text
stringlengths 746
31k
|
|---|
A 48-year-old male with no significant past medical history who was a restrained driver in a motor vehicle accident sustained multiple injuries in the crash () and had a prolonged and difficult extrication from the crash site before being brought to Ryder Trauma Center with a Glasgow Coma Scale of 15 approximately 1-2 hours after his accident. While in the resuscitation bay, bilateral chest tubes were placed for bilateral pneumothoraces and he had a positive FAST exam with tachycardia and severe hypotension (HR 128, BP 69/50). He was immediately brought to the operating room (OR) for emergency exploratory laparotomy, and splenectomy was performed for Grade V splenic injury, followed by abdominal packing without complete abdominal closure. His condition stabilized intraoperatively; no active abdominal bleeding or hematoma could be identified at that moment.\nA full-body CT scan was then requested to investigate other injuries. A list of numerous bone fractures that demonstrate the serious extent of the traumatic injury is shown in . The patient had also a scalp injury and needed additional workup to rule out traumatic brain injury. Head CT was negative. Chest CT demonstrated no further injuries other than minor pulmonary contusions and pneumothoraxes already being treated by the previously placed chest tubes. Abdominal contrasted CT identified a left renal artery injury and a nonenhancing ischemic left kidney but no other abdominal organ injuries (). In an attempt to salvage left kidney function despite over 4 hours of warm ischemia at that point, the patient was taken back to the OR for emergent repair of his left renal artery/in situ autotransplantation.\nAn occlusive 2 cm intra-arterial thrombus was removed, and a corresponding 2 cm damaged segment of the renal artery was excised. The kidney was flushed through the renal vein with histidine-tryptophan-ketoglutarate perfusion solution during the anastomosis of the renal artery. The left kidney was adequately perfused postreconstruction of the left renal artery ().\nDuring the two operations, the patient received a total of 7 units of packed red blood cells, 6 units of fresh frozen plasma, 2 units of cryoprecipitate, and 2 platelet transfusions. The patient was subsequently admitted to the Trauma Intensive Care Unit (TICU) for postoperative care. His hospital course was significant for worsening azotemia in the setting of decreased kidney function and falling urine output with a peak creatinine above 8 mg/dL. Dialysis and pressors were started on postoperative day 4. Eventually, his renal function improved, and his creatinine fell, and urinary output increased. He exhibited hypertension 2-3 weeks postrenal artery repair, but his systolic blood pressures eventually stabilized between 110 and 130 mmHg. He recovered in our TICU after multiple episodes of fungemia and bacteremia, was transferred to the trauma floor, and was discharged two months after admission. He is currently being followed in an outpatient clinic. After 18 months of follow-up, his serum creatinine level is 1.3 mg/dL and vital signs were within normal limits, without hypertension.\nOutpatient nuclear medicine renal scan indicated partial preservation of left renal function with a shrunken left kidney, and 16.3% () of split renal function attributed to the left kidney. Renal biopsy of the revascularized kidney was not performed. Left renal artery stenosis was not noted after its reattachment. |
A 30-year-old male with no prior medical history presented with nonradiating upper abdominal pressure and pain associated with early satiety and bloating. This was progressive over approximately 2 months before he sought medical attention. His physical exam demonstrated an easily visualized and palpable firm epigastric mass (). There were no signs of chronic liver disease such as ascites or jaundice.\nStandard tumor biomarkers such as CEA, AFP, and CA19-9 were normal, as was serum bloodwork for liver metabolic and synthetic function. Subsequent imaging workup demonstrated a large heterogeneous liver tumor approximately 27 × 13 × 20 cm in size, occupying his entire upper abdomen with mass effect and posterior displacement of the pancreas and stomach.\nMultiphase contrast enhanced computed tomography (CT) scan showed the tumor originating from the left liver spanning segments 2, 3, and 4 with no evidence of biliary obstruction. However, the left portal vein was not well-visualized beyond the portal bifurcation suggesting severe compression or occlusion. Similarly, the middle and left hepatic veins were not seen (). There were felt to be reactive ascites and a right pleural effusion but no clear evidence for metastatic disease in the thorax or abdomen.\nPercutaneous biopsy showed spindle cells consistent with an undifferentiated sarcoma. After multidisciplinary review, the patient was considered a surgical candidate but preoperative downsizing might help from a technical standpoint. Tumor embolization was thought to be feasible and worth attempting to achieve this. The patient thus underwent bland embolization to the tumor via the left hepatic artery. Approximately two weeks after procedure, CT angiogram showed unfortunately no significant change in size although perhaps with some tumor necrosis related to the procedure.\nThis mass continued to be highly symptomatic and it was felt that further surveillance would result in being minimal if any shrinkage of the tumor; thus resection for both palliation and potential cure was attempted. Given normal preoperative liver function, it was felt that the anticipated liver remnant after left hepatectomy would be sufficient with little risk for posthepatectomy liver failure.\nA chevron incision with midline extension allowed sufficient exposure of the porta hepatis and suprahepatic vena cava. There were extensive inflammatory changes around the tumor which appeared necrotic and there were hemorrhagic appearing ascites. The omentum was broadly adherent to the left side of the tumor, perhaps at the prior biopsy site. The tumor appeared to originate in segment 2 or 4 of the liver and essentially had replaced the entire left liver occupying the left upper quadrant and epigastrium (). It was compressing the anterior aspect of the stomach as well as the spleen laterally, and separating these structures required ligation of the greater curvature gastroepiploic vessels.\nThe bulk of the tumor did not permit rotation of the liver about the cava and thus no significant mobilization was attempted in favor of an anterior approach to the liver transection. Thus the transverse colon was retracted down and the porta hepatis exposed by gently elevating the front edge of the liver and working upwards along the hepatoduodenal ligament. Cholecystectomy was performed followed by exposure of the common bile duct and hepatic arteries. The left hepatic artery was divided at its origin. The portal vein was dissected to the umbilical fissure where the left portal vein branch was identified. There was insufficient space to divide the vessel but a silicone loop could encircle it to occlude the portal inflow to the left liver (). With this selective inflow control to the left liver, it was felt that a formal Pringle maneuver would not then be required during liver transection. The hilar plate was lowered and the left bile duct was identified just to the right of the umbilical fissure.\nSuperiorly, dissection was carried back to the anterior cava and the groove between the right hepatic vein and the middle hepatic vein was identified and developed. An attempt at a hanging maneuver to pass a traction tape between the vena cava and liver was unsuccessful due to anterior compression of the cava at segment 4. Intraoperative ultrasound was performed to confirm the location of the right portal vein as well as the middle hepatic vein. The middle hepatic vein was severely compressed laterally by the tumor with no clear plane between the two. Segment 4B of the liver was more or less free of tumor and that was where the parenchymal transection was initiated using a crush and clip technique as well as harmonic scalpel, marching down the quadrate lobe towards the left bile duct. Transection was continued through segment 4B towards segment 4A, and the left bile duct was divided sharply.\nThe liver could now be rotated to expose the upper aspect of the ligamentum venosum which was divided. To provide a gross margin of approximately 1 cm, the line of parenchymal transection was extended into segment 8, crossing to the right of the upper middle hepatic vein. The left and middle hepatic veins were then isolated and divided using a vascular stapler where they joined the inferior vena cava. A plane was developed along the anterior cava and the parenchymal transection completed using the harmonic scalpel. The left bile duct stump was closed primarily and completion ultrasound confirmed inflow to the right liver remnant. Additional hemostasis was achieved using a bipolar sealer and a right chest tube was placed to drain any anticipated reactive pleural effusion. Estimated blood loss for the procedure was 1,500 cc and operative time was 440 minutes. He received no transfusions during the case but was given 2 units on postoperative day 3 for symptomatic anemia. No peritoneal drain was left. The patient's hospital course was complicated by ileus and ascites leak from the apex of the incision which resolved with conservative medical management, and he was discharged home by POD#12. At three-month follow-up, the patient is doing well and has returned to work. His oncologist initiated doxorubicin and ifosfamide for adjuvant therapy and he will get surveillance imaging every 3 months. |
A 72 year old African American male, with past medical history of hypertension and recently diagnosed diffuse large B-cell lymphoma, was admitted to the hospital for fever and chills that started a day ago. He was discharged from the hospital two days ago on intravenous vancomycin for methicillin resistant Staphylococcus Epidermidis infection. The patient was initially admitted to a general medical floor, but his condition worsened within 24 hours and he went into septic shock and had to be transferred to the medical intensive care unit. He was hypotensive, tachycardic and tachypnic and had evidence of disseminated intravascular coagulation from sepsis. He was endotracheally intubated and placed on mechanical ventilatory support. Blood cultures grew Clostridium Difficile colitis. Appropriate antibiotics were started, and he was treated aggressively with intravenous fluids and also needed norepinephrine infusion for adequate blood pressure maintenance. He had a left subclavian central venous catheter inserted on the day of admission to the intensive care unit for administration of the vasopressor agent (Figure : Arrows show the tip of the central venous catheter abutted against the wall of superior vena cava).\nThe patient's condition improved and he was weaned off the norepinephrine by the third day. On the following day, patient suddenly became hypotensive. While he was being supported by aggressive resuscitative therapy, he had a chest radiograph done as part of the work up to diagnose the etiology of acute deterioration in the clinical condition. The chest radiograph showed widened mediastinum. A subsequent computed tomographic (CT) scan with intravenous contrast given through the left subclavian central venous catheter showed that the catheter had eroded through the wall of superior vena cava and there was extravasated contrast within the superior mediastinum (Figure : Computed scout image of the chest; arrows showing the extravasated contrast in the superior mediastinum; Figure : CT scan of chest with arrows showing the contrast in the mediastinum). Chest imaging from the day prior did not show these findings. There was no manipulation of the central venous catheter since its insertion. Bilateral chest tubes were inserted which drained bloody fluid. The central venous catheter was pulled out and patient recovered from the complication with supportive therapy. He later died during the same hospitalization from septic shock due to ventilator associated pneumonia from Pseudomonas Aeruginosa. |
A 49-year-old man, an amateur long-distance runner for 10 years, healthy and with no history of diseases, with positive results of periodic health examinations, had been suffering only from frequent headaches of unknown organic cause since early childhood. He had not suffered from any significant cardiac diseases apart from arrhythmia (single supraventricular extrasystoles) that did not require any medical treatment. Three months prior to the episode he had had his periodic exercise ECG, echocardiogram and Holter-ECG performed. None of them showed any contraindications for practising sport. Family history did not indicate any risk of vascular diseases either. After 3 h of the marathon race the patient started suffering binocular visual impairment in the form of flash lights variably narrowing his visual field. It was not accompanied by any other symptoms, neurological complaints or pain. The patient thought these symptoms were functional disorders caused by exhaustion and dehydration, so he only slowed down and finished the race. He did not suspect that this symptom might be caused by any trauma. After 2 h of rest the symptoms resolved spontaneously. After another 2 h the patient headed to the Accident and Emergency Department, where he underwent observation and was consulted by the neurologist, who did not recognize any abnormalities. He was also examined by the ophthalmologist and underwent ophthalmoscopy with the examination of acuity and field of vision. No abnormalities were found. He was discharged home with the diagnosis of function disorders caused by exhaustion. In another 7 days following the race the patient suffered only from permanent headaches, slightly more severe than the ones he used to complain about. Consequently he visited the neurologist again but again the examination did not reveal any abnormalities. He was referred for cervical spine X-ray and carotid artery Doppler ultrasound. The headache resolved after 8 days. Cervical spine X-ray did not reveal any significant abnormalities and Doppler ultrasound showed normal morphology of carotid arteries with no blood flow disturbances. At the next neurological examination, having no symptoms (based on interview only) he was referred for a scheduled imaging test: magnetic resonance imaging (MRI) of the head. The MRI test was performed 3 weeks after the episode. The magnetic resonance angiogram (MRA) showed the difference in the diameter of internal carotid arteries in the intracranial segment with features of the reduction of influx into the right internal artery, and the patient was suspected to have an intramural thrombus in the right internal carotid artery (RICA) observed at the lower end of the image (). Additionally, a small region of increased T2 and FLAIR signal was identified in the right parietal cortex suggestive of ischaemic focus. Three days later computed tomography angiography (angio-CT) of the neck was performed. It showed right internal carotid dissection of 3 cm in the precranial segment, narrowing its lumen down to 1.6 mm (). This diagnosis was confirmed by duplex Doppler examination, where the curved transducer showed the dissected part of the artery (). Regardless of the presence of intramural haematoma and canal stenosis, a tear with normal blood flow was observed. The decision was made to start antiplatelet treatment with clopidogrel at the dose of 75 mg (clopidogrel). After a week the antiplatelet therapy was replaced with anticoagulant treatment with rivaroxaban (rivaroxaban 10 mg) and a follow-up visit after 2 months was recommended. During therapy the patient gave up physical activity (he stopped his training but remained professionally active). After 6 weeks follow-up angio-CT of the neck, Doppler ultrasound of carotid arteries and Holter-ECG were performed on the hospital’s neurology ward. Due to the lack of improvement in the arterial stenosis (without significant deterioration) and the ongoing blood flow in the dissected region the patient was referred for intravascular treatment. On the Neurosurgery and Neurotraumatology ward the patient underwent contrast-enhanced digital subtraction angiography (DSA) of the carotid and cerebral arteries, which showed the presence of a pseudoaneurysm of 17 × 8 mm in the dissected region and critical internal carotid artery stenosis down to 0.5 mm (). A stent of 7 × 40 mm (Carotid Wallstent, Boston Scientific) was implanted into the internal carotid artery with a distal neuroprotection system (FilterWire EZ, Boston Scientific). The blood flow in the carotid artery reverted to normal with only trace flow in the region of dissection (). In the postoperative period acetylsalicylic acid and clopidogrel were administered for 3 months, and after that acetylsalicylic acid alone. Due to moderate hypertension (135/90) the treatment was supplemented with perindopril arginine (perindopril 2.5 mg) once daily. Follow-up Doppler ultrasound performed 1 month after the intervention showed correct blood flow through the artery of restored 5 mm diameter, without any intramural blood flow. Follow-up vascular MRI of the head involving the cranio-cervical junction was performed 3 months following the vascular procedure. It showed full remodelling of the vascular wall without intramural changes and with normal blood flow. Magnetic resonance imaging did not show the ischaemic lesion in the parietal lobe on the side of the dissection, visualized in the previous test. During a 6-month observation period the patient did not present any clinical symptoms, and radiological assessment confirmed almost complete resorption of the intramural thrombus. Complete diagnostic tests showed no disease which could predispose the patient to carotid artery dissection. |
A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.\nShe returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.\nThe patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper extremity and intra-aortic measurements exceeded 100 mmHg. CTA was subsequently performed to evaluate the extent of the lesion and confirmed a stenosis 1.3 cm proximal to the celiac origin measuring 5 mm at its narrowest point (Figures and ). The patient underwent arteriogram; the stenosis was successfully navigated and a Protege 14 × 40 x 12 mm nitinol stent (Medtronic Vascular, Santa Rosa CA) was delivered followed by a 10 mm postdilation balloon. A completion arteriogram demonstrated excellent flow across the stent.\nAfter stenting, the patients' systolic blood pressure was 140-160 mmHg, and she experienced resolution of her lower extremity claudication. She was discharged from the hospital on Aspirin and Plavix and a blood pressure regimen consisting of lisinopril, hydralazine, amlodipine, and carvedilol.\nShe was lost to follow-up until two years later when she returned to the hospital with a blood pressure of 220/85 mmHg, with complaints of chest discomfort. CTA demonstrated stenosis in the distal portion of the aortic stent. An angiogram was performed, and the stent was ballooned to 12 mm. Pressure gradient measurements taken before and after dilatation decreased from 60 mmHg to 20 mmHg. On follow-up one year later, she continued to experience excellent blood pressure control. |
A 27-year-old Egyptian man working as a clerk presented with a discharging sinus in the right side of his neck (). The man had a right submandibular sialadenectomy 8 years before presentation. The patient reported the sinus to appear after removing a drain which has been placed. This surgery was performed elsewhere. He also complained of pain below his chin and an increase in the amount of discharge on mastication. No history of fever. The patient reported receiving several trials of antibiotic therapy in an attempt to cure his condition. He had an X-ray done before presentation. The report of the excised gland pathological examination was not available.\nOn examination the man was 90 kilograms body weight and 182 centimeters height, there was a healed scar of previous surgery and a discharging sinus in the right submandibular region the discharge was purulent. No palpable swellings or enlarged cervical lymph nodes were found. Bimanual examination was done and there were no palpable swelling in the floor of mouth. A provisional diagnosis of a salivary fistula was considered.\nNeck X-ray showed no abnormality. A CT fistulogram was undertaken (), which showed a blind ending track leading to cavity just beneath the right side of floor of mouth. It also confirmed excision of the right submandibular gland.\nA decision to perform neck exploration was undertaken. During surgery gentle probing of the track was done then dissection was carried out revealing the sinus track passing medial the digastric muscle and up to sublingual area (). The tracks ended into a cyst below the mandible in the area where we typically ligate and divide the submandibular duct. On opening the cyst a purulent discharge appeared and irrigation of the cavity further revealed white fabric fibers (). With traction on these fibers two small sponges were found and removed (). The track was then excised and the cavity and wound copiously irrigated with saline. A suction drain was inserted and wound closed. The patient had an uneventful postoperative course and primary healing was achieved. |
A 48-years old male patient visited the Department of Otorhinolaryn-gology due to a palpable mass in the soft palate for several years. On physical examination, a mass was palpated and it was round shaped, 4×4 cm sized, non-tender and fixed to the underlying soft tissue and it had a hard consistency. The mass had a smooth surface and the overlying mucosa was not involved. An anterior rhinoscopic examination revealed normal mucosa and there was no mass in both the nasal cavities. Following a fine needle aspiration biopsy, the mass of the soft palate was considered to be a pleomorphic adenoma. The computed tomographic scan showed a round shaped, 4×4 cm sized mass with well enhanced soft tissue density in the soft palate without invasion of the adjacent tissues (), but the scan did not show a mass in any other region of the head and neck, including the sphenoid sinus (). Therefore, the mass was resected and the defect of the soft palate was not continuous into the nasal cavity. The defect of the soft palate was treated by primary closure without reconstruction. Histopathological examination of the specimen revealed the presence of a benign pleomorphic adenoma.\nOne year later, the patient visited the clinic due to a mass of the soft palate and diplopia that was present for the previous one month. On physical examination, a round shaped, 1×1 cm sized mass with a hard consistency and that was non-tender and fixed to the underlying soft tissue was seen. The mass had a smooth surface and the overlying mucosa was not involved. An anterior rhinoscopic examination revealed the normal overlying mucosa in both the nasal floors. The diplopia symptom was due to paralytic strabismus according to an examination performed by ophthalmologists. Computed tomography and magnetic resonance imaging were performed. The coronal and axial T2-weighted magnetic resonance imaging sequences showed a round shaped, 1×1 cm sized mass with high signal intensity at the soft palate without invasion of the adjacent tissues () and a large mass lesion with high signal intensity at the sphenoid sinus that apparently extended to the both posterior ethmoid sinuses (). However, the sphenoid sinus had no abnormal lesion seen on the previous computed tomographic scan obtained one year previously (). The mass of the soft palate was considered to be a pleomorphic adenoma based on a fine needle aspiration biopsy. In addition, a transnasal endoscopic biopsy was performed under local anesthesia for making the histological diagnosis of the mass in the sphenoid sinus, and a histopathological examination of the specimen revealed the presence of a benign pleomorphic adenoma without atypical cells (). However, treatment of the mass was not performed as the patient refused surgical treatment and follow-up. |
A 26-year-old chinese man was admitted to our hospital because of dysphagia for over one year. Results of his physical examination were normal. Gastroscopy revealed a giant esophageal submucosal protrusion with a smooth surface that was located 20 to 26 cm from the incisors. Ultrasonic gastroscopy revealed a giant mucous prominence of the esophagus located 23 cm from the incisors that originated from the muscularis propria and was suspected to be a leiomyoma because of its smooth surface and normal color (Figure ). Chest computed tomography (CT) showed a round high-density shadow on the right front edge of the esophagus at the level of the aortic arch to the inferior pulmonary vein, and this was suspected to be a leiomyoma of the middle esophagus. Upper gastrointestinal contrast radiography showed a leiomyoma of the middle esophagus and compensatory expansion of the upper esophagus (Figure ). After preoperative preparation, surgery was performed under single-lumen endotracheal intubation. The patient was placed in the left lateral position. An incision was made in the eighth intercostal space at the right posterior axillary line, and a thoracoscope was introduced through the incision. For the operation, one incision was made in the seventh intercostal space between the right scapular line and the posterior axillary line, and another incision was made in the fourth intercostal space between the auscultatory triangle and the anterior axillary line (Figure ). Exploration revealed that the tumor had spread to the entire length of the thoracic esophagus. The pleura mediastinalis was incised above the diaphragm to expose the lower segment of the esophagus. The muscularis of the esophagus was cut to expose the capsule of the tumor, and a well-defined solid tumor with an intact capsule and rich blood supply was revealed. The lower pole of the tumor along the capsule was gradually isolated. The lower pole of the tumor was sutured with thick silk to facilitate pulling up of the tumor. The incision in the pleura mediastinalis and the muscularis of the esophagus was extended in the direction of the cranium. The arch of the azygos vein was severed using an Endo GIA Universal Stapler. The incision was extended until it reached the upper edge of the tumor, allowing for exploration of the esophageal mucosa and gradual isolation of the tumor outside the mucosa until complete tumor resection was achieved. Two mucosal ruptures (with diameters of about 0.4 cm and 0.3 cm) in the middle esophagus occurred because of the tight adhesion of the tumor to the mucosa. Both ruptures were repaired by interrupted suturing with absorbable thread. Observation with an esophagoscope introduced through the mouth showed that the esophageal mucosa was intact, and no bubbles were observed after gas injection. The interrupted sutures in the muscularis of the esophagus were embedded in the wound. The operation took approximately 180 min to complete. The tumor was approximately 22.5 × 10 × 7.5 cm3 in size and tough in quality, with a lobulated ellipsoidal shape (Figure ). After the operation, the patient underwent water fasting, gastrointestinal decompression, acid suppression, and anti-infection treatment. The patient’s exhaustion abated and defecation resumed on the fifth postoperative day. Contrast radiography of the esophagus on the sixth postoperative day showed intact smooth esophageal mucosa with no obvious leakage (Figure ), so the stomach tube was removed and the patient began to consume liquid food. Postoperative pathologic results showed a spindle-cell tumor of the esophagus without significant cellular atypia with 0–1 karyokinesis/10 high-power fields, supporting the diagnosis of esophageal leiomyoma. The patient was discharged on the 10th postoperative day. He has been followed up for 10 months, and all his symptoms have disappeared with no abnormalities.\nEsophageal leiomyoma is more common than other esophageal benign tumors []. Its biological origin is the muscularis of the esophagus, and it is most commonly located in the middle or lower segments of the esophagus []. According to the literature, the size of esophageal leiomyomas vary from 1 cm to 29 cm in diameter []. Patients with esophageal leiomyoma often have no specific symptoms, and they are diagnosed during routine physical examinations. Esophageal leiomyomas greater than 10 cm in diameter are generally designated as giant leiomyomas [,]. Most patients with giant leiomyoma of the esophagus have symptoms such as dysphagia and chest congestion. The traditional surgical approach for esophageal leiomyoma is typically referred to as “small surgery, large incision” as it involves open thoracotomy, and the tumor may even be resected through a thoracoabdominal incision in combination with gastroesophagostomy or tumor enucleation [,]. Because of the large tumor size and unclear boundaries with surrounding tissues, all previously reported giant leiomyomas of the esophagus [,,-] were treated by open thoracotomy or tumor resection through a thoracoabdominal incision in combination with gastroesophagostomy. Traditional open thoracotomy can cause relatively serious operative trauma and negatively affects postoperative respiratory function and diet restoration, in addition to inevitable anastomotic complications [,,], all of which can worsen the prognosis. In recent years, a series of domestic and international centers have gradually implemented minimally invasive surgeries for the treatment of esophageal leiomyoma, including resection or enucleation [-] of esophageal leiomyoma by thoracoscopy [,,], laparoscopy [,], or Da Vinci robot-assisted thoracoscopy []. All of these surgical approaches achieved good curative effects, and their complications were less than with open thoracotomy. A report by Ozdil et al. [] described treatment of esophageal leiomyoma with endoscopic percutaneous injection of ethanol. However, most of the esophageal leiomyomas treated in this manner were smaller than 10 cm. There are fewer reports describing minimally invasive surgeries for giant leiomyomas of the esophagus. Chen [] reported two cases of giant leiomyoma treated by thoracoscopic enucleation, but the tumor sizes were 10 × 7 × 4 cm and 8 × 6 × 3 cm, which are smaller than giant leiomyoma of the esophagus. In this report, a patient with giant leiomyoma of the esophagus, 22.5 × 10 × 7.5 cm in size, which is the largest reported in current literature on PubMed and Cochrane, underwent thoracoscopic enucleation at our hospital. He received detailed preoperative assessment, and the entire surgery was conducted using a thoracoscope. The patient resumed intake of a normal diet after the operation. After following the patient for 8 months after the operation, it was determined that a curative effect was achieved. Examination of the integrity of esophageal mucosa by gastroscopy at the end of the operation is crucial for resuming normal diet postoperatively, as well as avoiding esophageal fistulas and related complications []. Laceration of the esophageal mucosa is the most common intraoperative and postoperative complication associated with enucleation of esophageal leiomyoma []. When the mucosal layer tightly adheres to the muscularis of the esophagus, lacerations of different sizes and numbers can easily occur during the process of tumor isolation. The lacerated mucosa sites should immediately be repaired by suturing with absorbable thread under thoracoscopic guidance followed by interrupted suturing of the muscularis. The repair work and the integrity of esophageal mucosa should be confirmed with gastroscopy. |
We report a 1 year and 4-month-old African male, who was admitted to our hospital because of recurrent episode of cough for 8 months and bowing of the legs for 6 months prior to admission.\nThe recurrent episodes of dry cough were worse at night and early morning, and he also had episodes of wheezing but no bluish coloration of the mucous membrane. He attends the outpatient clinic monthly, and prior to his recent admission, he had been admitted twice in an interval of two months due cough and difficulty in breathing, which were successfully treated with nebulized salbutamol and antibiotics. There is no history of asthma or atopy on the family. During the course of his illness, he was noted to have inward bending of the lower limbs, which was more prominent when standing. He has no history of trauma, limb length discrepancy, or swelling. His anterior frontanelle closed at one year, and he had no history of hair loss or balding patches. He had his first tooth eruption at 7 months, and no report of pain or pus discharge from the teeth was noted. He attained early developmental milestones until the age of 7 months, and the delay was noted subsequently as he was unable to crawl, stand, and walk during the recent admission. He had no history of convulsions or use of anticonvulsant medications, hoarseness of voice, or history suggestive of malabsorption disorder, liver disease, or kidney disease. There is no history of consanguinity or similar disease in the family.\nHis mother received adequate prenatal care and had adequate sun exposure. She had no history of muscle or bone pain during pregnancy. She reports taking diet consisting of eggs and fish in here regular diet, and she had a good appetite and no reported illnesses or drug exposure apart from hematinics during the gestational period. Her pregnancy was uneventful, and she delivered by SVD at the gestational age of 38 weeks, a male baby weighing 3.1 kg and started breastfeeding on the same day. The baby was only exclusively breastfed for 2 months, formula milk was introduced at 3 months of age, and he was weaned at 6 months. Currently, he feeds on foods rich in vitamin D and had adequate intake in terms of quality and quantity and also had adequate sun exposure. Immunization is appropriate for his age, and his weight gain pattern is appropriate for his age.\nOn his recent admission, he was alert, had some palmar pallor, no angular stomatitis or chelitis, no craniotabes, and no dental caries. His respiratory rate was 53 cyles per minute with the lower chest in drawing, and oxygen saturation was 89% in room air. He had a dull percussion note on the left inframammary and infrascapular regions with vesicular breath sounds, and he had crackles on the left inframammary and infrascapular and axillary regions with a prolonged expiratory phase, but no obvious wheezes were heard.\nMusculoskeletal findings showed no rachitic rosary or Harrison's groove, but revealed skull bossing and a widened wrist and genu varus ().\nThe other systems were essentially normal.\nBlood investigations which were done on the initial visit are as shown in Tables and .\nHe had elevated alkaline phosphatase (ALP) and serum parathyroid hormone with normal calcium, phosphorous, and 25D OH levels, consistent with stage 2 vitamin D-dependent rickets type 1 [, ].\nComplete blood count results showed microcytic hypochromic anemia and leukocytosis with predominant neutrophilia consistent with sepsis [].\nThe C-reactive protein (CRP) level was also raised suggesting pyogenic infection. Liver and renal functions were normal.\nRadiographs of the distal radius and ulna bone () revealed (a) cupping/fraying in both the lower ends of the radius and ulna bone, (b) cortical thinning, epiphyseal widening, and X-ray of the proximal and distal tibia and fibula showed (c) bowing of legs and growth arrest lines. Chest X-ray showed opacification on the middle zone.\nIn view of the symptoms, physical examination, and investigation findings, we had a diagnosis of vitamin D-dependant rickets type 1, bronchial asthma, severe pneumonia, and moderate hypochromic microcytic anemia.\nThe patient was treated with salbutamol nebulization 2.5 mg 6 hrly for 48 hrs, then budenoside twice daily via a metered inhaler, then iv ceftriaxone 750 mg once daily for 3 days, and then was discharged home on syrup cefixime for 7 days. He was also started on calcitriol 0.25 μgm once daily.\nOn subsequent outpatient follow-up clinic, his hemoglobin had returned to normal level and respiratory symptoms were improving. ALP was still high, and thus calcitriol was increased to a dose of 0.5 μgm once daily and oral calcium supplements were added. At his 6 months of follow-up visit, he had a considerable improvement in his respiratory symptoms, ALP was still remarkably high 1100 IU/L, and other tests for monitoring of serum vitamin D, calcium, phosphorous, and PTH could not be done due to financial constrains. He still had persisted genu varus and was on vitamin D and calcium.\nA 4-year-old male presented with developmental delay, poor weight gain, and recurrent chest infection for the past 3 years and worsening of bone pain since 9 months of age; he was delivered at the gestational age of 37 weeks, a male baby weighing 3.2 kg at birth and attained a maximum weight of 8.2 kg at 1 year. Thereafter, his weight was stagnant with a recent weight drop to 7 kg. With regard to his developmental milestone, his speech, social skills, and fine motor were appropriate for age, but he had delayed gross motor development as at age of 4 yrs he could not sit without support or stand which could be attributed to constant severe bone pain. His mother reported adequate nutrition intake and adequate sun exposure and she had optimal prenatal care with no history of bone pain. Tooth eruption was normal and no reports of abscess per oral cavity, alopecia, oliguria, or history suggesting malabsorption. He had a history of recurrent chest infection characterized by dry cough worse at night, which were being relieved by bronchodilators; he had no history of wheezes or bluish coloration of lips. His vaccination was up to date. He is the last born in a consanguineous Caucasian family of 5 children, with a history of sibling death at 1 year of age due to recurrent chest infections. Both parents were 38 years old at the time of consultation.\nOn examination, he had normal hair distribution, his weight was 7 kg, and height was 83 cm making weight for length below –3SD and length for age below –3SD, consistent with severe wasting and stunting.\nHas had widening of the wrists and genu varus on the limb, and he has no alopecia, dental abscess, or rachitic rosary.\nPast investigations conducted at 9 months of age when he showed early signs revealing elevated alkaline phosphatase, low level of phosphorous calcium, and low serum vitamin D with serum parathyroid hormones within the normal range for age and sex are shown in .\nThese results showed elevated ALP low phosphorous, hypocalcemia, and normal PTH in keeping with phosphopenic rickets [, ].\nHe was kept on 5 µgm per day of phosphorous and calcium supplements in the previous 6 months and yet control labs revealed low calcium, low phosphorous, and elevated urinary phosphorous levels and the parathyroid hormone levels were normal.\nDuring a year of follow-up on a high dose of vitamin D and phosphorus, though there was no clinical or biochemical improvement, he still had abnormal results as shown in .\nX-ray of the limbs repeated at the age of 4 years when he presented to our hospital showed a fracture of the middle radius, with significant cortical thinning ().\nThe child died at 4 years and 7 months due to severe chest infection causing septicemia and before death was kept in mechanical ventilation and antibiotics, with no improvement, and the cause of death was respiratory failure. |
The EOM flap was performed in a 57-year-old female for chest wall reconstruction after resection of a grade 3 angiosarcoma of the left breast. The patient first underwent a modified radical mastectomy without breast reconstruction, followed by wide excision of the chest wall skin once angiosarcoma was confirmed. The EOM flap was used for delayed reconstruction of the patient’s chest wall defect which measured approximately 30 cm × 30 cm (Fig. ), a surface area of 900 cm2. The flap was elevated without the anterior rectus sheath, in the inter-fascial planes between the deep surface of the external oblique muscle and the superficial surface of the internal oblique, with minimal muscle mobilization, and with no sacrifice to the vascular pedicle or perforating vessels from the external oblique to the subcutaneous flap, which were all clearly identified and preserved during the procedure for safety precautions. It was then inserted with minimal tension. Further mobilization could easily have been performed with complete elevation of the muscle to the posterior axillary line and detachment of the EOM off its costal origins and its iliac crest insertion; care taken to avoid injury to its blood supply. The patient was discharged postoperative day #7 and was directed to shower and perform local wound care with Xeroform and abdominal pad dressings. The patient was followed in the office every 4–6 weeks for 6 months. Serial physical exams revealed some epidermolysis and partial thickness necrosis that was appreciated at the superior medial borders, measuring collectively less than 4 cm × 2 cm. The patient was instructed to continue with local wound care as described. The patient did not experience any frank wound dehiscence or any other concerning complications. Thirteen months after the initial procedure, the patient underwent replacement of the aortic valve. In anticipation of cardiac exploration, re-elevation, and mobilization of the prior EOM flap was required. Incisions were made over the healed EOM flap extending over the sternum inferiorly allowing for re-elevation and closure without tension. By postoperative day 2, there was a possible area of partial versus full thickness necrosis versus intermittent venous congestion. Local wound care was initiated, and patient was followed throughout her hospital stay and seen as an outpatient every 2 weeks for 2 months postoperatively. The flap remained viable and healed without evidence of frank dehiscence or necrosis (Fig. ). |
A 72-year-old man was admitted with right flank pain and massive hematuria with clot retention. The patient was a heavy smoker, and did not report any history of trauma, recent medical intervention or known lithiasis. He denied any bleeding disorder and was not taking any medications. His blood pressure was normal and so were his blood count, biochemical and coagulation parameters. A rinsing catheter was introduced and the hematuria resolved within a few days. Ultrasonographic examination of the kidneys and bladder was unremarkable.\nOn a subsequent CT scan, a small soft tissue mass was depicted within the right renal pelvis. The lesion did not significantly enhance after injection of contrast medium and there was no dilatation of the affected renal unit. There was no evidence of urinary tract lithiasis or other pathology (Figure ).\nThe CT scan could not differentiate between a blood clot and a tumor. In the presence of a filling defect in the renal pelvis, although slightly enhancing, the presence of an urothelial lesion had to be excluded. Urine cytology was negative. A cystoscopy with advancement of a ureteral catheter into the right pelvis was carried out in order to selectively obtain a sample for urine cytology and perform a retrograde study. Cystoscopy and upper tract cytology were both negative for a high-grade bladder tumor. The retrograde study of the right ureter and pelvicaliceal system did not demonstrate any filling defect in the right renal pelvis and calyces. Based on these findings, the CT findings were attributed to a blood clot in the right renal pelvis and the investigation proceeded with renal arteriography.\nSelective right renal arteriography was carried out shortly following the resolution of the hematuria, and demonstrated an area of tortuous, coiled vascular channels with early filling of the renal vein within two seconds after the start of the injection(Figure ). Therefore, a right peripelvic renal AVM was diagnosed and a transcatheter superselective embolization of the lesion with the use of coils was performed successfully during the same session (Figure ).\nAt follow-up one year later, with non-enhanced and enhanced CT, there were no abnormalities found. The patient remains free of symptoms. |
A 72-year-old woman, diagnosed with a 4 cm large, locally advanced pancreatic cancer (LAPC) in the pancreatic head (), received a self-expanding metallic stent in the common bile duct due to a biliary obstruction. The tumor treatment alternatives were discussed at a multidisciplinary conference and the patient was considered unresectable due to tumor encasement of the superior mesenteric artery and vein. Palliative treatment with gemcitabine was initiated, but was discontinued after only a short while due to severe diarrhea. The patient was deemed unsuitable for other types of chemotherapy and was assessed for IRE treatment at our hospital but was excluded due to the presence of the metallic stent. However, 5 months after diagnosis, the patient contacted a private clinic where she was accepted for and later underwent an IRE procedure.\nAfter the IRE treatment the diarrhea continued and after 1 month she still suffered from increasing abdominal pain. Computed tomography (CT) revealed a small abscess and raised the suspicion of a bowel perforation (). As there was no sign of peritonitis, she was treated with antibiotics and subsequently sent home.\nEight weeks after the IRE treatment, she still had extensive diarrhea and both clinical and laboratory signs of an infection. She was admitted to our hospital and was operated with a laparoscopic loop sigmoidostomy because of the diarrhea. Two days after surgery, she went into hypovolemic shock with a distended abdomen. Peritonitis, or hemorrhage, was suspected and she underwent emergency laparotomy. The surgeons found no hemorrhage but an extensive, well-organised abscess formation behind the transverse colon and both the transverse colon and the duodenum were perforated in close vicinity to the stent. A right hemicolectomy was performed and an attempt was made to suture the duodenum, with several drains being left in the abdomen.\nDue to the damage to the duodenal wall, the suture did not hold and she received both a percutaneous gastrostomy and percutaneous transhepatic drain of the common bile duct postoperatively. Seventeen days after the laparotomy, she started to bleed and an angiography revealed a pseudoaneurysm on a pancreatic branch of the superior mesenteric artery. The bleeding was treated with a coil (), however, 3 days later she died from a further hemorrhage.\nBefore this the patient signed an informed consent to publish her case. |
A 53-year-old man presented to the emergency department with chest pain that started on the day of admission. He was a smoker, with dyslipidemia treated by atorvastatin 20 mg, with no family history of cardiac disease or significant pediatric history. He was in good general condition and had no signs of heart failure. His ECG showed sinus rhythm and ST segment elevation in the inferior leads ().\nThe patient underwent emergency coronary angiography. The right coronary artery (RCA) was totally occluded with an aneurysm involving the ostium (). Filling of the distal RCA from the left coronary system was observed. Giant aneurysms in the proximal portions of the left anterior descending (LAD) and left circumflex coronaries () were demonstrated. A second marginal branch was demonstrated with slow flow and filling defects.\nAn attempt to pass a guide wire to the proximal RCA through the ostial aneurysm failed, and the patient was transferred to the coronary care unit and treated with aspirin, clopidogrel, fractionated heparin, and morphine.\nEchocardiography showed good left ventricular contraction with an estimated ejection fraction of 55% and wall motion abnormalities in the inferior and posterior walls. Peak troponin T was 1027 ng/l on the second day of hospitalization and decreased to 226 ng/l on the 7th day of hospitalization (normal < 13 ng/l). The angiographic findings were attributed to KD based on the proximal location and size of the aneurysms and the lack of another explanation for these findings.\nA cardiac computed tomography was performed, which revealed a giant thrombotic nonocclusive aneurysm in the proximal LAD with calcifications of the margins of the aneurysm (); the maximal outer size of the LAD aneurysm is 35 × 33 mm, and the size of the lumen of the LAD is 9 × 11 mm. Moderate aneurysmal dilatation of the proximal left circumflex and an ostial thrombotic aneurysm of the right coronary artery were observed.\nOne week after admission, the patient underwent coronary bypass surgery. The giant aneurysm of the proximal LAD () was identified by the surgeons, and the left internal mammary artery was connected to the distal LAD. The right internal mammary artery was connected to the first marginal branch, and a saphenous vein graft was connected to the distal RCA.\nRecovery from surgery was unremarkable, and a graded exercise test performed 3 months after surgery showed good aerobic capacity with no complaints or ST segment deviations. |
Patient 1 is a 67-year-old male who presented to our clinic 41 years after his initial hip replacement. His initial surgery was performed in 1974, with the latest revision for periprosthetic infection 2 years prior to presentation to our clinic. He had undergone 5 previous surgeries and had a history of PJI with Escherichia coli at an outside hospital. On initial presentation, the patient had loose-appearing femoral stem with severe osteolysis (). He had a history of hypertension, deep vein thrombosis with pulmonary embolism, and asthma. After preoperative medical optimization, the patient underwent resection of proximal femur down to the distal femur metaphysis and placement of an MAAS (). He was allowed to partial weight bear to his affected limb postoperatively and was treated with 6 weeks of IV ceftriaxone. Intraoperative cultures grew E coli again. He underwent completion of his 2-stage reconstruction after 17.2 weeks using a tapered revision hip prosthesis in combination with a femoral allograft. An intramedullary nail with lateral locking plate was used for allograft fixation distally (). Patient opted to delay his second stage reconstruction after his antibiotic holiday as he was functioning well with the spacer and had several social challenges he needed to resolve prior to reimplantation. Erythrocyte sedimentation rate and C-reactive protein normalized prior to this surgery. This construct was chosen for several reasons. First, we did not wish to proceed with total femur replacement as this was our last option and patient had a native pain-free knee. Second, other proximal femur constructs would have been technically challenging, given the short amount of femur distally along with the difficulty obtaining fixation in the metaphysis of the femur versus the diaphysis. He was allowed to touch down weight bear in the immediate postoperative period after his reimplantation and then advanced to weight bear as tolerated at a later date. At his latest follow-up 1.15 years after reimplantation, patient was ambulating with pain-free range of motion of the hip and no recurrence of infection. The allograft showed signs of incorporation with callus formation posteriorly, and the implant remained well fixed. |
In December 2017, a 57 year-old male was referred to the Oral Medicine Department of Dental Faculty of Babol University of Medical Sciences. The chief complaint was a massive and rapidly growing swelling in his left maxillary alveolar ridge after tooth extraction a month before. The lesion was a sessile exophytic mass with lobular surface which was erythematous in some areas. He also complained from spontaneous bleeding and tenderness. The whole lesion measurements were approximately 5cm x 5cm. The involved teeth including left maxillary canine and lateral incisor had mobility grade III ().\nBased on his own statements, the patient was considered as a heavy smoker who had been smoking for a long time and reported a history of having a lung malignancy since December 2016. A complete evaluation of his medical history was performed by exploring the documents of his previous hospitalization. First, after consulting with a lung specialist, a core needle biopsy from right lung mass was done and microscopic examination of sections revealed harboring neoplastic proliferation of epithelial cells with sheet and alveolar pattern. Neoplastic cells had large hyperchromatic nuclei, clear to granular eosinophilic cytoplasm and prominent nucleoli. Inflammatory cell infiltration and multifocal necrosis were observed (). Immunohistochemistry showed strong positive reaction to CK7 and there was no response to CK20, TTF1 and CDX2. The pathologist determined it as non-small-cell carcinoma, probably TTF1 negative lung carcinoma.\nNo remarkable finding was shown by brain MRI taken in January 2017. Whole body bone scan was performed which showed abnormal increased uptake in the right first rib. The scan pattern suggested either a lung tumoral mass with the involvement of the first rib or radiotracer uptake by the soft tissue tumoral mass only (without bone involvement), therefore CT scan was recommended. The rest of skeleton was unremarkable. In February 2017, spiral CT of chest without contrast showed a mass lesion with ill-defined margins in the right lung apex with a maximum diameter of 62x30 millimeters in favor of a malignant process. Diffuse bilateral patchy nodular densities were noted in both lungs. There was no evidence of pleural effusion and chest wall was normal. According to all of those diagnostic procedures, the final diagnosis was unresectable Pancoast tumor. Therefore, the patient was referred to oncology service where appropriate treatment was commenced utilizing chemo-radiotherapy followed by adjuvant chemotherapy with cisplatin. Exploring the panoramic view disclosed an ill-defined radiolucency in the left maxillary area extending superiorly to the orbital floor together with cortical perforation of the alveolar ridge ipsilaterally. Left maxillary canine showed floating in air appearance, and widening of periodontal ligament was obvious in left incisors ().\nNumerous specimens were taken from different parts of the lesion for histopathologic examination. Microscopic slides showed malignant neoplastic proliferation of polygonal cells in sheets and islands pattern. Most of tumoral cells had atypical hyperchromatic nuclei, and many clear cells were observed within tumoral sheets. Cellular and nuclear pleomorphism, abundant atypical mitoses, vascular invasion and large multifocal necrosis were seen ().\nAccording to patient’s medical history, metastatic nature of the lesion was almost decisive, but because of existing undifferentiated malignant cells, immunohistochemistry staining was recommended to confirm the origin of metastasis. Since there was no reaction to HMB45 and S100 protein, melanoma and neural crest tumors were excluded. The response to CK 5/6 was strongly positive and also positive reaction to CK7 was noticed but no response to P63, CK20, CD5, CD117, WT1 and EBV were observed ().Considering the whole findings, the metastatic lesion was designated as a squamous cell carcinoma with pulmonary origin. The consultant maxillofacial surgeon determined on not performing a surgical intervention not only because the jaw lesion did not seem to be operable due to its enormous size, but basically for the primary site of tumor which had not been eradicated appropriately. Therefore the patient was referred back to oncologist to give his advice concerning the proptitious options of chemotherapy. As the tumor was in stage IV, it was declared that chemotherapy might exacerbate the patient’s general condition. So symptomatic treatment was opted just for relieving the probable excruciating pain. Three months after commencing the case evaluation, the patient was still alive and no progression of the disease was noted. |
A 63-year-old woman presented with pain at the volar side of the left wrist. She had undergone surgery for carpal tunnel syndrome of the left wrist in 2006 at another hospital. After the surgery, she reported to us that she had a fluid collection in the operation site after the surgery. She had received revision surgery four times during one year. Tissue culture and PCR analysis for mycobacteria were performed, but the results were all negative. The patient was afebrile and in good general health.\nRadiographs and MRI of the left hand were obtained one year after the initial surgery. The chest radiographs was normal and the hand radiographs revealed no bony abnormality. However, MRI of the hand showed a proliferative tenosynovitis of the flexor tendon sheath along the tracts of the flexor digitorum tendons involving from the wrist and mainly to the distal portion of the second digit. This lesion showed diffuse peripheral enhancement. The flexor tendons were intact and there were not any definite signal changes of the bone marrow (). At that time, her wrist pain was tolerable, so she did not receive any specific medical treatment and she'd just taken painkiller for three years.\nAs time went by, volar side wrist pain and a restricted range of motion of the left wrist had developed. She finally visited our hospital for further management and evaluation in 2010. On physical examination, there was 4 cm palpable mass-like lesion in the volar side of the left wrist, and tenderness on that lesion was also present. The blood tests showed an erythrocyte sedimentation rate of 27 mm/hr and a C-reactive protein level of 1.06 mg/L; the general hematologic and biochemical parameters were in the normal ranges. A radiograph revealed bony erosions along the margin of the left radiocarpal bones with osteoporotic change and the distance between the scaphoid and lunate was widened over 4 mm. On the oblique view, there was a 4 cm round bulging mass at the volar aspect (). MRI was not performed at that time.\nThus, considering her slowly progressing clinical history and the image findings such as multiple erosive bone lesions with a bulged soft-tissue lesion, tuberculous arthritis with an abscess pocket was the most possible diagnosis even though the tuberculosis previous tests were negative. Under the impression of tuberculous arthritis, she underwent tenosynovectomy and mass excision. The biopsy material from the soft tissue was sent for microbiological and pathological analysis. During the operation, the clinician found a capsule containing a high viscosity yellowish content, but there was no pus. An abscess in the proximal scapholunate ligament, as well as chronic inflamed soft tissue along the flexor tendons and synovium, were also found.\nThe acid-fast stain, the culture and PCR analysis for mycobacteria were negative. The histology revealed fibroadipose tissue with chronic inflammation. A few weeks later, atypical acid-fast bacilli were grown and these were identified to be Mycobacterium intracellulare.\nThe patient was prescribed of the same medication as the first patient, and she is currently being followed, but she still suffers from wrist pain. |
A 45 years old male patient, attended the neurology emergency department on 3rd January 2016 due to right limb numbness for 6 days and convulsive seizure for 3 days. Six days before the hospital visit, the patient experienced numbness in the right upper limb and instability while holding without obvious incentive but did not seek immediate medical intervention. Three days before admission, the patient experienced convulsive seizure in the right upper limb while remaining conscious, which was relieved after 1 min. Similar attacks occurred intermittently on six further occasions. The patient had a 3-year history of hypertension with the highest blood pressure being 180/110 mmHg. He also had a history of smoking and drinking lasting more than 30 years. He was born and has always lived in Beijing, with no history of contact with infested water, infectious zone, other radioactive substances or toxins. Upon admission, the patient was examined to be obese with no subcutaneous nodules. Neurological examinations showed full level muscle strength in the right upper limb, accompanied with diminished needling response. Emergency head CT scan (2016-1-1) showed lower density in the left parietal lobe. As the patient manifested as an acute onset of right limb weakness and hemiparesis,with low density lesions in the left occipital lobe on CT and a history of hypertension, the patient was hospitalised with a preliminary diagnosis of acute stroke and secondary epilepsy.\nAfter hospitalisation, head MRI scan (2016-1-4) displayed a lesion in the left parietal lobe of unknown nature. After enhancement in the magnetic field, a larger area of oedema was found around the lesion in the left parietal lobe which could indicate glioma or other inflammatory diseases. Since the nature of the brain lesion did not match the characteristics of common cerebrovascular diseases, intracranial angiography DSA was used but found no obvious vascular abnormalities or stenosis. Further examinations including lumbar puncture, immune rheumatoid factors and parasite antibody detections were carried out. A raised cerebrospinal fluid pressure was found to (215 mm H2O) with no red or white blood cells present. After consultation within the neurology department, intracranial tumor was considered and therefore prepared for stereotactic biopsy of the brain. At this point, pathology results came back positive for Spirometra mansoni IgG. On further questioning the patient admitted that he had drank tap water and eaten frogs when travelling in another province during June–September 2015. Given his medical history, and results from head MRI and blood tests, the patient was considered to be infected with Spirometra mansoni and surgical intervention or antihelmintic chemotherapy was recommended .\nThe patient accepted pharmaceutical treatment and was given praziquantel (1600 mg, 20 mg/kg) 3 times a day for 10 days. During these 10 days, the patient reported occasional headache and was treated for dehydration before discharge from the hospital. The patient was also administration oral sodium valproate 500 mg 3 times a day to control seizures.\nThe patient was hospitalised again in March and July 2016 and treated with praziquantel (1600 mg,20 mg/kg) 3 times a day for 10 days. His headaches were eased with intravenous infusion of 20% 250 ml mannitol twice a day.\nLumbar puncture (Table Examination of cerebrospinal fluid), head MRI, blood biochemistry, conventional blood analysis and parasite antibody examinations (Table Spirometra mansoni IgG antibody) were also carried out on both occasions. On 13th Jul 2016, the patient was free from numbness and seizures in the upper limb.\nTable displays the laboratory results of lumbar puncture performed on the three occasions when he was admitted to hospital and during the 1-year follow-up appointment. CSF analysis showed normal results except for a few white and red blood cells during his second hospital stay most likely resulting from the procedure itself. Table shows the Spirometra mansoni IgG result on three occasions. Note that the IgG result became negative during his third hospital stay following three courses of praziquantel treatment.,.\nEnhanced head MRI scans were performed during the three hospital stays in January, March, and July 2016. Figure A-A3display head MRI scans performed on 8th January. The scans showedan abnormal horseshoe signal in the left parietal lobe with a low T1WI signal and a high T2WI + FLAIR signal. Enhanced scan showed irregular wreath in the lesion without enhancement in the surrounding. This type of abnormality in the left parietal lobe may indicate glioma. During the second hospital stay, the MRI scan carried out on 17th March showed abnormal small stripes of signal shadow in the left parietal lobe with a decreased range. It also showed clearer abnormal veil-like signal shadow in the left parietal lobe as compared to the previous MRI scan. These results may indicatethe presence of Spirometra within this area of the brain. During the third hospital stay, MRI scan on 7th July detected only minor abnormalities in the bilateral frontal lobes and parietal lobes indicating that the lesions has reduced significantly or resolved. The follow-up on 12th December showed no abnormality in the head MRI scan. MRI scans from each hospital visit are shown in Fig. . |
We present a case of a 51-year-old otherwise healthy man, who suffered from rapid visual loss in the left eye following contusion. Ocular trauma was caused during a football match by a ball, which hit an index finger located just in front of the bulbus. The patient attended our department on April 27, 2004, one week after the injury, when the vision in the left eye decreased to light perception with inaccurate light projection and hand movements in a lower part of visual field. The best-corrected visual acuity in the right eye was 1.0. Intraocular pressures were 18 mmHg in the right eye and 45 mmHg in the left eye. Examination of the anterior segment and fundus of the right eye revealed no pathology. The left eye showed discrete injection of the conjunctiva and keratic precipitates with mild anterior chamber flare and cells. There was iridodonesis, cleft syndrome and a relative afferent pupillary defect in the left eye. The fundus examination of the left eye revealed swelling of the optic disc, large ischemic macular edema, superficial retinal hemorrhages, narrowing of the arterioles and dilatation of the venules (Figure ). Fluorescein angiography of the left eye showed macular edema and vascular leakage in the venous phase (Figure ). Duplex Doppler ultrasonography and computed tomography scans of the brain and orbits were normal.\nBased on the clinical findings, the presumed diagnosis of ocular ischemic syndrome was made. The patient was initially treated with vaso-active drugs in addition to corticosteroids. Intravenous methylprednisolone (500 mg daily for 5 days) followed by 60 mg of oral prednisone daily was indicated due to swelling of the optic disc and macular edema. Despite intensive therapy, the fundus examination showed progression of ischemic lesions. Visual acuity in the left eye was light perception with inaccurate light projection. The finding on the right eye was without changes. The patient was discharged on oral prednisone 50 mg daily.\nOn May 24, 2004, four weeks after pulse intravenous corticosteroid treatment, vision in the initially uninvolved right eye decreased to 0.25. Fundus examination of the right eye disclosed swelling of the optic disc with hemorrhages, blurring of the optic disk margins and ischemic macular edema (Figure ). In the left eye, massive vitreous opacities made evaluation of the fundus impossible.\nA differential diagnosis of antiphospholipide syndrome, masquerading syndrome, viral retinitis or specific inflammation was considered.\nNo neurological or other abnormalities were found on systemic examination. The findings from magnetic resonance imaging and magnetic resonance angiography of brain and orbits were within normal limits. The cerebrospinal fluid was negative for VZV DNA and enteroviruses RNA. Chest X ray and abdominal ultrasonography were normal. Leukocyte count, hematocrit and activated partial tromboplastin time (APTT) were normal, liver tests showed elevated levels of alaninaminotranspherase (ALT; 2.63 ukat/l). Anti-cardiolipin antibodies were negative. Serologic tests for syphilis and human immunodeficiency virus (HIV-1/-2) were negative. Serum was evaluated regarding evidence for herpesviruses by means of polymerase chain reaction (PCR). Low levels of VZV and EBV EBNA-1 IgG antibodies were detected in serum, whereas IgM antibodies were absent; as well antibodies of respiratory infections or neuroinfections were negative. Blood cultures were also negative. Immunofenotypization showed lower count of lymphocytes in peripheral blood, without plasma cell neoplasia.\nOn May 27, 2004, an aqueous tap of the left eye was performed and samples were submitted for cytological and virological analysis. PCR of aqueous humour was negative for herpesviruses family and cytology confirmed non-purulent intraocular inflammation. The patient was treated with corticosteroids. The best-corrected visual acuity in the right eye decreased to 0.02. Due to progressive impairment of the clinical status, the corticosteroid therapy was stopped. Fundus examination demonstrated several enlarging foci of necrotizing retinitis with extensive posterior pole involvement (Figure ). Based on the clinical appearance, a diagnosis of presumed necrotizing herpetic retinopathy was made. The patient was commenced on high-dose intravenous acyclovir (4 × 500 mg per day for 2 weeks). Two days later, visual loss with acuity reduced to light perception with inaccurate light projection occurred in the right eye. In the left eye, there was progression of vitreous opacities and the vision was light perception with inaccurate light projection.\nOn June 4, 2004, a diagnostic pars plana vitrectomy and retinal biopsy were carried out in the left eye. The vitreous cavity was filled with 16% perfluoropropane (C3F8) gas. A part of retina and samples of diluted and undiluted vitreous were obtained. Due to failure of the antiviral treatment and ocular disease progression, the patient underwent a pars plana vitrectomy in the right eye on June 9, 2004.\nPCR of retina of the left eye and undiluted vitreous of both eyes were positive for VZV. Undiluted vitreous was negative for HSV-1 and -2, CMV, EBV. PCR of diluted vitreous was negative for herpesviruses family. Mycobacterium tuberculosis was not detected using PCR in vitreous of both eyes. Cultivation of vitreous for bacteria and fungi was negative; Toxoplasma gondii antibodies were also negative. Histopathological examination confirmed non-purulent intraocular inflammation. Immunofenotypization of vitreous of both eyes showed no plasma cell neoplasia.\nIn two weeks, intravenous acyclovir was followed by oral acyclovir (5 × 400 mg daily). In the right eye, large foci of retinal atrophy with reduced inflammatory reaction were present. Owing the cataract induced by gas, fundus of the left eye was not visible.\nThe patient was discharged on acyclovir 4 × 400 mg daily. However, an exudative retinal detachment was seen in the right eye and vision decreased to 0. Vision in the left eye was light perception with inaccurate light projection. On examination 4 weeks later, B-scan ultrasonography of the left eye confirmed the exudative retinal detachment. Nevertheless, despite intensive treatment with intravenous antiviral medication, the patient became completely blind in both eyes. |
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was treated in a moon walker boot and 5mg of intravenous Zolendronic acid as a bolus dose. She was asked to continue with oral Alendronic acid 10mg on alternate days for 12 weeks. The patient was reviewed at 12 weeks. There was no tenderness around the talus or calcaneus. A repeat radiograph showed that the fracture of the talus had healed (). She has been on yearly review since. |
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.\nFor the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a careful conversation with the patient, she decided to undergo BRAF inhibitor therapy.\nA treatment regimen with vemurafenib 960 mg PO twice daily was started on October 4, 2016. Prior to the initiation of therapy, a new MRI performed on September 24 revealed a lesion measuring 24 × 21 × 19 mm. After 2 weeks of therapy, the patient was asymptomatic and was not using any analgesic medication. During the course of therapy, she experienced grade one anorexia, nausea and fatigue, without any severe therapy-related adverse events. MRI performed in April 2017 revealed stable disease (24 × 18 × 15 mm), and her last MRI performed in September 2017 evidenced a reduction of the lesion size (18 × 13 × 14 mm) (Fig. ). The patient currently remains asymptomatic with excellent tolerance to the medication. |
A 42-year-old female patient presented with a history of failed endodontics followed by extraction and socket preservation in relation to #31 six months prior to reporting to the implant clinic. The adjacent teeth #32 and #41 showed endodontic restorations. After clinical and radiological evaluation it was decided to place a 3.0 × 12 mm single piece implant$. Adequate primary stability was obtained at the time of placement. When reviewed after six weeks, the site showed signs of abscess formation in the alveolar mucosa in relation to implant #31. There was no evidence of probing depth around the implant, but radiographs revealed peri-implant bone loss at the middle third region. The implant was found to be stable with no mobility. Open flap debridement was done and the implant surface decontaminated with universal implant deplaquer$$. The implant was subsequently followed up for a period of one year with regular three-month clinical and radiological reviews.\nThe normal peri-implant sulcus depth and absence of other inflammatory signs in the peri-implant mucosa suggests that anterograde peri-implantits was not the cause for bone loss observed in this case. Even though endodontic therapy was performed in the adjacent teeth, placement of implant might have triggered latent periapical pathology[] from the adjacent teeth. Recent evidence suggests the existence of an autoimmune response[] in the periapical area in relation to an antigen which may be microbial in origin. The host response that is triggered off, may affect the host tissues as a result of similarity between the microbial and the host antigens, such as the heat shock proteins. In such instances, even after thorough debridement of the root canal has resulted in elimination of the microbial antigens, the host response may ensure continuation of an active inflammatory process.\nThe process of implant placement could result in activation of this latent response either due to overheating or contamination or a combination of both. This activation could have resulted in the rapid bone loss in a short period of time. The importance of periodic clinical and radiographic examination of implants that are placed adjacent to endodontically treated teeth has to be emphasized and a shorter recall program has to be instituted to identify and manage retrograde peri-implant bone loss in its early stages. |
A 42-year-old Swiss woman presented with intermittent weakness of the limbs lasting from several minutes to 2 days. Medical history was notable for migraine and 3 caesarean sections. The first episode of flaccid paresis occurred during her first pregnancy at the age of 23 years with a fall from the couch when she could not move her right arm and leg for several minutes, without associated disturbance of cognition or sensory symptoms. Examination at the emergency room after recovery was normal. Brain imaging was not performed because of the pregnancy. Two subsequent EEGs were normal, and no specific diagnosis was made at the time. She had a history of migraine, and we cannot definitively exclude the possibility that this first episode of unilateral weakness was a migraine aura without headache. However, her typical migraine episodes are headache and are distinct from this presentation. Fifteen years later, while driving, she noted weakness of her arms, legs, and trunk severe enough to warrant stopping the car. Weakness recovered slowly after 15 minutes. A similar episode occurred a few months later. Potassium levels and clinical examination when asymptomatic were normal. Subsequently, the frequency of similar episodes with flaccid paresis of her limbs, affecting predominantly the legs and lasting several minutes, increased and they occurred daily, always after resting. No correlation with food intake or fasting was reported. In addition, she complained of painless cramps in her arms and legs muscles, which could become painful if she tried to stretch her muscles. These lasted up to 10 minutes and also occurred during sleep.\nA detailed neurologic examination at the age of 42 years revealed no abnormalities. A relatively thin and long face with a small lower jaw was noted, but she was not overtly dysmorphic. On follow-up examination, she presented with flaccid weakness of her right hand lasting for 2 days. Motor and sensory nerve conduction studies, repetitive motor nerve stimulation, and EMG in the limbs and paravertebral muscles performed after recovery from the acute episode were unremarkable. The McManis test was negative. Laboratory testing revealed no thyroid dysfunction; electrolytes and creatine kinase were normal. Muscle biopsy of the tibialis anterior muscle was unremarkable. Genetic testing revealed RYR1 gene variants Arg1507Gln and Gly2446Ser in trans. Arg1507Gln is a missense variant with a minor allele frequency of 0.00001 in ExAC that has been previously found in other myopathic phenotypes. Gly2446Ser, although not previously reported, localizes to a recognized MH-associated mutational hot spot (). PP gene testing was negative. |
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was treated in a moon walker boot and 5mg of intravenous Zolendronic acid as a bolus dose. She was asked to continue with oral Alendronic acid 10mg on alternate days for 12 weeks. The patient was reviewed at 12 weeks. There was no tenderness around the talus or calcaneus. A repeat radiograph showed that the fracture of the talus had healed (). She has been on yearly review since. |
An 11-year-old Indian girl presented with a history of recurrent non-healing left leg venous ulcers associated with swelling of the involved limb. There was no associated erythema and her leg was non-tender. There was no history of trauma. There was no significant antenatal history in her mother and our patient was delivered normally at a local hospital with an uneventful postnatal period. There was no history of umbilical cannulation, cardiac catheterization, or any other femoral intervention. She had reported these symptoms since early childhood but no medical evaluation was done in the past. There were no other complaints.\nHer physical examination was remarkable for large venous collaterals on her anterior abdominal wall with flow from below upwards (Fig. ). She was also noted to have swelling and multiple venous ulcers on her left lower limb (Fig. ). Both lower limbs had varicose veins. There was no calf tenderness. There was pedal edema on her left lower limb. The rest of her examination was normal.\nOn color Doppler examination, her infrarenal IVC as well as her bilateral internal and external iliac veins were not visualized. A short segment of her proximal right common femoral vein and proximal superficial femoral vein were faintly visualized. Her left-sided common femoral, superficial femoral, and popliteal veins were not visualized.\nA computed tomography (CT) venogram done to define her venous anatomy showed absence of infrarenal IVC as well as absence of bilateral common iliac and left common femoral veins (Fig. ). A short segment of her right common femoral vein was seen with collaterals draining into her anterior abdominal wall. Her venous system at the level of the renal vein and above was normally developed (Fig. ). There were well-developed collaterals over her anterior abdominal wall and in her bilateral lower limbs. The superficial venous system of her bilateral lower limbs was well developed and draining from collaterals.\nEchocardiography showed normal cardiac anatomy and function.\nWith symptomatic treatment, her venous ulcers improved. There were no surgical or interventional therapies possible in this case. She was not started on anticoagulation therapy. |
A 23-year-old female presented to the outpatient clinic of our hospital with complaints of abdominal fullness, early satiety, intermittent left upper quadrant abdominal pain and left flank pain for the last 3 months. No significant family history or history of trauma was described. Examination of the abdomen showed a non-tender enlarged mass in the left hypochondrium spanning upto the right iliac fossa. The report indicated a large space occupying lesion in the left upper quadrant of abdomen with probable origin being the spleen. A CT scan of abdomen and pelvis with IV contrast was advised for further evaluation which confirmed a 16.7 × 14.2 × 12.4 cm3 large splenic cyst on the upper outer pole with no intrinsic enhancement or internal septa, having a mass effect on the left kidney pushing it downwards and rotating it while putting a stretch on the left renal vessels (Figs and ). There was also a mass effect on the body and fundus of the stomach which explains the fullness and satiety by the patient. Serologic testing for Echinococcus was also performed and found to be negative.\nA decision to preserve as much of spleen as possible was undertaken and the patient was prepared for laparoscopic fenestration of the cyst. Preoperative vaccination against encapsulated microorganisms was carried out 2 weeks prior to surgery, in case an intraoperative situation prompted to go ahead with total splenectomy. The patient was placed in an improvised position being tilted 45° to the right lateral side with a sandbag under lumbar region to allow for placement of the first trocar avoiding the spleen. Veress needle CO2 insufflation was carried out to achieve a pneumoperitoneum at 14 mmHg via an incision in the left flank at the lateral border of rectus in the midclavicular line at the level of the umbilicus with an appropriate distance from the palpable edge of the spleen. Entry was gained into the abdominal cavity using 10 mm Visiport through the same incision and then three more working ports were inserted under direct vision: a 5 mm in the left anterior axillary line at the level of umbilicus, a 10 mm in the midline and a 10 mm in the left midaxillary line at appropriate triangulation distances of one another. An enlarged splenic cyst was seen with adhesions with the anterior abdominal wall. Dissection was initiated using the Harmonic Scalpel and the phrenicocolic, lienorenal and phrenicosplenic ligaments were divided to gain access to the cyst and allow mobilization. Once mobilized, aspiration was carried which allowed over 2 L of serous fluid to be withdrawn and aiding in further dissection with ease (Fig. ). The cyst wall was then excised off the splenic parenchyma and the inner epithelial lining was cauterized using monopolar diathermy (Fig. ). The excised cyst wall was removed using an endobag and specimen sent for histopathology. Irrigation and suction was further carried out before placing a 16 Fr penrose drain and omentum was packed in the splenic bed to prevent recurrence. The drain was removed after 48 h and patient was comfortably discharged on her second postoperative day. Pathology results were consistent with benign splenic epithelial cyst and the cystic fluid showed no evidence of malignant cells. The patient remains in good health and symptom free. A follow-up ultrasound done 3 months after surgery showed no evidence of cyst recurrence. |
A 37-year-old woman purposely came to the outpatient department of our district hospital in the North West Region of Cameroon for a refill of her propranolol medication. She reported taking the drug routinely for palpitations. On further inquiry, she reported being well until 12 months prior to presentation when she suddenly became aware of her heartbeat, initially on moderate exertion and then even at rest. It had been recurrent and lasting several minutes each time it occurred. It progressively became associated with dyspnoea initially on moderate exertion and then on mild exertion, such that she had to quit farming which was her main source of income. After consulting at various health facilities in the North West Region of Cameroon, she was prescribed irregular and alternate daily regimens of 40 mg propranolol and 0.25 mg digoxin which she had been taking for 12 months at the time she presented at our hospital. Although the medications conferred her some relieve, she noticed a progressive weight loss over the 12-months period prior to consulting at our hospital, from 85 to 58 kg despite an abnormal increase in her appetite for food. She also experienced frequent watery stools (averagely six times daily). About 6 months prior to presentation, she complained of heat intolerance and profuse sweating resulting in sleeping with minimal clothing. In addition, she noticed spontaneous resting tremors of her hands which started at the same time as the heat intolerance. Three months prior to presentation at our hospital, she noticed a painless lump on her neck that progressively increased in size.\nOn reviewing her medical records, we noticed a number of investigations requested at various hospitals which she visited during the 8 months preceding her presentation at our hospital. These included electrocardiographs, echocardiograms, HIV tests, full blood counts, fasting blood sugar, thyroid hormone assays, which were all without particularity but for the electrocardiography results which always showed a sinus tachycardia. She has no known history of exposure to radiations or family history of malignancies.\nPhysical examination revealed a chronically ill-looking middle aged woman. Her eyes were normal (Fig. ). Her voice was clear. She had fine resting tremors of her hands with her arms outstretched. There was a left anterolateral neck mass measuring 4 × 3 cm (Fig. ). The mass was rubbery, mobile, non-tender, moved with swallowing, and not fixed to overlying or underlying tissue. No bruit was heard over the mass. There was no palpable cervical lymphadenopathy. Her vital signs were normal but for regular respiratory and pulse rates of 35 breaths/min and 104 beats/min respectively. Her BMI was 20.1 kg/m2. There was discrete bilateral pedal pitting oedema. The rest of the physical examination was without notable findings. In view of this presentation, a presumptive diagnosis of HT was made and we placed her on propranolol, 40 mg twice daily. Our hospital was not equipped with the necessary diagnostic tools, so we referred the patient to a regional hospital which is about 10 km from our locality. To confirm our diagnosis, we requested for a functional [serum T3, T4, Thyroid stimulating hormone (TSH)] and structural (ultrasound) assessment of the thyroid. The patient was counter-referred to us with the following results:Functional assessment of the thyroid: levels of serum T3, T4, and TSH (Table ). Structural assessment of the thyroid (ultrasound scan): The left thyroid lobe appeared enlarged, heterogeneous, with a fairly iso-echoic, well-defined homogenous solid mass (3.6 × 1.8 × 2.9 cm in size). The right lobe was without particularity. No cervical lymphadenopathy was observed.\nIn view of these findings, we concluded on a primary HT most likely due to a toxic uninodular goiter. Again, due to the limited resources in our hospital, we referred the patient to a hospital which is over 30 km from our locality for initiation of a course of methimazole. She was placed on 60 mg methimazole daily, 4 weeks after which she underwent a left thyroid lobectomy. The resected lobe (Fig. ) was sent for histopathology. The postoperative course was uneventful.\nThe lobe weighed 33.5 g and was received in formalin as two grey-tan soft tissue fragments: a large (6.5 × 5 × 3.5 cm) and a small (3 × 1.5 × 1 cm) fragment. Cutting demonstrated a red tan cut surface with a 3 × 2.3 × 2 cm nodule inside the bigger piece. Microscopic examination of representative sections of the large fragment with a full thickness section of the nodular structure revealed a nodular proliferation of enlarged pale cells with marginated chromatin and overlapping nuclei. Pink “bubble gum”-like colloid was focally noted. The lesion was partially encapsulated and displayed areas with fibrosis and more follicular appearance of the aggregates. Based on these, a histological diagnosis of PTC (pT2N0M0) was made.\nWe monitored the patient through scheduled regular visits and referrals. Figure shows the Incision site on the anterior aspect of the neck 2 weeks after lobectomy. We observed a progressive decline in hyperthyroid symptoms and signs: the palpitations regressed as well as the diarrhoea and polyphagia; the heat intolerance regressed and 1 month postoperatively, her weight increased from 58 to 68 kg. |
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was treated in a moon walker boot and 5mg of intravenous Zolendronic acid as a bolus dose. She was asked to continue with oral Alendronic acid 10mg on alternate days for 12 weeks. The patient was reviewed at 12 weeks. There was no tenderness around the talus or calcaneus. A repeat radiograph showed that the fracture of the talus had healed (). She has been on yearly review since. |
A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.\nHis blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.\nA specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.\nIn addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.\nHe underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.\nNine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).\nThis procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.\nAfter 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .\nAt 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual. |
Patient CK is a 57-year-old man with a medical history of allergic rhinitis and obstructive sleep apnea who presented to clinic in May 2017 with nasal obstruction of 3 years’ duration which was refractory to medical management with nasal steroids and saline. He was a former boxer and reported a history of 3 open septorhinoplasties to correct trauma-related nasal defects and 1 incision and drainage of a septal hematoma following the last open rhinoplasty in 1982. On examination, a soft compressible mass was observed filling the anterior nasal cavity bilaterally arising from the anterior septum. The rest of the examination was normal. The patient presented with a prior needle aspiration revealing respiratory epithelium, confirming mucocele. To assess for interval changes prior to surgery, we obtained an updated computed tomography (CT) sinus scan revealing a 2.4 cm × 2.0 cm × 2.0 cm cystic mass in the anterior septum with dystrophic calcification particularly of the right wall of the cyst ( and ). He was taken to the operating room, and 6 cc of a thick gelatinous material was aspirated from the mass and sent for culture. Transnasal endoscopic approach was performed after making a modified Killian incision just anterior to the curvature of the mass on the right side. Three layers of tissue were noted with the superficial layer being the septal flap followed by a fibrous and boney layer with the mucosal lining of the cyst being noted most medially ( and ). At the end of the case, all the mucous membrane lining was removed along with the dystrophic bone, and the right and left septal flaps were re-approximated with quilting suture. Doyle splints were placed at the end of the case and left in place for 3 weeks. Final pathology for the case reflected bone and respiratory epithelium consistent with a mucocele. At the first postoperative visit, the splints were removed and nasal endoscopy examination revealed flat septal flaps without crusting or swelling. The patient reported significant improvements in nasal airflow. |
R. A. is a 51 y/o male with a history of uncontrolled, non-medicated diabetes and a 20 pack-year cigarette habit who presented to the emergency department on July, 17 2011 with fibrinous discharge from a 5 × 3 cm wound in the left lower extremity. The patient was involved in a motorcycle accident in 2009 in the Dominican Republic that resulted in open fractures of the left tibia and fibula. He subsequently underwent four surgeries in the Dominican Republic on the left lower extremity, including a surgery that involved placement of a plastic implant in the left proximal tibia (). After moving to the United States, R. A. presented to the Emergency Department after noticing opening of the operative site at the left proximal tibia and exposure of the plastic implant with associated discharge.\nUpon physical examination, R. A. was noted to have a 5 × 3 cm wound about the anterior aspect of the left proximal tibia. The wound extended through the associated soft tissues of the limb and a cement spacer implant, which was used to fill the bone void at the left tibia during a previous surgery in the Dominican Republic, was visible (). Much of the anterior portion of the spacer was exposed to air. There was fibrinous exudate around the injured area but no frank erythema. Soft tissue examinations of the injured area demonstrated decreased attenuation and edema in the tibialis posterior muscle. It was noted that there was periostial new bone formation about the margins of the distal tibial fragment. Evaluation of the left fibula demonstrated non-unioned fracture in the proximal third fibular shaft.\nOn July 20, 2011 R. A. underwent surgery on the left lower extremity, which included irrigation and debridement, intraoperative deep tissue biopsy, removal of the plastic spacer implant, insertion of antibiotic beads, and insertion of an antibiotic spacer at the site of the segmental defect of the proximal tibia. The segmental defect length was approximately nine cm, with the intact proximal tibia measuring 2.5 cm and the intact distal tibia measuring eight cm. A vacuum-assisted-closure skin graft was also placed on the open wound on the left lower extremity by the Plastic Surgery Department. Deep tissue biopsy cultures were positive for Klebsiella pneumoniae and Pseudomonas aeruginosa. Post surgery, R. A. was placed on zosyn (3.375g per IV every 6 hours) and vancomycin (1g per IV every 12 hours) antibiotic medication before being switched to meropenum (500mg every 6 hours) and vancomycin (1.25g every 12 hours) on July 23, 2011 as recommended by the Infectious Diseases Department.\nOver the next two years R. A.’s chronic osteomyelitis of the tibia was treated with irrigation and debridements and antibiotic treatments. On July 24, 2011, R. A. underwent surgery again which resulted in the replacement of his antibiotic spacer, irrigation and debridement, and the removal of his antibiotic beads. On July 26, 2011, R.A.’s antibiotic medication was changed to meropenum (1g every 8 hours). On July 28, 2011, another surgery was performed to exchange the antibiotic spacer, conduct another irrigation and debridement, and conduct a saucerization of the left tibia. On August 23, 2011, R. A. received another debridement and a split- thickness skin graft. On August 30, 2011, R. A.’s antibiotic treatment was changed to meropenum (2g every 8 hours). On August 31, 2011 R. A. received an Ilizarov-type hybrid external fixator to provide stability to the left tibia ().\nFor several months, R. A. was able to ambulate with crutches without weight bearing on the left lower extremity, but R. A.’s chronic osteomyelitis remained persistent and his wound continued to drain. At this time, several long-term treatment strategies were discussed with R. A. as it was decided that he had an infection that could not be eradicated without amputation of the limb. Other modalities that were initially considered were the Papineau Technique and distraction osteogenesis. The Papineau technique is a type of open bone grafting technique in which wounds are packed with cancellous bone, usually for infected nonunions. However, this requires that the wound be clean and have adequate blood supply. In addition, the white count, ESR, and CRP should have normalized and the host has a normal immune system and adequate nutritional parameters. In addition, distraction osteogenesis after acute limb-shortening for segmental tibial defects has been shown have success [] however, in the presence of chronic osteomyelitis it was not a viable option for patient R.A. However, despite multiple irrigation and debridements and prolonged course of antibiotics, the continued prescience of infection made the chance for success for those modalities low.\nDue to the short length of his native proximal tibia, a traditional below knee amputation was not a reasonable treatment option. Other levels considered were at the through knee and the above knee level, but there was concern for the loss of function and increase in energy expenditure that accompanies an amputation performed at these levels. After deliberation, consideration was given to a rotationplasty of the distal tibia to unite it to the proximal tibia and provide the patient with a below knee amputation of appropriate length. This would be the best option to provide definitive eradication of the infection while preserving the maximum knee function possible. On June 13, 2012, R. A. underwent surgery again to remove the taylor spatial frame from the left lower extremity, conduct an irrigation and debridement, and exchange the antibiotic spacer at the left proximal tibia. Another tissue biopsy from the left proximal tibia during this surgery showed growths of Methicillin-Sensitive Staphylococcus aureus. On June 18, 2012, R. A. received another irrigation and debridement and exchange of his antibiotic spacer.\nOn June 21, 2012, a rotationplasty was performed on R. A.’s left lower extremity. Prior to the operation, R. A. was neurovascularly intact at the foot and ankle. First, R. A’s antibiotic spacer was removed without difficulty and the surgical incision was extended distally, while poor quality skin and fine extracts were resected. Dissection of the left ankle joint was then conducted from medial to lateral, exposing tendons and neurovascular bundles. The ankle joint was then disarticulated without difficulty and the distal tibia and fibula were exposed subperiosteally 1.5 cm proximal to the plafond. A supramalleolar osteotomy was made and exposure continued proximally while the tibia was dissected. Careful attention was paid to avoid injury to neurovascular bundles to ensure that adequate blood supply to the soft tissue remained intact. The distal tibia was then measured with the goal of providing about eleven cm of bone to the below knee amputation stump site Eight cm of distal tibia was then cut and dissected from associated soft tissue and significant scar tissue. Next, the proximal part of the dissected distal tibia was osteotomized at the level of the previous fracture with special attention paid to ensure that the posterior tibial artery remained intact to maintain good blood supply to the area. After the dissection was completed, the distal flap was then turned up to the proximal leg and the connection was held in place with multiple k-wires (, ). Fluoroscopic evaluation revealed good alignment of the attachment site in coronal and sagittal planes. This attachment site was then secured using a proximal humeral locking plate held in place with a combination of locked and nonlocked screws on the medial side (, ). A 3.5 recon plate was placed laterally to further support this alignment (,). Soft tissue closure was performed using #1 vicryl, 2-0 vicryl, and 3-0 nylon after irrigation and placement of a JP drain. Sterile dressing was placed and the patient was noted to have tolerated the procedure well. Following the surgery, R. A. was placed on IV vancomycin (1g every 12 hours) and meropenem (500mg every 6 hours). On postoperative day 1, R. A. was able to ambulate well with crutches without putting weight on the left lower extremity. On June 26, 2012 R. A. was discharged and instructed to visit the Antibiotic Infusion Clinic daily to continue his vancomycin and meropenem treatment. R. A. also followed-up frequently with the Orthopaedics Department so that his surgical wounds could be closely monitored. On July 18, 2012, R. A.’s sutures were removed from the operative site and his left lower extremity was noted to be clean and dry with no evidence of drainage or erythema. Sensation of light touch was intact at the left lower extremity and the skin was noted to be well perfused. R. A.’s range of motion at the left knee joint was 0-30 degrees and he was instructed to continue with physical therapy and to avoid bearing any weight on the left lower extremity until at least three months after the date of surgery.\nOn August 21, 2012, R. A. followed up again with the Orthopaedics Department. His wounds were noted to be dry and intact with no drainage or erythema. His range of motion had also increased to 0-65 degrees. X-rays taken during this visit demonstrated no change in alignment or position of the stump of the proximal tibia and intact hardware at the proximal tibia with no evidence of loosening. By November 6, 2012, R. A.’s range of motion had improved to 0-110 degrees and X-rays showed a healing osteotomy site, unchanged alignment of the proximal tibia, and improved ossification.\nOn February 21, 2013, during a follow-up with the Orthopaedics department, it was revealed that R. A. had been fitted for prosthesis but had been unable to obtain one due lack of insurance coverage. Additionally, R. A. had drainage from an area at the left distal thigh at a surgical incision site on the medial aspect of his left lower extremity. The drainage site showed no frank pus but a small amount of white drainage. The area showed no erythema and was not tender to palpation. The rest of R. A.’s surgical wounds were healing well and it was suspected that this wound was likely a superficial suture abscess and not a deep infection. R. A. was given oral clindamycin for antibiotic treatment, which ameliorated the drainage but was ceased after 12 days due to a possible allergic reaction to the medication, which caused a rash.\nOn February 27, 2013, an x-ray showed that there was no evidence of osteomyelitis and it was noted that there was no drainage from any surgical incisions. On March 20, 2013, R. A.’s surgical incision sites were all noted to be clean, dry, and intact. On April 8, 2013 R. A.’s surgical incision sites were all well healed and there was no evidence of drainage. His range of motion was measure to be about 0-45 degrees of flexion and x-rays from this follow-up demonstrated adequate alignment at the inter-transport site. There was good incorporation of the segmental fracture and no change in alignment.\nOn July 30, 2013, R. A. showed no signs of drainage from any of his surgical incision sites. On physical examination, R. A. was noted to have healed from the surgery well and showed no signs of wound breakdown (, ). There was no erythema, drainage, or other signs of infection and the stump site was nontender to palpation. R. A.’s range of motion was noted to be 0-55 degrees of flexion and full extension at the knee joint was observed (, ). There was no pain during range of motion. X-rays showed that the proximal tibia was well healed with intact hardware and no evidence of loosening (). It was noted that the main concern regarding this follow- up was R. A.’s inability to obtain prosthesis because he was denied access to Medicaid due to his lack of citizenship. |
A 45 years old male patient, attended the neurology emergency department on 3rd January 2016 due to right limb numbness for 6 days and convulsive seizure for 3 days. Six days before the hospital visit, the patient experienced numbness in the right upper limb and instability while holding without obvious incentive but did not seek immediate medical intervention. Three days before admission, the patient experienced convulsive seizure in the right upper limb while remaining conscious, which was relieved after 1 min. Similar attacks occurred intermittently on six further occasions. The patient had a 3-year history of hypertension with the highest blood pressure being 180/110 mmHg. He also had a history of smoking and drinking lasting more than 30 years. He was born and has always lived in Beijing, with no history of contact with infested water, infectious zone, other radioactive substances or toxins. Upon admission, the patient was examined to be obese with no subcutaneous nodules. Neurological examinations showed full level muscle strength in the right upper limb, accompanied with diminished needling response. Emergency head CT scan (2016-1-1) showed lower density in the left parietal lobe. As the patient manifested as an acute onset of right limb weakness and hemiparesis,with low density lesions in the left occipital lobe on CT and a history of hypertension, the patient was hospitalised with a preliminary diagnosis of acute stroke and secondary epilepsy.\nAfter hospitalisation, head MRI scan (2016-1-4) displayed a lesion in the left parietal lobe of unknown nature. After enhancement in the magnetic field, a larger area of oedema was found around the lesion in the left parietal lobe which could indicate glioma or other inflammatory diseases. Since the nature of the brain lesion did not match the characteristics of common cerebrovascular diseases, intracranial angiography DSA was used but found no obvious vascular abnormalities or stenosis. Further examinations including lumbar puncture, immune rheumatoid factors and parasite antibody detections were carried out. A raised cerebrospinal fluid pressure was found to (215 mm H2O) with no red or white blood cells present. After consultation within the neurology department, intracranial tumor was considered and therefore prepared for stereotactic biopsy of the brain. At this point, pathology results came back positive for Spirometra mansoni IgG. On further questioning the patient admitted that he had drank tap water and eaten frogs when travelling in another province during June–September 2015. Given his medical history, and results from head MRI and blood tests, the patient was considered to be infected with Spirometra mansoni and surgical intervention or antihelmintic chemotherapy was recommended .\nThe patient accepted pharmaceutical treatment and was given praziquantel (1600 mg, 20 mg/kg) 3 times a day for 10 days. During these 10 days, the patient reported occasional headache and was treated for dehydration before discharge from the hospital. The patient was also administration oral sodium valproate 500 mg 3 times a day to control seizures.\nThe patient was hospitalised again in March and July 2016 and treated with praziquantel (1600 mg,20 mg/kg) 3 times a day for 10 days. His headaches were eased with intravenous infusion of 20% 250 ml mannitol twice a day.\nLumbar puncture (Table Examination of cerebrospinal fluid), head MRI, blood biochemistry, conventional blood analysis and parasite antibody examinations (Table Spirometra mansoni IgG antibody) were also carried out on both occasions. On 13th Jul 2016, the patient was free from numbness and seizures in the upper limb.\nTable displays the laboratory results of lumbar puncture performed on the three occasions when he was admitted to hospital and during the 1-year follow-up appointment. CSF analysis showed normal results except for a few white and red blood cells during his second hospital stay most likely resulting from the procedure itself. Table shows the Spirometra mansoni IgG result on three occasions. Note that the IgG result became negative during his third hospital stay following three courses of praziquantel treatment.,.\nEnhanced head MRI scans were performed during the three hospital stays in January, March, and July 2016. Figure A-A3display head MRI scans performed on 8th January. The scans showedan abnormal horseshoe signal in the left parietal lobe with a low T1WI signal and a high T2WI + FLAIR signal. Enhanced scan showed irregular wreath in the lesion without enhancement in the surrounding. This type of abnormality in the left parietal lobe may indicate glioma. During the second hospital stay, the MRI scan carried out on 17th March showed abnormal small stripes of signal shadow in the left parietal lobe with a decreased range. It also showed clearer abnormal veil-like signal shadow in the left parietal lobe as compared to the previous MRI scan. These results may indicatethe presence of Spirometra within this area of the brain. During the third hospital stay, MRI scan on 7th July detected only minor abnormalities in the bilateral frontal lobes and parietal lobes indicating that the lesions has reduced significantly or resolved. The follow-up on 12th December showed no abnormality in the head MRI scan. MRI scans from each hospital visit are shown in Fig. . |
A 79-year-old female non-smoker presented with painless swelling below the left side of the mandible angle, which was first noticed 4 years previously (). She had no history of cardiovascular disease, diabetes mellitus and trauma to the head and neck. The palpable mass was pulsatile and had a diameter of 5 cm. Intraoral examination was unremarkable. A computed tomography (CT) () and a magnetic resonance imaging scan demonstrated the presence of a 5-cm left submandibular gland tumor, whereas contrast-enhanced CT () and ultrasonography revealed a 3.8 × 3.3 cm aneurysm of the facial artery with a cystic structure. We judged a submandibular tumor with pseudoaneurysm or a true aneurysm and suggested treatment options for the mass. The patient selected surgical excision under general anesthesia in response to the pathological diagnosis and to ensure the recovery of her esthetic appearance. We, therefore, consulted endovascular surgeons for angiography and internal trapping before the surgical excision, considering that there was a risk of bleeding during the operation.\nA parent vessel occlusion was performed with coils by endovascular surgeons from the distal to the proximal side of the aneurysm under local anesthesia (). After the endovascular trapping with coils, the facial mass was non-pulsatile.\nA total of 8 days after the internal trapping, the patient underwent an operation for excision of the aneurysm under general anesthesia. Skin incision was made using the submandibular approach at 4-cm below the inferior border of the mandible, thus exposing the facial artery and the aneurysm. The mass adhered to a left submandibular gland and the gland did not have any structural change. We, therefore, isolated and saved the gland from the mass. Subsequently, we ligated the facial artery and excised the mass, and then closed the skin using a 5-0 nylon suture (, ). The histopathological examination of the excised mass confirmed a true aneurysm of the facial artery with organized thrombus. There was no bleeding from the wound during or after surgery. The postoperative course was uneventful; the patient had no facial nerve palsy and there was no recurrence of the aneurysm during a 6-month follow-up period. |
A 39-years-old female, mother of 3 children, with a history of intracerebral hemorrhage at the age of one and with a family history of sudden death in a second degree relative, presented in May 2018 at the emergency department of the University Hospital Královské Vinohrady in Prague after an episode of chest pain and shortness of breath that occurred during a funeral ceremony. At the time of admission, the physical examination revealed no abnormal findings, her blood pressure was 155/80 mmHg, her height was 185 cm and weight was 95 kg. She was on standard antidepressant therapy and flavonoids.\nAt the time of admission, the electrocardiogram was normal, D-dimers were elevated to 4170 μg/l and high-sensitive troponin T was negative. The CT computed tomography (CT) angiography revealed a dilated aortic root and a Stanford type B aortic dissection. The left vertebral artery originated atypically from the true lumen of aortic arch as a third branch just before the origin of left subclavian artery. The right vertebral artery was hypoplastic. The left renal and accessory renal artery flow originated from the false lumen and the dissection extended to the origin of the left common iliac artery. Transesophageal echocardiography showed an intimal flap extending through the whole length of the descending aorta with a small mobile echogenic structure in the proximal part of the false lumen. The aortic root was dilated to 51 × 54 mm and the aortic valve was tricuspid with an insignificant central regurgitation jet. The left ventricular function was normal, without regional wall motion abnormalities. Mild regurgitation of the mitral and tricuspid valves without signs of mitral valve prolapse was noted (Fig. a, b). Digital subtraction angiography was also performed and confirmed the type B aortic dissection. It also revealed that compression of the true lumen is not as significant as the CT angiography showed before. The proximal entry tear was located immediately distal to the origin of left subclavian artery and the distal re-entry was located at the level of the visceral arteries (Fig. a, b).\nAt the time of admission, the approach was conservative. Considering the stable clinical condition of the patient, with no recurrent pain, no signs of malperfusion or rupture, acute intervention was not indicated. Antihypertensive medication was administered and up-titrated until effective control of blood pressure was achieved. The CT angiography was repeated 15 days after admission. The results showed progression of the size of descending aorta from 35 mm to 40 mm with compression of the true lumen in the thoracoabdominal region, but with no clinical or laboratory correlation or symptoms. The hospitalization duration was 32 days and no complications occurred. The patient was discharged on a combination of antihypertensive drugs - carvedilol, perindopril, amlodipine and urapidil. After 3 months CT angiography was performed again. The results showed slight uncomplicated progression of the descending aorta to 44 mm, with no further progression of the aortic root size.\nGenetic studies revealed autosomal dominant connective tissue disorder with heterozygous mutations c.605C > T in gene TGFBR1 which is associated with Loeys-Dietz syndrome. According to the current guidelines for aortic diseases from 2014 management should be tailored in reference to extensive vascular imaging at baseline and family history of vascular events [].\nFurther therapeutic approach was considered by the Heart team in collaboration with angiologists and vascular surgeons. As a contemporary less invasive alternative to existing ascending aorta procedures, our patient underwent a personalized external aortic root support procedure (PEARS). The procedure was performed successfully without the use of cardiopulmonary bypass. After 8 days of hospitalization the patient was discharged (Fig. ).\nAs for the aortic dissection, the Heart team in collaboration with angiologists and vascular surgeons recommended a conservative approach with close surveillance of the patient. Thoracic endovascular aortic repair or open surgery would only be considered if any complication occurred or if the size of descending aorta showed rapid further progression. The CT angiography performed 14 months after the first medical contact demonstrates excellent effect of the PEARS procedure with stability of the ascending aortic dimensions and morphology and does not show further progression of the size of the descending aorta (Fig. ).\nMeanwhile, all three children of our patient underwent a cardiologic examination. In all of them the ascending aorta was dilated and genetic studies confirmed gene mutation related with Loeys-Dietz syndrome. The oldest child underwent aortic root operation; the others are under close surveillance. |
A 67-year-old woman was diagnosed with a high-grade undifferentiated pleomorphic sarcoma following the resection of a rapidly growing soft-tissue mass. Her symptoms began 11 months prior to diagnosis when she initially fell on her hip and felt a bump with associated pain. In the emergency room, the initial history and physical examination resulted in the diagnosis of a hematoma around her proximal femur. Her symptoms worsened over the next nine months and she experienced recurrent falls. Radiographic imaging six weeks prior to her initial cancer diagnosis did not reveal significant abnormalities. Due to the concern for a possible hip fracture, a CT scan without intravenous contrast was obtained. While the CT confirmed no displaced fracture, it indicated clinical correlation for a nonspecific left thigh tissue collection suggestive of a hematoma. An MRI was obtained after the CT and demonstrated a soft-tissue mass in the subcutaneous tissue of the left hip suspicious for sarcoma. The patient had a consultation with an orthopedic oncologic specialist one week following the MRI and underwent a radical resection of the sarcoma the next day.\nThe pathology report revealed a 13.5 cm superficial left hip undifferentiated high-grade pleomorphic sarcoma with 50-60% necrosis. Margins were negative, with the closest evidence of cancer being 2 mm within surgical margins. A staging chest CT one week after surgery demonstrated two tiny lung nodules with the larger nodule measuring 4 mm which indicated a recommended follow up of three to six months. Of note, there was also a small hypodense lesion in the spleen that was inadequately visualized. Tumor stage was established to be Stage III measuring 13.5 cm at its greatest dimension. The tumor, node, metastasis (TNM) staging was established to be pT2a, cN0, cM0 without evidence of lymph node involvement or distant metastases. The patient had two follow-up appointments with the surgeon who recommended a consult to medical and radiation oncology on both occassions. She had consultations at two other institutions including a sarcoma clinic, with a recommendation of adjuvant chemotherapy and adjuvant radiation. Another chest CT was performed six weeks after surgery that demonstrated the stability of the 4 mm pulmonary nodule in the right upper lobe. The tiny nodular focus along the right hemidiaphragm was also stable.\nTwo months after surgery, she underwent adjuvant radiation at Beaumont Hospital (Royal Oak, Michigan, United States) for six weeks receiving 60 Gray. At the onset of radiation treatments, the physician identified a palpable seroma in the posterior thigh with tenderness. A 3-6 month follow up was recommended to monitor this finding. Upon completion of an abdominal MRI, there was no suspicious adenopathy or mass lesions in the abdomen. However, there were multiple liver cysts and a stable splenic lesion suggesting hemangioma or lymphangioma. At the next post-surgical appointment four months following her initial surgery, the physician noted that the patient was verbalizing anxiety about receiving chemotherapy. She expressed the feeling that no one was listening to her and that she did not want to proceed with chemotherapy. The physician encouraged the patient to follow this recommended course of action and proceed with the provided referrals. Upon conclusion of the appointment, she agreed to proceed but subsequently did not receive this adjuvant chemotherapy.\nAnother chest/abdomen/pelvis CT was performed four months following surgery which showed the development of four new pulmonary nodules which were concerning for metastasis (Figure ). In addition, a large (approximately 13.1 x 9.9 x 10.3 cm) fluid collection within subcutaneous tissue was observed in the left lateral aspect of the left hip. The differential diagnosis list for this finding included seroma, chronic hematoma or abscess. Two stable hypodense lesions were noted, one each in the liver and spleen. The patient followed up with medical oncology from this institution after this finding.\nClinical findings\nThis patient presented to physical therapy six months after her initial sarcoma diagnosis and surgery (Figure ). She presented with left shoulder, left flank and left thigh pain. She reported that her past medical history included the left hip sarcoma resection with adjuvant radiation therapy (RTx). She previously attended physical therapy at another facility for treatment of the shoulder pain which began after the course of RTx due to worsening pain. She was seeking care from Beaumont St. Clair Shores Physical Therapy due to a fresh onset of left flank pain and increasing left hip pain. Her physician recommended the aquatic therapy available at our facility. She did not have a prescription with her at the time of screening but stated that her previous prescription was for the shoulder only. Based upon the initial screening for rehabilitation needs, a prescription for lymphedema of the left lower extremity, abdomen, hip, flank, and shoulder pain was sent to her referring physical medicine as well as a rehabilitation (PMR) physician. The initial referral provided by the referring physician did not specify any precautions, contraindications, or other restrictions.\nSubjective History\nThe patient stated she lived in a home with her husband and developmentally disabled adult son. Prior to the onset of her symptoms and deficits eight months ago, she exercised regularly using a treadmill and exercise bike in her home. She was very distressed about the recent weight gain of more 40 pounds since surgery and RTx. She stated that the treatment at the other PT clinic included exercises for the shoulder, 5-10 minutes of “massage” on the shoulder area and 10 minutes of heat at the end. It was during the course of this previous episode of care that the left flank pain began. The left hip pain had been ongoing since surgery and RTx, and had worsened recently. She expressed significant anxiety about the course of her cancer survivorship with regards to determining who to use for medical oncology and what course of treatment to take. She had received consultations from multiple institutions but was unable to decide on a course of action. She also stated that she felt as though no one was listening to her concerns. She denied alcohol or illicit drug use but was a former smoker (25 years) having quit 16 years ago. Her current pain management regimen was 1 tablet of oxycodone (Percocet 10/325 mg) two times per day (despite being prescribed every six hours as needed for pain) and an acetaminophen (Tylenol 500 mg) tablet as needed. She avoided the use of her prescribed cyclobenzaprine (Flexeril) because it made her feel like a “zombie” and resulted in an increase in muscular spasms.\nThe patient had a past medical history significant for resection of a benign tumor in the pituitary gland causing acromegaly. She also had recurrent episodes of vertigo that had been successfully treated with medication for nearly ten years. She had hypertension that was also managed with medication. She had a right knee meniscus injury approximately three years ago that was resolved with physical therapy intervention. Finally, she had a history of cholecystectomy.\nTests and Measures\nThe patient’s subjective functional deficits of greatest concern were pain (7-10/10), difficulty with sleep, standing to wash dishes, dressing, grooming and sitting tolerance so she could watch television with her son. Evidence-based subjective assessment tools of Patient-Specific Functional Scale (PSFS), Upper Extremity Functional Index (UEFI) and Modified Oswestry Disability Index (ODI) were used. Although the patient’s series of events did not allow for reassessment of these measures, it is worthwhile to note that the minimally clinically important difference (MCID) or minimum important difference (MID) for each of these measures have been established.\nStratford developed the PSFS in 1995 for use in patients presenting with various musculoskeletal disorders, having varying levels of independence and established the minimum detectable change (90% confidence interval) for the average of 3-5 activities to be two points; and for a single activity, three points []. In 2014 in a cohort study of 1,708 consecutive subjects, Abbott presented the MID for the PSFS average score (1.3-2.7), UEFI (6-11), Lower Extremity Functional Scale (LEFS) (9-16), Neck Disability Index (NDI) (-14) and ODI (-12) when compared to the 15-point Global Rating of Change (GROC), the recommended reference standard for studies of MID [-]. Horn established the PSFS to be reliable, valid and responsive to change in knee, lower back, and neck dysfunction []. Hefford further established the reliability, validity, and responsiveness of the PSFS with upper extremity dysfunction []. Chesworth found that the UEFI was a reliable measure (Intraclass correlation coefficient (ICC)=0.94) []. The MCID for the UEFI was found to be between 6-7 depending on which version of the UEFI was used. Chesworth also identified that the MCID was smaller for those with a problem in their dominant arm as compared to a problematic non-dominant arm. Schwind et al. noted that there is not one definitive MCID for the Modified ODI, and that a 30% change or a 5, 6, 10 and even a 17-point change may be the MCID []. Although this test does not have a clear MCID, it is very commonly used in patients with back pain and is frequently referenced and understood by insurance companies in helping to determine reimbursement.\nFunctional and objective deficits were identified during the examination and resulted in patient-centered prognosis, goals, and interventions (Table ). Goals were also established for the self-reported UEFI and Modified ODI that are noted above. In addition, the therapist and patient developed and mutually agreed upon PSFS functional goals including the following: (1) improved quality and quantity of sleep, (2) increased sitting tolerance to improve quality of life with family activities and (3) decreased difficulty with dressing, grooming, and household chores.\nEvaluation and Clinical Decision-making\nBased on her complaints of positioning difficulty during RTx and clinical findings, evidence demonstrated that the onset of shoulder pain was a result of mechanical dysfunction. She discontinued PT at the previous facility due to the onset and continuation of flank pain and the increasing left hip/thigh pain. It is also reasonable to consider that exercises or activities during the previous PT could have contributed to the new onset of pain. Her PMR physician advised aquatic therapy for an alternative pain management option.\nAt that time, the major concern was continued surveillance of lung nodules with a “concern for metastasis” noted in the imaging report approximately two months prior to PT examination. Despite lack of evidence of osseous metastasis, there was awareness created by the therapist that it was a small but possible outcome. Therefore, treatment options needed to focus on optimal mobility and pain control utilizing minimal and controlled force as needed, which would decrease the risk of fracture/dislocation if osseous metastasis occurred.\nOf additional concern was the patient’s indecision regarding selection of a medical treatment plan and provider. This caused a significant delay in receiving any medical intervention that may have had a significant effect on her disease process. Based on the information obtained from numerous sources, the patient was quite frustrated and anxious, feeling as though no one was listening. Yet the medical documentation indicated that she was being provided a clear and consistent recommendation to have adjuvant chemotherapy. A significant barrier to her accepting this treatment plan seemed to be her concern for her son’s well-being in the event she was unable to help him.\nThe patient’s emotional and psycho-social concerns warranted referral to social work, psychology/psychiatry, and case management. Upon inquiry whether she had access to any of these services, she stated that she received counseling during home visits but she had been unable to sit long enough to tolerate a session. She had tried to utilize the social work services at an outside institution, but was extremely frustrated that she was advised over the phone to seek anti-anxiety medication. The therapist and patient also discussed community and social work resources that may be available for her son.\nPhysical Therapy Prognosis\nThe patient’s deficits included pain, decreased ROM and strength, and lymphedema of the abdomen and left thigh. These resulted in limitations with functional activities affecting her ability to care for herself and her family. It was anticipated that deficits could be resolved with a treatment plan that included: (1) education for positioning, body mechanics, activity modification, joint protection and postural training (2) aquatic therapy to provide an exercise medium that would reduce the effects of the recent weight gain that was making it more difficult for her to move (3) neuromuscular re-education to improve movement patterns to reduce pain (4) manual interventions to also reduce pain, increase blood flow, improve joint mobility and flexibility and (5) manual lymph drainage to facilitate circumferential reduction in the abdomen and left upper leg.\nTherapeutic interventions\nAfter the initial evaluation, the patient received three visits of physical therapy to attempt to reduce the patient's pain and improve her impairments and functional limitations. When these did not demonstrate improvements, the patient was referred back for further diagnostic and medical workup.\nVisit 1: Interventions and Outcomes\nVisit 1 of treatment included aquatic exercises for ROM, endurance, stretching, and pain control for approximately 30 minutes. The manual treatment that was performed on-land included techniques focusing on pain control and mobility such as upper quadrant soft tissue mobilization (STM) to her periscapular muscles, functional massage to the upper trapezius, supraspinatus, subscapularis and latissimus, and lower quadrant STM to the left hip scar tissue, iliotibial band, hamstrings, quadriceps, gluteals, quadratus lumborum, and thoracic and lumbar paraspinals. Education provided included energy conservation, activity modification and positioning for pain control.\nThe patient verbally reported that her pain was reduced from 4/10 to 2/10 after her aquatic exercises, but increased after getting dressed. After her on-land treatment, her pain was reported at 3/10. She had visible improvements with upper extremity range of motion (ROM) and decreased tissue tension in the upper and lower quadrants. She demonstrated a good understanding of the educational interventions provided to her.\nVisit 2: Interventions and Outcomes\nVisit 2 of treatment included aquatic exercises as established on Visit 1. She also participated in land-based treatment which focused on her thoracic symptoms. She stated she had less pain today (3/10) but felt like a spasm could happen at any moment. She tried a whole Flexeril tablet the night before treatment Visit 2, but felt no relief of symptoms. Her pain was described as cramping inferior to the scapula. Interventions included assessment of thoracic and rib alignment, that identified elevated left ribs 6-10. Also, the T6-T10 segments were found to be positioned in right rotation and right side bending.\nThe mobilization techniques chosen were based on the Nordic System of Orthopedic Manual Therapy (OMT) and Mulligan’s SNAGs, NAGs, and Mobilizations with Movement techniques [-]. Nordic OMT includes identifying a need for mobilization after the loss of joint movement, pain with movement, and pain with specific functional activities. It also requires identifying the pain-free articular translatoric movement for the glide to be performed that improves pain and movement. In addition, active patient movement through a specified range of motion and pain-free over-pressure are utilized. Reassessment of the movement pattern identifies the outcomes of the treatment.\nMobilizations included left ribs 6-10 utilizing Mobilization with Movement (MWM) techniques as described by Mulligan []. These MWM techniques generally include Natural Apophyseal Glides (NAGs) and Sustained Natural Apophyseal Glides (SNAGs) which is the “concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient” []. These techniques included depression with expiration, T6-10 anterior-superior NAGs and T6-10 anterior-superior with side bending SNAGs. Soft tissue mobilizations for bilateral thoracic paraspinal muscles were additionally performed. Education included diaphragmatic breathing with counting out loud during exhalation to facilitate the glottis, diaphragm and pelvic floor; proper sitting posture with emphasis on symmetry, avoiding positions of coupled rotation and side bending into the position of dysfunction, and performing straight plane active range of motion thoracic flexion/extension, bilateral rotation and bilateral side bending in pain free range.\nThe patient demonstrated better motor control during aquatic exercises as measured by therapist clinical observation. She advanced to bilateral lower extremity standing straight leg raise exercises and increased reps for all upper extremity exercises. She reported that her pain went down to a 2/10, while in the pool but that it came back up to a 4/10 after dressing herself (specifically with putting on her bra).\nThe T9 motion segment remained slightly rotated to the right while all other segments and ribs demonstrated improved alignment as measured by therapist palpatory assessment. The patient stated she was slightly achy after mobilizations but her pain was improved (2/10) and her paraspinals muscles no longer felt like they were going to spasm. She demonstrated understanding and competence with the extensive education in diaphragmatic breathing, posture, positioning and mobility exercises with the focus of pain control and facilitating improved movement patterns.\nVisit 3: Interventions and Outcomes\nThe patient subjectively reported that she had to take a pain pill that morning due to “a lot” of pain overnight because she was trying to be more active over the weekend with walking more. Her mid-back pain was 5/10 and left shoulder pain was 3/10. The patient’s aquatic exercises were continued as previously established.\nThe patient was able to tolerate increased repetitions for all shallow water exercises. Handheld paddles designed to provide minimal water resistance during aquatic movement were utilized during upper extremity exercises. She ended the aquatic component of her treatment session with decreased pain (3/10) in both locations.\nUpon initiation of on-land treatment, the patient stated that she did not want to proceed with additional treatment that day. She stated she had received the results of her most recent CT scan and that they were “not good.” The patient made no mention of test results prior to or during the aquatic treatments on this date. She expressed significant frustration stating that she was not receiving definitive guidance from her physicians. She reported that she was attempting to pursue ongoing cancer care with an outside institution which provided one of her consultations, but was having difficulty scheduling appointments.\nThe evaluating therapist reviewed the recent results of the CT of the chest/abdomen/pelvis. Results included multiple new masses in the abdomen/pelvis including the left iliacus muscle and an enlarged left inguinal lymph node (Figures -). In addition, bony metastases were noted to the left femoral head and right iliac crest (Figure -). Finally, a T7 vertebral lesion was found measuring 2.7 cm x 2.2 cm with extension into the spinal canal abutting the spinal cord (not pictured).\nThe evaluating therapist had an extensive conversation with the patient by utilizing active listening to her extraordinary distress. This included notation of severe pain that was not being managed effectively. While her subjective assessment of her pain was 2-5/10, she was concerned about the amount of pain medication required to decrease her pain. This was leading to increased anxiousness since she could not tolerate performing her daily tasks as well as her family’s personal finances and medical/social work management for her son with developmental disabilities. She was acutely aware of her potential mortality and was trying to get her affairs in order for her son, but she was so stressed from her pain she could not function. She stated her husband was not a source of support or assistance. She stated repeatedly that she "is at the end of my rope; it would be better if I just shoot myself. I wouldn't do it; but that is how bad I feel." Of note, numerous risk assessments by this institution’s physicians and this writer were previously negative for suicidal ideations. Upon inquiry, the patient stated that when she spoke with the social worker from the sarcoma clinic three days prior, she was recommended anti-anxiety medications but had not acted upon this advice. The therapist encouraged the patient to seek resources through these disciplines for securing her son's future and addressing her own mental health.\nThe patient was also advised on the importance of following up with medical oncology and her referring physician to determine if it was in her best interest to continue with PT at this time based on these new findings. The patient was encouraged to go to the emergency room (ER) to seek medical attention to control her pain and to obtain further testing if appropriate. She was very discouraged by the thought of not being able to continue with her pool exercises since it was the only thing she looked forward to, but verbalized understanding of the importance of receiving medical clearance with regards to the most recent test results. The therapist was provided with options and advised that the patient should go to the emergency room for care based on her emotional and medical issues. She left the facility with a plan to seek further medical attention after she got affairs in order for her son.\nThe treating therapist also provided advocacy by contacting her institution’s palliative care team for information regarding palliative care options for this patient. The patient was subsequently called to reinforce this recommendation. Later that evening, the patient presented to the emergency room and was admitted with consults to medical oncology and orthopedics.\nOutcomes\nHer hospital course of care included an MRI that indicated extensive metastatic disease. The dominant T7 vertebral lesion demonstrated possible pathologic vertebral fracture with extension into the posterior elements and apparent near-complete effacement of the left neural foramen with a likely compromise of the exiting nerve root. An abutment of the ventral spinal cord without intrinsic spinal cord signal abnormalities was identified. Some degree of posterior cerebrospinal fluid space remained. Evidence of anterior and left lateral epidural invasion at this level was noted, as well as the T12 lesion exerting a mass effect on the dura, which may have been invading it (Figures -).\nThe patient was advised by her attending physician that her best course of action was to transfer to an outside institution for surgical intervention to stabilize the spine, and subsequent medical management through the sarcoma clinic. She was transferred to that institution three days after admission.\nUpon follow-up, the patient reported that she received surgical intervention on her thoracic spine. However, she was unclear of the details. She was transferred to a skilled nursing facility near her home to be more conveniently located to her family. Additional follow-up has been unsuccessful as at the time of writing this case report. |
An 87-year-old male presented with recurrent episodes of hematuria and pelvic discomfort for six months due to recurrent lower urinary tract infections. He had a urological past medical history significant for low risk Gleason 3 + 3 prostate cancer (1/12 cores positive of right prostatic lobe only) treated with primary right-sided prostatic focal cryotherapy in 1996. His prostate cancer had been detected as a result of an elevated PSA and an abnormal digital rectal examination. At time of cryotherapy, he had no prostatic calcifications visible on TRUS or CT scan. Since his treatment, his serum PSA levels had been undetectable, and two subsequent CT scans of the abdomen and pelvis were negative for lymphadenopathy or evidence of metastatic disease. In addition, he had previously undergone a subtotal parathyroidectomy for hypercalcemia that had hence resolved before his diagnosis of prostate cancer.\nPhysical examination of the patient revealed an alert and oriented male with minimal suprapubic tenderness. On digital rectal examination, the prostate was approximately 40 grams and smooth without irregularity. He had a 500 cc postvoid residual. The remainder of physical examination was within normal limits. Urine analysis was positive for leukocyte esterase and 26 WBC per HPF. His serum PSA was undetectable. A noncontrast CT of the abdomen and pelvis revealed bilateral renal cysts without hydronephrosis and a 17 × 15 × 12 mm calcification of the right lobe of the prostate ().\nThe decision was made to proceed with TURP to relieve the obstruction as his symptoms had not improved with oral tamsulosin and finasteride. General anesthesia was induced, and a 22F cystoscope was passed through the urethra into the bladder without obvious signs of obstruction or trauma. Upon further investigation, there was enlargement of the right lateral lobe of the prostate from a protruding and visible calcified growth at the right bladder neck consistent with the previous CT findings. Lithotripsy with a holmium laser failed to penetrate the embedded stone given the intermixed soft tissue; therefore, a 27F resectoscope using a wedge loop was utilized to remove prostate and bladder neck tissue from around the stone. Once the soft tissue was removed, another attempt to laser the stone was performed; however, the laser failed to penetrate the stone. Again, the resectoscope using a wedge loop was utilized and relatively large sheets of stone were successfully removed with ease. A 24F three-way urinary catheter was left in place to gentle traction with continuous bladder irrigation overnight. The urine was clear of continuous bladder irrigation on postoperative day one, and the urinary catheter was removed. He was able to void freely with minimal postvoid residual and was discharged home that afternoon. Stone composition revealed calcium phosphate (hydroxy and carbonic apatite). |
The case presented here is of a 47-year-old man with a psychiatric history of major depressive disorder (MDD), three prior suicide attempts, anxiety disorder and with no medical comorbidities or substance use disorders. The patient showed a progressive exacerbation of his MDD over a period of one year after losing his job in construction, and increasing marital distress. He was found hanging from a rope with a suicide note, by family members. Family accounts indicated his last interaction was three minutes prior to being found hanging. Emergency Medical Services (EMS) was activated after the patient was successfully released from the hanging rope but was found to be unresponsive. EMS indicated that on arrival, they found the patient in a decorticate position with pupils fixed, and in state of a cardiac arrest. He was successfully resuscitated but remained unconscious.\nOn arrival in the emergency room, routine examination and radiological workup showed no evidence of carotid intimal dissection, thrombus formation, tracheal stenosis, cervical spinal injury or spinal cord injury. However, there was superficial soft tissue injury on the neck along the tracks of the rope used for hanging. He was admitted to the intensive care unit (ICU), with interventions including mechanical ventilation with a target oxygen saturation of 94%-98% and a target arterial blood gas pO2 of 70-100 mmHg and pCO2 of 40 mmHg and monitoring for complications such as acute respiratory distress syndrome (ARDS) and further cardiac arrest and raised intracranial pressure. His course in the ICU indicated he was maintained at a target systolic blood pressure (SBP) of 100 mmHg with an intermittent need for a dose of adrenaline not exceeding 20 mcg/min. His ICU course was complicated by the development of aspiration pneumonia for which he was managed with 2 g of cefepime intravenously every 12 hours for seven days and vancomycin for a total of 2 g divided as 500 mg every six hours. He was eventually successfully weaned off mechanical ventilation. A repeat examination for complications of his suicide attempt indicated no evidence of neurologic sequelae such as hemiplegia, central cord syndrome, or spinal cord injury. Of note, during his mental status examination, he was oriented to person and time but not situation, as he was unable to recall the events of his admission to the hospital. He remained depressed over work and marital problems. When attempts were made to orient him to the likely suicide attempt including the suicide note, he was reported to have expressed that it was not possible that he could have resorted to hanging himself. He reported that if he had harmed himself, he would be remorseful of the event and seek methods to prevent it; however, he did not recall attempting to harm himself. He expressed that although he was aware of his stressors and depressed mood, he was unable to think through a process that would lead him to draw a conclusion to end his own life.\nHe was admitted to inpatient psychiatry service for the ongoing depressed mood, poor recollection of his suicide attempt. On initial psychiatric evaluation in inpatient psychiatry, he continued to report depressed mood, anhedonia, poor sleep and poor appetite changes. He could not recall taking any action as a result of his depressed mood and reported he coped with his depression by keeping himself busy with work. The patient continued to express the egodystonic nature of suicidal thoughts or actions. He reported he had no desire or impulse to harm himself and could not have hanged himself prior to coming to the hospital. In addition, he reported no recollection of his prior suicide attempts and appeared distressed when he was told he may have tried to harm himself in the past. When he was shown the scars around his neck, he was unable to recall how they had happened. He expressed that his egosyntonic response to his stressors was to utilize his family support and to use religious means to cope with his stressors. Collateral information obtained from family indicated that this would be his fourth suicide attempt. Previous attempts involved overdose on medications and he was managed on the medical floors with observation only. He also had several hospitalizations for depression and suicidal ideations that he openly expressed to his family. According to family members, after the prior instances of suicide attempt, he was able to acknowledge his attempt and express remorse for his attempts, unlike his current attempt. In addition, he sought treatment for his mental illness willingly following those attempts, and was managed on Lamictal 50 mg twice daily. The family reported they had been supportive of him following the attempts and he often opened up about his feelings without reservations. There was no reported high emotionality or frustration by family members expressed towards his mental illness or suicide attempts and they were surprised he was not able to recollect these attempts. According to them, this was the first time he could not remember his suicide attempts, as he openly discussed them in the past and sought support from family about them.\nOn mental status examination upon hospitalization, the patient was alert but not oriented to time, place, or person. The patient was disoriented, unkempt, and exhibited psychomotor retardation on examination. During his stay, he alternated between recognizing being in a hospital and believing he was at a construction site where he had to perform different working tasks. No focal neurologic deficits were noticed on the neurologic exam except for marked bilateral intention tremor. In light of his difficulty with recollection, his mental status was assessed for which he scored 15/30 on the Montreal Cognitive Assessment (MoCA) exam with significant difficulties especially in word recollection and scored 4/30 on the Mini-Mental State Exam (MMSE). The Hamilton Depression Rating Scale (HAM-D) score was 26.\nRoutine workup during admission including levels of vitamin B12, folate, vitamin B1, thyroid stimulating hormone (TSH), and rapid plasma reagin (RPR) was within normal limits. Urine toxicology was also negative. Non-contrast head computed tomography (CT) and MRI were also performed. There was no evidence of acute bleeding, mass, or midline shift intracranially. The results of the imaging studies indicated that the ventricular system and subarachnoid spaces were prominent, suggesting cerebral atrophy. More specifically, beginning in the frontal cortex, there was ischemic injury with volume loss in the medial frontal cortex region. The lateral and medial ventral prefrontal cortex were preserved with no signs of structural injury due to ischemia of the region. The dorsal PFC was also preserved. Extensive volume loss was noted in the medial temporal lobe structures including left hippocampus, lateral temporal lobes, anterior frontal poles, the parietal lobes, insular cortex and the cerebellum. These findings are shown in Figures , .\nHis treatment plan involved the management of his depressed mood, as well as exploring and improving his insight into his suicidal behavior and developing alternative coping strategies during stressful life events. During the course of hospitalization on the psychiatric floor, he was commenced on sertraline 50 mg that was titrated to 200 mg due to subtherapeutic doses. He saw slight improvement in his mood, but still remained depressed and his medication was augmented with aripiprazole starting at 5 mg PO daily and increased to 10 mg over a period of one week, again due to subtherapeutic doses. No side effects to either medication were reported. At the end of the third week, he showed a response to treatment with an HAM-D score of 18, although he still had neurovegetative features of poor sleep. He was prescribed trazodone 150 mg PO hs to augment antidepressant effect and for insomnia. In addition, he was able to discuss his stressors and his reasons for depression much more clearly. However, he continued to maintain no recollection of his suicide attempt that led to his current admission, or any prior suicide attempts. He was still able to recollect other details of his life unrelated to suicide. He acknowledged the distressing nature of his stressors, but insisted he utilizes spirituality as coping strategies, and will continue to utilize the same for coping. He externalized any act of suicide by any person as being the work of outside forces based on his religious beliefs. The patient expressed that such an act would not follow from his thought processes. When shown the scar around his neck, he stated it may have been a work-related injury or some skin disorder. He also insisted no recollection of prior suicidal thoughts or actions. He was discharged home, with improvement in his depressed mood, to his family who provided support and additional nursing services. He denied any suicidal ideations, plans or intent, and continued to report no recollection of his recent or prior suicide attempts. |
15-month-old male baby, a product of an uneventful dizygotic pregnancy with his twin brother being totally normal, was delivered by cesarean section due to obstetric reasons. At the age of 7 days, he was admitted in another hospital for the excision of a tongue dermoid cyst prior to referral to our center. The patient was referred to KFSHRC primarily for the evaluation of an incomplete cleft palate with a tongue mass. On examining the patient, a cleft palate was noted with a midline hard tumor at the posterior edge of a bifid palate at a size of around 2.5 × 1.5 cm, along with a residual tongue lesion measuring 2 × 1.5 cm at the anterior dorsal surface of the tongue.\nThe patient was planned to have MRI () that showed a midline palatal defect involving both hard and soft palates, along with what appears to be a polypoidal mucosal mass with retention cysts protruding through defect from the right nasal cavity to the palate posteriorly. The radiologist then suggested CT facial bones to be done.\nOn the next visit, CT facial bones were done and showed cleft lip and palate with other findings, as shown in .\nThe impression, based on radiological findings and clinical examination, was a skull base mass at the clivus, extending to the sphenoid sinus. In addition to that, the patient had a midline nasal mass in the area of the nasion with extension to the skin but without any sinus.\nGiven that the patient had a cleft palate, the decision was made to perform combined endoscopic transnasal and transoral resection of the clival lesion with resection of the midline nasal structure. Informed consent for the surgery was then taken from the family.\nThe patient was taken to the operation room. Nasal examination under general anesthesia using a 30-degree scope was done for the first time, and we were able to identify a clival hard lesion that was extending through the cleft into the oral cavity. Access to both sides of the lesion was achieved by a small posterior septectomy, lateralizing the inferior turbinate and incising the posterior septum. Using a diamond drill, the lesion was drilled off the clivus. And by using a true cutting instrument, all soft tissue attachments were released intranasally, superiorly, medially, and laterally. The remaining attachment was an anterior attachment to the floor of the nose, which was released by a transoral approach. At this stage, en block resection of the mass was achieved.\nFor the other mass over the nasion, a midline incision was done over the nasion. After elevating the periosteum, a cyst was identified with resultant cavitation in the bone. The cyst was dissected completely, and the cavity was drilled using a diamond drill to remove any remaining soft tissue. The incision was then closed in two layers.\nPostoperatively, the patient was doing fine and tolerating oral feeding. After 24 hours, he was discharged with a clinic appointment.\nOn histopathological examination, grossly, the clival mass was white-tan irregular firm tissue measuring 2 × 2 × 1 cm, with homogeneous white nodular cut surface. The midline nasal mass was white-tan hemorrhagic fibrous tissue, measuring 2 × 2 × 0.3 cm. So, both masses showed the presence of teratoid hairy polyps with meningothelial cells and tooth tissue noted. No endodermal elements were seen on the submitted specimen, as shown in .\nRegular follow-ups with CT scans showed no progression in the teratoid over a period of 18 months postoperatively. Given that he is asymptomatic with no clinical signs of recurrence, the decision was elected to observe the patient on serial imaging keeping in mind that the patient may need surgical intervention through an endoscopic or craniotomy approach in the future depending on the symptoms and any progression. The parents were counselled in detail regarding their child's condition. |
A 48 year old male resident of a psychiatric institution presented to the emergency department with diarrhea, vomiting and decreased mental status. He had a history of hypertension, schizophrenia, hypothyroidism and factor XII deficiency. He was not receiving any anticoagulation for his Factor XII deficiency at the time of presentation. According to his emergency department record he was febrile to 38.7 Celsius with mild abdominal distension and tenderness on physical examination. A computed tomographic (CT) scan of his abdomen did not demonstrate any intraabdominal abnormality. An empiric diagnosis of infectious diarrhea with dehydration was made and the patient was discharged back to his facility on Levofloxacin and Metronidazole and intravenous fluids. Three days later, he represented to the emergency department with persistent diarrhea and a metabolic acidosis. A repeat CT scan was obtained which demonstrated an ill-defined rectosigmoid mass, but no obstruction. The pulmonary artery was seen on the uppermost cuts of this scan and there was no evidence of pulmonary embolus at this time (Figure ). Sigmoidoscopy revealed no mass or mucosal abnormality and the patient was admitted to the medical intensive care unit with continued broad spectrum antibiotics, intravenous hydration and hemodynamic monitoring. He was hemodynamically stable. Sequential compression devices were documented to be in place for DVT/PE prophylaxis.\nOn hospital day two, the patient developed increasing abdominal tenderness which was associated with fevers up to 39.5 degrees Celsius and acute renal failure. Surgery was consulted and recommended urgent operative exploration. Upon exploration the patient was found to have mesenteric venous thrombosis with a segment of ischemic small bowel. He underwent small bowel resection and was returned to the intensive care unit for continued resuscitation. At this time a heparin infusion was initiated given the patient's known factor XII deficiency and demonstrated mesenteric venous thrombosis. His partial thromboplastin time (PTT) was maintained between 60 and 80 seconds. The following day he had not improved; he was returned to the operating room where a second segment of ischemic bowel was discovered and further resection was performed. The patient again returned to the intensive care unit in critical condition requiring pressor support with levophed and continued ventilatory support with a PaO2 to FiO2 ratio of 180. At this point he was evaluated and found to be a candidate for rhAPC. This was initiated six hours after the completion of his operation. Due to concerns about potential bleeding complications, the heparin infusion was discontinued when the rhAPC was started. At the time of heparin discontinuation the patients PTT was 82 seconds and he had no clinical evidence of DVT or PE. His activated protein C level at that time was less than 10.\nOver the course of the following two days, the patient showed significant hemodynamic improvement and pressors were discontinued. By day 3 PaO2 to FiO2 ratio had risen to over 300 and he was requiring minimal ventilatory support. On postoperative day 4, the patient developed acute hypoxia with increasing ventilatory requirements. Spiral computed tomographic scan of his chest with intravenous contrast demonstrated a large saddle pulmonary embolism (Figure ). Heparin infusion was reinstituted and the rhAPC drip was discontinued after 78 hours of the 96 hour course. Doppler studies of the lower extremities and echocardiography revealed no evidence of deep venous or mural thrombus. Subsequently, the patient weaned from the ventilator and was extubated on postoperative day 8. He was transferred to a hospital ward and oral anticoagulation was begun on postoperative day 9. The patient was discharged on postoperative day 13 on oral anticoagulation with an INR or 2.2. |
A 57-year-old Nepali female presented to the emergency department with right lower quadrant abdominal pain and associated mass. She never had any previous episodes of pain and denied trauma to the area. The mass was first noted 2 years before presentation. It was initially the size of a pea, and had grown in size over the last 2 years. On exam, the patient had an erythematous non-pulsatile, 2 × 3 cm2 mass that was non-tender to palpation. The mass had a positive doppler signal, and the patient had palpable dorsalis pedis and posterior tibial pulses bilaterally.\nOn CT and ultrasound imaging of the abdomen, the patient was found to have an anomalous venous connection between the left and right saphenous veins. The connection traversed across the anterior abdominal wall and contained an aneurysmal segment close to the right saphenofemoral junction that was 3.6 cm in diameter and was partially thrombosed (Figs and ). The patient had a duplex ultrasound on hospital day one that showed the femoral veins to be patent bilaterally. Systemic anticoagulation was started with warfarin. On hospital Day 2, the patient’s pain improved and she was subsequently discharged on warfarin therapy before her INR was therapeutic with an outpatient lower extremity venous duplex to ensure no further progagation of the thrombus.\nFour days after her initial presentation, her venous duplex showed acute deep venous thrombosis in the left common femoral vein with more subacute thrombus in the left popliteal vein, the left greater saphenous vein and the left lesser saphenous vein. The patient was referred to the emergency department from the outpatient imaging facility and her INR was found to be 1.7. She was given therapeutic subcutaneous enoxaparin injections and discharged with instructions for her continued outpatient warfarin therapy.\nThe patient then presented to the emergency department on the sixth day after initial presentation with chest pain and dyspnea. Her INR was now 2.3. On CT imaging of the chest, it was discovered that the patient had a pulmonary embolus in a right lower lobe posterior segmental arterial branch. She was subsequently admitted and placed on therapeutic heparin. Her symptoms quickly resolved and she was discharged on warfarin therapy with a therapeutic INR. |
A 30-year-old systemically healthy male patient presented with a chief complaint of growth in the mouth involving lower-left back teeth region of the jaw. The patient had noticed a small painless growth about few years back. There was a very gradual increase in size, which led to discomfort while eating as the extent of growth had reached the occlusal plane [] since 3 months. Patient also complained of interference of growth while chewing and food lodgement between molars. Patient complained purulent discharge and constant dull pain in the same region. There was no history of intake of any hormonal supplements, but the patient was given antibiotics by some dentist for the same.\nThe extraoral examination did not reveal any facial asymmetry. Lymph nodes were not palpable. Intraoral examination revealed a solitary diffused growth, pale bluish red in color, measuring around 2×1.5 cm seen in the interdental region in relation to the left first molar and second molar region that did not extend lingually []. The superior surface of lesion showed indentation of the upper teeth as a result of surface ulceration. The growth was pedunculated. There was no mobility or pathological migration of any of the molars was not present. Pus discharge while probing []. Oral hygiene of the patient was fair.\nThe intraoral periapical radiograph of teeth 46 and 47 region revealed widening of the periodontal ligament space, marked interdental bone loss with change in the trabecular pattern of bone. Roots of the involved teeth did not show any signs of resorption []. The occlusal radiograph did not show the expansion of bony plates.\nBlood examination revealed normal values. The treatment comprised of oral prophylaxis and surgical excision of the growth by gingivectomy procedure under local anesthesia.\nAlthough many treatment techniques have been described for PG, when it is large or occurs in a surgically difficult surgically area, choosing an appropriate treatment modality can be difficult. Excisional biopsy is indicated for the treatment of PG. Except when the procedure would produce marked deformity: in such a case, incisional biopsy is mandatory. Conservative surgical excision and removal of causative irritants (plaque, calculus, foreign materials, and source of trauma) are the usual treatments[] for gingival lesions.\nHere, local anesthesia 1 : 80,000 given to the patient and abscess was drained with the help of the periodontal probe. In this case, PG was associated with periodontal abscess and bone loss, so interval bevel gingivectomy was performed. The flap is designed in the manner that removed lesion form interdental papilla. Periosteum reflected and exposed the underlying bone [].\nAfter complete degranulation and scaling, root planning angular defect was filled with G-BONE® bone alloplast (hydoxyapatite + tricalcium sulphate) [] and flap was sutured. Periodontal pack was given for facilitate healing. The biopsy specimen was sent for the microscopic examination.\nTen days later, periodontal pack and suture were removed and satisfactory healing of the gingiva was seen.\nPatient revisited after 3 months. Complete healing of the operated area was observed at 3 month follow-up visit []. Radiograph also shows sign of bone fill [].\nHistopathological findings in the photomicrograph shows hematoxilin–eosin-stained section showing the overlying epithelium had hyperplastic parakeratinized stratified squamous epithelium exhibiting areas of pseudoepitheliomatous hyperplasia []. Highly vascular connective tissue exhibiting numerous small and large endothelium-lined channels engorged with red blood cells. Thickened wall of blood vessels, proliferating endothelial cells and few lymphatic vessels were evident. Mixed inflammatory cell infiltrate consisting predominantly of neutrophils and lymphocytes were also seen []. There was no evidence of atypia or malignancy. The clinical and histopathological features were suggestive of PG. |
A 56-year-old man presented to the emergency department with 5 days of abdominal pain, diaphoresis, nausea and vomiting. He had been unable to tolerate any food for the previous 48 hours. He was otherwise healthy and took no medications. He had no history of prior surgery.\nOn physical examination, he was mildly tachycardic, diaphoretic, normotensive and had a mildly distended abdomen with diffuse tenderness without peritoneal signs. Laboratory results showed a mild leukocytosis with a white blood cell count of 14 K and hypochloraemia, hyponatraemia and hypokalaemia. After intravenous fluid resuscitation, computed tomography of the abdomen showed very dilated proximal small bowel and stomach with extensive inflammatory changes and fat stranding throughout the proximal mesentery (). The distal and colonic mesentery appeared normal.\nHe was admitted to the hospital for electrolyte replacement, and a nasogastric tube was placed to decompress the bowel. The following day his electrolytes had normalized, but his WBC had elevated to 16 K, and he developed peritonitis.\nEmergent laparotomy was performed. He was found to have multiple enlarged necrotic mesenteric lymph nodes with purulent material draining from the capsule of the nodes (). Several large areas of the proximal mesenteric fat were necrotic with vascular occlusion and thrombosis, which was causing ischemia of the proximal jejunum. The proximal jejunum was very dusky and dilated, while the distal small bowel and colon was normal. The duodenum was spared. The necrotic fat and lymph nodes extended down to and around the superior mesenteric artery, where multiple side branches off the artery showed no blood flow by Doppler examination. The ischemic small bowel was excised along with its mesentery down to the superior mesenteric artery, to include the excision of the necrotic lymph nodes (). The bowel was left in discontinuity, and the patient was taken to the intensive care unit with a temporary abdominal closure. He was taken back to the operating theatre the next day for a second look, and the remaining small bowel was found to be viable and healthy. A duodenal to distal jejunal anastomosis was performed and the abdomen was closed.\nThe patient made a rapid recovery and was discharged on hospital day six. The pathology report documented multiple enlarged and necrotic lymph nodes with necrotic mesenteric fat and vascular occlusion, as well as ischemic changes to the intestine. No malignancy was identified. The lymph nodes did not show non-caseating granuloma formation or other granulomas within the nodes. All blood cultures and the operative cultures of the purulent lymph nodes failed to show any bacterial or viral growth. The cultures were also negative for the tuberculosis and fungi. Since the necrotizing process appeared to be non-infectious, an extensive autoimmune work-up was later performed, which was only weakly positive for rheumatoid factor. Double-stranded DNA antibodies, anti-nuclear antibodies, anti-phospholipid antibodies and sedimentation rates were normal. Rheumatology consultation did not result in any additional treatment. The patient was seen back in the office for 6-month and 1-year follow-ups and was back to work and had no recurrence and no additional problems. |
A 33-year-old female patient who was still breastfeeding 10 months after her first natural delivery visited our outpatient clinic because of a left intertrochanteric fracture caused by falling from standing height. Before her pregnancy, the patient had no hypertension, diabetes mellitus, or other chronic diseases. She had no history of long-term drug use, smoking, or alcohol intake. She had not had any operations, did not suffer from hip or femur trauma, and had no family history of osteoporosis or hip fracture. During her pregnancy, the patient had no preeclampsia, eclampsia, gestational hyperthyroidism, or other metabolic diseases. She had no history of chronic diarrhea and never used glucocorticoids, heparin, or other drugs. Calcium 600 mg and vitamin D3 700 IU were supplemented every day during pregnancy, but she discontinued taking calcium and vitamin D after delivery. The patient had never complained about lower back or transient hip pain or a decrease in self-awareness of height during pregnancy and lactation. The patient experienced pain in the left hip after a fall, and could not stand on her left leg. At a physical examination, shortening deformity at the left leg was found, the range of motion in the left hip was restricted because of pain, and there was localized tenderness with palpation on the left hip. Percussion pain in the left lower limb was positive, but there was no tenderness in the spinal process in the thoracolumbar region and paravertebral muscles. Hip radiography () showed a left intertrochanteric fracture. Although the patient never complained about low back pain, magnetic resonance imaging of the thoracic and lumbar spine identified a new compression fracture in the L1 vertebra with marrow edema (). Laboratory test results are shown in . Serum calcium and parathyroid hormone concentrations were in the normal range, and 25-hydroxyvitamin D3 and albumin concentrations were low. BMD was measured with DXA, which showed a reduction in density in the hip and lumbar vertebrae ().\nThe patient was recommended to discontinue breastfeeding. Enhanced nutritional support, additional calcium (600 mg/day), and vitamin D (1200 IU/day) were provided, but she was not recommended to receive other anti-osteoporosis drugs, such as bisphosphonates and teriparatide. The patient underwent open reduction and internal fixation. She was administered dalteparin sodium (0.2 mL/day, 2500 IU) to prevent deep vein thrombosis during the perioperative period and pain was alleviated with celecoxib (cyclooxygenase 2 inhibitor). The patient was instructed to perform muscle strengthening exercises and moderately improve the range of motion in the hip and knee joints, but walking or standing with the left leg was temporarily forbidden.\nThe current report was approved by the ethical board of Capital University Friendship Hospital, Beijing, China. The patient gave verbal consent for scientific application and publication of her clinical data. |
The patient is a 59 year old Caucasian female who lives alone in a council flat and has been known to mental health services for depression with somatic features. She presented to The Oleaster via the Home Treatment Team with worsening symptoms of somatisation and a loss of mobility. These symptoms began over twenty years ago where the patient described severe back and leg pain associated with cramping, paraesthesia, paresis and anergy. She felt this was as a result of a spinal injury she sustained while giving birth to her son. A magnetic resonance image of her spine only revealed disc degeneration. Prior to 2003 the patient had 14 admissions to hospital for these symptoms. Her mental health deteriorated over the days preceding admission and this manifested itself by hopelessness, despair and suicidal ideation. She felt she was a rotting corpse and expressed the wish of wanting to die. There were no current or previous attempts to commit suicide. She was low in mood and suffered from anhedonia. The patient displayed hostile behaviour. She also experienced reduced concentration, early morning awakening and a suppressed appetite. Furthermore, she was unable to shower because of the pain in her legs and consequently her personal hygiene deteriorated. The patient explained that the blood circulation to her legs was compromised therefore resulting in her legs rotting and falling off. In her opinion, she felt she had always been misdiagnosed and was pre-occupied about this. She asked why she was not in a nursing home as my legs are not working, rather than a mental health hospital.\nThe patient also suffered from rumination, constantly focusing on her back and leg pain in addition to conveying somatic delusions.\nShe had previously been discharged from inpatient services only two months prior to this admission. During her last inpatient stay, she was detained under Section 3 of the MHA 2007. Following initial treatment with antipsychotic and antidepressant medication the patient’s mental state did not improve. She was therefore offered ECT and after 2 sessions she refused to have further courses of ECT. The patient at this time appealed against her detention and upon assessment appeared to have capacity. A SOAD was sought to review her capacity status. The SOAD concluded that the patient had capacity and ECT was therefore not viable and consequently it was withdrawn. The patient was subsequently discharged on a community treatment order with follow up in the community.\nPrior to this informal admission, the patient had been functioning well in the community, no longer pre-occupied with her legs and successfully undertaking her activities of daily living. Her marked progress in the community resulted in her Community Psychiatrist reducing the doses of her antidepressant and antipsychotic medication. This reduction in medication exacerbated a relapse of her delusional beliefs.\nShe has a history of hypertension and currently adheres to a depot pipothiazine injection every two weeks and duloxetine. There is no family history of psychiatric illness. The patient was brought up by her mother and stepfather, performing well at school and worked as a legal secretary until the birth of her first child. She was married for 18 years, however, is now divorced and attributes this to the problem with my legs. The patient has a 20 year history of smoking pack year history and previously consumed large quantities of alcohol, however has been abstinent for 1 year. She has never used illicit drugs. There is no forensic history and she independently resides in a council flat, receiving benefits with regular support from her son.\nUpon examination, the patient was dressed in appropriate clothing, however appeared dishevelled and unkempt. She was anxious, rubbing her legs with her hands, and pacing the room. She made poor eye contact, making it difficult to establish a robust doctor-patient rapport. There was no psychomotor retardation. Her speech was normal and she exhibited biological and cognitive features of depression. There was presence of nihilistic delusions as the patient felt her legs were rotting, however, there were no delusions of poverty or guilt. There was no evidence of hallucinations. Cognition was not affected, however, the patient had no insight. She claimed there was nothing wrong with her mental health, attributing all her symptoms to a physical aetiology. The patient’s physical examination was unremarkable and her full blood count, urea and electrolytes and thyroid function tests were normal.\nThe patient was diagnosed with severe depression according to ICD-10, associated with Cotard’s phenomenon. Her medication was readjusted to her previous dose in which her mental state was stable. Initially, during the admission, the patient kept a low profile, minimally interacting with staff and patients. On multiple occasions she fell to the floor, unable to move, stating that she cannot walk as her legs have fallen off. She had very poor dietary and fluid intake and showed evidence of severe weight loss. ECT was explained and offered to the patient in which the patient agreed to consent for therapy. She also requested physiotherapy as she felt this helped with her back pain in the past. Olanzapine was soon added and physiotherapy was discontinued as it was felt this was perpetuating her delusional beliefs. She continued on ECT, anti-depressant and antipsychotic medication. Four weeks later she was reported to be much brighter in herself. Her insight improved with an understanding that there was an element of mental illness, however she still felt this was secondary to physical causes. The pipothiazine depot injection was stopped. After a course of twelve ECTs, the patient was eating and sleeping well, attending to her personal hygiene, her mood was subjectively and objectively euthymic and her nihilistic delusions had resolved. She had no suicidal or homicidal ideations and therefore was discharged from inpatient services.\nShe has been followed up by the Community Mental Health team and agreed to have maintenance ECT. The patient has been undertaking her daily activities, showing no signs of depression and the interval between ECT sessions is soon to be increased. |
A 78-year-old nondiabetic male, presented with two chronic nonhealing ulcers of six months duration, one on the posterior part of left lower leg, measuring 3.3 × 1.8 cm with a fibrinous base and a second cutaneous ulcer on the anterior part of right leg, measuring 3.0 × 2.0 cm with a fibrinous base []. The patient reported a sensation of tightness in and around the ulcer sites with increasing severity. Both ulcers had thick nonhealing edges with a punched out appearance. The patient had been administered previously with various medications, including various types of antibiotics for six months with no improvement in the healing of the ulcers. He was on Tab. methotrexate 15 mg once-a-week for seronegative rheumatoid arthritis from past 10 years. He had no history of psoriasis at any time. He underwent complete blood investigations, which showed no pancytopenia or any other significant hematological abnormality. Culture and sensitivity tests from ulcer sites were repeatedly sterile for bacteria and fungi. Venous and arterial doppler studies of both lower limbs were done to exclude peripheral vascular disease and were normal. In view of underlying rheumatoid arthritis, a biopsy of both the ulcers was performed. There was no histopathological evidence of vasculitis or granulomatous lesions []. After extensively reviewing the clinical and investigational findings, it was found that the appearance and characteristics of the ulcers resembled those of methotrexate-induced ulcer previously reported in the literature. After a detailed discussion with the patient, methotrexate was stopped and the ulcerated lesion was closely monitored. Also, the patient was monitored for any exacerbation of rheumatoid arthritis. Two weeks after withdrawal of methotrexate, the ulcer showed definite signs of healing and by six weeks it was almost complete healed []. No other significant adjunctive wound healing measures were given. There was no exacerbation of symptoms of rheumatoid arthritis. Subsequent to complete ulcer healing, the patient was started on Tab. hydroxychloroquin on the advice of the rheumatologist to prevent recurrence of arthritis. The patient is being followed up from the past three months and remains asymptomatic with no recurrence of ulcers or joint pains.\nThe dramatic healing of the chronic ulcer beginning within about two weeks after stopping methotrexate in the absence of any other adjunctive wound healing measures lends evidence to methotrexate being responsible for causation of the chronic ulcers. |
The patient is a 25-year-old Japanese woman afflicted with athetoid cerebral palsy as a result of a six minutes period of anoxia at the time of birth. Both upper and lower limbs exhibited pronounced involuntary movements and she was rated as level II according to the Gross Motor Function Classification System (GMFCS) []. She presented with a combined crouch and spastic gait pattern. Both hips internally rotated during gait with an equinus foot position, however, she was able to ambulate and ride a bicycle without assistance. She was able to climb stairs one step at a time. She initially twisted and injured the right knee in a fall from a bicycle in 1999. The obvious injury was not pointed out in X-ray examination by the local physician, and the injury was left untreated at that time. She reported an uncomfortable sensation in her right knee since her fall in 1999. She again experienced pain and instability in the right knee while walking and using the stairs in 2001. X-ray, CT and physical examination by another local physician diagnosed an avulsion fracture involving the ACL at the tibial insertion with an intraarticular loose body (Figure A and B). Arthroscopic resection of the loose body and fixation of the avulsed bone fragment under pull-out technique was performed in 2001. Bone healing at the ACL tibial insertion site was not successful and symptoms still remained. An additional surgery for resection of the bone fragment at the tibial ACL insertion was performed in 2003. The patient continued to feel pain and instability when walking after the second surgery, even with the use of the functional ACL brace. Our examination revealed physical findings of involuntary movement, making objective evaluation of ACL function difficult to perform using accurate testing or instruments. Her involuntary movement was increased when she was nervous, such that attaching instrumentation around her leg for testing created anxiety and therefore exaggerated her involuntary movement. Her Lysholm score was 31 points and an International Knee Documentation Committee (IKDC) score was 26.4 []. In addition, she felt a strong sense of discomfort when walking, and the visual analog scale (VAS) was 66 mm on a 100-mm scale. Her popliteal angle was 0°, and no voluntary hamstring contraction was palpated. The patient was able to ambulate using the functional ACL brace. Magnetic resonance imaging (MRI) under sedation indicated that the distal insertion of the ACL was not clear (Figure ). A degenerative change in the posterior horn of the lateral meniscus was also confirmed on MRI.\nThe clinical manual tests for ACL laxity, to include the Lachman and Pivot shift tests had positive findings under anesthesia. Examination using the arthrometer such as Kneelax or KT-2000 was not performed. Arthroscopy revealed the presence of tiny bone fragments at the site of the ACL-tibial attachment, with reduced ACL tension and degenerative tearing of the posterior portion of the lateral meniscus (Figure A and B). Anatomical double-bundle autologous hamstring graft ACL reconstruction and partial menisectomy was performed. Articular cartilage degeneration was noted on the lateral femoral condyle and was classified as Grade II according to the Outerbridge classification. The semitendinosus and gracilis tendons were each double folded to create an anteromedial bundle with a diameter of 7.0 mm and a posterolateral bundle with a diameter of 5.5 mm (Figure ). Using an accessory far medial portal, the respective bone tunnels were created at the anatomical positions proposed by Yasuda et al.[]. The bundles were fixed with the knee at 20° of flexion using an EndoButton CL (Smith & Nephew, Andover, MA) on the femoral side, and a double-spike plate (Meira, Aichi, Japan) on the tibial side.\nCast immobilization with the knee at 20° of flexion was utilized for the first three postoperative weeks to prevent hyperextension due to involuntary movement. Knee extension was restricted to −10° for the first 3 months using the functional ACL brace. Partial weight-bearing was started at 1 week following surgery, with full weight-bearing at 4 weeks. Involuntary leg movements made an effective strengthening protocol impossible to perform, so the functional ACL brace was kept in place for 6 months following surgery. Isokinetic strength measurements were also not taken due to her involuntary movement. In addition, accurate assessment with manual examination techniques, such as the Lachman test, or objective measurements of joint stability with an arthrometer were also omitted due to her involuntary movements. Postoperative evaluations were therefore performed using stress radiography with the knee at 90° of flexion, pulling the tibia forward, to evaluate the anterior displacement rate of the tibia based on the results of midpoint measurements (Figure A) []. Stress radiograph evaluation at 6 months following surgery showed a 63% anterior displacement of the tibia. This finding indicated that the reconstructed ACL had appropriate available tension (Figure B), so the knee brace was removed. The stress radiography of the contralateral, non-injured, knee showed a similar 60% anterior translation of the tibia (data not shown). Moreover, preoperative knee instability had disappeared, and the patient expressed a high degree of satisfaction with the postoperative results. The patient felt no knee pain or instability during the course of activities of daily living or even when walking quickly at 8 months after the operation.\nExamination of the patient 1 year after surgery revealed a Lysholm score of 72 points and an IKDC score of 64.4. The patient continued to feel no knee pain or instability with activities of daily living or when walking quickly. VAS evaluation was scored at 0 mm, with absolutely no pain or sense of discomfort. She did have tenderness upon palpation of the tibial fixation devices.\nA second-look arthroscopic evaluation was performed 13 months following the ACL surgery and removal of the fixation devices. The Lachman and pivot shift tests performed under anesthesia remained negative. Examination using the arthrometer such as Kneelax or KT-2000 was not performed. Both bundles of the reconstructed ligament were intact. These results were excellent based on the evaluation criteria defined by Kondo (Figure ) [].\nThe patient examination at 36 months following the ACL reconstruction revealed a Lysholm score of 81 points and an IKDC score of 75.9. The stress radiographic evaluation at 36 months following ACL surgery indicated a 61% anterior translation of the tibia (Figure ). The patient was able to walk, jog, and ride a bicycle without aid, knee pain, instability or the previous uncomfortable sensation. |
A British Caucasian girl aged 15 years presented to our institution with a double thoracic scoliosis. She was diagnosed with TCS type 1 on the basis of clinical findings and genetic testing. As part of the underlying condition she had bilateral conductive hearing impairment treated with hearing aids. She also had a mild degree of micrognathia with good mouth opening and lower jaw protrusion. There was no history of chest or upper airway infections and she had an effective cough. There was no family history of syndromic conditions or scoliosis.\nThe development of a scoliosis was first noted at the age of 14 years. No treatment was given at that stage and the deformity gradually progressed. At presentation to our clinic, she was post-menarche with height 162.7cm, arm span 171cm, body weight 50.6kg, and body mass index 31.2.\nOn clinical examination, she had a severe right thoracic scoliosis which was rotated to the right and was producing a marked prominence of the rib cage and scapula adjacent to the convexity of the curve. There was also thoracic translocation and listing of her trunk to the right with associated waistline asymmetry and prominence of the left side of her pelvis. A left upper thoracic scoliosis was present and this resulted in levelling of her shoulders. Her pelvis was level with no evidence of leg-length discrepancy. There were no skin or soft tissue abnormalities overlying her spine. She reported no neurological abnormality. A neurological examination confirmed normal tone, muscle power, sensation and tendon reflexes in her upper and lower limbs, as well as symmetrically elicited abdominal reflexes. There were no upper motor neuron signs.\nRadiographs of her spine during initial assessment in our clinic revealed a right thoracic scoliosis extending from T6 to L1 and measuring 90° and a left upper thoracic scoliosis extending from T1 to T6 and measuring 51°. Thoracic kyphosis was within normal limits but lumbar lordosis was increased with an overall negative sagittal balance of her spine. The radiological evaluation excluded the presence of congenital anomalies affecting her vertebral column and chest wall. There were no features suggestive of congenital spinal stenosis and the interpedicular distance was within normal limits across all spinal segments. Her Risser grade was 2 with closed triradiate cartilage bilaterally, indicating that she had been through the most rapid stages of skeletal growth.\nDue to the severity of her scoliosis the decision was made to proceed with surgical correction. In the presence of the underlying syndromic condition, a preoperative assessment was organised and this included spinal magnetic resonance imaging (MRI), and cardiac, anaesthetic and respiratory reviews.\nHer spinal MRI demonstrated no intraspinal anomalies, normal appearance of the pedicles and no evidence of spinal stenosis. The cardiology evaluation including electrocardiogram and cardiac ultrasound showed normal function. The respiratory review including chest radiographs, capillary blood gas sample and sleep studies demonstrated a restrictive pulmonary disease with forced expiratory volume in 1 second 51% and forced vital capacity 62% predicted. The anaesthetic evaluation did not demonstrate any significant airway anomaly that could complicate intubation and confirmed the patient’s fitness to undergo scoliosis surgery. Blood test results including full blood count, urea, electrolytes, liver function tests, C-reactive protein, and coagulation screen were within normal limits. At the time of surgery, 5 months following her initial clinical presentation, progression of both thoracic curves was noticed to 102° and 63° (Figure ). Both curvatures were significantly rigid as evidenced by supine maximum traction radiographs.\nOur patient underwent a combined single-stage anterior and posterior spinal arthrodesis extending from T2 to L4 vertebrae with the use of pedicle hook, sublaminar wires and pedicle screws, and rod instrumentation at age 15 years and 5 months (Figure ). The anterior procedure included an open right thoracotomy through an incision along the length of the 8th rib which was excised subperiosteally. Her spine was exposed from T5 to T12 and 7-level discectomies with anterior thoracoplasties that were performed to increase flexibility and allow correction of the rigid deformity. During the posterior stage, a subperiosteal exposure of her spine to the tips of the transverse processes with extensive facetectomies was performed in order to further mobilise the curve. This was followed by an interfacetal and intertransverse arthrodesis using locally harvested bone from the spinous processes and supplemented by autologous rib graft. Posterior instrumentation was used to correct the deformity and the corrective manoeuvers included apical segmental translation, rod de-rotation, as well as proximal/distal distraction/compression of the construct. Intraoperative spinal cord monitoring was performed throughout the surgery recording cortical and cervical somatosensory and transcranial electrical motor evoked potentials and there were no problems. Postoperatively, she was transferred to our intensive care unit (ICU) intubated with a right chest drain.\nOur patient was extubated on the first postoperative day and remained in the ICU for a total of 6 days. During the initial postoperative period, her nutrition was maintained with nasogastric feedings. There were no neurological abnormalities and she gradually mobilised out of bed without external support to the spine. She received intensive respiratory physiotherapy as there was evidence of a small bilateral pleural effusion which required placement of a pigtail catheter in her left chest cavity. Non-invasive ventilation was not required. She was discharged on oral feedings 14 days after admission and made an uneventful recovery. Postoperative radiographs showed correction of her right thoracic scoliosis from 102° to 25° and the upper thoracic scoliosis from 63° to 24° with a balanced spine in the coronal and sagittal planes (Figure ).\nAt latest follow-up 3 years after surgery, she had no complaints of her back and she had returned to normal activities including sports. She was skeletally mature as determined by the complete development of the iliac apophysis (Risser grade 5). Repeat spinal radiographs demonstrated no loss of scoliosis correction across the instrumented levels and no detected pseudarthrosis. There was also no evidence of add-on junctional deformity either above or below the levels of the spinal fusion. |
The patient is a 30-year-old pregnant woman, gravida 1 para 0, 170 cm and weighted 82 kg at 18 weeks’ gestation. Her initial NIPT result showed an unexpected 5 Mb deletion and 9 Mb duplication on the short arm of chromosome 18. Because of the rare discovery, the patient was then referred to us for genetic counseling sessions and further genetic tests were issued with the complete consent of her parents to investigate if the pregnant woman, her biological parents and the fetus were healthy. After cytogenetic and molecular examinations, a rare de novo 18p terminal deletion with inverted duplication was identified in the pregnant woman, but her parents and the fetus were normal.\nThe course of her pregnancy was uneventful with the exception of hypothyroidism at 7 weeks’ gestation and treated with Euthyrox from then on. Despite an uneventful family history, the patient had a healthy appearance with slightly poor and slow verbal performance, and she also gave trained answers to certain scenes or questions during genetic counseling sessions rather than engaging herself in independent and creative dialogue. The patient and her family were unaware of the 18p rearrangement. Past medical record only included binocular strabismus as a dysmorphic feature, which was corrected by surgery at the age of 7. Additionally, the patient was discovered to have mild intellectual disability with an intelligence quotient (IQ) value of 78 (evaluated using the Urban version of Chinese Wechsler young children scale of intelligence), and speech delay at the age of 10. Furthermore, according to her parents, she also had perception deficits to stereoscopic structures, some difficulties with mathematics, and a history of epilepsy before adulthood.\nThe patient has been adequately cared and supported by her family, receiving good education and training since childhood. Currently the patient works full time. Overall, it is difficult to observe any significant abnormality in the patient without close contact or professional examination. Given this, we recommended that her family should continue to take care of the patient, and if she would want to be pregnant again, the prenatal diagnosis or assisted reproductive technology combined with preimplantation genetic testing might be a good option for the birth defect prevention. |
A 41-year-old Caucasian man presented to hospital with intense pain in his right forearm. The pain exhibited a gradual onset over 2 days, but was abruptly worsened following the simple task of tightening a screw with a screwdriver. His background was from a middle class family with no known risk of hereditary disease. He was in a stable relationship and the father of two children, both in their twenties, from a previous marriage. After completing high school he had earned a university degree in education of children with disabilities, which was also his current profession. His alcohol consumption was moderate and he did not smoke tobacco. Despite his relatively young age, his medical record contained a comprehensive list of previous diseases. At age 25 he underwent fundoplication because of gastric reflux. The procedure was repeated 3 years later due to persisting symptoms. At 29 he was diagnosed as having Hodgkin’s lymphoma. He initially received combination chemotherapy of doxorubicin, bleomycin, vinblastine, and dacarbazine, but this was terminated due to development of leg weakness. To compensate for chemotherapy intolerance, he subsequently received radiotherapy toward lymph nodes in his neck with a total of 40 gray. Consequently, he developed hypothyroidism as a side effect.\nHe had previously been on thyroid hormone replacement therapy for 7 years. During these years he had been changing the thyroxine medication from synthetic levothyroxine to a preparation derived from porcine thyroid glands, before ending up with a combination of the two. The previous 6 months he had expressed frustration over a general lack of well-being, claiming that the current thyroid hormone replacement therapy did not improve his symptoms. During several visits to his endocrinologist he had communicated a strong desire to discontinue thyroxine hormone replacement therapy completely, in order to see whether it would make him feel better. The idea was supported by his endocrinologist, provided that he, the patient, would be willing to control thyroid function every week, in collaboration with his general physician. In the months leading up to the decision to abandon levothyroxine therapy completely, our patient’s medical record indicated that he was on a natural preparation derived from porcine thyroid glands corresponding to a daily dose of 19 μg of levothyroxine and 4.5 μg of liothyronine in addition to 50 μg of levothyroxine 4 days a week and 25 μg of levothyroxine the remaining 3 days. Approximately 3 months after he had in fact discontinued thyroxine hormone replacement therapy completely, he found himself being examined in the emergency unit because of acute severe pain in his right forearm. At the time of admission, his regular medication included esomeprazole 40 mg twice a day and 100 mg of ferrous sulfate once a day only.\nDuring clinical examination in the emergency unit after midnight, severe pain was located on the dorsal side of his right forearm. His arm appeared swollen on examination, but the overlying skin was completely normal. A brief neurological examination revealed reduced sensibility to sensation on his right forearm compared to his left, especially on the ulnar side. Brachioradial reflexes were normal on both sides, whereas biceps and triceps reflexes were unsuccessfully elicited on either side. Reduced muscular power was described in his fingers and wrist on the right side, but our patient spontaneously disclosed that this was due to the pain being increased during contraction of these muscles. His blood pressure was 165/102 mmHg, pulse 90 beats/minute, respiratory rate 22 per/minute, and rectal temperature 37.0 °C. He did not present any obvious symptoms or clinical signs frequently seen in hypothyroidism, such as lethargy, hair loss, cold intolerance, or myxedema. His creatinine kinase was elevated to 1659 IU/L (range 40–280). The results of a screening of blood tests including complete blood count, liver function tests, renal function tests, and C-reactive protein were all within the reference range. The resident surgeon ordered overnight elevation of our patient’s arm and opioid analgesics. Despite repeated administration of orally administered analgesics (1 g acetaminophen every 6 hours, 50 mg tramadol hydrochloride once) and intravenously administered opioid analgesics (5 mg oxycodone every 2 hours for 8 hours, followed by 5 mg morphine every 2 hours for 8 hours), he continued to complain of intense pain in his right forearm. The next morning a clinical evaluation of our patient revealed no improvement in pain or edema. His creatinine kinase had increased slightly to 1722 IU/L, and the surgeon on call diagnosed our patient as having compartment syndrome and referred him for immediate surgery. A preoperative computed tomography (CT) scan was performed, which revealed edema in the extensor carpi ulnaris muscle (Fig. ), but no signs of an underlying process such as bleeding, tumor, or abscess. Complementary blood tests revealed a thyroid-stimulating hormone of 30.5 μIU/ml (range 0.2–4.3) and free thyroxine of 7 μmol/L (range 9–22), indicating hypothyroidism. A summary of the blood samples and their timing is provided in Table . After induction of general anesthesia by a combination of remifentanil (1 μg/kg per minute), propofol (180 mg), succinylcholine (80 mg) and fentanyl (200 μg), a straightforward fasciotomy was performed. The diagnosis of compartment syndrome was subsequently confirmed by the bulging of the affected muscle following opening of the fascia.\nThe surgery successfully removed the intense pain of our patient’s forearm. However, a new problem surfaced in the postoperative ward, where he started complaining of similar intense pain in both calves, only a few hours after recovering from the forearm fasciotomy. Upon examination of his legs 3 hours after the forearm fasciotomy had been completed, his calf muscles appeared swollen, but soft and there was no clinical sign of compartment syndrome or myxedema. An ultrasound examination of his lower extremities was performed, but showed open deep veins bilaterally, excluding venous thrombosis as a source of the pain. The pain subsequently increased over the next few hours, but responded to elevation and opioid analgesics (5 mg oxycodone intravenously administered every 2 hours for 6 hours). The next morning, 18 hours after the forearm fasciotomy, the pain in his calves was still present but less severe and thyroid hormone replacement therapy was initiated with a levothyroxine dose of 50 μg a day. Over the next few days the pain in his calves gradually subsided, before disappearing completely on day 3 after the surgery. The edema of his forearm muscle also diminished over the next few days and the skin was closed on day 6 after the fasciotomy.\nOur patient was followed regularly by an endocrinologist after he was discharged from hospital. His thyroid function stabilized on a substitution regime of 10 μg of liothyronine a day, in addition to 150 μg of levothyroxine 4 days a week and levothyroxine 125 μg the remaining 3 days of the week. Eight months after discharge he was seen by a neurologist. A full neurological examination only revealed normal findings, specifically demonstrating symmetrical and normal power, and normal sensation and function of his hand and wrist. |
A 55-year-old caucasian man underwent OLT for alcoholic cirrhosis. Prior to transplantation the patient only had a minimal amount of ascites. Apart from atrial fibrillation he had no other comorbidities. The transplant procedure and the early postoperative course were uneventful. The patient was discharged home on the 9th post-operative day with normal liver function tests and in good general condition. Three months post transplantation he presented with prominent ascites resistant to conventional diuretic treatment.\nAll of the typical causes of post-transplant ascites were initially excluded. There were no signs of bacterial peritonitis, and paracentesis revealed ascitic fluid to be transudate. Doppler ultrasound and computed tomography were normal, showing patent anastomoses and no other morphological or vascular abnormalities. Liver biopsy showed no signs of graft failure or rejection. Liver function tests and other laboratory values were within normal limits. Apart from atrial fibrillation, there were no abnormalities in the cardiac status. Heart ultrasound showed mild mitral insufficiency with a slightly elevated pressure in the right ventricle. The ascites was explained by poorly regulated atrial fibrillation aggravated by mild anemia which upon correction improved slightly.\nApart from atrial fibrillation the patient had no significant past medical history prior to transplantation.\nThe patient had no significant personal or family history.\nEighteen months post transplantation he developed dyspnea with severe fatigue and peripheral edema with prominent ascites and a significant weight gain. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology.\nCardiac catheterisation revealed slightly elevated pressures in all four chambers and equalization of diastolic chamber pressures also known as the square root sign. This is the typical presentation of constrictive pericarditis and computed tomography showed excessive pericardial calcifications (Figures and ). The patient underwent an open pericardiectomy. The procedure was complicated by acute kidney injury which required intermittent hemodialysis. This was followed by improvement of the patient’s general condition as well as of his renal function. There were no other complications related to the procedure. Following pericardiectomy, ascites improved dramatically with complete regression of all symptoms. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft. |
Our case is that of a 43-year-old primiparous woman. She was diagnosed with Behçet disease at the age of 34 years; she presented with recurrent oral ulceration, recurrent genital ulceration, and pseudofolliculitis with characteristic acneiform nodules. She had no eye lesions. Her condition was well controlled with prednisolone (PSL) 8 mg/day oral dose. She fell pregnant spontaneously and visited our perinatal center for her prenatal care. As she was detected with hypertension at her first visit, we recommended that she check her blood pressure regularly at home. She developed fever, oral ulcers, and arthralgia at 16 weeks of gestation, due to which a relapse of Behçet disease was suspected. Because her condition was controlled well with PSL, the daily oral dose of PSL was increased from 8 mg to 10 mg. At this time, ulceration and pain of the vulva were not observed. She visited our outpatient clinic for a regular prenatal examination at 18 weeks and 4 days of gestation, which was when an ulcer localized in the vagina was incidentally observed (). The ulcer was painless and the patient had no symptoms in the vulva either (). Chlamydial and gonococcal infection were not detected, and cytology of the vaginal wall showed no findings suggesting malignancy. As the other symptoms of Behçet disease were resolved after the dose of PSL had been increased, the same dose was maintained. At the next prenatal care visit, at 22 weeks and 4 days of gestation, the vaginal ulcer had disappeared and other symptoms of Behçet disease were not seen. At 28 weeks and 0 days of gestation, atypical genital bleeding and vaginal ulcer recurrence were observed (). At the same time, recurrence of the oral ulcer and arthralgia as well as a mild increase in the fever were observed; based on these symptoms, she was diagnosed with a relapse of Behçet disease and the daily dose of PSL was increased from 10 mg to 15 mg. The vaginal ulcer disappeared at 29 weeks and 2 days of gestation (). Thereafter, there was no relapse of the symptoms of Behçet disease.\nAt 33 weeks and 0 days of gestation, her blood pressure had increased, due to which she was admitted to the hospital. She was diagnosed with severe preeclampsia superimposed. Induction of labor was conducted but it was not effective, and we performed cesarean section at 37 weeks and 6 days of gestation. She delivered a male infant weighing 2002 g. There were no complications in the postoperative course, and she was discharged with her baby at 7 days after cesarean section. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery.\nThe patient was explained about the possibility of publishing this case as a case report and the accompanying images. She provided consent. |
A 66-year-old woman presented with severe osteoarthritis of both knees. Her weight was 89 kg and body mass index was 33. She had no other medical or surgical history. She subsequently underwent bilateral simultaneous total knee replacement surgery under general anaesthesia and with the use of tourniquet throughout. A standard medial parapatellar incision was used. A rotating platform prosthesis (LCS, Depuy, Warsaw) with uncemented femoral and tibial components was utilised, and the patellae were resurfaced with a cemented all polyethylene patella components. A satisfactory intraoperative result was obtained in both knees with a range of movement from 0 to 125. The deep layer of the medial collateral ligaments was partially released from the tibia for access during the procedure but no other soft tissue releases were required. The patient made an uneventful initial postoperative recovery and was discharged at day five after surgery. At 2 weeks after operation, she had obtained a range of motion of 0 to 90. At 10 weeks after operation she presented with a range of motion of 30 to 75 affecting the left knee only. By 12 weeks, she had decreased this range of motion of 40 to 75 with the left knee and 5 to 75 affecting the right knee. She had suffered no trauma to the knee. Blood tests revealed a CRP of 9, ESR of 85, and WCC of 4.7. Aspiration of the joint did not reveal any evidence of infection. X-rays showed calcification around the knee including the quadriceps tendon (Figures , , and ). After a review of the literature, a decision was made to treat the loss of range of motion nonoperatively, with nonsteroidal anti-inflammatory medication (Diclofenac 50 mg tds) and other regular types of analgesia and physiotherapy. Physiotherapy consisted of weekly session focusing on range of movement exercises with additional sessions of hydrotherapy. Symptoms gradually improved and by 8 months she had regained a range of motion of 10 to 100 degrees in the left knee and 5 to 105 degrees in the right knee. |
A 79-year-old male patient presented with a painless tumor of the right cheek, located below and laterally to the right zygomatic bone. The mass had existed for at least six months and was slowly increasing in size. Hypertension, diabetes, hyperuricemia, and hypercholesterolemia were mentioned in the medical history. No previous significant pathology or surgery was reported in the head and neck area. Computed and magnetic tomography, with 1.25 mm thickness cuts in the transverse plane and with image reconstruction cuts of 1.25 and 2.5 mm in coronal and sagittal planes, respectively, revealed a lesion of 1.64 cm × 4.8 cm in dimensions which occupied the right buccal space, originating from the right major zygomaticus muscle, and extending to the right anterior part of the parotid gland (Figures and ). There was homogeneity in composition with a distinguishable contrast intake in comparison with the healthy side and discrete vessels throughout the circumference of the lesion. The tumor had smooth outlined limits with projections in the anterior area of the right parotid gland and the lateral portion of the masseter muscle. A malignant lesion in the buccal space could not be excluded from the differential diagnosis. However, the characteristics of the lesion were not exactly compatible with typical malignancies of the area, including salivary gland carcinoma and lymphoma. Blood tests did not reveal any specific findings, with white blood test count on the lower normal levels. The patient did not present any B-type symptoms or showed any signs of localized lymphadenopathy. FNA biopsy was performed, retrieving numerous lymphocytes and nonspecific atypical cells, and was characterized as nondiagnostic (). The patient refused to undergo a second FNA biopsy. The decision for excision under general anesthesia was then taken as the possibility of a malignant lesion could not be excluded. The patient underwent resection through a modified parotidectomy incision (Figures –). The tumor was meticulously dissected and found to macroscopically infiltrate the anterior border of the parotid gland and deeply infiltrate the ipsilateral masseter muscle. Specific attention, with the aid of nerve monitoring, was taken for the identification and preservation of buccal and marginal branches of the facial nerve. A significant portion of the masseter muscle had to be excavated along with the tumor, and the specimen was eventually followed into the buccal fat pad and removed after careful identification of the parotid duct. Meticulous hemostasis and wound closure in layers with a closed-suction drain followed. Recovery from surgery was uneventful.\nPermanent histology described a solid white/brown ulcerated neoplastic mass with a maximum diameter of 5.3 cm (). Infiltration was found by a lymphohyperplastic neoplasm, with diffuse architecture containing small modified lymphocytes, prolymphocytes, and immunoblasts that built multiple proliferation centers. Immunohistochemistry was CD20+, PAX-5+, CD3−, CD5+, CD23+, CyclinD1, CD43+, CD10−, BCL6−, MUM1−, Ki67 15%, and Cd30 2%. These findings were compatible with chronic lymphocytic leukemia/lymphoma, and the patient was referred to the hematology department for further management. Staging was performed and revealed stage IVA B-lymphocyte lymphoma, with extralymph node spreads in the parotid area and thoracic paravertebral region (T5-T11) of the spinal cord, but without infiltration of the bone marrow. A management decision of watchful waiting was taken by the hematologists, and the patient was placed on close follow-up. One year later, the patient has remained clinically stable, and imaging findings are invariable. |
Our case is a 13-year-old Arabian girl who presented to our institution referred from a periphery center with 3 days’ history of colicky abdominal pain, vomiting, and constipation. She did not report any previous episodes of constipation. She was reviewed at our emergency department and was found to have a distended tympanic abdomen that was soft all over with no tenderness. Bowel sounds were sluggish and a digital rectal examination revealed an empty rectum. A plain abdominal film showed a hugely dilated loop of bowel, arising from her pelvis, which had the appearance of a coffee bean (Fig. ). The plain abdominal radiograph confirmed the presence of a sigmoid volvulus. A rectal tube was inserted carefully to decompress the volvulus which succeeded and gave her immediate relief from her symptoms. She was admitted to our pediatric surgical ward and had a nasogastric tube inserted and was started on intravenously administered antibiotics. The next day she was asymptomatic but a contrast enema showed the twist to be evident with an incomplete obstruction (Fig. ). Due to the findings on contrast enema she went for endoscopic decompression of the volvulus under general anesthesia. The twist was causing venous congestion and was successfully reduced (Fig. ). A rectal tube was left in place post endoscopic reduction for 24 hours. She was asymptomatic thereafter but her parents requested discharge and they were granted their wish as they wanted to travel to their country. In her country she was investigated and was advised conservative management and observation. A month after her previous attack, and after she had returned to Bahrain from her native country, she presented with the same signs and symptoms that she had in our institution with the same radiological findings but this time the volvulus could not be decompressed by a rectal tube at the emergency department or by endoscopy (Fig. ). Her parents were advised that she should undergo surgery to which they consented. As this was considered an emergency, her bowel was not prepared. She was taken to an operative room 24 hours after the failed endoscopy reduction. She underwent laparotomy with the finding of the sigmoid occupying her whole abdominal cavity and was found on delivery to be hugely dilated with a 360o twist. There was no evidence of gangrene of the bowel and the rest of her colon was healthy and normal (Fig. ). We performed a sigmoidectomy with primary anastomosis (Fig. ). The resected sigmoid showed no features of ischemia, but evident features of chronic inflammation and abundant ganglia (Fig. ). Postoperatively she had paralytic ileus that resolved after 10 days. Following that she did well and was discharged home on the 12th postoperative day. She is still free of symptoms 1 year after her resection. |
A 34-year-old, healthy male patient was referred to the Department of Conservative Dentistry and Endodontics with the chief complaint of pain in the lower right back tooth from two weeks before.\nClinical examination of the involved region revealed a carious lesion involving the occlusal surface of the crown of the mandibular right second premolar, the tooth was tender to percussion, with no periodontal pockets and was in the physiologic range of mobility. Pulp vitality testing with an electric pulp tester revealed an exaggerated response compared to the clinically normal adjacent and contralateral teeth. Cold and heat testing of the tooth also showed a positive response. The pre-operative radiograph of the tooth () confirmed the occlusal carious lesion approaching the pulp and there was discontinuation of the apical lamina dura.\nThe wide pulp canal space till the middle third of the canal showed a sudden thinning that led to the suspicion that there was a variation in the morphology. An angled radiograph showed that the mandibular first premolar also showed a similar morphology. () The radiograph of the contralateral side also showed a similar morphology. ()\nBased on the clinical, radiologic and electric pulp testing findings, a diagnosis of acute irreversible pulpitis with acute apical periodontitis was made and a nonsurgical endodontic treatment was planned. The treatment plan was explained to the patient and his consent was obtained. The tooth was anesthetized with 2% lidocaine solution with adrenaline through inferior alveolar nerve block injection of the right side and a standard access cavity was prepared after rubber dam isolation on the mandibular right second premolar. The oval access cavity preparation revealed two canal orifices that was then modified to a triangular shape to reveal the third orifice ().\nThe pulp was extirpated from all the three canals and the working length was determined using an electronic apex locator (Root ZX, J. Morita, USA) and it was confirmed using a radiograph ().\nThe canals were explored and a glide path was established using #10 and #15 K files (Mani Inc. Japan). The cleaning and shaping was then carried out with a crown down technique using ProTaper Universal (Dentsply, USA) NiTi rotary files with copious irrigation using 3% sodium hypochlorite and normal saline solution. The canals were filled with an intracanal medicament (Apexcal, Ivoclar Vivadent, Canada) for ten days for disinfection of the root canal followed by obturation with guttapercha cones and AH Plus (Dentsply, USA) root canal sealer. A post-obturation radiograph was obtained and the coronal access cavity was temporarily restored with Cavit™ G (3M ESPE, USA).\nThe tooth was permanently restored with a dual-cure hard fluoride releasing core build up material by HardCore (Pulpdent, USA) following a week (). The patient was recalled after one week, one month and 6 months later and he was symptom-free with no tenderness on percussion; the follow-up radiographs showed a continuous lamina dura with no periapical changes (). |
A 93-year-old woman visited our hospital with a chief complaint of palpable mass over the right cheek. The mass began to appear about 1 year ago and was gradually enlarged (). On physical examination, a round, 2.0×1.5 cm sized erythematous mass was observed on her right cheek. The patient complained of a slight itching sense, but neither pain nor tenderness was observed. The patient had no specific underlying disease, no history of operation, no history of radiation therapy and no familial history of cancer.\nPunch biopsy was performed at the dermatology department and the pathological findings confirmed the diagnosis of basal cell carcinoma. The patient and her family were hesitant to undergo surgery because of her old age. About 7 months later, the patient revisited us for surgery with a significantly enlarged 5.5×4.5×4.0 cm sized mass (). It was confirmed that the mass began to grow rapidly about 2 weeks ago without trauma or any specific medical history. It showed focal ulceration with yellowish purulent discharge. The patient suffered from pain, and mild tenderness was also observed. However, there was no localized or generalized lymphadenopathy and her facial nerve function was intact.\nWe recommended other radiologic examinations to identify the degree of tumor invasion and metastasis, but those could not be progressed because the patient and her family wanted only a palliative treatment.\nUnder general anesthesia, the mass was widely excised with a safety margin of 5 mm, and superficial parotidectomy was performed because of tumor invasion to the parotid gland (). Based on the result of frozen biopsy, the resection margin was clear, so that we could preserve the facial nerve branches (). The resulting defect was covered with a transposition flap from the ipsilateral posterior auricular area () and the donor site was closed primarily ().\nA histopathologic examination of the excised mass showed a poorly differentiated sebaceous carcinoma with a clear resection margin (). The patient was followed up 10 months postoperatively and the long-term result was satisfactory without any complications (). |
A 47-year-old right hand dominant male working as a stable hand presented to the emergency department of a tertiary trauma and orthopedic referral center following a crush injury to the left hand. The injury had occurred while the patient had been assisting a friend to park a 4 × 4 vehicle. The vehicle had been reversing slowly towards a wall with the patient's hand behind the vehicle. The mechanism of injury suggested axial loading of the thumb between the vehicle and the wall. He presented directly to the emergency department with severe pain, swelling, and an obvious deformity at the wrist. The patient had no background medical or surgical history of note and reported no previous injuries to the affected limb. He was an active smoker of 30 cigarettes per day.\nOn examination in the emergency department, he had significant pain and swelling in the left wrist and forearm. There was a superficial abrasion over the dorsal aspect of the affected hand; however, this was considered to be a closed injury. There was significant tenderness over the carpals, particularly at the trapezium, with associated reduced range of motion at the wrist and thumb. There was no neurovascular compromise or associated tendon injury.\nThe AP radiograph reveals disruption of the continuation of arc I between the proximal border of the triquetrum and the proximal border of the trapezium, with the trapezium displaced in a radial direction (). This represents a volar dislocation of the trapezium. There was no associated fracture of the trapezium or any other associated bony injuries.\nThe patient subsequently underwent closed manipulation under general anesthesia. The surgeon achieved anatomical reduction by gripping the patient's thumb in one hand and applying a distracting force, while simultaneously applying pressure on the radial aspect of the trapezium with the thumb of the surgeon's other hand. The trapezium was stabilized with three 1.6 mm Kirschner wires percutaneously inserted from the radial side. One wire passed from trapezium to scaphoid, one wire passed from trapezium to capitate, and one wire passed from trapezium to trapezoid (). The wrist was immobilized in a below-elbow molded POP thumb spica cast. The patient was discharged later on the same day.\nThe patient remained in cast for a total of six weeks at which point the percutaneous wires were removed in the outpatient department and the hand and wrist were mobilized (). He was referred to the local hand therapy service. Follow-up examination at three months revealed excellent range of motion (wrist flexion 60°, wrist extension 30°, pronation 80°, supination 80°, and radial abduction at base of thumb 60°). He had returned to full manual work activities at 8 weeks postoperatively and was no longer requiring analgesia (). |
A 55-year-old woman with Ollier disease and congenital limb deformities presented to our clinic in October 2013. She was originally diagnosed in April 2011 with progressive right hemiparesis and language and memory problems. Imaging studies demonstrated a large left-sided hemispheric mass []. She underwent a craniotomy and subtotal resection of the lesion that was diagnosed as an anaplastic astrocytoma. The postoperative course was complicated by postoperative hemorrhage, extended mechanical ventilation, a tracheostomy, and a percutaneous endoscopic gastrostomy tube placement. The patient had a very gradual and slow recovery but remained densely hemiparetic in the right leg, with facial droop and cognitive dysfunction. She did not receive any postoperative adjuvant treatment such as radiation or chemotherapy; treatment for the brain tumor was offered to the patient but was declined by her and her family. In 2012, she developed a pulmonary embolism and was anticoagulated with fragmin. In 2013, she had an episode of acute pain in the left forearm, and recommendations for more diagnostic tests to rule out a potential malignant transformation of her bony tumors were declined by the patient who also refused any further diagnostic or therapeutic measures.\nShe was recently seen in the clinic in September 2014 and was remarkably stable despite the lack of any postoperative adjuvant therapy. On examination, she continues to have right facial droop and right hemiparesis but with intact cranial nerves II–XII. Left arm was immobile due to pain but the left leg had full strength. The patient had moderate expressive aphasia but followed requests and answered simple questions easily. There were no spasticity or contractures present. Psychiatric evaluation showed a pleasant, cooperative individual, with poor short-term memory and psychomotor slowing. The husband described typical hypothalamic gelastic seizures episodes, 2–3 brief episodes per month despite the fact that she was on seizure prophylaxis medication. She had an magnetic resonance imaging (MRI) in August 2014 that showed stable disease without any interval []. In addition, we performed an IDH-1 mutation analysis using immunohistochemistry technique that yielded a positive result for the presence of the mutation in the specimen obtained in surgery at 2011 []. |
A 78-year-old-man with chronic renal failure had been on hemodialysis via an arteriovenous fistula on his left arm three times a week for 4 years. He was scheduled for revision of an arteriovenous fistula on the right arm because of occlusion of the fistula. He had a prosthetic mitral valve and an intravenous pacemaker that had been set to 65 beats per minute in ventricular back-up mode for 15 years. The pacemaker had been implanted because he had suffered from acute mitral regurgitation due to rupture of the chordae tendinae associated with myoxomatous degeneration of the mitral leaflets and sick sinus syndrome 2 months after the prosthetic mitral valve surgery. The patient’s medical history also included hypothyroidism and chronic hepatitis B with thrombocytopenia and splenomegaly but not chronic obstructive lung diseases (COPD). Preoperative transthoracic echocardiography (TTE) revealed normal left ventricular (LV) ejection fraction (EF = 53 %) with a restrictive pattern of LV inflow, as indicated by a 2.3 ratio of early transmitral inflow peak velocity to atrial transmitral inflow peak velocity, suggesting elevated left atrial pressure. Moderate pulmonary hypertension was diagnosed, with a 48-mmHg tricuspid valve pressure gradient calculated from the tricuspid regurgitant jet velocity. There were no abnormalities in the native aortic valve or the prosthetic mitral valve.\nIn the operating room, we started continuous electrocardiogram (ECG) on standard lead II, automated noninvasive measurement of blood pressure every 5 min, and measurement of oxygen saturation by pulse oximetry (SpO2). A right supraclavicular brachial plexus block was performed under ultrasound guidance with 30 mL of 0.75 % ropivacaine. After confirming the anesthetic effect of the block, surgery was started 30 min later under the observation of by a registered nurse who worked in the operating rooms. While no sedatives were administered during surgery, the patient was given supplementary oxygen at 3 l per minute via a face mask during the surgery because he reported some difficulty breathing 20 min after injection of the local anesthetic. His complaint resolved soon thereafter. The patient’s blood pressure was stable between 160/75 mmHg and 170/80 mmHg, his heart rate was 70–80 beats per minute, and SpO2 was between 96–100 %. Although an arteriovenous fistula was created within approximately 80 min as planned, inadequate blood flow of the fistula was detected by Doppler ultrasound. The patient consented to immediately undergoing the surgery a second time. About 10 min after surgery began again, he complained of dyspnea and nausea, accompanied by a decrease in SpO2 to 70 %. Oxygen flow was increased to 10 l per minute. Five minutes after that, his SpO2 decreased further to 50 %, and he was unresponsive to verbal commands.Anesthesiologists were called at this time. The patient was unresponsive to verbal and painful stimuli, and his arterial pulse could be palpated easily. Because his breath sounds were diminished, we assisted his ventilation via a bag-mask device, followed by placement of a #5 laryngeal mask airway (LMA). Ventilatory support was continued with 100 % oxygen. SpO2 returned to 100 % soon thereafter, but the patient remained unconscious with stable blood pressure of 155/80 mmHg and heart rate of 75 beats per minute. Gas analysis of a blood sample from the femoral artery showed pH 6.93, pCO2 121 mmHg, and pO2 98 mmHg. We speculated that the loss of consciousness was caused by acute hypercapnia, while the underlying cause remained undetermined. We decided to abort interrupt the surgery, and the surgical wound was closed. A portable supine chest radiograph was not remarkable as compared with the preoperative one, showing hilar haziness of the lung field, no signs for pneumothorax, and a slight elevation of the right hemidiaphragm, with increased density at both lung bases. These findings were compatible with pulmonary congestion (Fig. ).\nWe performed a bedside ultrasound examination to identify the cause of the acute hypercapnic respiratory distress. No apparent changes compared to the preoperative recording were detectable by TTE, including visually estimated LVEF (approximately 55 %). There was lung sliding with A-lines and a normal B-line pattern on the right and left anterior chest walls, confirming the absence of pneumothorax on the chest roentgenogram and ruling out the pulmonary congestion suggested by the chest roentgenogram, respectively. We found that there was no movement of the right diaphragm during the respiratory cycle, while normal respiratory movement of the left diaphragm was visualized by M-mode ultrasound imaging (Fig. ). A diagnosis of right hemidiaphragmatic paralysis caused by phrenic nerve palsy was made. We canceled further examinations such as computed tomography and magnetic resonance imaging. The patient was transferred to the intensive care unit, and positive pressure ventilation was continued for respiratory support via the LMA at 40 % FO2. Spontaneous breathing became increasingly stronger, and he gained full consciousness after 2 h. The LMA was removed, and ventilator support was terminated.\nWe confirmed restoration of respiratory movement of the right hemidiaphragm by means of ultrasonography. The next day he was uneventfully transferred to the ward. A portable chest roentgenogram on that day showed that the right hemidiaphragm was shifted downward, suggesting the restoration of normal diaphragmatic function (Fig. ). A new arteriovenous fistula was uneventfully created under supraclavicular brachial plexus block with 20 mL of 0.75 % ropivacaine 1 week later.\nWe presented a case of hypercapnic respiratory distress and loss of consciousness resulting from transient phrenic nerve palsy associated with supraclavicular brachial plexus block. Interscalene brachial plexus block almost invariably causes ipsilateral phrenic nerve palsy []. However, it is thought to occur less frequently with brachial plexus block via the supraclavicular approach, depending on the amount of local anesthetic used and the techniques employed (e.g., nerve stimulator or ultrasound guidance). Respiratory symptoms are uncommon during the brachial plexus block irrespective of the approaches [].\nWe detected hemidiaphragmatic paralysis in this patient with hypercapnic respiratory distress by means of bedside ultrasonography. There have been few ultrasonographically documented cases of hemidiaphragmatic palsy after supraclavicular brachial plexus block.\nHemidiaphragmatic paralysis is usually asymptomatic at rest, because it is compensated for by other respiratory muscles; at most, it may lead to limitations in exercise []. Urmey et al. [] investigated the effects of hemidiaphragmatic paralysis on pulmonary function during interscalene brachial plexus block and concluded that the block should not be performed in patients who are dependent on intact diaphragmatic function. Hemidiaphragmatic paralysis causes decreased values on pulmonary function tests, such as forced vital capacity, forced expiratory volume, and peak expiratory flow rate []. In addition, it causes abdominal expansion during inspiration, leading to regional hypoventilation in the ipsilateral lower lung and a reduction in gas exchange. These changes are usually compensated for by recruitment of the intercostal or accessory muscles []. However, they may become symptomatic, causing dyspnea or hypoventilation in the supine position because of enhanced shift of the paralyzed diaphragm toward the head []. In addition to the supine position, there are at least two other possible explanation for the development of hypercapnic respiratory distress with loss of consciousness in this patient. First, limited cardiopulmonary reserve may be responsible, as evidenced by the patient’s implanted prosthetic mitral valve and pacemaker and his advanced age of 86 years []. Second, chronic renal failure itself may be a high risk. Afonso et al. [] reported three consecutive cases of respiratory arrest necessitating tracheal intubation in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block; however, the exact underlying causes other than chronic renal failure and obesity could not be delineated. The authors suggested that chronic renal failure may represent a high-risk group for respiratory failure after supraclavicular brachial plexus block.\nOxygen administered via a face mask may have transiently relieved the patient’s respiratory symptoms when he had difficulty breathing soon after brachial plexus block. We speculate that this may have resulted in further depression of respiration and thus in hypercapnia and, consequently, loss of consciousness. Recognition of risk factors for developing symptomatic hemidiaphragmatic paralysis in this patient or earlier examination with ultrasound might have led us to avoid brachial plexus block or to initiate ventilatory support earlier instead of administering oxygen via face mask.\nBedside ultrasound plays a pivotal role in the management of acute respiratory distress and in finding its underlying causes []. M-mode recording of the diaphragmatic dome through a respiratory cycle is an easy way to document a nonfunctioning diaphragm, while in the present case, the supine chest roentgenogram was not conclusive for the diagnosis of hemidiaphragmatic paralysis. Absence of thickening of the diaphragm at the zone of apposition with the rib base is an alternative ultrasonographic technique for the diagnosis of diaphragmatic paralysis [].\nPoint-of-care ultrasound is becoming an essential diagnostic skill for all physicians []. Anesthesiologists routinely use ultrasound machines for procedures such as catheter placement or nerve blocks, as well as transesophageal echocardiography for cardiac surgery. Thus, they are familiar with ultrasound machines and should therefore be able to improve patient care by the addition of diagnostic ultrasonography. Training to ensure competent use of this technology is thus of utmost importance [, ]. |
A 70-year-old male was referred to our hospital with anterior chest pain and a precordial mass in September 2004. He had undergone right radical nephrectomy in July 2002, and renal cell carcinoma, T1aN0M0, stage I, had been diagnosed. Medical follow-ups had been conducted routinely without any treatment. In May 2004, after he experienced anterior chest pain, computed tomography (CT) was performed. This revealed in the sternum a low density mass that gradually increased in size during the following three months. In September 2004, there was an 8 × 7 cm mass, and destruction of some of the cortical bone of the manubrium sterni had occurred, so a CT-guided percutaneous needle biopsy was performed. (Fig. ) The mass was composed of clear tumor cells arranged in an alveolar configuration, and metastatic renal cell carcinoma was diagnosed histologically. (Fig. ) We performed distant metastasis check up and check his physical function preparing for an operation. No evidence of other distant metastases was seen. We took a chest CT prior to the operation after an admission, the tumor shadow was the same comparing with previous chest CT before the biopsy. The patient underwent a partial resection of the sternal bone with wide margin including whole tumor tissue in November 2004. The postoperative clinical course was uneventful and the patient was discharged 11 days later. Pathological examination revealed only granulation tissue which composed of wide bleeding area and necrosis area with strong infiltration of inflammatory cells especially for fibroblasts. The entire resected tissue specimen was checked carefully, but no carcinoma cells were detected. (Fig. ) We judged that a complete, spontaneous regression of metastatic renal cell carcinoma had taken place. The patient's medical history was taken in minute detail in relation to any kind of treatment for renal cell carcinoma, but he had received no such treatment and taken no medication, including alternative medicine, nor had he consumed any "health foods" at any time during the course of the disease. He is now receiving interferon therapy and is in good condition without recurrence for eight months after surgery. |
Our case is that of a 43-year-old primiparous woman. She was diagnosed with Behçet disease at the age of 34 years; she presented with recurrent oral ulceration, recurrent genital ulceration, and pseudofolliculitis with characteristic acneiform nodules. She had no eye lesions. Her condition was well controlled with prednisolone (PSL) 8 mg/day oral dose. She fell pregnant spontaneously and visited our perinatal center for her prenatal care. As she was detected with hypertension at her first visit, we recommended that she check her blood pressure regularly at home. She developed fever, oral ulcers, and arthralgia at 16 weeks of gestation, due to which a relapse of Behçet disease was suspected. Because her condition was controlled well with PSL, the daily oral dose of PSL was increased from 8 mg to 10 mg. At this time, ulceration and pain of the vulva were not observed. She visited our outpatient clinic for a regular prenatal examination at 18 weeks and 4 days of gestation, which was when an ulcer localized in the vagina was incidentally observed (). The ulcer was painless and the patient had no symptoms in the vulva either (). Chlamydial and gonococcal infection were not detected, and cytology of the vaginal wall showed no findings suggesting malignancy. As the other symptoms of Behçet disease were resolved after the dose of PSL had been increased, the same dose was maintained. At the next prenatal care visit, at 22 weeks and 4 days of gestation, the vaginal ulcer had disappeared and other symptoms of Behçet disease were not seen. At 28 weeks and 0 days of gestation, atypical genital bleeding and vaginal ulcer recurrence were observed (). At the same time, recurrence of the oral ulcer and arthralgia as well as a mild increase in the fever were observed; based on these symptoms, she was diagnosed with a relapse of Behçet disease and the daily dose of PSL was increased from 10 mg to 15 mg. The vaginal ulcer disappeared at 29 weeks and 2 days of gestation (). Thereafter, there was no relapse of the symptoms of Behçet disease.\nAt 33 weeks and 0 days of gestation, her blood pressure had increased, due to which she was admitted to the hospital. She was diagnosed with severe preeclampsia superimposed. Induction of labor was conducted but it was not effective, and we performed cesarean section at 37 weeks and 6 days of gestation. She delivered a male infant weighing 2002 g. There were no complications in the postoperative course, and she was discharged with her baby at 7 days after cesarean section. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery.\nThe patient was explained about the possibility of publishing this case as a case report and the accompanying images. She provided consent. |
A previously healthy 38-year-old gravida 1, para 0 was admitted to labor and delivery in active labor at 38 + 5 weeks estimated gestational age. Her prenatal course was complicated by an episode of nephrolithiasis at 28 weeks gestation and gestational hypertension that was diagnosed on her admission. The patient received epidural anesthesia for pain control. She progressed to complete dilation and effacement and began pushing efforts at +1 station. During the second stage of labor, different positioning techniques were utilized while pushing. No further descent of the fetal head was made over the course of four hours despite adequate contractions and active pushing, and she underwent an uncomplicated primary low transverse cesarean section for arrest of descent. She was discharged to home on postoperative day two with no issues noted before discharge.\nThe patient was seen in clinic on postoperative day four for a blood pressure check and complained of difficulty ambulating since delivery, requiring assistance for walking, and mild bilateral lower extremity edema. Upon reviewing her delivery and hospital course, the patient did report that she had some weakness when walking prior to hospital discharge but her symptoms had progressed to the point of needing ambulatory assistance. On examination, she was noted to have a steppage gait, decreased strength of the left lower extremity, and intact sensation to the bilateral lower extremities with bilateral foot drop. The patient also complained of right-sided lower back and buttock pain with movement and intermittent “lightning bolt” sensation to thighs.\nShe was readmitted on postoperative day four for hypertensive control as well as additional evaluation of her lower extremity neuropathy. Anesthesiology and neurology were also consulted given her neuropathy symptoms. The neurology exam was notable for a wide based gait secondary to weakness, grossly intact sensation, and mild weakness on ankle dorsiflexion. Magnetic resonance imaging of the lumbar spine was obtained to evaluate for epidural hematoma, which showed no remarkable findings. Her bilateral plexopathy was felt to be secondary to a common peroneal nerve injury, likely from prolonged pressure to the lateral knee resulting in compression of the peroneal nerve between the fibular head, the biceps tendon, and gastrocnemius muscle during her prolonged pushing phase. Physical therapy was consulted and further evaluation with electromyographic studies was also recommended. She was discharged to home on postoperative day six with adequate blood pressure control on oral antihypertensive therapy and subjectively and objectively improved strength in her bilateral lower extremities.\nThe patient was evaluated on postoperative day 7 reporting significant improvement in pain and ambulation since hospital discharge and declined physical therapy at that time. On postoperative day 14, the patient was again seen in clinic and reported no change in symptoms or gait and a physical therapy consult was ordered as well as a follow-up appointment with neurology for an electromyographic study. The patient did not follow up with physical therapy or neurology and was subsequently seen on postoperative day 21 when she again reported significant improvement in her gait and near resolution of her foot drop. Our patient recovered spontaneously without any therapeutic intervention and was noted to have a normal neurological exam, 5/5 strength on dorsiflexion bilaterally, and approximately 85% resolution of her foot drop by 7 weeks postpartum. |
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.\nFor the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a careful conversation with the patient, she decided to undergo BRAF inhibitor therapy.\nA treatment regimen with vemurafenib 960 mg PO twice daily was started on October 4, 2016. Prior to the initiation of therapy, a new MRI performed on September 24 revealed a lesion measuring 24 × 21 × 19 mm. After 2 weeks of therapy, the patient was asymptomatic and was not using any analgesic medication. During the course of therapy, she experienced grade one anorexia, nausea and fatigue, without any severe therapy-related adverse events. MRI performed in April 2017 revealed stable disease (24 × 18 × 15 mm), and her last MRI performed in September 2017 evidenced a reduction of the lesion size (18 × 13 × 14 mm) (Fig. ). The patient currently remains asymptomatic with excellent tolerance to the medication. |
A 29-year-old female presented to the emergency department with the complaint of left side pain. Sensitivity in the left costovertebral region was detected during physical examination. No kind of operation or chronic disease was recorded in the medical history and family history of the patient. Creatinine value was found to be 1.37 ng/dL in the blood biochemistry examination. In the urinary system ultrasonography (USG), it was observed that the right kidney was atrophic, that the left ureter was dilated as far as the ureterovesical junction, that there was grade III hydronephrosis in the left kidney, and that there was a massive lesion of 3 × 4 cm extending into the bladder on the left side wall of the bladder (). In each abdominal contrast Computed Tomography (CT) scan of the patient, it was seen that the left ureter and renal pelvis were severely dilated and that there was a massive lesion of 3 × 4 cm extending into the bladder on the left ureter orifice on the left side wall of the bladder (). In the medical history of the patient, it was recorded that the patient had complaints of hematuria and severe pelvic pain which had been ongoing for 4-5 menstrual cycles. On transvaginal USG, a mass of 4 × 4 cm of cystic appearance was detected in simple form in the left ovary. In cystoscopy, the left orifice could not be seen although the right orifice was monitored. A red-colored solid lesion in the papillary structure was observed in the left area conforming to the symmetry of the right orifice. The lesion was partially resected by resectoscope. The resected material was sent to the pathology laboratory for histological examination. Percutaneous nephrostomy was attached to the left kidney under USG guidance. Contrast material was administered to the patient through the nephrostomy catheter, and anterograde pyelography was taken. It was observed that the contrast material was not transmitted to the bladder in the ureterovesical junction (). At follow-up examinations, within 3 days, the hydronephrosis in the left kidney had receded and the serum creatinine value was determined to have returned to normal limits. The nephrostomy catheter was removed on the third day as renal functions had returned to normal and the hydronephrosis had receded. The final pathology result of the resected material was reported as “endometriosis” (). The patient was referred to the gynaecology clinic. The tumor markers of the patient were determined as Ca 125: 92.2 μ/mL (0–35 μ/mL) and Ca 19.9: 138.4 μ/mL (0–37 μ/mL). Hormonal treatment was planned to be administered to the patient by the gynaecology and obstetrics department. During the surgery, the Levonorgestrel-Releasing Intrauterine System (Mirena) was inserted into the patient. After the application of LNG-IUS, while there was no reduction in the tumour markers at 3 months, when the tumour markers were evaluated at 6 months, they were seen to have receded to normal reference values. At the end of 12 months, the mass had completely recovered and the symptoms had disappeared. |
An 80-year-old female patient who has a history of taking agents for hypertension and diabetes mellitus (The patient personally discontinued the medications two weeks ago) for more than 20 years was transferred to our emergency room from another medical center with sudden developed dyspnea and drowsy consciousness. She presented abdominal distension and hypovolemic status with 85 mmHg systolic blood pressure. The patient had visited two other hospitals and magnetic resonance imaging (MRI) for lower back pain and left sciatica which were developed three months ago had been performed respectively. The leg symptom was dominant on L4 and 5 dermatomes, but specific and definite dermatome was not noted. The straight leg raise test and the sign of myelopathy showed negative results. In each hospital, she received several times of epidural block under the impression of left neural foraminal and subarticular stenosis on L4-5 (). The symptom was sustained by a shortening of interval and an increasing of intensity, although there were some alleviations of the symptom immediately after the procedures. She developed sudden and severe abdominal pain while staying in a rest room after a left L4 and 5 selective transforaminal epidural block using triamcinolone and bupivacaine at the second-visit hospital. There were no abnormal signs related with procedure and chemical laboratory studies except mild elevation of serum creatinine (1.46 mg/dl). The abdominal pain was aggravated without any alleviation under painkillers and she was transferred to our emergency room. Whole abdominal computed tomography (CT) was performed for evaluating abdominal symptom and it revealed a huge hematoma presenting as a leakage of dye on the retroperitoneal space with calcified large sized fusiform aneurysm containing thrombus and arising from the left common iliac artery ().\nIn a retrospective review of MRIs performed in other hospitals, it was noted that there was a large aneurysm originating from the left common iliac artery with irritating the surrounding lumbosacral plexus, and thrombus was slowly growing inside of the aneurysm. (). The patient was not able to undergo an operation for the ruptured aneurysm of the common iliac artery due to severe hypovolemic condition and expired in the end. |
An 11-year-old boy was transferred to our institution with right knee pain and swelling after a fall while skiing occurred on the same day. He described the hitting of the frontal aspect of his leg. A physical examination revealed swelling and tenderness on the patella, the lateral aspect of the distal femur, and the medial aspect of the proximal tibia. Because of the pain, the knee could not be examined properly. The range of motion was severely limited by the pain, but a neurovascular examination was normal. Standard radiographs showed prepatellar intra-articular effusion and an isolated avulsion fracture with the elevation of the tibial attachment of the PCL (\n). The diagnosis was subsequently confirmed by computed tomographic scanning, and other bone lesions were excluded (\n). The tibial fragment measured 11 × 4 mm and presented a maximal displacement of 7 mm. No other ligamentous, meniscal, or chondral injuries were observed in a magnetic resonance imaging examination (\n). Because of minimal displacement, we decided to treat the avulsion fracture in a conservative way. The knee was immobilized for 6 weeks, with a long leg cast with 30 degrees of knee flexion. The patient was asked to walk with crutches, avoiding weight bearing. After removing the cast, the patient was allowed to begin gentle range-of-motion activities and weight bearing. The patient was asked to report for regular clinical and radiological controls every 4 to 6 weeks until 3 months after the trauma. No pain or instability was detected during a physical examination, and magnetic resonance imaging showed progressive consolidation of the fracture over time. Subsequently, the patient was allowed to progressively return to sport activities, reporting only rare episodes of knee joint swelling and slight pain during severe exertion. In addition, the patient was asked to fill in the functional knee score of Tegner and Lysholm (1985).\nWith a result of 90/100, the outcome was evaluated as good.\nA computed tomographic scanning and a magnetic resonance imaging performed 10 months after the trauma showed complete consolidation of the tibial attachment of the PCL (\n). At this time, the patient has returned to his previous level of physical activity, reporting no complaints. A physical examination revealed no pain or instability of the knee, and muscular strength was comparable to the strength of the contralateral leg.\nFourteen months after the trauma, we re-evaluated the patient for the last time. He was completely asymptomatic, the clinical examination was normal, and the functional knee score of Tegner and Lysholm gave an excellent result with 100/100 points. We decided to discontinue this tight surveillance, and the patient was asked to report for annual controls until complete skeletal growth is achieved.\nWritten informed consent was obtained from the patient's parents regarding publication of this case report and its accompanying images. |
A 77-year-old female was seen in our plastic surgery clinic for evaluation of a right medial thigh mass. The patient was referred to us by a general surgeon who had recommended resection and required assistance with the reconstruction of the resulting defect. The patient had had the mass for over 40-50 years. The mass had rapidly enlarged over the previous six months and was interfering with walking, sitting, and the ability to wear clothing. She reported some localized discomfort and pain but denied any paresthesia or signs and symptoms of claudication. She had not sought any intervention for the mass in the past.\nHer past medical history was significant for hypertension and obesity. Her physical examination revealed a very large mass protruding from the right medial thigh, measuring more than 40 cm in its greatest dimension (Figure ). The color and texture of the overlying skin were normal and without ulcerations. The contralateral thigh was normal for her body habitus. Laboratory studies, including complete blood count and basic metabolic panel, were within normal limits. Based on the size of the mass and physical characteristics, our differential diagnosis included a large lipoma versus a sarcoma. An MRI with and without gadolinium had been obtained by the general surgeon and revealed a very large superficial exophytic mass in the right medial thigh with characteristics most suggestive of adiposis dolorosa (Figure ).\nThe patient underwent a dermolipectomy and delayed reconstruction. The procedure involved resection of the skin and the subcutaneous tissue (dermolipectomy). The mass had not invaded the muscles or the fascia. The patient was noticed to have large fatty tissue within the mass. The resected tissues were sent for pathological analysis (Figure ). The resulting defect was about 50 x 15 x 1 cm and could not be closed primarily (Figure ). Part of the wound was closed primarily, and a wound VAC was placed on the remainder to help prepare the wound bed for delayed closure with STSG. The patient underwent multiple wound VAC changes and the wound was deemed ready for skin grafting when there was evidence of healthy granulation tissue in the wound bed (Figure ). She underwent placement of STSG and placement of wound VAC to secure the graft 18 days after the initial surgery. The wound VAC was eventually taken down one week later, and there was excellent take of the STSG. Seven weeks after the procedure, the skin graft was healthy and there was only a negligible amount of contour deformity (Figure ). The patient also reported no discomfort and was able to ambulate, sit, and wear clothing with no difficulty. The postoperative pathological report revealed edematous fibro-adipose tissue and chronic inflammation, consistent with adiposis dolorosa. Her appearance has improved, and she is able to walk, sit, and wear underwear without any difficulty. There is currently no physical evidence of recurrence. |
A 4-year-old, male child of Indian origin was referred to the emergency department of Sheri Kashmir Institute of Medical Sciences, the tertiary care institute of the state with a history of being in a road traffic accident causing chest and abdominal trauma. At the peripheral centre where the child was first seen resuscitation had been started and a chest tube had been placed on the right side and 200 ml of blood had been drained. The child was referred because of history of eventration of the diaphragm on the same side. At admission the child was semiconscious, pale, had features of respiratory distress with a rate of 54 breaths per minute and was in shock with no palpable peripheral pulse and an unrecordable BP. Immediately the child was intubated and further lines were set up to enable resuscitation. Secondary survey revealed bruise over the right chest, decreased air entry on the right side, central placed mediastinal structures and normal heart sounds. Rest of his examination was normal.\nAfter resuscitation the patient was taken for CT scan of abdomen and chest. CT showed free fluid in the abdominal cavity, a right sided retroperitoneal haematoma, a right lung contusion, a right haemothorax and the presence of right sided chest tube (). The diaphragm was noted at higher level but it could not be determined whether there was any injury to it (). Subsequently the patient was subjected to exploratory laparotomy because a TDR could not be ruled out by imaging. At surgery note was made of complete rupture of the right dome of the diaphragm with almost the whole liver in the right chest. The retroperitoneal haematoma was found to be non-expanding and about 300 ml of blood was found in the abdominal cavity. The right lower lobe of lung was contused, the pericardium was torn on the right side and its edges were bleeding. The pericardial edges were cauterized, the liver returned to the abdominal cavity and the diaphragm repaired with 2/0 prolene interrupted mattress sutures.\nThe patient was electively ventilated for 24 hours after which he was extubated and shifted to ward. On the second postoperative the patient started draining chyle (400-500 ml/day) from the right chest tube, confirmed by biochemical analysis. His drainage subsequently decreased by the 10th day after which the chest tube was removed and the patient sent home. Presently the child is doing well and is on follow up. |
A 21-year-old male patient reported in the Department of Oral and Maxillofacial Surgery with a progressive limitation of mouth opening and swelling on the left temporal region since two months. The patient had a history of trauma to the left temporal region two months back, which was a hit by a heavy vehicle jack rod. As there were no fractures of the facial/skull bones or any other complications at the time of injury, symptomatic treatment was given to the patient at a local hospital.\nOn local examination, a gross swelling was noticed in the left temporal region, which was soft in consistency and non-tender []. The patient had limitation of jaw movements and mouth opening was only 15 mm []. There were no other bony or soft tissue injuries noticed during examination. Magnetic resonance imaging (MRI) was performed, which showed a hematoma within the temporalis muscle []. Thus, a diagnosis was established as hematoma and the patient was taken up for surgical evacuation of hematoma. Intraoperatively, a mouth opening of 40 mm was achieved and the patient was discharged on the sixth postoperative day with some muscle relaxants and advised forceful mouth opening physiotherapy. At the time of discharge, the patient's mouth opening was 30 mm and review on the first, third and sixth week postoperatively showed that there was recurrence of trismus, which was progressive and the patient's mouth opening was limited to 2 mm [].\nA computed tomography (CT) scan was performed, which showed calcified masses within temporalis muscle suggestive of extraskeletal bone formation []. A provisional diagnosis of MOT was established and the patient was taken for surgery with a treatment plan of excision of calcified masses and coronoidectomy. Intraoperatively, flakes of calcified masses were removed along with a part of temporalis muscle and ipsilateral coronoidectomy was performed. Intraoperative mouth opening of 38 mm was achieved and postoperatively forceful mouth opening physiotherapy was advised along with muscle relaxants. The excised tissue was sent for histopathological examination, which showed muscle fiber bundles and a classical appearance of zonal pattern with central connective tissue zone, intermediate immature bone with osteoblasts and peripheral mature bone confirming the diagnosis of MOT of temporalis and medial pterygoid muscle [Figures and ].\nA planned conservative management protocol was followed and the patient was strictly advised normal physiotherapy. A six-month follow-up showed that the patient's condition had improved with an effective mouth opening of 30 mm. The present case emphasizes not only on the importance of considering MO in the differential diagnosis of limitation of opening of the jaws but also on the improvement of the overall mouth opening and treatment results. |
A 40-year-old African American, morbidly obese female patient was referred to our service for evaluation of left buttock mass (). She reported minor discomfort and she did not tolerate sitting down for long periods of time. She described that the mass had been growing slowly for the past six months. She described no urinary, rectal, or gynecological symptoms. She had no prior surgeries. On physical examination there was a bulging mass on the left lateral wall of the vagina without any direct invasion; the rectum had a normal tone with displacement of the left lateral wall towards the midline; the left perineal area revealed a 25 × 14 cm soft mass.\nEndoscopic ultrasound demonstrated a demarcated fat plane between the rectum and the mass. However, the CT scan found no clear fat plane between the mass and the surrounding structures. Imaging revealed the mass within the subcutaneous tissue of the left perirectal region, displacing the anal canal to the right and displacing superiorly the levator ani musculature. Uterine leiomyomas and diverticulosis were found incidentally. The MRI dimensions of the mass were 23 × 8 × 11 cm and showed no muscular or osseous invasion, with well-defined walls and considerable enhancement with a preliminary diagnosis of a pedunculated leiomyoma; however, a soft tissue sarcoma could not be ruled out (). There was concern that this tumor was directly invading the surrounding structures, such as the rectum, vagina, anal sphincter, or adnexa. On the basis of the results of the imaging studies, a large leiomyoma was suspected, but we could not rule out a low grade soft tissue sarcoma. Surgical resection was performed and no direct extension into surrounding structures was found; muscle fibers of the anal sphincter were densely adherent to the tumor and were divided close to the tumor in order to preserve function. After the surgery the patient had no anal dysfunction and she was discharged just with pain medication. She denied fecal incontinence or dyspareunia. After two-year followup she remains without recurrence. |
A 45-year-old female with accidental flame burns of the chest and upper limbs (approximately 30%) was referred from another hospital with high fever and breathlessness requiring Ventilatory support. She was primarily treated there for superficial burns, during which time a right internal jugular vein catheter was inserted in the intensive care unit (ICU) for administration of drugs and volume. Five days after insertion of the CVC, the patient developed high fever and, over the next 7 days, breathing difficulty, this was interpreted as sepsis and supported by laboratory investigation and growth of methicillin-resistant Staphylococcus aureus (MRSA) in the blood sample. Appropriate antibiotics were administered and the patient showed no clinical improvement despite 3 weeks of antibiotic treatment. She persistently recorded high temperatures and was breathless even at rest. She was referred in this status to our hospital and was put on respirator for poor blood gas values. Further evaluation of sepsis with transthoracic echocardiogram showed large vegetation, measuring approximately 3 cm, on the anterior tricuspid leaflet (ATL) with no tricuspid regurgitation. Other cardiac valves were normal. Trans-oesophageal echocardiogram confirmed the findings []. The patient had to be ventilated for respiratory decompensation secondary to showering of the pulmonary circuit by tiny vegetations on the ATL and was taken for surgery immediately. Through a standard median sternotomy, the heart was placed on cardiopulmonary bypass and the tricuspid valve was approached through the right atrium after cardioplegic arrest. Large vegetation was seen occupying almost half of the anterior tricuspid leaflet [], and the vegetation seemed to travel down the chordal apparatus as well. Other leaflets of the tricuspid valve and the pulmonary valve were normal. Total vegetectomy was performed with curettage of the anterior tricuspid leaflet and the remaining defect in the ATL [] was repaired with a piece of native pericardium. Because the patient was culture positive for MRSA, a prosthetic ring was not placed and the patient weaned off cardiopulmonary bypass with minimal support. She was afebrile the next day of surgery and remained so till her discharge from the hospital. The vegetation grew MRSA. |
A four-year-old female child presented to us with complaints of dysphagia and regurgitation of solid food. A contrast-enhanced CT scan (CECT) of the chest done elsewhere revealed an aberrant right subclavian artery []. A 256 slice CECT scan was ordered in our hospital for the exact anatomical characterization of the aberrant vessel. The scan showed an aberrant origin of the right subclavian artery from the medial wall of the descending thoracic aorta, just distal to the origin of the left subclavian artery [Figures and ]. The artery crossed to the right side at the level of the fourth thoracic vertebra, causing posterior compression of the esophagus. An additional finding that was noted was the common origin of the right and left common carotid arteries. The arch was left-sided, with a left descending thoracic aorta. An echocardiogram done showed a large ostium secundum atrial septal defect (ASD) of 20 mm, with a dilated right atrium and right ventricle.\nUnder general anesthesia a median sternotomy was performed. The arch was followed down from the top and the aberrant right subclavian artery was identified just distal to the origin of the left subclavian artery on the medial wall of the descending thoracic aorta. Loss of the right radial artery trace on clamping the aberrant vessel confirmed that the vessel was indeed the right subclavian artery. The artery was carefully divided at its site of origin and the aortic end oversewn with two layers of continuous polypropylene sutures. The artery was next brought to the right side from behind the esophagus and the anastomosed end side to the right common carotid artery, after confirming that there was no torsion of the mobilized vessel []. Pericardial patch closure of the ostium secundum ASD was performed in a routine manner, under cardiopulmonary bypass, under mild hypothermia using the standard cannulation techniques. The patient had an uneventful postoperative course and was discharged on day six from the hospital. The patient had no complaints of dysphagia or regurgitation of food on discharge. |
An 18-year-old female patient presented to our outpatient department with pain in her left knee of 3 years duration. There was a history of fall 3 years ago. She felt pain while walking and while standing up from squatting position. The patient gave no history of locking episodes. On clinical examination, there was no obvious swelling over her left knee. There was no tenderness around the knee except for tenderness over the medial joint line. The patient complained of pain during terminal flexion. There was no laxity in the knee. McMurray test was positive for the medial meniscus. Rest of the examination of the knee was unremarkable.\nThe patient had already been treated with physiotherapy and occasional analgesics. We decided to image the left knee. The radiographs of the knee revealed no abnormality (). We performed magnetic resonance imaging (MRI) scan of the knee and expected it to show a medial meniscal tear. Initial reporting by the radiologist confirmed a medial meniscal tear without a mention of it being discoid. However, because the body of the meniscus was seen in 4 consecutive sagittal sections of the MRI scan ( and ), we suspected a discoid medial meniscus and got the scan reported again. This time, the radiologist reported it as a torn discoid medial meniscus. We decided to perform arthroscopic partial meniscectomy and meniscoplasty for the patient.\nArthroscopy confirmed a discoid medial meniscus occupying the entire medial tibial plateau (). The anterior part of the discoid meniscus was attached along the anterior cruciate ligament (ACL) (). However, no obvious tear could be visualized (). We then trimmed the lateral edge of the meniscus lying toward the intercondylar region which revealed a large cleavage tear completely restricted to the interstitial part (). We resected the upper and lower flaps till a stable peripheral semilunar rim of meniscus was obtained (). Postoperatively, the patient was started on a physiotherapy protocol to preserve range of motion and muscle strength. Weight bearing was started after pain due to surgery subsided. 2 weeks postoperatively, the patient attained full range of motion and was pain-free even on terminal flexion. |
A 60-year-old man visited the Oral Medicine and Radiology Department, complaining of a mild intermittent pain associated with sudden ulcerated growth on the right maxillary edentulous alveolar ridge since 1 month earlier. The patient gave a history of extraction of teeth in the same region one year before. On examination, a diffuse mild extra oral swelling was present on the right cheek, with proptosis and watery discharge from the right eye (). On palpation, extraorally the swelling was mildly tender and discontinuity was felt on the right infra orbital margin. Intraoral examination revealed a soft well defined ulcerated growth on the right maxillary edentulous alveolar ridge, extending from the right maxillary first molar region to the maxillary tuberosity region posteriorly. The surface of the growth was covered with a yellowish necrotic material. It was slightly tender on palpation ().\nThe clinical differential diagnosis included the most common malignancies in the oral cavity such as squamous cell carcinoma (SCC), minor salivary gland tumor, and carcinoma of the maxillary sinus. Panoramic radiograph revealed severe bone destruction of the right maxilla distal to the canine. The floor of the right maxillary sinus was also destroyed. Computed tomography (CT) scan was performed and sections were taken in the axial, coronal, and sagittal planes. Coronal section revealed a large soft tissue density lesion with its epicentre in the maxillary sinus, causing destruction of all walls of the maxillary sinus, extending medially into the lateral wall of the nasal septum, left nasal cavity involving the inferior and middle turbinates, laterally into the pterygopalatine fossa, superiorly into the orbit, inferiorly causing destruction of the hard palate and alveolar processes of the right maxilla in the molar region. There was no evidence of calcification (). Three dimensional CT reconstructions using the bone and soft tissue settings demonstrated a large lytic lesion in the right maxillary sinus destroying all walls of the maxillary sinus, hard palate, and alveolar process in the molar region ( and ).\nThe patient was advised to undergo routine haematological examination, and an incisional biopsy was performed which revealed a cellular connective tissue stroma predominantly made up of lymphocytes, the majority being large cells and a few small cells showing vesicular nuclei with prominent nucleoli. Scattering foamy macrophages were seen amongst these cells. It was finally diagnosed as diffuse large cell lymphoma (). The patient was referred to the oncology department, who started chemotherapy; unfortunately, the patient passed away after two cycles of chemotherapy. |
A 55-year-old man was admitted with progressing dysphagia and dyspnea. He had been diagnosed with aortic arch aneurysm 4 years earlier. At that time, a computed tomography (CT) scan had demonstrated a huge aortic arch aneurysm with a maximal diameter of about 6.8 cm (). However, he had refused further treatment at the time. On arrival, a chest radiograph revealed marked aneurysmal dilatation of the entire arch (). On the follow-up CT scan, the size of the aneurysm had increased up to a maximal diameter about 9 cm and the trachea was nearly collapsed and deviated into the right side (). The proximal descending aorta was also involved down to the level of the 7th thoracic vertebra. The patient was also diagnosed with single vessel disease by coronary angiography performed for preoperative evaluation. Therefore, we planned total arch replacement and a coronary arterial bypass graft.\nGeneral anesthesia was administered and a double-lumen endotracheal tube was used to permit deflation of the left lung during the distal anastomosis. The patient was maintained in a supine position with the left chest elevated by about 30 degrees. Initially, the right axillary artery and left femoral artery were exposed for cardiopulmonary bypass. After exposure of the right axillary artery and left femoral artery, an L-shaped skin incision was made through an upper partial sternotomy and left anterior thoracotomy along the 5th intercostal space (). Thereafter, the left internal thoracic artery was harvested for coronary arterial bypass grafting in a skeletonized fashion. After exposure of the innominate artery and left common carotid artery, the left subclavian artery was exposed through a small left supraclavicular incision to the neck because the left subclavian artery was seated deeply and deviated upwards. After systemic heparinization, arterial cannulae in each artery for systemic circulation were inserted through the right axillary and left femoral artery with Seldinger's technique. Venous drainage was performed through a single two-stage cannula inserted into the right atrial appendage. Cardiopulmonary bypass was established and a left ventricular vent catheter was inserted through the right upper pulmonary vein prior to lowering the body temperature. After aortic cross-clamping, HTK solution (Custodiol; Kohler Chemie, Alsbach-Hahnlein, Germany) was delivered via the aortic root. The ascending aorta was transected at the sinotubular junction level and proximal anastomosis was constructed with a three-branched Dacron graft prepared previously () from a 28 mm InterGard four-branched graft (Maquet, Rasttat, Germany). After hypothermic circulatory arrest was accomplished by cooling to a rectal temperature of 20℃ with cardiopulmonary bypass, the aortic arch was opened. The innominate artery was clamped and antegrade selective cerebral perfusion was started using the right axillary artery and a catheter placed into the left carotid artery. After clamping the descending aorta at the level of the 9th thoracic vertebra, cardiopulmonary bypass was started for lower body perfusion through the femoral artery cannula. Next, the left subclavian artery was ligated with an EndoGIA 30×4.8 mm stapler (Covidien, Mansfield, MA, USA) and an innominate artery and left common carotid artery were reconstructed with the branches of the graft. The heart and brain were reperfused from the other branch of the graft after discontinuation of cerebral perfusion (). After left lung deflation, distal anastomosis was performed with another 28 mm Dacron tube graft. Finally, proximal graft and distal graft anastomosis was performed during whole body perfusion. After completion of the graft anastomosis, we performed a carotid to left subclavian bypass graft using a remnant of the 8 mm Dacron graft through the left supraclavicular incision previously made. Systemic rewarming was then initiated. During rewarming, we performed a left internal mammary artery to left anterior descending artery bypass graft. The total operation time was 350 minutes. The total cardiopulmonary bypass time and aortic cross clamping time were 280 and 120 minutes, respectively. The operation was uneventful and the patient was discharged after 2 weeks. A postoperative follow-up CT scan revealed no aneurysmal dilatation of the aorta (). |
A 41 years old Egyptian male with an unremarkable past medical or surgical history presented to the King Saud medical city emergency department, with two days history of abdominal pain, associated with nausea, vomiting, and abdominal distention. The pain was colicky and started gradually without any bowel motion or flatus for two days. The drug and family history was unremarkable. Patient had tachycardia, with normal blood pressure and oxygen saturation of 100 % in room air. The abdomen was found to be distended and tender all over with an empty rectum by digital rectal examination (DRE). Upright chest and abdominal X-ray showed multiple air fluid levels with no air under the diaphragm (). CT abdomen showed a dilated proximal small bowel loop and a picture of SBO at distal ileal loops (). The patient resuscitated with intravenous (IV) fluids and kept nil per os (NPO). A nasogastric tube was inserted, and the patient was shifted to the operating room. Laparoscopic exploration showed dilated small bowel loops with collapsed distal ileum and an inflammatory band was found 20 cm from ileocecal junction originating from a small bowel diverticulum with no palpable intraluminal masses (). The inflammatory band was present at the distal part of the diverticulum and was adhered to a small bowel segment leading to obstruction. The band was released, and wedge resection of the diverticulum was performed at its base by gastrointestinal anastomosis (GIA) on healthy tissue, about 2 cm from the inflamed segment, which is a standard surgical approach for MD. The postoperative period was uneventful. The patient was initially kept at regular surgical floor bed and then discharged on the second postoperative day, when he passed good bowel motion. The histopathology result on follow up visit showed MD with Schistosoma infection, most likely by Schistosoma mansoni. The patient was referred afterwards to the infectious disease department for initiation of praziquantel, which is the drug of choice for schistosomiasis and is effective against all Schistosoma species. This is an extremely rare case of acute SBO. It demonstrates the importance of diagnostic laparoscopy in all patients with virgin abdomen who present with acute bowel obstruction. |
A 42-years old male patient was referred to a local hospital with a sudden onset of dizziness, nausea, as well as vomiting, and MRI revealed a partially thrombosed aneurysm adjacent to the left portion of the medulla (). The patient was admitted to our hospital without any major symptoms. An initial DSA image demonstrated dilatation at the fourth segment of the left VA, thus indicating a VADA without the involvement of the posterior inferior cerebellar artery (PICA) (). The right vertebral and basilar artery showed no major abnormalities. He had a medical history of hypertension and hyperlipidemia, but no previously reported head trauma and family history of aneurysm. The patient had a history of smoking 20 cigarettes a day for 20 years, which was ceased just at the time of this admission.\nWe treated the left VADA using endovascular pipeline embolization for preserving the normal blood flow. In addition, a dual antiplatelet therapy, comprising 300 mg aspirin and 300 mg clopidogrel were administered 5 days before the surgery. Under general anesthesia, a pipeline embolization device (PED) was successfully implanted with satisfactory adherence between the PED and vessel wall. No intraoperative complications were encountered, and the right VA was preserved. He was discharged home 1 week after the operation and prescribed dual antiplatelet therapy (aspirin 100 mg/day and clopidogrel l00 mg/ day) for 6 months. Angiography conducted at 5 months after initial treatment revealed the patency of the VA and partial aneurysm residues (). This residual of the left VADA persisted on 14 months () and 2 years (), and completely occluded at 3 years angiography follow-up (). The volume of the aneurysm did not significantly alter from 14 months () and as noted in 2 years of follow-up MR images (), and the patient did not display any adverse symptoms after the surgery.\nIn addition, no major abnormalities were found in the right VA at 5 months after initial treatment (). Surprisingly, follow-up imaging 14 months postoperatively showed a segmental dilatation and narrowing of the right VA (), which suggested the formation of a de novo VADA. Stent-assisted coiling was performed for this de novo VADA. Under general anesthesia, Guglielmi detachable coils were positioned in the dissecting aneurysms after placing an LVIS stent in the true lumen of the VA (). Dual antiplatelet therapy was prescribed to him as done before. The patient had an uneventful postoperative progression with no observation of any occurrence of neurological deficits. Moreover, a 20 months angiography follow-up revealed complete occlusion of the aneurysm (). |
A ten-year-old boy presented for a second opinion to the pediatric outpatient clinic with complaints of periodic swelling and pain in the right jaw region. Since two years, periodic swelling occurred every other month and remained present for several days to weeks. Consumption of acid fluids was painful. No fever was noted. During earlier acute phases, antibiotics had been administered twice, with a positive effect on the duration of the symptoms. Earlier ultrasound examination, dynamic magnetic resonance imaging (MRI) and sialography at the time of the swelling did not reveal any abnormalities, although his parents reported that he remained without symptoms for three months after the sialography, which was longer than normal. Medical and family history revealed no relevant facts, especially no history of autoimmune disease. The boy was vaccinated according to the Dutch vaccination program.\nBecause of the frequent and recurrent character of the symptoms, the parents were seeking a second opinion after an earlier diagnosis of chronic recurrent parotitis. When he presented at the outpatient clinic, swelling and pain of the right jaw region had been present for one month ().\nPhysical examination did not reveal abnormalities in the mouth and ears, except for the fact that he was not able to fully open his mouth (trismus). There were no signs of infection, periodontitis, caries or purulent saliva discharge in the mouth. Blood analysis showed an elevated erythrocyte sedimentation rate (ESR), and a normal amylase. The first echography performed during complaints showed lymphadenitis, without parotitis, while a second echography, also during complaints, showed a parotitis. The results of the examinations are listed in . As not all examinations were compatible with parotitis, and as there was no explanation for the fact that the boy was unable to fully open his mouth, a new MRI of the jaw was performed. This showed a diffusely broadened mandible, several areas of interruption of the cortex as well as soft tissue swelling (), which was considered to be compatible with osteomyelitis. A technetium scan confirmed the diagnosis of osteomyelitis (), while a skeletal scintigraphy showed no other foci (). Biopsy showed signs of remodeling with fibrosis, consistent with chronic osteomyelitis. These examinations led to diagnosis of mandibular primary chronic osteomyelitis (MPCO).\nA decortication was performed (). After surgery, the boy did not report any further complaints or relapses. |
A 59-year-old female reported to our outpatient department with the complaint of huge extraoral swelling on the left side of the face for 5 years. The swelling was initially smaller in size and had progressively increased over time. The patient gave a history that she had consulted a private practitioner 2 months ago who had planned for excision of salivary gland tumor. A well-defined, ovoid, multilobular swelling of size 8 cm × 9 cm with superioinferior extent from left zygomatic arch to about 4 cm below the lower border of the mandible and anteroposterior from the anterior border of masseter to 1 cm beyond posterior border of mandible was noted. The left ear lobule was slightly raised and everted []. Facial and eye movements were normal on examination. Intraoral examination reveals a nonhealing suspicious ulcer over the left posterior buccal mucosa distal to second molar of size 1 cm × 1 cm. Clinically there were no neck nodes. Fine needle aspiration cytology (FNAC) of the extraoral swelling was done, which was suggestive of a benign mixed tumor. Incisional biopsy was performed for intraoral lesion, which was suggestive of well-differentiated squamous cell carcinoma (SCC) [].\nAfter obtaining presurgical workup and written informed consent, surgery was planned. The skin incision was given over the prominent part of tumor to remove the excess skin paddle, which was extended to the lower part and tunneled to perform supraomohyoid neck dissection in the same sitting. The marginal mandibular nerve was identified from beneath the lower incision margin and retrograde tracing was performed to locate the main nerve truck, which was preserved []. Intraoral mucosal malignancy was excised with safe margins and reconstructed using the buccal fat pad. Postoperative period was uneventful []. Final histopathological report of extraoral tumor suggested pleomorphic adenoma, while Intraoral tumor was Grade 1 SCC with negative margins. None of the neck nodes were found harboring metastatic tumor. There was no apparent clinical recurrence with regard to parotid gland tumor and oral mucosal lesion on a 2 years follow-up. |
A 45 years old male patient, attended the neurology emergency department on 3rd January 2016 due to right limb numbness for 6 days and convulsive seizure for 3 days. Six days before the hospital visit, the patient experienced numbness in the right upper limb and instability while holding without obvious incentive but did not seek immediate medical intervention. Three days before admission, the patient experienced convulsive seizure in the right upper limb while remaining conscious, which was relieved after 1 min. Similar attacks occurred intermittently on six further occasions. The patient had a 3-year history of hypertension with the highest blood pressure being 180/110 mmHg. He also had a history of smoking and drinking lasting more than 30 years. He was born and has always lived in Beijing, with no history of contact with infested water, infectious zone, other radioactive substances or toxins. Upon admission, the patient was examined to be obese with no subcutaneous nodules. Neurological examinations showed full level muscle strength in the right upper limb, accompanied with diminished needling response. Emergency head CT scan (2016-1-1) showed lower density in the left parietal lobe. As the patient manifested as an acute onset of right limb weakness and hemiparesis,with low density lesions in the left occipital lobe on CT and a history of hypertension, the patient was hospitalised with a preliminary diagnosis of acute stroke and secondary epilepsy.\nAfter hospitalisation, head MRI scan (2016-1-4) displayed a lesion in the left parietal lobe of unknown nature. After enhancement in the magnetic field, a larger area of oedema was found around the lesion in the left parietal lobe which could indicate glioma or other inflammatory diseases. Since the nature of the brain lesion did not match the characteristics of common cerebrovascular diseases, intracranial angiography DSA was used but found no obvious vascular abnormalities or stenosis. Further examinations including lumbar puncture, immune rheumatoid factors and parasite antibody detections were carried out. A raised cerebrospinal fluid pressure was found to (215 mm H2O) with no red or white blood cells present. After consultation within the neurology department, intracranial tumor was considered and therefore prepared for stereotactic biopsy of the brain. At this point, pathology results came back positive for Spirometra mansoni IgG. On further questioning the patient admitted that he had drank tap water and eaten frogs when travelling in another province during June–September 2015. Given his medical history, and results from head MRI and blood tests, the patient was considered to be infected with Spirometra mansoni and surgical intervention or antihelmintic chemotherapy was recommended .\nThe patient accepted pharmaceutical treatment and was given praziquantel (1600 mg, 20 mg/kg) 3 times a day for 10 days. During these 10 days, the patient reported occasional headache and was treated for dehydration before discharge from the hospital. The patient was also administration oral sodium valproate 500 mg 3 times a day to control seizures.\nThe patient was hospitalised again in March and July 2016 and treated with praziquantel (1600 mg,20 mg/kg) 3 times a day for 10 days. His headaches were eased with intravenous infusion of 20% 250 ml mannitol twice a day.\nLumbar puncture (Table Examination of cerebrospinal fluid), head MRI, blood biochemistry, conventional blood analysis and parasite antibody examinations (Table Spirometra mansoni IgG antibody) were also carried out on both occasions. On 13th Jul 2016, the patient was free from numbness and seizures in the upper limb.\nTable displays the laboratory results of lumbar puncture performed on the three occasions when he was admitted to hospital and during the 1-year follow-up appointment. CSF analysis showed normal results except for a few white and red blood cells during his second hospital stay most likely resulting from the procedure itself. Table shows the Spirometra mansoni IgG result on three occasions. Note that the IgG result became negative during his third hospital stay following three courses of praziquantel treatment.,.\nEnhanced head MRI scans were performed during the three hospital stays in January, March, and July 2016. Figure A-A3display head MRI scans performed on 8th January. The scans showedan abnormal horseshoe signal in the left parietal lobe with a low T1WI signal and a high T2WI + FLAIR signal. Enhanced scan showed irregular wreath in the lesion without enhancement in the surrounding. This type of abnormality in the left parietal lobe may indicate glioma. During the second hospital stay, the MRI scan carried out on 17th March showed abnormal small stripes of signal shadow in the left parietal lobe with a decreased range. It also showed clearer abnormal veil-like signal shadow in the left parietal lobe as compared to the previous MRI scan. These results may indicatethe presence of Spirometra within this area of the brain. During the third hospital stay, MRI scan on 7th July detected only minor abnormalities in the bilateral frontal lobes and parietal lobes indicating that the lesions has reduced significantly or resolved. The follow-up on 12th December showed no abnormality in the head MRI scan. MRI scans from each hospital visit are shown in Fig. . |
A 33-year-old male presented to our emergency department with an acute onset of right sided facial nerve paralysis associated with a 4-day history of severe otalgia and intermittent tinnitus. He had a known background of a stable middle ear mass for which he was observed for 3 years at a different institution. He was otherwise fit and healthy with no comorbid illnesses or regular medications. Examination findings were consistent with an inflammatory middle ear effusion with a bulging tympanic membrane associated with right sided facial nerve palsy. Tuning fork tests demonstrated a conductive hearing loss in the affected ear. All other cranial nerves were intact. The patient was admitted under ENT for intravenous antibiotics and steroids. Within 72 hours of antibiotics administration, the otalgia subsided with improving facial nerve movement as well. He was discharged on oral antibiotics with follow-up in our outpatient department. With resolution of his middle ear infection, a pale red-pink mass was visible behind the tympanic membrane.\nFurther imaging demonstrated a middle ear mass with partial disruption of the facial canal. A subsequent angiogram demonstrated an avascular middle ear mass. Mixed hearing loss was demonstrated in the right ear on audiogram. The patient was electively taken to the operating theatre for a middle ear exploration and mastoidectomy with the intention of confirming the nature of the tumour and performing a subtotal removal. Intraoperative frozen section raised the possibility of a neuroendocrine tumour. The patient was successfully discharged on postoperative day 1. At 2 months follow-up postoperative hearing was preserved with normal facial nerve function and no evidence of recurrence.\nExamination of histological sections stained with haematoxylin and eosin revealed small fragments of mucosa with underlying pieces of vital bone. The mucosa was surfaced by nonkeratinising stratified squamous epithelium which showed no epithelial dysplasia with no evidence of surface origin of the tumour. The underlying lamina propria was extensively infiltrated by an unencapsulated tumour. The tumour cells were arranged in small irregular nests and trabeculae with surrounding fibrosis. Occasional glandular structures were also identified. The individual tumour cells had scanty granular eosinophilic cytoplasm with hyperchromatic nuclei. Mitoses were not observed. There was no evidence of necrosis within the tumour. The tumour cells demonstrated positive staining for cytokeratin (AE1/AE3) with keratin 7 (CK7) staining the luminal cells in the glandular structures. The neuroendocrine immunohistochemical markers (CD56, chromogranin, and synaptophysin) were positive. No sustentacular cells were identified (S-100 negative) and the tumour had a low proliferation index of 3-4% (Ki-67). |
A 58-year-old man without any medical history got hit by his handcart and was admitted into a local hospital, complaining of persistent sharp pain in the lower abdomen and mild pain in the left leg. His physical examination revealed significant lower abdominal tenderness, and the ultrasonic examination showed a large collection of abdominal fluid. Furthermore, the blood from abdominal paracentesis demonstrated intra-abdominal hemorrhage. The left femoral pulse and the distal pulses were palpable, with no further attention paid to the left lower limb. An emergency exploratory laparotomy under combined spinal and epidural anesthesia was performed. About 1450 mL blood was sucked from the abdomen and the mesentery of the ileum where the bleeding was located. Hemostasis was achieved with suturing and ligation. After the surgery, the patient felt numbness and coolness below the level of his left knee, but the surgeon thought it was due to the effect of the anesthesia and no pulse examination was performed.\nThe patient was transferred to our unit after 32 h from the accident and presented with severe numbness and impaired motor function of the left lower limb. The complete examination of his leg showed the absence of the left femoral pulse and the distal pulses, together with calf muscle weakness and diminished sensation of the entire foot. Subsequently, computed tomography (CT) angiogram revealed that the left common iliac artery was occluded (). This patient was immediately sent to the operation room. A femorofemoral artery bypass was established at the common iliac artery. The postoperative physical examination revealed a palpable pulse and warm skin. Postoperative Doppler ultrasound demonstrated the presence of blood flow.\nUnfortunately, severe pain and significantly progressive swelling occurred on the second day after revascularization. Characteristically, the calf was tender to palpation and pain increased with passive motion at the ankle. Compartment syndrome caused by the ischemia-reperfusion injury was diagnosed, and the four-compartment fasciotomy of the calf was performed for decompression. Wound closure was delayed, and the wound was temporarily covered with vacuum sealing drainage (VSD) because of high skin tension. The wound was then managed with skin-graft from the lateral thigh 10 days later after leg swelling subsided; 3-month follow-up showed ambulatory function with braces and the progressive wound healing, despite the weakness in dorsiflexion and numbness in the first dorsal web space due to a probable peroneal nerve damage. After 6 months, the patient could walk independently, and improved sensation in the leg was achieved. The patient gave informed consent for the information and image included in this report, which was also approved by the Institutional Review Board of The First Affiliated Hospital of Wenzhou Medical University. |
A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.\nHis blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.\nA specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.\nIn addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.\nHe underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.\nNine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).\nThis procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.\nAfter 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .\nAt 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual. |
Three years before his admission to our hospital, a 26-year-old Chinese man began to manifest, for no apparent reason, restricted affect, poor speech, diminished sense of purpose, and diminished social drive. His affect was diminished no matter what his parents told him. He lacked interest in doing anything, and did not talk to others. When his parents asked him questions, he answered only “I don’t know”. Sometimes his speech was disorganized and incoherent. He also lost desire to work at his job as a bank clerk, although he previously performed well. He preferred to stay at home and did not want to participate in activities or have contact with friends. His sleep and appetite were poor. He showed no disturbance of consciousness. After these symptoms continued for about 6 months, he was taken by his parents and hospitalized in a local psychiatric ward. General physical and neurologic examinations and routine laboratory investigations at that time showed no notable abnormalities. He was, therefore, diagnosed with schizophrenia and treated with risperidone at a maximal dosage of 6 mg per day for 12 weeks. The patient did not respond, and he was discharged with a weight of 59 kg and body mass index (BMI) of 20.41 kg/m2.\nAfter discharge, the patient presented with the same symptoms and he was taken by his parents to our outpatient department 1 year before he was admitted to our hospital. The outpatient physicians diagnosed him with schizophrenia and treated him for 10 weeks with a maximal dose of olanzapine of 20 mg per day. He responded poorly, so he was admitted to our hospital at the request of his parents. The patient reported never smoking and occasionally drinking small amounts of wine. He had no family history of mental disorders. His vital signs were stable, and no abnormal physical or neurologic signs were detected at admission. Blood and urine tests were routine, blood glucose and liver and renal functions were normal, and no evidence of infection was found. His thyroid function was normal. Cerebrospinal fluid (pressure, appearance, cells, proteins, glucose, chloride, and immunoglobulin) and brain magnetic resonance imaging were also normal. The following serum levels were measured: IL-1β, 8 pg/mL (reference range, 0–5 pg/mL); soluble interleukin-2 receptor (sIL-2R), 812 U/mL (223–710 U/mL); IL-6, 10 pg/mL (0–7 pg/mL); IL-8, 51 pg/mL (0–62 pg/mL); IL-10, 8.8 pg/mL (0–9.1 pg/mL); tumor necrosis factor-α (TNF-α), 8.7 pg/mL (<8.1 pg/mL); and CRP, 5.5 mg/L (<5 mg/L). Electroencephalography, electrocardiography, and transcranial Doppler ultrasound results were normal. The patient and his family members denied any abuse of illicit substances. The patient’s weight was 66 kg and BMI was 22.84 kg/m2.\nThe patient was diagnosed with schizophrenia based on the Structured Clinical Interview for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Patient Version. The patient was followed up for 6 months after diagnosis to confirm the presence of schizophrenia. The patient was diagnosed with DS using the Schedule for Deficit Syndrome (SDS). We dynamically classified the patient and reassessed this classification at 6 and 12 months later using the SDS. The patient scored 82 on the Scale for Assessment of Negative Symptoms (SANS). Cognitive function was assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB) () at admission as well as 10 weeks later ().\nThe patient was treated with aripiprazole at a maximal dose of 20 mg per day, and treated with minocycline as adjunct therapy, which was gradually titrated to 100 mg twice daily. After 12 weeks of adjunct treatment, persistent and enduring negative symptoms improved. The patient reported no complaints or side effects from the minocycline, he was able to care for himself during daily activities, and his social engagement improved. His communication with parents and contact with friends notably improved. When his parents told him a joke, he laughed. He was willing to exercise and agreed to join a skills training group. The SANS score was 47, and serum levels of IL-1β were 5 pg/mL; sIL-2R, 670 U/mL; IL-6, 6 pg/mL; IL-8, 48 pg/mL; IL-10, 9.1 pg/mL; TNF-α, 7.1 pg/mL; and CRP, 3.6 mg/L. At 12 months follow-up after discharge from our center, he reported no signs of negative symptoms and reported that he was functioning well in the community. |
A female child aged 10 years came with complaint of irritable behavior, and communication problem. The patient was absolutely normal till age of 5 years. The child is a product of consanguineous marriage wherein her father is her mother's maternal uncle. The child is born at full term normal vaginal delivery, no intranatal maternal infections, no complications after birth, the child attained age appropriate motor and language milestones till 5 years of age. The child was toilet trained and was able to control her bowels and bladder. The child also attended school wherein she learnt to recite poems and stories. She also used to take bath all by herself with soap and water under supervision.\nAt the age of 4 years the patient developed a severe attack of upper respiratory tract infection for which she suffered with fever and cough for 6 months and had pleural effusion for which the fluid is drained. The parents were instructed to use medications for 1 month with regular follow ups but they could not do so due to financial restraint. The patient from then on started to get severe attacks of fever and was only treated by an unqualified health worker. She stopped going to school and started to lose all the communicative milestones like talking sentences, calling her family members by name. She used to sit alone all day self-absorbed in play and showed increased anger and irritability, wherein she would hit or bite anyone who disturbed her. She stopped playing with her friends which she previously used to enjoy doing. She also stopped asking for food and would only cry if she is hungry. She also stopped taking personal hygiene and used to pick up bits of sticks and stones from floor and put in her mouth. She also did not sleep all night and used to cry for no apparent reason. She even lost the toilet training she acquired previously and started to pass stools and urine in clothes. With the above complaints the patient was brought to Mamata General Hospital to the Psychiatric OP. The patient was admitted in psychiatry ward all the investigations done like complete blood picture to rule out and blood dyscrasias, liver function tests for any metabolic abnormalities, blood urea and creatinine for renal abnormalities, urine test for sugar and proteinuria. All the investigations were normal. Computerized tomography of brain showed marked reduction of brain volume with less sulci and gyri and enlarged ventricles. IQ test revealed that the patient has an IQ of 37.5. The patient was started on resperidon 1 mg once a day and over the next 3 week she improved, the symptoms of anger and irritability have reduced and she also started to sleep normally. Her motor coordination improved, and she was able to feed herself which she previously was not able to. On subsequent follow-ups for the next 6 months child has shown improvement in communication in the form of naming objects and also her social interaction also improved wherein she started to play with other children at her home. She has been referred to a higher center wherein she is being given special training to improve her cognitive abilities. The child is scheduled for clinical interview for every 2 months with the above medication and training to assess the improvement. Till now 3 follow-up visits have take place and substantial improvement was found in above-mentioned areas. |
An 85 year old Caucasian female was admitted with a four day history of increasing abdominal pain at her ileal conduit site with nausea but no vomiting. Five years prior, she was diagnosed with a high grade urothelial carcinoma, and underwent a total cystectomy with formation of a right iliac fossa ileal conduit. There was no evidence of tumour recurrence after 5 years of follow up. She did not have any other previous abdominal surgery and no significant past medical history.\nAt the time of her presentation, she had mild fever but did not have vomiting. She had normal bowel function and her urine output via the ileostomy was normal. Physical examination revealed a firm, irreducible mass lateral to her stomal site with overlying erythema. The stoma was healthy in appearance. There was also a reducible midline abdominal hernia. Her white cell count was elevated but all other blood tests including electrolytes, renal function, bilirubin and liver function tests were normal. A CT scan with oral gastrograffin contrast showed a midline abdominal hernia with small bowel loops, and a parastomal hernia containing an enlarged, thick-walled mass which did not contain oral contrast (Fig. ). With close proximity to the liver and absence of the gallbladder from its anatomical position, a gallbladder hernia was suspected. The alternative diagnosis of herniation of small bowel was considered, but with lack of oral contrast within the hernia, it was considered less likely.\nAt operation on the same day, a urinary catheter was placed in the stoma, and a midline laparotomy was performed. Following dissection and reduction of the midline abdominal hernia, the parastomal defect was defined (Fig. ). A 14 gauge needle was used to drain the hernia contents of which bile was extracted, confirming the presence of the gallbladder in the hernia (Fig. ). The gallbladder was then able to be reduced, and noted to be acalculous but thick walled and oedematous (Fig. ). A cholecystectomy was performed. The large remaining parastomal defect was not closed to not risk the blood supply to the ileal conduit. The patient had an uneventful post-operative course and was discharged on day five. She was well at her one month follow up. Histopathology of the specimen showed chronic cholecystitis without carcinoma. |
A 22-years old male patient presented with dyspnoea, fatigue and systemic hypertension. Physical examination revealed an increased second heart sound with an associated gallop rhythm and a diastolic murmur heard best at the cardiac apex. Radial pulses were normal but the femoral pulses were weak. Blood pressure measured at the left arm was higher than the one measured at the left leg. Chest X-ray showed rib notching and cardiomegaly (Figure ). Further evaluation with echocardiography revealed an aortic root dilatation of 42 mm with ascending aorta dilatation 68 mm and concomitant severe aortic valve insufficiency (3+). The left ventricle was dilated with end diastolic diameter 75 mm and associated systolic dysfunction with an ejection fraction of 35 percent. Pulmonary hypertension 60 to 25 mean 40 mm Hg was also present. Thoracic CT scanning with intravenous contrast medium showed an ascending aorta aneurysm of 68 mm (Figure ).\nCardiac catheterization was performed showing normal coronary arteries and severe aortic coarctation with a 70 mm Hg gradient measured across the descending aorta. The minimum diameter of the stenotic region on the aorta was 2 mm. The patient was classified as functional class III according to NYHA.\nCorrection of aortic coarctation was performed first by using a less invasive method. After heparinization and administration of antibiotic prophylaxis, dilatation across the coarctation site with balloon angioplasty was performed. Dilatation was accomplished by using 3 consecutive catheters of increasing size (8, 12, and 15 mm in diameter respectively). Post-dilatation aortography showed no residual gradients and the stenotic region was increased to 15 mm in diameter. The procedure was uncomplicated and the patient was released the following day.\nTwo weeks after balloon angioplasty the patient was re-admitted for management of the intracardiac pathology. Pre-operational thoracic CT scanning was performed to exclude any post-dilatational aneurysm formation at the site of balloon anchorage and determine descending aorta diameter (Figure ). Arterial cannulation at the right axillary artery was performed using a synthetic PTFE 8 mm graft. The purpose of this was twofold; to avoid the cannulation difficulties of inserting the aortic cannula into the hypoplastic femoral arteries and prevent vascular damage to the aorta after the recent angioplasty. A two-staged venous cannula was inserted into the inferior vena cava and cardiopulmonary bypass was established. Because of the ascending aorta aneurysmal dilatation and the concomitant aortic valvular regurgitation the patient underwent replacement of the ascending aorta with a metallic valved conduit (St Jude 27 mm) using the modified Bentall procedure. Cross-clamping time was 111 min and total bypass time was 138 min. The patients' recovery was unremarkable and he was discharged on the 12th postoperative day.\nAt follow-up three years postoperatively the patient is normotensive with a functional aortic valve. Repeat CT scanning showed no re-coarctation or aortic aneurysm formation. |
A 20-year-old white woman, para 1 + 0, presented to our institution with a history of sudden onset of severe lower abdominal pain and nausea. The pain was described as constant, sharp, radiated to her back, and associated with episodes of vomiting after a few hours. Similar episodes of pain were experienced in the previous few months and diagnosed as a case of bilateral dermoid in another hospital but the case was not documented. These episodes of pain were, however, shorter in duration and resolved spontaneously. She was otherwise well and there were no other associated gastrointestinal or genitourinary symptoms. She had no previous history of any illnesses or allergies. She denied the use of any medications. She had one pregnancy, usual course, and delivered normal spontaneous vaginal delivery. There was no family history of malignancies. There was no significant family or psychosocial history. Her menarche commenced at the age of 11 years with subsequent regular cycles.\nOn physical examination, she was alert, in mild distress, and her vital signs were within normal limits. An abdominal examination showed lower abdominal tenderness, with muscle guarding to palpation but there was no distension. Intestinal sounds were normal. An external genital examination was normal. A pelvic examination revealed bilateral adnexal tenderness on vaginal touch. Her full blood counts, serum biochemistry, and tumor marker were within the normal ranges. Urine analysis and pregnancy test were negative.\nAn ultrasound examination was performed bedside demonstrating bilateral ovarian cystic masses, on the left side around 14 × 11 cm and right side 8 × 6 cm with negative Doppler flow in the ovarian tissue with evidence of solid components. On the basis of these findings, ovarian torsion caused by adnexal mass was the likely diagnosis. Our patient was counselled and signed informed consent for laparoscopic ovarian detorsion, cystectomy, possible oophorectomy, and laparotomy if needed.\nIntraoperative findings confirmed a bilateral ovarian torsion that was the same size as that found by ultrasound. Our patient’s left ovary looked necrotic and was found to be twisted twice over. Detorsion of both ovaries were performed but the necrotic appearance of her left ovary did not improve and bleeding was observed from the necrotic ovary (Fig. ) but her right ovary improved in color (Fig. ). The decision was made by the surgical team to perform a left-sided salpingo-oophorectomy and right cystectomy. There were no major intraoperative complications. The pain resolved completely after surgery and the final pathologic diagnosis was mature ovarian teratoma (dermoid). She was discharged on the second postoperative day and advised to follow up after 4 weeks. Her postoperative period was uneventful. She recovered completely from her surgery and has gone back to her normal daily activity. |
A 73-year-old right hand dominant male presented to the clinic complaining of persistent pain on the ulnar aspect of his left hand. His symptoms began 3 months prior, after falling onto the ulnar aspect of his hand. The patient had been evaluated at the time of injury in the emergency department and subsequently at an urgent care facility where the correct diagnosis remained unidentified despite obtaining the radiographic images shown in (, ).\n3 months after his initial injury, the patient presented to the senior author’s office with the primary complaint of persistent pain at the base of his fifth metacarpal. He also noted that his small finger would get caught outside his pocket when retrieving an item. On physical examination of the left hand, a slight small finger abduction deformity was noted throughout digital range of motion. There was tenderness to palpation over the base of the metacarpal and no signs of neurological or vascular impairment. Posteroanterior (PA), lateral, and oblique radiographs reviewed from the time of injury and those taken at the time of presentation demonstrated a dislocation of the fifth metacarpal base in a volar and ulnar direction.\nThe decision was made with the patient to proceed with operative reduction and fixation of his chronic injury. A longitudinal incision was made along the dorsal aspect of the fifth metacarpal. The extensor tendons were protected and retracted. Surrounding intrinsic musculature and fibrous tissue were released from the metacarpal allowing visualization of the CMC joint. Successful reduction was accomplished with axial traction and manual pressure applied in a palmar to dorsal direction at the base of the metacarpal. An appropriate reduction was fluoroscopically confirmed at the metacarpal base, and the abduction deformity was reduced. The fifth metacarpal was then stabilized with parallel Kirschner wires to the fourth metacarpal distally and proximally. The reduction was confirmed and supported with an additional Kirschner wire driven retrograde through the CMC joint into the hamate ().\nThe patient was immobilized in an ulnar gutter splint and pins were maintained for 6 weeks. He was given a home exercise program to begin following pin removal. The patient was followed postoperatively at 6 weeks, 10 weeks, and 6 months. Clinical improvement was assessed by measuring QuickDASH scores and grip strengths measured with a Jamar grip dynamometer, as shown in (). The patient’s QuickDASH score was 6.8 at his 10-week follow-up and 4.5 at his 6-month follow-up. At 6 months, the patient’s grip strength had returned to normal. He was pain free, achieved full range of motion in his fingers and wrist, and the reduction was well maintained. The patient was very satisfied with his treatment and post-operative outcome. Radiographs and clinical photographs were taken at the patient’s 6-month post-operative follow-up, as shown in (, ), respectively. |
Our case is that of a 43-year-old primiparous woman. She was diagnosed with Behçet disease at the age of 34 years; she presented with recurrent oral ulceration, recurrent genital ulceration, and pseudofolliculitis with characteristic acneiform nodules. She had no eye lesions. Her condition was well controlled with prednisolone (PSL) 8 mg/day oral dose. She fell pregnant spontaneously and visited our perinatal center for her prenatal care. As she was detected with hypertension at her first visit, we recommended that she check her blood pressure regularly at home. She developed fever, oral ulcers, and arthralgia at 16 weeks of gestation, due to which a relapse of Behçet disease was suspected. Because her condition was controlled well with PSL, the daily oral dose of PSL was increased from 8 mg to 10 mg. At this time, ulceration and pain of the vulva were not observed. She visited our outpatient clinic for a regular prenatal examination at 18 weeks and 4 days of gestation, which was when an ulcer localized in the vagina was incidentally observed (). The ulcer was painless and the patient had no symptoms in the vulva either (). Chlamydial and gonococcal infection were not detected, and cytology of the vaginal wall showed no findings suggesting malignancy. As the other symptoms of Behçet disease were resolved after the dose of PSL had been increased, the same dose was maintained. At the next prenatal care visit, at 22 weeks and 4 days of gestation, the vaginal ulcer had disappeared and other symptoms of Behçet disease were not seen. At 28 weeks and 0 days of gestation, atypical genital bleeding and vaginal ulcer recurrence were observed (). At the same time, recurrence of the oral ulcer and arthralgia as well as a mild increase in the fever were observed; based on these symptoms, she was diagnosed with a relapse of Behçet disease and the daily dose of PSL was increased from 10 mg to 15 mg. The vaginal ulcer disappeared at 29 weeks and 2 days of gestation (). Thereafter, there was no relapse of the symptoms of Behçet disease.\nAt 33 weeks and 0 days of gestation, her blood pressure had increased, due to which she was admitted to the hospital. She was diagnosed with severe preeclampsia superimposed. Induction of labor was conducted but it was not effective, and we performed cesarean section at 37 weeks and 6 days of gestation. She delivered a male infant weighing 2002 g. There were no complications in the postoperative course, and she was discharged with her baby at 7 days after cesarean section. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery.\nThe patient was explained about the possibility of publishing this case as a case report and the accompanying images. She provided consent. |
The patient was a 27-year-old man who sprained his right thumb while playing softball, resulting in tenderness and swelling around the interphalangeal (IP) joint. He was a software engineer, and his dominant hand was the right hand. Physical examination revealed complete loss of active extension and also that passive extension and active flexion of the IP joint were full. The IP joint was stable against radial and ulnar stress. The images of plain radiography and computed tomography showed an avulsion fracture of one-third to half of its articular surface at the base of the distal phalanx (). Using the hook plate technique, open reduction was performed under general anesthesia 19 days after the injury (). An incision was made along the crease on the dorsal side of the IP joint. The fracture was reduced and fixed using a hook plate adapted from a 1.5 mm micro module (KLS Martin, Germany, ). One of the holes was cut, and one-third of its circumference was removed. The ends of the crescent arc were bent approximately 100° by pliers to form two sharp pointed hooks (). Two small longitudinal incisions were made at the EPL. The hook plate was slid under the nail matrix, the hooks were inserted through the slips, and the bone fragment was gripped. The screw was inserted into the plate hole to add compression to the fragment. The articular congruency and stability of the fragment in the direction of passive flexion were checked, and the wound was closed.\nThe splint was maintained for 1 week before motion of the IP joint was allowed, and the patient returned to work 1 day after surgery. Bone union was achieved and the plate was removed 3 months after the procedure (). At the last follow-up of 6 months after surgery, the active range of motion at the IP joint was 80 degrees of flexion and 8 degrees of extension. The range of motion on the contralateral side was 85 degrees of flexion and 10 degrees of extension (Figures and ). The patient had a transverse line nail deformity () that gradually improved. According to Crawford's evaluation criteria [], the result was excellent. The patient experienced no injury-related difficulties both at work and while playing softball. |
A 53 kg, 157 cm, 35-year-old primigravida at the 38th week of pregnancy was admitted for a cesarean section due to breech presentation. She had been diagnosed with TA 7 years prior to this presentation. However she refused medications and further evaluation until delivery. Computed tomographic angiography performed 3 years prior had revealed that the left common carotid artery and left subclavian artery were totally occluded along with a thrombotic aneurysm 5.8 × 5.2 × 9.6 cm in size (). She also had a localized dissection in the low abdominal aorta and focal stenosis in the descending aorta as well as a large left coronary aneurysm and about 50% stenosis of the right coronary artery. Plain chest radiographs revealed a huge superior mediastinal mass which was suspected of an aneurysm with thrombus in the left subclavian artery (). Cardiac single photon emission computed tomography and echocardiography were performed preoperatively to follow up on her coronary artery statuses. These examinations showed an old myocardial infarct, a persistent perfusion defect in the basal inferior wall and a reduction in wall motion.\nThe patient had been diagnosed with Type III TA as determined by the involvement of the aortic arch and coronary artery as well as the descending thoracic and abdominal aortas. She developed dyspnea on exertion with New York Heart Association Functional Class III. On physical examination, peripheral pulsations were weak in all limbs except the right arm. Heart rate was 120 beats/min, and non-invasive blood pressure (NIBP) was 96/78 mmHg in the right upper limb and 95/69 mmHg in the left upper limb. NIBP in the lower limbs measured 148/99 mmHg on the right and 156/95 mmHg on the left. She was cooperative and neurological examinations indicated normal results. A slowly titrated epidural anesthesia was selected to maintain hemodynamic stability. Regional anesthesia functioned as a simple and reliable monitor of cerebral perfusion through the patient's level of consciousness. For these reasons, we planned and executed an elective caesarean section under epidural anesthesia.\nOn arrival at the operating room, we began intraoperative monitoring by electrocardiography, pulse oximetry and NIBP measurement. Electrocardiography was unremarkable with a heart rate of 126 beats/min and the pulse oximeter on her right index finger displayed a normal waveform with a saturation of 95-96% in room air. She was alert and oriented, and her initial NIBP was 113/77 mmHg in the right upper limb. Her left radial, brachial and axillary arteries pulsed feebly, whereas her brachial and axillary arterial pulsations were stronger on the right than on the left. An artery cannula was placed in the right radial artery under local anesthesia connected to a FloTrac™ sensor and Vigileo™ monitor system (Edward Lifesciences, Irvine, CA, USA) device for continuous cardiac output assessments to monitor continuous blood flow. The initial cardiac index was 1.5 L/min/m2. A cerebral oximeter probe (Invos™, Cerebral/Somatic Oximeter 5100C, Somanetics Corporation, Troy, MI, USA) was attached to the forehead. The initial regional cerebral oxygen saturation (rSO2) levels were 64% on the right and 51% on the left.\nAfter placing the patient in the left lateral recumbent position, the median approach was performed with loss of resistance technique using an 18 G Tuohy needle between the L4 and L5 lumbar spines. The catheter was inserted and fixed. Her position was then changed to the supine position with a wedge under her right hip. The height of the block was increased gradually to T5 by using 11 ml of 2% lidocaine injected through an epidural catheter. Oxygen was administered via a VentiR mask, and a capnometer was installed below her nose to monitor respiration. The value of rSO2 was stable. Ten minutes after skin incision, a 3,180 gram girl was delivered and her Apgar score was 8 at 1 minute and 9 at 5 minutes.\nThree minutes after delivery, the placenta was removed and 20 IU of oxytocin diluted in 1,000 ml of 0.9% saline continued to be intravenously infused. The rSO2 levels dropped from 64 to 61% on the right and from 51 to 39% in the left at 6 minutes after delivery. At that time, we were able to obtain NIBP measurements. Arterial blood pressure was 56/48 mmHg without changes in cardiac index. She complained of dysarthria, tinnitus, and stiffness of the posterior neck (). An intravenous infusion of phenylephrine (100 mcg) and rapid administration of colloid (300 ml over 10 minutes) improved dysarthria, tinnitus and stiffness of the posterior neck as rSO2 increased from 61 to 78% on the right and from 39 to 56% on the left. There was no corresponding change in arterial blood pressure and cardiac index with the increase of the NIBP to 81/71 mmHg. However, she still complained of numbness of the face and blurred vision. Her laboratorial test results were as follows: hemoglobin, 9.0 mg/dl; hematocrit, 26%; Na+, 135 mg/dl; K+, 3.03 mg/dl; and Ca2+, 0.85 mmol/L.\nThe patient's facial numbness and blurred vision were resolved 20 minutes after the neurologic symptoms developed. Over time, her arterial compliance was reduced and invasive arterial blood pressure waveform damped along with a progressive decline in pulse pressure (). She lost about 1,000 ml of blood and received, in total, 500 ml of colloid solution, 2,500 ml of crystalloid, and 1 unit of blood were infused.\nThe patient was transferred to the intensive care unit for special attention to neurologic symptoms with continuous arterial blood pressure monitoring. Even though no focal neurologic deficits, postoperative brain magnetic resonance imaging and a magnetic resonance angiographic study were performed to rule out acute cerebral infarction. Magnetic resonance imaging showed multiple old infarcts in the right frontal and left frontotemporoparietal areas and a suspicious acute left cerebellar small infarct. In addition, there were complete occlusions of the left subclavian, left common carotid, internal carotid and middle cerebral arteries. There were near-complete occlusions of the bilateral proximal vertebral arteries. The left distal vertebral artery was reconstituted by the left thyrocervical trunk (). She refused further treatments, including surgery. She was discharged on the sixth postoperative day. |
A 25-year-old female presented to our facility with aggressive behavior and over activity for the last six weeks. Her mother was the informant and she seemed to be well aware of her disease. She described that her daughter had approximately 18-20 of such episodes for the last ten years and the last episode was about one month back when she developed aggressiveness without any inciting event. She walked out of her home barefoot and called the emergency numbers for complaining against her husband whom she has been abusing for the last couple of hours. During the illness, she visited few physicians and took multiple antipsychotics. She was admitted three times to an inpatient psychiatric unit for the same illness. This time she developed the same aggressive behavior after she had a fight with a shopkeeper and started verbally abusing him. The neighbors and brought her back home. She remained aggressive and abusive at home as well, especially towards her brother and her mother. She also developed a sense of paranoia and suspicion towards her mother and her neighbors. She accused them of bad behavior and thought that they were plotting to send her to a mental institution. According to the mother, the patient had become overactive and roamed around the house without any purpose. She has become talkative and talked continuously about the people she didn’t like and verbally abused them. Her sleep has decreased from eight hours to four hours, and she has not been eating much. Her mother did not describe any history of drug abuse, trauma, suicidal ideation, gait disturbances or febrile illness. Her symptoms had severely affected her daily life and relationships. As per her mother, she has torn all her past medical records.\nOn reviewing her family history, we found that her father had a similar condition for the past forty years which is now controlled by medications. Both the mother and elder brother have also been diagnosed with BPD and are compliant to treatment. Physical examination of the patient was normal. On mental state examination, the mood is elevated, and there is increase rate, rhythm, the volume of talk and increased flow and flight of ideas preoccupied with gloominess. The patient was admitted to the psychiatric unit and was assessed according to bio-psycho-social model. Her Young Mania Rating Scale (YMRS) was 45; she had a working diagnosis of bipolar type 1 according to the fifth edition of DSM (DSM-5). She was started on olanzapine, sodium valproate, procyclidine, haloperidol, propranolol, and maintained with hydration and nutrition. The patient was hospitalized and was discharged after three weeks with a stable mental condition. She is currently being followed at the outpatient department with no relapse since her last admission. |
The case is a 66 year old female, who is a known case of diabetes mellitus with a long-lasting medical history of recurrent right upper abdominal pain with extension to the tip of the right scapula accompanied with vomiting. The first episode was in June 2006 managed as biliary colic after rule out of ischemic heart disease and based on ultrasound report of distal common bile duct (CBD) stone (measuring 5.5 mm). At that time, all liver enzymes and liver function tests and alkaline phosphatase levels were normal. Ultrasound also demonstrated mild dilation of the left liver lobe intrahepatic biliary ducts.\nIn December 2006, about 6 months earlier than the first episode, checkup ultrasound had been done for the patient that showed only mild focal fatty change in lateral segments of left liver lobe without similar findings of biliary ducts. Pain of the first mentioned episode was subsided spontaneously and the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) 1 month later but there was no visible CBD stone on ERCP at that time.\nIn June 2011, another abdominal pain with similar features to the first episode made the patient referred to the hospital. Abdominal ultrasound was subsequently ordered which showed ectasia of left liver lobe intrahepatic biliary ducts in 2nd and 3rd segment and a heterogeneous echogenic area in the hepatic 4th segment measuring 20 mm × 17 mm × 40 mm seemed to be the cause of biliary dilatation, suggestive for ductal infiltrative lesions.\nAn abdominal computed tomography (CT) scan was performed on June 2011, (images not provided) which demonstrates a hypodense mass-like lesion in the origin of the left hepatic duct measuring 38 mm × 18 mm × 34 mm with extension to peripheral branches causing dilation of left main hepatic duct and left intrahepatic biliary ducts. Differential diagnosis made by CT scan was a polypoid mass arising from biliary ducts or thick sludge fulfilling biliary ducts.\nIn June 2011, magnetic resonance cholangiopancreatography (MRCP) was done [] that showed intrahepatic biliary duct ectasia of the left liver lobe accompanied with an area of filling defect within dilated biliary ducts with branching distribution mostly due to neoplastic lesion or mucin. Ultrasound-guided tissue sampling of left liver lobe was performed in July 2011 which reveals dilatation of biliary ducts with no evidence of malignancy on pathological study.\nIn June 3, 2016 another episode of severe abdominal pain and vomiting occurred. The blood chemistry profile was normal. As patient mentioned weight loss at that time endoscopy and colonoscopy were ordered which both were normal. CT scan showed tubular branching hypodense mass in the left liver lobe with extension to the left hepatic bile duct. Tissue sampling was recommended but was not repeated another time.\nAs patient symptoms (interpreted as recurrent cholangitis) were continued and accompanied by weight loss, till September 2018 another contrast enhanced abdominal CT scan was done []. CT scan revealed left liver lobe biliary ectasia with an infiltrative soft-tissue density within intrahepatic biliary ducts suggestive for cholangiocarcinoma versus pyogenic recurrent cholangitis.\nAt this time (September 2018) MRCP was ordered for more evaluation. MRCP demonstrates a T2 high signal intensity lesion in the left liver lobe accompanied with intrahepatic biliary duct ectasia and parenchymal shrinkage [].\nCholangiocarcinoma versus focal cholangitis or hepatitis was in differential diagnosis based on MRCP.\nEUS was done in March, 2019 which demonstrates a 50 mm × 30 mm hypoechoic mass in the left liver lobe containing dilated intrahepatic ducts up to 6 mm. The CBD was unremarkable and measured 6 mm in the proximal part.\nHence, tissue sampling of mentioned infiltrative mass was performed in May 2019 revealing cholangiocarcinoma developing in intraductal papillary neoplasm of bile duct in microscopic pathological study and mucin secreting neoplasm (adenocarcinoma) with GI origin on immunohistochemistry study.\nAnother contrast enhanced abdominal CT scan was ordered in May, 2019 before surgery [] which demonstrates heterogeneous mass in size of 70 mm × 42 mm at left liver lobe accompanied with perilesional staining and focal peripheral biliary duct ectasia. Branching and extension of mentioned mass were seen through left hepatic duct without involvement of portal or hepatic veins, with mild enlargement in size in comparison to previous study.\nThe patient underwent surgery, which gross pathology findings consisted of an intraparenchymal mass in the left liver lobe with the largest gross specimen measuring 3 cm.\nMicroscopic pathological findings of resected mass were consistent with cholangiocarcinoma with involvement of regional lymph nodes []. |
A 63-year-old man presented to Orthopaedics Outpatient Department (OPD), All India Institute of Medical Sciences, New Delhi with a history of pain in bilateral knees for 10 years. He had more pain on the left knee as compared to the right knee. He had developed a sudden onset foot drop in the left lower limb for the last four months.\nHis pain in the left knee was severe to an extent that he was not able to walk even up to one block. He had to use a walker for ambulation. His activities of daily living such as using a transport, climbing stairs, squatting and sitting cross legged were limited. He also gave a history of recurrent episodes of giving way in the left knee. He developed a localized swelling on the lateral aspect of left knee, which was insidious in onset and progressed gradually over a period of the last one year. He had no history of any trauma to the left knee. He did not have any back pain or any radiating pain in his left lower limb. He had a history of coronary artery disease in the past for which he received treatment in the form of an angioplasty with a cardiac stent.\nOn physical examination, the patient was 178 cm tall and weighed 74 kg. He walked with high steppage gait and had a varus thrust. The tibiofemoral angle was 10° varus (), on weight bearing. On palpation, the patient had medial joint line tenderness and there was patellofemoral crepitus. There were two swellings located on the lateral aspect of the knee. The first swelling was located 1 cm above the lateral joint line and 4 cm lateral to the lateral patellar border and measured 4 cm × 6 cm. The other swelling was located 1 cm below the lateral joint line and 2.5 cm lateral to the lateral patellar tendon measuring 2 cm × 4 cm (). The skin around both the swellings was normal. The patient had 10° of flexion contracture and the range of motion was 10–110° flexion. Examination of the ligaments in maximal extension revealed 10 mm of opening of the lateral joint line on varus stress test with a soft end point and with valgus stress the alignment of the knee improved to normal with a bony end point ( and ).\nNeurological examination revealed a 0/5 motor power in the tibialis anterior and the extensor hallucis longus of the left lower limb. The sensory examination revealed decreased sensation over the dorsum of the left foot and the first dorsal web space. Examination of the hip and the spine revealed no abnormality.\nRadiographs of both the knees’ anteroposterior and lateral views showed tricompartmental osteoarthritis of both the knees with opening of the lateral joint space. There was lateral subluxation of the tibia with respect to the femur ( and ). Electromyography and nerve conduction study revealed a peroneal nerve neuropathy at the level of the knee.\nA total knee arthroplasty (TKA) along with exploration and decompression of peroneal nerve for the left knee was done. A primary TKA (NEXGEN; Zimmer Biomet, Warsaw, Indiana) was performed (). Ligament balancing was done by performing medial release. We used posterior stabilized insert with cemented femoral and tibial components with a tibial stem.\nThe peroneal nerve was explored and decompressed by making a 3–5 cm oblique incision parallel to the course of nerve at the neck of the fibula. Skin and the subcutaneous fascia were cut in the same plane. With the help of Metzenbaum scissors and blunt dissection, the retinaculum was identified. The cysts were found under the fascia. Blunt dissection showed cystic wall. An effort was made to remove the cyst without violating the cystic wall, however decompression of the cyst was necessary. Incision of the cyst extruded viscous yellow tinted liquid. The decompressed cyst was then clamped with the Alice forceps and the dissection was started from proximal to the distal directions taking care not to injure the common peroneal nerve around it. The cyst was then removed in toto and was sent for histopathology (). The peroneal nerve was found to be embedded between the two cysts and had a flattened surface. The nerve was freed of all the adhesions around it (). Furthermore, the nerve was decompressed at the level of deep peroneal muscle fascia after exposing the underlying peroneal muscles.\nThe patient was made to walk 24 h later with protected weight bearing with the assistance of a walker. The patient was evaluated at two weeks and three months postoperatively. At three months postoperatively, the knee pain has resolved completely and the patient is able to walk and climb stairs unassisted. The power of the left ankle and toe dorsiflexors has improved to 5/5. |
Our case is that of a 43-year-old primiparous woman. She was diagnosed with Behçet disease at the age of 34 years; she presented with recurrent oral ulceration, recurrent genital ulceration, and pseudofolliculitis with characteristic acneiform nodules. She had no eye lesions. Her condition was well controlled with prednisolone (PSL) 8 mg/day oral dose. She fell pregnant spontaneously and visited our perinatal center for her prenatal care. As she was detected with hypertension at her first visit, we recommended that she check her blood pressure regularly at home. She developed fever, oral ulcers, and arthralgia at 16 weeks of gestation, due to which a relapse of Behçet disease was suspected. Because her condition was controlled well with PSL, the daily oral dose of PSL was increased from 8 mg to 10 mg. At this time, ulceration and pain of the vulva were not observed. She visited our outpatient clinic for a regular prenatal examination at 18 weeks and 4 days of gestation, which was when an ulcer localized in the vagina was incidentally observed (). The ulcer was painless and the patient had no symptoms in the vulva either (). Chlamydial and gonococcal infection were not detected, and cytology of the vaginal wall showed no findings suggesting malignancy. As the other symptoms of Behçet disease were resolved after the dose of PSL had been increased, the same dose was maintained. At the next prenatal care visit, at 22 weeks and 4 days of gestation, the vaginal ulcer had disappeared and other symptoms of Behçet disease were not seen. At 28 weeks and 0 days of gestation, atypical genital bleeding and vaginal ulcer recurrence were observed (). At the same time, recurrence of the oral ulcer and arthralgia as well as a mild increase in the fever were observed; based on these symptoms, she was diagnosed with a relapse of Behçet disease and the daily dose of PSL was increased from 10 mg to 15 mg. The vaginal ulcer disappeared at 29 weeks and 2 days of gestation (). Thereafter, there was no relapse of the symptoms of Behçet disease.\nAt 33 weeks and 0 days of gestation, her blood pressure had increased, due to which she was admitted to the hospital. She was diagnosed with severe preeclampsia superimposed. Induction of labor was conducted but it was not effective, and we performed cesarean section at 37 weeks and 6 days of gestation. She delivered a male infant weighing 2002 g. There were no complications in the postoperative course, and she was discharged with her baby at 7 days after cesarean section. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery.\nThe patient was explained about the possibility of publishing this case as a case report and the accompanying images. She provided consent. |
The patient was a 28-year old woman primipara with c/s 7 years ago. She came to our clinic with a history of abnormal uterine bleeding from 2 years before. She was pregnant two years ago and he had experienced an episode of vaginal bleeding in 6 weeks of pregnancy without any previous sonography. So, she was undergone curettage due to diagnosis of incomplete abortion. After that her menses were irregular and she had frequently a sustained annoying pain in her lower abdomen almost always.\nShe had several negative pregnancy tests. Her βhCG level was less than 2 and in sonography the endometrial thickness was13 mm with a fine heterogenicity and one local hypoechogenicity with 7×4mm diameter, which was probably endometrial polyp. The left adnex was normal and there was a mix echo lesion in 17×24 mm diameters with an echolucency area around it with 14 mm diameter in right ovary (). It had abnormal circulation in color Doppler and was suspicious to aneurism. In physical exam the abdomen was soft without any tenderness or palpable mass although the patient was obese and it had made the exam of her abdomen and adnexes difficult.\nIn her MRI report there was an approximately 23×17 mm mass separable from right ovary with T1 low and T2 high signal. No fat signal is seen in the mass. There was also no evidence of aneurism. The patient was undergone laparoscopy and hysteroscopy due to pain and complex adnexal mass and abnormal uterine bleeding. In laparoscopy the left adnex was normal. In the right adnex it was an old tubal pregnancy that has involved almost half of the tube with significant calcification in the mass but there was not any rupture or hemorrhage evidences in the tube or any adhesion around it.\nThe salpangostomy was done and the calcificated mass was extracted completely. In hysteroscopy there was a little polyp and it was extracted. The pathology report of tubal mass was ghost of chorionic villi compatible with degenerated products of conception. Three months later the patient was good with no pain in her lower abdomen. We obtained informed written consent from this patient and the next one to use her data in our report. |
A 41-year-old black male was admitted for the investigation of recurrent episodes of lower gastrointestinal bleeding over the previous 10 years that had become more frequent over the last three months. Since childhood, he had undergone repeated treatments of oral iron supplementation for anemia that was difficult to clinically control. He had received blood transfusions at two instances to control the severe anemia. The patient reported that, since childhood, he had blue spots, similar to varicose veins, distributed in his hands, arms, legs, and trunk that increased in size and number with his age. The lesions had varying diameters (1 cm to 12 cm) and were usually regularly raised mushrooms, resembling small bubbles of blue coloration (). One of these skin lesions was located at the elbow and had demonstrated several episodes of bleeding after trauma; it had been excised and sent for examination. The histopathological examination of this lesion confirmed the diagnosis of cutaneous hemangioma. Upon physical examination, the patient was in a good general condition with severe mucocutaneous pallor. The examination of the skin on the body's surface showed numerous injuries resembling raised mushrooms with soft consistency and depressive compression that most often involved the trunk and upper limbs. The red blood cell counts showed severe anemia (Hemoglobin 6.1 g/dL) and hypochromic microcytosis with the presence of 4% reticulocytes. The serum iron level was 18 mg/dL. Upon digital rectal examination, we found blood on the glove without palpable masses.\nTo clarify the origin of the lower digestive bleeding, the patient underwent a colonoscopy that identified, in addition to hemorrhoidal disease of the III degree, numerous venous malformations measuring 1.5 × 2.0 cm that were scattered throughout the mucosa of the colon and rectum (). One of these lesions showed signs of recent bleeding after being removed with snare cautery. Histopathological examination revealed numerous dilated blood vessels in the lesion with signs of recent hemorrhage located mainly in the submucosal layer (). The presence of hemangiomas of the colon associated with cutaneous venous malformations allowed the diagnosis of BRNS. The hemorrhoidal disease was treated by two sessions of rubber band ligation, which were performed uneventfully. Currently, the patient is healthy and has not presented with new episodes of gastrointestinal bleeding; his anemia is well-controlled two years after the described procedures. |
A 55-year old male patient was admitted for the occipital and frontal headaches he had suffered with for the previous 7 days before admission to the hospital. They occurred after he had lifted heavy objects. The headaches occurred when he sat or stood up, but they subsided when he was lying down. He had received no treatment for this, but 3 days before admission, his headaches had worsened. On the day he was admitted, he experienced dull pain of 8/10 on the VAS in the occipital and frontal areas, as well as in the cervical area, and this was accompanied by nausea. So he visited the department of neurosurgery as an outpatient and was admitted. There were no strange findings in his past history. He had no past history of trauma or dural puncture in the head or spine. A physical examination performed on the day he was admitted showed no strange findings either. But a brain MRI showed he had diffuse pachymeningeal enhancement and a subdural effusion (). A CSF study showed the CSF opening pressure in the sitting position to be 40 mmH2O, there was increased protein at 64.5 mg/dl and the glucose level was 59 mg/dl. A cytologic examination of the CSF and a bacterial culture test showed no strange findings. Spinal MRI showed a dilated epidural venous plexus. An RNC showed that the CSF leaked to the left at the cervical level and to the right at the middle thoracic level. It also showed that the radioactive tracer was quickly being excreted through the bladders and kidneys (). These findings were diagnosed to be a CSF leak/SIH in the cervical and thoracic levels. Conservative treatment was administered for 2 days, including liberal hydration, bed rest and the administration of NSAIDs. But when standing, his pain persisted at 8/10 on the VAS. So he was referred to the Department of Pain for consultation. On day 3 of admission, 6 ml of autologous EBP was injected under fluoroscopic guidance between C4 and C5, as well as 6 ml of autologous EBP was injected between T5 and T6. The patient experienced immediate pain relief. 8 hours after the EBP, his pain was 2/10 on the VAS. On day 4 of admission, the pain was 0/10 on the VAS. On the second brain MRI, there was little change in the pachymeningeal enhancement, but the subdural effusion had decreased. He experienced no headaches afterwards. So on day 6, he was discharged. He was still asymptomatic at the 3 month follow up, and he is still being monitored. |
A 46-year-old man was referred for left chronic leg pain. The patient was involved in a plane accident 30 years before sustaining a femoral shaft fracture treated with a reamed Kuntscher nail and a posterior wall acetabulum fracture treated with open reduction and internal fixation with lag screws (). The patient came to our outpatient clinic complaining about inguinal pain and chronic leg pain with limitation of activities of daily living, although he was able to walk for more than one hour. On physical examination, the patient had no limitation of the hip range of motion. The ipsilateral knee had full range of motion and the patient did not need any crutches to walk without limping. Neurovascular examination was normal. The PostelMerléd’Aubigné scale was 14 points (4 for pain, 5 for walking and 5 for range of motion). Overall alignment of the extremity was anatomic. As a part of the initial evaluation, a blood test with infection parameters was performed and was negative for infection. Pre-operative radiographs showed a healed femoral fracture in all 4 cortices with an intramedullary Kuntscher nail without locking screws and cortical thickening at the fracture site ().\nThe patient was informed about the incipient arthritis of the hip and the possibility to perform a one-stage or two-stage surgery. The surgical risks were discussed with the patient, including pain after hardware removal and failure to remove the nail, specially this last point because other surgeons had tried to do the same procedure few years before and had failed after many hours of surgery. The patient decided to have two-stage surgery. Firstly, remove the nail at all costs and depending on the outcome of this first surgery he would assess the hip replacement surgery.\nThe patient was put in a lateral position and a lateral hip approach was done. The first step was to find the proximal tip of the nail which was found seated deep in the great trochanter. The initial device used to remove the nail was the conical extraction tool that was unsuccessful after several attempts. After the overgrowth bone was removed of the proximal part of the nail a hook extraction system was engaged with difficulty. However, the nail did not move after multiple hits with a 1 kg hammer and finally the hook broke itself. At this point, we decided to use the saw to perform a simple unicortical osteotomy in the proximal third of the femur to decompress the endomedullar canal (). After this decompression osteotomy we tried to hit the nail from below with an impactor engaged in the proximal hole of the nail. However, the implant remained in the same position.\nAfter trying all these different ways to remove the nail being unsuccessful, we decided to continue the longitudinal osteotomy from proximal to distal in the lateral side of the femur. The nail was found in place with on growth and overgrowth in almost entire length of the nail. A new attempt to hammer the nail from below was performed and the nail started to move gradually until the proximal hole of the nail broke (). After so many attempts, we did not give up and proceeded to drill a new hole distally with a diamond drill () to finish the nail removal.\nFinally, the Kuntscher nail was removed in its entirety without any other complications. Subsequently, several cerclages and a bone allograft was used to close the longitudinal osteotomy ().\nThe patient was admitted to the hospital for pain and bleeding control. On the second day of hospitalization, the patient underwent a blood transfusion as his hemoglobin was reported to be 7.1 g/dl. The patient was discharged on day 4 after antibiotic prophylaxis, deep vein thrombosis prophylaxis with low-weight-molecular heparin and ambulation with crutches without weight bearing. At 8 weeks of follow-up, patient was allowed to walk with gradual weight bearing. The patient was satisfied at 1 year of follow-up with no complications and the X-ray showed complete healing of the longitudinal osteotomy ().\nAt the time of this case report, the patient is free from pain in the leg with only sporadic hip pain, so there is no indication of hip replacement surgery for the time being |
We report the case of a 62-year-old female with a familial history of bleeding disorder diagnosed with GT at the age of 15 during the investigation of menorrhagia. She had been frequently transfused throughout her life, until her menopause at 52, when bleeding episodes ceased.\nThe patient did not present with additional bleeding manifestations until she was 60 when the first GI bleeding episode occurred. In November 2012, she was admitted at a local hospital due to massive lower GI bleeding. She was severely anemic, requiring transfusion of many units of packed red blood cells (PRBC). Colonoscopy was performed and detected an angiodysplastic lesion at the rectum and another at the cecum with active bleeding. Adrenaline injection therapy was performed and an endoscopic clip was successfully placed and stopped the bleeding from the active lesion. At that time, she was also started on tranexamic acid. One month later she was re-evaluated in our service referring sporadic GI bleeding episodes that were controlled with the continuous use of tranexamic acid.\nDuring the following months, she experienced several GI bleeding episodes requiring transfusion of a total of 25 units of PRBC (). Oral and intravenous iron replacement therapy were started during this period. Three upper GI endoscopies, two colonoscopies, one capsule endoscopy and a radionuclide scan were performed on different bleeding episodes she experienced between September 2013 and August 2014 and failed to identify the origin of the bleeding.\nA presumptive diagnosis of angiodysplasia was made and a trial of thalidomide was started in September 2014, on a dose of 50 mg daily. After 15 days and no side effects reported, the dose was increased to 100 mg daily and continued that way for almost 6 months. While on thalidomide treatment, she started to present drowsiness and mild paresthesia on her lower limbs. Continuous tranexamic acid and iron replacement were maintained. During the period of thalidomide use, a reduction in the number and severity of bleeding episodes as well as in transfusion requirements was noted (). After five months on thalidomide, the patient started to present recurrent GI bleeding episodes that demanded treatment with rFVIIa, platelet transfusion, and continuous tranexamic acid. Thalidomide was then suspended. At this occasion, platelet refractoriness was confirmed with the presence of anti-GPIIb/IIIa (Gi5) demonstrated by monoclonal antibody-specific immobilization of platelet antigen (MAIPA) test. Bleeding became more severe and were only partially controlled with rFVIIa and platelet transfusion. She died in April 2015, due to persistent hemorrhage and sepsis caused by hospital-acquired infection. |
Subsets and Splits