblastoma (determined by histopathology) in the right temporal lobe. As it can be observed in , at the time of diagnosis the tumor is located very close to the cortex. This corresponds with a higher probability of seizures, symptom that led this patient to a first medical consultation. Patient-specific analysis of this glioma determined that it was characterized by a net proliferation rate of 0.107 cells/day and a net diffusion (migration) rate of 0.255 in white matter. Corresponding tumor mass velocity and invisibility index were 120.8 mm/year and 2.38 , respectively. Considering the range of values reported for high grade gliomas (velocities of 10 to 200 mm/year and invisibility index of 2 to 20 \n), those values meant that this tumor had a relatively intermediate growth velocity and low invisibility index. These parameters describe a relatively ‘benign’ tumor in relation with the glioblastoma spectrum. In correspondence with (but independently from) this prediction, this was a relatively rare case that was left without surgical intervention up to five months from diagnosis.\nSimulation of case 1 in a ‘virtual patient’ began with the localization of an initial unique tumor cell in the white matter of the superior temporal gyrus. Malignization of the tumor was predicted around 152 days (five months) after its onset and diagnosis after 267 days (nine months). The whole simulation of this case can be observed in the File Case S1 video submitted as a supporting information file. shows the real and simulated tumor at the diagnosis time for different tumor views. In simulated images ( and 1(e)), the central white area represents the concentrated tumor mass while the black surrounding area indicates tumor infiltration, with low concentration of tumor cells invading normal brain tissue.\nA good correlation between real and simulated radios of the tumor mass can be observed (8.9 vs. 9.7 mm, respectively). When the simulated image is generated with the same detection level as the MRI technique (around 400 cells/\n), there is also a fairly good correlation between real and simulated infiltrative areas (compare with 1(d), axial view). Simulated infiltrative areas detected at 1 cell/, nevertheless, indicate that they would be underestimated by current diagnostic imaging. This is something also reported by others and it is related to one of the main potential clinical utilities of this type of models.\npresents the tumor mass and infiltration 20 days after diagnosis time. At this time, real and simulated tumor mass radios are 12.1 and 12.2 , respectively. Simulated infiltrative areas also correlate well with those derived from real images when generated at the same detection level (see , axial view), but a higher level of detection indicates again that this area may be larger than that evidenced by real MRI images. These two moments (diagnosis time and 20 days after) were used to estimate the main parameters of the model (net proliferation and diffusion rates) in a patient-specific way. Tumor evolution to the next time stage (40 days after diagnosis) was then predicted by the model.\nshows the predicted tumor-mass and infiltrative areas 40 days after diagnosis, over different slices from the axial plane, given a better overview of the 3D tumor evolution. A good correspondence can be observed between real and simulated images generated at a detection level of 400 cells/mm\n2 (compare first with second row of images). Here, tumor mass radii are 14.8 and 15.8 mm, respectively. Again, a higher detection level of 1 cell/ indicates larger invasion than that observed by MRI real images (third row). These results indicate a fairly good prediction accomplished by the numerical model.\nsuperimposes the predicted tumor mass at different times upon the Talairach atlas, indicating the main brain structures that are being affected by tumor evolution. At diagnosis time (270 days from tumor onset, ), tumor mass affects 8.2% of the Brodmann area 41 and 12.6% of the Brodmann area 42 (references 2 and 3, respectively). These areas belong to the primary auditory cortex (Heschl’s gyrus). Related main functions are basic processing of auditory stimuli (speech and non-speech) , and processing of sound intensity , .\n50 days after diagnosis (320 days from tumor onset, ), the tumor mass invades great part of transverse and superior gyrus of the temporal lobe (references 1 and 6, respectively) and 10.9% of the Brodmann area 22 (reference 4). If the dominant cerebral hemisphere were the right one, this area would be part of the Wernicke’s area, fully related to auditory comprehension of language . If it was not, as in the majority of cases, this area would have also roles related with receptive language but in a subordinated way, leading to a bilateral dissociation design . This seems to be the case with functions related to lexical ambiguity resolution, where left and right Wernicke’s areas function as processors of dominant and subordinated meanings of ambiguous words, respectively.\n100 days after diagnosis (370 days from tumor onset, ), the tumor has expanded to the pre-central gyrus of the frontal lobe (10) and up to the right lateral ventricle (7). It also affected 21.4% of the Brodmann area 43 (9), 10.7% of the Brodmann area 13 (8) and 3.3% of the Brodmann area 39 (5). Brodmann area 43 is associated with some motor responses to vibrotactile digit stimulation and to spoken language . Brodmann area 13 belongs to the insular cortex, that is reported to participate in somatosensory , olfaction and taste , and verbal memory functions , among others. Finally, Brodmann area 39 is also part of the Wernicke’s area or its contralateral homologous. In the right hemisphere, it is generally associated to visuospatial processing and music reading . predicts that, at the time of death (survival time of 140 days after diagnosis or 410 days from tumor onset), the tumor mass has extended through the insula (11), lentiform nucleus (12) and thalamus (13).\npresents tumor status at the predicted time of death. The estimated tumor mass diameter (assuming an spherical shape) at this moment is 62.9 mm, a value slightly smaller than the lethal size parameter used (70 mm, see ). This might be attributed to the corrections added to the model in relation with tumor location. Indeed, at this time the tumor mass edge reaches the ‘foramen magnum’, as is evidenced by the Talairach atlas in . This means that herniation, and consequently death, could be imminent.
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A 32 year-old woman who had suffered mild dyspnea on exertion and developed sudden progressive worsening of dyspnea was transferred to our hospital. She had no risk factors of APE but protein S deficiency. Transthoracic echocardiography showed right ventricular dilatation without right ventricular hypertrophy, a D-shaped left ventricle, and tricuspid pressure gradient of 50 mmHg. Enhanced CT scan showed enlarged pulmonary trunk, floating thrombi in the bilateral interlobar pulmonary arteries, infiltrates suggesting pneumonia in both upper lobes (), and deep vein thrombus in both popliteal veins. The patient presented with severe hypoxia, which was not improved after intubation with SpO2 of 76% on FiO2 of 1.0; tachycardia with pulse rate of 108 bpm; and hypotension with blood pressure of 111/70 mmHg with administration of noradrenaline (0.5γ/kg/min). We instituted veno-arterial ECMO with percutaneous femoral cannulation and performed an emergent pulmonary embolectomy. We did not make a diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) at the surgery. We found neither organized thrombus nor yellow plaques, which is often seen in CTEPH, in the main and lobar pulmonary arteries. We did not observe clearly inside the segmental arteries due to back bleeding and were not sure that stenosis in the segmental artery was caused by organized thrombus. Intraoperative transesophageal echocardiography showed patent foramen ovale with right to left shunt. It was presumed that infiltrates in the upper lobes and PE in the lower lobes caused ventilation perfusion (V/Q) mismatch leading to severe hypoxia, and right to left shunt through patent foramen ovale further exacerbated hypoxia. We performed pulmonary embolectomy and closure of patent foramen ovale under cardiopulmonary bypass (). Poor oxygenation was sustained after weaning from cardiopulmonary bypass but gradually improved in the following several hours in the intensive care unit (ICU). However, the patient presented with hypotension and decrease in urine output thereafter. The Swan–Ganz catheter showed pulmonary hypertension with pulmonary artery pressure of 50/42 (37) mmHg and transthoracic echocardiography showed right ventricular dilatation and a D-shaped left ventricle. We presumed that unidentified or residual pulmonary hypertension caused right heart failure and treated with NO inhalation and epoprostenol. The patient was gradually recovered and extubated on postoperative day 7. Despite discontinuance of epoprostenol, transthoracic echocardiography showed no pulmonary hypertension. After a 3-month anticoagulation therapy, pulmonary angiography showed webs and bands in both inferior lobe arteries (), which were the same obstruction seen in CT scan obtained shortly after the surgery, and right heart catheterization showed pulmonary artery pressure of 35/14 (24) mmHg. Based on her clinical course, it was presumed that the patient had preexistent unidentified chronic pulmonary thromboembolism at the time of the index PE. We assumed that severe PH after the surgery might have been attributed to residual fresh thrombus and hypoxia-induced vascular spasm since pulmonary artery pressure returned to almost normal with anticoagulation therapy and PGI2 administration.\nWe obtained the patients’ consent to the submission and publication of this case report, and they signed a standard publication consent form of our institution.
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A 60-year old female underwent a phase III Oxford UKA [Biomet UK Ltd, Bridgend, United Kingdom] in 2006 for antero-medial osteoarthritis. A minimally invasive medial para-patellar approach was used and medium sized femur, 44 X 28mm tibia and 3mm meniscal bearing insert were implanted. She had an uneventful post-operative recovery. She was completely asymptomatic and was discharged from the follow-up at two years following the surgery with no symptoms and a range of motion of 0 to 130 degrees.\nShe presented to the Accident and Emergency (A&E) department in April, 2013 with history of a sudden onset of pain and swelling in the same knee. She heard a ‘pop’ in the knee while standing and did not report any obvious injury to the knee. On clinical examination, she was haemodynamically stable and afebrile and there was moderate effusion in the knee. The range of motion was from 30 to 60 degrees and she was unable to weight bear through the knee due to pain. The radiographs of her knee in the A&E department raised a suspicion of posterior dislocation of the polyethylene insert (). There was no evidence of loosening of femoral or tibial components.\nThe white cell count and CRP were normal, excluding an acute infection. She was admitted to the ward and surgical exploration was planned for the following day, with the view of changing the polyethylene insert or to revise the components if they were loose or damaged. The knee was opened through the previous scar of medial para-patellar approach. Intraoperatively, both the femoral and the tibial components were found to be well fixed with no scratches and rest of the knee did not show any evidence of osteoarthritis. The polyethylene insert was found to be fractured through the middle (). The anterior half was sitting on the tibial component and the posterior half was dislodged into the posterior compartment of the knee, stuck to the posterior capsule. It was not possible to retrieve that fragment from the front.\nThe operating surgeon had two options; either to remove both the components and then retrieve the fragment from the front or to retrieve it through a posterior incision. Eventually, rather than making a separate skin incision, the previous skin incision was extended and medial skin flap was raised to expose the postero-medial aspect of the knee. Deep fascia was incised to expose the pes anserinus. An interval was created between the pes anserinus and the medial collateral ligament anteriorly and medial head of Gastronemius posterioly (). Capsulotomy was performed through this\ninterval and the dislodged part of the polyethylene insert was retrieved through the opening. The polyethylene insert showed some pitting and whitening and it seemed to have fractured cleanly through the thinnest part (). A new polyethylene of the same size insert was implanted. The patient made uneventful recovery following the surgery. At two year follow-up she was completely asymptomatic with the range of knee movement from 0 to 125 degrees.
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A female baby with a birth weight of 750 g and a male baby with a birth weight of 930 g were born at the gestational age of 26 weeks from a 29-year-old mother. Pregnancy was complicated by the preterm rupture of the membranes. The twins were resuscitated after birth, and they were intubated and surfactant therapy was administered. The male patient was extubated on the fourth day and was started to be followed up with nasal continuous positive airway pressure (CPAP). On the postnatal 28th day, the male patient was separated from CPAP and was started to be followed up with free oxygen. However, mechanical ventilation was continued in the female baby. The patients’ lung radiographic and clinical findings were compatible with severe BPD. It was decided to give MSC treatment on the postnatal 32nd day to both patients. Mesenchymal stem cells (2x106/kg) were given by the intravenous route and 1x107/kg MSCs were given by the intrathecal route. The patients were monitored using lung USG and the images were recorded.\nAtelectasis, consolidation, pleural line abnormalities, alveolar interstitial syndrome (AIS), B lines, and air bronchograms were seen on USG examinations of the lung in both patients before treatment. No significant change was found in lung USG repeated twelve hours after stem cell treatment (, ). Ultrasound examination of the lung performed in the female patient three days after treatment and revealed pulmonary consolidation, partial resolution in divided areas, atelectatic regions, and also, it was observed that pleural line abnormalities persisted. In the male patient, lung USG revealed that B lines and AIS disappeared, but pleural line irregularity persisted.\nLung USG of the female patient performed nine days after the treatment showed that pleural line irregularity reduced, A lines became prominent, and AIS areas gave place to B lines, and the patient’s need for oxygen decreased. A USG examination of the male patient revealed that A lines started to become prominent and AIS areas were replaced by B lines. Simultaneous echocardiography was planned for the patients. Hemodynamically significant PDA was found on echocardiography in the female patient, and the male patient had PDA that could be controlled by medical treatment. On the fifteenth day of treatment, a final follow-up USG examination was performed in the patients. It was observed that AIS areas were completely replaced by B lines, A lines became more prominent, and air bronchograms were present in pulmonary consolidation areas in the female patient (). However, the patient died of sepsis on the 18th day of treatment. The male patient’s lung ultrasonographic findings were almost normal (), his oxygen need was reduced and he was receiving free oxygen only during feeding. Subsequently, the patient was discharged after discontinuing oxygen support completely. Written informed consent was obtained from the parents to publish the findings and results of the patients. Mesenchymal stem cells to be used within the context of MSC treatment were obtained from Acıbadem Labmed Health Services Cell Laboratory.\nAs the cells cultured by mechanical and enzymatic procedures from the cord blood are observed to have covered 70% of the flask base, they are included in the first passage procedure; 3000–5000 cells/cm2 are planted, cultured with the relevant medium, and stored in an incubator. When they are observed to have covered 70% of the flask base five days later, they are included in the termination procedure. The MSCs obtained at the end of the procedure are diluted with isotonic solution and quality control samples are given (Cell number, Viability, Flow Cytometry, LAL; Mycoplasma, Microbiological quality control).
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A 65 year old lady presented through the Emergency Department with a 1 week history of abdominal pain after being knocked down by a horse she was holding, which resulted in the patient falling onto a stony path and hitting the right side of her abdomen. She complained of continued epigastric pain following the incident, which radiated through to her back and right upper quadrant.\nOn examination the patient had a low grade temperature (37.5°C) and was hypotensive at 96/61 mmHg, with a pulse rate of 96. Abdominal examination revealed right upper quadrant tenderness with no localised peritonism. Bloods showed a normal full blood count, lipase and liver function but did however reveal a C-reactive protein of 451. Chest and abdominal radiographs were normal with no signs of free air. An abdominal computed tomogram (CT) was performed which showed a moderate amount of ascitic fluid in the perihepatic space, around the porta hepatis and extending down to the pelvis.\nThe patient underwent a laparotomy, which revealed a ruptured gallbladder with free bile. There was no evidence of any associated injuries to the surrounding organs. Due to the friable nature of the gallbladder and associated inflammation cholecystectomy would have been extremely difficult. Therefore the decision was made to perform a partial cholecystectomy, below the level of the tear, and drainage.\nUnfortunately the drain came out unintentionally 3 days after the operation having drained almost 200 mls of bile in that period. There was continued leakage of bile through the drain site increasing in rate to approximately 300 mls per day for the next 48 hours. An abdominal ultrasound at the time showed a continued fluid collection in the pelvis.\nDue to the continued bilious drainage the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) on day 6 post-op. During this procedure a sphincterotomy was performed and a pig-tail stent inserted to allow drainage of the gallbladder. Following this intervention the patient's post-op course was unremarkable apart from a small wound infection. She was eventually discharged home 26 days after admission and the stent was removed 2 months later.
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A 68-year-old female was referred from an ENT specialist practitioner to the ENT-department due to multiple enlarged cervical lymph nodes located bilaterally and an involuntary weight loss of 10 kilograms over the last 6 months. There was no significant previous medical history. Fine needle aspiration biopsy (FNAB) suggested lymphoma and subsequent histological examination of an excised lymph node between level two and three from the left side of the neck confirmed the diagnosis of mantle cell lymphoma (MCL). PET-CT and bone marrow examination further demonstrated bone marrow involvement. Accordingly, the lymphoma was staged as Ann Arbor IVB and AJCC stage IV. The patient received eight series of R-CHOP followed by a scheduled 2-year-period of maintenance therapy with rituximab. Twelve months into maintenance therapy the patient developed a tender swelling of the right submandibular- and left sublingual gland. On clinical examination, a one-centimeter process with normal overlying mucosa was found in the left sublingual gland () along with a similar process in the right submandibular gland. Ultrasound of the left sublingual- and right submandibular gland revealed two hyperechoic one-centimeter tumors. Further examination and ultrasound of the neck revealed no enlarged lymph nodes. A magnetic resonance imaging (MRI) of the head and neck was performed (). PET-CT revealed a process of the sigmoid colon, but the bone marrow examination showed no signs of infiltration. MCL relapse was confirmed by subsequent excision and histological examination of the sublingual- and submandibular gland, as well as histological examination of a biopsy specimen taken from the sigmoid colon via colonoscopy. Histological examination of the excised sublingual gland showed salivary gland tissue infiltrated by lymphoid tumor cells appearing as blastoid cells with multiple membrane bound nucleoli (). Mitotic figures were seen in several of these cells. Immunohistochemistry showed positive reaction in the tumor cells' nuclei for PAX5, cyclin D1, and SOX11 and on the tumor cells' surface for CD5 and the proliferation index was estimated to >80%. Furthermore, flow cytometry detected 70.1% clonal B-cells positive for CD5, CD10, CD19, CD20, CD43, and CD79 and with lambda light chain restriction. FISH demonstrated an IGH/CCND1 translocation (65% of the cells showing a signal), consistent with a diagnosis of MCL. Ibrutinib was initiated but the patient died 18 month later due to advancing heart failure and declining performance status.
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A 46-year-old man with 20 pack-year was referred to our hospital for work up and investigations of a large anterior mediastinal mass as can be seen on chest radiography in March 2012. He had neither symptoms nor family history of neurofibromatosis Type I (NF-1). Mr. KS complained of dry nonproductive cough and dyspnea on exertion since January 2012. He was a known hypertensive and has been on irregular medications for a period of eight months. General physical examination revealed a soft cystic swelling in the right cervical region. Breath sounds were diminished on the left side with muffled heart sounds on auscultation. Contrast enhanced computed tomography (CT) scan of the chest revealed a large 17×9.9 cm minimally enhancing mass with speckled multifocal calcification in the anterior mediastinum (). The mass was seen extending up to the left anterior lateral chest wall with invasion of the pleura with evidence of mild pericardial effusion.\nA CT guided percutaneous core needle biopsy was performed. Histopathology revealed a tumor composed of cartilaginous areas and spindle cell morphology with pleomorphic hyperchromatic nuclei and yielded differential diagnosis of immature teratoma, teratocarcinoma, chondrosarcoma, MPNST with cartilaginous areas and sarcomatoid carcinoma with cartilaginous area. All the relevant tumor markers namely alpha feto protein (AFP), human chorionic gonadotrophin ( HCG) and lactate dehydrogenase (LDH) levels were within normal limits. Hence after discussion in tumor board, the decision was taken for complete excision of the tumor which was performed via a mini sternotomy.\nIntra operatively a large lobulated mass, soft to firm in consistency was seen in the anterior mediastinum extending from the retrosternal region to the region behind left anterior chest wall and was adherent to the pericardium and left pleura posteriorly and appeared to be arising from the intercostal nerve. No enlarged lymph nodes were identified. On gross inspection revealed a greyish white to a greyish brown encapsulated slightly nodular soft tissue mass measuring 18×16×10 cm and weighing 1490 g and showed no invasion of neighboring organs (). Serial sections through the mass revealed greyish white solid trabeculated cut surface with focal hemorrhagic and myxoid areas. Histopathologic examination showed a cellular tumor composed of spindle shaped cells arranged in sweeping bundles and fascicles. The cells had oval to spindle hyperchromatic nuclei with coarse chromatin and small nucleoli. There was mild nuclear pleomorphic and frequent mitotic figures (up to 10/10HPF). Cytoplasm was indistinct, eosinophilic and blended with intercellular collagen fibers. Some areas showed prominent myxoid changes. In some areas, islands of metaplastic cartilage could be identified along with areas of osseous differentiation. Spindle cells with wavy and buckled nuclei and occasional area of palisading was seen. Areas of necrosis and hemorrhage were also present with scattered small to medium sized blood vessels. Immunohistochemistry examinations revealed that the tumor cells stained positive for vimentin, S100 and Bcl2; negative for cytokeratin, cytokeratin 7, epithelial membrane antigen, desmin, SMA, Myf4 and CD99 consistent with the diagnosis of MPNST with cartilaginous and osseous differentiation, histologic grade II (). As the patient had undergone R0 resection, adjuvant treatment was not offered and was advised regular monthly follow up for close observation.
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A 24-year-old man of African descent was originally admitted to an outlying hospital in cardiogenic shock, secondary to viral myocarditis. He rapidly deteriorated and was admitted into the intensive care unit following development of acute renal failure. He was subsequently dialysed. His renal function gradually improved on dialysis while his cardiac function also significantly improved with the ejection fraction increasing from 20% on admission to 40%. About five days into admission, his hemoglobin was noted to have decreased gradually from the initial value of 148 g/L to 84 g/L despite packed red cell transfusions (). The platelet count similarly decreased progressively despite multiple platelet transfusions. Blood cultures were negative. The virology workup for cytomegalovirus, EBV, parvovirus B19, and HIV screening, were also negative. He was subsequently transferred to the University of Alberta Hospital for further review and management. Additional recommended testing following his transfer of care included screening for antiphospholipid, lupus anticoagulant and hepatitis B core antibodies. All were negative. The transfusion history confirmed that the patient had previously received packed cell transfusions perioperatively more than 2 yrs prior to the present illness. The patient deteriorated with development of purpuric skin lesions and epistaxis while the progressive drop in the platelet count continued. The onset of purpuric bleeding followed red cell transfusion given during hemodialysis as a result of the acute renal shut down. At the time of the referral, he was on methylprednisolone and tranexamic acid. A review of his CBC showed hemoglobin; 88 g/L and total white cells; 14.2 × 109/L (neutrophils 9.1). At the nadir, platelet count was 1 × 109/L. The international normalized ratio (INR) fluctuated between 1.1 at admission and 2.1. PTT was stable and within normal limits. A summary of the CBC values and transfusion dates is given in . Review of peripheral blood film confirmed marked reduction in platelets with no evidence of microangiopathy or morphologic atypia. Histocompatibility tests reported patient as having HLA antibodies with panel reactive antibody (PRA) of 97%. The patient was homozygous for HPA-1a and HPA-4a and had alloantibodies against HPA-1b (anti-HPA-1b) demonstrated by ELISA with strong reactivity, OD ratio >7.0 (ELISA kit GTI, Inc., Waukesha, WI) (see ). He received two doses of intravenous immunoglobulin (IVIG). Further transfusions of platelets were only from HLA matched donors who were HPA-1b homozygous only. At the time of discharge, his platelets had increased to 64 × 109/L. shows the trend of platelet count for the duration of admission. There was no further evidence of active bleeding or purpura and his hematologic profile gradually returned to normal values. He has remained clinically stable after discharge.
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A previously healthy 48 year old male presented to our surgical out-patient service complaining of a 3 month history of progressively worsening dysphagia for solids with associated regurgitation and unintentional weight loss of 14 kg. Physical examination was unremarkable and there was no evidence of organomegaly or lymphadenopathy. Subsequent oesophagoscopy revealed a large polypoid pigmented lesion at 30 cm. The lesion did not impede the passage of the scope. Multiple biopsies were taken. Two pigmented cutaneous lesions (no sinister features present in either lesion) were also excised – histology showed benign lesions. No evidence of melanoma was found.\nA staging CT scan of his thorax, abdomen and pelvis showed a well-defined eccentric mass in the mid-lower oesophagus. There was no apparent local invasion or regional lymphadenopathy.\nWhole body FDG PET/CT body scan confirmed the mass in the oesophagus with increased uptake in a high abdominal pre-aortic and high right paratracheal node consistent with metastasis. (see figure ).\nBiopsy results from the oesophagoscopy showed an infiltrating malignant tumour with prominent nucleoli and cells prominent in the submucosa and also in the basal layer of the squamous mucosa. S100 stain was positive. Features were consistent with malignant melanoma. The features that confirmed the primary nature of the neoplasm were the junctional change, multi-pleomorphic spindle shaped cells with prominent nucleoli and some lymphocytic infiltrate. (see figures &).\nThe absence of cutaneous, ocular, or mucosal melanoma elsewhere also supported a diagnosis of primary rather than secondary melanoma.\nHe underwent a three stage oesophagectomy with mediastinal lymphadenectomy. Seven of the twenty six lymph nodes were postitive for melanoma, including the two nodes highlighted by the FDG-PET scan. The remainder of his post-operative stay was unremarkable and he was discharged home.\nHe underwent a course of immunomodulatory therapy, consisting of a 4 week course of daily high dose IV Interferon alpha 2b and then received a thrice weekly lower dose subcutaneous regimen for a further 48 weeks. He tolerated this regimen well. He was seen regularly in the immediate follow up period and, at his 18 months post-operative review, there was no evidence of disease recurrence and he continued to do well.
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A 15-year-old female patient was referred to a surgeon for extraction of roots of tooth no. 36. Radiographic and clinical examination revealed favorable clinical situation for immediate transplantation of tooth no. 38.\nAll auto-transplantation procedures were performed following established surgical protocol. Prior to operation sufficient local anesthesia and a mouth-rinse of chlorhexidine 0.02% for at least 1 min were obtained. The tooth at the recipient site is then sectioned with a bur and extracted preserving alveolar bone. Recipient socket is prepared considering measurements of donor tooth germ from panoramic radiograph, — removal of the inter-radicular septum, trimming of neighboring teeth crowns in case of the recipient site narrowing is performed. Next, the donor tooth is carefully removed. In cases of total impaction, flap elevation, bone removal, tooth germ careful removal with the follicle around the crown is performed. When a donor tooth is erupted, careful circumcising around the tooth is made before luxation and gentle extraction preserving as much periodontal ligament (PDL) as possible, as it is imperative for tooth integration at the recipient site.[] Once removed, donor tooth is stored in its original socket until further adjustment of recipient socket are performed. A donor tooth should be handled as little as possible with a minimal delay between extraction and transplantation in order to ensure periodontal membrane vitality.\nAfter transplanted tooth is in its final position, it is stabilized with a criss-cross suture and it is fixed to adjacent teeth with light polymerizing resin and wire splint in slight infra-occlusion. A proper vertical position of the tooth is essential to allow it to erupt and fit into occlusion over the next few months. The transplanted tooth should not contact with opposing teeth during 1st month until it acquires physiological mobility. When donor tooth is positioned in occlusal level during operation (due to root full length development) a temporal bite raise using light cured resin on neighboring teeth is needed to secure transplanted tooth immobility.\nAfter operation, antibiotics (amoxicillinum 0.5 × 3/day), analgesia and anti-inflammatory drugs (nimesulidum 0.1 × 1/day) as well as soft food diet and hygiene recommendations are prescribed. First follow-up is carried out in 2 weeks for suture removal and in 4 weeks splint removal, periodontal probing, marginal gingiva and tooth mobility assessment was done. Tooth mobility was classified as grade I — slightly more than normal, grade II — moderately more than normal, grade III — severe mobility facio-lingually and mesio-distally combined with vertical displacement.[] Radiographic examination is done in 1, 3 and 6 months and additional sensitivity test to cold in 6 months post-operation.\nThe survival rate was 87% because two patients had lost their transplants. One failure occurred, 2 weeks after operation, due to loss of initial sutures that ensure tight gingival contact with a tooth, stability and prevent bacterial invasion into the blood clot between the tooth and socket. Another case was lost due to persisting infection in peri-apical tissue during transplantation resulting in fistula formation 1 month post-operation. Other 12 transplants showed moderately more than normal (grade II) tooth mobility 1 month post-operation with the surrounding gingiva similar to that of the adjacent teeth and normal probing depth; therefore, the splints were removed. Whereas, in one case tooth mobility was grade II-III with a slightly deeper pocket (5 mm) buccally during this follow-up. This tooth was left splinted for two more weeks. At 3 months post-operation, radiographic examination showed normal healing of recipient alveolus without tooth resorption signs in all 12 cases. 6 months after transplantation, all transplants were slightly more mobile than normal (grade I). On radiographs, a physiological periodontal space around the transplanted teeth and continuous root development was present. Tooth sensitivity to cold was similar to neighboring teeth. In 9 months follow-up, patients had no discomfort or any complaints about their transplants. Objectively, teeth that were positioned in occlusal level during operation (with root development ¾ or full length []) were fully functional with correct contacts when checked with marking paper in 1 month post-operation after splint and temporal bite-raise on neighboring teeth were removed. Teeth that were positioned in slight infra-occlusion during operation had minimal contacts with opposing tooth in 3 and fully contacted in 6 months post-operation [Figures –]. Transplants that were deeply positioned in the recipient site due to incomplete root development (½ of full root length) were still bellow occlusal line in 9 months post-operation, but with the presence of continuing root development [].
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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.
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A 49-year-old man was admitted with a complaint of dry cough over the last two weeks, and pulmonary nodules were incidentally found on his chest radiography () at our outpatient department. Due to the pulmonary nodules of unknown cause, CT of the chest was arranged. Multiple well-defined nodules (number: more than 10) were observed in both lungs (). Each nodule differed in size, ranging from 4 mm to 12 mm; moreover, the nodules were randomly distributed in every lobe, accompanied by minimal pleural effusions.\nThe patient denied being easily fatigued or having night sweats or rapid weight loss. No recent travel history was noted. The physical examination and all the laboratory tests presented no remarkable findings. We initially considered the nodules to have arisen from hematogeneous metastases. However, tumor markers, such as carcinoembryonic antigen, squamous cell carcinoma antigen, and prostate-specific antigen were all detected to be in the normal range. The gastroscopy and colonoscopy also showed within normal findings. After failing to find any possible primary malignancy, we arranged a whole body 18F-fluorodeoxyglucose (FDG) PET scan to evaluate the possible primary malignancy. The whole body FDG PET scan revealed no abnormal FDG uptake (). Our preoperative diagnosis of hematogeneous lung metastases was based on the presence of multiple pulmonary nodules of varying sizes, which distributed randomly throughout the lung; however, the findings of the whole-body FDG PET scan indicated that the nodules were possibly benign.\nTwo nodules each from the right middle and lower lobe were surgically removed; Histopathology revealed a fibrotic nodule with mild peripheral granulomatous inflammation and many cryptococcal spores () within the central necrotic area (). No evidence of malignancy was noted.\nAfter diagnosing pulmonary cryptococcosis, a series of examinations were performed for greater detail, such as immunoglobulin levels, HIV by enzyme-linked immunosorbent assay, serum and cerebrospinal fluid cryptococcal antigens, but tested negative. The patient was then administered intravenous fluconazole, shifting to oral drugs 400 mg per day, for three months, after discharge. The nodules remain stable in size and number, during a one year follow up.
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A 35 year old Chinese man experienced severe generalized headache over a couple of days. The headache was throbbing in nature and maximum in the posterior parietal regions. In addition, he also complained of double vision, neck pain and dizziness; however, denied having nausea or vomiting. The headaches were aggravated when he assumed an upright posture (sitting or standing) and alleviated when lying down. He did not have preceding history of strenuous physical activities such as heavy weight lifting, trauma or a lumbar puncture procedure. Neurological examination revealed bilateral mild restriction of lateral gaze (likely due to VI nerve involvement), which resulted in binocular diplopia on extreme horizontal gaze. His brain computed tomography with contrast was normal. MRI brain showed prominence of cortical veins and significant distension of dural venous sinuses raising the possibility of pachymeningitis without venous sinus thrombosis [Figure ,]. In addition, cervical spine MRI revealed engorged anterior epidural venous plexus at cranio cervical junction and upper cervical spine, with mild effacement of the subarachnoid space, raising the possibility of spontaneous intracranial hypotension secondary to cerebrospinal fluid (CSF) leak; however, no nerve root diverticula was noted. Repeated lumbar puncture (LP) failed to extract any CSF. Subsequently, LP under fluoroscopic guidance confirmed a low CSF pressure (5 cm of water). The routine CSF investigations for infective and inflammatory markers were all negative.\nHe was treated conservatively with strict bed rest, adequate hydration and analgesia. A radionuclide cisternography showed CSF leak at the junction of cervical 5 and cervical 6 (C6/ C7) vertebrae []. Treatment options including targeted epidural blood patch (EBP) were discussed; however, the patient opted for conservative management. He was discharged after a week. We had advised him to rest at home for another 2 weeks; however, he resumed normal activities on the very next day. Three days later, he presented again with severe headaches and worsening of diplopia. A repeat MRI brain showed bilateral subdural hematoma (SDH) []. Once again options of treatment were discussed with the patient and he decided for conservative management. He was continued on intravenous hydration, tablet caffeine and strict bed rest. After 2 weeks his headaches resolved completely and he was discharged well. He had further rest at home and resumed his routine duties 6 weeks after hospital discharge. He remained well and a follow-up CT scan done 3 months after discharge showed complete resolution of SDH. There has been no recurrence of symptoms since the last 14 months of follow-ups.
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Case #1 - Twelve-year-old Caucasian boy sustained a traumatic dog bite to the right elbow by a large stray dog and was brought to an outside hospital. X-rays were performed and reported no fracture, dislocation, or intra-articular air ().\nThe elbow wounds were irrigated with normal saline and bathed in a normal saline/betadine mixed solution for 15 min at this outside facility. The patient was given Augmentin as well as rabies immunoglobulin and vaccine due to the unknown canine vaccination history. He was then transferred to our tertiary children’s hospital for further orthopedic surgery evaluation. Evaluation in the emergency department revealed five 1 cm or smaller lacerations over the lateral elbow and another 1 cm laceration to the volar and proximal forearm, just distal to the antecubital fossa ().\nThe patient had near full range of motion, falling about 10 degrees shy of full extension and 10 degrees short of full supination, limited by pain. He was also found to be grossly neurovascularly intact of the median, radial, and ulnar nerves to motor and sensation with strong radial and ulnar pulses. A SLT was performed through the posterior arthroscopic portal site into the olecranon fossa []. Fluid was seen extravasating from the lateral elbow wounds once 20cc of normal saline was injected into the joint, thus a positive test. He was admitted overnight for continued antibiotics (Augmentin 875–125 mg every 8 h) and surgical arthroscopic irrigation and debridement the next morning. For the procedure, the patient was positioned supine with the elbow across the chest. The posterior arthroscopic portal was established as well as the anterolateral arthroscopic portal with 2.7 mm cannulas []. Three liters of normal saline irrigation were run through the joint and all the wounds with gentle curettage debridement. The wounds were then loosely closed, and a sterile dressing with a long arm splint was applied without a drain to allow soft tissue rest. He was discharged with Augmentin 400/57mg/5 mL BID prophylactically for 7 days. The patient followed up in the office 1-week and 4-week post-operatively. He was without any erythema, drainage, or signs of infection; however, mild elbow stiffness in extension had improved.\nCase #2 - Seven-year-old African American boy was in a bicycle accident and sustained a large laceration over the proximal ulna/posterior elbow. Evaluation in the emergency department revealed an approximately 15 by 4 cm “U” like laceration with a large flap over the posterior elbow/proximal ulna ().\nSubcutaneous tissue, muscle, and triceps tendon were visualized, however, no obvious joint capsule violation. The patient had near full range of motion, about 10 degrees shy of full flexion and extension limited by pain. He was grossly neurovascularly intact of the median, radial, and ulnar nerves to motor and sensation with strong radial and ulnar pulses. X-ray revealed posterior elbow soft tissue injury and no intra-articular air ().\nA small bony fragment was displaced from the posterior aspect of the proximal ulna. A SLT was performed through the anterolateral “soft spot” arthroscopic portal site4, and fluid was seen extravasating from the wound after 30cc of normal saline was injected ().\nHe was admitted overnight for continued antibiotics (IV Ancef 40 mg/mL every 8 h) and surgical arthroscopic irrigation and debridement the next morning. For the procedure, the patient was positioned supine with the elbow across the chest. The posterior arthroscopic portal was established as well as the anterolateral arthroscopic portal with 2.7 mm cannulas []. Three liters of normal saline irrigation were run through the joint and the wound with gentle curettage debridement. The small bony fragment was deemed non-viable and excised. The wound was then loosely closed, and a sterile dressing with a long arm splint was applied without a drain to allow soft tissue rest. He was discharged home with Cephalexin 500 mg BID prophylactically for 7 days. The patient followed up in the office 1-week and 4-week post-operatively without any erythema, drainage, or signs of infection and had near full elbow range of motion.
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A 53-year-old Hispanic man with past medical history significant for coronary artery disease, habitual intravenous heroin abuse, chronic untreated hepatitis C without cirrhosis, bipolar disorder, tobacco abuse of 80 pack-year, and degenerative disc disease presented from home to our hospital with chief complaint of left scrotal pain, diffuse abdominal pain, back pain, and chest pain. Four days prior to presentation, he was seen in the emergency department for chronic back pain and was discharged with naproxen and instruction to follow up with his primary care physician. Since then, he developed acute onset of sharp constant pain of his left testicle and his abdomen. He admitted to using ten bags of heroin intravenously daily. He underwent an incision and drainage one month prior for a skin abscess. He reported no new sexual partner and is only sexually active with his current girlfriend. Family history was significant for heart disease in both his parents and maternal grandparents. His vital signs on admission were within the normal range. Physical exam revealed a man, with cachexia and temporal muscle wasting, in moderate distress from pain. He had jaundice with icteric sclera. His lungs were clear to auscultation. His heart sounds had regular rate and rhythm without any audible murmur. He had a soft abdomen that was mildly distended and tender in all four quadrants. His genitourinary exam was significant for bilateral scrotal erythema and swelling, which was worse on the left and was tender to light touch. He had diffuse tenderness to his back including paraspinal muscles, but no tenderness to the spinal processes. He was alert and oriented to person, time, and place and could answer questions appropriately. He had no facial asymmetry or deviated tongue, and he displayed normal proximal and distal strength. Laboratory findings were significant for WBC of 12.1 K/mm3 with a neutrophil predominance of 90%, microcytic anemia with hemoglobin 7.7 g/dL and MCV 75.6 fL, and thrombocytopenia of 47 K/mm3. His direct bilirubin level was elevated (3.0 mg/dL), as were his alkaline phosphatase (282 U/L), AST (87 U/L), ALT (33 U/L), and LDH (393 U/L). His albumin was 1.7 g/dL and lactic acid was normal at 1.2 mmol/L. His HIV-screening test was negative, as were his gonorrhea and chlamydia molecular amplification tests. He was subsequently admitted to internal medicine service/floor for further management.\nHis initial work up included a urinalysis that was significant for 10–20 RBC per HPF, 5–10 WBC per HPF, and positive urine nitrite; an EKG that showed normal sinus rhythm; and a chest X-ray which was negative for cardiomegaly, pleural effusions, or lung consolidations. A computed tomography (CT) of his head did not show any intracranial abnormalities. A CT of his abdomen and pelvis without contrast was performed which revealed hepatosplenomegaly with multiple large wedge-shaped areas of hypoperfusion in the spleen, concerning splenic infarctions (). The scrotal ultrasound showed no torsions, but revealed left epididymo-orchitis, large complex left scrotal hydrocele, and bilateral testicular microlithiasis. A limited bedside transthoracic echocardiogram by the emergency department physicians revealed a small pericardial effusion with no observable valvular vegetations. Blood and urine cultures were collected, and he was initially started on the broad-spectrum antibiotics of vancomycin, piperacillin-tazobactam, and azithromycin considering his risk factors and clinical presentation.\nOvernight, he remained afebrile, but his leukocytosis worsened to 14.6 K/mm3, and he developed dyspnea and tachypnea with 24 breaths per minute. He became disoriented and was not answering questions appropriately. On exam, new findings of splinter hemorrhages, toe infarctions, and subconjunctival hemorrhaging were noted. Urine culture grew Serratia marcescens 50,000–100,000 CFU. Blood cultures also later grew the same organism, susceptible to all tested antibiotics including amikacin, aztreonam, cefepime, ceftriaxone, ciprofloxacin, gentamicin, ertapenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole. On hospital day 2, a formal transthoracic echocardiogram (TTE) revealed an ejection fraction of 60% (unchanged from three years prior) with a large echodensity on the aortic valve consistent with vegetation. Mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation were also noted. Antibiotics were subsequently changed toertapenem 1 g daily and ciprofloxacin 750 mg twice daily in consultation with infectious disease.\nThe patient continued to deteriorate the following day. He became more disoriented and agitated. He remained afebrile, but his tachypnea worsened to 30 breaths per minute, and new rales were now audible on lung auscultation. An arterial blood gas (pH 7.51; pCO2 21 mmHg; pO2 70 mmHg; HCO3 16 mmol/L; O2 saturation 93%) showed a respiratory alkalosis. A repeat chest X-ray showed new interstitial pulmonary edema and vascular congestion. A CT of the head without contrast was performed due to his altered mental status, which showed two areas concerning embolic infarcts in the left parietal lobe and the left cerebellum (), compared to the one obtained on admission. On hospital day 4, an urgent transesophageal echocardiogram (TEE) was performed which again demonstrated the large aortic valve vegetations (), but it now demonstrated acutely deteriorating moderate to severe aortic regurgitation, which was different from the TTE findings a few days prior that only showed mild-moderate aortic insufficiency. In addition, it also revealed a mildly dilated left ventricle. The aortic valve leaflet had prolapsed motion. Due to the presence of large aortic valve vegetations, multiple embolic phenomena, and a progressively worsening of his clinical condition, decision was made to perform an urgent aortic valve replacement.\nPostoperatively, he was managed in the surgical intensive care unit, where he developed a moderate-sized left pneumothorax requiring a chest tube placement. Slowly, his mental and clinical status began to improve. By hospital day 19, the patient was no longer agitated or disoriented. He displayed good appetite, and his chest tube was removed. His leukocytosis significantly improved to 8.0 K/mm3, and his repeat blood cultures did not grow any organisms for 5 days. Throughout his hospital course, he remained afebrile and did not receive any antipyretics. The lack of fever was concerning for an immunocompromised state, but he tested negative for HIV. He was ultimately discharged to a skilled nursing facility to complete his antibiotics, ertapenem 1 g daily with ciprofloxacin 750 mg twice daily, for a total course of 6 weeks, and to continue physical therapy.
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A 36 year-old man presented to the local hospital with the chief complaint of abdominal pain and "something protruded from the rectum." He had a two-month history of diarrhoea but now had constipation for the past 2 weeks. The prolapse happened that afternoon when he was straining to defecate. Physical examination was unremarkable except for a 15 cm × 15 cm, firm, immobile, non-tender mass in the left lower quadrant of the abdomen. On rectal examination, the prolapsed was an irregular soft mass non-contiguous with the anus. An immediate surgical reduction for prolapse was performed; however, it did not relieve the abdominal pain. A subsequent barium enema (Fig ) and a colonoscopy (not shown) revealed that the sigmoid colon was filled with a swollen intestine-like irregular mass and a separate large oval mass of about 12 cm in diameter, which prevented further visualization of the transverse or ascending colon. The patient was transferred to Peking Union Medical College Hospital for further evaluation and treatment.\nUpon admission, the patient still suffered from abdominal pain without symptoms of fever, tachycardia, nausea or vomiting. The abdominal plain film showed a mass with clear border on the left upper quarter (Fig ). An exploratory laparotomy was performed. When we firstly open the greater omentum, we were astonished by what we saw – a firm oval mass about 15 cm × 12 cm located beneath the spleen instead of transverse colon (Fig ). To figure out what the mass is, we decided to trace along the duodena, the jejunum to the distal end of the intestine, however, no ileocecal junction could be identified and the ileum and the sigmoid colon were connected by the mass. A diagnosis of extensive colonic intussusception was established. The intussusception was unable to be completely reduced by manual reduction, and a subtotal colectomy was performed.\nThe pathological examination demonstrated a 9 cm × 6 cm × 5 cm submucosal lipoma at the ileocecal junction without evidence of malignancy. The patient's post-surgical course was uneventful.\nWeight: 65 kg, Height: 172 cm, no smoking, drink alcohol occasionally for business stuffs. Family history: multiple lipoma of his father and brother.
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A 24-year-old female with Rett syndrome developed recurrent unilateral neck abscesses over a 6-month period.\nRett syndrome is a severe neurodevelopmental disorder characterized by the progressive loss of intellectual functioning, fine and gross motor skills and communicative abilities, deceleration of head growth and the development of stereotypic hand movements, occurring after a period of normal development [].\nAt initial consult, a 2 cm abcess overlying the left mastoid tip and a bony swelling arising from the EAC with overlying normal skin (Fig. ) obstructing the view of the left ear canal and tympanic membrane was noted. Following incision and drainage of the abscess in theatre, the patient returned 2 weeks later with a self-draining left neck wound. As she was otherwise systemically well, the patient was treated as an outpatient with a course of oral antibiotics and listed for excision of the EAC osteoma and exploration of her left mastoid cavity. Due to the patient's global learning disabilities, audiological assessment and imaging of her ears were only possible under general anaesthesia. A combined decision was taken to proceed to surgical exploration, as it was felt that these adjunctive tests will not impact on her immediate management and would subject the patient to an additional anaesthetic challenge.\nAt surgery, transmeatal exicision of the EAC osteoma revealed an underlying cholesteatoma that has caused bony erosion of the inferior canal wall (Fig. ) and formed a fistulous connection to the overlying neck skin (Fig. ). The post-aural sinus and fistula were excised through a post-auricular incision. A cortical mastoidectomy was performed to explore the mastoid cavity, which was found to be disease free. The temporalis fascia was harvested and used to reconstruct the inferior canal wall defect. Histopathologic examination of the excised tissues confirmed the synchronous dual pathology involving the EAC (Figs and ).\nThe patient's symptoms settled after surgery and the neck abscess healed completely. There was no clinically detectable neck disease or cholesteatoma formation in the left ear canal at her 12-month clinic review.
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48 y.o. male who was in good health until 5 days prior to the admission to Nishijima Hospital when severe pain and skin rash involving his left side of the face made him to visit an emergency service where he was diagnosed as having herpes simplex infection and was treated with antivirus agents and pain medications. However, the pain increased and the left side of the face became numb. In addition, blisters in the erythematous area coalesced and formed ulcer-like appearance. The patient also noticed left ptosis and double vision and became unable to open the mouth, which made oral intake impossible. The patient was admitted to the hospital for deteriorated general condition with dehydration, severe pain and fever. On admission, the patient was found to have partial paralysis of the left 3 rd, 5th and 6th cranial nerves in addition to severe erythema with edema and small ulcers, covering the left side of the face and frontal region. The hydration treatment was initiated with 3 bags of 500 ml glucose and electrolyte solution and continued for 6 days with a decreasing dose during the hospitalization. Initially, two bags of these solutions (500 ml) had been enriched with H2. No antibiotic was given. Before the infusion therapy, the patient was unable to open his left eye and the mouth (Figure , upper left). The picture of Figure upper right was taken after the patient was asked to open his left eye and the mouth. The patient was unable to do so, except for minimal opening of the mouth. However, 3 days after the admission and H2 infusion, the patient’s condition remarkably improved, including erythema, ulcers, pain level, opening the eye and mouth (Figure , lower left) and the patient became afebrile. Since cranial nerve functions recovered also and he became able to take oral soft nutrients, intravenous hydration was decreased to 2 bags of H2- enriched glucose-electrolyte solution (esuron B,200 ml/bag), daily. By the 6th hospital day, the patient was eating a regular food and his dehydration was corrected. He had no pain and the severe inflammation of the skin disappeared. The patient discharged home and no return of the skin erythema noted during a follow-up period (Figure , lower right).
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A 53-year-old Hispanic man with past medical history significant for coronary artery disease, habitual intravenous heroin abuse, chronic untreated hepatitis C without cirrhosis, bipolar disorder, tobacco abuse of 80 pack-year, and degenerative disc disease presented from home to our hospital with chief complaint of left scrotal pain, diffuse abdominal pain, back pain, and chest pain. Four days prior to presentation, he was seen in the emergency department for chronic back pain and was discharged with naproxen and instruction to follow up with his primary care physician. Since then, he developed acute onset of sharp constant pain of his left testicle and his abdomen. He admitted to using ten bags of heroin intravenously daily. He underwent an incision and drainage one month prior for a skin abscess. He reported no new sexual partner and is only sexually active with his current girlfriend. Family history was significant for heart disease in both his parents and maternal grandparents. His vital signs on admission were within the normal range. Physical exam revealed a man, with cachexia and temporal muscle wasting, in moderate distress from pain. He had jaundice with icteric sclera. His lungs were clear to auscultation. His heart sounds had regular rate and rhythm without any audible murmur. He had a soft abdomen that was mildly distended and tender in all four quadrants. His genitourinary exam was significant for bilateral scrotal erythema and swelling, which was worse on the left and was tender to light touch. He had diffuse tenderness to his back including paraspinal muscles, but no tenderness to the spinal processes. He was alert and oriented to person, time, and place and could answer questions appropriately. He had no facial asymmetry or deviated tongue, and he displayed normal proximal and distal strength. Laboratory findings were significant for WBC of 12.1 K/mm3 with a neutrophil predominance of 90%, microcytic anemia with hemoglobin 7.7 g/dL and MCV 75.6 fL, and thrombocytopenia of 47 K/mm3. His direct bilirubin level was elevated (3.0 mg/dL), as were his alkaline phosphatase (282 U/L), AST (87 U/L), ALT (33 U/L), and LDH (393 U/L). His albumin was 1.7 g/dL and lactic acid was normal at 1.2 mmol/L. His HIV-screening test was negative, as were his gonorrhea and chlamydia molecular amplification tests. He was subsequently admitted to internal medicine service/floor for further management.\nHis initial work up included a urinalysis that was significant for 10–20 RBC per HPF, 5–10 WBC per HPF, and positive urine nitrite; an EKG that showed normal sinus rhythm; and a chest X-ray which was negative for cardiomegaly, pleural effusions, or lung consolidations. A computed tomography (CT) of his head did not show any intracranial abnormalities. A CT of his abdomen and pelvis without contrast was performed which revealed hepatosplenomegaly with multiple large wedge-shaped areas of hypoperfusion in the spleen, concerning splenic infarctions (). The scrotal ultrasound showed no torsions, but revealed left epididymo-orchitis, large complex left scrotal hydrocele, and bilateral testicular microlithiasis. A limited bedside transthoracic echocardiogram by the emergency department physicians revealed a small pericardial effusion with no observable valvular vegetations. Blood and urine cultures were collected, and he was initially started on the broad-spectrum antibiotics of vancomycin, piperacillin-tazobactam, and azithromycin considering his risk factors and clinical presentation.\nOvernight, he remained afebrile, but his leukocytosis worsened to 14.6 K/mm3, and he developed dyspnea and tachypnea with 24 breaths per minute. He became disoriented and was not answering questions appropriately. On exam, new findings of splinter hemorrhages, toe infarctions, and subconjunctival hemorrhaging were noted. Urine culture grew Serratia marcescens 50,000–100,000 CFU. Blood cultures also later grew the same organism, susceptible to all tested antibiotics including amikacin, aztreonam, cefepime, ceftriaxone, ciprofloxacin, gentamicin, ertapenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole. On hospital day 2, a formal transthoracic echocardiogram (TTE) revealed an ejection fraction of 60% (unchanged from three years prior) with a large echodensity on the aortic valve consistent with vegetation. Mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation were also noted. Antibiotics were subsequently changed toertapenem 1 g daily and ciprofloxacin 750 mg twice daily in consultation with infectious disease.\nThe patient continued to deteriorate the following day. He became more disoriented and agitated. He remained afebrile, but his tachypnea worsened to 30 breaths per minute, and new rales were now audible on lung auscultation. An arterial blood gas (pH 7.51; pCO2 21 mmHg; pO2 70 mmHg; HCO3 16 mmol/L; O2 saturation 93%) showed a respiratory alkalosis. A repeat chest X-ray showed new interstitial pulmonary edema and vascular congestion. A CT of the head without contrast was performed due to his altered mental status, which showed two areas concerning embolic infarcts in the left parietal lobe and the left cerebellum (), compared to the one obtained on admission. On hospital day 4, an urgent transesophageal echocardiogram (TEE) was performed which again demonstrated the large aortic valve vegetations (), but it now demonstrated acutely deteriorating moderate to severe aortic regurgitation, which was different from the TTE findings a few days prior that only showed mild-moderate aortic insufficiency. In addition, it also revealed a mildly dilated left ventricle. The aortic valve leaflet had prolapsed motion. Due to the presence of large aortic valve vegetations, multiple embolic phenomena, and a progressively worsening of his clinical condition, decision was made to perform an urgent aortic valve replacement.\nPostoperatively, he was managed in the surgical intensive care unit, where he developed a moderate-sized left pneumothorax requiring a chest tube placement. Slowly, his mental and clinical status began to improve. By hospital day 19, the patient was no longer agitated or disoriented. He displayed good appetite, and his chest tube was removed. His leukocytosis significantly improved to 8.0 K/mm3, and his repeat blood cultures did not grow any organisms for 5 days. Throughout his hospital course, he remained afebrile and did not receive any antipyretics. The lack of fever was concerning for an immunocompromised state, but he tested negative for HIV. He was ultimately discharged to a skilled nursing facility to complete his antibiotics, ertapenem 1 g daily with ciprofloxacin 750 mg twice daily, for a total course of 6 weeks, and to continue physical therapy.
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A 36-year-old woman gravida 10 para 7 abortus 2 at 36 + 5 weeks of gestational age, presented for two consecutive days complaining of an increasing new onset of acute left upper quadrant pain. The pain was constant with intermittent worsening in her left upper quadrant and radiating to her left flank. During this gestation, she reported a previous presentation for abdominal pain with nausea lasting for 1 week. Those symptoms were associated with gastritis because no other cause was found.\nThe patient initially presented to the hospital for an increasing pain that was believed to be due to fetal movements or uterine contractions. She was given antispasmodics. However, the pain intensified which was the reason for her to seek medical advice again. She did not complain of any nausea or vomiting, nor decrease in appetite but she had 2 days of constipation. The patient’s medical history was unremarkable. Her obstetrical history included two spontaneous pregnancy losses that needed dilation and curettage at first trimester. She also had previous seven uncomplicated vaginal deliveries.\nOn presentation to the hospital, her blood pressure was 110/70 mmHg, her pulse was 84 beats per min, temperature was 36.9°C, saturation of O2 was 100%, respiratory rate was 20.\nOn physical examination, the patient appeared uncomfortable and agitated.\nHer abdomen was soft; the uterus was gravid with no fundal tenderness. Bowel sounds were present and normal. There was moderate tenderness on the left upper quadrant under the rib cage with mild rebound. She also had costovertebral angle tenderness on the left side. The patient was admitted to the delivery suite and initially was started on intravenous fluid hydration, proton pump inhibitor and analgesia. This provided minimal relief to the patient. Nonstress test monitoring was done at this time also showing reassuring reactivity of the fetal heart rate with no contractions.\nSeveral differential diagnoses are to be noted: renal colic, mesenteric infarction, splenic vein thrombosis, pregnancy associated pain, pancreatitis and spleen associated pain.\nA complete set of laboratory tests were done and were unremarkable except for microcytic anemia hemoglobin was 8.9 g/dl and hematocrit was 29%. She had normal liver enzymes, pancreatic enzymes and creatinine.\nAn abdominopelvic ultrasound was performed which showed oligohydramnios and sludge in the gallbladder. The appendix was not visualized, no gallstones, no biliary ducts dilation, no hydronephrosis. Doppler of the splenic vessels was not done, although splenic vein thrombosis was one of the differential diagnoses.\nAt this time induction of labor was decided due to oligohydramnios. The patient delivered a live born boy APGAR score 9 and 10 at 1 and 5 min weighing 3040 grams.\nIn postpartum period, the pain persisted and; therefore, surgical consultation recommended CT scan of the abdomen with contrast to rule out pancreatitis and splenic vein thrombosis. Subsequently the CT scan revealed left adrenal gland with decreased enhancement and adjacent inflammatory changes suggestive of an infarct. Right adrenal gland was normal. Normal appearing appendix, no anomalous vasculature was seen and MRI study was unlikely to add any more information; therefore, was not done.\nCortisol level and adrenocoticotropic hormone level were obtained to assess for adrenal insufficiency. The hemato-oncologist was consulted to workup the thrombophilia disorders that included testing for factor V Leiden, prothrombin mutation and MTHFR as well as antiphospholipid panel, protein C and S, antithrombin 3, factor II, factor XIII, plasminogen activator inhibitor-1 mutation and annexin A5 antibodies.\nThere was no adrenal insufficiency and thrombophilia workup showed MTHFR C677T homozygous mutation and HPA1 1a/1b heterozygous mutation. The results of workup of coagulopathies, adrenal insufficiency as well as thrombophilia disorders are shown in ( & ), respectively.\nAnticoagulation with low molecular weight heparin (LMWH) 40 mg subcutaneously (sc.) once daily was initiated to reduce the risk of another infarct in the contralateral adrenal gland. After 2 days, she was started on therapeutic dose LMWH 60 mg sc. for 1 week.\nAfter 4 days the patient was discharged home for outpatient postpartum care on prophylactic LMWH for 6 months. ( & ).\nDuring the 6 months follow-up, the patient did not have any complaints and was clinically and hemodynamically stable. She had to continue iron supplements because of her iron deficiency anemia. A timeline can be seen in .
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A 62-year-old male presented with a history of shortness of breath for one year, with his condition worsening over the past two to three months. Initially, he was able to walk three to four miles a day but has been able to walk only half to one mile over the last year. He gave a remote two-year history of cigarette smoking half a pack per day about 25 - 30 years ago. He was admitted to the hospital with similar complaints three months prior to his presentation. A computed tomography angiogram (CTA) of the chest done at that time showed no pulmonary embolism and no consolidation/parenchymal changes. An echocardiogram demonstrated an ejection fraction of 55% with a normal right ventricle and no valvular abnormality. The viral panel was positive for rhinovirus and he was deemed to have dyspnea because of the rhinovirus infection. On discharge, he was comfortable on room air with no active complaints, although he felt he was not back to his baseline exercise capacity.\nSometime later, the patient went to his primary care physician for persistent shortness of breath. To rule out coronary ischemia, a left heart catheterization was performed which showed normal coronary arteries.\nThe patient then presented to the pulmonary clinic with hypoxemia. Even with supplemental oxygen, the hypoxemia persisted. However, when asked to lay flat, his oxygen saturation improved to 95%. The patient’s previous CTA was reviewed and no abnormalities were seen. He was advised to go to the hospital emergency room (ER) for admission.\nThe patient was initially placed on a 3 liters (L)/minute nasal cannula without improvement in oxygen saturation. He was subsequently placed on a non-rebreather mask and his saturation improved to 98%.\nA complete blood count and comprehensive metabolic panel were normal. Arterial blood gas analysis performed on the non-rebreather mask showed a high alveolar-arterial gradient. A CTA was repeated to evaluate a pulmonary cause of platypnea-orthodeoxia syndrome. No pulmonary abnormality was detected.\nAn echocardiogram was performed which showed an atrial septal defect (ASD) on a bubble study and was confirmed on a transesophageal echocardiogram with right-to-left shunting (Figure ). The patient was transferred to another facility, where the closure of the ASD was done. On follow-up appointments, the orthodeoxia and platypnea had both resolved.
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A 10-year-old overweight Hispanic female (BMI > 28) complaining of abdominal pain for 2 days was brought to our emergency department (ED) by her mother. The pain reportedly started in the periumbilical area and later localized to the right lower quadrant. She also reported left lower quadrant pain, anorexia, and nausea but denied vomiting. She had no fever. Upon arrival to the emergency department, her vital signs were within normal limits for her age, but physical exam revealed generalized lower abdominal tenderness with rebound and guarding.\nHer laboratory investigation was positive for elevated white cell count of 12.10 per microliter of blood with a left shift. The rest of her laboratory results were within normal limits. Abdominal and pelvic CT scan were done which showed hyperemic appendix and hazy anterior mesentery and a small amount of free fluid (Figures –).\nBased on the history, physical exam, and CT scan findings, a diagnosis of acute appendicitis was made and the patient was taken to the operating room for laparoscopic appendectomy. Intraoperatively, a tortuous retrocecal appendix with free fluid was found, and appendectomy was performed without any complications. After performing the appendectomy, the omentum was noted to be adherent to the anterior abdominal wall and on careful examination, it was noted to be hemorrhagic and necrotic as shown in Figures and . The necrotic omentum was resected and sent for histopathological examination. Although the infarcted omentum was mostly in the midline anterior abdominal wall, we did not have the necessity to place additional ports and were able to successfully resect the omentum with standard laparoscopic appendectomy port placements (umbilical port, left iliac fossa port, and suprapubic port). The patient had an uneventful postoperative course and was discharged on the second operative day.\nHistopathological exam of the appendix revealed focal superficial acute mucositis and recent hemorrhage suggesting early acute appendicitis. Examination of the omental mass showed fragments of adipose tissue with hemorrhage, fat necrosis, and granulation tissue formation consistent with omental infarction (Figures –).
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We present a case of an 85-year-old female with a past medical history of right breast cancer status post mastectomy, hypothyroidism status post thyroid removal, hypertension, hyperlipidemia, and paroxysmal atrial fibrillation who presented to our hospital with a chief complain of shortness of breath and pinpoint left-sided chest pain.\nOn the physical exam, the patient was not in any acute distress. She complained of some mild difficulty breathing; however, no accessory muscle usage noted. Lungs were clear to auscultation bilaterally. The respiratory rate was 18 breaths per minute. Three plus pitting edema was noted from the mid-leg shaft to the ankles bilaterally. In the emergency department, an electrocardiogram revealed normal sinus rhythm with occasional premature atrial contractions. Troponin was negative. The outpatient stress test from two weeks prior did not show any signs of ischemia. Computed tomography of the chest showed a filling defect in the left atrium concerning a mass versus thrombus. An immediate bedside contrast transthoracic echocardiogram was performed and confirmed a filling defect with a mass-like lesion adherent to the superior posterior wall, not obstructing the flow of the pulmonary vein. Given the above finding, the patient was scheduled for a transesophageal echocardiogram the following morning which showed a 4 cm multi-lobular echogenic mass with calcifications in the left atrium likely arising from the pulmonary vein suspicious for malignancy. The cardiovascular surgery department requested pan CT which was negative for metastatic malignancy. Due to the patient's co-morbidities, the cardiovascular surgery team recommended left heart catheterization prior to surgery as the patient may also require coronary artery bypass graft (CABG) alongside the excision of the mass. The patient underwent left heart catheterization, which reported no evidence of occlusive coronary artery disease. Cardiovascular surgery department scheduled the patient for surgical debulking/removal via a minimally invasive approach. The specimen was reported to be multi-lobular and was resected in several fragments of tan, fleshy, and somewhat gelatinous appearing tissue in aggregate (Figure ).\nHistopathology showed spindle cell malignant neoplasm with small foci of bone and cartilaginous formation, suggestive of osteosarcoma. Since this finding is an extremely rare case, the pathology was sent out for expert consultation at John Hopkins, which reported this to be a high-grade sarcoma with focal osteosarcomatous differentiation (Figures and 3).
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A 50-year-old female patient presented to our department with complaint of pain and mild swelling on the right side of the face since the last 2 months. She gave a history that pain is aggravated while opening the mouth, chewing and on application of pressure on that area and was not relieved by NSAIDs. Her past medical history revealed history of typhoid fever 3 months back for which she had taken complete course of treatment.\nOn extraoral examination, maximal mouth opening was reduced to around 28 mm and a diffuse swelling around 1 × 1 cms in diameter was also observed in the right temporalis muscle which was soft to firm in consistency and was tender on palpation (). Examination of the TMJ and other muscles of mastication revealed normal findings. On intraoral examination edentulous spaces were present involving the right and left mandibular posterior teeth.\nOn the basis of the history and examination findings, a clinical provisional diagnosis of myofascial pain was made and the patient was put on the treatment of muscle relaxants Tab Myospaz forte two times a day and topical application of voveran emuigel along with hot fomentation, soft diet, and bilateral chewing. The patient reported to us after 3 days but she did not have relief whatsoever. Reevaluation of the case was done and she was advised of blood investigations along with ultrasonogram (USG) and MRI involving the right side of the face. The findings of the blood investigations were normal. USG showed the presence of a well-defined anechoic lesion around 1.2 × 1 × 0.9 cms involving the right temporalis muscle with its long axis parallel to its fibres and 14 × 12 mm echogenic nidus was also seen within it (). MRI revealed the presence of a rounded iso to mildly hyperintense lesion in the right temporalis muscle with an identifiable hypointense nidus on T1 and T2 and Fiesta-C images (). The lesion also displayed T1 and T2 hypointense rim along with edema involving the right temporalis muscle. The features on both USG and MRI were suggestive of cysticercosis involving the right temporalis muscle.\nFor the treatment the patient was advised of anthelmintic albendazole 400 mg BD AND Crocin SOS for 4 weeks. Four-week follow-up of the patient showed significant reduction in the pain and the size of the swelling. Mild swelling stiltreatment was continued for another 5 days. USG examination after 4 weeks and 5 days showed coml persisted so the plete resolution of the lesion with no focal lesion identifiable in the right temporalis muscle (). The swelling and pain had also subsided completely ().
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A 32 year old woman, initially presented at the age of 27 with stage 3 malignant melanoma. The patient underwent wide local excision of a 1.76 mm Breslow thickness melanoma from the right thigh and shortly afterwards was found to have a mass in the right groin. She underwent right inguinal block dissection, with 2 of 6 lymph nodes positive for melanoma. CT scan showed no evidence of other disease sites. The patient had adjuvant high dose interferon (20 MU/m2/d IV 5 days/wk × 4 weeks followed by 10 MU/m2 SC thrice weekly × 48 weeks) which was discontinued after nearly 7 months due to persistent neutropenia.\nWhen aged 31 and 19 weeks pregnant, the patient noticed a mass beneath her jaw consistent with right submandibular lymph gland enlargement and had exertional dypsnoea. A CT scan revealed a pericardial effusion of 1 cm depth. A transthoracic echocardiogram showed a right atrial mass prolapsing through the tricuspid valve with good preservation of ventricular function.\nAn MRI scan of the heart confirmed the mass to be more extensive measuring 8 cm in size and extending into the superior vena cava (fig ). An echocardiogram guided biopsy of the mass (fig ) revealed necrotic tumour with associated thrombus and adjacent normal myocardium. The viable tumour was composed of moderately pleomorphic epitheliod melanocyes (S100/HMB45 positive) with enlarged pleomorphic nuclei and prominent nucleoli.\nThe patient was keen to continue with pregnancy and after careful consideration was commenced on palliative chemotherapy with dacarbazine (800 mg/m2 IV every 3 weeks). The decision was to deliver the baby early by elective Caesarean section at 34 weeks of gestation considering the risk of sudden cardiac death of the mother, which would likely be associated with fetal demise. After 2 cycles of dacarbazine, an echocardiogram showed that the atrial mass was smaller.\nHowever an emergency Caesarean section was performed at 31 weeks gestation because of ante-partum haemorrhage. The baby delivered weighed 1.5 kg with no significant problems in the neonatal period. Histological examination of the placental tissue showed unremarkable cord and membranes. The placental bed showed an early third trimester architecture with good villous development. Focally there were groups of viable epitheliod melanocytes, similar to the cardiac tissues with associated thrombus (fig ). Immunohistochemistry revealed S100, HMB45 and melan A positivity, consistent with melanoma. As there had been a response on the echocardiogram, we decided to proceed to 8 cycles of dacarbazine chemotherapy. Following this, an MRI scan of the heart showed less tumour bulk with a maximum dimension of less than 2 × 3 cm. Clinically the patient had no dyspnoea on exertion. The right mandibular lymph gland enlargement was persistent and a selective neck dissection was done. This showed central degeneration in one lymph node with a peripheral rim of fibroconnective tissue showing melanin deposition, representing a response to chemotherapy.\nDespite the metastatic nature of her disease, this patient remains well and is currently awaiting opinion for cardiac surgery. Her baby is now 10 months old and is free of disease.
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A 26-year-old woman at 11 weeks of gestation presented to the emergency department for evaluation of severe nausea, dizziness, and double vision. The physician who evaluated her in the emergency room referred her to our department with a tentative diagnosis of WE based on the early gestation, nausea, and dizziness. She had hyperemesis gravidarum since 6 weeks of gestation. She first noted double vision 4 days prior to the emergency room visit. On questioning, she admitted that the gait difficulties secondary to dizziness worsened slightly each day. Her double vision was now continuous, and objects appeared skewed. She reported that she was nauseated and found it difficult to tolerate the double vision. She reported no definite weakness but had considerable difficulty walking without assistance. She reported no paresthesias or sensory loss in her limbs, trunk, or face. She had an unremarkable medical history and she had not been hospitalized. Her family history was significant for maternal IgA nephropathy. The obstetric examination at the time of admission revealed an 11-week gestation and a single live fetus was detected in utero. On the general physical examination, she appeared uncomfortable, but not acutely ill. She tended to keep her eyes closed. She did not have a history of an upper respiratory or gastrointestinal tract infection. She was fully alert with a normal mental status examination. Her eyes had dysconjugate gaze, with markedly restricted abduction of the left eye, and modest restriction of movement of both eyes in all other directions. There was no nystagmus. There was no ptosis, and the pupils were equal and normally reactive. The degree of ocular misalignment did not appear to fluctuate. Facial strength and sensation were normal. The palate elevated normally, and the tongue appeared normal as well. Hearing was intact. The tone, bulk, and strength of her extremities were normal. Rapid alternating movements of the hands and feet were slow. She was imprecise when performing the knee-heel-shin maneuver. Vibratory and temperature perception were normal in her hands and feet, but proprioception was impaired. She could not walk or stand without assistance, despite appearing to have sufficient motor strength. Brain magnetic resonance imaging (MRI) revealed no areas of restricted diffusion or other signal abnormalities. A lumbar puncture demonstrated no remarkable findings. A needle electromyogram (EMG) of the left upper and lower extremity muscles was normal. Brainstem stroke was excluded by MRI. Myasthenia gravis was denied by lacking diurnal fluctuation of symptoms and easy fatigability.A diagnosis of MFS was suspected, and the patient was treated with supportive care. Several serologic studies were obtained, including a normal thyroid-stimulating hormone (TSH) level, a normal antinuclear antibody (ANA) titer, and a negative rapid plasma reagin (RPR). The anti-GQ1b antibody titer was markedly elevated. Additionally, the anti-GD1b and anti-GT1a antibody titers were elevated in this patient. Before establishing the diagnosis of MFS, thiamine was administered, but the response to thiamine was poor. She had ophthalmoplegia, ataxia, areflexia, and absence of limb weakness and hypersomnolence. After the diagnosis of MFS was established, we considered intravenous immunoglobulin (IVIG) or no treatment. Because the natural history of MFS is favorable, we recommended no treatment. At a follow-up visit approximately 6 weeks after symptom onset, she reported diplopia on left gaze and no gait unsteadiness. Her clinical course was monophasic with improvements not further than 8 weeks. Her antepartum course was otherwise unremarkable, and she delivered a healthy male at term, weighing 3520 g. The infant Apgar scores were 8 at 1 minute and 8 at 5 minutes. The umbilical arterial blood pH was 7.398. Seven months following symptom onset, she had returned to her baseline state of good health and was doing well. The deep tendon reflexes had returned to normal.
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A 58-year-old woman presented with acute memory disturbance and headache. During the afternoon of the day of presentation, she did not have any complaints while she was at work. After finishing work, she drove home. By the time she arrived at her home, she developed a headache and nausea. Her husband noticed that her memory was severely disturbed and called an ambulance.\nIn the emergency department, she complained of headache and nausea but denied any visual disturbances. Her blood pressure was 187/100 mmHg, and her pulse rate was 77 beats per min. The remainder of the physical examination was normal. Neurologically, she was alert and oriented with respect to place and person but disoriented with regard to time. She was unable to acquire new information and to recall the events that occurred during the same or previous day. She repeatedly asked the same questions. Her remote and working memories were intact, and she showed no loss of personal identity. Her speech and reasoning were intact. There was no visual field defect, and the other neurological examinations were normal.\nHer laboratory tests, including those of the cerebrospinal fluid, were normal, and her brain magnetic resonance image (MRI) () was interpreted as normal. She was suspected of having a diagnosis of TGA. However, because we were concerned about her high blood pressure along with the headache and nausea, we treated her hypertension with nicardipine, observed her in the emergency ward, and planed a follow-up MRI looking for punctate high intensity spots in hippocampus on diffusion-weighted images (DWIs), the diagnostic finding for TGA. Subsequently, over the next 9 h, her blood pressure returned to normal, and her amnesia improved. She no longer had nausea. By the next morning, her amnesia had completely resolved, although there was a gap in her memory during the episode. The DWIs () of the brain MRI on the same day were normal, but the fluid attenuation inversion recovery (FLAIR) images () revealed high-intensity areas in the subcortical white matter of her left occipital, bilateral parietal, and right frontal lobes. Although small, the distribution and subcortical location of these areas were characteristic of vasogenic edema of PRES. In retrospect, only the right frontal lesion was discernable in the first MRI (). The magnetic resonance angiogram was normal. The following day, her blood pressure remained normal, and her headache resolved. She was placed on antihypertensive medications and discharged without any neurological deficits. One month later, a repeat MRI () showed that all lesions had disappeared. We finally diagnosed her with PRES.
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A 45-year-old woman, known case of rheumatic mitral stenosis had undergone balloon mitral valvotomy in 2007. She presented with a 6-month history of dyspnea on exertion (New York Heart Association Class II, NYHA II) without dizziness, syncope, or chest pain. Her prior medical evaluation revealed in addition, pulmonary arterial hypertension (PAH) and a PA aneurysm. On examination the patient was found to have a palpable systolic impulse at the second left intercostal space, a grade 3/6 systolic murmur and a 2/6 diastolic murmur at the lower and upper left sternal border, respectively. Chest radiography showed cardiomegaly and dilation of the main PA and its branches []. A transthoracic echocardiography demonstrated severe mitral stenosis, dilated right and left atria [], moderate tricuspid regurgitation with PAH (PA systolic pressure, 84 mmHg; ), an aneurysmally dilated main PA (66 mm) and right (25 mm) and left (24 mm) PA branches [ and , ], and severe pulmonary regurgitation [].\nFor evaluation of pulmonary vasculature, the patient underwent a computed tomographic angiography showing an aneurysm affecting the main PA []. In our patient, the PA aneurysm was associated with PH, this being the most prevalent association, described in 66% of the cases.[] Dyspnea as a symptom is difficult to ascribe to pulmonary aneurysm as it can occur in both PAH and PA aneurysm. Other symptoms that may be present in patients with PA aneurysms are hemoptysis, cyanosis, clubbing, chest pain, and cough.[] However, none of these were present in our patient. Intensive medical treatment has been one possible approach for PA aneurysms with clinical improvement of signs and symptoms[] and so treatment for PAH was started.\nAlthough other authors have reported PA aneurysms, as per our knowledge this is the largest described in a patient with rheumatic heart disease. Moreover, it would be challenging to ascertain whether pulmonary regurgitation was the cause of pulmonary dilation or on the contrary, if it was a consequence of the progressive dilation of the pulmonary trunk; severe pulmonary regurgitation with volume overload might play a role on the persistence of the pulmonary aneurysm.
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A 13-year-old female patient reported to the Department of Pediatric Dentistry, Panineeya Dental College, Hyderabad with a complaint of swelling in the palate region for the last 15 days. When detailed history was obtained, patient gave no history of systemic disease or allergies. Patient presented with congenitally missing tooth number 21. She observed a swelling for which she reported to an undisclosed private dental office where tooth number 22 was extracted. The nodular swelling on the buccal aspect of tooth number 22 disappeared and a swelling on the palatal aspect appeared within two days of extraction and rapidly increased to the present size, for which the patient reported to our institution.\nPatient presented with a 4.5 × 2.7 × 0.8 cm linear swelling, oval in shape, towards the left side extending from the palatal aspect of tooth number 21 to tooth number 26 (). The swelling presented as soft, fluctuant, sessile, and nontender. The orthopantomograph and the maxillary occlusal view radiograph revealed a diffuse radiolucency with relation to the extracted tooth number 22 (). During the first visit fine needle aspiration cytology (FNAC) was done and the microscopic features showed mixed inflammatory cell infiltrate chiefly lymphocytes and neutrophils within a fibrous background, suggestive of infected cystic fluid. The patient was prescribed broad-spectrum antibiotics for five days and was recalled at regular intervals.\nIt was observed that there was no difference in the size of the swelling, even after one week, so enucleation of the lesion was planned under general anaesthesia (GA). Complete haematological tests along with a radiograph of chest PA view were ordered as a preoperative protocol and the case was posted for treatment under GA. Nasotracheal intubation was done and nerve block with 2% lignocaine was given around the lesion. Crevicular incision was performed around the gingival margin on the palatal aspect extending from the regions of 16 to 26, anteroposteriorly. A full thickness mucoperiosteal flap was raised and complete dissection of the lesion was done separating it from the palatal mucosa (). Wound closure was done using 3-0 Vicryl and the acrylic feeding plate was placed, which was fabricated prior to the surgery. Extubation of the nasotracheal tube and recovery of patient were uneventful. Patient was recalled after one week for review and subsequently advised to discontinue the acrylic plate after 10 days ().\nThe excised specimen was sent for biopsy and microscopy revealed fibrous connective tissue consisting of plump, spindle shaped fibroblasts neovascularization with extravasated red blood cells. It also showed infiltrate of chronic inflammatory cells with no evidence of salivary gland tissue or nerve tissue, thus suggestive of inflammatory fibrosis (). The patient has been under followup for the last 6 months and no evidence of reoccurrence appeared ().
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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 ).
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A 46-year-old man suffered a penetrating injury to the face from the broken blade of an industrial grinder while doing demolition work. He was transferred to the emergency room with fading mental awareness. The facial laceration was 15 cm in length from nose to right cheek (). A piece of the broken blade was observed in the deep portion of the facial wound. Facial bone CTs revealed a blade fragment in the anterior skull base from his nose to the dorsum sellae area (). Brain CTs demonstrated the involvement of the right temporal lobe, cavernous sinus, paraclinoid segment of the carotid artery (). Also there were traumatic subarachnoid hemorrhage, pneumocephalus without apparent low attenuation area of the right ICA (). Raw data from CT angiography revealed non-visualization of the right carotid artery while left carotid artery density was visible (). The paraclinoid area was occupied by the foreign body, suggesting ICA encroachment. Delayed time to peak of the right side was noticed on perfusion CT suggesting right carotid artery occlusion (). Progressive left side weakness developed after admission. Because of the patient's critical condition, we needed prompt management to restore blood flow without digital substraction angiography (DSA). Emergency skull base surgery was planned to unblock the cavernous sinus. And then we considered extracranial to intracranial high flow arterial bypass in case of flow decrement on the right ICA. Conventional craniotomy was performed on the right pterional area. After extradural removal of the anterior clinoid process, micro-Doppler revealed restoration of carotid flow to the paraclinoid segment (). Intradural inspection revealed displacement of the carotid artery due to the foreign body (). The carotid artery was found to be impinged between the foreign body and anterior clinoid process, as expected from the CT angiography image (). Microscopic investigation of the intracranial lesion revealed disruption of the pituitary stalk and fracture displacement of the dorsum sellae, but not open injury to the intracranial ICA. A flow meter revealed 40 mL/min flow to the paraclinoid ICA (). The planned bypass surgery was cancelled. Eight hours elapsed from occlusion to reopening. Surgical glue was injected into the cavernous sinus to restore hemostasis. The broken blade was extracted from the face () without no massive bleeding. The wound was irrigated and the bone defect was closed with artificial dura and the temporalis muscle. Lumbar puncture and draining was performed to prevent leakage of cerebrospinal fluid (CSF) from the wound. And then, the surgery for Lefort I fracture and soft tissue defect on the right cheek was done by plastic surgeon. The patient recovered from his left side weakness and additional surgery to treat an infected wound was successful. The patient suffered from severe brain swelling due to ischemic brain injury on the lesion side but recovered fully after barbiturate coma therapy with the ICP monitoring for a week. He was treated with hormone replacement, including hydrocortisone and T4, due to the pitutitary stalk injury. Complete recanalization of the right ICA was confirmed by the DSA which was performed at 2 months after surgery (). He was discharged three months after admission without any motor weakness.
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32-year-old male with past medical history significant for type 1 diabetes, hypertension, hypothyroidism, and peripheral vascular disease initially presented to an outside institution emergency department with a one-day history of bloody diarrhea, 2-3 days of nausea/vomiting, jaundice, and altered mental status. Two weeks prior to the admission, the patient and his family members had an upper respiratory infection with symptoms/signs including low grade fever, cough, and congestion. These symptoms/signs had been gradually improving; however, 2-3 days prior to presentation in the outside emergency department, the patient started to have new symptoms of nausea and vomiting, fever, and jaundice with new onset of watery stool, which developed into bloody diarrhea one day prior to initial presentation. Upon admission at the outside institution, the patient was diagnosed with hemolytic anemia for which he was initiated on steroid therapy and received a single dose of IVIG treatment.\nInitial CT of the abdomen and pelvis was obtained on the day of admission at the outside institution (). At this time, CT appearance of the bone marrow was essentially normal. Following the admission, the patient rapidly developed acute renal failure, respiratory failure, altered mental status, and thrombocytopenia. Initial iliac bone biopsies/aspirations at the outside institution showed evidence of hemophagocytosis, and the possibility of HLH had been raised at this point.\nFor further specialized care, the patient was transferred to our tertiary institution where he had a prolonged hospitalization of over 2 months. During this hospitalization, the patient had an additional iliac bone biopsy/aspiration, which demonstrated extensive bone necrosis and again the morphologic features of hemophagocytosis. These additional biopsies were primarily performed in response to image progression of changes in the iliac bone to exclude underlying malignancy or infection, as these can be seen as a cause of secondary HLH. However, for lack of culture growth other than on an initial outside sputum culture, infectious etiologies were excluded early in this hospitalization and the patient was not placed on any antibiotics throughout the rest of the admission. No evidence of malignancy was found by laboratory, iliac biopsy, or other imaging tests. Other etiologies such as autoimmune disorder were also ruled out after a thorough clinical workup involving multiple medicine subspecialties including rheumatology, hematology, and nephrology evaluation. Laboratory evaluation included negative antiphospholipid and anti-dsDNA antibodies.\nBased on clinical and laboratory criteria including bone marrow biopsy with “morphologic features of hemophagocytosis,” elevated IL-2R receptors, absent NK cell function, pancytopenia, elevated ferritin, fevers, splenomegaly, and hypertriglyceridemia, the diagnosis of HLH was clinically established. Following the HLH-2004 treatment guidelines, the patient was treated with cyclosporine and corticosteroids. Etoposide was considered per the HLH-2004 guidelines; however, it was not administered as it can cause pancytopenia in actively bleeding patients.\nDuring this hospitalization, the patient had multiple noncontrast enhanced imaging studies as acute renal failure prevented the patient from receiving contrast. These imaging studies were primarily performed for evaluation of the cause of the secondary HLH and multiorgan failure. Noncontrast enhanced MRI approximately 8 weeks after the initial presentation showed fluid collections anterior to the sacroiliac joints and along the right piriformis muscle, which was interpreted as concerning for abscesses by the radiologist (). However, based on the clinical assessment, a source of active infection seemed unlikely, and this was deemed to represent inflammatory change possibly related to adjacent bone marrow necrosis. The patient remained off antibiotics throughout this hospitalization. Three days prior to discharge (11 weeks after initial presentation), a noncontrast enhanced CT of chest, abdomen, and pelvis was obtained ().\nApproximately three months after the initial presentation (2 weeks after discharge from our institution) the patient returned to the emergency department for decreased urine output and was readmitted for acute renal failure. Although the fluid collections noted in the bilateral iliacus muscles remained relatively stable in size, given their persistence, during this second admission, the infectious disease service requested drain placement, and the patient was initiated on ertapenem therapy. The abscess culture from the right iliacus muscle fluid collection grew Bacteroides fragilis only in broth; nonetheless, the full course of ertapenem was completed as an outpatient.\nApproximately 6 months after initial presentation, the patient presented again to the emergency department with new onset of back pain and fever. MRI of the lumbar spine () was obtained to evaluate for discitis/osteomyelitis given the patient's prior history of possible abscess. Three days later, a CT scan of the abdomen and pelvis with contrast was also obtained (). These images showed continued progression of osteonecrosis with worsening pelvic bone osteonecrosis and new imaging findings of diffuse lumbar spine osteonecrosis. A dedicated CT of the lumbar spine without contrast obtained approximately 8 months after the initial presentation showed further progression of the osteonecrosis (). Due to increasing left shoulder pain, MRI of the shoulder without contrast was obtained approximately 1 year after the initial presentation (), which demonstrated imaging evidence of avascular necrosis. Approximately 14 months after the initial presentation, the patient's abdominal CT also showed further progression of osteonecrosis involving both femoral heads (). Furthermore, the patient also eventually developed right shoulder osteonecrosis.
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A 62-year-old Caucasian male presented with swelling and fullness in the left posterior chest. Mild discomfort of the chest wall had worsened over the preceding 6 months. Pain was associated with sitting or leaning against a wall. His range of motion was normal, and he performed daily activities well. Physical examination revealed a morbidly obese white male with a non-tender fluctuant mass on the left side of the upper back. It extended above and below the left scapula. The right side was without abnormality. There were no surgical scars in the thoracic region. The fluctuant mass was the size of a deflated football. An upper midline scar of the neck was noted. The past surgical history included previous cervical spine surgery. The patient had two motor vehicle accidents that caused a lower right-sided lumbar injury. His past medical history was significant for hypertension, hyperlipidemia, sleep apnea, osteoarthritis, gastroesophageal reflux disease and chronic mild asthma.\nComputed tomography (CT) scan of the chest demonstrated a large cystic mass between the posterior aspect of the thoracic ribs and deep to the muscles of the left back and scapula. There was no obvious connection with the spinal cord or pleural space. No solid or enhancing component was identified.\nChest magnetic resonance imaging delineated a large cystic mass extending from the level of the lower neck to just above the level of the diaphragm measuring 11 cm transversely, 4.5 cm anteroposteriorly and 23 cm craniocaudally (Fig. ).\nThe primary care physician aspirated clear fluid under sterile conditions providing symptomatic relief. Cytologic studies were unremarkable. When the mass returned 2 weeks later, he was referred to our institution for further treatment. Due to symptoms referred to the cyst and the lack of response to aspiration, the decision was made to excise the lesion.\nThe patient underwent general endotracheal anesthesia and was placed in the right lateral decubitus position. A 2.5-cm longitudinal incision was made at a paramedian position on the left mid-back and it was carried through the level of the fascia by cautery. The paraspinous muscle fibers were separated and the bottom of the cyst was bluntly dissected free and the cyst was aspirated of its serous contents. A balloon dissector was inserted ventral to the cyst for additional blunt dissection. The balloon was inflated to grapefruit size and left inflated for 2 min for hemostasis. The balloon dissector created a larger space beneath the cyst and along its lateral margins. The balloon was then replaced with a Hasson trocar, and two additional 5-mm trocars were placed under direct vision to allow access to the CO2-filled cavity (Fig. ). Using a combination of blunt and electrocautery dissection, the cystic lesion was circumferentially freed from the trapezius muscle and cervical structures. Several feeding vessels were clipped and divided. Once freed, the cystic mass was removed in its entirety through the Hasson trocar site. Two 15-French round JP drains were inserted through the 5-mm trocar sites and placed to grenade suction.\nIntraoperatively, the aspirated cystic fluid was clear and devoid of malignant cells. Histologic analysis of the unilocular cyst revealed a primarily fibrous wall with some adipose tissue and associated vasculature. The cyst lacked a true epithelial lining and any malignant features such as hypercellularity, hyperchromasia, cellular pleomorphism or increased mitoses (Fig. ). The final pathologic diagnosis was that of a benign, fibrous-walled cyst.
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A 60-year-old female of north Indian origin, reported to the OPD of GMC, Patiala, on 2 April 2013 with the complaint of postmenopausal bleeding since six months. Bleeding was off and on and irregular in nature. She also had lower abdominal pain, which was mild in intensity, non-radiating and having no variability with change of posture or respiration. There was also a history of weight loss and decreased appetite over the last two months. There were no associated bowel or bladder complaints. There was no history of any long-term illness or any chronic disease or any prior hospitalization.\nPatient was moderately built. Vitals were stable with blood pressure 136/88mm Hg, pulse rate 76/min and respiratory rate 18/min; no pallor was present.\nOn per abdominal examination, a soft to firm midline mass was palpable, which was about 20 weeks as compared to a pregnant uterus and had smooth surface. The mass was mobile from side to side, with no tenderness or any changes in the overlying skin.\nOn per vaginal examination, the cervix was directed backward, uterus was anteverted, around 20 weeks size and mobile, B/L fornices were clear, and no tenderness was observed.\nPatient had already undergone an endometrial biopsy and cervical biopsy on 8 March 2013 at a private nursing home, which showed malignant mesenchymal lesion and features suggestive of chronic cervicitis. On computed tomography dated 22 March 2013, there was a large, well-defined heterogeneous enhancing mass of approximately 14 × 12 cm size seen arising from uterus with thinned out peripheral rim of normal myometrial tissue with possible infiltration into myometrial wall anteriorly with few nodular calcifications seen in the peripheral and central regions. Both the ovaries were normal looking. The pelvic fat planes were well maintained and appeared normal. Muscular and bony walls had normal outline. There was no lymphadenopathy.\nProbable diagnosis of endometrial growth was made and the patient was advised surgery. All necessary investigation was done.\nWithout much delay, the patient was taken up for surgery on 3 April 2013. Intraoperatively, the peritoneal sampling was taken and sent for cytology. The uterus was enlarged and about 20 weeks size and there were dense adhesions of omentum at the uterine fundus with anterior abdominal wall. Uterus along with bilateral ovaries and fallopian tubes was removed. Incidentally, plastic tip of Karman's cannula was found lying in the anterior uterine wall. [] Intraoperatively, the patient was transfused two units of packed cells.\nUterus was uniformly enlarged and surface was smooth apart from irregularity because of removal of adhesions. On cut section, the anterior wall of myometrium was thickened and showed degenerative changes. Whole of uterine cavity was filled with necrotic growth [].\nThere was richly cellular, neoplastic growth of elongated cells exhibiting pleomorphism, and many mitotic figures, bizarre cells, multinucleated giant cells and nuclear hyperchromatism were observed [Figures and ]. The growth was not circumscribed and was extending through the endometrium into the cavity. At most places, nuclei had rounded ends (cigar-shaped nuclei). Areas of hyaline change, necrosis and fibrosis were also present. It was diagnosed to be a case of leiomyosarcoma grade II. The peritoneal washings were found to be negative for malignant cells.\nThe postoperative period was uneventful and the patient was discharged in satisfactory condition after a hospital stay of seven days. Patient was asked to follow up in OPD but patient didn’t turn up. Patient was contacted telephonically and counseled. Two months postoperatively the patient came for follow up and was admitted for chemotherapy on 7 June 2013. Patient underwent all routine investigations and was given six cycles of chemotherapy in the form of:\nInjection Gemcitabine 1 g IV on day 1 and day 8 Injection Docetaxal 120 mg IV on day 1. Injection Emgrastin subcutaneously on day 4 and day 5.\nEach cycle of chemotherapy was given after an interval of three weeks. After two cycles of chemotherapy in the month of July, patient developed drug-induced pruritis but was managed conservatively. Patient successfully completed six cycles of chemotherapy on 17 October 2013. Patient was called upon for follow up in the month of November; all routine investigations were done and found to be normal. No abnormality was detected on per vaginal examination and chest X-ray was also normal. Patient was found to be in stable condition. Patient again visited the hospital for follow up in January and April 2014 and was found to be in stable condition and on per vaginal examination vault was healthy and no abnormality was detected. Repeat chest X-ray was done and was found to be normal. After one year of follow up, patient is found to be in good health.
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A 36-year-old Greek woman was admitted to the emergency room of our hospital with signs of acute abdomen. At admission, the physical examination revealed abdominal pain and abdominal distention. Our patient also complained of constipation and failure to pass gas or feces for three days. On physical examination, our patient had a painful distended abdomen. Digital examination revealed an empty rectum. An X-ray of her abdomen revealed a bowel obstruction (Figure ). The impression was that the large bowel obstruction was due to a tumor.\nOur patient had undergone a cesarean section for delivery of her first child, 12 years before this admission, in another country. One year after the cesarean, she was operated on for symphysiolysis because of an acute bowel obstruction. After that surgery our patient started taking oral contraception which she stopped when she decided to have a second pregnancy. The second child was delivered normally. She then resumed taking oral contraception for two years, and stopped. She then started having symptoms of menstrual irregularity and cyclic menstrual pain, but she did not seek any medical help.\nOur patient underwent exploratory laparotomy because of the bowel obstruction. There were adhesions in her abdomen between her appendix, uterus, the sigmoid and her left ureter. Her appendix was found with small abnormal lesions, and an appendectomy was performed. During adhesiolysis, the left ureter was injured, and it was restored at this point using a pig-tail. Her bowel was swollen and the feces could not pass through. The rectum stenosis (almost complete obstruction) was located 8-10 cm from her anus. A rectosigmoidectomy with rectal stump closure and temporary colostomy (Hartmann's procedure) was performed. Our patient recovered and was sent home. The pathology report showed endometriosis of the colon and the appendix (Figures , ). Because of the double location, the gynecologist prescribed medical treatment with triptorelin 3.75 mg every 28 days.\nSix months after surgery our patient had another operation for the restoration of large bowel continuity. Her bowel was checked and a specimen was sent to the pathologist. No endometriosis was found. Our patient was doing well at the one-year follow up.
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A 13-year-old female Motswana student, who is the first born in a family of two children and being raised by a single unemployed mother, was referred to a psychiatric hospital by her local facility. She presented with a 1 week history of calling out for people who were not there as if she were conversing with them and seeing things other people could not see. She was also reported to often appear anxious and was not sleeping well at night. The symptoms appeared to worsen daily, prompting the caregivers to seek help. There have been no preceding life events that may have precipitated the symptoms, and she had never been admitted or been on treatment for any psychiatric disorder before the current presentation.\nMs K was born via a normal vaginal delivery at 32 weeks gestational age, with a birth weight of 2.1 kg. The mother was Gravida 2, Para 2, and antenatal history was unremarkable. Her mother highlighted that the patient had delayed developmental milestones as she did not walk and talk until after age two. Regarding social development, Ms K was reported to prefer solitary activities, and if she interacted with others, she would choose children younger than her. She reportedly attended a normal stream school for 2 years but was transferred to a special needs school (i.e. school for children with learning difficulties) because of academic difficulties.\nOn medical history, she has been diagnosed with a complex congenital heart disease: pulmonary atresia, large ventricular septal defect, pulmonary regurgitation, right ventricular hypertension and failure. She underwent corrective surgeries for the cardiac conditions at ages 6 years and 12 years, an umbilical herniorrhaphy at 3 years and clubfoot repair at 2 years.\nTypical features of DGS on physical appearance were a broad flat nose, small ears and a thoracolumbar scoliosis, whereas the typical long face, hypertelorism and micrognathia were absent. Physical examination revealed a mediastinal scar and a pansystolic murmur. Her blood pressure was 113/83 mmHg, pulse rate was 114 beats/minute and temperature was 35.8 °C. Investigations such as full blood count, liver function test, urea and electrolytes were within normal ranges. A chromosomal analysis was positive for chromosome 22 deletion syndrome.\nMental status assessment on the index consultation revealed a well-nourished adolescent. She was very restless, pacing up and down the interview room, thus making it difficult to establish a rapport. There was no eye contact. She had a labile affect. She was socially inappropriate as she kept undressing during the interview. Thought process was mostly tangential. She had fixed belief that her family members were bewitching her. She reported that God was commanding her to take her clothes off and she admitted to seeing a short man in the interview room.\nA working diagnosis of acute schizophrenia-like psychotic disorder was made using the International Classification of Diseases-10 (ICD-10) diagnostic criteria. The patient was admitted on haloperidol 3 mg at night. Four days post admission, she was noted to have increased motor activity, restlessness and sialorrhea, whereas the psychotic symptoms persisted. Manic symptoms such as elated or irritable mood and increased energy were absent. On suspicion of akathisia, haloperidol was stopped and she was started on olanzapine, 5 mg once daily at night. The extra pyramidal side effects (EPSE) symptoms reduced after 2 days. Psychotic symptoms subsided on day nine post admission. She stabilised 2 weeks after admission and was discharged on olanzapine 5 mg once daily at night. She was reviewed in an outpatient clinic after 2 weeks and remained stable. She continued reviews as an outpatient for 4 months and medication dose was reduced to 2.5 mg nocte. A month later, she presented to OPD with history of poor sleep at night, laughing inappropriately and isolating self. Medication was reviewed upwards to olanzapine 5 mg nocte as it was on discharge. For long-term management, patient was to be enrolled in vocational training and behavioural therapy. A definitive diagnosis of early-onset schizophrenia in a patient with DiGeorge syndrome was made.
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An 11-year-old Asian male reported to the Department of Pedodontics and Preventive Dentistry with a chief complaint of missing upper anterior teeth for 5 years []. Detailed history revealed that there was a history of trauma due to fall while playing when the boy was 6 years old as a result of which, he lost his upper primary right central incisor. After which the boy was taken to the local doctor and on examination was informed that the permanent tooth would erupt subsequently. Other history was noncontributory.\nExtraoral examination did not reveal any abnormality. Intraoral examination was done wherein soft tissue examination showed normal gingival appearance and contours. Hard tissue examination: Teeth present [].\n16 55 54 5312 __ 21 22 63 64 65 26\n46 85 44 43 42 41 31 32 33 34 75 36\n64, 65 were grossly decayed and occlusal caries with 54, 55, 75, and 85.\nOn palpation, a prominence was felt in the maxillary labial vestibule near the frenal attachment with a palatal bulge on the right side.\nFollowing the clinical examination, an intraoral periapical (IOPA) radiograph was prescribed of the missing central incisor region. It showed the presence of a dilaceration of the right maxillary central incisor with no root visible and IOPA was taken to localize the tooth []. The IOPA radiograph taken could not conclusively localize the root of the tooth hence, a maxillary occlusal and orthopantomograph [] was further advised to confirm the findings of the IOPA. It was found that the tooth was dilacerated with crown inverted directed in the apical direction.\nAn orthodontic opinion was taken, and the treatment plan was decided based on the diagnosis made of an impacted dilacerated right maxillary central incisor secondary to trauma. Surgical extraction was planned followed by biologic restoration using the same tooth. Surgical extraction was planned as the tooth could not be aligned back into the arch due to the dilaceration and correcting the inversion.\nOral prophylaxis was done followed by restoration of 54, 55, 75, and 85 and pit and fissure sealant with 16, 26, 36, and 46 was done and extraction with 64, 65 under 2% local anesthesia with 1:80,000 adrenaline.\nAfter taking informed consent from the parents, surgical extraction was planned with 11 followed by the use of the crown as an interim prosthesis. After the surgical extraction, postoperative instructions were given. The patient was recalled after a week for follow-up.\nThe crown portion of the tooth was stored in saline. The pulp tissue was removed, and pulp chamber was cleaned with sodium hypochlorite and saline. The tooth was dried and etched, bonded and filled with composite, and access cavity was sealed.\nAfter 1 week, the sutures were removed, still some amount of soft tissue healing was remaining; hence, the prosthetic restoration was deferred for another week, and the patient was advised gum massaging and oral hygiene instructions were reinforced. On the subsequent appointment, biologic restoration was planned.\nThe extracted tooth was rinsed with normal saline and trimmed to in the horizontal plane maintaining the contours of the tooth up to the cementoenamel junction to match the adjacent teeth contacts and contours.\nThe natural tooth was etched, bonded, and interlig fiber splint were measured and fixed to the tooth on the lingual surface in the middle third of the tooth with flowable light-cure composite. The tooth along with the fiber splint was checked in the patient's mouth [].\nThe splint was fixed with flowable light-cure composite on the adjacent teeth (12,21,22) on the lingual side in the middle third after etching and bonding. Finishing and polishing were done. Postoperative occlusion and esthetics were checked [Figures and ]. Excess material was trimmed. Postoperative oral hygiene instructions were reinforced and the patient was advised soft diet and strict instructions to avoid biting anything hard from the front teeth were given. The regular follow-up of the patient is been done to monitor the patient, and the oral hygiene maintenance is reinforced.
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A 48-year-old female patient approached our clinic for the replacement of missing teeth in relation to the left posterior mandible. Medical history revealed hyperthyroidism past 5 years, for which the patient was under medication.\nOn intraoral examination, missing 36, 37, 46, 47 were identified [Figures and ] with inadequate intra-occlusal clearance in relation to 3rd and 4th quadrant. The treatment options were explained to the patient. Routine blood and radiographic investigation were carried out. The OPG showed unusual bifid inferior alveolar canal on both sides []. Since we had planned to replace 36, 37 with implants, a CBCT were taken for more accurate information. The exposure parameters of the BCT unit were, 90 kvP of tube voltage, with 10 mA of tube current and the exposure time was set at 14.20 s with a 360° X-ray source and images with an axial thickness of 200 μm were taken. Highly variable mandibular canal anatomy was seen bilaterally. On the left side, mandibular canal appeared to bifurcate lingually, and the superior branch further divides into multiple branches in 36, 37 region. The uppermost branch is just 2.3 mm below the alveolar crest. On the right side the mandibular canal bifurcates at the level of 48 and the nerve continues as a larger superior branch and a smaller inferior branch up to the mental foramen [Figures and ]. The height and the width of alveolar bone were also derived from the CBCT []. The patient was informed about the presence of this anatomical aberration, an informed consent obtained from the patient.\nRadiographic determination of final placement was done with the help of surgical stent. Presurgical preparation protocol was followed, and surgery was carried out under conscious sedation using midazolam. Local anesthesia was achieved using plain xylocaine. A full thickness mucoperiosteal flap was reflected in relation to 36, 37. Osteoplasty was performed, and a stent was positioned. The sequential pilot drill used to prepare the osteotomy site and Nobel Groovy 5 mm × 10 mm in 36 region and 5 mm × 11.5 mm in 37 region was placed [] and the flap was secured with vicryl sutures. The implant was angulated buccally to avoid the damage to the nerve. Postoperative instructions were given and the implant site healed uneventfully.\nFollow-up was done at three months interval and 6 months, screw retained prosthesis was loaded []. Clinical and radiographic examination at 6 months, 1 year, and also 2 years revealed no significant changes.
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