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MultiCaRe_Reasoning0 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 53.0
Sex: Female
Title: Littoral cell angioma mimicking hepatic tumor
Keywords: vascular tumor; diagnostic imaging; liver; pathology; spleen;
Abstract:
Littoral cell angioma is a rare vascular tumor of the spleen that was described by Falk et al. in 1991. Because of the limited number, untypical imaging manifestations, and lack of knowledge on this tumor type, these tumors are often misdiagnosed. In most cases, the tumor presents with multiple small hypoattenuating nodules in the spleen with delayed enhancement. However, solitary littoral cell angiomas have not been well described. We present the CT features of an unusual littoral cell angioma mimicking hepatic tumor.
Image Caption and Description:
Image caption: (a) Axial unenhanced CT image demonstrates an ill-marginated solitary mass that fills the left abdominal quadrant. (b, c) The mass enhanced gradually and heterogeneously during the arterial and portal phase. (d) At delay phase the mass was still hypodense relative to the spleen. (e) On the coronal image of portal phase, the mass was located between the left lobe of the liver and the spleen, and it appeared closely related to both organs
Image description: Axial unenhanced CT scan (Fig. 1a) confirmed an ill-defined heterogeneous mass 9.1 cm in diameter that filled the left abdominal quadrant, located between the left lobe of the liver and the spleen.
After intravenous contrast medium injection the mass enhanced gradually and heterogeneously (Fig. 1b-e), but was still hypodense relative to the spleen.
Image caption: (a) Variably sized vascular channels lined with flat and tall endothelial cells (HE, x 100). The endothelial lining cells of these vessels were positive for CD31 (b) ( x 100) and CD68 (c) ( x 200)
Image description: Histologic examination (Fig. 2) revealed that the lesion was composed of variably sized vascular channels lined with flat and tall endothelial cells, with papillary fronds extending into the vascular channels.
Case Report:
A 53-year-old woman presented with a 10-year history of intermittent abdominal pain, swelling and continuous vomiting. The patient denied presence of fever, nausea, and weight loss. There were no significant findings at physical examination. An abdominal ultrasound exam revealed a 10.4 x 10.0 cm mass of heterogeneous echogenicity in the left upper abdomen. Axial unenhanced CT scan (Fig. 1a) confirmed an ill-defined heterogeneous mass 9.1 cm in diameter that filled the left abdominal quadrant, located between the left lobe of the liver and the spleen. The CT attenuation of the mass was around 26-53 HU on non-enhanced scan. After intravenous contrast medium injection the mass enhanced gradually and heterogeneously (Fig. 1b-e), but was still hypodense relative to the spleen. There was no accompanying lymphadenopathy or evidence of malignant process elsewhere in the abdomen. Because the origin of the mass was unknown and a primary malignancy could not be excluded, the patient underwent an explorative laparotomy. During the operation, a well-encapsulated mass was found under the left hepatic lobe and the pedicle arising from the spleen. Resection of the mass and the spleen was performed.
Gross examination of the spleen showed splenomegaly (580 g, 15 x 10 x 9 cm) with an ill-defined brownish nodule (5 x 8 x 8 cm). Histologic examination (Fig. 2) revealed that the lesion was composed of variably sized vascular channels lined with flat and tall endothelial cells, with papillary fronds extending into the vascular channels. No atypical cells or mitosis were present. The endothelial lining cells of the vascular channels were positive for CD31 and CD68, factor VIII and negative for CD34, CD21, and CD8. These findings were considered diagnostic of benign splenic littoral cell angioma.
OUTPUT:
| PMC3738355 |
MultiCaRe_Reasoning1 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 69.0
Sex: Female
Title: Central retinal artery occlusion following laser treatment for ocular ischemic aortic arch syndrome
Keywords: mri; aortic arch; carotid artery stenosis; carotid duplex ultrasound; ocular ischemic syndrome; panretinal laser; retrobulbar block;
Abstract:
Objective:
Ocular ischemic syndrome is a rare blinding condition generally caused by disease of the carotid artery. We describe a 69-year-old female with a 50 pack-year smoking history with aortic arch syndrome causing bilateral ocular ischemic syndrome.
Methods:
The patient presented with progressive visual loss and temple pain. Slit lamp biomicroscopy revealed bilateral iris neovascularization. This finding prompted a cardiovascular work up. Panretinal photocoagulation with retrobulbar block was performed in the right eye.
Results:
A temporal artery biopsy was negative. The carotid duplex ultrasound showed only a 1-39% stenosis. MRA revealed a more proximal occlusion of the aortic branch for which she underwent subclavian carotid bypass surgery. At the one month follow up, the right eye suffered profound vision loss secondary to a central retinal artery occlusion.
Conclusion:
Ocular neovascularization may be one of the clinical manifestations of aortic arch syndrome. This case also illustrates the limitations of relying solely on carotid duplex ultrasound testing. We caution against overly aggressive panretinal photocoagulation utilizing retrobulbar anesthesia.
Image Caption and Description:
Image caption: Slit lamp biomicroscopy of the anterior segment of the left eye shows marginal (arrow) and peripheral (arrowheads) circumferential neovascularization of the iris.
Image description: Slit lamp biomicroscopy showed iris neovascularization of both eyes (Figure 1 (Fig. 1)).
Image caption: Optical coherence tomography of the right eye (A) and the left eye (B) without evidence of macular edema
Image description: Optical coherence tomography showed no evidence of macular edema (Figure 2 (Fig. 2)).
Image caption: Fluorescein angiogram showing significantly delayed arterial filling with 60 seconds in the right eye (A) and 52 seconds in the left eye (B) and poor peripheral perfusion. Arteries are attenuated and veins are dilated and non-tortuous in both eyes. The late film (C) shows mild capillary leakage in the right eye at 6 minutes but no macular edema or neovascularization.
Image description: Fluorescein angiography exhibited delayed arterial filling and poor peripheral perfusion (Figure 3 (Fig. 3)).
Image caption: MRA extracranial showing severe narrowing of the origin of the right brachiocephalic artery (yellow arrow) and complete occlusion of the left common carotid artery with distal reconstitution of flow near the bifurcation (red arrow).
Image description: MRA Extracranial showed proximal occlusion of aortic arch branches (Figure 4 (Fig. 4)).
Case Report:
A 69-year-old Caucasian female with coronary artery disease, hyperlipidemia, bilateral cataract extraction three years prior, and a fifty pack-year smoking history presented to the clinic with chronic, progressive vision loss greater in the right eye, bilateral photophobia and flashes, and right eye and temple pain. Best corrected visual acuity was 20/50 in both eyes. Pupils were equal and without afferent pupillary defect (APD). Intraocular pressure was 12 mmHg and 10 mmHg in the right and left eyes, respectively. Confrontation visual fields revealed an inferonasal depression in the right eye. Slit lamp biomicroscopy showed iris neovascularization of both eyes (Figure 1 (Fig. 1)). Dilated fundus examination showed unremarkable optic nerves, attenuated arteries, and dilated, non-tortuous veins in both eyes with few drusen in the right macula and very few hemorrhages. Optical coherence tomography showed no evidence of macular edema (Figure 2 (Fig. 2)).
Fluorescein angiography exhibited delayed arterial filling and poor peripheral perfusion (Figure 3 (Fig. 3)). Right temporal artery biopsy was negative for giant cell arteritis. We ruled out hyperviscosity syndromes, blood dyscrasia, diabetes, Takayasu, collagen vascular disease, thyroid orbitopathy and various infectious causes of retinal ischemia and aortitis. CBC, SPEP, HbA1c, ESR, CRP, FTA-ABS, and hypercoagulation panel were unremarkable. Carotid duplex ultrasound indicated only mild carotid stenosis (1-39%) bilaterally. At the time of initial presentation, the patient was taking Lipitor, Aspirin 81 mg, Relafen, Klonopin, Zoloft, and Nexium.
The patient received pan-retinal photocoagulation (PRP) in the right eye. Due to low tolerance, a retrobulbar block without epinephrine was administered to the right eye prior to the second PRP ten days later at which time 3,625 spots with a duration of 20 milliseconds of 500 mW were delivered using the indirect laser ophthalmoscope. Eighteen days after this laser session visual acuity had dropped significantly in the right eye to count fingers at 3' with APD and attenuated posterior vasculature consistent with central retinal artery occlusion. MRA Extracranial showed proximal occlusion of aortic arch branches (Figure 4 (Fig. 4)). Due to concern for diminished blood supply from the aortic arch, the patient received a left subclavian artery to right common carotid artery bypass graft. One month after surgery, neovascular glaucoma developed in the right eye with intraocular pressure of 34 mmHg and 22 mmHg in the left eye. Pressures remained stable on Combigan twice daily. We treated the left eye with short sessions of laser for a total of 2,200 burns (0.05-0.07 sec, 300 micron) using the Laser indirect system for one session and the Varia multicolor slit-lamp system for the remaining 5 sessions. Six months after the bypass surgery, she maintained a visual acuity of 20/50 in the left eye and intraocular pressure was 18 mmHg.
OUTPUT:
| PMC5015624 |
MultiCaRe_Reasoning2 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 60.0
Sex: Male
Title: Promising Combination Therapy with Bevacizumab and Erlotinib in an EGFR-Mutated NSCLC Patient with MET Amplification Who Showed Intrinsic Resistance to Initial EGFR-TKI Therapy
Keywords: bevacizumab; egfr mutation; erlotinib; lung cancer; met amplification;
Abstract:
In lung cancer, several potential mechanisms of intrinsic and acquired resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have been explored, including mesenchymal-epithelial transition factor (MET) signaling pathway activation. On the other hand, vascular endothelial growth factor (VEGF) production of EGFR-mutated lung cancer cells is stimulated by predominantly activated MET signaling pathway. Therefore, the inhibition of VEGF axis as the downstream target of MET signaling pathway seems promising. Here, for the first time, we report the potential efficacy of combination therapy with bevacizumab and erlotinib in an EGFR-mutated NSCLC patient with MET amplification who showed intrinsic resistance to initial EGFR-TKI therapy. The patient was a 60-year-old male smoker, showing performance status (PS) 2, who presented with stage IV lung adenocarcinoma (cT4N2M1a) harboring the EGFR exon 19 deletion mutation. He was started on gefitinib at 250 mg/day. However, by 28 days, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3. Then, repeat biopsy was performed, showing the positive MET amplification and the preserved EGFR exon 19 deletion mutation. Therefore, on the basis of the potential efficacy for activated MET signaling pathway as well as the confirmed safety by the known phase II trial for EGFR-mutated patients, the patient was started on combination therapy with bevacizumab at 15 mg/kg every 3 weeks plus erlotinib at 150 mg/day. By 21 days, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities.
Image Caption and Description:
Image caption: Chest X-ray and chest CT images before initial EGFR-TKI treatment. (a) Chest X-ray image showed a right hilar mass followed by lymphangitic carcinomatosis in the right lower lung field. (b) Chest CT image showed a large lung mass, extending to posterior chest wall and vertebral body, in the right lower lung as well as multiple lymphadenopathy and right pleural effusion.
Image description: In the imaging test of full body, chest X-ray and chest CT revealed a large lung mass, extending to posterior chest wall and vertebral body, surrounded by lymphangitic carcinomatosis in the right lower lung as well as multiple lymphadenopathy and right pleural effusion (Fig. 1a, b).
Image caption: Chest X-ray and chest CT images after 28 days of gefitinib therapy. (a) Chest X-ray image showed the increased right hilar mass and the worsened lymphangitic carcinomatosis. (b) Chest CT image showed interval progression of the lung mass and the lymphadenopathy.
Image description: However, by 28 days after the start of gefitinib therapy, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3 (Fig. 2a, b).
Image caption: Chest X-ray and chest CT images after 21 days of combination therapy with bevacizumab and erlotinib. (a) Chest X-ray image showed the decreased right hilar mass and the improved lymphangitic carcinomatosis. (b) Chest CT image showed interval response of the lung mass and the lymphadenopathy. Especially, cavitation of the lung mass as bevacizumab-specific response was observed.
Image description: By 21 days after the start of this combination therapy, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities (Fig. 3a, b).
Case Report:
A 60-year-old male smoker presented with persistent cough and severe right-back pain. His performance status (PS) was 2 by the pain despite opioid use in palliative care. In the imaging test of full body, chest X-ray and chest CT revealed a large lung mass, extending to posterior chest wall and vertebral body, surrounded by lymphangitic carcinomatosis in the right lower lung as well as multiple lymphadenopathy and right pleural effusion (Fig. 1a, b). Bronchoscopic biopsy of the tumor lead to a diagnosis of primary lung adenocarcinoma (cT4N2M1a, stage IV) harboring the EGFR exon 19 deletion mutation. No other molecular analysis was performed. The patient was started on gefitinib at 250 mg/day for the treatment of lung adenocarcinoma. However, by 28 days after the start of gefitinib therapy, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3 (Fig. 2a, b).
Then, repeat biopsy was performed from the lung tumor. First, in addition to the preserved EGFR exon 19 deletion mutation, EGFR T790M mutation was analyzed, resulting in negative status. Second, as a possible molecular alteration next to EGFR T790M mutation, fluorescence in situ hybridization (FISH) analysis for MET amplification was analyzed, resulting in positive status (mean MET per cell = 6.7, MET/CEP7 [centromeric enumeration probe for chromosome 7] ratio = 2.5). At this point, cytotoxic chemotherapy was not a candidate for treatment due to his poor PS. Furthermore, although crizotinib was known as potential MET inhibitor as well as anaplastic lymphoma kinase (ALK) inhibitor, combination therapy with crizotinib and EGFR-TKI was considered to lack the evidences about safety. Therefore, combination therapy with bevacizumab and erlotinib was selected on the basis of the potential efficacy for activated MET signaling pathway as well as the confirmed safety by the JO25567 phase II clinical trial.
The patient was started on erlotinib at 150 mg/day plus bevacizumab at 15 mg/kg every 3 weeks. By 21 days after the start of this combination therapy, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities (Fig. 3a, b). However, after 2 cycles of bevacizumab administration, he unfortunately fractured his face from falling down during the rehabilitation to improve the deteriorated activity of daily life (ADL). Then, he underwent open reduction and fixation of his face fracture under general anesthesia. Eventually, he was forced to quit this promising combination therapy.
OUTPUT:
| PMC6381877 |
MultiCaRe_Reasoning3 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 41.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 1. Right anterior oblique (RAO) cranial image of left coronary angiography showing spontaneous coronary artery dissection of left main (LM) and left anterior descending (LAD) artery (arrows).
Image description: SCAD of the left main (LM), left anterior descending (LAD), and left circumflex arteries (LCx; Figure 1). She was managed with emergent coronary artery bypass graft (CABG) of 2 vessels, including, left internal mammary artery to the LAD and saphenous vein graft (SVG) to the ramus intermedius artery.
Case Report:
A 41-year-old female with a past medical history of hypothyroidism and Prinzmetal's angina presented with worsening typical chest pain for 1 day. She was 10 weeks postpartum. Her pain was unresponsive to nitroglycerin and aspirin. Electrocardiogram showed T-wave inversions in anterolateral leads. She was taken to the cardiac catheterization laboratory and was found to have SCAD of the left main (LM), left anterior descending (LAD), and left circumflex arteries (LCx; Figure 1). She was managed with emergent coronary artery bypass graft (CABG) of 2 vessels, including, left internal mammary artery to the LAD and saphenous vein graft (SVG) to the ramus intermedius artery. Her subsequent recovery was uneventful and she was asymptomatic with normal echocardiogram at the 6-month follow-up.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning4 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 51.0
Sex: Male
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 2. Right anterior oblique (RAO) cranial view of right coronary angiography showing spontaneous coronary artery dissection of right coronary artery (RCA) (arrows).
Image description: He was taken to the cardiac catheterization laboratory where coronary angiography showed dissection of both the LAD and the right coronary artery (RCA; Figure 2).
Case Report:
A 51-year-old male with a history of SCAD presented to our medical Center with refractory angina and decreased exercise tolerance for 2 days. Electrocardiogram showed nonspecific ST-T wave changes with initial troponin level of 0.8 ng/mL (normal <0.01 ng/mL). He was taken to the cardiac catheterization laboratory where coronary angiography showed dissection of both the LAD and the right coronary artery (RCA; Figure 2). He was managed with the deployment of 2 overlapping drug-eluting stents with good angiographic results in the RCA. In his LAD, he had a residual dissection with an angiographically determined good flow. At the 3-month follow-up, he showed recovery of his exercise tolerance and no further episodes of angina.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning5 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 34.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 3. Right anterior oblique (RAO) cranial view of right coronary angiography showing spontaneous coronary artery dissection of proximal to mid right coronary artery (RCA) (arrows).
Image description: Repeat catheterization showed stable LAD dissection with new RCA dissection with TIMI grade 1 flow (incomplete filling of distal coronary artery; Figure 3).
Case Report:
A 34-year-old African American female with a recent Cesarean section presented with sudden-onset chest pain for 15 minutes. On admission, electrocardiogram showed ST-segment elevations in V4, V5, and V6. Cardiac catheterization was performed. It revealed a long dissection of the LAD, originating just distal to the ostium and extending up to the mid portion. Thrombolysis in myocardial infarction (TIMI) grade 3 flow (normal flow) was noted. She was initially managed with medical therapy. Two days later, she had recurrent chest pain. Electrocardiogram changes were consistent with ischemia. Repeat catheterization showed stable LAD dissection with new RCA dissection with TIMI grade 1 flow (incomplete filling of distal coronary artery; Figure 3). She underwent an emergent 2-vessel CABG (SVG to LAD and SVG to RCA). Her postoperative period was uneventful. She developed peripartum cardiomyopathy after 3 months but had recovered left ventricular systolic function at the 6-month follow-up.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning6 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 45.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 45-year-old female, professional marathon runner, with a history of Raynaud's phenomenon, migraines, gastroesophageal reflux disease, and serum-positive HLA-B27, developed a sudden-onset chest pain while riding her bicycle. The pain lasted 2 hours, throughout the duration of exercise, and was noted to radiate to her back and jaw. In the emergency room, the electrocardiogram showed anterior wall myocardial infarction (MI) with positive serum troponin of 0.15 ng/mL (normal <0.01 ng/mL). Cardiac catheterization ruled out coronary atherosclerotic disease. However, the LM had a long SCAD that was extending to the mid LAD. The blood supply distal to the lesion was compromised. It was successfully stented with 2 bare metal stents. At the 3-month follow-up, she had an uneventful recovery with partial recommencement of her strenuous physical activity.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning7 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 49.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 5. Right anterior oblique (RAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of mid-left anterior descending (LAD) artery (arrows).
Image description: Emergent catheterization revealed SCAD in the mid LAD with an unsuccessful wiring (Figure 4).
Case Report:
A 49-year-old female with stage IV sarcoidosis presented to our hospital with chest pain and shortness of breath. Electrocardiogram showed STEMI in the anterolateral leads. Emergent catheterization revealed SCAD in the mid LAD with an unsuccessful wiring (Figure 4). The patient was managed conservatively. Later, her hospital course was complicated by a left ventricular thrombus and an embolic stroke requiring anticoagulation. She was discharged to rehabilitation center where she stayed for a period of 6 weeks. At the follow-up in the outpatient clinic, the patient had no residual deficits of recent stroke and had no angina. Over the next year, she had worsening pulmonary hypertension secondary to her sarcoidosis and was deemed a suitable candidate for a heart and lung transplantation.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning8 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 56.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 6. Left anterior oblique (LAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of left circumflex artery (LCx) (arrows).
Image description: Left heart catheterization showed a SCAD involving the LCx with TIMI grade 3 distal flow (Figure 5).
Case Report:
A 56-year-old female developed sudden-onset, sharp chest pain that led to syncope. On admission, electrocardiogram showed NSTEMI with a troponin level of 4.5 ng/mL (normal <0.01 ng/mL). Left heart catheterization showed a SCAD involving the LCx with TIMI grade 3 distal flow (Figure 5). While receiving cardiac catheterization, she developed an acute stroke with left-sided visual field deficit and received intravenous tissue plasminogen activator with complete resolution. She was managed conservatively with medical therapy for NSTEMI. She remained compliant with her medications. Follow-up catheterization due to persistent chest pains showed healed LCx dissection with no atherosclerotic disease in the rest of her coronary arteries. She was started on nifedipine for possible diagnosis of Prinzmetal's angina (variant angina). Her symptoms improved drastically on subsequent follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning9 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 60.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 7. Right anterior oblique (RAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of first diagonal branch (D1) of left anterior descending (LAD) artery (arrows).
Image description: Coronary angiogram showed an abnormality in the diagonal branch of the LAD (mid D1 radiolucency) concerning for thrombus versus dissection (Figure 6).
Case Report:
A 60-year-old female presented to our medical institution with chest pain lasting 15 minutes. Electrocardiogram showed a new-onset right bundle branch block and she was found to have a troponin of 0.24 ng/mL (normal <0.01 ng/mL). Coronary angiogram showed an abnormality in the diagonal branch of the LAD (mid D1 radiolucency) concerning for thrombus versus dissection (Figure 6). Optical coherence tomography was performed to distinguish the lesion. Therein, a SCAD was noted, which was managed with drug-eluting stent placement. Final angiography displayed no evidence of thrombosis, distal embolization, or further dissection. She remained compliant with her dual antiplatelet therapy for 8 months. Subsequently, she experienced a major gastrointestinal bleeding after which clopidogrel (Plavix) was discontinued. She remained symptom-free on follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning10 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 34.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 8. Right anterior oblique (RAO) caudal view of left coronary angiogram showing spontaneous coronary artery dissection of mid left anterior descending (LAD) artery with intramural hematoma (arrows).
Image description: Coronary angiogram showed SCAD of the mid portion of the LAD with large intramural hematoma compromising the blood flow to the first and second diagonal branches of the LAD with TIMI grade 3 flow into distal vessel (Figure 7).
Case Report:
A 34-year-old female who was 38 weeks pregnant presented with atypical chest pain for 1 day. Electrocardiogram showed ST-segment elevations in the anterolateral leads with a negative first troponin level. Coronary angiogram showed SCAD of the mid portion of the LAD with large intramural hematoma compromising the blood flow to the first and second diagonal branches of the LAD with TIMI grade 3 flow into distal vessel (Figure 7). No intervention was done and she was admitted to the cardiac care unit where a conservative approach was adopted. After undergoing Cesarean section, repeat coronary catheterization was performed. It showed no evidence of intramural hematoma and a healed LAD dissection.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning11 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 36.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 9. Right anterior oblique (RAO) caudal view of left coronary angiography showing spontaneous coronary artery dissection of proximal left anterior descending (LAD) artery with compromised blood flow to diagonal branches (arrows).
Image description: Emergent catheterization showed a dissection of the proximal LAD after the first 2 septal perforators with evidence of luminal compromise by a hematoma (Figure 8).
Case Report:
A 36-year-old female who was 6-days postpartum presented with typical chest pain radiating to her left arm for 1 hour. Electrocardiogram showed ST-segment elevations in leads V2 and V3 and ST depressions in the inferior leads. Emergent catheterization showed a dissection of the proximal LAD after the first 2 septal perforators with evidence of luminal compromise by a hematoma (Figure 8). Conservative management was planned and she was started on dual antiplatelet therapy. Follow-up catheterization after 6 weeks showed no progression of the LAD dissection with resolution of the hematoma. She remained asymptomatic on follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning12 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 30.0
Sex: Male
Title: Malignant adenohypophysis spindle cell oncocytoma with repeating recurrences and a high Ki-67 index
Keywords: None
Abstract:
Adenohypophysis spindle cell oncocytoma (ASCO) is a rare tumor recently reported by Roncaroli et al in 2002. This tumor is considered a grade I tumor by the World Health Organization.We report a rare case of malignant ASCO with repeating recurrences and a high Ki-67 index-a challenging diagnosis guided by clinical presentations, radiological signs, and postoperative pathological tests.We represent a 30-year-old man who had suffered from headaches, diplopia, and impaired visual field and acuity. His magnetic resonance imaging revealed an abnormal sellar mass and was originally misdiagnosed as a pituitary macroadenoma. We present detailed analysis of the patient's disease course and review relevant literature.When surgically treated, the specimen revealed a typical histopathology pattern of ASCO. The tumor recurred for several times and the patient underwent 3 surgeries and 1 γ-knife treatment, which was accompanied by a continuously increasing Ki-67 index.This is the first reported case of malignant ASCO (WHO III-IV grade). Despite its rarity, ASCO should be considered in the differential diagnosis of sellar lesions that mimic pituitary adenomas.
Image Caption and Description:
Image caption: MRI for the abnormalities in the sellar region at different time points. A-C, Before the first surgery. A, Coronal-enhanced T1WI. B, Axial-enhanced T1WI. C, Sagittal-enhanced T1WI. D-E, Before gamma-knife treatment. D, Coronal-enhanced T1WI. E, Axial T1WI. F-H, Before the secondary surgery. F, Coronal-enhanced T1WI. G, Axial T1WI. H, Sagittal-enhanced T1WI. I-K, After the secondary surgery. I, Coronal-enhanced T1WI. J, Axial-enhanced T1WI. K, Sagittal-enhanced T1WI. L-P, Before the third surgery. L, Coronal T1WI. M, Coronal-enhanced T1WI. N, Coronal T2WI. O, Sagittal T1WI. P, Sagittal-enhanced T1WI. MRI = magnetic resonance imaging.
Image description: The magnetic resonance imaging (MRI) demonstrated an abnormal mixed signal mass with suprasellar, parasellar, and suprasellar invasiveness in the sellar area (Fig. 1A-C).
The sellar MRI revealed that the tumor recurred (Fig. 1D and E) and the patient underwent a gamma-knife treatment.
Necrosis, cyst degeneration, and hemorrhage within the tumor could be detected (Fig. 1F-H).
The sellar MRI after 1 week of the secondary surgery was shown as Fig. 1I to K.
The enhancement was inhomogeneous and the surrounding structures and tissues were further invaded (Fig. 1L-P).
Image caption: Histopathological and immunohistochemical examination images for the surgical specimen. A-K, Specimen after the first surgery. A, H & E, x10. B, H & E, x20. C, AE-1/AE-3, x10. D, AS-1, x10. E, CD34, x10. F, CD68, x10. G, Desmin, x10. H, S-100 protein, x10. I, SMA, x10. J, SMA, x20. K, Vimentin, x10. L, Specimen after the third surgery, Ki-67 proliferation index 45%, x10. H & E = hematoxylin and eosin, SMA = smooth muscle actin.
Image description: Ki-67 proliferation index was 6% (Fig. 2A-K).
ASCO. And the Ki-67 proliferation index increased to 45% (WHO III-IV grade, Fig. 2L), highly suggesting its malignancy.
Case Report:
A 30-year-old man came to Peking Union Medical College Hospital (PUMCH) with headaches, fatigue, diplopia, and impaired visual field and acuity for 6 months which had worsened since the previous 2 weeks. He denied polydipsia, polyuria, sexual hypoactivity, or any symptoms of unconsciousness, epilepsy, convulsion, and cognitive disorders. Physical examinations revealed that his right visual acuity was 0.5 and the left was 0.4. Goldmann perimetry revealed a bitemporal hemianopia. He was found to have ptosis of the right eyelid. The right pupillary reaction to light was absent. Other neurological examination results were normal. His past history was negative for head trauma. His social and family history and his system review were negative.
The magnetic resonance imaging (MRI) demonstrated an abnormal mixed signal mass with suprasellar, parasellar, and suprasellar invasiveness in the sellar area (Fig. 1A-C). The lesion was about 2.8 x 1.9 x 1.9 cm, inside which was some spotty necrosis. A dynamic contrast-enhanced scan showed heterogeneous enhancement. Relatively normal pituitary tissue with normal enhancement could be seen near the inferior lesion margin, but was squashed. The optic chiasma was mildly compressed but the basic shape was generally normal. The bilateral internal carotid arteries were also partly wrapped. Laboratory tests used to explore pituitary disorders showed normal levels of pituitary hormones, including prolactin (N < 20 mug/L), luteinizing hormone (LH) (N > 10 IU/L), follicle-stimulating hormone (FSH) (N > 20 IU/L), thyrotropin, and corticotropin. The diagnosis of nonfunctioning pituitary macroadenoma was suspected.
Via a trans-nasal-sphenoidal approach, a surgical exploration was performed. After drilling the sellar floor and opening the dura, a firm, tough, wheaten mass was found. As its consistency was too elastic and hypervascular to be easily cut by a surgical blade, and it adhered so tightly to the cavernous sinus and internal carotid artery, only subtotal resection was ultimately achieved. Repair of the sellar defect was done with autologous fat and fascia lata. The immediate postoperative sellar MRI was not performed. In a surprise twist, postsurgical hematoxylin and eosin (H & E) stained sections showed that the lesion contains epithelioid and spindled cells with eosinophilic cytoplasm arranged in sheets and nests. Mild-to-moderate nuclear atypia could also be observed. On immunohistochemical evaluation, the tumor cells were positive for Vimentin, CD68, CD34, Nestin, GFAP, Desmin, SMA, AE1/AE3, and S-100 protein, but were negative for NSE, Synuclein, NeuN, EMA, pituitary hormones (LH, FSH, ACTH, TSH, growth hormone, and prolactin), synaptophysin and chromogranin. Ki-67 proliferation index was 6% (Fig. 2A-K). The pathological test supported the diagnosis of adenohypophysis spindle-cell oncocytoma. The postsurgical course was uneventful and his clinical symptoms of headache and diplopia were markedly improved.
However, 1 month after the surgery, the patient's vision declined sharply and meanwhile he complained of severe ophthalmodynia of the right eye. The sellar MRI revealed that the tumor recurred (Fig. 1D and E) and the patient underwent a gamma-knife treatment. But the symptoms were not relieved significantly. Three months later, the sellar MRI showed the lesion was approximately 2.8 x 2.2 x 3.1 cm with equal T1 signal and inhomogeneous long T2 signal, which were enhanced with mass or nodosity after contrast administration. The suprasellar region, bilateral cavernous sinuses, and optic chiasma were further invaded. Necrosis, cyst degeneration, and hemorrhage within the tumor could be detected (Fig. 1F-H). A secondary surgery was performed through the left pterional approach. The tumor's texture was firm to elastic and the bleeding was heavy; therefore, we just performed a partial resection, decompressed the optic nerves and chiasm. The sellar MRI after 1 week of the secondary surgery was shown as Fig. 1I to K. Postsurgically, transient central diabetes-insipidus persisted for 2 weeks. Visual field and acuity remained unimproved. Histological evaluation revealed similar morphology and immunohistochemical profiles to the previous specimen. The Ki-67 index for this time increased to 19%. From the perspectives of pathologists, the pathological grade was considered WHO III.
One month after the secondary surgery, the patient came to PUMCH again complaining almost blindness and severe headache. A sellar MRI was arranged, demonstrating that the tumor recurred again to approximately 4.9 x 3.6 x 3.1 cm with necrosis, cyst degeneration, and hemorrhage. The enhancement was inhomogeneous and the surrounding structures and tissues were further invaded (Fig. 1L-P). The third surgery via a transsphenoidal approach was conducted for decompressing. Partial resection was achieved and the visual disturbance and headache were alleviated a lot. Pathological evaluation results were similar to previous, confirming the diagnosis of ASCO. And the Ki-67 proliferation index increased to 45% (WHO III-IV grade, Fig. 2L), highly suggesting its malignancy. The patient has already been followed up for nearly half a year and reported no recurrence of headache and visual deterioration. His right visual acuity was 0.4 and the left was 0.3, evaluated recently.
OUTPUT:
| PMC5287946 |
MultiCaRe_Reasoning13 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 40.0
Sex: Female
Title: A novel mucocele: Myxoglobulosis
Keywords: mucocele; mucus extravasation cyst; myxoglobulosis;
Abstract:
Oral extravasation mucoceles are among the most widely recognized submucosal lesions which are usually a result of trauma involving salivary glands and their ducts. This paper reports a case of a 40-year-old female patient with a chief complaint of a painless swelling on the lower lip since 6 months. Upon a provisional diagnosis of mucocele, surgical excision was carried out. Histopathological examination revealed a mucus extravasation cyst having lumen filled with unique mucinous globular structures similar to a rare variant of appendiceal mucocele, myxoglobulosis.
Image Caption and Description:
Image caption: Clinical image shows a well-defined, roughly oval swelling on the lower lip
Image description: Clinical examination revealed a well-defined, nontender, smooth-surfaced, roughly oval, fluctuant swelling [Figure 1].
Image caption: Histopathological image shows presence of large, eosinophilic globules having lamellated or whorled appearance (H&E stain, x4)
Image description: The lumen was filled with numerous mucinous globular structures which were oval or round in shape and of varying sizes [Figure 2].
Image caption: Histopathological image shows abundant mucin within the globules attached to the surrounding cystic capsule and few globules suspended freely within the lumen (PAS stain, x4)
Image description: Some of the globules were suspended freely within the lumen [Figure 3].
The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
Image caption: Histopathological image shows presence of mucin in the periphery with central cellular core (Alcian blue stain, x10)
Image description: Individual globules exhibited a mildly cellular core with peripheral laminations of dystrophic calcifications [Figure 4].
The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
Case Report:
A 40-year-old female patient was referred for evaluation of an asymptomatic swelling on the lower lip of 6 months duration with a history of local trauma. Clinical examination revealed a well-defined, nontender, smooth-surfaced, roughly oval, fluctuant swelling [Figure 1]. No relevant medical history was elicited. Oral hygiene was fair. A provisional diagnosis of mucocele was made; the lesion was excised under local anesthesia. Histopathological examination of the excised tissue revealed cystic lumen devoid of lining epithelium and surrounded by compressed granulation tissue and peripherally located mixed salivary glands. The lumen was filled with numerous mucinous globular structures which were oval or round in shape and of varying sizes [Figure 2]. Most of the globules present in the cystic lumen were attached to the surrounding cystic capsule and seemed dissociated from one another because of their globular organization. Some of the globules were suspended freely within the lumen [Figure 3]. Individual globules exhibited a mildly cellular core with peripheral laminations of dystrophic calcifications [Figure 4]. The granulation tissue forming the cystic wall was highly cellular, consisting of chronic inflammatory cells. The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
OUTPUT:
| PMC9106225 |
MultiCaRe_Reasoning14 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 29.0
Sex: Female
Title: Bochdalek hernia with retrocardiac spleen - Diagnostic dilemma for emergency care physicians-A case report
Keywords: bochdalek; diaphragm; emergency care; hernia; physician; retrocardiac; spleen;
Abstract:
Introduction:
Physicians working as first-level responders in emergency departments (ED) often encounter patients, of any age group with shortness of breath (SOB). Definitive diagnosis is quite challenging once the underlying pathology is rare and unusual and/or the ED physicians recommend and rely on non-specific investigations.
Presentation of case:
A 29-year-old female presented to the emergency department with sudden onset of shortness of breath and upper abdominal pain radiating to the left shoulder. Diagnosis of Bochdalek hernia was made clinically coupled with radiological findings of CXR and computed tomography (CT) by the surgeon on-call, while it was missed by an emergency care physician on her first visit.
Discussion:
Herniation of the abdominal contents into the thoracic cavity via the Bochdalek opening, commonly known as Bochdalek hernia is seen and diagnosed most commonly accidentally in early life. Adult cases of symptomatic Bochdalek hernia has been reported in the literature. These patients usually present with non-specific symptoms, thus pose a diagnostic challenge for an emergency care physician.
Conclusion:
The report of this case highlights the notion that such rare causes of acute onset dyspnea and upper abdominal pain pose a diagnostic challenge for novice emergency care physicians especially in situations where he/she does not ask for second-line help in general and recommend and rely on a non-specific investigation in specific.
Image Caption and Description:
Image caption: Pre-op x-ray chest with Chilaiditis Sign (a); Post-op x-ray chest (normal) (b).
Image description: Upon no improvement, the patient revisited the ED where chest x-ray (CXR) as primary imaging modality was requested by surgeon on-call that showed raised right hemidiaphragm with no well discernible outlines, air-filled bowel loops above the hepatic shadow, a chilaiditi's sign, with no mediastinal shift (Fig. 1a), thus a provisional diagnosis of the right-sided diagrammatic hernia was made.
Post-operative chest x-ray shows normal findings (Fig. 1b).
Image caption: Non-contrast CT-Intrathorasic Extrusion of Spleen, Stomach and Bowels (a); Non-contrast CT-retrocardiac spleen (b).
Image description:
Case Report:
A 29 years old female, physician by profession presented to the emergency department with a history of aggressive vomiting five weeks back followed by left upper abdominal, a single episode of loose motion, subcostal pain radiating to left shoulder associated with shortness of breath (SOB) and was unable to take full inspiration. The patient has a history of heartburn, early satiety, indigestion, and food regurgitation six years ago and diagnosed and managed as gastroesophageal reflux disease in her native country.
The primary evaluation shows a toxic looking afebrile patient with vitals as; respiratory rate-27/min, pulse 87/min. Along with first-level management, abdominal ultrasonography (US) and initial laboratory workup were done in ED with no abnormal findings and the patient discharged home after the primary management independently and not asking surgeon on-call help. Upon no improvement, the patient revisited the ED where chest x-ray (CXR) as primary imaging modality was requested by surgeon on-call that showed raised right hemidiaphragm with no well discernible outlines, air-filled bowel loops above the hepatic shadow, a chilaiditi's sign, with no mediastinal shift (Fig. 1a), thus a provisional diagnosis of the right-sided diagrammatic hernia was made.
Following CXR, a non-contrast CT requested showing stomach and parts of the colon in the right thoracic cavity (Fig. 2a) along with spleen located posterior to the heart - the retrocardiac spleen (Fig. 2b), thus a final diagnosis of Bochdalek hernia was made.
Severe vomiting, a few weeks earlier was the triggering event in the patient that led to the initiation of the clinical picture. After initial stabilization, the patient was transferred to a regional tertiary care facility for cardiothoracic surgeon evaluation and management where via open thoracotomy, contents reduced and fortunately there was no vascular compromise. Repair done. Post-operative chest x-ray shows normal findings (Fig. 1b). The patient had uneventful recovery and discharged home on 10th post-operative day. The patient did well in her follow-up period. To the best of our knowledge, it is the first reported case of Bochdalek hernia associated with the retrocardiac spleen in an adult female in the published literature.
OUTPUT:
| PMC7276389 |
MultiCaRe_Reasoning15 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 63.0
Sex: Female
Title: Carcinosarcoma of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma: a report of two cases
Keywords: alpha-fetoprotein; hepatoid adenocarcinoma; rhabdomyosarcoma; uterine carcinosarcoma;
Abstract:
We report two cases of uterine carcinosarcoma associated with alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma. Samples were obtained from two women aged 63 and 82 years. Serum AFP levels of the two samples were 10,131 and 401 ng/ml, respectively. Histologically, in both cases the tumor cells were composed of hepatoid adenocarcinoma component and sarcoma component including rhabdomyosarcoma. Immunohistochemical analyses revealed that AFP was expressed in the cytoplasm of the carcinomatous component. After surgery, the patients received six courses of carboplatin/paclitaxel chemotherapy, and the serum levels of AFP decreased to normal range. The first patient is alive and well at the 2-year follow-up, while the second patient died of disease 1 year after initial operative treatment. This is, to our knowledge, the second report of carcinosarcoma of the uterine corpus with AFP-producing hepatoid adenocarcinoma, as proven by immunohistochemical analyses.
Image Caption and Description:
Image caption: a Histological appearance of the carcinosarcoma. The carcinomatous component is composed of hepatoid adenocarcinoma and the sarcomatous component of spindle cells and large pleomorphic cells (HE, x400). b Tumor cells in the hepatoid areas show immunoreactivity for AFP (AFP, x400).
Image description: Microscopic examination showed that the polypoid tumor was a mixture of carcinomatous and sarcomatous components (fig. 1a).
Reactivity for AFP was cytoplasmic in the hepatoid carcinoma lesion (fig. 1b).
Case Report:
A 63-year-old multiparous woman, gravida 4, para 3, complained of abnormal vaginal bleeding of 2 months' duration. She went into menopause at age 54. The patient had no remarkable medical or family histories. On vaginal examination, the uterus was enlarged, non-tender, smooth and movable. Vaginal ultrasonogram and magnetic resonance imaging showed a polypoid mass of 14 x 10 cm in size in the uterus, possibly representing a carcinosarcoma or leiomyosarcoma. No free pelvic fluid was identified. Computed tomography (CT) showed the liver and bile ducts to be normal. The endometrial Pap smear was evaluated as positive. Biopsies of the endometrium were carried out and the histological diagnosis revealed carcinosarcoma. The serum AFP level was 10,131 ng/ml (normal <20). Other tumor markers and liver function test results were within normal limits. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy.
The resected enlarged uterus, weighing 560 g and measuring 14 x 12 x 7 cm, had a smooth glistening surface. The polypoid tumor originated from the uterine cavity when the anterior wall of the uterus was opened. The uterine adnexae were normal in shape and size. There was no evidence of a tumorous lesion. Microscopic examination showed that the polypoid tumor was a mixture of carcinomatous and sarcomatous components (fig. 1a). The tumor had invaded the uterine cervix, but no metastases were found in the dissected lymph nodes. The carcinomatous component showed adenocarcinoma arranged in sheets and cords with a hepatoid appearance. Reactivity for AFP was cytoplasmic in the hepatoid carcinoma lesion (fig. 1b). The sarcomatous component showed no reactivity for AFP. The large pleomorphic cells were positive for desmin, actin, CD10, MyoD1, and myoglobin and could be regarded as being rhabdomyosarcoma. There was no staining with S-100. In summary, the tumor was histopathologically diagnosed as heterologous uterine corpus carcinosarcoma associated with AFP-producing hepatoid adenocarcinoma.
Postoperatively, the patient received six courses of chemotherapy with paclitaxel (175 mg/m2) and carboplatin (AUC 5). This regimen was repeated every 3 weeks. After the third course of chemotherapy, the patient's serum AFP level decreased to 4.5 ng/ml. The patient is alive with no evidence of recurrence or increase in the serum AFP level in the 2 years since treatment.
OUTPUT:
| PMC3134036 |
MultiCaRe_Reasoning16 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 82.0
Sex: Female
Title: Carcinosarcoma of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma: a report of two cases
Keywords: alpha-fetoprotein; hepatoid adenocarcinoma; rhabdomyosarcoma; uterine carcinosarcoma;
Abstract:
We report two cases of uterine carcinosarcoma associated with alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma. Samples were obtained from two women aged 63 and 82 years. Serum AFP levels of the two samples were 10,131 and 401 ng/ml, respectively. Histologically, in both cases the tumor cells were composed of hepatoid adenocarcinoma component and sarcoma component including rhabdomyosarcoma. Immunohistochemical analyses revealed that AFP was expressed in the cytoplasm of the carcinomatous component. After surgery, the patients received six courses of carboplatin/paclitaxel chemotherapy, and the serum levels of AFP decreased to normal range. The first patient is alive and well at the 2-year follow-up, while the second patient died of disease 1 year after initial operative treatment. This is, to our knowledge, the second report of carcinosarcoma of the uterine corpus with AFP-producing hepatoid adenocarcinoma, as proven by immunohistochemical analyses.
Image Caption and Description:
Image caption: a Tumor showing a mixture of carcinomatous and sarcomatous components (HE, x100). b Tumor cells in the hepatoid areas immunoreactive for AFP (AFP, x400).
Image description: Histologically, the tumor was composed of carcinomatous and sarcomatous components (fig. 2a).
Immunohistochemistry also revealed AFP-positivity in many tumor cells (fig. 2b).
Case Report:
An 82-year-old woman, gravida 0, para 0, was referred to our hospital with vaginal bleeding of 2 months' duration. She had undergone surgery due to breast cancer at the age of 68. On pelvic examination, enlarged uterus without a palpable adnexal mass was detected. The vaginal wall showed no abnormalities. Portio vaginalis could not be detected, so the endometrial Pap smear could not be done. Magnetic resonance imaging revealed an enhanced mass, 8 cm in size, in the uterine corpus cavity, possibly representing malignant tumor. CT scan demonstrated ascites and no lymph nodes were detected. CT and ultrasonography revealed no abnormalities in the liver or bile duct. The serum AFP level was elevated (401 ng/ml), but no elevation of other markers, such as carcinoembryonic antigen or carbohydrate antigen 125, was observed. The blood count and serum biochemical data were unremarkable. From these results, malignant uterine tumor was highly suspected. A total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic washings was carried out. The resected uterus was enlarged and filled with a spongy material. There was no apparent extrauterine extension of the tumor. A partially necrotic polyp, 8 cm in size, was present within the endometrial cavity, which infiltrated into the myometrium for about two-thirds of its thickness but did not invade the cervix. Cytology of the pelvic washings was negative. Histologically, the tumor was composed of carcinomatous and sarcomatous components (fig. 2a). The carcinomatous component was an endometrioid adenocarcinoma with trabecular hepatoid cells, mostly showing hepatocellular carcinoma-like proliferation. Immunohistochemistry also revealed AFP-positivity in many tumor cells (fig. 2b).
The sarcomatous component showed rhabdoid features including spindle-shaped tumor cells. Occasional cells with eosinophilic cytoplasm and cytoplasmic cross-striations were identified. Immunohistochemistry showed focal positivity of tumor cells with desmin, MyoD1, and CD10. On pathologic examination, the tumor was interpreted as being a heterologous uterine corpus carcinosarcoma associated with AFP-producing hepatoid adenocarcinoma.
We did not carry out any adjuvant chemotherapy or irradiation because of the patient's advanced age, in addition, she and her family refused these therapies. Two months after the surgery, the patient's serum AFP level decreased to a normal level. However, multiple lung metastases with a high-serum AFP level reappeared and the patient died 1 year after the operation.
OUTPUT:
| PMC3134036 |
MultiCaRe_Reasoning17 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Female
Title: Daratumumab triplet therapies in patients with relapsed or refractory multiple myeloma: A "real world" experience
Keywords: daratumumab; multiple myeloma; real-word experience; relapsed refractory;
Abstract:
We report our retrospective analysis on 34 relapsed/refractory multiple myeloma (RRMM) patients treated with daratumumab based triplets. Twenty patients were females and 14 males. Median age was 73.2. Daratumumab was associated to lenalidomide in and dexamethasone (DRd) in 30 (88,3%) and to bortezomib and dexamethasone (DVd) in 4 cases (11,7%). The ORR was 88%. CR occurred in 12% of cases, VGPR in 44% and PR in 32%. The 12 months PFS and OS rates were 78% and 86,5%, respectively. Present data confirm those recently reported in the literature and further reinforce the early use of daratumumab-based triplets for RRMM patients.
Image Caption and Description:
Image caption: Kaplan-Meyer survival curves. (A) PFS in all patients, (B) OS in all patients, (C) PFS according to the best response, (D) PFS according to the previous lines of therapy, (E) PFS according to the sex, (F) OS according to the presence of anemia at relapse, G) OS according to the best response.
Image description: At a median follow-up of 16 months (range 35 - 1), the median PFS and OS have not been reached (NR); the 12-month PFS and OS rates were 78% and 86,5%, respectively (Fig. 1.
In the univariate analysis, the achievement of at least a VGPR, receiving just one line of previous therapy and the male gender resulted in a statistically significant better PFS (Fig. 1.
C, D, and E), whereas the absence of anemia at the start of the daratumumab-based triplets and the achievement of at least a VGPR predicted a better OS (Fig. 1.
Case Report:
The characteristics of patients are outlined in Table 1. Twenty of the 34 MM patients were females and 14 were males, the median age was 73,2 years (range 64.6-80.3) and the median time from diagnosis of MM to the first treatment with daratumumab was 37 months (range 235-3). Cytogenetic characteristics were obtained from only 7 patients, of these only one was unfavorable. Each patient received one line of therapy and 6 (14,7%) patients received two lines or more. All 34 RRMM patients received a previous bortezomib-based therapy in which bortezomib was given with dexamethasone alone (3 cases) or combined with melphalan (16 cases) or with thalidomide (15 cases). In addition, 4 patients received lenalidomide, 3 patients received pomalidomide and 1 patient received Carfilzomib. Before DRd, seven patients (20,6%) underwent to a prior autologous stem cell transplantation (ASCT), that it is consisted in a single ASCT in 5 patients and in a double ASCT in the other 2 cases.
Sixteen patients (47%) presented one or more comorbidities: cardiovascular diseases (11), solid tumors (4), metabolic disorders (3), other hematological disorders (2), rheumatological diseases (1), pulmonary diseases (1), neurological diseases (1) and gastrointestinal diseases (1).
Twelve patients (36%) were refractory to the previous therapy. Eight patients (23,5%) presented with anemia (Hb < 10 g/dl), 3 (8,8%) with chronic kidney disease (creatinine > 2 mg/dl), 19 (55,9%) with bone lesions, while none of the patients presented with hypercalcemia (Ca2+ > 11 mg/dl). Among the 34 patients, 18 (53%) had a monoclonal component (CM) > 2 g/dl and 18 patients (53%) had a Bence-Jones proteinuria.
All RRMM patients received daratumumab IV at the standard dose of 16 mg/kg whereas in 30 (88,3%) patients it was combined with lenalidomide and dexamethasone (DRd) and in the remaining 4 cases (11,7%) with bortezomib and dexamethasone (DVd). A median number of 8 cycles (range 1-32) was administered within a median follow-up of 16 months (range 1-35). Among DRd treated patients, the lenalidomide starting dose was reduced in 12 patients (35%) according to the renal function or due to neutropenia or thrombocytopenia. At the time of analysis, 25 (73,5%) patients were currently receiving treatment. Nine patients (26,5%) discontinued treatment for progressive disease (8 patients) and intolerance (1 case).
Patients who received at least two doses of daratumumab-based triplets were included in the statistical analysis. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier product-limit estimator.
The overall response rate (ORR) was 88%. A Complete Response (CR) occurred in 12% of cases, a Very Good Partial Response (VGPR) in 44%, and a Partial Response (PR) in 32%. The Median time to achieve at least a PR was 40 days (range 30-110 days). Progressive disease was observed in 8 patients (23,5%), in which 5 cases (14,7%) led to death. Twenty-six patients (76,4%) were responding to treatment at the time of analysis.
Moreover, 4 transplant-eligible patients, however refractory to the VTD scheme after a median of 6 cycles of daratumumab, deepened their response, allowed themselves to receive an ASCT, and then continued DRD therapy. One of these four patients progressed and died within 100 days after the transplant.
Adverse events are summarized in Table 2. The most common hematological toxicities of any grade were neutropenia (15 patients; 44%), managed with lenalidomide dose reduction, and thrombocytopenia (10 patients; 29%). Other common non-hematological toxicities of grade 1 involved 10 patients (29%), including asthenia, light-headedness and breathlessness, edema of lower extremities, intestinal intolerance with diarrheal episodes, and epigastralgia. Two patients (5,4%) presented pulmonary AEs, one case with pneumonia and the other case with a chronic obstructive pulmonary diseases (COPD) exacerbation. The only grade 4 AE case was observed at the beginning of the third cycle and consisted of intolerance with persistent gastrointestinal disorders that required patient hospitalization leading to a discontinuation of the therapy.
After an extensive oral premedication of our patients consisting of cetirizine dihydrochloride 10 mg, montelukast 10 mg, paracetamol 1000 mg and dexamethasone 20 mg that was administered once/daily from the day before to the day after the infusion, we observed a DARA infusion-related reactions (IRRs) in only 3 patients (8,8%). All IRRs were a grade 1 - 2 and occurred during the first infusion, with urticaria, tachycardia, and respiratory symptoms, such as bronchospasm and dyspnea.
At a median follow-up of 16 months (range 35 - 1), the median PFS and OS have not been reached (NR); the 12-month PFS and OS rates were 78% and 86,5%, respectively (Fig. 1. A and B). In the univariate analysis, the achievement of at least a VGPR, receiving just one line of previous therapy and the male gender resulted in a statistically significant better PFS (Fig. 1. C, D, and E), whereas the absence of anemia at the start of the daratumumab-based triplets and the achievement of at least a VGPR predicted a better OS (Fig. 1. F and G).
In the multivariate analysis, only the achievement of at least a VGPR resulted as an independent predictor of prolonged PFS, showing an HR of 0.037 (95% CI of 0.0001-0.988; p= .049). Interestingly, other potential predictors of unfavorable prognoses, such as the condition of early or late relapse, did not impact patients' clinical outcomes after DRd.
In the present series, 4 patients received DVd because they were previously exposed to lenalidomide. Compared to the DRd treated patients, they showed a worse PFS and a similar OS. Once again, the small number of cases did not allow conclusions to be drawn concerning this issue. Apart from the daratumumab triplet used, many other factors may have contributed to the worse outcome of these four patients, as for example, the fact that they all had received more than one line of previous therapies.
OUTPUT:
| PMC9184873 |
MultiCaRe_Reasoning18 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 71.0
Sex: Female
Title: Decitabine Induced Delayed Cardiomyopathy in Hematologic Malignancy
Keywords: None
Abstract:
Decitabine is a pyrimidine analogue of nucleoside cytidine, used for the treatment of myelodysplastic syndromes, chronic myelogenous leukemia, and acute myelogenous leukemia. We present a case of cardiomyopathy associated with decitabine used for secondary acute myelogenous leukemia. The patient presented with new heart failure symptoms and an ejection fraction decline.
Image Caption and Description:
Image caption: Transthoracic echocardiogram of the patient in parasternal long axis view (a) demonstrating an enlarged left ventricular cavity, in apical (four-chamber) view demonstrating a mildly abnormal end systolic (b) and normal end diastolic (c) left ventricular dimension (RV: right ventricle; LV: left ventricle; LA: left atrium; RA: right atrium).
Image description: Echocardiogram showed severe left ventricular systolic dysfunction (EF 28%), mildly abnormal end systolic dimension (Figure 1), and a mild reduction in right ventricular systolic function.
Image caption: Peak systolic strain pattern in cross-sectional view (a) and longitudinal view (b) demonstrates decrease in left ventricular strain pattern.
Image description: Global averaged left ventricular longitudinal peak systolic strain was abnormal at -12% (normal more negative than -18%) (Figure 2).
Case Report:
A 71-year-old female with a history significant for hypertension, hepatitis B, and hypothyroidism, underwent bone marrow biopsy which showed a hypercellular bone marrow with >90% cellularity and 81% myeloblasts expressing CD 34 and CD 117 markers, confirming a diagnosis of acute myeloid leukemia (AML). Molecular testing showed no evidence for FMS-like tyrosine kinase 3 internal tandem duplication, absence of nucleophosmin1 and KIT exon 8, and 17 mutations, suggesting a lower risk of relapse after chemotherapy. Based on cytogenetic studies, secondary AML was diagnosed. Given her advanced age, decitabine therapy was commenced. A baseline 2-D transthoracic echocardiogram (TTE) showed normal function with an ejection fraction (EF) of 55-60%. After completing 10 cycles of decitabine, she was noted to have a tachycardia and dyspnea by self-report. She was therefore referred to cardiology with these symptoms in preparation for allogeneic stem cell transplant.
The heart rate was 110/min, and a 2/6 ejection systolic murmur and a loud P2 with an S3 and S4 gallop were heard. Lungs were clear. No jugular venous distension or pedal edema was noted.
Laboratory data is significant for a serum creatinine level of 0.8 mg/dl, estimated glomerular filtration rate of 80 ml/min per 1.73 m2, and N-terminal pro-b-type natriuretic peptide level of 517 pg/ml. Her complete blood count showed a white blood cell count of 12.6 x 109/l with greater than 50% blasts, low hemoglobin at 7.8 g/dl, hematocrit value of 25%, large platelet count of 212 x 109/l, and lactate dehydrogenase level of 588 U/l. Serum troponin or creatinine phosphokinase levels were not performed due to a lack of discernibility in patients undergoing chemotherapy for cancer. Echocardiogram showed severe left ventricular systolic dysfunction (EF 28%), mildly abnormal end systolic dimension (Figure 1), and a mild reduction in right ventricular systolic function. Global averaged left ventricular longitudinal peak systolic strain was abnormal at -12% (normal more negative than -18%) (Figure 2). Nuclear stress test showed no evidence of coronary disease. Patient was euthyroid at the time of diagnosis.
The patient was diagnosed with New York Heart Association class II and American Heart Association stage B heart failure with reduced ejection fraction. In the absence of any viral illness, toxins, or coronary disease, or concomitant cardiotoxic medication use and known recent normal ejection fraction, the etiology was attributed to decitabine use. The patient was subsequently started on metoprolol succinate 50 mg twice a day and furosemide 20 mg daily. Follow-up echocardiogram 4 weeks later showed no change in the ejection fraction of 28%, but there was mild improvement in the global left ventricular longitudinal peak systolic strain at -15% (improved from -12%).
OUTPUT:
| PMC6186336 |
MultiCaRe_Reasoning19 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 24.0
Sex: Female
Title: Cysticercal Encephalitis in a Young Female: A Rare Presentation of Neurocysticercosis
Keywords: albendazole; dress syndrome; neurocysticercosis; taenia solium; tumour necrosis factor-alpha (tnfα);
Abstract:
One of the most frequent parasite infections of the central nervous system is neurocysticercosis. This neurologic condition is caused by Taenia solium (T. solium) larval infestation. Infected pork intake, poor hygiene practices, water tainted with T. solium, or asymptomatic carriers are the main ways of spread. We describe a case of neurocysticercosis in a young woman who presented with low-grade fever, headache, altered sensorium, and recurrent seizures. Computed tomography of the head revealed an inflammatory granuloma and a ring-increased attenuating lesion in the left temporal region. Additionally, a well-defined rounded discrete lesion was identified in the left parietal region on magnetic resonance imaging of the brain. Even if the symptoms do not initially suggest neurocysticercosis or if the patient lives in a region where the condition is uncommon, our case depicts adding neurocysticercosis to the differential diagnosis for encephalitis.
Image Caption and Description:
Image caption: An inflammatory granuloma on the right temporal side.
Image description: Further evaluation with a non-contrast computed tomography (CT) head shows a ring-enhancing lesion in the left temporal region with perifocal edema, an eccentric, and an inflammatory granuloma (Figure 1).
Image caption: MRI brain with contrast revealing a well-defined rounded discrete lesion seen in the left parietal region as shown in the sagittal (a), trans-axial (b), and coronal (c) sections.
Image description: In addition, magnetic resonance imaging (MRI) brain showed a well-defined rounded discrete hyperintense lesion in the left parietal region with mild to moderate vasogenic edema, leading to partial effacement of the adjoining sub-arachnoid space and moderate peripheral rim enhancement (Figure 2).
Image caption: MR venogram revealing that the left transverse sinus is hypoplastic.
Image description: On follow-up after two weeks, an MR venogram revealed that the left transverse sinus was hypoplastic, as shown in Figure 3.
Image caption: An urticarial, maculopapular eruption, and erythroderma as in arm.
Image description: However, on follow-up after two weeks, the patient developed skin rashes, remarkably elevated liver enzymes, and total bilirubin (Figure 4).
Case Report:
A 24-year-old female was brought to the emergency department with complaints of altered mental status and recurrent seizures associated with low-grade fever, headache, and altered sensorium for the last three days. The seizure was acute in onset, generalized tonic-clonic in nature, and associated with tongue biting, blood-tinged frothing, and urinary incontinence. It was her second episode of abnormal body movement and altered sensorium after being admitted to the hospital. Each episode lasted for 20-30 minutes. She returned from a hill station a few days ago, and her family and social history were insignificant.
On admission, the patient was afebrile, with a blood pressure of 110/70 mmHg, a Spo2 of 97%, and a heart rate of 86/min. Her physical examination revealed a Glasgow coma scale (GCS) score of 11 (eye: 4, verbal: 2, motor: 5). Her rest systemic examination was unremarkable. Her initial laboratory investigations were within normal range except for mild elevation of transaminases (Table 1). Further evaluation with a non-contrast computed tomography (CT) head shows a ring-enhancing lesion in the left temporal region with perifocal edema, an eccentric, and an inflammatory granuloma (Figure 1). In addition, magnetic resonance imaging (MRI) brain showed a well-defined rounded discrete hyperintense lesion in the left parietal region with mild to moderate vasogenic edema, leading to partial effacement of the adjoining sub-arachnoid space and moderate peripheral rim enhancement (Figure 2). On follow-up after two weeks, an MR venogram revealed that the left transverse sinus was hypoplastic, as shown in Figure 3.
Following confirmation of diagnosis, the patient was started on albendazole 400mg twice daily and carbamazepine. However, on follow-up after two weeks, the patient developed skin rashes, remarkably elevated liver enzymes, and total bilirubin (Figure 4).
After proper evaluation, immediately anti-epileptic drugs were discontinued, and for skin rashes, the patient was given oral fexofenadine and methylprednisolone, levetiracetam beside topical steroids. On subsequent follow-up, her rashes and deranged aminases resolved, and the patient was doing well.
OUTPUT:
| PMC9937515 |
MultiCaRe_Reasoning20 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Male
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 27-day-old boy presented to the emergency room with a 7-hour history of fever. After giving superficial skin cooling at home, the baby remained febrile. The peak temperature was 38.5 C. The baby had a poor appetite and symptoms of sneezing and a stuffy nose without vomiting and coughing. He was a term baby without extraordinary perinatal history. His parents had a history of sore throat and cough for several days during the Omicron epidemic, but they didn't test for SARS-CoV-2. After admission to our NICU, he was febrile at 38.3 C with a respiratory rate of 52 breaths/min and oxygen saturation of 95%-99% while breathing ambient air. His examination was remarkable for congested nares, clear rhinorrhea, and mild subcostal retractions. There were coarse breath sounds in all lung fields. No murmur of the heart could be heard. The liver was palpated at 1 cm-2 cm under the costal margin (consistent with age), and the spleen was not palpated. Laboratory data revealed that the total WBC count and the proportions of the major leukocyte subsets in peripheral blood were normal. Blood gas, C reactive protein (CRP), and transaminase levels were in the normal range. RNA test for SARS-CoV-2 from a throat swab was positive. Then, the baby was given physical cooling and nasal secretion removal to keep the airway clear (see Table 1).
The baby presented febrile once daily in the following four days, and the peak temperature decreased from 38.4 to 38 C. Meanwhile, he developed a cough and sputum, along with a dropping of SpO2 to 80% when feeding. His lung demonstrated scattered crackles (see Figure 1). Because of continuous fever and pneumonia, more investigations were performed. The total WBC count and the proportions of the major leukocyte subsets were still in the normal range. CRP was 4.3 mg/L (0-10 mg/L). Anemia was noticed: RBC was 2.73 x 1,012/L, hemoglobin was 91.0 g/L, and hematocrit was 27.4%. Alanine transaminase (ALT) was 88 U/L(<=41 U/L), aspartate transaminase (AST) was 180 IU/L(<=40 U/L), and glutamyltranspeptidase (gamma-GT) was 109 U/L(6-42 U/L). Further, pathogens tests identified that parainfluenza virus RNA was positive, but there was no evidence of infection for other pathogens such as RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B/H1N1/H3N2, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus. Ultrasonography for the heart and abdomen was normal. Therefore, the baby was given the nebulization treatment of budesonide and ipratropium bromide solution and given Glutathione for hepatoprotection. In addition, he inhaled oxygen intermittently to avoid hypoxia when feeding.
On the 7th day after admission, the patient was no longer febrile but was still coughing and had nasal congestion. On the 10th day, respiratory symptoms improved greatly, and we re-tested the liver function after 5 days of hepatoprotective treatment. The transaminase level elevated markedly. ALT was up to 645 U/L(<=41 U/L), AST increased to 480 IU/L(<=40 U/L), and gamma-GT was 491 U/L(6-42 U/L). However, bilirubin, blood ammonia, blood glucose, lipids, lactate, coagulation function, and albumin levels were within the normal range. The patient's perinatal medical history and family history were tracked carefully, and the possibility of inherited metabolic liver disease was ruled out. Furthermore, the patient's history of drug exposure before/after admission was also reviewed, and there was no evidence of drug-induced liver injury. So, virus infection may contribute to liver injury and the elevation of transaminase levels. When the immune system clears the virus, the injury should be alleviated. Thus, we only administered glycyrrhizin and bicyclol to promote recovery.
On the 14th day, the baby looked well with the normal physical examination. Laboratory tests demonstrated that ALT decreased to 125 U/L(<=41 U/L), AST was 44 IU/L(<=40 U/L), and gamma-GT was 283 U/L(6-42 U/L). He continued to take glycyrrhizin and bicyclol after being discharged home. The liver transaminase level returned to normal on 8 and 15 days after discharge (see Table 2 and Figure 2).
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning21 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Female
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 7-day-old girl was admitted to our NICU because of a 30-hour intermittent fever with a peak temperature of 38.5 C. Her parents noted that she had a stuffy nose with clear rhinorrhea and choked when feeding over the past two days. She coughed occasionally but had sputum in her throat. Her appetite was unchanged without increasing work of breathing, vomiting, and diarrhea. Her caregivers had confirmed infection of SARS-CoV-2 several days ago. Her mother was healthy during pregnancy but detected fetal hydronephrosis with the right duplex kidney in the third trimester. The baby was born through an uneventful C-section delivery at a gestational age of 40w+6. The baby looked well after birth, and there was no evidence of early-onset sepsis. On physical examination, she had a temperature of 38.6 C and mild tachypnea of a respiratory rate of 50 breaths/min without retraction. Her lungs demonstrated coarse breath sounds without crackles and wheezes. The lab investigations showed that CRP was increased to 19.8 mg/L(0-10 mg/L) (see Table 1).
WBC, blood gas analysis, transaminase level, and bilirubin levels were all in the normal range. The blood culture for bacteria was negative. Chest x-rays suggested increased and blurred bilateral lung markings in both lung fields (see Figure 1). Cardiac ultrasound demonstrated a left-to-right shunt of 2.6 mm through a patent foramen ovale (PFO). Abdominal ultrasound showed mild bilateral hydronephrosis and calculus in the right kidney (3.1 mm x 2.7 mm), and there were no abnormalities in the liver, gallbladder, and spleen structures. PCR and quick antigen tests for SARS-CoV-2 from the throat swab were positive. There was no evidence of infection from other viruses [RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus]. Normal saline helped to clean the airway, and nasal drops were used to relieve nasal congestion. Moreover, superficial skin cooling was given when the baby was febrile, and piperacillin/tazobactam was administered for pneumonia.
The baby's body temperature declined to normal on the 2nd day after admission. The respiratory symptom alleviated over the following days. On the 6th day, the laboratory tests showed that the transaminase level increased significantly without abnormality of bilirubin and albumin (see Table 2 and Figure 2). Then, the hepatoprotective treatment of glycyrrhizin and bicyclol was administered.
ALT decreased by half on the 11th day. Given that the baby had recovered from fever and respiratory symptoms, she was discharged home with oral drugs of glycyrrhizin and bicyclol and was continued to be followed up in the outpatient department. Two weeks later, lab tests suggested that ALT and AST decreased to the normal range.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning22 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Female
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 15-day-old girl was brought to the emergency center with a 2-day recurrent fever after contracting confirmed cases of COVID-19. The peak temperature was 38.1 C. Besides fever, she had a stuffy nose and a mild cough. She did not develop diarrhea and vomiting during the course. She had no complicated perinatal history. Her examination was febrile at 38.1 C with a respiratory rate of 48 breaths/min and oxygen saturation of 98%-100%. She had normal respiratory effort, and coarse breath sounds could be heard in all lung fields. Lab data of the WBC, CRP, blood gas, transaminase levels, and bilirubin levels were all in the normal range. The PCR test was positive for SARS-CoV-2 without other positive findings of other pathogens [RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus]. After admission, the baby was given the nebulization treatment of budesonide and ipratropium bromide, using normal saline and nasal drops to relieve nasal congestion and keep the nasal cavity clean (see Table 1).
The baby returned to normal temperature and developed frequent coughs over the days. Her lung examination demonstrated scattered crackles on the back side, and then, phlegm and wheezing sounds could be heard in the following days. Chest x-rays showed that bilateral lung markings increased and blurred, with patchy shadows on the right upper lung field (see Figure 1). The piperacillin/tazobactam for pneumonia was administered on the fourth day after admission. Since then, her symptoms and signs of respiratory improved gradually.
The baby got better on the 6th day after admission with wild nasal congestion. Laboratory tests showed that ALT and AST increased significantly (see Table 2 and Figure 2). She was also administered hepatoprotective treatment of glycyrrhizin and bicyclol. After a 2-week treatment, the liver function recovered totally.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning23 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Male
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 24-day-old boy was admitted to the NICU for an 8-hour history of fever with a peak temperature of 38 C. The parents complained that the baby had a mild cough with sputum, and they noticed he seemed to have facial and lip cyanosis when feeding. The baby was lethargic and had a poor appetite, accompanied by watery diarrhea without emesis. He was born at a gestational age of 36w+4 via cesarean delivery. He had no remarkable perinatal history. His mother confirmed COVID-19 with fever and cough before he had symptoms. On physical examination, his temperature was 38 C with a respiratory rate of 46 breaths/min; blood pressure was in the normal range, and his SpO2 was 97% while feeding and breathing ambient air. Coarse breath without crackling sounds in all lung fields could be heard. No heart murmur was detected. Prominent reticulated mottling of the skin could be seen on the lower extremities, especially when he was febrile. Capillary refill time in the lower extremity was 2 s. The liver was palpated at 1 cm under the costal margin, and the spleen was not palpated. Laboratory data revealed that WBC, subsets proportion, CRP, procalcitonin (PCT), blood gas, electrolytes, transaminase, and bilirubin levels were all in the normal range. Blood culture was negative. No other apparent abnormalities were reported on the routine stool test. PCR test for the SARS-CoV-2 virus was positive. The common respiratory pathogens such as influenza A/B, RSV, parainfluenza, adenovirus, mycoplasma, and chlamydia were negative. Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1). The cardiac ultrasound was normal. The CRP tests were repeated, and sepsis was ruled out in the next few days. So, the baby was administered piperacillin/tazobactam for 36 h and nebulization treatment was given (see Table 1).
The fever lasted for 2 days, and the peak temperature was 38.6 C. The baby recovered with occasional cough and mild nasal congestion on the 5th day after admission. On the 6th day, the ALT and AST were significantly increased (see Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus. He was also administered hepatoprotective treatment of glycyrrhizin and bicyclol.
The baby received hepatoprotective treatment for 5 days. On the 11th day after admission, repeated lab tests demonstrated that ALT and AST decreased to 97 U/L and 40 IU/L, respectively. Then he was discharged with hepatoprotective drugs. 4 days after discharge, the liver function went back to the normal range.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning24 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 5.0
Sex: Female
Title: Use of the adult attachment projective picture system in psychodynamic psychotherapy with a severely traumatized patient
Keywords: adult attachment projective picture system; adult attachment; psychoanalysis; psychotherapy; trauma;
Abstract:
The following case study is presented to facilitate an understanding of how the attachment information evident from Adult Attachment Projective Picture System (AAP) assessment can be integrated into a psychodynamic perspective in making therapeutic recommendations that integrate an attachment perspective. The Adult Attachment Projective Picture System (AAP) is a valid representational measure of internal representations of attachment based on the analysis of a set of free response picture stimuli designed to systematically activate the attachment system (George and West, 2012). The AAP provides a fruitful diagnostic tool for psychodynamic-oriented clinicians to identify attachment-based deficits and resources for an individual patient in therapy. This paper considers the use of the AAP with a traumatized patient in an inpatient setting and uses a case study to illustrate the components of the AAP that are particularly relevant to a psychodynamic conceptualization. The paper discusses also attachment-based recommendations for intervention.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Gloria lived in an intact family with her parents and three younger siblings until her parents divorced at age 5, but she provided no details about her childhood before this time and would not speak at all about her biological father. Gloria and her siblings lived predominantly with their mother after the divorce. Her mother remarried 5 years later when Gloria was 10 years old and she viewed her stepfather as her "actual" father. She described him as being humorous, loved, and trusted, but she also described him impulsive, irascible, and argumentative. Gloria seemed insecure about her stepfather's acceptance, wondering how far she could push him before he would break. Would he accept her even if she acted like a wild child? Gloria stated that "once a week I pushed him until he burst," and she told how she tested him with "mischievousness" so as to push her stepfather into beating her. Gloria's deliberate misbehavior and her stepfather's beatings were central to their relationship.
Gloria's first major traumatic experience as a sadistic rape in late adolescence. The only details that she provided about her rape was that it occurred during daytime and that she did not know the rapist. After the rape, she began around 3 weeks later to have sudden headache and fainting attacks, fainting as much as three times a day. She also developed chronic dissociation experiences. Gloria's symptoms appeared to be associated with feeling of being exposed and to school or performance-related pressure. Although these problems persisted, she did not seek psychological treatment. Her symptoms, especially fainting, diminished when she studied abroad. Her symptoms reoccurred after returning home 2 years later, however, and she decided to go back abroad.
OUTPUT:
| PMC4122203 |
MultiCaRe_Reasoning25 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 30.0
Sex: Female
Title: Use of the adult attachment projective picture system in psychodynamic psychotherapy with a severely traumatized patient
Keywords: adult attachment projective picture system; adult attachment; psychoanalysis; psychotherapy; trauma;
Abstract:
The following case study is presented to facilitate an understanding of how the attachment information evident from Adult Attachment Projective Picture System (AAP) assessment can be integrated into a psychodynamic perspective in making therapeutic recommendations that integrate an attachment perspective. The Adult Attachment Projective Picture System (AAP) is a valid representational measure of internal representations of attachment based on the analysis of a set of free response picture stimuli designed to systematically activate the attachment system (George and West, 2012). The AAP provides a fruitful diagnostic tool for psychodynamic-oriented clinicians to identify attachment-based deficits and resources for an individual patient in therapy. This paper considers the use of the AAP with a traumatized patient in an inpatient setting and uses a case study to illustrate the components of the AAP that are particularly relevant to a psychodynamic conceptualization. The paper discusses also attachment-based recommendations for intervention.
Image Caption and Description:
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Case Report:
Gloria's second major traumatic experience was at 30 years old when her boyfriend of 2 years died in an accident. Gloria had separated from him shortly before his death, the reason being that she was no longer able to tolerate physical closeness. She felt severely guilty about his death and her guilt had masochistic qualities. As a result, she did not have another intimate relationship for many years.
Gloria had recently experienced a third trauma prior to her decision to seek treatment. She had been in a serious accident in which she had been thrown out of her car and into the air rendering her unconscious. She was thought at first to be dead. Her physical injuries included three spinal discs and a strain on the cervical spine and her fainting episodes increased to many episodes a day. Although Gloria reported in her initial interview, almost proudly, saying "I survived this," and she had since was unable to work.
Gloria felt that her symptoms had become debilitating, and she noticed that her fainting spells seemed related to stress. Her headaches had become so severe that she risked becoming unconscious. She was not able to recall what preceded the headaches and she could not remember any indicators associated with their onset, such as less debilitating headaches or other physical warning signs. Gloria described herself as being on autopilot. This "defensive mechanism" had saved her life more than 20 years ago, but now this automatic mechanism was out of her control.
Gloria had not allowed herself to think about this until she entered treatment and her treatment goal was "to get rid of it." She had a stiff commitment to being strong and carrying on. "I want to function. I will get through this. I want to be able to work. I have worked for many years to wipe out the traumatic event, to get rid of it, to repress it." This perspective had dominated her life and kept her moving forward. She was frightened of not being able to be in control of her symptoms and the prospect of becoming dependent on the pain medication prescribed to combat her severe headaches.
was a prominent psychoanalyst to use ethological concepts to describe the infant's biologically predisposed attachment to a primary caregiver. He viewed relatedness in early childhood as a primary and independent developmental goal that is not subservient to a physiological needs (e.g., hunger) or psychoanalytically defined primary processes. The infant is perceived from an interactional perspective, with a focus on the relationships with primary attachment figures. Attachment theory maintained some foundations of psychoanalytic theory (e.g., the developmental point of view) and there is a strong literature that discusses the divergences and convergences of psychoanalysis and attachment theory (e.g.,) and also developed some aspects further, particularly the delineation of the internal world.) overview of the intersection of these two approaches demonstrated that the relationship between attachment theory and psychoanalysis is more complex than adherents of either community have generally recognized. This paper addresses some of these complexities by integrating attachment assessment using the Adult Attachment Projective Picture System (AAP) in psychodynamic psychotherapy in an adult traumatized patient.
proposed that one major difference between psychoanalysis and attachment theory falls in the description of forms of defensive processes. Traditional psychoanalytic models provide a complex constellation of defenses to interpret a broad range of intrapsychic phenomenon, including phantasy, dream, wish, and impulse (e.g.,). Attachment theory delineates two basic processes that manifest in three forms. According to), Bowlby defined defense as forms exclusion directed to modulating difficult and anxious experiences with attachment figures, and the child's experiences with incomplete or failed bids for parental protection, care, and comfort. He defined defenses in terms of two qualitatively distinct processes: deactivation (retaining elements of intellectualization and denial) and cognitive disconnection (retaining elements of splitting).) pointed out that under normal circumstances these two exclusion processes are associated with goals to maintain physical and psychological proximity in the attachment-caregiving relationship under conditions when the child's experiences with the attachment figure are less than satisfying. George and Solomon refined model suggesting that deactivation and cognitive disconnection organized and supported at least minimal forms of representational, behavioral, and emotional regulation. proposed that these forms defensive exclusion functioned to segregate (akin to repression) memory, affect, and experience when the attachment figure was not available, conceiving of an extreme process he termed "segregated systems." Segregated systems were thought as associated with the painful and chronic distress experiences, such as those that accompany loss. Bowlby posited that segregated systems were the intrapsychic root of symptoms related pathological mourning and severe psychopathology. Attachment theorists have since demonstrated that segregated systems are associated with experiences of failed protection, attachment trauma, and disorganized/dysregulated attachment behavior and representation.
Consistent with a psychoanalytic approach, some attachment theorists have suggested that utilization of defensive process models is needed to provide a complete picture of the emotional and behavioral regulation processes individuals develop from their childhood relationships with attachment figures. Further, concluded, "In order to understand the relationship between adult attachment and mental health risk we need to examine the attachment concepts of defense and segregated systems, the mental processes that define disorganization" (p. 295). These theorists operationally defined basic defense scheme as a central element for evaluating representational patterns of attachment using the Adult Attachment Projective Picture System. Suggesting that these representational structures have developed under conditions of attachment trauma (abuse, loss, failed protection), the concept of segregated systems is fruitful to explain some forms of relationship-based psychopathology in adults.
The discussion that follows provides some ideas about using attachment concepts in clinical work by showing how the perspectives of a psychoanalyst and attachment assessment may improve the understanding of an individual case of a traumatized patient with the diagnosis of a PTSD with dissociative states (e.g., fainting in response to stressful situations).
The lifetime prevalence of PTSD in Germany has been found to be 1.3% with a female-to-male ratio of 3.25-1. Traumatized patients are frequently misdiagnosed and mistreated in the mental health system. The number and complexity of the symptoms lead to fragmented and incomplete treatment. PTSD patients are vulnerable to become re-victimized by caregivers because of their difficulties with close relationships. Severely traumatized PTSD patients (complex trauma) develop difficulties in modulating arousal and show signs of severe affect dysregulation (e.g., aggression against self and other, and problems with social attachment and dissociative states).
Dissociation, defined as a deficit of the integrative functions of memory, consciousness and identity, is often related to traumatic experiences and traumatic memories. During clinical interviews, dissociation is suggested either by such a degree of unwitting absorption in mental states that ordinary attention to the outside environment is seriously hampered. Dissociation can be accompanied by a sudden lack of continuity in discourse, thought or behavior of which the person is unaware (supposedly due to intrusion of dissociated mental contents in the flow of consciousness). Thus, for instance, a dissociative patient may suddenly interrupt her speech during a therapeutic session, stare into the void for minutes, and become unresponsive to the therapist's queries as to what is happening to her. Or a patient suffering from PTSD may suddenly utter fragmented and incoherent comments on intrusive mental images (usually related to traumatic memories) that surface in consciousness and hamper the continuity of the preceding dialog with the therapist. In the most extreme variety of dissociation (Dissociative Identity Disorder), an alternate ego state may appear during the clinical dialog, reporting (sometimes with an unusual tone of voice, e.g., like a child) memories of childhood abuse of which the patient has previously been totally unaware, or expressing attitudes and beliefs quite extraneous to the patients' personality.
Furthermore, shattered meaning propositions predominate. Trust, hope and sense of agency is accompanied by social avoidance, with loss of meaningful attachment and therefore lack of participation in preparing for future.
The founding premise of attachment theory is that stress, especially traumatic stress, produces a strong desire for proximity to and comfort by attachment figures; this desire is built into human biology as a survival safety mechanism and the mechanism is functions unchanged throughout the life span. Attachment experience shapes the ways in which individuals manage stress and are especially important when individuals experience a traumatic event. When attachment is secure, individuals know how and when to seek attachment figures and develop internal representations of self as deserving of care. Attachment security fosters confidence and trust that figures are available, empathic, and sensitive to their needs; security is a buffer or resilience factor that supports recovery from trauma. When attachment is insecure, emotional and behavioral reactions when distressed may be made even more painful by unconscious evaluations that wishes for comfort are illegitimate. Insecurity may result in additional painful interactions with the attachment figures rather than the functional comfort and protection for which attachment was intended. Insecurity fosters anxiety, anger, and fear, and increases the risk of developing trauma-related emotional disorders. Extreme forms of insecurity are associated with the breakdown of attachment and caregiving regulatory mechanisms risk emotional and homeostatic dysregulation, often termed disorganized attachment. The risk of dysregulation is heightened when attachment relationships are threatened or threatening, such as parental loss or psychiatric debilitation or maltreatment. defined events such as these as attachment traumas, events that involve terrifying threats to the integrity of self or attachment relationships. Attachment disorganization, conceived in terms of mechanisms of dysregulation and attachment trauma, has been shown to predict vulnerability to severe psychiatric symptomology, including dissociative symptoms.
found the metaphor of a "drama triangle" useful in thinking about the intersection between dissociation and disorganized attachment. The dissociation triangle addresses how disorganized attachment fosters dissociative mechanisms that create incompatible and separate representations of self as victim, rescuer, and persecutor. The child's representation of the attachment figure is represented in a conflicting manifold way. On the one side, the attachment figure is represented as source of the child's fear, the self as a victim of attachment figure as persecutor. On the other side, the attachment figure by virtue of being the child's biological protector is viewed as the child's source of safety and protection (rescuer). In the child's mind, representation of self and attachment figure shift among these three incompatible models that are too complex to be synthesized into an integrated model of self. Liotti's model provides us with an integrated psychodynamic and attachment approach to our first questions concerning Gloria's illness, questions regarding the childhood origins of her episodes of near unconsciousness and her inability to ask for help following traumatic assault.
examined cognitive perspectives on unresolved attachment in patients diagnosed with PTSD. They proposed that unresolved loss, as defined in attachment assessment during interview, involves intrusion avoidance phenomena similar to those of PTSD. Specifically, they develop a model based on unresolved loss that involves the failure to integrate representations of self and the world following a loss. The features of unresolved loss can be understood as emerging as a result of the activation of unintegrated representations of the loss experience and cognitive and behavioral avoidance processes. In this model, the sudden intrusion of memories, cognitions, and emotions associated with the loss automatically captures attention and initiates behavioral dispositions that are incompatible. With regard to attachment, the authors suggested that this was the mechanism that interfered with caregiving behavior. Lack of attentional resources and incompatible response tendencies can also result from safety behaviors directed at avoiding the perceived negative consequences of activating trauma memory. The authors proposed that these processes offer a novel way of understanding the disturbances in behavior and speech that are evident in mothers who are designated as unresolved with respect to loss.
This suggests that representational attachment measures, like the AAP, can provide a good understanding of the movement that the client might be making toward empowerment, integration, or understanding. Thus, even if a patient's overall attachment is unresolved (i.e., dysregulated), there may be indications in their responses to the AAP stimuli that suggest they are moving toward mental organization. Given the negative outcomes that are associated with abuse, focusing on resources and defensive strategies is arguably important for therapeutic recommendations.
OUTPUT:
| PMC4122203 |
MultiCaRe_Reasoning26 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 20.0
Sex: Male
Title: Characterization of Forearm Muscle Activation in Duchenne Muscular Dystrophy via High-Density Electromyography: A Case Study on the Implications for Myoelectric Control
Keywords: duchenne muscular dystrophy; forearm; hand; high-density surface electromyography; motor control; myocontrol; principal component analysis (pca); wrist;
Abstract:
Duchenne muscular dystrophy (DMD) is a genetic disorder that results in progressive muscular degeneration. Although medical advances increased their life expectancy, DMD individuals are still highly dependent on caregivers. Hand/wrist function is central for providing independence, and robotic exoskeletons are good candidates for effectively compensating for deteriorating functionality. Robotic hand exoskeletons require the accurate decoding of motor intention typically via surface electromyography (sEMG). Traditional low-density sEMG was used in the past to explore the muscular activations of individuals with DMD; however, it cannot provide high spatial resolution. This study characterized, for the first time, the forearm high-density (HD) electromyograms of three individuals with DMD while performing seven hand/wrist-related tasks and compared them to eight healthy individuals (all data available online). We looked into the spatial distribution of HD-sEMG patterns by using principal component analysis (PCA) and also assessed the repeatability and the amplitude distributions of muscle activity. Additionally, we used a machine learning approach to assess DMD individuals' potentials for myocontrol. Our analysis showed that although participants with DMD were able to repeat similar HD-sEMG patterns across gestures (similarly to healthy participants), a fewer number of electrodes was activated during their gestures compared to the healthy participants. Additionally, participants with DMD activated their muscles close to maximal contraction level (0.63 ± 0.23), whereas healthy participants had lower normalized activations (0.26 ± 0.2). Lastly, participants with DMD showed on average fewer PCs (3), explaining 90% of the complete gesture space than the healthy (5). However, the ability of the DMD participants to produce repeatable HD-sEMG patterns was unexpectedly comparable to that of healthy participants, and the same holds true for their offline myocontrol performance, disproving our hypothesis and suggesting a clear potential for the myocontrol of wearable exoskeletons. Our findings present evidence for the first time on how DMD leads to progressive alterations in hand/wrist motor control in DMD individuals compared to healthy. The better understanding of these alterations can lead to further developments for the intuitive and robust myoelectric control of active hand exoskeletons for individuals with DMD.
Image Caption and Description:
Image caption: The figure shows the process of the electrode placement. (A) The flexible custom-made sleeve that was used for marking the skin of the participant. The sleeve is flexible only around the circumferal direction and stiff along the longitudinal direction of the arm. (B) The marked skin of the participant. The longitudinal inter-electrode distance (LID) is fixed at 2 cm (L), while the circumferal inter-electrode distance (CID) depends on the forearm width of each participant. (C) The participant with all the 64 electrodes placed. The imaginary line (red line) that connects the lateral epicondyle and the styloid process of the ulna was used as the border between the dorsal and ventral side of the forearm. The placement of the electrodes starts right above this line, with electrode number one placed proximally (at 20% of forearm length from the elbow) and eight distally. The rest of the electrode rows are placed counterclockwise as someone is looking at his right arm. (D) This way, electrodes 1-32 were placed over the dorsal side (see sketch) and 33-64 over the ventral side of the forearm. The center of gravity (COG) is also shown for this gesture.
Image description: The experimental setup (Figure 1) included several components, and it was designed to record HD-sEMG signals from the forearm in a repeatable and systematic way.
Then, we measured the forearm length from the lateral epicondyle until the styloid process of the ulna and the forearm circumference at 20% of the forearm length from the elbow (Figure 1).
The participant had to wear a perforated sleeve (Figure 1) with equally placed holes and elastic only along the circumferal direction to ensure that the electrode placement was standardized for all participants.
We used a non-permanent marker to mark the skin of the participant (Figure 1) and then visually inspect the markings before applying the electrodes.
The first row of electrodes was placed above the imaginary line between the lateral epicondyle and the styloid process of the ulna and the last row below in such a way that the line lay in the middle between the two rows of electrodes (Figure 1).
Image caption: The 10 repetitions of third Duchenne muscular dystrophy (DMD) participant (DP3) for wrist extension that were used to acquire the average normalized map. The lower part shows an example of the protocol followed to record the data. In this example, the participant was instructed to extend his wrist for 3 s and then rest for 3 s. This was repeated 10 times. The same procedure was followed for all the seven gestures.
Image description: Participants performed seven different gestures involving hand and wrist motions (Figure 2).
For every gesture, 10 repetitions of 3 s contractions were performed, together with 10 repetitions of 3-s resting periods between the contractions (Figure 2).
For every electrode, the average of this 1-s contraction was calculated and used to construct 10 heatmaps per gesture (Figure 2).
Image caption: The heatmaps of two representative gestures for the three participants with Duchenne muscular dystrophy (DMD) and one healthy participant. (A-D) show wrist extension heatmaps for DP1 (A), DP2 (B), DP3 (C), and HP6 (D). (E-G) show wrist flexion heatmaps for DP1 (E), DP2 (F), DP3 (G), and HP6 (H). Regarding wrist extension, all participants exhibit similar activation patterns. However, for wrist flexion, there is higher variability in the activation patterns within participants. X marks show the center of gravity (COG) for each heatmap. Only the activations that are higher than 80% are used to calculate the COG.
Image description: For the visual inspection of the forearm activity per gesture, we constructed activity heatmaps by averaging the 10 repetition heatmaps (Figure 3).
The COG was calculated over electrodes presenting activations equal or larger than 80% of the maximal value of the heatmap (Figure 3).
The 10 heatmaps, one per gesture repetition, were used to construct one single average heatmap per gesture per participant (Figure 3) that was used for the motor control analysis.
Image caption: The histogram of squared Pearson correlation between the 10 repetitions for all gestures and for all participants. High correlation shows similarity between the repetitions and thus high repeatability. Both healthy and Duchenne muscular dystrophy (DMD) participants achieved similarly high repeatability on the tasks. The full vertical lines represent the mean and the dashed the standard deviation. The number of unique comparisons between 10 repetitions is 45 multiplied by the seven gestures makes 315 unique comparisons per participant. That explains the total of 2,520 events in the healthy histogram compared to the 945 in the DMD.
Image description: For every gesture, this resulted in 45 unique comparisons between the 10 repetitions and thus 45 coefficients per gesture (Figure 4).
Image caption: (A) The maximum normalized (left) and absolute (right) activation for each of the 10 repetitions of each gesture for all participants. Healthy participants generally performed the tasks with low levels of maximum normalized activation, while participants with Duchenne muscular dystrophy (DMD) showed higher levels of maximum normalized activation during the tasks. However, the maximum absolute activations were higher for the healthy participants. The full vertical lines represent the mean and the dashed the standard deviation. (B) The average center of gravity (COG) for the seven gestures for the healthy participants (black) and the participants with DMD (red). Healthy participants (gray shaded area) show on average a broader spatial distribution of the seven gestures than the participants with DMD (red shaded area). The red line represents the imaginary line that connects the lateral epicondyle and the styloid process of the ulna and was used as the border between the dorsal and ventral side of the forearm (see also Figure 1). The COG coordinates are normalized over the forearm circumference (COGx) and length (COGy).
Image description: The temporal distribution of activations between healthy and DMD was calculated via normalized and absolute activations per repetition of each gesture (Figure 5A).
Figure 5B shows the average spatial distribution of the healthy and DMD participants.
Image caption: (A) The percentage of variance explained as a function of the number of cumulative principal components (PCs). More than 90% of the variance (blue dashed line) of the data of the participants with Duchenne muscular dystrophy (DMD) is explained by three PCs, while for the healthy by five. The full lines represent the mean and the dashed the standard deviation. For clarity, we include only up to 10 of the 63 components, as those explain more than 99% of the variance explained. (B) The averaged squared Pearson correlation between the seven gestures of both groups of participants in the form of a similarity matrix. High correlation shows similarity between the gestures. Both healthy and DMD participants show correlated gestures; however, this phenomenon is more prominent in the DMD participants. A high value shows high correlation where one is the maximum (diagonal). The number of unique comparisons between the seven gestures is 21 per participant.
Image description: This number was used to explore the repertoire of orthogonal and uncorrelated sEMG patterns produced by the two groups of participants (Figure 6A).
We averaged the correlation values of the healthy participants and the participants with DMD separately to identify which gestures are mostly correlated per population, and we presented this in the form of a similarity matrix (Figure 6B).
Case Report:
The DMD participants had different levels of hand function. Participant one (DP1, 20 years old) was able to use his hands functionally, and no contractures relevant to hand/wrist movement were observed. Participant two (DP2, 22 years old) was able to functionally use his hand but experienced a decrease in strength and minimal contractures relevant to hand/wrist movement. Participant three (DP3, 25 years old) was not able to use his hands at all and was affected by immediate onset of fatigue during its use. Extensive contractures relevant to finger movement were observed, and only minimal movement of the fingers was possible (see Supplementary Video). All participants were able to perform the experimental protocol.
The Medical Ethics Committee of Twente approved the study design, the experimental protocol, and the procedures (Protocol number: NL59061.044.16). The study was conducted according to the ethical standards given in the Declaration of Helsinki in 1975, as revised in 2008.
The experimental setup (Figure 1) included several components, and it was designed to record HD-sEMG signals from the forearm in a repeatable and systematic way. Muscular activity was measured with a 128-channel amplification system (REFA 128 model, TMS International, Oldenzaal, The Netherlands). We used 64 monopolar electrodes around the forearm to acquire the raw sEMG signals. The signals were recorded with a decimal gain of 26.55 before the analog-to-digital converter (ADC); however, this gain factor is compensated by the acquisition software (Polybench, TMS International, Oldenzaal, The Netherlands), after the ADC. Additionally, REFA includes a first-order analog low-pass filter placed before the ADC with a -3 db point at 6.8 kHz. The 6.8-kHz low pass helps to make the REFA immune to high-frequency electromagnetic interference such as mobile phone networks. The analog signals were sampled with a frequency of 2,048 Hz and digitally converted with a 24-bit conversion (a resolution of 0.018 muV per bit, 300 mV dynamic range). The ADC of the device has an anti-aliasing digital low-pass filter with a cutoff frequency of 0.2 * sample frequency. This filter inside the ADC is used to convert the 1-bit signal with a high frequency into a 24-bit signal with a lower frequency. The acquisition software was executed in a host laptop (Lenovo Thinkpad T490, Lenovo, Beijing, China) with a Windows 10 operating system (Microsoft Corporation, Washington, USA). A computer screen was used to provide visual feedback of the task to the participants.
Electrode placement and configuration were based on previous work that normalized the electrode locations to each participant's arm circumference in order to account for different forearm thicknesses (Table 1). The inter-electrode distance in the longitudinal direction of the forearm was kept constant at 2 cm for covering the entire forearm.
First, we cleaned the skin of the dominant forearm of the participant with alcohol. Then, we measured the forearm length from the lateral epicondyle until the styloid process of the ulna and the forearm circumference at 20% of the forearm length from the elbow (Figure 1). The participant had to wear a perforated sleeve (Figure 1) with equally placed holes and elastic only along the circumferal direction to ensure that the electrode placement was standardized for all participants. We used a non-permanent marker to mark the skin of the participant (Figure 1) and then visually inspect the markings before applying the electrodes.
Conductive gel was applied to each of the 64 electrodes with a syringe, and they were subsequently attached to the forearm. The first row of electrodes was placed above the imaginary line between the lateral epicondyle and the styloid process of the ulna and the last row below in such a way that the line lay in the middle between the two rows of electrodes (Figure 1). The first electrode was attached proximally starting at the 20% of the forearm length from the elbow. Electrodes were placed from proximal to distal and in counterclockwise direction (from the perspective of a right-handed participant). This way, electrodes 1-32 were placed over the dorsal side (mostly extensor muscles) and 33-64 over the ventral side (mostly flexor muscles) of the forearm. The reference electrode was placed at the distal end of the forearm, over the head of the ulna.
Participants performed seven different gestures involving hand and wrist motions (Figure 2). The chosen gestures included: hand open/close, thumb flexion/extension, wrist flexion/extension, and index extension. These were chosen as they are involved in the most frequent ADL. First, each participant was instructed to perform all gestures without constraints (dynamic) with maximal voluntary effort in a single recording. This way, we recorded the maximum voluntary contraction (MVC) for every electrode across all gestures. For every gesture, 10 repetitions of 3 s contractions were performed, together with 10 repetitions of 3-s resting periods between the contractions (Figure 2). The participants were instructed to perform all movements in a comfortable fashion in order to avoid forceful contractions that may elicit co-contractions of agonist-antagonist muscle groups.
The timing of the gestures was dictated with the use of visual feedback. The visual feedback illustrated via photographs of human hands which gesture had to be performed. The sequence of images served to instruct the participant as a metronome when to perform the gesture (image of gesture appearing for 3 s) and when to relax (image of relaxed hand appearing for 3 s). Additionally, the measurements were performed in the morning in order to avoid effects of the end-of-the-day fatigue, especially for the participants with DMD. Furthermore, the participants had short breaks between gestures in order to rest.
All signal processing and data analyses were performed in Matlab 2018b software (The MathWorks Inc., USA). The raw sEMG signals were processed offline in order to compute the envelopes for each of the 64 electrodes per gesture and per participant. First, the raw data were filtered with a band-pass filter (fourth-order Butterworth, 20-450 Hz). Additionally, a second-order digital infinite impulse response notch filter (cutoff frequency of 50 Hz, Q factor of 50) was used to remove the power line noise (50 Hz for the EU). Despite its main limitation (signal distortion around the attenuated frequency), notch filtering is the mainstream technique for powerline signal removal, and a narrow bandwidth with a high Q factor can already address this. For highly powerline-contaminated signals, spectral interpolation may be more appropriate. The signals were subsequently rectified and filtered with a low-pass filter (third-order Butterworth, 2 Hz). Our choice for the cutoff frequency was motivated by the low-frequency dynamic tasks involved in this study and our previous study on real-time sEMG control of a hand exoskeleton. The resulting envelopes were visually inspected segmented, according to the acquisition protocol, to 10 contractions and periods (each lasting approximately 3 s) and normalized. A threshold was selected to define the onset of the activity, and the next 3 s after the onset were chosen as a contraction period. The threshold was defined as the time that the signal exceeded 10 standard deviations of the baseline (non-contraction) activity similar to Di Fabio, and the final segmentation was additionally assessed visually. The maximum value of the envelope of each electrode across the complete dataset was used as a normalization value for each electrode. This value was acquired using a moving average window of 1 s in order to account for signal artifacts. Signal quality was visually assessed both in the time and frequency domains, and faulty channels were replaced by linear interpolation of their surrounding neighboring channels (8-neighborhood). Different local conditions were applied to faulty electrodes placed in the longitudinal extremes (<8 neighboring channels).
Every 3-s contraction was further segmented in 1-s segments by keeping only the middle second of the contraction (steady-state phase) and discarding the transient phase. For every electrode, the average of this 1-s contraction was calculated and used to construct 10 heatmaps per gesture (Figure 2). For the visual inspection of the forearm activity per gesture, we constructed activity heatmaps by averaging the 10 repetition heatmaps (Figure 3).
We analyzed the data to assess HD-sEMG pattern repeatability, peaks, and dimensionality, as well as individuals' potential to generate activation patterns suitable for myocontrol applications for both healthy and DMD participants. The raw data used for this analysis are available online. All signal processing and data analyses were performed in Matlab 2018b software (The Mathworks Inc., USA). In the remainder of this section, we describe a set of analyses aimed at investigating differences between DMD and healthy participants at the level of motor control properties (Motor Control Properties section) and myocontrol performance (Myocontrol Performance section).
The degree of repeatability across repetitions per participant was calculated using squared Pearson correlation. Each heatmap (8 x 8) was reshaped into a vector (1 x 64) before the calculation of the squared Pearson correlation. The coefficient was extracted among the 10 repetitions per gesture and per participant. For every gesture, this resulted in 45 unique comparisons between the 10 repetitions and thus 45 coefficients per gesture (Figure 4).
The temporal distribution of activations between healthy and DMD was calculated via normalized and absolute activations per repetition of each gesture (Figure 5A). A normalization factor was calculated across all gestures and repetitions. For each gesture, the maximum absolute and normalized value of the 64-electrode heatmap were calculated for every participant and each repetition and plotted.
Figure 5B shows the average spatial distribution of the healthy and DMD participants. The spatial distribution of the sEMG potentials over the 8 x 8 normalized heatmap was calculated using the center of gravity (COG) by calculating the dorsal-ventral and the proximal-distal position of it as proposed by Elswijk et al.. The COG was calculated over electrodes presenting activations equal or larger than 80% of the maximal value of the heatmap (Figure 3). This way, only clusters of electrodes with a high peak amplitude were considered for the calculation of the COG in order to focus on the most relevant area of activation for each gesture.
The 10 heatmaps, one per gesture repetition, were used to construct one single average heatmap per gesture per participant (Figure 3) that was used for the motor control analysis. We quantified differences in dimensionality of orthogonal and uncorrelated sEMG patterns between the healthy and DMD participants via a PCA to the gesture-specific heatmaps per participant. For every participant, we performed a PCA to the concatenation (64 x 70) of the sEMG heatmaps of all gestures and repetitions per participant [64 electrodes x (7 gestures x 10 repetitions)]. The number of PCs needed to reconstruct the original seven gesture heatmaps was identified per participant by means of the variance explained (VE), and it was taken as the number of PCs that summed together explained more than 90% of the total variance. This number was used to explore the repertoire of orthogonal and uncorrelated sEMG patterns produced by the two groups of participants (Figure 6A).
Additionally, we calculated the squared Pearson correlation between all the gestures per participant (the same way as we did for the repeatability, Activation Pattern Repeatability Tests section). The coefficient was extracted from the average normalized heatmap of the 10 repetitions per gesture and per participant. For every participant, this resulted in 21 unique comparisons between the seven gestures and thus 21 coefficients per participant. We averaged the correlation values of the healthy participants and the participants with DMD separately to identify which gestures are mostly correlated per population, and we presented this in the form of a similarity matrix (Figure 6B).
We explored participants' gesture recognition performance via an offline pattern recognition algorithm applied to the band-pass filtered data (fourth-order Butterworth, 20-450 Hz) of each participant. We used a linear discriminant analysis (LDA) to recognize each of the gestures performed. LDA is a commonly used pattern recognition algorithm for prosthetic control and already commercialized by COAPT LLC (Chicago, USA). We chose it for the ease of implementation, classification speed, and high accuracy compared to other similar approaches. The 10 steady-state segments for every gesture were concatenated and created a 10-s vector. We trained the classifier by extracting four time-domain features from the raw segmented data including mean absolute value, zero crossing, slope sign change, and waveform length. We chose for a feature extraction window of 200 ms (with an overlap of 100 ms), which would be within acceptable range for real-time myoelectric applications. The classifier was validated with a three-split Monte Carlo cross-validation approach. Each time, a different part of the segmented data was used for training (always 70%) and testing (always 30%). The average off-line classification accuracy of these three trainings was used as performance metric per participant. Additionally, we tested how the offline classification accuracy per participant was affected by the number of gestures that had to be classified.
OUTPUT:
| PMC7174775 |
MultiCaRe_Reasoning27 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Female
Title: Multimodal Imaging Characteristics of ADRP in a Family with p.Thr58Arg Substituted RHO Mutation
Keywords: None
Abstract:
Background:
Autosomal dominant retinitis pigmentosa (adRP) is a rare cause of progressive visual impairment in young patients and is frequently a result of RHO gene mutations. p.Thr58Arg rhodopsin mutation leads to misfolding of rhodopsin, subsequent accumulation in the endoplasmic reticulum, and leads to consecutive atrophy of photoreceptor cells through apoptosis.
Materials and methods:
We describe multimodal imaging findings in a 58-year-old female with adRP due to a c.173 C > G, p.Thr58Arg rhodopsin mutation (confirmed on genotyping), including ultra-wide-field fundus autofluorescence (UWF-FAF), color scanning laser ophthalmoscopy, structural optical coherence tomography (OCT), OCT-angiography (OCT-A), electroretinography (ERG), and visual field testing (HVF). Additionally, we compare the patient's phenotypic findings to those of her offspring, who was also affected by adRP.
Results:
The 58-year-old female and her son with symptoms of nyctalopia and decreased vision showed macular pigmentary changes in a bull's-eye pattern along with bone spicules in periphery with retinal atrophy. Genotyping confirmed p.Thr58Arg rhodopsin mutation. Wide area of dystrophic retina was noted on UWF-FAF, along with corresponding atrophy of photoreceptor layer on OCT. OCTA revealed complete nonperfusion of the superficial capillary plexus in areas of retinal dystrophy. ERG revealed increased latency and decreased amplitudes; HVF revealed constriction of visual fields consistent with retinal findings.
Conclusions:
Multimodal imaging is extremely helpful in delineating the extent of retinal dystrophy and comparable to ERG for monitoring of progress in retinitis pigmentosa. Photoreceptor layer thickness (measured with OCT) strongly correlated with ERG and can be used as a secondary surrogate for monitoring the disease progress.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 58-year-old female presented with complaints of progressive loss of vision and flashes of light in both eyes (OU). Her past ocular history was significant for progressive nyctalopia which was gradually worsening since her childhood. Her past medical history was significant for asthma, depression, musculoskeletal pain, well-controlled hypertension, and hyperlipidemia. Her systemic medications included hydrochlorothiazide, lisinopril, aspirin, albuterol, buspirone, duloxetine, lorazepam, gabapentin, hydrocodone-acetaminophen, tizanidine, and trazodone.
The patient's family history of adRP was further explored. Her paternal grandmother and the grandmother's two daughters were affected by RP. She has one son who is also affected with nyctalopia.
Her best-corrected visual acuity (BCVA) was 20/40 OD and 20/30 OS. Her intraocular pressure (IOP) was 20 OD and 19 OS. Anterior segment examination was unremarkable.
Fundoscopy of the right eye revealed normal optic nerve with a cup-to-disc ratio of 0.1 bilaterally. Examination of the posterior pole revealed perimacular pigmentary changes in a bull's-eye pattern. Large area of retinal atrophy in a doughnut shape was noted around vascular arcades. Attenuated vasculature was noted in the area of the dystrophic retina. Peripheral retinal examination revealed bone spicule pigmentation along the inferonasal quadrant.
Fundoscopy of OS showed similar findings. Bone spicules were noted in the inferotemporal quadrant.
OUTPUT:
| PMC7969344 |
MultiCaRe_Reasoning28 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 38.0
Sex: Male
Title: Multimodal Imaging Characteristics of ADRP in a Family with p.Thr58Arg Substituted RHO Mutation
Keywords: None
Abstract:
Background:
Autosomal dominant retinitis pigmentosa (adRP) is a rare cause of progressive visual impairment in young patients and is frequently a result of RHO gene mutations. p.Thr58Arg rhodopsin mutation leads to misfolding of rhodopsin, subsequent accumulation in the endoplasmic reticulum, and leads to consecutive atrophy of photoreceptor cells through apoptosis.
Materials and methods:
We describe multimodal imaging findings in a 58-year-old female with adRP due to a c.173 C > G, p.Thr58Arg rhodopsin mutation (confirmed on genotyping), including ultra-wide-field fundus autofluorescence (UWF-FAF), color scanning laser ophthalmoscopy, structural optical coherence tomography (OCT), OCT-angiography (OCT-A), electroretinography (ERG), and visual field testing (HVF). Additionally, we compare the patient's phenotypic findings to those of her offspring, who was also affected by adRP.
Results:
The 58-year-old female and her son with symptoms of nyctalopia and decreased vision showed macular pigmentary changes in a bull's-eye pattern along with bone spicules in periphery with retinal atrophy. Genotyping confirmed p.Thr58Arg rhodopsin mutation. Wide area of dystrophic retina was noted on UWF-FAF, along with corresponding atrophy of photoreceptor layer on OCT. OCTA revealed complete nonperfusion of the superficial capillary plexus in areas of retinal dystrophy. ERG revealed increased latency and decreased amplitudes; HVF revealed constriction of visual fields consistent with retinal findings.
Conclusions:
Multimodal imaging is extremely helpful in delineating the extent of retinal dystrophy and comparable to ERG for monitoring of progress in retinitis pigmentosa. Photoreceptor layer thickness (measured with OCT) strongly correlated with ERG and can be used as a secondary surrogate for monitoring the disease progress.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
The patient's 38- year-old son had similar symptoms of nyctalopia since he was a child. His past medical history was unremarkable. He denied distortions, floaters, and flashing lights OU. His past ophthalmic history was unremarkable.
His BCVA was 20/40-2 OD and 20/60-2 OS. Her intraocular pressure (IOP) was 20 OD and 19 OS. Anterior segment examination was unremarkable.
Fundoscopy of OD revealed normal optic nerve with a cup-to-disc ratio of 0.1 bilaterally. The fovea was normal. Large area of retinal atrophy was noted along the inferior arcade. An attenuated vasculature was noted in the area of the dystrophic retina. Peripheral retinal examination revealed bone spicule pigmentation along the inferonasal quadrant.
Fundoscopy of OS showed similar findings. Bone spicules were noted in the inferotemporal quadrant.
OUTPUT:
| PMC7969344 |
MultiCaRe_Reasoning29 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 8.0
Sex: Male
Title: Intraparenchymal Atypical Meningioma in Basal Ganglia Region in a Child: Case Report and Literature Review
Keywords: atypical meningioma; basal ganglia; intraparenchymal meningioma;
Abstract:
Intraparenchymal meningiomas without dural attachment are extremely rare, especially when they occur in basal ganglia region in child. An 8-year-old boy was admitted at our hospital, complaining of recurrent headache and vomiting for 3 months. Neurological examination showed impaired vision and mild paresis of the left extremities. Magnetic resonance imaging demonstrated a lesion located in the right basal ganglia region extending to superasellar cistern with solid, multiple cystic and necrotic components. Computed tomography revealed calcification within the mass. Due to the anterior cerebral artery involvement, a subtotal resection was achieved and postoperative radiotherapy was recommended. Histopathological examination indicated that the lesion was an atypical meningioma. The postoperative rehabilitation was uneventful. Mildly impaired vision and motor weakness of left extremities improved significantly and the patient returned to normal life after surgery. To our knowledge, intraparenchymal atypical meningioma in basal ganglia extending to superasellar cistern was never reported. The significance in differential diagnosis of lesions in basal ganglia should be emphasized.
Image Caption and Description:
Image caption: CT revealing calcification, necrosis, cystic formation of the mass lesion (A and B). No hyperostosis or bone absorbtion was observed (C).
Image description: CT (Fig. 1A, B) revealed an iso- to hyperdense lesion in the right basal ganglion extending to superasellar cistern, 4.0x4.4 cm in size with peripheral calcification.
No hyperostosis of sellaturcica was noticed (Fig. 1C).
Image caption: MRI showing a mass lesion in the right basal ganglia consisted of solid and cystic parts. The solid part manifesting isointense signal on T1-weighted (A), T2-weighted (B), and FLAIR (C) with heterogeneous enhancement (D and E); the cystic part showing hypointense signal on both T1-weighted (A) and FLAIR (C) and hyperintensity on T2-weighted images (B) without enhancement of the wall (D and E). Although the lower margin of the tumor touched the dorsum sellae dura, 'dura tail' sign was not noted (E). Postoperative MRI revealing that most of the tumor has been resected and the residual part detached from the dorsum sellae (F). Subdural fluid accumulation in the surgical region was also detected (F). FLAIR: fluid at tenuation inversion recovery, MRI: magetic resonance imaging.
Image description: Magnetic resonance imaging (MRI) demonstrated most of the mass lesion was iso-intense on T1-weighted, T2-weighted and fluid-attenuated inversion recovery images with inhomogeneous enhancement (Fig. 2A-E).
Postoperative MRI revealed that most of the tumor had been resected and the residual part has been detached from dorsumsellae (Fig. 2F).
Image caption: Hematoxylin-eosin staining exhibiting sheetlike growth, foci of spontaneous, increased cellularity, small cells with a high nucleus-to-cytoplasm ratio and prominent nucleoli (A: original magnification, x100; B: original magnification, x400). Immunohistochemical staining showing positive for epitheliod membrane antigen (D: original magnification, x400), but negative for glial fibrillary acidic protein (E: original magnification, x400) and S-100 protein (F: original magnification, x400). Ki-67 labeling index being approximately 10% (C: original magnification, x400).
Image description: Histopathological examination revealed features of atypical meningioma with Ki-67 labeling index been approximately 10% (Fig. 3A-C).
Immunohistochemistry showed the tumor positive for epithelial membrane antigen and negative for glial fibrillary acidic protein and S-100 protein (Fig. 3D-F).
Case Report:
An 8-year-old boy presented at our hospital complaining of recurrent headache and vomiting for 3 months. The patient saw a doctor in a clinic before admission to our hospital and took some medicine for cold. The symptoms got relief temporarily but became severe 1 week ago.
Neurological examination showed impaired vision and mild paresis (IV-grade of muscle strength) of the left extremities. CT (Fig. 1A, B) revealed an iso- to hyperdense lesion in the right basal ganglion extending to superasellar cistern, 4.0x4.4 cm in size with peripheral calcification. No hyperostosis of sellaturcica was noticed (Fig. 1C). Magnetic resonance imaging (MRI) demonstrated most of the mass lesion was iso-intense on T1-weighted, T2-weighted and fluid-attenuated inversion recovery images with inhomogeneous enhancement (Fig. 2A-E). No duraltail sign was noted. Diffusion tensor image revealed the right pyramidal tract was partially disrupted.
Under the guide of navigation, a transcortical (through the right middle frontal gyrus) approach was adopted to explore the lesion. There was no dural attachment, but the tumor was tightly adhered with the anterior cerebral artery (ACA). Small vessels supplied the anterior aspect of the tumor, subtotal resection (STR) was achieved.
Histopathological examination revealed features of atypical meningioma with Ki-67 labeling index been approximately 10% (Fig. 3A-C). Immunohistochemistry showed the tumor positive for epithelial membrane antigen and negative for glial fibrillary acidic protein and S-100 protein (Fig. 3D-F).
The patient suffered transient exacerbation of impaired vision and weakness of contralateral limbs after operation, which resolved significantly after 3 months follow-up. Postoperative MRI revealed that most of the tumor had been resected and the residual part has been detached from dorsumsellae (Fig. 2F).
OUTPUT:
| PMC5769854 |
MultiCaRe_Reasoning30 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Female
Title: Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature
Keywords: adjacent segment disease; epidural venous plexus; lumbar radiculopathy;
Abstract:
Background:
An engorged venous plexus may mimic nerve compression from a herniated disk on the magnetic resonance (MR) studies as they both have similar signal intensities. During a laminectomy, if an engorged venous plexus is encountered instead of a disk herniation, there may be marked unanticipated bleeding.
Case description:
A 58-year-old female who had a prior anterior lumbar interbody fusion later returned with recurrent radiculopathy. Adjacent segment disease from a spinal disk herniation was suspected based on the surgical history, physical examination, and imaging (MRI) findings. Rather than a disk, an engorged venous plexuses (EVP) was encountered intraoperatively.
Conclusion:
Here, we discussed our findings regarding a lumbar EVP rather than a herniated disk and reviewed the current literature. Although rare, a higher index of suspicion for these vascular malformations based on combined historical information and MRI studies should allow one to better detect and/or anticipate an EVP rather than a routine disk.
Image Caption and Description:
Image caption: Preoperative T2-weighted magnetic resonance imaging in (a) sagittal and (b) axial views demonstrating the left-sided lateral recess epidural venous plexus at the adjacent level above a fusion mimicking a herniated disk associated with adjacent segment disease.
Image description: The MRI showed what appeared to be an L4-L5 left-sided disk herniation above the level of her prior fusion (i.e., adjacent L4-L5 segment disk disease) [Figure 1].
Image caption: Intraoperative view down the minimally invasive tubular retractor showing (a) the lateral edge of the dural and nerve root with cottonoids and Surgicel hemostatic material at both the nerve root shoulder and axilla after encountering copious venous bleeding. (b) View of the nerve root after exploration which demonstrated no herniated disk bulge or fragment.
Image description: Due to the fragility of the plexus and recurrent venous bleeding, multiple hemostatic agents were repeatedly employed to control the bleeding [Figure 2].
Image caption: (a) Preoperative and (b) postoperative T2-weighted magnetic resonance imaging showing resolution of the epidural venous plexus after surgical intervention, confirming its etiology as the source of radiculopathy.
Image description: She was discharged on postoperative day 1 after a follow-up MRI confirmed an EVP as the ultimate etiology of her radiculopathy [Figure 3].
Case Report:
A 58-year-old female presented with the left lower radiculopathy. Seven years ago, she had a prior L5-S1 ALIF. On examination she had decreased the left lower-extremity 1/5 motor function in the tibialis anterior and extensor hallucis longus distributions, plus a 3/5 in the gastrocnemius. The MRI showed what appeared to be an L4-L5 left-sided disk herniation above the level of her prior fusion (i.e., adjacent L4-L5 segment disk disease) [Figure 1].
She subsequently underwent an L4-L5 left-sided minimally invasive microdiscectomy. After the laminotomy was completed and nerve root identified, there was a large venous plexus in the nerve root axilla extending ventrally and laterally. This was successfully coagulated with bipolar cautery. Due to the fragility of the plexus and recurrent venous bleeding, multiple hemostatic agents were repeatedly employed to control the bleeding [Figure 2]. After successful cauterization, a thorough examination of the nerve root and disk showed no free fragments or accompanying disk herniations.
Postoperatively, she reported immediate improvement of her foot strength and resolution of her left lower extremity and buttock pain. She was discharged on postoperative day 1 after a follow-up MRI confirmed an EVP as the ultimate etiology of her radiculopathy [Figure 3]. Six months later, an examination showed improvement to 4-/5 motor strength in the left tibialis anterior and extensor hallucis longus distributions, plus 4+/5 in the gastrocnemius.
OUTPUT:
| PMC7265352 |
MultiCaRe_Reasoning31 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 80.0
Sex: Male
Title: Use of single photon metal artefact reduction in the detection of an impacted capsule endoscope
Keywords: None
Abstract:
Wireless capsule endoscopy was introduced over a decade ago and is now a widely used tool in the investigation of gastrointestinal pathologies. Despite its ubiquity, the full profile of indications, contraindications and complications is still being developed. Metal artefact reduction is a software technique which can significantly reduce the artefact produced by metallic objects on CT scans. This case exemplifies a rare but noteworthy complication of capsule endoscopy and highlights a novel application of metal artefact reduction.
Image Caption and Description:
Image caption: Plain chest radiograph displayed a metallic object (arrow) at the thoracic inlet to the left of midline at T2 level.
Image description: A chest radiograph demonstrated a metallic object at the level of the second thoracic vertebra to the left of the trachea (Figure 1).
Image caption: Non-contrast CT of neck in axial (a and c) and coronal (b and d) reformats showed the capsule endoscope at the left lower neck. The metal aliasing artefacts obscure the adjacent soft tissues (a and b). The endoscope in Zenker's diverticulum was better depicted after the artefacts were markedly reduced with metal artefact reduction.
Image description: To pinpoint the exact anatomical location of the foreign body a non-contrast CT scan of the neck (Figure 2) was performed.
Case Report:
An 80-year-old male was being investigated at a tertiary hospital for iron deficiency anaemia. His medical history, symptomology and physical examination did not indicate a cause. After gastroscopy and colonoscopy were also unremarkable he was referred for capsule endoscopy. The delivery of the capsule in the morning was routine; however, review of the images 8 hlater showed a static picture and no evidence the capsule had entered the stomach. The patient was clinically stable and contacted to present to the emergency department with a suspicion of capsule impaction.
A chest radiograph demonstrated a metallic object at the level of the second thoracic vertebra to the left of the trachea (Figure 1). The patient had no known oesophageal or tracheal diverticulum and expressed no symptoms of dysphagia. To pinpoint the exact anatomical location of the foreign body a non-contrast CT scan of the neck (Figure 2) was performed. The effective dose of CT was 0.81 mSv. This confirmed the object was the capsule endoscope lying to the left of the hypopharynx. The adjacent soft tissue was obscured by aliasing metal artefacts arising from the capsule. A single photon metal artefact reduction (MAR) software technique (O-MAR; Philips Healthcare, Cleveland, OH) was applied which successfully removed most of the metallic artefacts. It revealed the capsule was impacted in an oesophageal diverticulum.
The capsule was successfully endoscopically removed under a general anaesthetic and the patient's recovery was uncomplicated. A follow-up barium swallow study confirmed the presence of a Zenker's diverticulum which the patient opted not to surgically repair as he was asymptomatic. He was also offered endoscopic insertion of the capsule endoscope to bypass the diverticulum; however, the patient refused. His anaemia resolved with iron transfusions but no definitive cause was found. He was discharged from the clinic.
OUTPUT:
| PMC6159178 |
MultiCaRe_Reasoning32 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 15.0
Sex: Female
Title: Misclassification of pregnancy-related deaths in adult mortality surveys: case study in Senegal
Keywords: None
Abstract:
Objective:
In countries with limited vital registration data, maternal mortality levels are often estimated using siblings' survival histories (SSH) collected during retrospective adult mortality surveys. We explored how accurately adult deaths can be classified as pregnancy related using such data.
Method:
The study was conducted in a rural area of south-eastern Senegal with high maternal mortality, Bandafassi. We used data from a demographic surveillance system (DSS) in this area to identify deaths of women at reproductive ages between 2003 and 2009 and to locate the surviving adult sisters of the deceased and interview them. Siblings' survival histories were linked at the individual level to death records, and verbal autopsy data obtained by the demographic surveillance system. We compared the classification of adult female deaths as pregnancy related or not in interviews and DSS records.
Results:
There were 91 deaths at reproductive ages in the Bandafassi DSS between 2003 and 2009, but only 59 had known surviving sisters. Some deaths were omitted by respondents, or reported as alive or as having occurred during childhood (n = 8). Among deaths reported both in the SSH and DSS data, 94% of deaths classified as pregnancy related in the DSS data were also classified as such by siblings' survival histories. Only 70% of deaths classified as not pregnancy related in the DSS data were also classified as such by siblings' survival histories.
Conclusion:
Misclassifications of pregnancy-related deaths in retrospective adult mortality surveys may affect estimates of pregnancy-related mortality rates.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
For each death, the DSS has systematically recorded the age at death and the date of death (including day and month of death). A detailed VA questionnaire has been collected for deaths of children aged < 15 years old since 1985, and for all deaths since 2003. VA questionnaires are usually completed by close relatives of the deceased. For adults, they include an assessment of whether the deceased was pregnant at the time of death. After review of VA data by physicians, a likely cause of death is assigned to each recorded death using ICD-9 codes. According to this database, maternal mortality is high ( 915 per 100,000 live births for 2003-06,).
In August 2010, we conducted a pilot study aimed at determining the feasibility of linking retrospective survey data collected during SSH to DSS data, at the individual level. Prior studies comparing SSH and DSS data had been conducted at the aggregate level, and thus did not permit examining misclassification biases. In total, we interviewed 268 women aged 15-59 years who had at least one female sibling known to have died at reproductive ages according to the DSS datasets since the 1980s. Respondents were asked to complete the standard SSH questionnaire used during the 2005 DHS in Senegal. Interviewers were recruited among those who had participated in that DHS. Some survey respondents were members of the same sibship, and some deaths were thus potentially reported multiple times during the SSH survey.
We focus here on the subset of deaths having occurred in 2003-2009 because detailed VA questionnaires for adult deaths were systematically introduced in the Bandafassi DSS in 2003, and because this period matches the "reference period" usually used in producing estimates of adult and maternal mortality using SSH data (Timaeus and Jasseh 2004). We identify PR deaths in the DSS data as follows: 1) we use demographic surveillance data on dates of births and deaths to identify deaths having occurred at the time of delivery or within 2 months of a delivery regardless of the actual cause; 2) we use data from the VA questionnaires (i.e., a yes/no question asking VA respondent whether the deceased was pregnant at the time of the survey) to identify deaths having occurred during pregnancy. It is important to note that, in order to classify a death as PR or non-PR according to the DSS data, we do not use the ICD-9 codes assigned by physicians to each death. In SSH data, we define PR deaths as deaths reported to have occurred either during pregnancy, delivery or within 2 months of delivery according to the respondent.
We could not compare PR classifications obtained from SSH and DSS data for all deaths observed between 2003 and 2009 because, for some of the deceased, there were no eligible sisters in the DSS population or eligible sisters could not be located. In other cases, we could not ascertain whether the recorded death was PR because of missing data in the DSS dataset and/or the VA questionnaire. We thus begin by comparing the age at death, date of death, and PR classification obtained from the DSS of included vs. excluded deaths. We do so using chi2 tests of association. Among included deaths, we then examine the cross-classification of deaths as PR or non-PR, according to the SSH and DSS data. We calculate the proportion of deaths identified as PR (non-PR) in the DSS dataset, which were also classified as PR (non-PR) deaths in the SSH data. We do so for all reports collected during the SSH survey, and for a restricted sample in which we select at random one report of death per sibship (to avoid double-counting). In the case of discrepant classifications of PR deaths between SSH and DSS data, we report a) the cause of death as ascertained by physicians (using VA data), b) the time since the last recorded birth of the deceased, and c) the relationship between the deceased and the person who completed the VA questionnaire (e.g., sister-in-law). Finally, we use SSH data to investigate agreement between sisters about the reported timing of death in sibships where multiple sisters were interviewed.
OUTPUT:
| PMC3678730 |
MultiCaRe_Reasoning33 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Female
Title: Gender Differences in Patients With COVID-19: Focus on Severity and Mortality
Keywords: covid-19; sars; sars-cov-2; female; gender; male; morbidity; mortality;
Abstract:
Objective: The recent outbreak of Novel Coronavirus Disease (COVID-19) is reminiscent of the SARS outbreak in 2003. We aim to compare the severity and mortality between male and female patients with COVID-19 or SARS. Study Design and Setting: We extracted the data from: (1) a case series of 43 hospitalized patients we treated, (2) a public data set of the first 37 cases of patients who died of COVID-19 and 1,019 patients who survived in China, and (3) data of 524 patients with SARS, including 139 deaths, from Beijing in early 2003. Results: Older age and a high number of comorbidities were associated with higher severity and mortality in patients with both COVID-19 and SARS. Age was comparable between men and women in all data sets. In the case series, however, men's cases tended to be more serious than women's (P = 0.035). In the public data set, the number of men who died from COVID-19 is 2.4 times that of women (70.3 vs. 29.7%, P = 0.016). In SARS patients, the gender role in mortality was also observed. The percentage of males were higher in the deceased group than in the survived group (P = 0.015). Conclusion: While men and women have the same prevalence, men with COVID-19 are more at risk for worse outcomes and death, independent of age.
Image Caption and Description:
Image caption: Trend data of clinical classification of severity in a Case series of COVID-19. Numbers of cases of men or women in different clinical classes of severity. Chi-square (chi2) test for trend indicated that males tend to experience more serious cases of COVID-19 than females according to the clinical classification of severity including Mild+Moderate, Severe, and Critical.
Image description: Critical pneumonia, respectively. Chi-square (chi2) test for trend indicated that men's cases of COVID-19 tended to be more serious than women's (P = 0.035), according to the clinical classification of severity (Figure 1).
Image caption: Role of age and gender in morbidity and mortality in a Cases series of SARS, in 2003. (A) The whole spectrum of age in patients who died from and survived SARS. (B) Comparation of age between males and females in both patients who died from and survived SARS. (C) Gender distribution in both patients who died from and survived SARS. (D) Survival analysis comparing mortality rates between male and female patients with SARS.
Image description: While the deceased patients were significantly older than the patients who survived (Figure 3A), ages were comparable between men and women in both patients who deceased and survived with SARS (Figure 3B).
The proportion of men was higher in the deceased group (53.2%) than in the group who survived (42.3%) (chi2 test, P = 0.027) (Figure 3C).
Survival analysis showed that men had a significantly higher mortality rate than women (31.2 vs. 22.6%) in this hospital-based cohort (hazard ratio [95% CI] 1.47 [1.05-2.06], P = 0.026) (Figure 3D).
Case Report:
The demographic and clinical characteristics are shown in Table 1. The median age was 62 years (IQR, 51 to 70). Fever (95.3%) and cough (65.1%) were the most common symptoms, while diarrhea (16.3) was not common. 37.2% of patients had at least one underlying disorder (i.e., hypertension, diabetes, cardiovascular diseases, and chronic lung diseases). There is no significant difference in median age between male and female groups, but the maximum of the range of IQR is lower in male (66 years in men vs. 73 years in women). Symptoms and comorbidities were comparable between men and women. As expected, men had a higher level of hemoglobin. However, male patients also had elevated serum creatinine, white blood cells, and neutrophils. Among the 43-case series, 13 (30.2%) were diagnosed with Mild or Moderate pneumonia, while 14 (32.6%) and 16 (37.2%) were diagnosed with Severe and Critical pneumonia, respectively. Chi-square (chi2) test for trend indicated that men's cases of COVID-19 tended to be more serious than women's (P = 0.035), according to the clinical classification of severity (Figure 1).
Between March 25 and May 22, 2003, a total of 524 SARS patients, including 139 deaths, in the Beijing area were reported from 29 hospitals enrolled in our analysis. Fever (98.4%) and cough (76.9%) were the most common symptoms, while diarrhea (6.7%) was not common. 57.0% of the patients had at least one of the concomitant diseases including hypertension, diabetes, cardiovascular diseases, and chronic lung diseases. The mean duration from self-reported symptoms to death was 15 (IQR: 10-19) days. Table 2 summarizes the clinical and biochemical characteristics of all SARS patients. The median age of the deceased patients was much higher than that of the patients who survived (57 vs. 32, P < 0.001). The rate of the concomitant diseases in the deceased patients was also higher than that of the patients who survived (57.0% vs. 17.9%, P < 0.001). While the deceased patients were significantly older than the patients who survived (Figure 3A), ages were comparable between men and women in both patients who deceased and survived with SARS (Figure 3B). The proportion of men was higher in the deceased group (53.2%) than in the group who survived (42.3%) (chi2 test, P = 0.027) (Figure 3C). Survival analysis showed that men had a significantly higher mortality rate than women (31.2 vs. 22.6%) in this hospital-based cohort (hazard ratio [95% CI] 1.47 [1.05-2.06], P = 0.026) (Figure 3D).
OUTPUT:
| PMC7201103 |
MultiCaRe_Reasoning34 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 54.0
Sex: Female
Title: A Novel Nonsense Mutation of ABCA8 in a Han-Chinese Family With ASCVD Leads to the Reduction of HDL-c Levels
Keywords: abca8; atherosclerosis; cholesterol efflux; nonsense mutation; reduced hdl-c levels;
Abstract:
Arteriosclerotic cardiovascular disease (ASCVD) is one of the major causes of death worldwide and most commonly develops as a result of atherosclerosis (AS). As we all know, dyslipidemia is a leading pathogenic risk factor for ASCVD, which leads to cardiac ischemic injury and myocardial infarction. Dyslipidemias include hypercholesterolemia, hypertriglyceridemia, increased low-density lipoprotein cholesterol (LDL-c) and decreased high density lipoproteins cholesterol (HDL-c). Mutations of dyslipidemia related genes have been proved to be the crucial contributor to the development of AS and ASCVD. In this study, a Han-Chinese family with ASCVD was enrolled and the lipid testing discovered an obvious reduced levels of HDL-c in the affected members. We then performed whole exome sequencing to detect the candidate genes of the family. After data filtering, a novel heterozygous nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was detected and validated to be co-separated in the family members by Sanger sequencing. Previous studies have proved that deleterious heterozygous ABCA8 variants may disrupt cholesterol efflux and reduce HDL-c levels in humans and mice. This study may be the second report related to ABCA8 mutations in patients with reduced levels of HDL-c. Our study not only contributed to the genetic counseling and prenatal genetic diagnosis of patients with ASCVD caused by reduced HDL-c levels, but also provided a new sight among ABCA8, cholesterol efflux and HDL-c levels.
Image Caption and Description:
Image caption: The clinical and genetic information of the family. (A) Pedigree of the family with low levels of HDL-c. Family members are identified by generations and numbers. Squares indicate male family members; circles, female members; closed symbols, affected members; open symbols, unaffected members; arrow, proband. (B) The coronary angiography of the proband, the arrow shows the stenosis of the anterior descending coronary artery. The ECG testing of the proband before percutaneous coronary intervention (C) and after percutaneous coronary intervention (D). (E) Sequencing results of the ABCA8 mutation. Sequence chromatogram indicates a C to T transition of nucleotide 3460. (F) The structure of ABCA8 and the summary of reported mutations of ABCA8.
Image description: Coronary angiography indicated approximately 60-80% stenosis of the anterior descending coronary artery (Figure 1B), ECG testing also suggested the patient suffered from CHD (Figure 1C).
And breathing sound of the lungs was clearly, the heart rate was normal (Figure 1D), and the insertion site recovered well.
After data filtering, a novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was identified and validated by Sanger sequencing in the proband (Figure 1E).
Sanger sequencing further confirmed that only the affected individuals (II-2, II-4, and III-1) carried the novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 (Figure 1F).
Case Report:
The proband (II-2), a 54-year-old lady, came to the hospital due to recurrent chest pain in last 2 years. Coronary angiography indicated approximately 60-80% stenosis of the anterior descending coronary artery (Figure 1B), ECG testing also suggested the patient suffered from CHD (Figure 1C). However, the lipid testing described the level of LDL-c (3.94 mmol/L; control: <3.12 mmol/L) and a distinctly reduced levels of HDL-c (0.41 mmol/L; control: 0.9-2.19 mmol/L) of the proband (Table 1). This discovery attracted our interest because most patients with ASCVD commonly presented high levels of LDL-c, TC, and TG. We then investigated the family history of the proband (II-2), which indicated that her young sister (II-4) has been diagnosed as the occlusion of left iliac artery and her father (I-1) was died from myocardial infarction at 60-year-old. Lipid testing further described that both her son (III-1) and her young sister (II-4) showed an overt reduced levels of HDL-c and normal levels of LDL-c, TC, and TG (Table 1). And his young sister (II-4) also suffered from arterial plaque in the left lower limb. The blood pressure of the proband was 80-120 mmHg and the fasting blood-glucose was 5.2 mmol/L. The proband (II-2) accepted the treatment of percutaneous coronary intervention, the proband did not complain any uncomfortable after treatment. And breathing sound of the lungs was clearly, the heart rate was normal (Figure 1D), and the insertion site recovered well. The II-4 is accepting recovery treatment by exercise and diet control.
We supposed that the low levels of HDL-c may be the leading cause of AS and ASCVD in this family. However, what's the genetic lesion underling the reduced levels of HDL-c in this family? We then isolated the genomic DNA of the proband and other family members (I-2, II-1, II-2, II-4, III-1, and III-2). Whole exome sequencing of the proband (II-2) was performed to detect the candidate gene of reduced levels of HDL-c.
In short, Exome capture and next-generation sequencing were conducted by Novogene Bioinformatics Institute (Beijing, China). One microgram of qualified genomic DNA from each person was captured by the Agilent's SureSelect Human All Exon kit V5 (Agilent Technologies, Inc., Santa Clara, CA, United States) and sequenced by Illumina Hiseq4000 (Illumina Inc., San Diego, CA, United States). Shortly, genomic DNA were randomly carved by Covaris S220 sonicator (Covaris, Inc., Woburn, MA, United States). Then the fragmented DNAs underwent three enzymatic steps: end repair, A-tailing and adapters ligation. The adapter-ligated DNA fragments were amplified with Herculase II fusion DNA polymerase (Agilent). Later, the exomes in the pre-capture libraries were captured by SureSelect capture library kit (Agilent). After DNA quality estimation, the captured DNA library was used for next-generation sequencing on Illumina Hiseq4000 platform. Downstream processing was carried out by Genome Analysis Toolkit (GATK), Varscan2 and Picard, and variant calls were performed by the GATK Haplotype Caller. Variant annotation referred to Ensemble release 82, and filtering was conducted by ANNOVAR Documentation.
The filtered non-synonymous SNPs or INDELs with an alternative allele frequency more than 1% in public databases were kicked before further analysis. The public databases contains the NHLBI Exome Sequencing Project Exome Variant Server (ESP6500), dbSNP1441, the 1000 Genomes project2, the ExAC database3 and in-house exome databases of Novogene (2500 exomes). Then the filtered SNVs and INDELs, predicted by SIFT4, Polyphen25, and MutationTaster6 to be damaging, were remained.
After data filtering, a novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was identified and validated by Sanger sequencing in the proband (Figure 1E). Previous studies have revealed that deleterious heterozygous ABCA8 mutations may disrupt cholesterol efflux and reduce HDL-c levels in humans and mice. No other meaningful mutations related to lipid metabolism has been identified. Sanger sequencing further confirmed that only the affected individuals (II-2, II-4, and III-1) carried the novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 (Figure 1F). The novel mutation, resulting a truncated protein, was absent in the healthy members (I-2, II-1, and III-2) and 200 local people who were used as an internal control to exclude the SNP in local people. Bioinformatics predicted that the newly identified mutation was deleterious and may disrupt the structure and function of ABCA8. On the basis of ACMG guidelines, the novel variant meetings the following criteria from the ACMG guidelines: PVS1, PS3, and PM2.
OUTPUT:
| PMC7373792 |
MultiCaRe_Reasoning35 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 68.0
Sex: Male
Title: Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report
Keywords: eyelid diseases; hordeolum; necrosis; necrotizing fasciitis;
Abstract:
We reported a case of upper eyelid necrosis initially misdiagnosed as a preseptal cellulitis following a hordeolum externum resulting in great damage to the upper eyelid (anterior lamella). The infection was successfully treated with surgical cleansing, drainage, and endovenous antibiotics. Early treatment may avoid severe complications such as eyelid deformity, systemic involvement, and blindness.
Image Caption and Description:
Image caption: Patient showing NF with eschar formation in upper eyelid in the right eye at the day of admission at the hospital. NF, necrotizing fasciitis.
Image description: At presentation, the patient's right eye was closed by erythematous and swelling of the right upper lid (Fig. 1).
Image caption: Tomography presenting preseptal edema and heterogeneous fluid, suggesting abscess in the right eyelid.
Image description: Figure 2 presents the aspect of both eyelids in the tomography.
Image caption: Patient presenting the upper eyelid aspect of the right eye minutes after the debridement.
Image description: Figure 3 presents the eyelid aspect immediately after the surgery.
Image caption: Upper eyelid aspect after 15 days of the debridement.
Image description: Seven days after debridement, he presented satisfactory cicatrization without any symptoms (Fig. 4).
Image caption: Upper eyelid aspect after 2 months of debridement with closed (a) and opened (b) eyes.
Image description: After 2 months, the eyelid was completely healed with no retraction (Fig. 5a, b).
Case Report:
A Caucasian 68-year-old male, without systemic diseases, was admitted in March 2020 to a tertiary care center (Hospital Vera Cruz, Campinas, Sao Paulo, Brazil) with history of right upper eyelid swelling and redness for 10 days, which became progressively worse. He denied fever, worsening of visual acuity, or pain due to eye movements.
At presentation, the patient's right eye was closed by erythematous and swelling of the right upper lid (Fig. 1). Vital signs at the time of hospital admission were as follows: systemic blood pressure = 130 x 70 mm Hg, cardiac frequency = 71 bpm, and body temperature = 37.1 C. The full blood count presented a white blood count of leukocytes = 6,478 mm3 (neutrophils = 4,060 mm3, eosinophils 30 mm3, basophils = 20 mm3, lymphocytes = 1,790 mm3, and monocytes = 580 mm3). All of them were within the normal range.
Ophthalmologic exam at the time of admission showed visual acuity of 0.4 logMAR in both eyes (OU) with spectacles, clear conjunctiva, clear cornea, and nuclear cataract 2+ in OU. Ocular motility and pupillary reflex were normal in OU. The intraocular pressure was 12 mm Hg in OU (with Icare tonometer, which is a rebound tonometer). Fundoscopy showed pink optic disc with sharp margins and a cup to disc ratio of 0.5 in OU.
Computerized tomography revealed preseptal and soft tissue edema with an abscess in the anterior right upper eyelid but no signs of orbital involvement or orbital fractures. Figure 2 presents the aspect of both eyelids in the tomography. A presumptive diagnosis of hordeolum with preseptal cellulitis and abscess was made, and intravenous amoxicillin and clavulanate potassium 500/125 mg were administrated twice a day.
The development of purulent discharge from the upper eyelid with an abscess and necrosis was evident. Therefore, the patient underwent abscess drainage and wound debridement. During the procedure, necrosis was observed involving almost the full thickness of the right upper eyelid, measuring 30 x 30 mm in the central area. The tissue surrounding the abscess was friable and necrotic and did not bleed. The necrotic tissue was debrided until healthy viable tissue appeared throughout the wound and no evidence of infection was present in the reminiscent tissue. The wound was left open to heal by secondary intension. Figure 3 presents the eyelid aspect immediately after the surgery.
Given the clinical improvement in his local and systemic condition, the patient was continued on intravenous amoxicillin and clavulanate twice a day for 48 h and was discharged with the same oral antibiotics. He also started using topical medication with retinol acetate (10,000 IU/g), amino acids (25 mg/g), methionine (5 mg/g), and chloramphenicol (5 mg/g) in the affected eyelid for 7 days, 3 times a day.
Seven days after debridement, he presented satisfactory cicatrization without any symptoms (Fig. 4). After 2 months, the eyelid was completely healed with no retraction (Fig. 5a, b).
OUTPUT:
| PMC8138243 |
MultiCaRe_Reasoning36 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 35.0
Sex: Female
Title: Intractable hemifacial spasm treated by pulsed radiofrequency treatment
Keywords: facial nerve; hemifacial spasm; pulsed radiofrequency treatment;
Abstract:
Hemifacial spasm is defined as unilateral, involuntary, irregular twitching of all or parts of the muscles innervated by facial nerves. Here, we present a case of recurrent hemifacial spasm after microvascular decompression (MVD) treated with pulsed radiofrequency (PRF) treatment with good results. A 35-year-old woman suffered from recurrent hemifacial spasm after MVD that was refractory to medical treatment and botulinum toxin injections. We attempted a left facial nerve block twice. Then, we applied PRF at a maximum temperature of 42℃ for 120 sec. Some response was observed, so we applied PRF two additional times. The frequency of twitch decreased from 3-4 Hz to < 0.5 Hz, and subjective severity on a visual analogue scale also decreased from 10/10 to 2-3/10. PRF treatment might be an effective medical treatment for refractory hemifacial spasm and has fewer complications and is less invasive compared with those of surgery.
Image Caption and Description:
Image caption: Final position of the local anesthetic block needle under fluoroscopic guidance. The needle was positioned around the stylomastoid foramen. (A) Anteroposterior view. (B) Lateral view.
Image description: Both sides of the mastoid process and mandible were superimposed on a lateral fluoroscope imaging view (Fig. 1).
Case Report:
A 35-year-old woman developed MVD due to a left HFS 6 years ago, which was refractory to medical treatment. Results of preoperative brain magnetic resonance image and electromyography were normal. Surgery was successfully performed, and the postoperative findings revealed that the branch of the left anterior inferior cerebellar artery had been compressing the VII-VIII cranial nerve complex. The pateint did not show any specific symptoms for about 3 and a half years after MVD. But, the symptoms began to recur 1 year ago and she was medicated with 0.5 mg clonazepam for 3 months, and received two local botulinum toxin injections. No treatment effect occurred, so she visited our pain clinic. The patient was experiencing a twitch on the infraorbital area and chin when the HFS was severe, and spasm frequency was 3-4 Hz. Discomfort on the visual analogue scale (VAS) was 10/10. We initially attempted a left stellate ganglion block twice, but no effect was observed, Then, we performed a fluoroscope-guided left facial nerve block twice using 4 ml of 2% lidocaine, and 20 mg triamcinolone. No complications occurred, and the HFS symptoms were relieved for 4 days. Thus, we decided to perform PRF on the facial nerve. In the right lateral decubitus position, the patient's chin was slightly lifted, which exposed the mastoid process. Both sides of the mastoid process and mandible were superimposed on a lateral fluoroscope imaging view (Fig. 1). The skin was prepared with betadine and aseptic draping. We used a 10 cm, 22-G Sluijter-Mehta cannula needle with a 0.5 mm active tip and verified accurate needle position by fluoroscopy. A 5 mm skinwheal appeared from the mastoid process to the nose beginning at the needle entry point of the local anesthetic. We explored facial nerves with 50 Hz, 0.5 V sensory stimulation to the tongue and 2 Hz, 1.0 V motor stimulation to the left hemi face when the tip of the needle was positioned around the stylomastoid for amen. We administered three PRF pulses at 42C for 120 seconds after confirming that the needle tip was near the facial nerve. After the procedure, we injected 3 ml of 4% lidocaine mixed with 20 mg triamcinolone. The patient was symptom free for only 4 days, so we applied additional PRF treatments twice using the same method to obtain a longer effect. When the patient returned as an outpatient 1 week after the second PRF treatment, HFS frequency was improved to < 0.25 Hz, and subjective complaints improved on the VAS (2-3/10). The modified MacNab criteria at 1 week after the procedure were good. The patient was followed up at 3, 6, 9, and 12 months via telephone, and symptom relief was maintained continuously.
OUTPUT:
| PMC3546213 |
MultiCaRe_Reasoning37 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 20.0
Sex: Male
Title: Total knee arthroplasty and femoral osteotomy with a patient-specific cutting guide to treat haemophilic arthritis with severe extra-articular deformity: A case report and review of literatures
Keywords: psi; case report; extra-articular deformity; haemophilic arthritis; total knee arthroplasty;
Abstract:
Background:
Total knee arthroplasty (TKA) is recommended for haemophilic patients with end-stage arthritis. TKA combined with a one-stage extraarticular osteotomy is uncommon in the treatment of haemophilic arthritis (HA) with severe extra-articular deformities (EADs) and a history of inhibitors under the guidance of a patient-specific cutting guide (PSI).
Case presentation:
We reported a 20-year-old male patient with severe haemophilia, limited knee functionality, a 30° sagittal deformity on the femoral side and a history of inhibitors. We adopted the Van Creveld protocol to decrease the inhibitors. TKA and extra-articular osteotomy (EAO) were performed simultaneously and sequentially under the guidance of PSI. An appropriate central alignment of the lower limb was restored by using cement prostheses with antibiotics and femur shaft locking compression plates. The last follow-up showed that the knee function was good, the VAS score was 0, the WOMAC score was 18 and the ROM was 0°-95°.
Conclision:
Regular haematology management can reduce the perioperative bleeding risk in haemophilic patients treated with inhibitors. PSI plays an important role in guiding the TKA and EAO of end-stage HA patients with severe EAD.
Image Caption and Description:
Image caption: (A,B) Preoperative appearance of the right lower limb which shows that the right foot cannot touch the ground; (C,D) preoperative range of joint motion (20 -90 ); (E-G) postoperative appearance of the right lower limb and the right foot touching the ground; (H,I) postoperative range of joint motion (0 -95 ).
Image description: Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 106 (Figure 1, Table 2). Other systemic examinations were normal.
Image caption: (A) Full-length x-rays of both lower limbs (weight-bearing); (B-E) anteroposterior and lateral x-rays of the knee joints and femur. The sagittal deformity angle of the femur was 30 (anterior); (F) full-length computer tomography film of right lower limb; (G,H) computer model of distal femoral osteotomy; (I) distal femur osteotomy guide plate in TKA; (J, K) osteotomy and reduction guide plate for extra-articular deformities; (L,M) models of femur in lateral and overhead positions after the osteotomy.
Image description: Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 106 (Figure 1, Table 2). Other systemic examinations were normal.
X-ray and CT showed that the patient's right knee joint space was narrow, with a right femoral flexion deformity (30 , sagittal, anterior) (Figure 2).
Case Report:
A 20-year-old male presented with pain and limited motion in the right knee for 15 years. The patient presented to our clinic with HA, restricted flexion and extension of the right knee and a sagittal deformity of the right femur 8 months prior to the surgery. He was diagnosed with severe haemophilia A (coagulation factor VIII was 1.52%) and haemophilic arthritis of right knee. At the age of 13, the patient was fixed with plaster for a fracture of the femoral shaft, which resulted in a malunion.
Because he was positive for inhibitors, the patient was re-examined regularly by the Haematology Clinic after discharge. The patient did not take any interventions during the first 4 months while being positive for inhibitors. During this period, the patient suffered from knee joint bleeding and recovered after ice compression and lying in bed. In the 5th month after the discovery of the inhibitors, the patient received irregular injections of factor VIII intravenously (1,000 IU, BIW or TIW, Kovaltry, Bayer), which did not follow the haematologist's recommendation. After 66 days of injections, he was still positive for inhibitors. Since then, the patient started to receive regular injections of factor VIII (1,500 IU, BID) intravenously. Forty-nine days after the first injection, he became negative for inhibitors (Table 1). The patient came to the hospital again 3 days prior to the surgery.
Preoperative examinations showed the patient had pain in his right knee. His right foot could not touch the ground. The range of joint motion (ROM) was 20 -90 , the visual analogue scale (VAS) was 7 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 106 (Figure 1, Table 2). Other systemic examinations were normal. X-ray and CT showed that the patient's right knee joint space was narrow, with a right femoral flexion deformity (30 , sagittal, anterior) (Figure 2).
OUTPUT:
| PMC9852490 |
MultiCaRe_Reasoning38 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 42.0
Sex: Female
Title: Acute pulmonary embolism caused by enlarged uterine leiomyoma: a rare presentation
Keywords: echocardiography; leiomyoma; pulmonary embolism; thrombolytic therapy;
Abstract:
Patient:
Female, 42.
Final diagnosis:
Acute pulmonary embolism.
Symptoms:
Chest pain • dyspnea.
Medication:
Streptokinase • Warfarin.
Clinical procedure:
.-
Specialty:
Cardiology and Neoplasm.
Objective:
Management of emergency care.
Background:
Deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) caused by pelvic vein compression are rare and life-threatening complications of leiomyoma of the uterus.
Case report:
We report a 42-year-old virgin woman with a history of leiomyoma who presented to the emergency department with complaints of dyspnea and pleuritic chest pain with transient spotting. On physical examination, she had a non-tender abdomen with a 20-week size uterus. Imaging investigations revealed an acute DVT in her left leg and a huge uterine-derived mass compressing the common iliac veins. Transesophageal echocardiography (TEE) demonstrated an echogenic mass in her right pulmonary artery consistent with thrombosis. The patient was completely cured using thrombolytic therapy and myomectomy, and was well at 1 year after thrombolysis.
Conclusions:
PE caused by pelvic vein compression is a rare complication of leiomyoma, which should be considered. Thrombolytic therapy associated with myomectomy can be implemented for treating such cases, and TEE can be used for diagnosing suspected high-risk PE.
Image Caption and Description:
Image caption: A clot in the right pulmonary artery diagnosed by transesophageal echocardiography. AO - aorta, MPA - main pulmonary artery, RPA - right pulmonary artery.
Image description: In addition, a 2.6 1.6 cm echogenic mass was detected in the left pulmonary artery, consistent with thrombosis (Figure 1).
Image caption: Uterine leiomyoma and the compression of both common iliac veins. The arrows show the venous compression (white arrows) and the uterine mass (black arrows).
Image description: Given her leiomyoma history, she underwent magnetic resonance imaging (MRI), which revealed a huge uterine-derived mass compressing both common iliac veins (Figure 2).
Case Report:
A 42-year-old, non-smoking, virgin woman presented to our institution with complaints of dyspnea and pleuritic chest pain since 2 days ago along with 2-month transient spotting. She had a history of leiomyoma since 5 months ago, and was hospitalized due to vaginal bleeding, and had been undergone therapy by a gonadotropin-releasing hormone (GnRH) agonist and medroxyprogesterone acetate, intramuscularly. To control her anemia, she was given oral ferrous sulfate. There was no relevant familial history of the same condition. On physical examination, she was anxious and tachypneic on admission, with body mass index of 24.7 kg/m2, body temperature 37 C, blood pressure 100/70 mmHg, heart rate 120 beats per min, respiratory rate of 24 breaths per min, and 96% oxygen saturation while breathing room air. Other findings included regular heart beat with a 2/6 systolic murmur in the left sternal border, clear lung sound, and a non-tender abdomen with a 20-week size uterus. There was no swelling in her lower limbs.
An electrocardiogram revealed a sinus tachycardia and inverted T waves in v1 to v3 and inferior leads. Hematologic testing revealed hemoglobin of 11.3 g/dL and other results were within normal limits. Coagulation factors were also unremarkable. A chest radiograph showed Westermark sign without pleural effusion. An ultrasound investigation revealed an acute DVT in the popliteal and superficial femoral veins of her left leg and an enlarged leiomyoma of the uterus. Thereafter, transesophageal echocardiography (TEE) demonstrated normal left ventricle systolic function, severe right ventricle enlargement, McConnell sign, moderate tricuspid regurgitation, severe pulmonary hypertension of 110 mmHg, and dilatation of the main pulmonary artery. In addition, a 2.6 1.6 cm echogenic mass was detected in the left pulmonary artery, consistent with thrombosis (Figure 1). Given her leiomyoma history, she underwent magnetic resonance imaging (MRI), which revealed a huge uterine-derived mass compressing both common iliac veins (Figure 2).
Due to massive PE, the patient was administered loading dose of 250 000 units of streptokinase and the infusion of 100 000 units per hour during 24 h. After undergoing thrombolysis, her general condition significantly improved, and then she underwent anticoagulation therapy. One unit of packed red blood cells was also transfused. Examination by TEE on the fourth day revealed the disappearance of the pulmonary artery thrombosis. After achieving a therapeutic range of international normalized ratio (range 2.0-3.0), she was discharged on warfarin 5 mg daily.
The patient was followed for 3 months and then evaluated again and examined using TEE and ultrasonography, which demonstrated normal findings. After withholding warfarin preoperatively, she underwent myomectomy instead of hysterectomy due to her uterus preservation. Warfarin therapy commenced again following surgery, and she was discharged in stable condition on warfarin therapy. Nine months after myomectomy, she was well, without evidence of thromboembolism.
OUTPUT:
| PMC4108191 |
MultiCaRe_Reasoning39 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 67.0
Sex: Male
Title: Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis
Keywords: medication-related osteonecrosis of the jaw (mronj); mandibulectomy reconstruction; remote pectoralis major flap; zoledronic acid;
Abstract:
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A totally bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented himself in March 2018 to Maxillofacial Surgery Department of County Clinical Hospital of Craiova.
OUTPUT:
| PMC8200619 |
MultiCaRe_Reasoning40 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Male
Title: Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis
Keywords: medication-related osteonecrosis of the jaw (mronj); mandibulectomy reconstruction; remote pectoralis major flap; zoledronic acid;
Abstract:
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
The patient had pain in the anterior mandibular arch, with exposed necrotic bone. Diagnostic was stage 2 MRONJ.
Bisphosphonate treatment was discontinued about 6 months in advance.
Following clinical examination corroborated with the imaging investigations, it was decided to adopt a conservative treatment which consisted in removing the necrotic bone tissue by marginal resection of the mandible down to the clinically healthy bone, associated with lavages with antiseptic solutions and antibiotic therapy.
Patient gave the written informed consent for the treatment, and also for publication of his case.
Although initially the evolution was favorable, after about 2 weeks there were numerous infectious episodes that required repeated antibiotic treatment.
OUTPUT:
| PMC8200619 |
MultiCaRe_Reasoning41 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis
Keywords: medication-related osteonecrosis of the jaw (mronj); mandibulectomy reconstruction; remote pectoralis major flap; zoledronic acid;
Abstract:
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
Image Caption and Description:
Image caption: Stage 2 MRONJ. Clinical aspect of dehiscence in the operated area, 2 weeks after surgical intervention of removing the necrotic bone tissue by marginal resection of the mandible down to the clinically healthy bone (a). Radiological aspect of MRONJ (b)
Image description:
Image caption: Clinical images of mandibulectomy reconstruction with remote pectoralis major flap associated with primary reconstruction plate. Submandibular incision from the left mandibular angle to the right mandibular angle with the exposure of the entire mandibular body (a). Large area of bone necrosis in the anterior mandibular arch level (b). Segmental anterior mandibular resection (c). Resected fragment (d). Restoration of the contour of the mandibular arch with titanium primary reconstruction plate (e). Pectoralis major flap closing the resulting defect (f). Flap rotated in the oral cavity with the tegument part closing the endo-oral mucosa defect (g)
Image description:
Case Report:
The patient developed a dehiscence in the operated area (Figures 1 a, b).
Due to the progressive nature of MRONJ, it was decided to perform a radical surgery, with the written informed consent of the patient.
Under general anesthesia, a submandibular incision was made from the left mandibular angle to the right mandibular angle with the exposure of the entire mandibular body (Figure 2a).
It was revealed a large area of bone necrosis in the anterior mandibular arch level (Figure 2b).
The contour of the mandibular arch was recorded with a guide plate.
Segmental anterior mandibular resection was performed with large bone bur drills under saline irrigation down to healthy bone with normal bone specific bleeding (Figures 2 c, d).
The surgical specimen was sent for histopathological examination to exclude malignancy.
As the resulting defect was large, it was decided to restore the contour of the mandibular arch with titanium primary reconstruction plate covered with a pectoralis major flap to close the resulting defect (Figures 2 e, f).
The thoraco-acromial artery was included in the pectoralis major flap (Figure 2f).
It was rotated in the oral cavity with the tegument part closing the endo-oral mucosa defect (Figure 2g).
The donor site was closed primarily after flap harvest.
Surgical treatment was associated with postoperative antibiotic therapy for a period of 7 days.
Both the endo-oral wound and the donor site wound healed without complications.
OUTPUT:
| PMC8200619 |
MultiCaRe_Reasoning42 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis
Keywords: medication-related osteonecrosis of the jaw (mronj); mandibulectomy reconstruction; remote pectoralis major flap; zoledronic acid;
Abstract:
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
There were no more inflammatory areas and the patient did not complain of local pain.
OUTPUT:
| PMC8200619 |
MultiCaRe_Reasoning43 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Mandibulectomy Reconstruction with Pectoralis Major Island Flap Associated with Primary Reconstruction Plate for Mandibular Medication-Related Osteonecrosis
Keywords: medication-related osteonecrosis of the jaw (mronj); mandibulectomy reconstruction; remote pectoralis major flap; zoledronic acid;
Abstract:
A bimaxillary edentulous male patient, aged 67 years, diagnosed with prostate cancer who underwent intravenous bisphosphonates treatment (zoledronic acid) for about one year presented with pain in the anterior mandibular arch, with exposed necrotic bone, and was diagnosed with stage 2 medication-related osteonecrosis of the jaw (MRONJ). MRONJ is the development of bone necrosis in the oral cavity as an adverse reaction in patients treated with antiresorptive and antiangiogenic medication, without radiation therapy to the head and neck. This persistent bone necrosis does not always respond to standard treatments. The reconstruction technique with pectoralis major flap, at a distance, associated with the primary reconstruction plate, was an effective treatment modality for the treatment of large osteonecrosis noncompliant with conservatory treatments. Through this technique, the morpho-functionality of the jaw can be restored almost completely.
Image Caption and Description:
Image caption: Intraoral aspect of healed mandibular area after 6 months from intervention (a). Intraoral aspect of healed mandibular area after 1 year from intervention (b)
Image description:
Case Report:
The patient was monitored weekly for the first month after discharge and then monthly for up to one year after surgery (April 2019).
At 6 months and 1 year after the intervention, there were no recurrences of MRONJ (Figures 3 a,b).
OUTPUT:
| PMC8200619 |
MultiCaRe_Reasoning44 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 32.0
Sex: Female
Title: Successful prenatal management of ventricular tachycardia and second-degree atrioventricular block in fetal long QT syndrome
Keywords: congenital long qt syndrome; fetal magnetocardiography; prenatal management; ventricular arrhythmia; ventricular tachycardia/torsades de pointes;
Abstract:
None
Image Caption and Description:
Image caption: Case 1. A: At 29 weeks, a fetal echocardiogram showed ventricular tachycardia (VT) with a ventricular rate of 220 beats per minute (bpm), compared with an atrial rate of 130 bpm. B: Fetal magnetocardiography (fMCG) revealed polymorphic VT. C: fMCG showed a prolonged QT interval (591 ms) during sinus rhythm.
Image description: One week later, a follow-up fetal echocardiogram showed a ventricular rate of 220 bpm (atrial rate was 130 bpm) (Figure 1A).
An fMCG was then performed which revealed nonsustained VT alternating with sinus rhythm (rate 130 bpm) (Figure 1B).
The QTc was 591 ms (Figure 1C).
Image caption: Case 1. A: The infant's heart rate at the time of birth was 56 beats per minute (bpm), and he had a 2:1 atrioventricular block. B: On the 14th day of life, the electrocardiogram showed a sinus rhythm with a left bundle branch block pattern. C: At the age of 5 months, an implantable cardioverter-defibrillator was implanted.
Image description: The heart rate at birth was 56 bpm owing to functional second-degree AVB with 2:1 conduction (Figure 2A).
On the 14th day of life, the infant's electrocardiography showed sinus rhythm with a left bundle branch block pattern (Figure 2B).
The shock lead was implanted subcutaneously through the left thoracodorsal region, and the generator was placed under the right abdominal rectus muscle (Figure 2C).
Case Report:
A 32-year-old woman in the 28th week of her fifth pregnancy was referred to our institution with a 3-week history of fetal bradycardia (fetal heart rate 60 beats per minute [bpm]). She had no personal or family histories of cardiac arrest, seizures, or syncope. Of her 4 pregnancies, only 1 had ended in a miscarriage. The initial fetal echocardiogram at our institution revealed a structurally normal heart with normal size, normal function, and second-degree AVB (V rate 60 bpm, atrial rate 120 bpm). Her antibody screen was negative for anti-SSA and anti-SSB antibodies. One week later, a follow-up fetal echocardiogram showed a ventricular rate of 220 bpm (atrial rate was 130 bpm) (Figure 1A). An fMCG was then performed which revealed nonsustained VT alternating with sinus rhythm (rate 130 bpm) (Figure 1B). The VT was present about 75% of the time. The QTc was 591 ms (Figure 1C).
Over the ensuing days, the TdP continued and the fetus developed severe hydrops. We therefore decided to administer an intravenous loading dose of magnesium (4 g) followed by a continuous infusion (1-1.4 g/h) to maintain a maternal serum level of 1.2-1.4 (normal = 0.65-1.05 mmol/L). The mother's baseline magnesium level was 0.72 mmol/L. Within 3 days of magnesium infusion the frequency of TdP decreased (by fMCG the fetus was in sinus rhythm 80% of the time). Because of the concern for an SCN5A R1623Q mutation, we began treatment with mexiletine (600 mg orally per day). The fetus remained in sinus rhythm (rate 100 bpm) with continuous magnesium infusion and oral mexiletine given to the mother. At 35 weeks the fetus became bradycardic and was found to be in second-degree AVB.
The mother underwent an elective cesarean section at 35 weeks' gestation and a 2334-g male infant was delivered. The heart rate at birth was 56 bpm owing to functional second-degree AVB with 2:1 conduction (Figure 2A). Immediately after delivery, temporary transvenous pacing wires were placed. On the second day of life, a permanent pacemaker was implanted. We also administered oral mexiletine (4 mg/kg/d) and intravenous propranolol (0.02 mg/kg/h); no VT was observed. On the 14th day of life, the infant's electrocardiography showed sinus rhythm with a left bundle branch block pattern (Figure 2B). On the 40th day of life, the mexiletine blood levels declined, and TdP occurred despite ventricular pacing (VVI 80 bpm). The TdP spontaneously terminated.
The VVI pacing rate was increased to 110 bpm. When the infant was at the age of 5 months, weighing 6.6 kg, we placed an implantable cardioverter-defibrillator (ICD). The shock lead was implanted subcutaneously through the left thoracodorsal region, and the generator was placed under the right abdominal rectus muscle (Figure 2C). Following implantation of the ICD, the child did not experience any appropriate or inappropriate shocks during 4 years of follow-up. He received oral mexiletine (12 mg/kg/d) and propranolol (2 mg/kg/d).
Genetic testing of this case revealed a KCNH2 missense mutation (S624R). To date, there has been no functional analysis of this mutation. His mother's QTc was 440 ms, and his father's was 390 ms. Neither of the parents had any mutation in this locus. However, we did not exclude parental germinal mosaicism.
OUTPUT:
| PMC5420015 |
MultiCaRe_Reasoning45 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 35.0
Sex: Female
Title: Successful prenatal management of ventricular tachycardia and second-degree atrioventricular block in fetal long QT syndrome
Keywords: congenital long qt syndrome; fetal magnetocardiography; prenatal management; ventricular arrhythmia; ventricular tachycardia/torsades de pointes;
Abstract:
None
Image Caption and Description:
Image caption: Case 2. A: At 24 weeks' gestation, the initial fetal echocardiography showed fetal ventricular tachycardia with a ventricular rate of 187 beats per minute (bpm) and an atrial rate of 123 bpm. B: Fetal magnetocardiography (fMCG) revealed sustained ventricular tachycardia with a V rate of 220 bpm. C: fMCG showed a prolonged QT interval (511 ms) during transient sinus rhythm. D: At this time, the fetus also developed ascites, skin edema, and pericardial effusion as symptoms of severe hydrops.
Image description: The fetal echocardiogram revealed a peristent tachycardia with atrioventricular dissociation (Figure 3A).
The fMCG confirmed the clinical diagnosis of VT with a rate of 220 bpm (Figure 3B) with a prolonged (511 ms) QTc during brief (<20% of the recording time) episodes of sinus rhythm (rate 110-120 bpm) (Figure 3C).
However, despite maternal serum magnesium levels of 1.28 mmol/L (normal range 0.65-1.05 mmol/L), the VT persisted and the fetus became hydropic (Figure 3D).
Case Report:
A 35-year-old woman was referred to our institution at 24 weeks' gestation because of a fetal pericardial effusion and fetal tachycardia. The family history was positive for a paternal KCNH2 missense mutation (T613M) diagnosed after a syncopal episode. The fetal echocardiogram revealed a peristent tachycardia with atrioventricular dissociation (Figure 3A). The fMCG confirmed the clinical diagnosis of VT with a rate of 220 bpm (Figure 3B) with a prolonged (511 ms) QTc during brief (<20% of the recording time) episodes of sinus rhythm (rate 110-120 bpm) (Figure 3C). The mother was admitted to the hospital for continuous intravenous magnesium treatment to terminate the fetal VT. However, despite maternal serum magnesium levels of 1.28 mmol/L (normal range 0.65-1.05 mmol/L), the VT persisted and the fetus became hydropic (Figure 3D). Ten days after the mother was on magnesium, we initiated propranolol (initial dose 60-120 mg orally per day), following which the VT resolved. We continued magnesium by a continuous infusion (1.4 g/h) after we started propranolol. fMCG revealed a decreased fetal sinus rate from 120 to 110 bpm. The hydrops then improved gradually. The mother's daily total heart beats decreased from 129,108 to 103,206 (average heart rate decreased from 90 to 71 bpm) after propranolol administration, indicating beta-adrenergic blocking effect. Subsequently, the fetal sinus rhythm (rate 110 bpm) was maintained. A 2010-g female infant was delivered by elective cesarean delivery at 37 weeks' gestation. After birth, the infant's electrocardiography showed an intermittent left bundle branch block pattern. On the fifth day of life, she developed second-degree AVB with a ventricular rate of 60-80 bpm and metabolic acidemia owing to poor cardiac output. She urgently underwent temporary epicardial ventricular pacing lead implantation. At the age of 3 months, sustained VT occurred immediately after permanent pacemaker implantation and was successfully terminated by cardioversion. Hypokalemia (serum potassium level was 2.9 mmol/L) during intensive care likely contributed to the VT. VT did not recur after the potassium was corrected. Her genetic testing identified the KCNH2 missense mutation (T613M), identical to that of her father. She received oral mexiletine (7 mg/kg/d) and propranolol (3 mg/kg/d) with pacing (VVI 110 bpm) for 23 months.
OUTPUT:
| PMC5420015 |
MultiCaRe_Reasoning46 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 53.0
Sex: Male
Title: Massive Haemoptysis due to Obscure Aetiology: Perils and Management Dilemmas
Keywords: None
Abstract:
Pulmonary actinomycosis is an important differential diagnosis in patients with long-standing pulmonary infiltrates related to poor oral hygiene or compromised immune function. Up to a quarter of cases of thoracic actinomycosis are misdiagnosed as lung malignancy. Here, we report a 56-year-old man with a hypodense lesion in the left lower lobe presenting with recurrent massive haemoptysis for about one year. He underwent left lower lobe lobectomy due to intractable haemoptysis. Histopathological examination demonstrated actinomycosis infiltrating the left lower lobe. Rarity of the case was the presence of actinomycosis in an immunocompetent individual and without underlying preexisting lung disease. Also, intractable massive haemoptysis necessitating surgical excision which proved to be both diagnostic and curative due to actinomycosis is an unusual occurrence.
Image Caption and Description:
Image caption: Chest X-ray revealed raised left hemidiaphragm and left midzone opacity, creating a positive silhouette sign with the left cardiac border.
Image description: Chest X-ray showed an inhomogeneous opacity in the left lower zone with raised left diaphragm (Figure 1), and CECT (contrast-enhanced computer tomogram) chest showed a hypodense lesion with irregular margins in the anterior segment of the left lower lobe adjacent to the descending aorta and associated subcarinal lymphadenopathy (Figures 2 and 3).
Image caption: Irregular margin air space consolidation with cavitations seen in the left anterior segment adjacent to descending aorta.
Image description: Chest X-ray showed an inhomogeneous opacity in the left lower zone with raised left diaphragm (Figure 1), and CECT (contrast-enhanced computer tomogram) chest showed a hypodense lesion with irregular margins in the anterior segment of the left lower lobe adjacent to the descending aorta and associated subcarinal lymphadenopathy (Figures 2 and 3).
Image caption: An irregular mass is seen on the left lower lobe adjacent to aorta with pleural involvement.
Image description: Chest X-ray showed an inhomogeneous opacity in the left lower zone with raised left diaphragm (Figure 1), and CECT (contrast-enhanced computer tomogram) chest showed a hypodense lesion with irregular margins in the anterior segment of the left lower lobe adjacent to the descending aorta and associated subcarinal lymphadenopathy (Figures 2 and 3).
Image caption: GMS stain highlighting delicate branched filaments.
Image description: Histopathology was suggestive of chronic inflammatory cells with focal aggregates of lymphocytes with positive GMS staining for actinomycosis (Figure 4).
Case Report:
A 53-year-old male, smoker (20 pack-years), occasional alcoholic, presented with complaints of blood expectoration of 400 ml in one episode followed by 100-150 ml for 2-3 days. He had 3 episodes of similar history which required hospitalizations and emergency care since 9 months. He denied history of fever, chest pain, and loss of appetite. He underwent cholecystectomy 3 years ago. There was no history of systemic immune suppression like diabetes. He had undergone bronchial artery embolization for massive haemoptysis; however, his haemoptysis persisted and diagnosis remained elusive after evaluation with sputum studies and CT-guided aspiration cytology, biopsy, and bronchoscopic lavage. He was treated for LRTI with multiple courses of antibiotics for more than 9 months.
On examination, vitals were normal with no respiratory distress. Oral hygiene was poor with dental caries. Respiratory examination revealed scattered crackles in the left lower lobe area. Chest X-ray showed an inhomogeneous opacity in the left lower zone with raised left diaphragm (Figure 1), and CECT (contrast-enhanced computer tomogram) chest showed a hypodense lesion with irregular margins in the anterior segment of the left lower lobe adjacent to the descending aorta and associated subcarinal lymphadenopathy (Figures 2 and 3). Image-guided transthoracic biopsy showed type 2 alveolar cell hyperplasia with negative immunohistochemistry. Bronchoscopy confirmed left lower lobe bleed with any endoluminal lesion. Bronchial wash was negative for microbiological and cytological studies including AFB stain, geneXpert for MTB complex, and pyogenic culture. Patient's symptoms of haemoptysis persisted; hence, CT angiogram was performed, which showed dilated vascular channels within the lesion without any obvious extravasations of contrast and no aortic abnormality.
Probable diagnosis of the left intrapulmonary vascular lesion was made and hence the patient underwent left lower lobe lobectomy. Intraoperatively, the left lower lobe was adherent posterolaterally to the aorta and diaphragm. Multiple prominent blood vessels in areas of adhesion were seen. Histopathology was suggestive of chronic inflammatory cells with focal aggregates of lymphocytes with positive GMS staining for actinomycosis (Figure 4). Postoperatively, the patient received parenteral benzylpenicillin 20 lakh units 6th hourly for 3 months. The patient was in regular follow-up, and no further episodes of haemoptysis and no recent respiratory complaints are reported.
OUTPUT:
| PMC6288572 |
MultiCaRe_Reasoning47 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 33.0
Sex: Female
Title: Multinodular and vacuolating neuronal tumor (MVNT): A presumably incidental and asymptomatic case in an intractable epilepsy patient
Keywords: brain tumor; dnet, dysembryoplastic neuroepithelial tumor; eeg, electroencephalogram; fdg-pet, 18 fluoro-2-deoxyglucose positron emission tomography; flair, fluid-attenuated inversion recovery; long-term video electroencephalogram; mri, magnetic resonance imaging; mvnt, multinodular and vacuolating neuronal tumor; magnetic resonance imaging (mri); post-encephalitis epilepsy; t2wi, t2-weighted image; veeg, long-term video electroencephalogram;
Abstract:
Introduction:
Multinodular and vacuolating neuronal tumor (MVNT) had been initially described as an epilepsy-related brain tumor, but recent studies demonstrated it could be found incidentally in non-epilepsy patients.
Case report:
A 33-year-old woman with intractable post-encephalitis epilepsy presented a cluster of multinodular T2 hyperintensity in the left temporal lobe, which was very similar to the characteristics of MVNT. Long-term video electroencephalogram demonstrated that the habitual seizures were originated from bilateral temporal area and the interictal epileptic discharges were seen multifocally, although the lesions with MVNT appearance were localized in the left temporal lobe. It was presumed that the epilepsy in this patient was due to encephalitis in the past, and the link between the lesions and the epilepsy in this patient seemed weak.
Conclusion:
Although MVNT had been considered as an epilepsy-related brain tumor, we suggest it is not necessarily preferable to perform surgical resection of MVNT even on patients with epilepsy, unless epileptic foci are highly related to MVNT.
Image Caption and Description:
Image caption: (A-D) A cluster of multiple nodular high intensity lesions without mass effect (arrowheads), which was compatible with multinodular and vacuolating neuronal tumor (MVNT), was shown in the white matter of the left temporal lobe in fluid-attenuated inversion recovery (FLAIR) of brain magnetic resonance imaging (MRI). (E) Moderately reduced uptake of nuclide (arrows) was detected in the lesion area in 18 fluoro-2-deoxyglucose positron emission tomography (FDG-PET) of brain.
Image description: T2-weighted image (T2WI) and fluid-attenuated inversion recovery (FLAIR) in white matter of the left temporal lobe along with the border of inner cortex (Fig. 1A). The lesions did not show any mass effect or enhancement with gadolinium.
The characteristics of MRI findings were consistent with those of MVNT. 18 fluoro-2-deoxyglucose positron emission tomography (FDG-PET) of brain demonstrated moderate decrease of uptake in the lesion area (Fig. 1B).
Image caption: Long-term video electroencephalogram demonstrated two types of seizures: (A) Rhythmic waves started from middle-temporal area (T3) and gradually increased its amplitudes and spread to ipsilateral frontal area, then to the contralateral hemisphere; (B) The similar pattern of rhythmic waves started from the right anterior-temporal area (F8).
Image description: Her consciousness was partially impaired during the seizure. vEEG showed rhythmic wave that started from the left middle temporal area and spread to the ipsilateral frontal region, and then to the contralateral hemisphere (Fig. 2A); The other started with lightheadedness and vEEG showed similar rhythmic waves that started from the right anterior temporal area (Fig. 2B).
Case Report:
A 33-year-old woman with intractable epilepsy was referred to our epilepsy center for clinical evaluation. At age 31, she experienced status epilepticus subsequent to a febrile episode and following prolonged coma that continued several weeks. She had no prior history of epilepsy or seizure-related disorders. Initial diagnosis was limbic encephalitis, based on inflammatory findings of cerebrospinal fluid. She was treated with intravenous steroid administration and plasma exchange at another hospital. Although she gradually recovered from comatose state and discharged home in two months without any disability for daily living, symptomatic epilepsy with frequent seizures with impaired awareness persisted. She described that her seizure started with strange odor or deja vu sensation, and then she felt dizziness or lightheadedness. It sometimes accompanied jerky movements of the right side of her face and arm, and eventually led to impaired awareness. Although she was taking levetiracetam 1000 mg and lamotrigine 400 mg, she usually had 1-2 seizures a day. She had previously taken carbamazepine, lacosamide, perampanel and topiramate which did not lead to improvement.
Her latest brain magnetic resonance imaging (MRI) revealed a cluster of variably sized multiple nodular high intensity lesions on T2-weighted image (T2WI) and fluid-attenuated inversion recovery (FLAIR) in white matter of the left temporal lobe along with the border of inner cortex (Fig. 1A). The lesions did not show any mass effect or enhancement with gadolinium. Similar findings were also observed in the past MRI when the patient had encephalitis two years before, and the size of the lesions were not different from the latest one. The characteristics of MRI findings were consistent with those of MVNT. 18 fluoro-2-deoxyglucose positron emission tomography (FDG-PET) of brain demonstrated moderate decrease of uptake in the lesion area (Fig. 1B). Laboratory findings of her blood and cerebrospinal fluid did not reveal any other causes of epilepsy.
Long-term video electroencephalogram (vEEG) was performed for 72 h and three habitual seizures were recorded: Two of them started with deja vu and strange odor sensation followed by nodding movement of the head and subsequent fluttering of right hand and foot. Her consciousness was partially impaired during the seizure. vEEG showed rhythmic wave that started from the left middle temporal area and spread to the ipsilateral frontal region, and then to the contralateral hemisphere (Fig. 2A); The other started with lightheadedness and vEEG showed similar rhythmic waves that started from the right anterior temporal area (Fig. 2B). Interictal EEG showed frequent multifocal spikes and sharp waves in the bilateral anterior to middle temporal area.
Based on the EEG findings that demonstrated the multiple independent seizure onsets in both hemispheres, the patient was considered to have bilateral multifocal epileptic foci, whereas the lesions with MVNT appearance on MRI were localized in the left temporal lobe. Although MVNT had been described as an epilepsy-related brain tumor, we refrained from resection surgery because it was not certain that the lesions were epileptogenic in this patient. She has been followed up with multiple antiepileptic drugs.
OUTPUT:
| PMC6921157 |
MultiCaRe_Reasoning48 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 4.0
Sex: Female
Title: The language faculty that wasn't: a usage-based account of natural language recursion
Keywords: cultural evolution; domain-general processes; language evolution; language faculty; recursion; sequence learning; usage-based processing;
Abstract:
In the generative tradition, the language faculty has been shrinking-perhaps to include only the mechanism of recursion. This paper argues that even this view of the language faculty is too expansive. We first argue that a language faculty is difficult to reconcile with evolutionary considerations. We then focus on recursion as a detailed case study, arguing that our ability to process recursive structure does not rely on recursion as a property of the grammar, but instead emerges gradually by piggybacking on domain-general sequence learning abilities. Evidence from genetics, comparative work on non-human primates, and cognitive neuroscience suggests that humans have evolved complex sequence learning skills, which were subsequently pressed into service to accommodate language. Constraints on sequence learning therefore have played an important role in shaping the cultural evolution of linguistic structure, including our limited abilities for processing recursive structure. Finally, we re-evaluate some of the key considerations that have often been taken to require the postulation of a language faculty.
Image Caption and Description:
Image caption: Examples of complex recursive structures with one and two levels of embedding: Center-embeddings in German (top panel) and cross-dependencies in Dutch (bottom panel). The lines indicate noun-verb dependencies.
Image description: These two types of recursive constructions produce multiple overlapping non-adjacent dependencies, as illustrated in Figure 1, resulting in rapidly increasing processing difficulty as the number of embeddings grows.
Christiansen and Chater, Forthcoming, for discussion). Can our limited ability to process multiple complex recursive embeddings similarly be shown to reflect constraints on sequence learning? The embedding of multiple complex recursive structures:whether in the form of center-embeddings or cross-dependencies:results in several pairs of overlapping non-adjacent dependencies (as illustrated by Figure 1).
Image caption: Human performance (from Bach et al.,) on center-embedded constructions in German and cross-dependency constructions in Dutch with one or two levels of embedding (left). SRN performance on similar complex recursive structures (from Christiansen and MacDonald,) (right).
Image description: Figure 2 shows the results of the Bach et al. study on the left-hand side.
The right-hand side of Figure 2 shows the mean sentence GPE scores, averaged across 10 novel sentences.
Case Report:
Considerable variations in recursive abilities have also been observed developmentally. Dickinson showed that recursive language production abilities emerge gradually, in a piecemeal fashion. On the comprehension side, training improves comprehension of singly embedded relative clause constructions both in 3-4-year old children (Roth,) and adults (Wells et al.,), independent of other cognitive factors. Level of education further correlates with the ability to comprehend complex recursive sentences (Dabrowska,). More generally, these developmental differences are likely to reflect individual variations in experience with language (see Christiansen and Chater, Forthcoming), differences that may further be amplified by variations in the structural and distributional characteristics of the language being spoken.
Together, these individual, developmental and cross-linguistic differences in dealing with recursive linguistic structure cannot easily be explained in terms of a fundamental recursive competence, constrained by fixed biological constraints on performance. That is, the variation in recursive abilities across individuals, development, and languages are hard to explain in terms of performance factors, such as language-independent constraints on memory, processing or attention, imposing limitations on an otherwise infinite recursive grammar. Invoking such limitations would require different biological constraints on working memory, processing, or attention for speakers of different languages, which seems highly unlikely. To resolve these issues, we need to separate claims about recursive mechanisms from claims about recursive structure: the ability to deal with a limited amount of recursive structure in language does not necessitate the postulation of recursive mechanisms to process them. Thus, instead of treating recursion as an a priori property of the language faculty, we need to provide a mechanistic account able to accommodate the actual degree of recursive structure found across both natural languages and natural language users: no more and no less.
We favor an account of the processing of recursive structure that builds on construction grammar and usage-based approaches to language. The essential idea is that the ability to process recursive structure does not depend on a built-in property of a competence grammar but, rather, is an acquired skill, learned through experience with specific instances of recursive constructions and limited generalizations over these (Christiansen and MacDonald,). Performance limitations emerge naturally through interactions between linguistic experience and cognitive constraints on learning and processing, ensuring that recursive abilities degrade in line with human performance across languages and individuals. We show how our usage-based account of recursion can accommodate human data on the most complex recursive structures that have been found in naturally occurring language: center-embeddings and cross-dependencies. Moreover, we suggest that the human ability to process recursive structures may have evolved on top of our broader abilities for complex sequence learning. Hence, we argue that language processing, implemented by domain-general mechanisms:not recursive grammars:is what endows language with its hallmark productivity, allowing it to "...make infinite employment of finite means," as the celebrated German linguist, Wilhelm von Humboldt (: p. 91), noted more than a century and a half ago.
Language processing involves extracting regularities from highly complex sequentially organized input, suggesting a connection between general sequence learning (e.g., planning, motor control, etc., Lashley,) and language: both involve the extraction and further processing of discrete elements occurring in temporal sequences (see also e.g., Greenfield,; Conway and Christiansen,; Bybee,; de Vries et al.,, for similar perspectives). Indeed, there is comparative, genetic, and neural evidence suggesting that humans may have evolved specific abilities for dealing with complex sequences. Experiments with non-human primates have shown that they can learn both fixed sequences, akin to a phone number (e.g., Heimbauer et al.,), and probabilistic sequences, similar to "statistical learning" in human studies (e.g., Heimbauer et al.,, under review; Wilson et al.,). However, regarding complex recursive non-linguistic sequences, non-human primates appear to have significant limitations relative to human children (e.g., in recursively sequencing actions to nest cups within one another; Greenfield et al.,; Johnson-Pynn et al.,). Although more carefully controlled comparisons between the sequence learning abilities of human and non-primates are needed (see Conway and Christiansen,, for a review), the currently available data suggest that humans may have evolved a superior ability to deal with sequences involving complex recursive structures.
The current knowledge regarding the FOXP2 gene is consistent with the suggestion of a human adaptation for sequence learning (for a review, see Fisher and Scharff,). FOXP2 is highly conserved across species but two amino acid changes have occurred after the split between humans and chimps, and these became fixed in the human population about 200,000 years ago (Enard et al.,). In humans, mutations to FOXP2 result in severe speech and orofacial motor impairments (Lai et al.,; MacDermot et al.,). Studies of FOXP2 expression in mice and imaging studies of an extended family pedigree with FOXP2 mutations have provided evidence that this gene is important to neural development and function, including of the cortico-striatal system (Lai et al.,). When a humanized version of Foxp2 was inserted into mice, it was found to specifically affect cortico-basal ganglia circuits (including the striatum), increasing dendrite length and synaptic plasticity (Reimers-Kipping et al.,). Indeed, synaptic plasticity in these circuits appears to be key to learning action sequences (Jin and Costa,); and, importantly, the cortico-basal ganglia system has been shown to be important for sequence (and other types of procedural) learning (Packard and Knowlton,). Crucially, preliminary findings from a mother and daughter pair with a translocation involving FOXP2 indicate that they have problems with both language and sequence learning (Tomblin et al.,). Finally, we note that sequencing deficits also appear to be associated with specific language impairment (SLI) more generally (e.g., Tomblin et al.,; Lum et al.,; Hsu et al.,; see Lum et al.,, for a review).
Hence, both comparative and genetic evidence suggests that humans have evolved complex sequence learning abilities, which, in turn, appear to have been pressed into service to support the emergence of our linguistic skills. This evolutionary scenario would predict that language and sequence learning should have considerable overlap in terms of their neural bases. This prediction is substantiated by a growing bulk of research in the cognitive neurosciences, highlighting the close relationship between sequence learning and language (see Ullman,; Conway and Pisoni,, for reviews). For example, violations of learned sequences elicit the same characteristic event-related potential (ERP) brainwave response as ungrammatical sentences, and with the same topographical scalp distribution (Christiansen et al.,). Similar ERP results have been observed for musical sequences (Patel et al.,). Additional evidence for a common domain-general neural substrate for sequence learning and language comes from functional imaging (fMRI) studies showing that sequence violations activate Broca's area (Lieberman et al.,; Petersson et al.,; Forkstam et al.,), a region in the left inferior frontal gyrus forming a key part of the cortico-basal ganglia network involved in language. Results from a magnetoencephalography (MEG) experiment further suggest that Broca's area plays a crucial role in the processing of musical sequences (Maess et al.,).
If language is subserved by the same neural mechanisms as used for sequence processing, then we would expect a breakdown of syntactic processing to be associated with impaired sequencing abilities. Christiansen et al. tested this prediction in a population of agrammatic aphasics, who have severe problems with natural language syntax in both comprehension and production due to lesions involving Broca's area (e.g., Goodglass and Kaplan,; Goodglass, :see Novick et al.,; Martin,, for reviews). They confirmed that agrammatism was associated with a deficit in sequence learning in the absence of other cognitive impairments. Similar impairments to the processing of musical sequences by the same population were observed in a study by Patel et al.. Moreover, success in sequence learning is predicted by white matter density in Broca's area, as revealed by diffusion tensor magnetic resonance imaging (Floel et al.,). Importantly, applying transcranial direct current stimulation (de Vries et al.,) or repetitive transcranial magnetic stimulation (Udden et al.,) to Broca's area during sequence learning or testing improves performance. Together, these cognitive neuroscience studies point to considerable overlap in the neural mechanisms involved in language and sequence learning2, as predicted by our evolutionary account (see also Wilkins and Wakefield,; Christiansen et al.,; Hoen et al.,; Ullman,; Conway and Pisoni,, for similar perspectives).
Comparative and genetic evidence is consistent with the hypothesis that humans have evolved more complex sequence learning mechanisms, whose neural substrates subsequently were recruited for language. But how might recursive structure recruit such complex sequence learning abilities? Reali and Christiansen explored this question using simple recurrent networks (SRNs; Elman,). The SRN is a type of connectionist model that implements a domain-general learner with sensitivity to complex sequential structure in the input. This model is trained to predict the next element in a sequence and learns in a self-supervised manner to correct any violations of its own expectations regarding what should come next. The SRN model has been successfully applied to the modeling of both sequence learning (e.g., Servan-Schreiber et al.,; Botvinick and Plaut,) and language processing (e.g., Elman,), including multiple-cue integration in speech segmentation (Christiansen et al.,) and syntax acquisition (Christiansen et al.,). To model the difference in sequence learning skills between humans and non-human primates, Reali and Christiansen first "evolved" a group of networks to improve their performance on a sequence-learning task in which they had to predict the next digit in a five-digit sequence generated by randomizing the order of the digits, 1-5 (based on a human task developed by Lee,). At each generation, the best performing network was selected, and its initial weights (prior to any training):i.e., their "genome":was slightly altered to produce a new generation of networks. After 500 generations of this simulated "biological" evolution, the resulting networks performed significantly better than the first generation SRNs.
Reali and Christiansen then introduced language into the simulations. Each miniature language was generated by a context-free grammar derived from the grammar skeleton in Table 1. This grammar skeleton incorporated substantial flexibility in word order insofar as the material on the right-hand side of each rule could be ordered as it is (right-branching), in the reverse order (left-branching), or have a flexible order (i.e., the constituent order is as is half of time, and the reverse the other half of the time). Using this grammar skeleton, it is possible to instantiate 36 (= 729) distinct grammars, with differing degrees of consistency in the ordering of sentence constituents. Reali and Christiansen implemented both biological and cultural evolution in their simulations: As with the evolution of better sequence learners, the initial weights of the network that best acquired a language in a given generation were slightly altered to produce the next generation of language learners:with the additional constraint that performance on the sequence learning task had to be maintained at the level reached at the end of the first part of the simulation (to capture the fact that humans are still superior sequence learners today). Cultural evolution of language was simulated by having the networks learn several different languages at each generation and then selecting the best learnt language as the basis for the next generation. The best learnt language was then varied slightly by changing the directions of a rule to produce a set of related "offspring" languages for each generation.
Although the simulations started with language being completely flexible, and thus without any reliable word order constraints, after <100 generations of cultural evolution, the resulting language had adopted consistent word order constraints in all but one of the six rules. When comparing the networks from the first generation at which language was introduced and the final generation, Reali and Christiansen found no difference in linguistic performance. In contrast, when comparing network performance on the initial (all-flexible) language vs. the final language, a very large difference in learnability was observed. Together, these two analyses suggest that it was the cultural evolution of language, rather than biological evolution of better learners, that allowed language to become more easily learned and more structurally consistent across these simulations. More generally, the simulation results provide an existence proof that recursive structure can emerge in natural language by way of cultural evolution in the absence of language-specific constraints.
NP {N (PP)}
PP {adp NP}
An important remaining question is whether human learners are sensitive to the kind of sequence learning constraints revealed by Reali and Christiansen's simulated process of cultural evolution. A key result of these simulations was that the sequence learning constraints embedded in the SRNs tend to favor what we will refer to as recursive consistency (Christiansen and Devlin,). Consider rewrite rules (2) and (3) from Table 1:
(3) [NP buildings [PP from [NP cities [PP with [NP smog]]]]]
(4) [NP [PP [NP [PP [NP smog] with] cities] from] buildings]
(5) [NP buildings [PP [NP cities [PP [NP smog] with]] from]]
(6) [NP [PP from [NP [PP with [NP smog]] cities]] buildings]
Together, these two skeleton rules form a recursive rule set because each calls the other. Ignoring the flexible version of these two rules, we get the four possible recursive rule sets shown in Table 2. Using these rules sets we can generate the complex noun phrases seen in (3)-(6):
The first two rules sets from Table 2 generate recursively consistent structures that are either right-branching (as in 3) or left-branching (as in 4). The prepositions and postpositions, respectively, are always in close proximity to their noun complements, making it easier for a sequence learner to discover their relationship. In contrast, the final two rule sets generate recursively inconsistent structures, involving center-embeddings: all nouns are either stacked up before all the postpositions (5) or after all the prepositions (6). In both cases, the learner has to work out that from and cities together form a prepositional phrase, despite being separated from each other by another prepositional phrase involving with and smog. This process is further complicated by an increase in memory load caused by the intervening prepositional phrase. From a sequence learning perspective, it should therefore be easier to acquire the recursively consistent structure found in (3) and (4) compared with the recursively inconsistent structure in (5) and (6). Indeed, all the simulation runs in Reali and Christiansen resulted in languages in which both recursive rule sets were consistent.
Christiansen and Devlin had previously shown that SRNs perform better on recursively consistent structure (such as those in 3 and 4). However, if human language has adapted by way of cultural evolution to avoid recursive inconsistencies (such as 5 and 6), then we should expect people to be better at learning recursively consistent artificial languages than recursively inconsistent ones. Reeder, following initial work by Christiansen, tested this prediction by exposing participants to one of two artificial languages, generated by the artificial grammars shown in Table 3. Notice that the consistent grammar instantiates a left-branching grammar from the grammar skeleton used by Reali and Christiansen, involving two recursively consistent rule sets (rules 2-3 and 5-6). The inconsistent grammar differs only in the direction of two rules (3 and 5), which are right-branching, whereas the other three rules are left-branching. The languages were instantiated using 10 spoken non-words to generate the sentences to which the participants were exposed. Participants in the two language conditions would see sequences of the exact same lexical items, only differing in their order of occurrence as dictated by the respective grammar (e.g., consistent: jux vot hep vot meep nib vs. inconsistent: jux meep hep vot vot nib). After training, the participants were presented with a new set of sequences, one by one, for which they were asked to judge whether or not these new items were generated by the same rules as the ones they saw previously. Half of the new items incorporated subtle violations of the sequence ordering (e.g., grammatical: cav hep vot lum meep nib vs. ungrammatical: cav hep vot rud meep nib, where rud is ungrammatical in this position).
The results of this artificial language learning experiment showed that the consistent language was learned significantly better (61.0% correct classification) than the inconsistent one (52.7%). It is important to note that because the consistent grammar was left-branching (and thus more like languages such as Japanese and Hindi), knowledge of English cannot explain the results. Indeed, if anything, the two right-branching rules in the inconsistent grammar bring that language closer to English3. To further demonstrate that the preferences for consistently recursive sequences is a domain-general bias, Reeder conducted a second experiment, in which the sequences were instantiated using black abstract shapes that cannot easily be verbalized. The results of the second study closely replicated those of the first, suggesting that there may be general sequence learning biases that favor recursively consistent structures, as predicted by Reali and Christiansen's evolutionary simulations.
The question remains, though, whether such sequence learning biases can drive cultural evolution of language in humans. That is, can sequence-learning constraints promote the emergence of language-like structure when amplified by processes of cultural evolution? To answer this question, Cornish et al. (under review) conducted an iterated sequence learning experiment, modeled on previous human iterated learning studies involving miniature language input (Kirby et al.,). Participants were asked to participate in a memory experiment, in which they were presented with 15 consonant strings. Each string was presented briefly on a computer screen after which the participants typed it in. After multiple repetitions of the 15 strings, the participants were asked to recall all of them. They were requested to continue recalling items until they had provided 15 unique strings. The recalled 15 strings were then recoded in terms of their specific letters to avoid trivial biases such as the location of letters on the computer keyboard and the presence of potential acronyms (e.g., X might be replaced throughout by T, T by M, etc.). The resulting set of 15 strings (which kept the same underlying structure as before recoding) was then provided as training strings for the next participant. A total of 10 participants were run within each "evolutionary" chain.
The initial set of strings used for the first participant in each chain was created so as to have minimal distributional structure (all consonant pairs, or bigrams, had a frequency of 1 or 2). Because recalling 15 arbitrary strings is close to impossible given normal memory constraints, it was expected that many of the recalled items would be strongly affected by sequence learning biases. The results showed that as these sequence biases became amplified across generations of learners, the sequences gained more and more distributional structure (as measured by the relative frequency of repeated two- and three-letter units). Importantly, the emerging system of sequences became more learnable. Initially, participants could only recall about 4 of the 15 strings correctly but by the final generation this had doubled, allowing participants to recall more than half the strings. Importantly, this increase in learnability did not evolve at the cost of string length: there was no decrease across generations. Instead, the sequences became easy to learn and recall because they formed a system, allowing subsequences to be reused productively. Using network analyses (see Baronchelli et al.,, for a review), Cornish et al. demonstrated that the way in which this productivity was implemented strongly mirrored that observed for child-directed speech.
The results from Cornish et al. (under review) suggest that sequence learning constraints, as those explored in the simulations by Reali and Christiansen and demonstrated by Reeder, can give rise to language-like distributional regularities that facilitate learning. This supports our hypothesis that sequential learning constraints, amplified by cultural transmission, could have shaped language into what we see today, including its limited use of embedded recursive structure. Next, we shall extend this approach to show how the same sequence learning constraints that we hypothesized to have shaped important aspects of the cultural evolution of recursive structures also can help explain specific patterns in the processing of complex recursive constructions.
So far, we have discussed converging evidence supporting the theory that language in important ways relies on evolutionarily prior neural mechanisms for sequence learning. But can a domain-general sequence learning device capture the ability of humans to process the kind of complex recursive structures that has been argued to require powerful grammar formalisms (e.g., Chomsky,; Shieber,; Stabler,; Jager and Rogers,)? From our usage-based perspective, the answer does not necessarily require the postulation of recursive mechanisms as long as the proposed mechanisms can deal with the level of complex recursive structure that humans can actually process. In other words, what needs to be accounted for is the empirical evidence regarding human processing of complex recursive structures, and not theoretical presuppositions about recursion as a stipulated property of our language system.
Christiansen and MacDonald conducted a set of computational simulations to determine whether a sequence-learning device such as the SRN would be able to capture human processing performance on complex recursive structures. Building on prior work by Christiansen and Chater, they focused on the processing of sentences with center-embedded and cross-dependency structures. These two types of recursive constructions produce multiple overlapping non-adjacent dependencies, as illustrated in Figure 1, resulting in rapidly increasing processing difficulty as the number of embeddings grows. We have already discussed earlier how performance on center-embedded constructions breaks down at two levels of embedding (e.g., Wang,; Hamilton and Deese,; Blaubergs and Braine,; Hakes et al.,). The processing of cross-dependencies, which exist in Swiss-German and Dutch, has received less attention, but the available data also point to a decline in performance with increased levels of embedding (Bach et al.,; Dickey and Vonk,). Christiansen and MacDonald trained networks on sentences derived from one of the two grammars shown in Table 4. Both grammars contained a common set of recursive structures: right-branching recursive structure in the form of prepositional modifications of noun phrases, noun phrase conjunctions, subject relative clauses, and sentential complements; left-branching recursive structure in the form of prenominal possessives. The grammars furthermore had three additional verb argument structures (transitive, optionally transitive, and intransitive) and incorporated agreement between subject nouns and verbs. As illustrated by Table 4, the only difference between the two grammars was in the type of complex recursive structure they contained: center-embedding vs. cross-dependency.
The grammars could generate a variety of sentences, with varying degree of syntactic complexity, from simple transitive sentences (such as 7) to more complex sentences involving different kinds of recursive structure (such as 8 and 9).
(7) John kisses Mary.
(8) Mary knows that John's boys' cats see mice.
(9) Mary who loves John thinks that men say that girls chase boys.
The generation of sentences was further restricted by probabilistic constraints on the complexity and depth of recursion. Following training on either grammar, the networks performed well on a variety of recursive sentence structures, demonstrating that the SRNs were able to acquire complex grammatical regularities (see also Christiansen,)4. The networks acquired sophisticated abilities for generalizing across constituents in line with usage-based approaches to constituent structure (e.g., Beckner and Bybee,; see also Christiansen and Chater,). Differences between networks were observed, though, on their processing of the complex recursive structure permitted by the two grammars.
To model human data on the processing of center-embedding and cross-dependency structures, Christiansen and MacDonald relied on a study conducted by Bach et al. in which sentences with two center-embeddings in German were found to be significantly harder to process than comparable sentences with two cross-dependencies in Dutch. Bach et al. asked native Dutch speakers to rate the comprehensibility of Dutch sentences involving varying depths of recursive structure in the form of cross-dependency constructions and corresponding right-branching paraphrase sentences with similar meaning. Native speakers of German were tested using similar materials in German, where center-embedded constructions replaced the cross-dependency constructions. To remove potential effects of processing difficulty due to length, the ratings from the right-branching paraphrase sentences were subtracted from the complex recursive sentences. Figure 2 shows the results of the Bach et al. study on the left-hand side.
SRN performance was scored in terms of Grammatical Prediction Error (GPE; Christiansen and Chater,), which measures the network's ability to make grammatically correct predictions for each upcoming word in a sentence, given prior context. The right-hand side of Figure 2 shows the mean sentence GPE scores, averaged across 10 novel sentences. Both humans and SRNs show similar qualitative patterns of processing difficulty (see also Christiansen and Chater,). At a single level of embedding, there is no difference in processing difficulty. However, at two levels of embedding, cross-dependency structures (in Dutch) are processed more easily than comparable center-embedded structures (in German).
Christiansen and MacDonald demonstrated that a sequence learner such as the SRN is able to mirror the differential human performance on center-embedded and cross-dependency recursive structures. Notably, the networks were able to capture human performance without the complex external memory devices (such as a stack of stacks; Joshi,) or external memory constraints (Gibson,) required by previous accounts. The SRNs ability to mimic human performance likely derives from a combination of intrinsic architectural constraints (Christiansen and Chater,) and the distributional properties of the input to which it has been exposed (MacDonald and Christiansen,; see also Christiansen and Chater, Forthcoming). Christiansen and Chater analyzed the hidden unit representations of the SRN:its internal state:before and after training on recursive constructions and found that these networks have an architectural bias toward local dependencies, corresponding to those found in right-branching recursion. To process multiple instances of such recursive constructions, however, the SRN needs exposure to the relevant types of recursive structures. This exposure is particularly important when the network has to process center-embedded constructions because the network must overcome its architectural bias toward local dependencies. Thus, recursion is not a built-in property of the SRN; instead, the networks develop their human-like abilities for processing recursive constructions through repeated exposure to the relevant structures in the input.
As noted earlier, this usage-based approach to recursion differs from many previous processing accounts, in which unbounded recursion is implemented as part of the representation of linguistic knowledge (typically in the form of a rule-based grammar). Of course, this means that systems of the latter kind can process complex recursive constructions, such as center-embeddings, beyond human capabilities. Since Miller and Chomsky, the solution to this mismatch has been to impose extrinsic memory limitations exclusively aimed at capturing human performance limitations on doubly center-embedded constructions (e.g., Kimball,; Marcus,; Church,; Just and Carpenter,; Stabler,; Gibson and Thomas,; Gibson,; see Lewis et al.,, for a review).
To further investigate the nature of the SRN's intrinsic constraints on the processing of multiple center-embedded constructions, Christiansen and MacDonald explored a previous result from Christiansen and Chater showing that SRNs found ungrammatical versions of doubly center-embedded sentences with a missing verb more acceptable than their grammatical counterparts5 (for similar SRN results, see Engelmann and Vasishth,). A previous offline rating study by Gibson and Thomas found that when the middle verb phrase (was cleaning every week) was removed from (10), the resulting ungrammatical sentence in (11) was rated no worse than the grammatical version in (10).
(10) The apartment that the maid who the service had sent over was cleaning every week was well decorated.
(11) *The apartment that the maid who the service had sent over was well decorated.
However, when Christiansen and MacDonald tested the SRN on similar doubly center-embedded constructions, they obtained predictions for (11) to be rated better than (10). To test these predictions, they elicited on-line human ratings for the stimuli from the Gibson and Thomas study using a variation of the "stop making sense" sentence-judgment paradigm (Boland et al.,; Boland,). Participants read a sentence, word-by-word, while at each step they decided whether the sentence was grammatical or not. Following the presentation of each sentence, participants rated it on a 7-point scale according to how good it seemed to them as a grammatical sentence of English (with 1 indicating that the sentence was "perfectly good English" and 7 indicating that it was "really bad English"). As predicted by the SRN, participants rated ungrammatical sentences such as (11) as better than their grammatical counterpart exemplified in (10).
The original stimuli from the Gibson and Thomas study had certain shortcomings that could have affected the outcome of the online rating experiment. Firstly, there were substantial length differences between the ungrammatical and grammatical versions of a given sentence. Secondly, the sentences incorporated semantic biases making it easier to line up a subject noun with its respective verb (e.g., apartment-decorated, service-sent over in 10). To control for these potential confounds, Christiansen and MacDonald replicated the experiment using semantically-neutral stimuli controlled for length (adapted from Stolz,), as illustrated by (12) and (13).
(12) The chef who the waiter who the busboy offended appreciated admired the musicians.
(13) *The chef who the waiter who the busboy offended frequently admired the musicians.
The second online rating experiment yielded the same results as the first, thus replicating the "missing verb" effect. These results have subsequently been confirmed by online ratings in French (Gimenes et al.,) and a combination of self-paced reading and eye-tracking experiments in English (Vasishth et al.,). However, evidence from German (Vasishth et al.,) and Dutch (Frank et al.,) indicates that speakers of these languages do not show the missing verb effect but instead find the grammatical versions easier to process. Because verb-final constructions are common in German and Dutch, requiring the listener to track dependency relations over a relatively long distance, substantial prior experience with these constructions likely has resulted in language-specific processing improvements (see also Engelmann and Vasishth,; Frank et al.,, for similar perspectives). Nonetheless, in some cases the missing verb effect may appear even in German, under conditions of high processing load (Trotzke et al.,). Together, the results from the SRN simulations and human experimentation support our hypothesis that the processing of center-embedded structures are best explained from a usage-based perspective that emphasizes processing experience with the specific statistical properties of individual languages. Importantly, as we shall see next, such linguistic experience interacts with sequence learning constraints.
Previous studies have suggested that the processing of singly embedded relative clauses are determined by linguistic experience, mediated by sequence learning skills (e.g., Wells et al.,; Misyak et al.,; see Christiansen and Chater, Forthcoming, for discussion). Can our limited ability to process multiple complex recursive embeddings similarly be shown to reflect constraints on sequence learning? The embedding of multiple complex recursive structures:whether in the form of center-embeddings or cross-dependencies:results in several pairs of overlapping non-adjacent dependencies (as illustrated by Figure 1). Importantly, the SRN simulation results reported above suggest that a sequence learner might also be able to deal with the increased difficulty associated with multiple, overlapping non-adjacent dependencies.
Dealing appropriately with multiple non-adjacent dependencies may be one of the key defining characteristics of human language. Indeed, when a group of generativists and cognitive linguists recently met to determine what is special about human language (Tallerman et al.,), one of the few things they could agree about was that long-distance dependencies constitute one of the hallmarks of human language, and not recursion (contra Hauser et al.,). de Vries et al. used a variation of the AGL-SRT task (Misyak et al.,) to determine whether the limitations on processing of multiple non-adjacent dependencies might depend on general constraints on human sequence learning, instead of being unique to language. This task incorporates the structured, probabilistic input of artificial grammar learning (AGL; e.g., Reber,) within a modified two-choice serial reaction-time (SRT; Nissen and Bullemer,) layout. In the de Vries et al. study, participants used the computer mouse to select one of two written words (a target and a foil) presented on the screen as quickly as possible, given auditory input. Stimuli consisted of sequences with two or three non-adjacent dependencies, ordered either using center-embeddings or cross-dependencies. The dependencies were instantiated using a set of dependency pairs that were matched for vowel sounds: ba-la, yo-no, mi-di, and wu-tu. Examples of each of the four types of stimuli are presented in (14-17), where the subscript numbering indicates dependency relationships.
(14) ba1 wu2 tu2 la1
(15) ba1 wu2 la1 tu2
(16) ba1 wu2 yo3 no3 tu2 la1
(17) ba1 wu2 yo3 la1 tu2 no3
Thus, (14) and (16) implement center-embedded recursive structure and (15) and (17) involve cross-dependencies. Participants would only be exposed to one of the four types of stimuli. To determine the potential effect of linguistic experience on the processing of complex recursive sequence structure, study participants were either native speakers of German (which has center-embedding but not cross-dependencies) or Dutch (which has cross-dependencies). Participants were only exposed to one kind of stimulus, e.g., doubly center-embedded sequences as in (16) in a fully crossed design (length x embedding x native language).
de Vries et al. first evaluated learning by administering a block of ungrammatical sequences in which the learned dependencies were violated. As expected, the ungrammatical block produced a similar pattern of response slow-down for both for both center-embedded and cross-dependency items involving two non-adjacent dependencies (similar to what Bach et al.,, Bach et al., found in the natural language case). However, an analog of the missing verb effect was observed for the center-embedded sequences with three non-adjacencies but not for the comparable cross-dependency items. Indeed, an incorrect middle element in the center-embedded sequences (e.g., where tu is replaced by la in 16) did not elicit any slow-down at all, indicating that participants were not sensitive to violations at this position.
Sequence learning was further assessed using a prediction task at the end of the experiment (after a recovery block of grammatical sequences). In this task, participants would hear a beep replacing one of the elements in the second half of the sequence and were asked to simply click on the written word that they thought had been replaced. Participants exposed to the sequences incorporating two dependencies, performed reasonably well on this task, with no difference between center-embedded and cross-dependency stimuli. However, as for the response times, a missing verb effect was observed for the center-embedded sequences with three non-adjacencies. When the middle dependent element was replaced by a beep in center-embedded sequences (e.g., ba1 wu2 yo3 no3<beep> la1), participants were more likely to click on the foil (e.g., la) than the target (tu). This was not observed for the corresponding cross-dependency stimuli, once more mirroring the Bach et al. psycholinguistic results that multiple cross-dependencies are easier to process than multiple center-embeddings.
Contrary to psycholinguistic studies of German (Vasishth et al.,) and Dutch (Frank et al.,), de Vries et al. found an analog of the missing verb effect in speakers of both languages. Because the sequence-learning task involved non-sense syllables, rather than real words, it may not have tapped into the statistical regularities that play a key role in real-life language processing6. Instead, the results reveal fundamental limitations on the learning and processing of complex recursively structured sequences. However, these limitations may be mitigated to some degree, given sufficient exposure to the "right" patterns of linguistic structure:including statistical regularities involving morphological and semantic cues:and thus lessening sequence processing constraints that would otherwise result in the missing verb effect for doubly center-embedded constructions. Whereas the statistics of German and Dutch appear to support such amelioration of language processing, the statistical make-up of linguistic patterning in English and French apparently does not. This is consistent with the findings of Frank et al., demonstrating that native Dutch and German speakers show a missing verb effect when processing English (as a second language), even though they do not show this effect in their native language (except under extreme processing load, Trotzke et al.,). Together, this pattern of results suggests that the constraints on human processing of multiple long-distance dependencies in recursive constructions stem from limitations on sequence learning interacting with linguistic experience.
In this extended case study, we argued that our ability to process of recursive structure does not rely on recursion as a property of the grammar, but instead emerges gradually by piggybacking on top of domain-general sequence learning abilities. Evidence from genetics, comparative work on non-human primates, and cognitive neuroscience suggests that humans have evolved complex sequence learning skills, which were subsequently pressed into service to accommodate language. Constraints on sequence learning therefore have played an important role in shaping the cultural evolution of linguistic structure, including our limited abilities for processing recursive structure. We have shown how this perspective can account for the degree to which humans are able to process complex recursive structure in the form of center-embeddings and cross-dependencies. Processing limitations on recursive structure derive from constraints on sequence learning, modulated by our individual native language experience.
We have taken the first steps toward an evolutionarily-informed usage-based account of recursion, where our recursive abilities are acquired piecemeal, construction by construction, in line with developmental evidence. This perspective highlights the key role of language experience in explaining cross-linguistic similarities and dissimilarities in the ability to process different types of recursive structure. And although, we have focused on the important role of sequence learning in explaining the limitations of human recursive abilities, we want to stress that language processing, of course, includes other domain-general factors. Whereas distributional information clearly provides important input to language acquisition and processing, it is not sufficient, but must be complemented by numerous other sources of information, from phonological and prosodic cues to semantic and discourse information (e.g., Christiansen and Chater,, Forthcoming). Thus, our account is far from complete but it does offer the promise of a usage-based perspective of recursion based on evolutionary considerations.
In this paper, we have argued that there are theoretical reasons to suppose that special-purpose biological machinery for language can be ruled out on evolutionary grounds. A possible counter-move adopted by the minimalist approach to language is to suggest that the faculty of language is very minimal and only consists of recursion (e.g., Hauser et al.,; Chomsky,). However, we have shown that capturing human performance on recursive constructions does not require an innate mechanism for recursion. Instead, we have suggested that the variation in processing of recursive structures as can be observed across individuals, development and languages is best explained by domain-general abilities for sequence learning and processing interacting with linguistic experience. But, if this is right, it becomes crucial to provide explanations for the puzzling aspects of language that were previously used to support the case for a rich innate language faculty: (1) the poverty of the stimulus, (2) the eccentricity of language, (3) language universals, (4) the source of linguistic regularities, and (5) the uniqueness of human language. In the remainder of the paper, we therefore address each of these five challenges, in turn, suggesting how they may be accounted for without recourse to anything more than domain-general constraints.
One traditional motivation for postulating an innate language faculty is the assertion that there is insufficient information in the child's linguistic environment for reliable language acquisition to be possible (Chomsky,). If the language faculty has been pared back to consist only of a putative mechanism for recursion, then this motivation no longer applies:the complex patterns in language which have been thought to pose challenges of learnability concern highly specific properties of language (e.g., concerning binding constraints), which are not resolved merely by supplying the learner with a mechanism for recursion.
But recent work provides a positive account of how the child can acquire language, in the absence of an innate language faculty, whether minimal or not. One line of research has shown, using computational results from language corpora and mathematical analysis, that learning methods are much more powerful than had previously been assumed (e.g., Manning and Schutze,; Klein and Manning,; Chater and Vitanyi,; Hsu et al.,; Chater et al.,). But more importantly, viewing language as a culturally evolving system, shaped by the selectional pressures from language learners, explains why language and languages learners fit together so closely. In short, the remarkable phenomenon of language acquisition from a noisy and partial linguistic input arises from a close fit between the structure of language and the structure of the language learner. However, the origin of this fit is not that the learner has somehow acquired a special-purpose language faculty embodying universal properties of human languages, but, instead, because language has been subject to powerful pressures of cultural evolution to match, as well as possible, the learning and processing mechanism of its speakers (e.g., as suggested by Reali and Christiansen's,, simulations). In short, the brain is not shaped for language; language is shaped by the brain (Christiansen and Chater,).
Language acquisition can overcome the challenges of the poverty of the stimulus without recourse to an innate language faculty, in light both of new results on learnability, and the insight that language has been shaped through processes of cultural evolution to be as learnable as possible.
Fodor argue that the generalizations found in language are so different from those evident in other cognitive domains, that they can only be subserved by highly specialized cognitive mechanisms. But the cultural evolutionary perspective that we have outlined here suggests, instead, that the generalizations observed in language are not so eccentric after all: they arise, instead, from a wide variety of cognitive, cultural, and communicative constraints (e.g., as exemplified by our extended case study of recursion). The interplay of these constraints, and the contingencies of many thousands of years of cultural evolution, is likely to have resulted in the apparently baffling complexity of natural languages.
Another popular motivation for proposing an innate language faculty is to explain putatively universal properties across all human languages. Such universals can be explained as consequences of the innate language faculty:and variation between languages has often been viewed as relatively superficial, and perhaps as being determined by the flipping of a rather small number of discrete "switches," which differentiate English, Hopi and Japanese (e.g., Lightfoot,; Baker,; Yang,).
By contrast, we see "universals" as products of the interaction between constraints deriving from the way our thought processes work, from perceptuo-motor factors, from cognitive limitations on learning and processing, and from pragmatic sources. This view implies that most universals are unlikely to be found across all languages; rather, "universals" are more akin to statistical trends tied to patterns of language use. Consequently, specific universals fall on a continuum, ranging from being attested to only in some languages to being found across most languages. An example of the former is the class of implicational universals, such as that verb-final languages tend to have postpositions (Dryer,), whereas the presence of nouns and verbs (minimally as typological prototypes; Croft,) in most, though perhaps not all (Evans and Levinson,), languages is an example of the latter.
Individual languages, on our account, are seen as evolving under the pressures from multiple constraints deriving from the brain, as well as cultural-historical factors (including language contact and sociolinguistic influences), resulting over time in the breathtaking linguistic diversity that characterize the about 6-8000 currently existing languages (see also Dediu et al.,). Languages variously employ tones, clicks, or manual signs to signal differences in meaning; some languages appear to lack the noun-verb distinction (e.g., Straits Salish), whereas others have a proliferation of fine-grained syntactic categories (e.g., Tzeltal); and some languages do without morphology (e.g., Mandarin), while others pack a whole sentence into a single word (e.g., Cayuga). Cross-linguistically recurring patterns do emerge due to similarity in constraints and culture/history, but such patterns should be expected to be probabilistic tendencies, not the rigid properties of a universal grammar (Christiansen and Chater,). From this perspective it seems unlikely that the world's languages will fit within a single parameterized framework (e.g., Baker,), and more likely that languages will provide a diverse, and somewhat unruly, set of solutions to a hugely complex problem of multiple constraint satisfaction, as appears consistent with research on language typology (Comrie,; Evans and Levinson,; Evans,). Thus, we construe recurring patterns of language along the lines of Wittgenstein's notion of "family resemblance": although there may be similarities between pairs of individual languages, there is no single set of features common to all.
Even if the traditional conception of language universals is too strict, the challenge remains: in the absence of a language faculty, how can we explain why language is orderly at all? How is it that the processing of myriads of different constructions have not created a chaotic mass of conflicting conventions, but a highly, if partially, structured system linking form and meaning?
The spontaneous creation of tracks in a forest provides an interesting analogy (Christiansen and Chater,). Each time an animal navigates through the forest, it is concerned only with reaching its immediate destination as easily as possible. But the cumulative effect of such navigating episodes, in breaking down vegetation and gradually creating a network of paths, is by no means chaotic. Indeed, over time, we may expect the pattern of tracks to become increasingly ordered: kinks will be become straightened; paths between ecological salient locations (e.g., sources of food, shelter or water) will become more strongly established; and so on. We might similarly suspect that language will become increasingly ordered over long periods of cultural evolution.
We should anticipate that such order should emerge because the cognitive system does not merely learn lists of lexical items and constructions by rote; it generalizes from past cases to new cases. To the extent that the language is a disordered morass of competing and inconsistent regularities, it will be difficult to process and difficult to learn. Thus, the cultural evolution of language, both within individuals and across generations of learners, will impose a strong selection pressure on individual lexical items and constructions to align with each other. Just as stable and orderly forest tracks emerge from the initially arbitrary wanderings of the forest fauna, so an orderly language may emerge from what may, perhaps, have been the rather limited, arbitrary and inconsistent communicative system of early "proto-language." In particular, for example, the need to convey an unlimited number of messages will lead to a drive to recombine linguistic elements is systematic ways, yielding increasingly "compositional" semantics, in which the meaning of a message is associated with the meaning of its parts, and the way in which they are composed together (e.g., Kirby,).
There appears to be a qualitative difference between communicative systems employed by non-human animals, and human natural language: one possible explanation is that humans, alone, possess an innate faculty for language. But human "exceptionalism" is evident in many domains, not just in language; and, we suggest, there is good reason to suppose that what makes humans special concerns aspect of our cognitive and social behavior, which evolved prior to the emergence of language, but made possible the collective construction of natural languages through long processes of cultural evolution.
A wide range of possible cognitive precursors for language have been proposed. For example, human sequence processing abilities for complex patterns, described above, appear significantly to outstrip processing abilities of non-human animals (e.g., Conway and Christiansen,). Human articulatory machinery may be better suited to spoken language than that of other apes (e.g., Lieberman,). And the human abilities to understand the minds of others (e.g., Call and Tomasello,) and to share attention (e.g., Knoblich et al.,) and to engage in joint actions (e.g., Bratman,), may all be important precursors for language.
Note, though, that from the present perspective, language is continuous with other aspects of culture:and almost all aspects of human culture, from music and art to religious ritual and belief, moral norms, ideologies, financial institutions, organizations, and political structures are uniquely human. It seems likely that such complex cultural forms arise through long periods of cultural innovation and diffusion, and that the nature of such propagation depends will depend on a multitude of historical, sociological, and, most likely, a host of cognitive factors (e.g., Tomasello,; Richerson and Christiansen,). Moreover, we should expect that different aspects of cultural evolution, including the evolution of language, will be highly interdependent. In the light of these considerations, once the presupposition that language is sui generis and rooted in a genetically-specified language faculty is abandoned, there seems little reason to suppose that there will be a clear-cut answer concerning the key cognitive precursors for human language, any more than we should expect to be able to enumerate the precursors of cookery, dancing, or agriculture.
Prior to the seismic upheavals created by the inception of generative grammar, language was generally viewed as a paradigmatic, and indeed especially central, element of human culture. But the meta-theory of the generative approach was taken to suggest a very different viewpoint: that language is primarily a biological, rather than a cultural, phenomenon: the knowledge of the language was seen not as embedded in a culture of speakers and hearers, but primarily in a genetically-specified language faculty.
We suggest that, in light of the lack of a plausible evolutionary origin for the language faculty, and a re-evaluation of the evidence for even the most minimal element of such a faculty, the mechanism of recursion, it is time to return to viewing language as a cultural, and not a biological, phenomenon. Nonetheless, we stress that, like other aspects of culture, language will have been shaped by human processing and learning biases. Thus, understanding the structure, acquisition, processing, and cultural evolution of natural language requires unpicking how language has been shaped by the biological and cognitive properties of the human brain.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
OUTPUT:
| PMC4550780 |
MultiCaRe_Reasoning49 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 72.0
Sex: Male
Title: Clostridium subterminale Septicemia in a Patient with Metastatic Gastrointestinal Adenocarcinoma
Keywords: None
Abstract:
Clostridium subterminale is a rare member of the Clostridiaceae family that is rarely cultured. This report examines a case of Clostridium subterminale cultured from the blood of a 72-year-old man who was ultimately diagnosed with metastatic gastrointestinal (GI) adenocarcinoma. The patient was receiving treatment for nosocomial pneumonia prior to culture of the C. subterminale, which led to suspicion for malignancy. Extensive GI and oncologic workup demonstrated multiple comorbidities and a primary GI cancer, which likely caused a breach in the GI mucosa and C. subterminale entrance into the bloodstream. After a prolonged intensive care unit (ICU) stay, the patient died on hospital day 23. Though rarely reported, C. subterminale septicemia has been demonstrated in patients with malignancy, specifically of the GI tract. Therefore, this case represents a typical C. subterminale septicemia patient. Given the prevalence of Clostridia and the contemporary emergence of multidrug resistant (MDR) microorganisms, both typical and atypical cases regarding rare members of the species have a significant role in the clinical management and public health planning.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 72-year-old male with a past medical history of quadriplegia, hypertension, hyperlipidemia, neurogenic bladder, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and chronic hepatitis presented to the emergency department with an acute change in mental status. He was a full-time resident at an assisted living nursing home, and his baseline mental status was awake, alert, and oriented to person, place, and time (AAOx3). Upon arrival in the emergency department, he was oriented only to self. Prior to this admission, the patient was being treated for a urinary tract infection and was on day seven of nitrofurantoin and cefepime. On examination, he was hypotensive at a blood pressure of 81/59 mmHg, pulse rate of 115 beats per minute, respiratory rate of 21 breaths per minute, and oxygen saturation of 78% while breathing ambient air. He was in visible respiratory distress and was lethargic, but arousable. He received a nebulizer treatment and was placed on a non-rebreather mask at 6 liters, after which his oxygen saturation rose to 99%. A chest X-ray was taken and revealed left lower lobe pneumonia. His urinalysis was positive for an infection despite current antibiotic compliance. He began vancomycin and piperacillin/tazobactam for health care-associated pneumonia and was admitted to the ICU. Respiratory status worsened, and he required intubation.
Despite these interventions, on his second day of admission, he continued to have copious clear secretions. Pulmonology diagnosed him with aspiration pneumonia and sputum cultures were obtained, which demonstrated moderate white blood cells, rare epithelial cells, few Gram-positive cocci in clusters, and rare yeast. His antibiotics were adjusted for sensitivities to vancomycin and meropenem. To further evaluate his ongoing pulmonary issues, a chest CT scan was obtained, revealing increasing bilateral pleural effusions and patchy sclerotic foci concerning for possible bone metastases, enlarged mediastinal lymph nodes, and nodular infiltrate in the right mid- and upper lung fields. Gastroenterology was consulted for colonoscopy to identify a primary tumor, but the patient was deemed too unstable for a nonemergent procedure. Thoracocentesis revealed exudative pleural effusions negative for malignancy. Abdominal and pelvic CT demonstrated hydronephrosis and a right-sided staghorn renal calculus but no masses.
With these interventions, our patient began to improve, yet daily sedation interruptions and spontaneous breathing trials failed. Initial blood culture results showed Gram-positive bacilli, and further speciation of the organism was requested. On day 13, blood cultures were finalized and grew Clostridium subterminale. Sputum and stool testing showed Pseudomonas aeruginosa and Clostridium difficile, so metronidazole was started. Gastroenterology again stated that the patient was too unstable for colonoscopy and suggested a bone biopsy, which he underwent the following day. The preliminary pathology report stated that the bone biopsy was likely malignant adenocarcinoma, which was confirmed on hospital day 21. Biopsy indicated that the tumor was positive for markers CK7 and CA19-9; primary sites with this immunophenotypic profile include the upper GI tract and pancreaticobiliary system. Carcinoembryonic antigen (CEA) was elevated at 73.8 (normal CEA nonsmokers < 5.1; smokers < 6.6) and CA19-9 was 3,146 (normal < 45). Per oncology, he was not a candidate for any interventions due to his comorbidities.
On day 23, he had increasing secretions and was agitated despite completion of his antibiotic course. The patient's three daughters decided on terminal extubation, and comfort measures were initiated. At 21 : 12 on hospital day 23, the patient was pronounced dead.
OUTPUT:
| PMC5987309 |
MultiCaRe_Reasoning50 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 61.0
Sex: Male
Title: Aspergillus Pericarditis with Tamponade in a Renal Transplant Patient
Keywords: None
Abstract:
Aspergillus pericarditis is a rare and life-threatening infection in immunosuppressed patients. It has nonspecific clinical manifestations that often mimic other disease entities especially in patients who have extensive comorbidities. Diagnosis is oftentimes delayed and rarely done antemortem. A high degree of suspicion in immunocompromised patients is necessary for evaluation and timely diagnosis. This is a case of Aspergillus pericarditis with cardiac tamponade in a renal transplant patient with liver cirrhosis. Two months after transplant, he developed decompensation of his cirrhosis from hepatitis C, acute cellular rejection, and Kluyvera bacteremia, followed by vancomycin-resistant Enterococcus faecium (VRE) bacteremia. Four months after transplant, the patient presented with lethargy and fluid overload. He subsequently developed shock and ventilator-dependent respiratory failure. An echocardiogram showed pericardial effusion with cardiac tamponade. He had emergent pericardiocentesis that showed purulent drainage. He was started on broad-spectrum antibiotics. Amphotericin B was initiated when the pericardial fluid grew mold that was later identified as Aspergillus fumigatus. The patient quickly decompensated and expired.
Image Caption and Description:
Image caption: Brain MRI showing multiple septic emboli.
Image description: Subsequent MRI of the brain revealed multiple septic emboli (Figure 1).
Image caption: TEE showing possible small mitral valve vegetations.
Image description: TEE showed possible small mitral valve vegetations (Figure 2) and resolution of the pericardial effusion.
Case Report:
The patient is a 61-year-old male with end stage renal disease from hypertension with cadaveric renal transplant recipient who developed acute decompensated liver cirrhosis from viral hepatitis C after transplant.
Two months after transplant, he had several episodes of gastrointestinal bleeding, urinary tract infections, and cardiac arrest with acute allograft dysfunction requiring renal replacement therapies. His mycophenolate mofetil was held. The transplant kidney biopsy showed evidence of acute cellular rejection with acute tubular necrosis that was treated with high-dose steroids. However, his allograft function never recovered and he required supportive hemodialysis. He also developed Kluyvera bacteremia followed by VRE bacteremia.
Four months after transplant, the patient presented with altered mental status and severe volume overload. On admission, the patient was lethargic, afebrile, and normotensive but tachycardic. Physical examination revealed severe anasarca and asterixis with no focal deficit. Diagnosis of metabolic encephalopathy was entertained. Urgent hemodialysis for uremia was started. His lactulose was increased for presumed hepatic encephalopathy without any improvement.
On the 5th hospital day, the patient suddenly became unresponsive, hypotensive with shock, hypoxic, and febrile. He was intubated and started on vasopressors. Chest X-ray showed left lower lobe consolidation, but did not reveal cardiomegaly. His ECG showed diffuse ST segment elevations. PR segment depressions, electrical alternans, and low QRS voltage were absent. Transthoracic echocardiogram showed moderate size pericardial effusion localized circumferentially. This was accompanied by right ventricular compression with tamponade physiology. The patient had emergent pericardiocentesis with pericardial drain placement. A total of 320 ml of purulent fluid was drained. His blood pressure improved and he was taken off vasopressors. He was also started on daptomycin and cefepime.
On the 6th hospital day, the patient continued to be lethargic. A CT scan of the head showed evidence of multifocal infarctions. Subsequent MRI of the brain revealed multiple septic emboli (Figure 1). These results raised suspicion of infective endocarditis for which a transesophageal echocardiogram (TEE) was performed. TEE showed possible small mitral valve vegetations (Figure 2) and resolution of the pericardial effusion. Blood cultures grew vancomycin-resistant Enterococcus faecium. The hemodialysis catheter was changed over the wire and culture of the catheter tip was subsequently found to be negative. Cefepime was switched to ceftaroline for better daptomycin binding to bacterial membrane.
On the 7th hospital day, mold grew in pericardial fluid culture. Amphotericin B was initiated to cover both Aspergillus and Mucor. The patient continued to clinically deteriorate and went into septic shock. The family gave him a do-not-resuscitate status and he expired on the 7th hospital day. The mold was eventually identified as Aspergillus fumigatus 10 days after the patient died.
Cardiac aspergillosis remains a diagnostic challenge especially without prior established pulmonary aspergillosis. A high degree clinical suspicion on an immunocompromised patient is needed to direct the clinical investigation. There are currently thirty-two cases of pericardial aspergillosis found in literature. Eight had clinical signs of cardiac tamponade. Only three, including our case, did not have established pulmonary or other forms of aspergillosis. Most diagnoses were postmortem. Only six out of the thirty-two were cured.
Among patients predisposed to aspergillosis, cancer is the most common underlying medical condition (44%), followed by bone marrow transplant (25%), solid-organ transplant (13%), HIV/AIDS (3.8), autoimmune (2%), and systemic steroid use (3.5%). Our patient is a renal transplant patient with concurrent immunosuppressant use. His clinical course was complicated by acute decompensated liver cirrhosis, acute renal allograft dysfunction, and severe infections within two months of renal transplant. These extensive comorbidities made him susceptible to opportunistic infections. Four months after his renal transplant, he had aspergillosis pericarditis with tamponade that eventually led to his demise.
Weiland et al. studied the clinical pattern of aspergillosis in renal transplant patients. The median time between aspergillosis infection and transplantation was found to be three and a half months. For patients with history of acute rejection, aspergillosis occurred within two months of treatment of acute rejection. These data are consistent with the clinical course of our patient. Weiland et al. also found that aspergillosis took place alongside other illnesses. The most common associated infection was CMV followed by bacterial infections. One-fourth of patients affected were also multiple transplant recipients. Weiland et al. concluded that for renal transplant patients, patients with CMV, recent acute rejection and recipients of multiple transplants appear to be more susceptible to aspergillosis.
The clinical features of cardiac aspergillosis are nonspecific and often depend on which part of the heart is involved. Myocardial aspergillosis is the most common form of the infection and can account to up to 83% of cases. It may occur alone but often with endocarditis or pericarditis. It is often asymptomatic, although it can manifest as a conduction abnormality and is usually diagnosed during autopsy.
Aspergillosis endocarditis occurs in 17% of patients and presents as fever, embolic episodes, or heart murmur. Unlike Aspergillus endocarditis where large vegetations are easily seen in echocardiography, myocardial or pericardial aspergillosis are harder to detect. Our patient had septic emboli to the brain, a frequent sequelae of endocarditis. Transesophageal echocardiogram did reveal possible small valvular vegetations. This shows that the patient may have accompanying infective endocarditis. Embolic events in the setting of aspergillosis without significant valvular vegetations may also signify mural endocarditis. Aspergillus mural endocarditis is not always apparent in echocardiograms and may start off as a subendocardial focus before developing into an abscess.
Aspergillus is difficult to grow in blood cultures. Our hospital uses Bactec Fx culture system and requires 5-7 ml of blood sample per culture bottle. In this patient, a bottle of blood culture on admission did not grow any organism. On day 5, when the patient was clinically deteriorating, repeat blood cultures consisting of two bottles only grew Enterococcus faecium. On day 6, repeat blood cultures again showed no growth in one bottle and E. faecium in the second bottle. It was only in the pericardial fluid fungal culture collected on day 5 that Aspergillus fumigatus was demonstrated and grown.
Aspergillus pericarditis occurs in multisite infections and is seen in 17% of cardiac aspergillosis. It presents as chest pain, hypotension, tamponade, or pericardial friction rub. In our patient, diffuse ST segment elevations and hypotension pointed towards cardiac tamponade. Before this, his lethargy was attributed to metabolic encephalopathy. The patient, however, quickly deteriorated and eventually expired.
The initial therapy for invasive aspergillosis is voriconazole, a broad-spectrum triazole antifungal. It has been shown to be more effective than amphotericin B and is associated with lower mortality rate. Our patient, on the other hand, was started on amphotericin B when pericardial fluid revealed mold. This is to cover for both Aspergillus and Mucor. Mucor is another mold infection that occurs in transplant patients and voriconazole does not have anti-Mucor activity. Furthermore, for patients who have liver disease like ours or for patients who cannot tolerate voriconazole, a lipid formulation of amphotericin B is the next alternative to voriconazole.
Other treatment strategies involve combination therapy of voriconazole and echinocandins. The combination therapy may be used as primary treatment or as salvage therapy. The dual therapy was shown to have superior outcomes than voriconazole alone in one study. Echinocandins, however, are not used as initial monotherapy of aspergillosis. They can be used as salvage therapy for those who cannot tolerate or are refractory to triazoles.
Invasive aspergillosis portends a poor prognosis and has a case fatality rate (CFR) of 58%. The CFR for liver transplant patients is 67.6, while kidney transplant patients' CFR is 62.5%. For pericardial aspergillosis, only six out of thirty-two patients of the cases published in literature have been cured. Factors that contributed to the survival of the six patients were early detection, recovery from immunosuppression, pericardiectomy, and combination antifungal therapy.
In conclusion, pericardial aspergillosis is a rare and fatal disease in immunosuppressed patients. It is often insidious and has nonspecific clinical manifestations. A high degree of clinical suspicion is required for early detection and diagnosis. Once diagnosed, aggressive treatment is warranted.
OUTPUT:
| PMC5337835 |
MultiCaRe_Reasoning51 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 34.0
Sex: Female
Title: Successful Treatment of Invasive Mucormycosis in Orthotopic Liver Transplant Population
Keywords: None
Abstract:
Mucormycosis is caused by ubiquitous fungi and encompasses a variety of different opportunistic syndromes in humans that disproportionately affect immunocompromised patients. Mortality has been documented to range between 50 and 100%; however, location of infection greatly dictates likelihood of survival. Treatment of mucormycosis involves aggressive surgical intervention and combination therapy of antifungal agents. In solid organ transplant recipients, immunosuppressive agents used to prevent rejection of the transplanted organ pose additional obstacles in the treatment of invasive fungal infections. We report on 3 high models for end-stage liver disease (MELD-Na) score orthotopic liver transplant (OLT) recipients who all were diagnosed with Rhizopus spp. infections with positive, 1-year outcomes after aggressive, individualized treatment.
Image Caption and Description:
Image caption: Image of cutaneous mucormycosis in patient 1 status postfasciotomy.
Image description: On this admission, the patient was taken to the operating room (OR) for fasciotomy (Figure 1).
Case Report:
The first patient is a 34-year-old Caucasian female with a past medical history consisting of autoimmune hepatitis, type 1 diabetes mellitus requiring insulin pump, end-stage renal disease, history of deep vein thrombosis, peripheral vascular disease with femoral popliteal bypass, and extensive history of solid organ transplantations (previously underwent 6 organ transplants consisting of 3 kidneys and 3 livers) with the most recent being a simultaneous liver-kidney transplant 20 months prior to presentation. The patient was being maintained on tacrolimus, mycophenolate mofetil, and prednisone for immunosuppression (Table 1). Due to loss of previous graft from rejection, she was maintained on a high-dose triple drug immunosuppressive regimen to prevent recurrence of rejection. One month prior to diagnosis, she presented with acute left leg pain and swelling felt to be secondary to chronic pain from hardware repair of extremity several years ago. She continued to experience extremity pain and was subsequently admitted. On this admission, the patient was taken to the operating room (OR) for fasciotomy (Figure 1). No necrotic tissue was found, and she was sent home with a wound vacuum. Upon follow-up with her outpatient wound clinic, fat necrosis was noted on the affected leg and a debridement was completed. A rapid genetic sequencing swab (MicroGen Diagnostics ) was run at the clinic showing 94% Enterococcus faecalis, 93% Rhizopus oryzae, and 5% Aspergillus flavus. The patient presented to our hospital for further work up of polymicrobial infection and potential invasive fungal disease.
On hospital day 2, she was started on intravenous (IV) isavuconazole 372 mg daily and returned to the OR for debridement. Preliminary tissue, fungal, and anaerobic culture reports from the OR grew diphtheroids, Klebsiella oxytoca, Enterococcus faecalis, and an unidentified mould. On hospital day 5, the cultures identified the mould as Rhizopus spp. Intravenous liposomal amphotericin B 3 mg/kg daily was added. The same day she went back to the OR for debridement, and a biopsy sample was sent to pathology. The pathology report confirmed organisms consistent with mucormycosis. On hospital day 15, she went back to the OR for another serial debridement and biopsy. That same day, fungal susceptibilities returned, displaying isavuconazole resistance (Table 2). She was switched to oral posaconazole 300 mg daily and IV micafungin 150 mg daily in addition to amphotericin B. Three days later, her wound vacuum was replaced, and the pathology report showed multifocal fungal elements seen on a Grocott-Gomori's methenamine silver stain consistent with clinical history of 'Mucor/Rhizopus.' There was necrotic tissue with no definite involvement of vessels or margins. Dermal and subcutaneous tissue displayed necrosis, hemorrhage, fibrosis, granulation tissue, and foreign body giant cell reaction. The wound vacuum was left in place, and on hospital day 20, another wound culture grew mould. At this point, given the aggressive nature of the disease, it was decided to utilize amphotericin B deoxycholate irrigation in the wound vacuum and continue systemic antimicrobials. Amphotericin B 50 mg in 1000 mL sterile water for irrigation was added to the Veraflo wound vacuum, and pulse lavages were administered to the affected area twice daily. Nine days later, the patient went back to the OR for another debridement and repeat pathology report from that sample showed no evidence of fungus. The patient received amphotericin wound vacuum irrigation with pulse lavages for a total of 20 days. She was discharged on oral posaconazole 300 mg every 8 hours and ascorbic acid 1000 mg tablet daily to help with absorption and therapeutic drug monitoring (Table 3) with plans to follow-up for the skin graft of the area. The patient remained Rhizopus spp. free at 1-year postdiagnosis.
OUTPUT:
| PMC8668347 |
MultiCaRe_Reasoning52 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Female
Title: Successful Treatment of Invasive Mucormycosis in Orthotopic Liver Transplant Population
Keywords: None
Abstract:
Mucormycosis is caused by ubiquitous fungi and encompasses a variety of different opportunistic syndromes in humans that disproportionately affect immunocompromised patients. Mortality has been documented to range between 50 and 100%; however, location of infection greatly dictates likelihood of survival. Treatment of mucormycosis involves aggressive surgical intervention and combination therapy of antifungal agents. In solid organ transplant recipients, immunosuppressive agents used to prevent rejection of the transplanted organ pose additional obstacles in the treatment of invasive fungal infections. We report on 3 high models for end-stage liver disease (MELD-Na) score orthotopic liver transplant (OLT) recipients who all were diagnosed with Rhizopus spp. infections with positive, 1-year outcomes after aggressive, individualized treatment.
Image Caption and Description:
Image caption: Patient 2 CT abdomen exhibiting bowel perforation secondary to mucormycosis.
Image description: POD18 and an indium scan exhibiting increased uptake in the abdomen; however, leukocytosis resolved and the patient was discharged to inpatient rehabilitation. Patient was then readmitted on POD30 for increased abdominal pain, and a computed tomography (CT) scan exhibited free air in her abdomen suspicious for gastric perforation (Figure 2).
Case Report:
Patient 2 is a 58-year-old Caucasian female with past medical history significant for obesity and upper gastrointestinal bleed who underwent an OLT secondary to chronic hepatitis C virus (HCV) infection and alcoholic cirrhosis. MELD-Na at time of transplant was 42. There were no immediate complications that occurred throughout the procedure. Immunosuppression consisting of a corticosteroid taper, tacrolimus, and mycophenolate mofetil (Table 1) was started on day of transplant per institution protocol. Infection prophylaxis consisted of sulfamethoxazole/trimethoprim (POD3), valganciclovir (POD1), and voriconazole (started 5 days prior to transplantation per protocol for high MELD-Na pretransplant patients in intensive care units).
On POD10, department of infectious diseases was consulted for persistent leukocytosis and abdominal cramping. Notable findings included an endoscopy exhibiting ulcerations and old blood on POD18 and an indium scan exhibiting increased uptake in the abdomen; however, leukocytosis resolved and the patient was discharged to inpatient rehabilitation. Patient was then readmitted on POD30 for increased abdominal pain, and a computed tomography (CT) scan exhibited free air in her abdomen suspicious for gastric perforation (Figure 2). The patient was emergently taken to the OR for exploratory laparotomy with findings of a large necrotic ulcer in the antrum causing spillage of gastric contents. An OR biopsy sample resulted in Rhizopus spp., and on POD33, the patient was initiated on IV liposomal amphotericin B 3 mg/kg daily, micafungin 150 mg daily, and isavuconazole 372 mg every 8 hours. After 48 hours of therapy, the patient was transitioned from isavuconazole 372 mg every 8 hours to daily. In conjunction with the antifungal regimen, weekly OR debridement and washouts were performed which resulted in persistently positive margins. After two weeks of treatment (POD46), fungal susceptibilities resulted exhibiting azole resistance with amphotericin B minimal inhibitory concentration (MIC) of 4 mcg/mL (Table 4). Due to these results, amphotericin B was increased to 5 mg/kg and oral terbinafine 500 mg every 12 hours was added. Additionally, liposomal amphotericin B 250 mg/500 mL OR irrigation dwells for 30 minutes were performed by a four-quadrant wash with abdomen oscillation with each dwell taking place 5 days a week. After a total of 8 OR amphotericin B irrigation dwell completions and continued systemic combination antifungal therapy, the patient's abdominal wall was closed on POD49. On POD53, isavuconazole was switched to IV posaconazole 300 mg every 12 hours with dose adjustments per therapeutic drug monitoring (Table 3) and nystatin 100,000 unit/mL suspension to be swallowed was added. The closure of the abdomen was complicated by dehiscence and necrotic appearing tissue at the incision site. After debridement, advancement of fasciocutaneous flap, and incisional wound vacuum placement, the amphotericin dose was transitioned to 7.5 mg/kg three times a week in preparation for discharge. Amphotericin B was continued outpatient until POD213 and posaconazole for a year from discharge. The patient remained Rhizopus spp. free at 1-year postdiagnosis.
OUTPUT:
| PMC8668347 |
MultiCaRe_Reasoning53 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 62.0
Sex: Female
Title: Successful Treatment of Invasive Mucormycosis in Orthotopic Liver Transplant Population
Keywords: None
Abstract:
Mucormycosis is caused by ubiquitous fungi and encompasses a variety of different opportunistic syndromes in humans that disproportionately affect immunocompromised patients. Mortality has been documented to range between 50 and 100%; however, location of infection greatly dictates likelihood of survival. Treatment of mucormycosis involves aggressive surgical intervention and combination therapy of antifungal agents. In solid organ transplant recipients, immunosuppressive agents used to prevent rejection of the transplanted organ pose additional obstacles in the treatment of invasive fungal infections. We report on 3 high models for end-stage liver disease (MELD-Na) score orthotopic liver transplant (OLT) recipients who all were diagnosed with Rhizopus spp. infections with positive, 1-year outcomes after aggressive, individualized treatment.
Image Caption and Description:
Image caption: Patient 3 MRI image mucromycosis growth in sinuses.
Image description: MRI findings showed persistent marked pansinusitis with focal left nasal bridge ulceration and extension of inflammation into the postseptal inferomedial extraconal fat of the left orbit with no acute intracranial abnormality identified (Figure 3).
Image caption: Patient 3 postsurgical intervention.
Image description: In POD13, the patient underwent extensive surgical intervention including a partial rhinectomy, bilateral endoscopic sinus surgery with left medial maxillectomy, resection of intranasal contents, septectomy, inferior and middle turbinate resection, bilateral ethmoidectomy, right maxillary antrostomy, and resection of left lamina papyracea (Figure 4).
Case Report:
The last patient is a 62-year-old Caucasian female with a past medical history of hypertension and coronary artery disease who underwent an OLT secondary to chronic HCV infection and alcoholic cirrhosis. MELD-Na at time of transplant was 51. Overall, the patient tolerated the procedure well. Due to intra-abdominal hemorrhage from ongoing coagulopathy, the patient's abdomen was packed with a planned second operation for completion of the biliary anastomosis on POD2. Immunosuppression with a corticosteroid taper, tacrolimus, and mycophenolate mofetil was started on the day of transplant per institution protocol (Table 1). Infection prophylaxis consisted of sulfamethoxazole/trimethoprim (POD3), valganciclovir (POD1), and voriconazole (started 24 days prior to transplant). Hepatitis B total core antibody resulted positive, and tenofovir disoproxil was initiated POD6.
On POD6, empiric antimicrobials were broadened in response to increased leukocytosis. A minibronchoalveolar lavage was performed on POD8, and cultures resulted mould on POD 10. Prophylactic voriconazole was increased to treatment dosing, and inhaled amphotericin B was started. POD12 observation of a lesion on the patient's nose raised suspicion for mucormycosis, and that same day, the cultures resulted in Rhizopus spp. Triple antifungal therapy was initiated (IV liposomal amphotericin B 7.5 mg/kg, posaconazole 300 mg every 12 hours, and micafungin 150 mg daily). MRI findings showed persistent marked pansinusitis with focal left nasal bridge ulceration and extension of inflammation into the postseptal inferomedial extraconal fat of the left orbit with no acute intracranial abnormality identified (Figure 3). In POD13, the patient underwent extensive surgical intervention including a partial rhinectomy, bilateral endoscopic sinus surgery with left medial maxillectomy, resection of intranasal contents, septectomy, inferior and middle turbinate resection, bilateral ethmoidectomy, right maxillary antrostomy, and resection of left lamina papyracea (Figure 4). Multiple returns for debridement occurred until the patient was found to have extensive necrotic tissue involving the skull base. Given involvement of the skull base, further debridement was stopped as this was unresectable. Susceptibilities resulted showing azole resistance and amphotericin B MIC of 0.25 mcg/mL (Table 5). Due to limitations of further surgical debridement and continued positive biopsy samples for 5 months postdiagnosis despite triple antifungal therapy, nasal packing was impregnated with amphotericin B deoxycholate 50 mg (1 mg/mL) and exchanged every 24 hours to accomplish a higher, localized concentration to combat the lack of tissue perfusion. The amphotericin B nasal packing was in addition to the triple antifungal therapy previously described. Three weeks after initiation of amphotericin B nasal packing, an obtained biopsy sample resulted negative for invasive fungal disease. Nasal packing was discontinued 4 days after negative results, and triple antifungal therapy was continued. The patient was discharged to a long-term acute care hospital with continuation of dual antifungal therapy (amphotericin 7.5 mg/kg daily and oral posaconazole 300 mg every 12 hours) with plan for follow-up reconstruction surgery. The patient remained Rhizopus spp. free at 1-year postdiagnosis.
OUTPUT:
| PMC8668347 |
MultiCaRe_Reasoning54 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 80.0
Sex: Female
Title: Atypical Presentation of Atraumatic Spinal Subdural Hematoma Associated with Warfarin: A Case Report and Review of the Literature
Keywords: None
Abstract:
Nontraumatic spinal subdural hematomas secondary to anticoagulants are remarkably rare. A case of spontaneous, atraumatic subdural hematoma involving the thoracic region in an 80-year-old woman on warfarin is reported. The patient presented with gross motor and sensory loss, delayed onset of incontinence, and no other symptoms. An MRI suggested an epidural hematoma concentrated around the T4-T9 levels. She was taken emergently to the OR approximately 30 hours after the initial onset of symptoms for a T3-T11 laminectomy. No epidural hematoma was noted. However, discoloration and bulging of the thecal sac were noted, and the dura was incised longitudinally from T2 to T10 revealing an expansive jelly-like blood clot which was evacuated. Postoperatively, the patient had regained 1/2 sensory function in the bilateral lower extremities. At the 2-week mark, the patient was still incontinent and showed 2/2 sensory and 2/5 motor functions in select muscle groups in her bilateral lower extremities. Completely nontraumatic, spontaneous subdural hematomas of the spine are very rare, and early surgical decompression within 24 hours from symptom onset may allow neurological recovery. Large extensive laminectomies up to 10 thoracic levels have been shown to be safe and effective in a few cases, including our case.
Image Caption and Description:
Image caption: Sagittal T1 (a) and STIR (b) images of the thoracolumbar spine. A large hyperintense signal from the proximal thoracic to the lumbar spine can be seen on the STIR image.
Image description: She was transferred to an outside hospital and underwent an MRI, which as read by an attending senior radiologist who suggested an epidural hematoma concentrated around the T4-T9 levels (Figures 1(a) and 1(b)).
Image caption: Sagittal T1 (a) and STIR (b) postoperative MRI images of the thoracolumbar spine showing a large multilevel thoracolumbar laminectomy. Postoperative fluid collections are demonstrated on the STIR image.
Image description: An MRI demonstrated a multilevel decompressive thoracolumbar laminectomy (Figures 2(a) and 2(b)), and the patient was discharged to a rehabilitation facility. At the two-month follow-up period, the patient had transitioned to a long-term nursing care facility and her neurological status remained unchanged.
Case Report:
We report on an 80-year-old Caucasian woman on warfarin for atrial fibrillation who sustained a spontaneous, atraumatic, spinal subdural hematoma in the thoracic region. The patient awoke in the morning to use the bathroom. Approximately 1 hr after returning to her bed, she was unable to move bilateral lower extremities and was incontinent. She reported no back pain, headache, nausea, vomiting, or any constitutional symptoms. She was transferred to an outside hospital and underwent an MRI, which as read by an attending senior radiologist who suggested an epidural hematoma concentrated around the T4-T9 levels (Figures 1(a) and 1(b)). She was reversed for an INR of 3.6 and then transferred to Albany Medical Center for further management. On examination, the patient was comfortable without any pain. She had a loss of bowel and bladder function and had no sensory or motor function below T5. The patient was seen by a fellowship-trained orthopaedic spine surgeon, and her spinal cord injury was classified as a T5 ASIA impairment scale A.
She was taken emergently to the OR approximately 30 hours after the initial onset of symptoms. After a T3-T11 laminectomy, the spinal cord was fully visible, but no epidural hematoma was noted. However, discoloration and bulging of the thecal sac were noted, and the dura was incised longitudinally from T2 to T10 revealing an expansive jelly-like blood clot. The hematoma was evacuated, and the dura closed with a 4'0-NUROLON.
Postoperatively, the patient had regained 1/2 sensory function in the bilateral lower extremities. At the 2-week mark, the patient was still incontinent, showed 2/2 sensory and 2/5 motor functions in select muscle groups in her bilateral lower extremities. The patient's spinal cord injury was classified as an L2 ASIA impairment scale C. An MRI demonstrated a multilevel decompressive thoracolumbar laminectomy (Figures 2(a) and 2(b)), and the patient was discharged to a rehabilitation facility. At the two-month follow-up period, the patient had transitioned to a long-term nursing care facility and her neurological status remained unchanged.
OUTPUT:
| PMC6545747 |
MultiCaRe_Reasoning55 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 37.0
Sex: Female
Title: Transvenous embolization for carotid-cavernous fistula in a patient with vascular type of Ehlers-Danlos syndrome--direct superior ophthalmic vein approach: case report
Keywords: None
Abstract:
The vascular type of Ehlers-Danlos syndrome (vEDS) is an autosomal dominant hereditary disease characterized by connective tissue fragility throughout the body, including the arteries, viscera, and gastrointestinal tract. We report a case in which we performed transvenous embolization (TVE) via direct superior ophthalmic vein (SOV) approach to treat a direct carotid-cavernous fistula (CCF) in a patient with Ehlers-Danlos syndrome (EDS). The patient was a 37-year-old woman who developed tinnitus in her left ear and a headache during examination in the outpatient clinic of another hospital in order to make a definitive diagnosis of vEDS, and she was referred to our hospital and examined. Based on the results of all of the studies she was diagnosed with a CCF. Conservative treatment was attempted, but was not very effective. Because of progressing aphasia, TVE was performed via the SOV direct cut. There were no intraoperative or postoperative complications. It has been reported that cerebral angiography is generally contraindicated in vEDS and that the morbimortality associated with endovascular treatment is very high. When performing treatment it is necessary to be sufficiently aware of the risks it entails.
Image Caption and Description:
Image caption: Dynamic CTA (preop: axial lateral). A: Dynamic CTA shows dilatation of the left SOV and insufficient intracranial circulation. B: Dynamic CTA shows aggravation of CCF. An increase in the dilatation of the left SOV can be observed in addition to intracranial cortical vein reflux. C: Dilatation of the left SOV and marked retrograde flow in the left intracranial veins can be seen. CCF: carotid-cavernous fistula, CTA: computed tomography angiography, SOV: superior ophthalmic vein.
Image description: Although the symptoms temporarily improved in response to intermittent manual compression of the carotid artery, they became more severe again (Fig. 1).
Image caption: Preoperative, intraoperative, and postoperative DSA, DA (lateral view). Preoperative (top), intraoperative (middle), and postoperative (bottom). Digital subtraction angiograms (left common carotid arteriogram, lateral view). Preoperative angiogram: A large-volume direct carotid-cavernous fistula (CCF) shunt into the jugular vein is visible in the vicinity of the internal carotid artery at C3-4 in the early arterial phase. Outflow via the shunt into the left superior ophthalmic vein, left sylvian vein, left pterygoid sinus, and venous plexus is visible. More specifically, there was retrograde flow from the left sylvian vein to the cortical veins, and the veins had become dilated and tortuous. In addition, there was also retrograde flow to the right superior ophthalmic vein via the cavernous sinus. Hardly any normal circulation from the arteries into the cranium was observed. Postoperative angiogram: Retrograde flow from posterior to the cavernous sinus into the posterior cranial fossa and retrograde flow into the venous plexus were observed, and although a residual CCF was visible, because the retrograde flow into the right cavernous sinus had resolved and sufficient normal circulation had developed.
Image description: Marked retrograde flow into the intracranial veins was observed, and treatment was performed as described below (Fig. 2).
Case Report:
The patient was a 37-year-old woman with a history of intestinal perforation, but no history of cranial or orbital trauma recently.
While undergoing genetic diagnosis of vEDS in the outpatient clinic of another hospital, the patient experienced a sudden onset of a vascular murmur in the vicinity of the left ear, tinnitus, and a headache. The tinnitus disappeared when the left carotid artery was compressed, and a bruit was heard over the left eyeball. No clear abnormal findings were detected by computed tomography (CT) of the head, but magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head revealed a CCF, and the patient was referred to our hospital and examined.
The patient's consciousness level was clear on arrival at our hospital. Ophthalmological examination indicated corrected visual acuity of 1.0/1.0. Bilateral Amsler grid testing indicated no abnormalities at any point in either visual field. The left eye was markedly red with dilated irregular conjunctival and subconjunctival vessels. Hess chart testing indicated abducens nerve paralysis. Based on the patient's family history, past medical history, and the imaging findings, there was a strong possibility of a CCF complicating EDS, and because of the possibility that angiography would cause vascular injury, the preoperative evaluation was performed by 3D CTA.
Elder brother: Dissection of the thoracic aorta
Father's family: Rupture of the abdominal aorta, sudden death
Although the symptoms temporarily improved in response to intermittent manual compression of the carotid artery, they became more severe again (Fig. 1). Because of the development of higher function disorders, including aphasia and agnosia, associated with marked cortical reflux within the cranium, endovascular treatment (TVE) was performed under general anesthesia. A direct CCF from the vicinity of the left internal carotid artery (ICA) at the C3-4 level was confirmed by digital subtraction angiography (DSA). Marked retrograde flow into the intracranial veins was observed, and treatment was performed as described below (Fig. 2).
OUTPUT:
| PMC4508704 |
MultiCaRe_Reasoning56 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 31.0
Sex: Male
Title: Wernicke's Encephalopathy: An Unusual Consequence of the Acquired Immune Deficiency Syndrome-Case Report and Literature Review
Keywords: None
Abstract:
Introduction. Wernicke's encephalopathy is a well-described syndrome characterized by the classic triad of confusion, ataxia, and ophthalmoplegia. Wernicke's encephalopathy results from thiamine (vitamin B1) deficiency. Common causes include alcoholism and gastric disorders. Wernicke's has been described in patients with acquired immune deficiency syndrome (AIDS); however, given these patients' immunosuppressed state, the diagnosis of Wernicke's encephalopathy is not apparent. Case Presentation. A 31-year-old previously healthy male presented to the ER complaining of progressive dyspnea. Workup revealed HIV/AIDS and PCP pneumonia. He was treated and improved. On day 14 he became confused and developed nystagmus and ataxia. Considering his immunocompromised state, infectious and neoplastic etiologies topped the differential diagnosis. CT head was negative. Lumbar puncture was unremarkable. Brain MRI revealed increased T2 signal in the medial thalamus bilaterally. Intravenous thiamine was administered resulting in resolution of symptoms. Discussion. The classic triad of Wernicke's encephalopathy occurs in 10% of cases. When immunosuppressed patients develop acute neurologic symptoms infectious or neoplastic etiologies must be excluded. However, given the relative safety of thiamine supplementation, there should be a low threshold for initiating therapy in order to reverse the symptoms and prevent progression to Korsakoff dementia, which is permanent.
Image Caption and Description:
Image caption: Upright posterior-anterior projection chest X-ray demonstrating diffuse reticular-nodular opacities in both lungs.
Image description: Chest X-ray showed diffuse bilateral reticulonodular opacities (Figure 1).
Image caption: Grocott's methenamine silver (GMS) stain of bronchoalveolar lavage specimen demonstrating black staining round cysts (arrow) in the alveolar exudate diagnostic of Pneumocystis jiroveci pneumonia.
Image description: Bronchoalveolar lavage was preformed; Grocott's methenamine silver stain of the washings demonstrated Pneumocystis jiroveci (Figure 2).
Image caption: MRI demonstrating slight increase in T2 signal in the medial bilateral thalamus (arrows).
Image description: MRI of the brain revealed a slight increase in T2 signal within the medial aspect of thalamus bilaterally (Figure 3).
Case Report:
A 31-year-old male presented to the emergency room complaining of progressive dyspnea and productive cough over the course of 4 months. He also noted decreased appetite with a 50-pound weight loss over the past 5 months. He had no significant past medical or surgical history and was not taking any medications. His family history was unremarkable. He quit smoking tobacco two months ago due to worsening respiratory status; he rarely used alcohol and never used recreational drugs. He was unmarried and in a long-term heterosexual relationship and denied multiple sexual partners. He was currently working in an automobile parts factory as a janitor. After high school he had enlisted in the army and served for four years; at that time he was stationed in Hawaii. While in Hawaii he visited a single prostitute on several occasions.
Initial vital signs revealed temperature was 99.9 F, blood pressure 128/83 mmHg, pulse 134 beats per minute, and respiratory rate 22 breaths/minute; oxygen saturation was 92% on room air. He was in moderate respiratory distress, yet was awake, alert, and cooperative. Extraocular muscles were intact; there was no nystagmus or scleral icterus. Pupils were equal, round, and reactive to light. He had thrush under his tongue and on the palate. There was no palpable lymphadenopathy. Heart rate was regular with no murmurs, rubs, or gallops by auscultation. There were no palpable thrills. He had equal chest rise bilaterally. Breath sounds were diminished throughout, with rales and dullness to percussion in the lower lung fields bilaterally. Sensory and motor examination was grossly intact.
Laboratory data revealed white blood count 13,900/mcL, hemoglobin 7.2 g/dL, platelets 370,000/mcL, sodium 131 mmol/L potassium 5.8 mmol/L, chloride 99 mmol/L, carbon dioxide 17 mmol/L, blood urea nitrogen 155 mg/dL, and serum creatinine 8.9 mg/dL. Arterial blood gases showed a pH of 7.39, pCO2 32.2 mmHg, bicarbonate 19.1 mmol/L, and pO2 74.5 mmHg on 3 L nasal cannula. Chest X-ray showed diffuse bilateral reticulonodular opacities (Figure 1). He was found to be HIV positive with CD4 count of <5 cells/cc and viral load of 1,180,000 copies. Bronchoalveolar lavage was preformed; Grocott's methenamine silver stain of the washings demonstrated Pneumocystis jiroveci (Figure 2). He received antibiotics and steroids with gradual improvement.
On hospital day 14, he became confused and acutely developed nystagmus with both a horizontal and prominent vertical component. He was also found to have ataxia with finger to nose testing and difficulty sitting up without support. Considering his immunosuppressed state, infectious and neoplastic etiologies were the primary diagnostic considerations. Lumbar puncture revealed clear CSF, normal opening pressure, and normal cell counts. Polymerase chain reactions for Epstein-Barr virus, Herpes simplex virus, cytomegalovirus, and John Cunningham (JC) virus were negative. Nontreponemal serological screening for syphilis (VDRL), toxoplasmosis antibody, and Cryptococcus antigen titers were negative. CT of the head did not show any intracranial mass, hemorrhage, or other acute findings. MRI of the brain revealed a slight increase in T2 signal within the medial aspect of thalamus bilaterally (Figure 3). After excluding infection and neoplasm, the clinical diagnosis of Wernicke's encephalopathy was made. Intravenous thiamine was administered resulting in resolution of symptoms, which confirmed the diagnosis.
OUTPUT:
| PMC3722985 |
MultiCaRe_Reasoning57 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 48.0
Sex: Female
Title: Severe hypereosinophilic syndrome successfully treated with a monoclonal antibody against interleukin 5 receptor α - benralizumab
Keywords: hes; il-5; il-5 receptor; benralizumab; hypereosinophilic syndrome; monoclonal antibody;
Abstract:
Hypereosinophilic syndrome (HES) is a group of a rare diseases characterized by marked eosinophilia in blood or tissue and eosinophil-related clinical manifestations. Benralizumab is a humanized, monoclonal antibody against interleukin 5 (IL-5) receptor α, which is expressed on human eosinophils. Here, we present the case of a patient with severe HES in whom treatment with benralizumab, an anti-IL-5 receptor monoclonal antibody, was initiated 6 months ago. Prior to benralizumab administration, the patient was treated with glucocorticoids (GS) and mepolizumab. However, instead of the applied treatment and normal level of peripheral eosinophils the patient presented with fluctuating lower respiratory tract symptoms and recurrent exacerbations of HES. Treatment with benralizumab (30 mg s.c. every 4-6 weeks) was started, resulting in significant improvement of respiratory signs and symptoms, normalization of eosinophil count and significant reduction of the methylprednisolone dose (after 5 doses of benralizumab administration). No substantial side effects have been noted during treatment and 6-month follow-up. We argue that in the severe and relapsing course of HES, rescue treatment with benralizumab should be taken into account, particularly in cases of relative inefficacy of GS and mepolizumab.
Image Caption and Description:
Image caption: CT scan: diffuse pansinusitis (12.06.2019)
Image description: However, instead of the applied treatment and normal level of peripheral eosinophils (< 500 cells/microl) she presented with fluctuating lower respiratory tract symptoms (wheezing, rhonchi, cough, dyspnea), recurrent exacerbations of pansinusitis with persisting hearing impairment (Fig. 1).
Image caption: Ground glass opacities on high-resolution CT (31.12.2019)
Image description: Ground glass opacities on high-resolution CT were described (Fig. 2).
Case Report:
In June 2017, a nonsmoker 48-year-old woman with a history of persistent bronchial asthma and chronic pansinusitis was diagnosed with respiratory failure in the course of hypereosinophilic syndrome. Computed tomography (CT) of the chest showed massive interstitial infiltrates and laboratory tests revealed eosinophilia (8286 cells/microl). Therapy with systemic and inhaled glucocorticoids and inhaled bronchodilators was started, with moderate improvement. Further workup displayed elevated level of eosinophils (8%) in bronchoalveolar lavage (BAL) fluid and negative antinuclear and antineutrophil cytoplasmic antibodies. Previous attempts to taper oral GS led to flare of the disease; therefore the patient had add-on therapy with the humanized anti-IL-5 monoclonal antibody mepolizumab for several months (last dose was given in May 2019). However, instead of the applied treatment and normal level of peripheral eosinophils (< 500 cells/microl) she presented with fluctuating lower respiratory tract symptoms (wheezing, rhonchi, cough, dyspnea), recurrent exacerbations of pansinusitis with persisting hearing impairment (Fig. 1). In July 2019 functional endoscopic sinus surgery was performed, revealing eosinophilic (approx. 10% of the cells) chronic infiltrates of the mucosal stroma.
In December 2019 the patient was admitted to the Department of Rheumatology and Immunology due to exertional dyspnea and cough. Physical examination revealed diffuse expiratory wheezing and prolonged expiration. Initial workup revealed blood eosinophilia (2840 cells/microl) and an elevated level of immunoglobulin E (134 IU/ml, reference range < 100); with normal levels of vitamin B12, tryptase and immunoglobulin G. There were no parasitic eggs or larvae in a stool sample. The patient was negative for FIP1L1-PDGFRA, JAK2 and ETV6-PDGFRB mutations. A bone marrow aspirate revealed an elevated level of eosinophils (< 10% of the cells); no other pathologies were identified. Cytogenetic analysis showed a normal female karyotype. Ground glass opacities on high-resolution CT were described (Fig. 2). Bacterial and fungal cultures of BAL fluid did not yield any organisms. Increased eosinophils in BAL fluid (10%) confirmed HES flare. Therapy with intravenous methylprednisolone (40 mg daily for 5 days, subsequently tapered), combined with inhaled GC and bronchodilators was started. Reduction of methylprednisolone dose less than 32 mg daily led to HES flare.
OUTPUT:
| PMC8574116 |
MultiCaRe_Reasoning58 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 36.0
Sex: Female
Title: Adult congenital horseshoe lung with bilateral pulmonary sequestration: A case report
Keywords: cta; horseshoe lung; adults; pulmonary sequestration;
Abstract:
Horseshoe lung (HL) is an infrequent congenital lung anomaly. Its main feature is that the lower lungs on both sides extend behind the pericardium and fuse across the midline, usually accompanied by pulmonary dysplasia. It is reported that 80% of HL is relevant to the abnormal return of some pulmonary veins from the right lung to the inferior vena cava or right atrium (scimitar syndrome). Most patients are within 5 years old, most commonly within 1 year old, but HL may also have no apparent clinical symptoms or mild symptoms. This case is a 36-years-old adult female who developed left chest pain more than a month ago and continued to worsen for 10 days. The patient also had repeated pulmonary infection with cough and expectoration.
Image Caption and Description:
Image caption: The lung window in axial and sagittal position of multi-detector spiral CT shows that the bilateral basal lung isthmus is connected, extending behind the pericardium and crossing the midline for fusion. The left lower lung basal segment has sparse lung markings, with increased transparency, and patchy shadows can be seen near the spine at the bottom of both lungs.
Image description: There was an obvious pleural interface between the isthmus and the left lung (arrow) (Figures 1 and 2).
Image caption: The lung window in sagittal position of multi-detector spiral CT: there is an obvious pleural interface between the isthmus and the left lung (arrow).
Image description: There was an obvious pleural interface between the isthmus and the left lung (arrow) (Figures 1 and 2).
Image caption: Transparent imaging shows the isthmus lung tissue among the lungs (arrow).
Image description: Transparent imaging (Figure 3) showed the isthmus lung tissue among the lungs (arrow).
Image caption: The three-dimensional volume-rendered imaging of the bronchus shows that the bronchial branches of the lower lobe of the left lung are thinner than those of the right side. Cystic changes can be seen at the beginning of the lower lobe of the left lung. The outer and posterior basal segments of the lower lobe of the left lung fuse at the beginning, and the distal branches are sparse (arrows).
Image description: The three-dimensional volume-rendered imaging of the bronchus (Figure 4) showed that the bronchial branches of the lower lobe of the left lung were thinner than those of the right side.
Image caption: Maximum intensity projection (MIP) can be seen in the basal segment of the lower lobe of both lungs, with the left lung as the focus, and multiple calcified nodules can be seen in it.
Image description: Thoracic CT angiography scanning (Figures 5 and 6): consolidation shadow could be seen in the basal segment of the lower lobe of both lungs, with the left lung as the focus, and multiple calcified nodules could be seen in it.
Image caption: Volume-rendering image of CT angiography (CTA): the blood supply arteries of bilateral lesions directly originate from the adjacent trunk of thoracic aorta (arrows).
Image description: Thoracic CT angiography scanning (Figures 5 and 6): consolidation shadow could be seen in the basal segment of the lower lobe of both lungs, with the left lung as the focus, and multiple calcified nodules could be seen in it.
Case Report:
The patient was a 36-year-old female. The left side chest pain occurred more than 1 month ago and continued to deteriorate for 10 days. She had repeated pulmonary infection, accompanied by cough and expectoration. Her maximum temperature was 38.5 C, without chest tightness and dyspnea. Physical examination: the chest was barrel shaped, and no definite abnormality was found in chest auscultation and palpation. Cardiac examination was normal. The laboratory test of human immunodeficiency virus (HIV) was negative, and there was no contact history of tuberculosis. The patient's abdominal CT plain scan showed no obvious abnormality.
The lung window in axial and sagittal position of multi-detector spiral CT showed that the bilateral basal lung isthmus was connected, extending behind the pericardium and crossing the midline for fusion. The left lower lung basal segment had sparse lung markings, with increased transparency, and patchy shadows could be seen near the spine at the bottom of both lungs. There was an obvious pleural interface between the isthmus and the left lung (arrow) (Figures 1 and 2). Transparent imaging (Figure 3) showed the isthmus lung tissue among the lungs (arrow). The three-dimensional volume-rendered imaging of the bronchus (Figure 4) showed that the bronchial branches of the lower lobe of the left lung were thinner than those of the right side. Cystic changes could be seen at the beginning of the lower lobe of the left lung. The outer and posterior basal segments of the lower lobe of the left lung fused at the beginning, and the distal branches were sparse. Thoracic CT angiography scanning (Figures 5 and 6): consolidation shadow could be seen in the basal segment of the lower lobe of both lungs, with the left lung as the focus, and multiple calcified nodules could be seen in it. The blood supply arteries of bilateral lesions directly originated from the adjacent trunk of thoracic aorta (arrows).
OUTPUT:
| PMC9869191 |
MultiCaRe_Reasoning59 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 55.0
Sex: Male
Title: Quality-of-life benefits and evidence of antitumour activity for patients with brain metastases treated with gefitinib
Keywords: None
Abstract:
Brain metastases are a common complication of non-small-cell lung cancer (NSCLC). The role of chemotherapy in the treatment of brain metastases has not been clearly defined. Emerging case reports of patients with recurrent NSCLC treated as part of the Expanded Access Programme reveal that gefitinib ("Iressa", ZD1839) has clinical activity in some patients with brain metastases. Here, we describe a number of case studies documenting the response of patients with brain metastases to treatment with gefitinib. Many of these patients had quality-of-life benefits with improvement of neurological and systemic symptoms; some had a partial response of their brain metastases and even complete responses have been seen in a few patients. One case report also describes a durable long-term response with concurrent treatment with gefitinib and radiotherapy. Such results call for larger trials designed to evaluate and define the role of gefitinib in the treatment of brain metastases in NSCLC patients, either as a single agent or in combination with radiation therapy.
Image Caption and Description:
Image caption: Computed tomography scan before and after treatment with gefitinib. Reproduced with permission from: Cappuzzo F, Calandri C, Bartolini S, Crino L (2003b).
Image description: The complete response in the brain was observed 6 weeks after treatment with gefitinib started in a patient who had completed whole-brain radiotherapy 3 months prior to the beginning of gefitinib (Figure 1).
Image caption: Case history of a patient with NSCLC and brain metastases taking gefitinib. Data previously presented by: van Zandwijk N. Risk/benefit of gefitinib ('Iressa', ZD1839). Oral presentation at the ICE meeting, Madrid, June 2003. Used with permission.
Image description: ICE meeting showed good tolerance of concurrent gefitinib and radiotherapy (van Zandwijk [b], ICE abs, personal communication). In this case study, a 55-year-old male exsmoker with stage IV NSCLC and multiple pulmonary (lymphangitic) metastases developed multiple brain metastases (approximately 20 small lesions) after receiving treatment with gefitinib for >1 year (Figure 2).
Image caption: Computed tomography scan before and after treatment with gefitinib and radiotherapy (case history shown in Figure 2). Previously presented by: van Zandwijk N. Risk/benefit of gefitinib ('Iressa', ZD1839). Oral presentation at the ICE meeting, Madrid, June 2003. Reproduced with permission.
Image description: Delayed imaging 9 months later showed almost complete resolution of the brain metastases (Figure 3).
Case Report:
The case reports of patients with brain metastases secondary to NSCLC treated with gefitinib as part of the compassionate-use programme have recently been reported as published case studies, at the World Conference on Lung Cancer 2003, at the American Society of Clinical Oncology 2003 conference and at the 'Iressa' Clinical Experience (ICE) meeting (Awada, ICE abs; Cappuzzo [a & b], ICE abs; Dieriks, ICE abs; Stein, ICE abs; de la Cruz [a & b], ICE abs; Maione, ICE abs; Martinez, ICE abs; Diaz-Canton, ICE abs; van der Kamp, ICE abs; van Zandwijk [b], ICE abs; Petruzelka [a], ICE abs; Azemar, ICE abs; Roggero, ICE abs; Kowalski, ICE abs; Martin-Algarra, ICE abs; Pavlakis, ICE abs). (See appendix for ICE abstracts). Together, these case reports suggest that gefitinib has activity in NSCLC brain metastases. The results of published case series are shown in Table 1 .
Most notable are the cases with a complete remission of brain metastases. In the largest case series that included 27 patients who had asymptomatic or symptomatic brain metastases, two of 20 evaluable patients had a response in the brain, with complete remission in one patient. In another case series described in two separate publications by Cappuzzo et al, eight patients with NSCLC and brain metastases were treated with gefitinib (; [a & b] ICE abs). One patient had a complete response and seven had partial responses in the brain, all within 3 months of treatment. The complete response in the brain was observed 6 weeks after treatment with gefitinib started in a patient who had completed whole-brain radiotherapy 3 months prior to the beginning of gefitinib (Figure 1). All eight patients experienced improvements in neurological and systemic symptoms.
described the case report of a patient who had achieved a complete response in the brain following treatment with gefitinib. This particular patient was diagnosed in July 1999 with stage IV adenocarcinoma of the left lung. In March 2001, after treatment with three different chemotherapy regimens, asymptomatic brain metastases were detected and subsequently treated with whole-brain radiotherapy. However, by October 2001 the patient's condition had deteriorated, with progressive brain metastases, and the patient was readmitted to hospital. Treatment with gefitinib started in November 2001 after which computed tomography scans showed that brain metastases had disappeared and that there was a marked regression of the lung tumour. The patient was then discharged in December 2001 and was able to resume full-time work for nearly 8 months. Two other published case reports also describe patients whose brain metastases responded to treatment. In all three of these cases, patients had worsening neurological symptoms and deteriorating performance status before treatment with gefitinib. Following treatment, a significant clinical improvement was seen in all three patients: brain metastases disappeared in the patient already described and the sizes of the other two patients' lesions decreased. Quality of life was improved in all three patients.
One patient described at the ICE meeting showed good tolerance of concurrent gefitinib and radiotherapy (van Zandwijk [b], ICE abs, personal communication). In this case study, a 55-year-old male exsmoker with stage IV NSCLC and multiple pulmonary (lymphangitic) metastases developed multiple brain metastases (approximately 20 small lesions) after receiving treatment with gefitinib for >1 year (Figure 2). Radiotherapy to the brain (10 x 3 Gy) and continued treatment with gefitinib resulted in disease stabilisation and symptom improvement and the patient was able to return to work. Delayed imaging 9 months later showed almost complete resolution of the brain metastases (Figure 3). Thus, although gefitinib did not prevent the development of brain metastases, concurrent treatment with radiotherapy and gefitinib resulted in a durable clinical response.
In total, 25 case reports of gefitinib use in patients with brain metastases and NSCLC were described at the ICE meeting (including the eight patients described by Cappuzzo et al) (Awada, ICE abs; Cappuzzo [a & b], ICE abs; Dieriks, ICE abs; Stein, ICE abs; de la Cruz [a & b], ICE abs; Maione, ICE abs; Martinez, ICE abs; Diaz-Canton, ICE abs; van der Kamp, ICE abs; van Zandwijk [b], ICE abs; Petruzelka [a], ICE abs; Azemar, ICE abs; Roggero, ICE abs; Kowalski, ICE abs; Martin-Algarra, ICE abs; Pavlakis, ICE abs). Of these, three patients had a complete response, 10 a partial response, eight had stable disease and four patients had progression of their brain metastases. In all of these case reports, treatment with gefitinib appears to have been well tolerated. Any reported adverse events are consistent with the adverse-event profile of gefitinib established in Phase II trials in patients with advanced NSCLC. There was also no unexpected or cumulative toxicity described for the patient who received concurrent gefitinib and radiotherapy (van Zandwijk [b], ICE abs).
OUTPUT:
| PMC2750244 |
MultiCaRe_Reasoning60 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 41.0
Sex: Male
Title: Respiratory failure caused by intrathoracic amoebiasis
Keywords: hiv; agranulocytosis; amebiasis; amoebic empyema; trimethoprim-sulfamethoxazole;
Abstract:
A 41-year-old male was admitted to the hospital with symptoms of diarrhea, fever and rapidly progressive respiratory distress. A chest radiograph and computed tomography (CT) of the chest and the abdomen showed a large amount of right pleural effusion and a large liver abscess. The patient was thus diagnosed to have amoebic colitis, amoebic liver abscess and amoebic empyema complicated with an HIV infection. The patient demonstrated agranulocytosis caused by the administration of trimethoprim-sulfamethoxazole. However, the administration of granulocyte colony-stimulating factor made it possible for the patient to successfully recover from agranulocytosis, and he thereafter demonstrated a good clinical course.
Image Caption and Description:
Image caption: Chest radiography showing complete opacity of the right lung with a shifted mediastinum to the left.
Image description: A chest radiograph and computed tomography (CT) of the chest showed a large amount of right pleural effusion (Figure 1).
Image caption: Computed tomography (CT) of the abdomen showing a large liver abscess.
Image description: A CT scan of the abdomen detected large liver abscess (Figure 2).
Image caption: The features of the pleural fluid showing a milk-chocolate brown or cafe au lait color.
Image description: Thoracentesis revealed milk chocolate or cafe au lait colored pleural fluid (Figure 3).
Case Report:
A 41-year-old male was admitted to the hospital with symptoms of diarrhea, fever, dyspnea and right pleural effusion. The illness began in the latter part of August 2008, initially presenting with diarrhea and fever. He was an MSM and the serology for HIV antibody was positive. He had no history of traveling abroad, alcoholism, any medication or intravenous drug use. His vital signs on admission were; conscious, blood pressure 95/60 mmHg, pulse late 146 beats/min, respiration, 45 breaths/min, saturation O2 (room air), 88% and body temperature 39 C. The notable findings of a physical examination included emaciation (BMI 16.1), oral candidasis and decreased breath sounds on the right side of his chest. A chest radiograph and computed tomography (CT) of the chest showed a large amount of right pleural effusion (Figure 1). A CT scan of the abdomen detected large liver abscess (Figure 2). The laboratory data included a leukocyte count of 10,320/muL with 89% neutrophils, 8% lymphocytes, 3% monocytes, hemoglobin 8.8 g/dL, C-reactive protein 23.6 mg/dL, aspirate aminotransferase 95 U/L, alanine aminotransferase 74 U/L, alkaline phosphatase 478 U/L, gamma-glutamyl transpeptidase 134 U/L, albumin 2.1 g/dL, total cholesterol 57 mg/dL, blood urea nitrogen 18.4 mg/dL, creatine 0.57 mg/dL and hyponatremia (123 mEq/L). The findings of human immunodeficiency virus type 1 antibody tests were positive for enzyme immunoassays (EIA) and also based on the Western blot method. Thoracentesis revealed milk chocolate or cafe au lait colored pleural fluid (Figure 3). In an examination of the pleural fluid, cytology, bacterial culture, smear and polymerase chain reaction to detect Mycobacterium tuberculosis DNA were negative, the adenosine deaminase activity was 240 IU/L. The pleural fluid showed a cell count of 40125/mL (74.3% neutrocytes, 25.7% monocytes). Other examinations of the laboratory findings detected cysts of Entamoeba histolytica in the patient's stool. The CD4 lymphocyte count in the peripheral blood was 179/muL (repeated counts for CD4 lymphocytes ranged from 286 to 359/muL) and the amount of HIV-RNA was 3700 copies/muL (repeated counts for HIV-RNA ranged from 43,000 to 90,000 copies/mL). Although E. histolytica was not identified from the pleural fluid, antibodies (fluorescence antibody technique) against E. histolytica were demonstrated in the serum (200x). The patient was thus diagnosed to have amoebic colitis, amoebic liver abscess and amoebic empyema complicated with an HIV infection. The right side pleural effusion was drained using a chest tube and he was administered metronidazole (2250 mg/day) orally for 28 days in total. A large volume of pus was drained from the right thoracic space. A small volume remained. The right lung was re-expanded. His fever, dyspnea and general condition significantly improved thereafter. The patient was therefore administered trimethoprim-sulfamethoxazole to prevent pneumocystis pneumonia and itraconazole to prevent fungal infections. However, he developed agranulocytosis 22 days after administration. The absolute neutrophil count was 0/muL. Agranulocytosis in this case was therefore considered to have been caused by the administration of trimethoprim-sulfamethoxazole. After the discontinuation of trimethoprim-sulfamethoxazole, the recombinant human granulocyte colony-stimulating factor (G-CSF) drug filgrastim was administered daily at a dose of 200 mug/m2 intravenously. Following 4 days of treatment with G-CSF, the patient's absolute neutrophil count was above 9/muL, while after 7 days of treatment it was 2990/muL (white blood cell count 4600/muL, neutrophils 65%). The patient did not demonstrate any further infection during the clinical course. He was discharged 45 days after admission.
OUTPUT:
| PMC3108731 |
MultiCaRe_Reasoning61 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 74.0
Sex: Female
Title: A Case of Adult T-Cell Leukemia/Lymphoma Complicated with Bilateral Chylothorax
Keywords: None
Abstract:
We present the case of a 74-year-old Japanese woman who presented with dyspnea, a palpable right breast mass, and swollen right axillary lymph node. Imaging studies revealed bilateral pleural effusion and systemic lymph adenopathy and pleural fluid study showed high levels of triglycerides. A right inguinal lymph node biopsy disclosed malignant lymphoma cells that were human T-cell leukemia virus type 1 (HTLV-1) provirus DNA-positive, a condition endemic to patient's birthplace, by the Southern blot hybridization method. She was diagnosed as having adult T-cell leukemia/lymphoma (ATL) with chylothorax. After commencing chemotherapy for ATL, her chylothorax disappeared and swollen lymph nodes reduced remarkably, indicating an association between the chylothorax and ATL. Bilateral chylothorax is a relatively rare condition associated with such nontraumatic causes as ATL. Clinicians should therefore bear chylothorax in mind when encountering patients with pleural effusion. A detailed medical history can also enable prompt diagnosis and appropriate treatment.
Image Caption and Description:
Image caption: Computed tomography of the chest and abdomen depicted bilateral pleural effusion (arrows) (a, b) and ascites (arrowheads) (c). Axillary lymph adenopathy (circles) (b) and inguinal lymph adenopathy (circles) (d) were present.
Image description: A contrast-enhanced computed tomography (CT) scan of the chest and the abdomen revealed bilateral pleural effusion and ascites with lymphadenopathy (Figure 1).
Image caption: Appearance of bilateral pleural effusion of the chest was lightly bloody and chylous from each thoracic cavity.
Image description: Bilateral pleural effusion samples appeared chylous (Figure 2) with high triglyceride concentrations (Table 2) and class III cytology.
Image caption: Histological findings of the right inguinal lymph node displayed diffuse architectural effacement (a). Neoplastic cells were medium- to large-sized with nuclear pleomorphism (b).
Image description: A biopsy obtained from the right inguinal lymph node showed diffuse infiltration of moderate- to large-sized lymphoid cells with a pleomorphic nucleus and prominent nucleoli (Figure 3) that were CD3+, CD4+, CD5+, CD8-, CD20-, and CD21- on immunohistochemistry (Figure 4).
Image caption: Tumor cells were CD3+ (a), CD4+ (b), CD5+ (c), CD8- (d), CD 20- (e), and CD21- (f) on immunohistochemistry.
Image description: A biopsy obtained from the right inguinal lymph node showed diffuse infiltration of moderate- to large-sized lymphoid cells with a pleomorphic nucleus and prominent nucleoli (Figure 3) that were CD3+, CD4+, CD5+, CD8-, CD20-, and CD21- on immunohistochemistry (Figure 4).
Image caption: Southern blot analysis of HTLV-1 provirus DNA depicted two bands (red arrows) in after BamH-I digestion and two bands (red arrows) after Hind III digestion. 1: BamH-I; 2: EcoR-V; 3: Hind III.
Image description: Two monoclonal bands for HTLV-1 provirus DNA were observed in lymph node specimens by Southern blot hybridization analysis (Figure 5).
Image caption: Clinical course of the patient. Abbreviations: PSL: prednisolone; LDH: lactate dehydrogenase; sIL-2R: soluble interleukin-2 receptor.
Image description: The clinical course of the patient is summarized in Figure 6.
Case Report:
A 74-year-old Japanese woman was referred to our hospital with dyspnea, a palpable mass in the right breast, and an enlarged lymph node in the right axilla that had worsened during the two months before admission. History taking revealed that she had moved from her birthplace in Kumamoto prefecture of southwestern Japan to Nagano prefecture after marriage. She had no other remarkable history of disease, transfusion, medication, or drug abuse.
On presentation, patient's body temperature was 37.2 C with a heart rate of 127 bpm and peripheral artery oxygen saturation of 92% in ambient air. Her vesicular sounds decreased without crackling on chest auscultation. Physical examination revealed a distended abdomen without hepatosplenomegaly. Systemic lymphadenopathy and pretibial edema pitting were noted.
Blood examination (Table 1) disclosed a lymphocyte count of 680/muL and less than 1% morphological flower cells. Peripheral laboratory tests were as follows: aspartate aminotransferase, 37 U/L; alanine aminotransferase, 6 U/L; lactate dehydrogenase (LDH), 622 U/L; total bilirubin, 1.5 mg/dL; soluble IL-2 receptor, 27,500 U/mL (normal range: 135-421 U/mL); and calcium, 12.9 mg/dL. HTLV-1 antibody was positive. A contrast-enhanced computed tomography (CT) scan of the chest and the abdomen revealed bilateral pleural effusion and ascites with lymphadenopathy (Figure 1). Bilateral pleural effusion samples appeared chylous (Figure 2) with high triglyceride concentrations (Table 2) and class III cytology. A biopsy obtained from the right inguinal lymph node showed diffuse infiltration of moderate- to large-sized lymphoid cells with a pleomorphic nucleus and prominent nucleoli (Figure 3) that were CD3+, CD4+, CD5+, CD8-, CD20-, and CD21- on immunohistochemistry (Figure 4). Two monoclonal bands for HTLV-1 provirus DNA were observed in lymph node specimens by Southern blot hybridization analysis (Figure 5). Tumor cell infiltration into the bone marrow was negative in an aspiration biopsy. Based on these findings, the patient was diagnosed as having lymphomatous ATL.
The clinical course of the patient is summarized in Figure 6. High-dose methylprednisolone therapy was deemed ineffective for her chylothorax since continuous pleural effusion drainage of 500 to 1,000 mL/day was necessary. The patient was soon shifted to a reduced-dose LSG15 chemotherapy regimen with prophylactic hydration, rasburicase, and bisphosphonate. After the first course of modified LSG15 (consisting of vincristine, cyclophosphamide, doxorubicin, prednisolone, vindesine, etoposide, ranimustine, and carboplatin), she required pleural effusion drainage of less than 200 mL/day. Her systemic lymphadenopathy and pleural effusion disappeared over the two subsequent LSG15 treatment courses as confirmed by CT and normalization of LDH and calcium levels.
OUTPUT:
| PMC6398058 |
MultiCaRe_Reasoning62 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 21.0
Sex: Female
Title: Intestinal stones: A rare cause of bowel obstruction
Keywords: intestinal stones; enterolithiasis; mechanical intestinal obstruction; small bowel obstruction; stricture; ulcerative colitis;
Abstract:
Enterolithiasis or intestinal stones are uncommonly reported. Enterostasis is the cause of stone formation mainly secondary to tuberculous strictures. Although it is unusual, enteroliths can cause intestinal obstruction. We report a case of a mechanical partial intestinal obstruction in a patient with ulcerative colitis previously treated with total colectomy, with the rare diagnosis of multiple primary enterolithiasis.
Image Caption and Description:
Image caption: Plain abdominal X-ray film showing multiple radiopaque shadows within the
small bowel (left). Axial CT (top right) showing absence of gallstones
(white arrow). Axial CT (bottom right) showing intraluminal ovoid structures
with peripheral calcification and a hypointense center (white arrow) and
(bottom left) adnexal mass (black arrow).
Image description: We further proceeded with plain computed tomography scan to reach to a final diagnosis of multiple enterolithiasis in the small bowel (Figure 1).
Image caption: (a) Ovarian cyst alongside multiple enteroliths with an average diameter of
1 cm after surgical removal. (b) Intact left corpus luteal cyst. (c) Ovarian
cyst alongside multiple enteroliths with an average diameter of 1 cm after
surgical removal. (d) Dissected enterolith with exposed core showing
white-colored aggregates.
Image description: The size of the enteroliths averaging 1 cm did not allow manual "milking" of the stones into the rectum (Figure 2).
Case Report:
A 21-year-old woman was admitted for gradually progressive colicky pain over the hypogastrium for 6 days, associated with vomiting and constipation. She was able to pass flatus, but with cessation of bowel movements. She was diagnosed to have ulcerative colitis (UC) in the past for which total colectomy was performed, followed by a manual side-to-end ileorectal anastomosis. She had previous episodes of partial SBO that resolved with antispasmodics and had an untreated menometrorrhagia for the past year.
She was hemodynamically stable and her abdomen was not distended. Multiple scars from previous abdominal surgery were visible. There was tenderness in all four quadrants, but no signs of peritonism. No anterior wall defects were palpated. Bowel sounds were hyperactive. Parents rejected vaginal and rectal examination.
Plain abdominal X-ray showed multiple radiopaque shadows within the small bowel, no air-fluid levels or dilated loops. We further proceeded with plain computed tomography scan to reach to a final diagnosis of multiple enterolithiasis in the small bowel (Figure 1).
Laparotomy was done after 48 h of poor response to conservative management. Abdominal exploration revealed multiple dense and cohesive adhesions predominantly in the distal small bowel. An anastomotic ileorectal stricture was found, along with multiple stones. The size of the enteroliths averaging 1 cm did not allow manual "milking" of the stones into the rectum (Figure 2). In the pelvic cavity, a cystic mass in the left ovary was found. No communicating fistula was identified between gallbladder and duodenum. Next, left salpingo-oophorectomy was performed, stricture was excised, stones were removed, and intestinal continuity restored with manual end-to-end ileorectal anastomosis at a distance of 12 cm from the anal verge. This was followed by dilation and curettage (D&C).
In the post-operative period, marked malnutrition was detected with a decrease in serum albumin; for this reason, total parenteral nutrition (TPN) was initiated; 5 days after ex-lap, she presented abundant discharge of succus through the wound. Urgent relaparotomy was performed. Anastomotic leak was found and was managed by dismantling of the anastomosis with closure of the rectal stump and end-ileostomy. Analysis of the biochemical composition of the intestinal stones showed the presence of calcium dihydrate oxalate (85%), calcium monohydrate oxalate (10%), and carbonate apatite (5%). The patient made good recovery and continued well upon discharge.
OUTPUT:
| PMC6537081 |
MultiCaRe_Reasoning63 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 80.0
Sex: Female
Title: Renal cell carcinoma with gallbladder metastasis: a case report
Keywords: renal cell carcinoma; case report; gallbladder; metastasis;
Abstract:
Renal cell carcinoma (RCC) is the most frequent renal neoplasm, with a high rate of metastasis, especially in the lungs and bones. The gallbladder is one of the rare metastatic sites. We report an 80-year-old woman who presented with chronic right flank pain for the last six months. A computer tomography scan revealed a heterogeneous right renal mass measuring 86 ×76× 68 mm and multi lithiasis in the gallbladder. A right radical nephrectomy, lymphadenectomy, and cholecystectomy were performed. The postoperative clinical course was uneventful, without any complications. The histological results showed a clear RCC with metastasis to the gallbladder. After 12-months follow-up, the patient is free from disease. In conclusion, even though the coexistence of metastatic gallbladder from clear RCC is rare, the possibility of concurrence should be considered if suspected findings in the gallbladder are identified intraoperatively.
Image Caption and Description:
Image caption: abdominal computed tomography scan showing a mass in the right kidney 86 x 76 x 68 mm
Image description: Diagnostic assessment: abdominal computer tomography (CT) scan revealed a heterogeneous right renal mass measuring 86 x76x 68 mm and arising from the upper and middle pole (Figure 1), with a lymph node of 8 mm diameter detected in the renal hilum as well as a multi lithiasis gallbladder (Figure 2).
Image caption: abdominal computed tomography scan showing a gallstone
Image description: Diagnostic assessment: abdominal computer tomography (CT) scan revealed a heterogeneous right renal mass measuring 86 x76x 68 mm and arising from the upper and middle pole (Figure 1), with a lymph node of 8 mm diameter detected in the renal hilum as well as a multi lithiasis gallbladder (Figure 2).
Image caption: histological examination images for the gallbladder: (A) gallbladder wall showing tubullopapillary carcinoma, low power x 25; (B) gallbladder wall showing tubullopapillary carcinoma, high power x 100; (C) immunohistochemistry findings: CK7 positive; (D) immunohistochemistry findings: AMACR-positive
Image description: The polypoid lesion of the gallbladder was identical to those of the renal tumor population, made up of large, plant-like cells with clear cytoplasm, adopting an acinar or solid architecture within a stroma rich in small vessels (Figure 3A, Figure 3B).
Immunohistochemistry was positive for cytokeratin CK7, AMACR (a-Methylacyl Coenzyme A Racemase), cytokeratin (AE1/AE3), and vimentin (Figure 3C, Figure 3D).
Case Report:
Patient information: an 80-year-old woman was admitted for chronic right flank pain in the last six months, with one episode of hematuria. The patient mentioned a history of weight loss, decreased appetite, and generalized weakness. There was no significant medical or family history or any relevant past interventions.
Clinical findings: the physical examination was unremarkable. The temperature was 37.3 C, blood pressure 124/84 mmHg, and pulse rate regular at 86 beats/min. In palpation, we revealed mild tenderness in the right flank but without any palpable mass.
Diagnostic assessment: abdominal computer tomography (CT) scan revealed a heterogeneous right renal mass measuring 86 x76x 68 mm and arising from the upper and middle pole (Figure 1), with a lymph node of 8 mm diameter detected in the renal hilum as well as a multi lithiasis gallbladder (Figure 2). Laboratory tests did not detect any alterations, and gave the following results: white blood cell count was 79.000/mm3, red blood cell count 5,3.106/mm3, hemoglobin 13.0 g/dL, hematocrit 39.1%, platelets 19.6 x 104/microL, total bilirubin 0.6 mg/dL, direct bilirubin 0.2 mg/dL, aspartate transaminase 25 IU/L, alanine transaminase 19 IU/L, albumin 4.25 g/ dL, lactate dehydrogenase 240 IU/L, beta-glutamyltransferase 27 IU/L, alkaline phosphatase 201 IU/L, amylase 129 IU/L, blood urea nitrogen 11.6 mg/dL, creatinine 8 mg/L, C-reactive protein 3 mg/L, urinalysis pH 7.0, no uric protein, no urinary sugar, no ketone body, no uric blood, no bilirubin, and no white blood cell, and no bacteriuria. A chest CT was done and did not show any metastasis. The presumptive diagnosis was a renal tumor classified T2a-N2-M0, associated with a multi lithiasis gallbladder.
Therapeutic interventions: a right open radical nephrectomy via subcostal incision with lymph node dissection and cholecystectomy was performed. The surgical exploration showed a right renal large superior polar exophytic mass with two palpable hilar lymphadenopathies. The wall of the gallbladder appeared normal except for its lithiasis content. The surgical intervention was performed successfully without adhesion or local invasion.
Follow-up and outcome of interventions: the postoperative course was without complications, and the patient was uneventfully discharged on the fifth postoperative day. Pathological assessment of the specimen showed the tumor was well-circumscribed, measuring 9 x 7 x 5 cm and subtotally effacing the kidney. At sectioning, it was tan-yellow with large necrotic areas. The gallbladder was thin-walled with a 0.4 x 0.3 submucosal nodule. Microscopically the renal tumor consisted of a tubulopapillar lined by pseudostratified layers of cells with abundant eosinophilic cytoplasm and high nucleolar grade. It was a clear cell RCC with the pathologic stage of pT2a, Fuhrman 3. The polypoid lesion of the gallbladder was identical to those of the renal tumor population, made up of large, plant-like cells with clear cytoplasm, adopting an acinar or solid architecture within a stroma rich in small vessels (Figure 3A, Figure 3B). Immunohistochemistry was positive for cytokeratin CK7, AMACR (a-Methylacyl Coenzyme A Racemase), cytokeratin (AE1/AE3), and vimentin (Figure 3C, Figure 3D). The morphologic and phenotypic profiles were consistent with synchronous metastasis from renal carcinoma. Additionally, the histopathological study found several lymph nodes to be invaded. So, the final stage of the tumor was pT2a-N2-M1. The follow-up was carried out by CT scan at six months, and then after one year, the patient did not present a recurrence, and the renal function remained normal.
Patient perspective: the patient was informed about the all procedure, complication and outcome, and she was agreeing about it. The patient was pleased with the care she received throughout therapy.
Informed consent: written informed consent was obtained from the patient for participation in our study.
OUTPUT:
| PMC9834804 |
MultiCaRe_Reasoning64 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 61.0
Sex: Female
Title: Suspected Neratinib Macular Toxicity Presenting As Macular Telangiectasia Type II
Keywords: chemotherapy-related toxicity; maculopathy; retinal toxicity; tyrosine kinase receptor inhibitors; retina;
Abstract:
The purpose of this case report is to present the first case of neratinib maculopathy. We describe the initial presentation, baseline characteristics, imaging findings, and outcomes. The case report is accompanied by a thorough literature review including possible mechanisms of tyrosine kinase inhibitor (TKI) maculopathy. Neratinib is a novel TKI that is commonly used in the treatment of breast-associated malignancies. Neratinib toxicity presents similarly to macular telangiectasia type II but differs with the fine granular hypofluorescent areas spanning the limit of the posterior pole and vascular arcades as well as the nasal aspect of the optic nerve. We report a case of suspected macular toxicity secondary to neratinib. Concomitant use of neratinib in conjunction with docetaxel and other chemotherapeutics with known retinal side effects should alert clinicians of an increase in the risk of macular toxicity. Albeit commonly reported ocular side effects of TKIs, maculopathy is a rare and potentially overlooked side effect. Patients that have planned chemotherapy should undergo a baseline retinal examination.
Image Caption and Description:
Image caption: Fundus photographs. A: Pigmentary changes in the fovea (black arrow), B: Pigmentary changes on the macula temporally
Image description: The hyperpigmentation in the left eye presented a more diffuse appearance with a lacy pattern (Figure 1 A).
Of note, the scarring and pigmentary clumping extended beyond the arcades in a reticular and lacy fashion in the left eye (Figure 1 B).
Image caption: Optical coherence tomography. A: Full-thickness scarring (black arrow), B: Internal limiting membrane (ILM) draping and cavitations (black arrow)
Image description: Optical coherence tomography revealed full-thickness scarring mostly of the outer retina in the right eye while presenting internal limiting membrane (ILM) draping and cavitations (Figure 2).
Image caption: Fundus autofluorescence. A: Hypo-autofluorescence within the macular and nasal to the optic nerve (white arrow), B: Hypo-autofluorescence spanning the full length of the macula
Image description: The right eye presented similar features from the nasal to the optic disc as well (Figure 3).
Image caption: Fluorescein angiography. A, B: Early hyperfluorescence from a lesion in the fovea (white arrow); C, D: Leakage in latter frames from lesions and cysts in the macula (white arrow)
Image description: Fluorescein angiography revealed early staining and late leakage beyond the area of foveal scarring in the right eye (Figure 4).
There was leakage also present from a smaller lesion inferiorly on the macula in the left eye (Figure 4 D).
Case Report:
The patient is a 61-year-old Hispanic woman with a history of left breast cancer, diabetes mellitus type 2, and hypertension. The patient's medication history before her diagnosis of breast cancer included metformin 500mg twice a day (BID) orally (PO), and Lisinopril 10mg PO daily. She initially presented with left breast pain in 2018 and went to the emergency department. A mammogram was performed revealing a 1.2 cm hypoechoic cystic lesion in the left breast in the periareolar region. A biopsy was performed and determined to be a malignant invasive ductal carcinoma grade 3 out of 3 estrogen receptor (ER)/progesterone receptor (PR) negative HER-2 positive. The patient underwent a left modified radical mastectomy with sentinel lymph node dissection. Pathology showed a 1.8 cm grade 3 invasive carcinoma, pT1c, N0, M0, ER negative, PR negative, and HER2 positive. The patient underwent six cycles of docetaxel, carboplatin, and trastuzumab. She also received a year-long course of trastuzumab. Afterward, the patient started on neratinib 200mg daily.
The patient presented to the ophthalmology consultation for blurry vision six months after the initiation of neratinib. Ophthalmological examination revealed a best corrected visual acuity (BCVA) of 20/300 (PH: 20/200) right eye and 20/25 in the left eye. Intraocular pressure of 15 mmHg in both eyes. The anterior segment exam was unremarkable with posterior chamber intra-ocular lenses. The posterior segment presented with an optic nerve that was pink and sharp with normal cup-to-disc ratios in both eyes. The macula revealed pigmentary changes; with some areas of hyperpigmentation in the macula in the right eye. The hyperpigmentation in the left eye presented a more diffuse appearance with a lacy pattern (Figure 1 A). Of note, the scarring and pigmentary clumping extended beyond the arcades in a reticular and lacy fashion in the left eye (Figure 1 B).
The left eye presented with more profound changes in comparison to the fellow eye. Optical coherence tomography revealed full-thickness scarring mostly of the outer retina in the right eye while presenting internal limiting membrane (ILM) draping and cavitations (Figure 2).
Fundus autofluorescence revealed hypoautofluorescense in areas of pigmentary clumping that extended beyond the arcades. The right eye presented similar features from the nasal to the optic disc as well (Figure 3).
Fluorescein angiography revealed early staining and late leakage beyond the area of foveal scarring in the right eye (Figure 4). There was leakage also present from a smaller lesion inferiorly on the macula in the left eye (Figure 4 D).
OUTPUT:
| PMC9941022 |
MultiCaRe_Reasoning65 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 42.0
Sex: Male
Title: Abdominal wall metastasis in scar after open resection of an adrenocortical carcinoma
Keywords: abdominal wall metastasis; adrenal cortex; carcinoma;
Abstract:
A 42-year-old man patient presented with progressively increasing, occasionally painful lump in the left upper and central abdomen. Investigations revealed well-defined capsulated left adrenocortical carcinoma. Tumor was resected successfully along with left kidney. Tumor recurred in the abdominal surgical scar 1.5 years after surgery. We are reporting this case because of rarity of metastatic recurrence of an adrenocortical carcinoma in the abdominal surgical scar 1.5 years after resection of primary tumor.
Image Caption and Description:
Image caption: Recurrence in abdominal wall scar.
Image description: In October 2010, patient presented with swelling in anterior abdominal wall rapidly increasing for last 2 months (Figure 1).
Image caption: Contrast-enhanced computed tomography abdomen showing recurrence in abdominal wall scar.
Image description: CECT thorax and abdomen was done which revealed a soft tissue mass lesion in the anterior abdominal wall at umbilical level involving the anterior abdominal wall muscle (B/L rectus abdominis), subcutaneous tissues and overlying skin with small calcific foci within, measuring 64.7x66x54 mm (Figure 2).
Image caption: Histology of metastatic adrenocortical carcinoma.
Image description: Cytological features were consistent with metastatic adrenocortical carcinoma (Figure 3).
Case Report:
In March 2009, a 42-year-old man patient presented with progressively increasing, occasionally painful lump in the left upper and central abdomen for past 2 months. On physical examination there was a hard, partially mobile, mildly tender 10x10 cm lump with irregular surface occupying the left lumber, left central abdomen and part of left hypochondrium. Contrast-enhanced computed tomography (CECT) abdomen revealed well-defined capsulated heterogeneous soft tissue density lesion with evidence of calcification and patchy contrast enhancement, superior to left kidney (size 164x111x174 mm); no metastasis or lymphadenopathy was there. Computed tomography (CT) - guided true cut biopsy revealed adrenocortical carcinoma. Biochemical examination was consistent with nonfunctioning tumor. In April 2009 the tumor was resected encapsulated along with left kidney (i.e. no rupture of capsule or spillage of tumor occurred). Histological analysis of specimen showed adrenocortical carcinoma with focal areas of capsular invasion and left kidney was unremarkable. No adjuvant chemotherapy was given. The patient was discharged from hospital after eight days. Patient was followed up in out patient's department for 6 months but then patient stopped coming to outpatient department for follow up.
In October 2010, patient presented with swelling in anterior abdominal wall rapidly increasing for last 2 months (Figure 1). Patient was not having any symptoms apart from mild pain locally. On physical examination, there was a single hard, well defined, immobile, mildly tender 80x70 mm lump with irregular and bleeding surface occupying umbilical region. CECT thorax and abdomen was done which revealed a soft tissue mass lesion in the anterior abdominal wall at umbilical level involving the anterior abdominal wall muscle (B/L rectus abdominis), subcutaneous tissues and overlying skin with small calcific foci within, measuring 64.7x66x54 mm (Figure 2). There was no extension beyond the muscle. Cytological features were consistent with metastatic adrenocortical carcinoma (Figure 3). There was no evidence of metastasis elsewhere.
Patient was diagnosed as metastatic adrenocortical carcinoma so resection and abdominal wall reconstruction was planned but patient refused for any kind of treatment and opted for some indigenous medicines for his disease. After 2 months, he was brought to casualty department in state of shock with profuse bleeding from tumor site. Despite extensive resuscitation, patient couldn't be salvaged.
OUTPUT:
| PMC3981348 |
MultiCaRe_Reasoning66 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 60.0
Sex: Female
Title: Frontal bone metastasis from an occult follicular thyroid carcinoma: Diagnosed by FNAC
Keywords: frontal bone; occult follicular thyroid carcinoma; skull metastasis;
Abstract:
Metastatic deposits in skull bones from follicular thyroid carcinoma is rare, and metastatic disease in skull being the presenting symptom without obvious thyroid lesion (occult primary) is even rarer. A 60-year-old female patient presented with a mass in the frontal region of the skull. Fine needle aspiration cytology was done which revealed an adenocarcinoma with repeated follicular pattern, reminiscent of follicular neoplasm of thyroid, which on immunocytochemistry revealed positivity for thyroglobulin. Patient was investigated further for primary thyroid malignancy, and imaging revealed a nodule in the left lobe of thyroid. Neuroimaging showed osteolytic lesion involving the cranium.
Image Caption and Description:
Image caption: (a) Computed tomography of the head showing soft tissue lesion on scalp in the frontal region with destruction of underlying bone. (b) Cytological smear showing cells arranged in microfollicular structures and having monotonous enlarged hyperchromatic nuclei (Leishman, x100). (c) Immunocytochemistry showing positivity for Thyroglobulin (IHC, x200)
Image description: Smears showed cells arranged in a repeated microfollicular pattern having monotonous enlarged, hyperchromatic nuclei, reminiscent of follicular neoplasm of thyroid and were suspected to be metastasis from FTC [Figure 1b].
Immunocytochemistry was done and the cells showed positive staining for thyroglobulin [Figure 1c] and cytokeratin.
Contrast enhanced computed tomography (CT) demonstrated a 3 x 3 cm soft tissue lesion in scalp in frontal region with destruction of underlying bone [Figure 1a].
Case Report:
A 60-year-old woman had a frontal mass which she incidentally noticed 1 year back. The mass had been painless and was slowly, but gradually, increasing in size, and hence the delay in presentation. On presentation, her general physical, systemic, and neurological examination were within normal limits. Local examination revealed a 4 x 3.5 x 3 cm mass in the right frontal region. It was pulsatile in nature, firm in consistency, and was fixed to the skull. The skin over the swelling was stretched but was otherwise normal. Routine blood tests and thyroid function tests were normal. Skull X-ray showed a large frontal lesion with some focal calcification in the soft component of the lesion. Fine needle aspiration cytology (FNAC) from the skull swelling was obtained and stained with Leishman stain. Smears showed cells arranged in a repeated microfollicular pattern having monotonous enlarged, hyperchromatic nuclei, reminiscent of follicular neoplasm of thyroid and were suspected to be metastasis from FTC [Figure 1b]. Immunocytochemistry was done and the cells showed positive staining for thyroglobulin [Figure 1c] and cytokeratin.
The patient had no history related to thyroid disease and was clinically euthyroid. Her subsequent workup included thyroid ultrasonography which revealed an occult primary in form of 1 x 1 cm well-defined hyperechoic lesion in the left lobe, with flow on color Doppler, which was suggestive of malignancy. Contrast enhanced computed tomography (CT) demonstrated a 3 x 3 cm soft tissue lesion in scalp in frontal region with destruction of underlying bone [Figure 1a]. Hence, the patient diagnosis was skull metastasis with occult FTC. She was advised further investigation and treatment which she refused, and has since been lost to follow-up.
OUTPUT:
| PMC5259936 |
MultiCaRe_Reasoning67 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Design of a trial-based economic evaluation on the cost-effectiveness of employability interventions among work disabled employees or employees at risk of work disability: the CASE-study
Keywords: None
Abstract:
Background:
In the Netherlands, absenteeism and reduced productivity due to work disability lead to high yearly costs reaching almost 5% of the gross national product. To reduce the economic burden of sick leave and reduced productivity, different employability interventions for work-disabled employees or employees at risk of work disability have been developed. Within this study, called 'CASE-study' (Cost-effectiveness Analysis of Sustainable Employability), five different employability interventions directed at work disabled employees with divergent health complaints will be analysed on their effectiveness and cost-effectiveness. This paper describes a consistent and transparent methodological design to do so.
Methods/design:
Per employability intervention 142 participants are needed whereof approximately 66 participants receiving the intervention will be compared with 66 participants receiving usual care. Based on the intervention-specific characteristics, a randomized control trial or a quasi-experiment with match-criteria will be conducted. Notwithstanding the study design, eligible participants will be employees aged 18 to 63, working at least 12 h per week, and at risk of work disability, or already work-disabled due to medical restrictions. The primary outcome will be the duration of sick leave. Secondary outcomes are health status and quality of life. Outcomes will be assessed at baseline and then 6, 12 and 18 months later. Economic costs will consist of healthcare costs and cost of lost production due to work disability, and will be evaluated from a societal perspective.
Discussion:
The CASE-study is the first to conduct economic evaluations of multiple different employability interventions based on a similar methodological framework. The cost-effectiveness results for every employability intervention will be published in 2014, but the methods, strengths and weaknesses of the study protocol are discussed in this paper. To contribute to treatment options in occupational health practice and enable the development of guidelines on how to conduct economic evaluation better suited to this field; this paper provides an important first step.
Trial registration:
Four trials involved in the CASE-study are registered with the Netherlands Trial Registry: Care for Work (NTR2886), Health and Motion (NTR3111), Guidance to Excel in Return to Work (NTR3151), Care for Companies/Second Care (NTR3136).
Image Caption and Description:
Image caption: Employability interventions included in the CASE-study.
Image description: An overview of these interventions is provided in Figure 1.
Case Report:
We will carry out an economic evaluation designed for at least five Dutch employability interventions. Those undertaking the evaluation are not connected with the organisations or individuals who have developed, or are in the process of developing the employability interventions so no competing interests arise. Within the CASE-study each existing or innovative intervention will be compared with usual care for work-disabled employees or those at risk of work disability due to medical restrictions. At the start of the CASE-study, nine programmes were interested in participating in the project. Unfortunately four programmes could not collaborate because they were unable to provide the minimum required number of participants eligible for the study, or could not provide a comparable control group. The remaining five employability interventions have the ability to comply to the minimal requirements and focus on primary care, secondary or specialist care, and/or on the interaction between the employer and employee. Two existing employability interventions (called 'Best Practices') and three newly developed employability interventions are included in the study. The employability intervention focussing on primary care aims to acknowledge the importance of employability in general practice. This intervention is under development at the University of Nijmegen (UMC St Radboud). The employability intervention in specialist care is being developed jointly by the VU University Medical Centre Amsterdam (VUMC) and the Institute for Health and Care Research (EMGO+) and focuses on employability among patients who suffer from rheumatoid arthritis. The third newly developed intervention aims at improving the interaction between the employee and his/her employer by appointing an independent mediator. The intervention is being developed by a separate team at Maastricht University. One of the 'Best Practice' interventions, developed by Health & Motion Nederland, offers patients with physical health complaints the ability to implement a range of exercises learned at the physiotherapeutic setting in their working environment by means of a workplace-intervention. The fifth and final intervention is developed by Second Care/Care for Companies (Best Practice) and aims at achieving sustainable employability among patients with physical and/or psychological health complaints using a multidisciplinary approach. An overview of these interventions is provided in Figure 1.
It is beyond the scope of this design article to describe the precise content of each employability intervention in detail. This will be done when the results of the economic evaluation per employability intervention are published. What is of importance in this paper is that the employability interventions use an innovative, systematic approach in order to support work participation in employees with health complaints. These are innovative because both the healthcare system and the private/work life of the employees are considered in the intervention. The features of the interventions differ according to the patient population, but the aim remains the same: to reduce sickness absence and increase the potential of achieving sustainable employability.
The protocol for this study has been approved by the Ethics Committee of Psychology (ECP107) at Maastricht University, the Netherlands.
OUTPUT:
| PMC3273437 |
MultiCaRe_Reasoning68 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 4.0
Sex: Female
Title: Scleral Fixation of Akreos AO60 Intraocular Lens Using Gore-Tex Suture: An Eye on Visual Outcomes and Postoperative Complications
Keywords: None
Abstract:
Purpose:
"In-the-bag" placement of an IOL is the Holy Grail for any cataract surgeon. However, in the absence of capsular integrity, alternative surgical options to place the IOL must be sought. We aim to report the clinical outcomes and safety profile of scleral-fixated Akreos AO60 intraocular lens implantation using Gore-Tex suture, combined with pars plana vitrectomy.
Methods:
This is a single-center, retrospective case series descriptive study. Electronic clinical records of all patients subjected to scleral fixation of a Bausch and Lomb Akreos AO60 IOL combined with pars plana vitrectomy, between April 1, 2017, and August 1, 2021, were reviewed. Data concerning age, sex, laterality, past ophthalmological history, pre- and postoperative best-available visual acuity, surgical indication, and intra- and postoperative complications were collected. Measured outcomes were the differences in best-available visual acuity and frequency of postoperative complications.
Results:
A total of 37 eyes (20 right eyes and 17 left eyes) from 36 patients (16 females and 20 males) were included in the statistical analysis. The mean age at time of surgery was 72.0 ± 12.4 years. The mean follow-up period was 548.9 days (range 39-1564 days). Globally, the mean best-available logMAR visual acuity improved from 1.61 preoperatively (0.025 decimal equivalent) to 0.57 postoperatively (0.3 decimal equivalent), this difference being statistically significant (P < 0.001). Indications for surgery included aphakia due to complicated cataract surgery (24.3%; n = 9); subluxated IOL due to closed trauma (21.6%; n = 8); PEX-related subluxated IOL (16.2%; n = 6); non-traumatic, non-PEX-related subluxated IOL (18.9%; n = 7); subluxated crystalline lens due to closed trauma (8.1%; n = 3); aphakia due to open-globe injury (5.4%; n = 2); silicone-induced IOL opacification (2.7%; n = 1); and aphakia post-endophthalmitis (2.7%; n = 1). Postoperative complications included transient ocular hypertension (27.0%; n = 10), transient corneal edema (18.9%; n = 7), cystoid macular edema (18.9%, n = 7), self-limited hypotension (5.4%, n = 2), self-limited vitreous hemorrhage (2.7%, n = 1), central retinal vein occlusion (2.7%, n = 1), late retinal detachment (2.7%, n = 1), and Akreos IOL opacification (2.7%, n = 1). No suture-related complications were observed.
Conclusion:
There was a statistically significant improvement in visual acuity after scleral fixation of Akreos AO60 intraocular lens using Gore-Tex suture, with no suture-related problems recorded. This procedure seems to be a valuable alternative for posterior chamber IOL placement when secondary IOL implantation is required.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A total of 42 eyes of 41 patients were identified. Of these, 37 eyes (20 right eyes and 17 left eyes) from 36 patients had a minimum of 1 month of follow-up and were included in the statistical analysis. 44.4% (n = 16) of patients were females. The mean age at the time of surgery was 72.0 +- 12.4 years old (range 31-92 years old). The mean follow-up period was 548.9 days (range 39-1564 days).
Relevant past ophthalmological history included closed-globe trauma in 12 eyes (32.4%), pseudoexfoliation (PEX) syndrome in 8 eyes (21.6%), glaucoma in 7 eyes (18.9%), previous PPV for retinal detachment repair in 5 eyes (13.5%), pathological myopia in 4 eyes (10.8%), open-globe trauma in 3 eyes (8.1%), exudative age-related macular degeneration in 2 eyes (5.4%), diabetic retinopathy without macular edema in 2 eyes (5.4%), dry age-related macular degeneration, previous penetrating keratoplasty, endophthalmitis, diabetic retinopathy with macular edema, retinal venous occlusion, toxic optic neuropathy, and Vogt-Koyanagi-Harada syndrome in 1 eye each (2.7%). Population baseline characteristics are represented in Table 1.
Indications for surgery included aphakia due to complicated cataract surgery (24.3%; n = 9); subluxated IOL due to closed trauma (21.6%; n = 8); non-traumatic, non-PEX-related subluxated IOL (18.9%; n = 7); PEX-related subluxated IOL (16.2%; n = 6); subluxated crystalline lens due to closed trauma (8.1%; n = 3); aphakia due to open-globe injury (5.4%; n = 2); silicone-induced IOL opacification (2.7%; n = 1); and aphakia post-endophthalmitis (2.7%; n = 1).
All patients underwent scleral fixation of an Akreos AO60 IOL using Gore-Tex suture, combined with either 23- or 25-gauge PPV. 1 eye (2.7%) underwent concomitant glaucoma surgery with Ahmed valve implantation.
The mean best-available preoperative logMAR VA was 1.61 +- 0.73 (0.025 decimal equivalent). The mean best-available postoperative logMAR VA was 0.57 +- 0.66 (0.3 decimal equivalent), and, globally, the improvement from pre- to postoperative best-available VA was statistically significant (P < 0.001). VA was 5/10 (logMAR 0.3) or better in 3 eyes (8.1%) preoperatively, as compared to 17 eyes (45.9%) postoperatively. Subgroup analysis considering indication for surgery revealed a statistically significant postoperative vision improvement for patients with aphakia due to complicated cataract surgery (P=0.028), subluxated IOL due to closed trauma (P=0.028), non-traumatic, non-PEX-related subluxated IOL (P=0.028), and PEX-related subluxated IOL (P=0.043). Visual improvement was noted for patients in the remaining subgroups, but this difference did not reach statistical significance. Subgroups of silicone-induced IOL opacification and aphakia post-endophthalmitis included a single eye, and statistical significance could not be calculated.
During the study period, 1 eye (2.7%) had postoperative visual deterioration of 2 lines in the Snellen chart, and 7 eyes (21.6%) had no change in VA.
There were 3 eyes (8.1%) with reported intraoperative complications: one iatrogenic retinal hole done during vitrectomy; a flat peripherical serous choroidal detachment; and an intraoperative vitreous hemorrhage.
Postoperative complications included ocular hypertension (27.0%; n = 10), transient corneal edema (18.9%; n = 7), cystoid macular edema (18.9%, n = 7), self-limited hypotension (5.4%, n = 2), self-limited vitreous hemorrhage (2.7%, n = 1), one case of central retinal vein occlusion (2.7%), one case of late retinal detachment (2.7%), and one case of Akreos IOL opacification (2.7%). Retinal detachment was managed with PPV with gas endotamponade; Akreos opacification is awaiting surgery to replace the IOL; the central retinal vein occlusion has been receiving intravitreal injections of 1.25 mg bevacizumab and 2 cases of macular edema resolved after intravitreal injections of corticosteroids (one case with intravitreal 2 mg triamcinolone alone, and the other with 2 mg triamcinolone, followed by 0.7 mg dexamethasone intravitreal implant). All of the other complications were managed medically, with topical treatment. No suture-related complications were observed, namely, suture breakage, IOL displacements, or suture-related inflammation. Also, there were no cases of postoperative endophthalmitis, choroidal detachment, or uveitis-glaucoma-hyphema syndrome.
Clinical outcomes are reviewed in Table 2.
OUTPUT:
| PMC8712131 |
MultiCaRe_Reasoning69 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 74.0
Sex: Male
Title: Two cases of primary human parechovirus pneumonia in adults
Keywords: bronchoalveolar lavage fluid; hpev; pcr; viral pneumonia; human parechovirus;
Abstract:
Human parechoviruses (HPeV) are mainly isolated from upper respiratory tract infection and gastroenteritis in children. HPeV has not been screened for in the past studies of community-acquired pneumonia (CAP) in adults, and its association with CAP is unknown. We present two cases that HPeV was detected by multiplex polymerase chain reaction for respiratory viruses using bronchoalveolar lavage fluid and diagnosed as pneumonia caused by HPeV.
Image Caption and Description:
Image caption: Chest X-rays in case 1. Chest X-ray on admission (A) showed consolidation and reduced volume of the right lung. The greatest deterioration had occurred on day 8 (B), and by the time of discharge on day 18, they had improved but were still somewhat present (C). The reduced volume of the right lung has remained after two years (D).
Image description: Chest X-ray showed consolidation and reduced volume of the right lung (Fig. 1-A).
CAP and started antibiotics (ampicillin/sulbactam + clarithromycin). Consolidation and volume reduction of the right lung continued to deteriorate, reaching a peak on the 8th day of hospitalization, but they gradually improved (Fig. 1-B, C).
Pneumonia has not recurred as of 2 years after discharge, but the reduced volume of the right lung has remained (Fig. 1-D).
Image caption: Chest computed tomography (CT) in case 1. Chest CT on admission showed bilateral consolidation (right dominant), ground-glass opacities (GGOs) around the consolidation, and air-bronchogram accompanying traction bronchiectasis within the consolidation. The GGOs in part showed non-segmental distribution.
Image description: Computed tomography (CT) (Fig. 2) on admission showed bilateral consolidation (right dominant), ground-glass opacities (GGOs) around the consolidations, and air-bronchogram accompanying traction bronchiectasis within the consolidations.
Case Report:
A 74-year-old man presented to our hospital with dyspnea and cough in May. He had developed productive cough, sore throat, and nasal discharge three weeks before, muscle pain two weeks before, and fever and dyspnea three days before his admission. He had no medical, family, or social history of note, and no close contact with infected people. He was an ex-smoker (10 pack-years). His vital signs included a body temperature of 37.6 C, heart rate of 116 beats/min with a regular rhythm, and blood pressure of 137/84 mmHg. On physical examination, fine crackles were audible on the dorsal side of the bilateral lower lung regions, but no other remarkable findings were seen. Chest X-ray showed consolidation and reduced volume of the right lung (Fig. 1-A). Computed tomography (CT) (Fig. 2) on admission showed bilateral consolidation (right dominant), ground-glass opacities (GGOs) around the consolidations, and air-bronchogram accompanying traction bronchiectasis within the consolidations. The GGOs in part had non-segmental distribution. His arterial blood gases under ambient air showed a pH of 7.45, PaO2 of 70.2 Torr, PaCO2 of 35.7 Torr, and bicarbonate of 24.3 mmol/L, and biochemical examination of his blood and urine showed elevation of the erythrocyte sedimentation rate and C-reactive protein and aspartate aminotransferase levels. Pneumococcal and Legionella urinary antigen test, Mycoplasma antigen from throat swab specimens, and influenza antigen from nasal swab specimens were all negative. Autoantibodies were negative. No bacteria other than oral flora were cultured in the sputum cultures. We performed bronchoscopy and bronchoalveolar lavage (BAL) in the right middle lobe (with 20 of 150 mL recovered). The total cell count of the BAL fluid was 5.3 x 105 cells/mL, including 44.7% lymphocytes (cluster designation [CD]4/CD8 ratio, 3.16), 7.1% eosinophils, and 23.9% neutrophils. BAL fluid yielded no bacteria, and adequate specimens for evaluation could not be collected from transbronchial lung biopsy.
We diagnosed him as having CAP and started antibiotics (ampicillin/sulbactam + clarithromycin). Consolidation and volume reduction of the right lung continued to deteriorate, reaching a peak on the 8th day of hospitalization, but they gradually improved (Fig. 1-B, C). Serum antibody titers against Mycoplasma pneumoniae, Legionella sp., Chlamydophila pneumoniae, Chlamydia psittaci, adenovirus, human parainfluenza virus, RS virus, and influenza virus in the convalescent phase did not significantly increase compared with those measured in the acute phase. Pneumonia has not recurred as of 2 years after discharge, but the reduced volume of the right lung has remained (Fig. 1-D). Multiplex real-time reverse transcriptase PCR (RT-PCR) with a commercially available kit (FTD Resp 21 Kit; Fast Track Diagnostics, Silema, Malta) for respiratory viruses using frozen-stored BAL fluid was performed later and was positive only for HPeV. We ultimately diagnosed him as having primary HPeV pneumonia.
OUTPUT:
| PMC6831859 |
MultiCaRe_Reasoning70 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 46.0
Sex: Male
Title: Two cases of primary human parechovirus pneumonia in adults
Keywords: bronchoalveolar lavage fluid; hpev; pcr; viral pneumonia; human parechovirus;
Abstract:
Human parechoviruses (HPeV) are mainly isolated from upper respiratory tract infection and gastroenteritis in children. HPeV has not been screened for in the past studies of community-acquired pneumonia (CAP) in adults, and its association with CAP is unknown. We present two cases that HPeV was detected by multiplex polymerase chain reaction for respiratory viruses using bronchoalveolar lavage fluid and diagnosed as pneumonia caused by HPeV.
Image Caption and Description:
Image caption: Chest X-rays in case 2. Chest X-ray on admission (A) showed nodular consolidation on both sides of the lung that had almost resolved at day 8 (B).
Image description: Chest X-ray (Fig. 3-A) showed nodular consolidation on both sides of the lungs.
A follow-up chest X-ray (Fig. 3-B) was clear, and he was discharged on the 10th hospital day with no complications.
Image caption: Chest computed tomography (CT) in case 2. Chest CT on admission showed patchy consolidation and GGOs along the bronchial vascular bundle in the upper and lower lobes of the left lung and upper segment of the right lower lobe. Traction bronchiectasis and volume reduction of the lungs were not observed.
Image description: Chest CT (Fig. 4) on admission showed patchy consolidation and GGOs along the bronchial vascular bundle in the upper and lower lobes of left lung and S6 of the right lung.
Image caption: Histologic findings. Histologic findings from transbronchial lung biopsy in case 2 showed organization, swollen pneumocytes, and alveolar septal thickening with inflammatory cells (hematoxylin and eosin staining; magnification, x 50).
Image description: BAL fluid was 2.1 x 105 cells/mL, including 80.8% macrophages, 12.7% lymphocytes (CD4/CD8 ratio, 10.6), 4.9% eosinophils, and 1.6% neutrophils. BAL fluid yielded no bacteria, but transbronchial lung biopsy revealed organization, swollen pneumocytes, and alveolar septal thickening with inflammatory cells (Fig. 5).
Case Report:
A 46-year-old man had a fever and sore throat 10 days before hospital admission, and shortness of breath developed 6 days before admission in May. A local physician diagnosed him as having CAP and administered levofloxacin, but the symptoms did not improve and he presented to our hospital. He had no medical, family, or social history of note, and no close contact with infected people. He was an ex-smoker (15 pack-years). His vital signs included a body temperature of 37.4 C, heart rate of 81 beats/min with a regular rhythm, and blood pressure of 99/66 mmHg. On physical examination, fine crackles were audible on the dorsal side of the left middle lung regions, but no other remarkable findings were seen. Chest X-ray (Fig. 3-A) showed nodular consolidation on both sides of the lungs. Chest CT (Fig. 4) on admission showed patchy consolidation and GGOs along the bronchial vascular bundle in the upper and lower lobes of left lung and S6 of the right lung. Neither traction bronchiectasis nor volume reduction of the lungs were observed. His arterial blood gases under ambient air showed a pH of 7.46, PaO2 of 85.9 Torr, PaCO2 of 36.9 Torr, and bicarbonate of 25.4 mmol/L, and biochemical examination of his blood and urine showed an elevated C-reactive protein level of 7.62 mg/dL but no other remarkable findings. Pneumococcal and Legionella antigen test in urine, Mycoplasma antigen from throat swab specimens, and influenza antigen from nasal swab specimens were negative. Autoantibodies were negative. Sputum cultures showed no bacteria cultured other than oral flora.
We performed BAL in the right middle lobe (with 69 of 150 mL recovered). The total cell count of the BAL fluid was 2.1 x 105 cells/mL, including 80.8% macrophages, 12.7% lymphocytes (CD4/CD8 ratio, 10.6), 4.9% eosinophils, and 1.6% neutrophils. BAL fluid yielded no bacteria, but transbronchial lung biopsy revealed organization, swollen pneumocytes, and alveolar septal thickening with inflammatory cells (Fig. 5).
We administered antibiotics (ampicillin/sulbactam + clarithromycin), and his clinical symptoms and chest infiltrates improved promptly after admission. A follow-up chest X-ray (Fig. 3-B) was clear, and he was discharged on the 10th hospital day with no complications. Serum antibody titer against M. pneumoniae, Legionella sp., Chlamydophila pneumoniae, Chlamydia psittaci, adenovirus, human parainfluenza virus, RS virus, and influenza virus measured in the convalescent phase did not significantly increase compared with those in the acute phase. Multiplex real-time RT-PCR for respiratory viruses using BAL fluid was positive only for HPeV. We finally diagnosed him as having primary HPeV pneumonia.
OUTPUT:
| PMC6831859 |
MultiCaRe_Reasoning71 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 49.0
Sex: Female
Title: Methotrexate and actinomycin D chemotherapy in a patient with porphyria: a case report
Keywords: None
Abstract:
Background:
Despite their broadly recommended use as chemotherapeutic agents, the porphyrogenicity of methotrexate and actinomycin D have not been confirmed. Accordingly, it is not known whether these agents are safe for use in patients with porphyria.
Case presentation:
In this report, we present a case of an invasive mole with lung metastasis in a 49-year-old Japanese woman who had previously been diagnosed with acute intermittent porphyria at 27 years of age but had no recent history of acute intermittent porphyria attacks. Her serum human chorionic gonadotropin level was elevated 1 month after hysterectomy, and she was referred to our center for chemotherapy. After she received 100 mg of methotrexate, drug eruptions were observed starting on day 3 and grew progressively worse. Erythema and mucosal erosion spread throughout her body, whereupon she was administered prednisolone. In addition, our patient experienced febrile neutropenia and required granulocyte colony- stimulating factor treatment. No changes in our patient's urinary coproporphyrin or uroporphyrin levels were detected during this entire episode. Methotrexate was replaced by actinomycin D (0.5 mg/body intravenously on days 1-5 every 2 weeks). After five uneventful cycles of actinomycin D, our patient achieved and maintained a normal serum human chorionic gonadotropin level for 3 years.
Conclusions:
Methotrexate and actinomycin D did not induce acute porphyric attacks in this patient with acute intermittent porphyria; however, severe adverse effects were noted with methotrexate. Although further investigation is required, our data suggest that these agents are nonporphyrinogenic and can therefore be used to treat patients with comorbid porphyria.
Image Caption and Description:
Image caption: Changes in serum human chorionic gonadotropin (hCG) levels, urinary 8-carboxyl porphyrin (URO) and urinary 4-carboxyl porphyrin (COPRO) during treatment. ACT-D actinomycin D, ATH abdominal total hysterectomy, D&C dilatation and curettage, MTX methotrexate
Image description: One month after D&C, our patient presented with an elevated serum human chorionic gonadotropin (hCG) level (Fig. 1).
No changes in our patient's urinary coproporphyrin or uroporphyrin levels were observed despite the appearance of skin lesions (Fig. 1).
ACT-D was not implicated as either porphyrinogenic or nonporphyrinogenic, our patient received intravenous ACT-D at a dose of 1.5 mg/day on days 1-5 of every 2-week period, starting on day 70 of her clinical course. As shown in Fig. 1, her serum hCG level effectively decreased, and the lung metastasis disappeared without any porphyric attacks. After five cycles of ACT-D, her serum hCG level stabilized at 3.2 mIU/mL. Although other chemotherapeutic drugs were considered, a negative serum hCG level was achieved and maintained for the following 3 years.
Image caption: Progress of eruption. On day 6, erythema with infiltration appeared on the trunk (upper panel); blisters containing bloody serum developed on our patient's hands (middle panel), and erosive lesions and a furred tongue were observed in her mouth (lower panel). On day 8, the erythema became brown (upper panel); bullous lesions were observed on her hands (middle panel), and mucosal erosion of her mouth continued (lower panel). On day 18, the erythema improved, leaving only pigmentation (upper panel); the bullous rash was epithelialized with scaling (middle panel), and some erosive lesions became blood-filled blisters (lower panel)
Image description: On day 5, the eruptions expanded over her whole body and worsened, with ulcers developing on the oral mucosa (Fig. 2).
Image caption: Abdominal skin biopsy. Microabscesses formed under the stratum corneum, with neutrophilic and eosinophilic invasion, and neutrophilic exocytosis was observed in the epidermis (hematoxylin and eosin staining, x20 and x40 magnification)
Image description: Liquefaction was also observed between the epidermis and dermis, and eosinophilic, neutrophilic, and lymphocytic invasion from the layer between the epidermis and dermis to the superficial layer of the dermis was noted (Fig. 3).
Case Report:
A 49-year-old Japanese woman (gravida 4, para 3) was diagnosed with AIP at the age of 27. Our patient had repeatedly visited the hospital for stomachaches beforehand; however, approximately 2 years of consultations passed before she was accurately diagnosed. Afterwards, she avoided elements known to precipitate acute attacks, and had not experienced an acute porphyria attack since she was 33 years of age. In addition, she began hypertension treatment with amlodipine besylate at the age of 40 years, and her last pregnancy had spontaneously aborted 4 years prior to the present event. In July 2011, this patient visited a local private clinic for atypical vaginal bleeding and was referred to a general hospital because of suspected spontaneous abortion. She was subsequently diagnosed with a acute intermittent porphyria hydatidiform mole via dilatation and curettage (D&C).
One month after D&C, our patient presented with an elevated serum human chorionic gonadotropin (hCG) level (Fig. 1). As fertility preservation was deemed impossible, she underwent an abdominal total hysterectomy. Pathological study of the resected specimen revealed an invasive mole, but no metastasis was observed. However, our patient's serum hCG level was again elevated 1 month after hysterectomy, and she was referred to Saitama Medical Center for chemotherapy to address expected AIP-associated complications. An X-ray computed tomography scan of her chest, performed at our institution, revealed a lung metastasis. The FIGO 2000 staging and risk factor scoring system indicated a stage III:41 gestational trophoblastic neoplasia (GTN) (Tables 1 and 2), and our patient was accordingly diagnosed with a low-risk GTN. Her treatment strategy included intramuscular MTX administration at a dose of 20 mg/day for 5 days every 2 weeks.
MTX chemotherapy was initiated after our patient provided informed consent, which included an understanding that MTX had not been implicated as either porphyrinogenic or nonporphyrinogenic. Our patient experienced small eruptions on the hands and epigastric region on day 3 of chemotherapy. However, a dermatologist did not interpret these eruptions as drug-related, and thus treatment was continued. On day 5, the eruptions expanded over her whole body and worsened, with ulcers developing on the oral mucosa (Fig. 2). Our patient was unable to eat or drink owing to the severe pain caused by mucosal erosion; moreover, she complained of painful micturition because of a sore on her vulva. A skin biopsy revealed drug eruption instead of a porphyric skin lesion. In particular, microabscesses had formed under the stratum corneum, with neutrophilic and eosinophilic invasion, and neutrophilic exocytosis was observed in the epidermis. Liquefaction was also observed between the epidermis and dermis, and eosinophilic, neutrophilic, and lymphocytic invasion from the layer between the epidermis and dermis to the superficial layer of the dermis was noted (Fig. 3). No changes in our patient's urinary coproporphyrin or uroporphyrin levels were observed despite the appearance of skin lesions (Fig. 1). She received intravenous prednisolone at 60 mg/day beginning on day 5 to treat the drug eruption.
On day 11, our patient experienced febrile neutropenia (absolute neutrophil count [ANC] on day 8 was 1,380/muL but decreased to 12/muL on day 11) and was treated subcutaneously with 75 mug/day of granulocyte-colony stimulating factor (G-CSF) for 3 days beginning on day 11. However, as she was unable to recover from neutropenia (ANC remained at 12/muL on day 13), additional subcutaneous G-CSF at 150 mug/day was administered for 2 days beginning on day 13, and her neutropenia finally resolved on day 15 (ANC, 1598/muL). During that time, her skin lesions and stomatitis also began to improve, and the prednisolone dose was reduced to 40 mg/day. As she was able to eat on day 17, oral prednisolone administration at 20 mg/day was started on day 20 and tapered on day 24. She was discharged on day 25.
Although our patient's serum hCG level decreased with MTX treatment, it became elevated during treatment interruption. Chemotherapy with ACT-D was therefore considered. After providing informed consent to ACT-D treatment and acknowledging that ACT-D was not implicated as either porphyrinogenic or nonporphyrinogenic, our patient received intravenous ACT-D at a dose of 1.5 mg/day on days 1-5 of every 2-week period, starting on day 70 of her clinical course. As shown in Fig. 1, her serum hCG level effectively decreased, and the lung metastasis disappeared without any porphyric attacks. After five cycles of ACT-D, her serum hCG level stabilized at 3.2 mIU/mL. Although other chemotherapeutic drugs were considered, a negative serum hCG level was achieved and maintained for the following 3 years.
OUTPUT:
| PMC4717627 |
MultiCaRe_Reasoning72 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 69.0
Sex: Female
Title: Lancisi sign: giant C-V waves of tricuspid regurgitation
Keywords: None
Abstract:
None
Image Caption and Description:
Image caption: a Giant systolic pulsations with prominent V-waves, known as the Lancisi
sign or C-V waves (please see on-line Video 1 and 2); b transthoracic echocardiography 4-chamber view demonstrating a dilatated right atrium and right ventricle and severe tricuspid regurgitation with a moderately reduced right ventricular function (RA right atrium, RV right ventricle, TR tricuspid regurgitation, LA felt atrium, LV left ventricle)
Image description: On jugular venous examination, giant systolic pulsations with prominent V-waves, known as the Lancisi sign or C-V waves, were noted (Fig. 1a, Video appendix 1 and 2).
Case Report:
A 69-year-old woman with a history of surgical mitral valve repair for severe mitral regurgitation 12 years prior presented with a 6-month history of dyspnea on exertion (NYHA functional class II), exercise intolerance, and swelling of her abdomen and lower limbs. On jugular venous examination, giant systolic pulsations with prominent V-waves, known as the Lancisi sign or C-V waves, were noted (Fig. 1a, Video appendix 1 and 2). On auscultation, a loud first heart sound was audible, with a loud pulmonary component of the second heart sound along with an apical mid-diastolic rumble. A holosystolic murmur at the left lower sternal border that increased during inspiration was also noted. Lower limb edema, ascites and an enlarged, pulsatile liver were present. Transthoracic echocardiography demonstrated normal left ventricular function with an ejection fraction of 55 % and a normal function of the mitral valve. It also confirmed the presence of a dilated right atrium and right ventricle and a severe tricuspid regurgitation (TR) with a moderately reduced right ventricular function. The patient was referred for a surgical tricuspid annuloplasty, but given an increased operative mortality risk refused to undergo the operation.
TR is a relatively common abnormality. Since this condition is frequently asymptomatic and may not be detected on routine physical examination, it is often diagnosed solely by echocardiography. Usually, there are no specific signs or symptoms. Yet, in case of severe TR, giant C-V waves or the Lancisi sign can be found on the jugular venous examination. With increasing tricuspid regurgitation, there is an increased backflow of blood to the right atrium during systole. In patients with severe tricuspid regurgitation, the V wave of tricuspid regurgitation merges with the C wave forming a single prominent C-V wave that is often mistaken for the large carotid-pulse wave of severe aortic regurgitation. Other signs and symptoms include painful hepatosplenomegaly, ascites, and peripheral edema. Auscultation reveals a loud first heart sound with a loud pulmonary component of the second heart sound, an apical mid-diastolic rumble, and a holosystolic murmur at the left lower sternal border. Generally, tricuspid valve disease occurs secondary to left-sided heart valve disease, in particular mitral valve disease (i.e., functional TR) (Appendix 3). It is a marker of adverse outcome, and patients with moderate/severe TR have a worse prognosis. Primary TR (Appendix 3) is treated surgically if severe, and the patient is symptomatic. However, during concomitant left-sided heart valve surgery, a moderate/severe secondary TR with either raised pulmonary artery pressures or tricuspid annular dilatation should also be treated.
OUTPUT:
| PMC5114320 |
MultiCaRe_Reasoning73 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 29.0
Sex: Female
Title: Guillain-barré syndrome in pregnancy: an unusual case
Keywords: gbs; immunomodulating therapy; post-partum period; pregnancy;
Abstract:
Guillain-Barré syndrome (GBS) is rare in pregnancy with an estimated incidence between 1.2 and 1.9 cases per 100,000 people annually, and it carries a high maternal risk. We report a 29-year-old primigravida who had pain and progressive heaviness of both lower limbs in her third trimester of pregnancy. The attending gynecologist ascribed these symptoms to ongoing pregnancy. The intrapartum period (lower segment caesarian section) passed uneventfully. On third postpartum day, the patient developed weakness of all the four limbs. A detailed history and physical examination pointed toward GBS although there was no antecedent infective episode. Subsequent nerve conduction velocity studies and cerebrospinal fluid analysis confirmed GBS. All other investigations including electrolytes were normal. The patient improved without the introduction of immunomodulating therapy.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 29-year-old primigravida started with pain and mild heaviness in the both lower limbs distally associated with occasional pins and needles sensation in 35th week of pregnancy. Her symptoms were progressive. Over the next 10 days, the patient noticed knee buckling with frequent falls and difficulty in sitting and standing from supine position. At the end of 36th week, an emergency LSCS (lower segment caesarian section) was performed for decreased fetal heart rate. LSCS was uneventful and a healthy baby was born. Second post-partum day, the patient was discharged. On third post-partum day, the patient complained of weakness all the four limbs (in addition to persisting symptoms), more in lower limbs and was not able to maintain the erect posture. In this state, the patient was brought to our accident and emergency department. A detailed history was taken which revealed initiation of symptoms during third trimester of pregnancy without any preceding illness. Subsequent clinical examination revealed sinus tachycardia, fluctuating hypertension, power of 4/5 in upper limbs, 3/5 in lower limbs, hypotonia, areflexia (lower limbs), flexor plantar response, and mild involvement of all the modalities of sensation. A working diagnosis of GBS was made and all other investigations including nerve conduction studies, arterial blood gases, electrolytes, and later cerebrospinal fluid analysis were planned.
Arterial blood gas analysis showed pO2=89 mmHg, saturation = 94.6%, pCO2=42 mmHg, and pH = 7.39. Serum potassium was 4.1 meq/L, sodium 136 meq/L and bicarbonate 25 meq/L. Electrocardiography showed sinus tachycardia and routine blood chemistry was normal. Serological tests for campylobacter jejuni, EBV, cytomegalovirus, and mycoplasma pneumonae were negative. Electrophysiological studies revealed decreased amplitude of compound action potentials in median and common peronial nerves with decreased conduction velocity and abnormal F waves. After 7 days, lumbar puncture was performed and cerebrospinal fluid chemistry revealed raised protein of 7.8 g/L and normal cell count, confirming the diagnosis. The patient received treatment in the form of physiotherapy and close observation of symptoms and signs to which she rapidly responded with respect to power and sense of well-being over next 72 h, without the intervention of immunomodulating drugs. Sinus tachycardia and episodic hypertension was treated with atenolol. The patient was discharged after 2 weeks of hospital stay with power of 5/5 in upper limbs, 4+/5 in right lower limb, and 4/5 in left lower limb with persisting areflexia in lower limbs.
OUTPUT:
| PMC3894025 |
MultiCaRe_Reasoning74 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 19.0
Sex: Female
Title: Aneurysmal Bone Cyst of the Lumbar Spine in a Patient with Turner Syndrome: A Case Report
Keywords: turner syndrome; aneurysmal bone cysts; expandable cage; intraoperative navigation; preoperative embolization;
Abstract:
None
Image Caption and Description:
Image caption: Preoperative X-ray and CT.. (a) X-ray AP view showing a lytic lesion involving the left L5 vertebral body illustrating a winking owl sign (arrow) (b) The reconstructed lumbar CT scan reveals a lytic expansive lesion involving the L5 vertebral body and left pedicle. Left: sagittal view, and right: axial view.
Image description: Plain radiographs showed an osteolytic lesion involving the left L5 vertebra with a winking owl sign observed on anteroposterior(AP) views (Fig. 1a).
Computed tomography (CT) revealed pathological fractures of the L5 vertebral body and left pedicle along with osteolytic changes (Fig. 1b).
Image caption: MRI of the lumbar spine showing characteristic findings of aneurysmal bone cysts.. T2-weighted sagittal images and T2-weighted axial image centered on the L5 pedicle revealing a cystic lesion involving the left L5 vertebral arch, pedicle, and vertebral body with fluid-fluid levels (arrow).
Image description: Magnetic resonance imaging (MRI) revealed a lobulated lesion with fluid-fluid levels in the left vertebral arch, pedicle, and vertebral body of the L5 vertebra with high and low signal intensities on T2- and T1-weighted images, respectively. (Fig. 2a, b).
Image caption: Preoperative embolization and Pathology photograph.. (a) Embolization of the bilateral L4 lumbar arteries and left iliolumbar artery was performed. (b) Intraoperative photograph after resection of the tumor. The left L5 nerve root was preserved, and the cage was inserted cephalad to the L5 root and then expanded. (c) In a low-power view, fibrous connective tissue associated with capillary proliferation (white arrow) and fibrin deposition (black arrow) are observed. These findings are consistent with the diagnosis of an aneurysmal bone cyst. (d) In a high-power view, there is fibrous connective tissue associated with capillary proliferation. No malignancy is observed.
Image description: We performed preoperative arterial embolization of the bilateral L4 lumbar arteries and the left iliolumbar artery to prevent intraoperative hemorrhage (Fig. 3a).
Using intraoperative navigation to identify tumor margins, a thorough curettage was performed to remove the tumor (Fig. 3b).
The final pathological diagnosis of ABC was made by confirming the fibrous connective tissue accompanied by capillary proliferation and partial fibrin deposition, with no signs of malignancy (Fig. 3c, d).
Image caption: Postoperative X-ray and MRI.. (a) Postoperative X-ray of the lumbar spine (b) Postoperative MRI two years after surgery with no signs of recurrence. (c) Postoperative CT two years after surgery showing interbody fusion between L4 and S1 within the expandable cage and by the right posterolateral fusion mass.
Image description: Pedicle screws were inserted into L4 and S1, and an expandable cage packed with autologous bone chips was placed between the vertebral bodies to reconstruct the lumbar spine's anterior strut (Fig. 4a).
At two years follow up, CT and MRI showed no apparent signs of recurrence (Fig. 4b, c).
Case Report:
The patient is a 19-year-old female with Turner syndrome. She presented at our hospital after acute exacerbation of low back pain that had been present for one month. Her body height was 140 cm, and her weight was 39 kg. Tenderness was noted in the left buttock, but no lower limb muscle weakness or sensory disorders were observed. Plain radiographs showed an osteolytic lesion involving the left L5 vertebra with a winking owl sign observed on anteroposterior(AP) views (Fig. 1a). Computed tomography (CT) revealed pathological fractures of the L5 vertebral body and left pedicle along with osteolytic changes (Fig. 1b). Magnetic resonance imaging (MRI) revealed a lobulated lesion with fluid-fluid levels in the left vertebral arch, pedicle, and vertebral body of the L5 vertebra with high and low signal intensities on T2- and T1-weighted images, respectively. (Fig. 2a, b).
An aneurysmal bone cyst (ABC) of the L5 vertebra was suspected from the image findings. We performed preoperative arterial embolization of the bilateral L4 lumbar arteries and the left iliolumbar artery to prevent intraoperative hemorrhage (Fig. 3a). Using intraoperative navigation to identify tumor margins, a thorough curettage was performed to remove the tumor (Fig. 3b). Rapid intraoperative diagnosis supported the diagnosis of ABC. The final pathological diagnosis of ABC was made by confirming the fibrous connective tissue accompanied by capillary proliferation and partial fibrin deposition, with no signs of malignancy (Fig. 3c, d). Pedicle screws were inserted into L4 and S1, and an expandable cage packed with autologous bone chips was placed between the vertebral bodies to reconstruct the lumbar spine's anterior strut (Fig. 4a).
After surgery, she had complete pain relief. At two years follow up, CT and MRI showed no apparent signs of recurrence (Fig. 4b, c).
ABC frequency is reported to be approximately 1.4% of all primary bone tumors, with 3-30% of the cysts originating in the spinal column). In the spine, ABCs mostly occur in the thoracic or lumbar spines of young patients aged 10-20 years, with approximately 60% affecting the posterior spinal column components). The treatment options for ABC are surgical curettage and bone transplantation), embolization), radiotherapy), and drug injections). Recently, the effective treatment of ABC with embolization alone was reported), but there is a risk of spinal cord infarction due to inadvertent embolization of the Adamkiewicz artery. Therefore, surgery has been selected in most cases to treat ABC that arise in the spine, but there are reports of severe intraoperative hemorrhage,). Therefore, recent reports on ABC treatment often include accounts of surgical treatment with preoperative arterial embolization,). Along with the therapeutic effects of embolization, the reduction in intraoperative hemorrhage allows the surgeon to operate safely and precisely. In this case, arterial embolization was suitable because the ABC was localized in the L5 vertebra, where there is a low risk of embolizing the Adamkiewicz artery. Since she had a pathologic fracture of L5, we selected surgery instead of observing the effects of embolization.
OUTPUT:
| PMC6834456 |
MultiCaRe_Reasoning75 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 19.0
Sex: Female
Title: Aneurysmal Bone Cyst of the Lumbar Spine in a Patient with Turner Syndrome: A Case Report
Keywords: turner syndrome; aneurysmal bone cysts; expandable cage; intraoperative navigation; preoperative embolization;
Abstract:
None
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
This case is rare because of the coexistence with Turner syndrome. Patients with Turner syndrome are mainly characterized by a short stature and lack of secondary sexual characteristics). The risk of gonadoblastoma, colon cancers, and central nervous system tumors have been reported to be greater in patients with Turner syndrome than in the normal population, possibly due to the allelic losses of the X chromosome which has been shown to contains genes related to immunity and cancer. Growth hormone therapy, to treat these patients' short stature, may also increase the risk of cancer). Since this patient had received previous growth hormone therapy to increase her growth rate, it is possible that the growth hormone therapy may have lead to the onset of ABC. However, there has been no report of ABC occurring in a patient with Turner syndrome, so the relationship between Turner syndrome and ABC may not be strong. The height of the present case was 140 cm, which is short compared with the mean body height (157.7 cm) of 19-year-old Japanese females. Since she was without neurological symptoms, we were able to preserve the nerve roots by locally adjusting the cage height with an expandable cage to reconstruct the anterior column).
Here we reported a case of ABC occurring in the spinal column of a patient with Turner syndrome who was treated with preoperative embolization, surgical curettage, and posterior fixation using an expandable cage.
Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.
Author Contributions: Tadashi Nukaga, and Akihiko Hiyama wrote and prepared the manuscript, and all of the authors participated in the study design. All authors have read, reviewed, and approved the article.
OUTPUT:
| PMC6834456 |
MultiCaRe_Reasoning76 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 39.0
Sex: Female
Title: Melorheostosis: a rare entity: a case report
Keywords: ct; mri; melorheostosis; sclerotic bone dysplasias;
Abstract:
Melorheostosis is a rare entity belonging to the group of sclerotic bone dysplasias. Described for the first time in 1922 by Leri, it remains imperfectly known as clinical presentations are highly variable, and the etiological diagnosis is not fully elucidated. We report a case of polyostoticmelorheostosis for which radiological investigations were complete, in order to study this disease.
Image Caption and Description:
Image caption: Flowing candle wax condensation in the proximal femur on a plane radiography, specific of the Leri's disease
Image description: Plain radiographs of the pelvis and proximal femur showed hypercondensation of the medial cortex of the left femur below the calcar, the classic flowing candle wax, combined with condensation of the iliac side of the sacroiliac joints bilaterally (Figure 1).
Image caption: CT scan showing condensation of the iliac sides of sacro iliac joints
Image description: CT of the pelvis and left femur was performed and showed an hypercondensation in the medial cortex of the left femur, and a bilateral condensation of the iliac side of the sacroiliac joints (Figure 2, Figure 3).
Image caption: The caracteristic candle wax condensation of the proximal femur below the calcar in the CT scan
Image description: CT of the pelvis and left femur was performed and showed an hypercondensation in the medial cortex of the left femur, and a bilateral condensation of the iliac side of the sacroiliac joints (Figure 2, Figure 3).
Image caption: MRI on T2 sequence showing the condensation of the iliac side of the sacro iliac joints with no involvment of the joint nor the soft tissues
Image description: An MRI was performed and showed the same bone condensation without extensions to the soft tissues (Figure 4).
Image caption: Scintigraphy showing hyper fixation of the proximal femur and the sacro iliac joints
Image description: Scintigraphy (Figure 5) and plain radiographies remained similar to initial assessments.
Case Report:
We report the case of a 39 years-old female, with no past medical history, whose complaint was a spontaneous one week evolving isolated left cruralgia. The clinical examination was unremarkable apart from an anterior thigh pain at the mobilization of the left hip. No quadriceps hypotrophy, no fever and no limitations in the joints motion were found. Plain radiographs of the pelvis and proximal femur showed hypercondensation of the medial cortex of the left femur below the calcar, the classic flowing candle wax, combined with condensation of the iliac side of the sacroiliac joints bilaterally (Figure 1). Lab tests were normal. The diagnosis of melorheostosis was raised and we completed the explorations by a whole body bone scan that showed increased uptake in the proximal left femur and both sacroiliacs. CT of the pelvis and left femur was performed and showed an hypercondensation in the medial cortex of the left femur, and a bilateral condensation of the iliac side of the sacroiliac joints (Figure 2, Figure 3). The patient was put under analgesics and nonsteroidal anti -inflammatory drugs, with improvement of symptoms from J3 of hospitalization. An MRI was performed and showed the same bone condensation without extensions to the soft tissues (Figure 4). Given these findings, biopsy was not performed, and the patient was discharged to be followed in our consultation by standard radiographs every three months, and an annual bone scan. At last follow up, two years of the first consultation, two episodes of left cruralgia have been reported, and yielded by three days anti -inflammatory treatments. Scintigraphy (Figure 5) and plain radiographies remained similar to initial assessments.
OUTPUT:
| PMC4258217 |
MultiCaRe_Reasoning77 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 26.0
Sex: Male
Title: Mediastinal abscess, an unusual way of presentation of eosinophilic esophagitis
Keywords: eosinophilic; eosinophilic esophagitis; esophagitis; mediastinal abscess;
Abstract:
Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. EoE represents a chronic, local immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Mediastinal abscess is an uncommon condition that typically appears after esophageal perforations or thoracic surgeries, usually requiring treatment for surgical intervention due to its high morbidity-mortality. Mediastinal abscess, outside these two contexts, is extremely rare. We present the case of a mediastinal abscess secondary to EoE. It is important to think about this entity when there is a mediastinal abscess without trauma or previous surgery.
Image Caption and Description:
Image caption: a CT image with the mediastinal abscess (yellow arrow) behind the esophagus (green arrow). b Pathological findings showing diffusely infiltrated eosinophils, with microabscess formation
Image description: For that reason it is decided to perform thoracic-abdominal computed tomography (CT), where a collection of 8 x 4 x 5 cm is displayed in the third inferior-posterior of the esophagus compatible with hematoma vs mediastinal abscess (Fig. 1).
Case Report:
We present the case of a 26-year-old male who is referred to the digestive consultation by two episodes of spontaneous paraesophageal abscess in an interval of 2 years.
It is a patient with no pathological history of interest that is presented in the Emergency Service for dysphagia for solids of 3 days of evolution that at the same time was suffering stabbing chest pain and fever of up to 38.8 C in the last 24 h. In the last year the patient had already been in the Emergency Room (ER) twice for chest pain with non-altered complementary tests. The patient denies having any traumatic history or onset of symptomatology after food impaction. The physical examination shows no abnormality on a hemodynamically stable patient. It is performed a blood test showed a C reactive protein (CRP) 190 mg/L (Normal values 0-5 mg/L), and white blood cells 12,000/muL (Normal values 4000-10,000). For that reason it is decided to perform thoracic-abdominal computed tomography (CT), where a collection of 8 x 4 x 5 cm is displayed in the third inferior-posterior of the esophagus compatible with hematoma vs mediastinal abscess (Fig. 1).
The surgery service is contacted and it is decided to choose the conservative treatment with broad-spectrum antibiotics and absolute diet. During the admission, a echocardiogram with normal results was performed, an esophagogram that does not present alterations and a gastroscopy, where a linear ulcer of 5 mm in distal third of esophagus with biopsy that shows granulation tissue was found.
The patient is discharged 7 days after, with the normalization of his analytical and clinical parameters, and showing a correct oral tolerance for later control in consultations.
An outpatient USE is requested 3 weeks later, after being discharged, where no paraesophageal collection is displayed. Gastroscopy was repeated where the esophageal ulcer is not visualized and biopsies are taken from the distal and proximal esophagus. In those biopsies, it is noticed an eosinophilic inflammatory infiltration of 40 eosinophils per field.
The patient does not attend any control, so no treatment is started.
One year later the patient returns to the emergency department with chest pain and dysphagia with same characteristics, and elevation of CRP and white blood cells. Again, a toraco-abdominal CT is performed, objectivizing mediastinal collection in the same location as 1 year before, with a size of 7 x 4 x 4 cm, compatible with abscess, which is retreated in a conservative manner with broad spectrum antibiotics. After 10 days, a CT control confirms resolution of the collection.
Ambulatory gastroscopy is performed with biopsy-taking by objectivizing an eosinophilic inflammatory infiltrate compatible with eosinophilic esophagitis.
The patient denies dysphagia, chest pain, heartburn or any other clinic between episodes of mediastinal abscess.
It starts treatment with proton pump inhibitor in double doses during 8 weeks, persisting the eosinophilic inflammatory infiltrate in the biopsies. It is agreed a diet with the patient where two foods will be removed (milk and wheat), obtaining histological remission, and identifying the milk as the cause of the inflammation.
After 2 years of follow-up, the patient maintains milk and derivatives restriction, and has not shown again any episodes of mediastinal abscess.
OUTPUT:
| PMC6396444 |
MultiCaRe_Reasoning78 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 56.0
Sex: Male
Title: Implant-associated Hoffa's Fracture in a Floating Knee: A Case Report and Review of Literature
Keywords: floating knee; hoffa; polytrauma;
Abstract:
Introduction:
Complex floating knee in the presence of a previous implant creates an unusual fracture pattern which is a rare entity and poses a unique challenge in management and subsequent rehabilitation.
Case report:
A 56-year-old psychiatric patient who jumped from height had a polytrauma and a floating knee injury. Following the primary care and damage control surgery with knee-spanning fixator at some other centers, he was shifted to us on ventilator care and was directly admitted to intensive care unit for further management. On presentation, it was a floating knee injury with gross comminution of both femur and tibia with associated Hoffa with bent implant in situ. It was managed by plating of both lower end femur and tibia and at the end of 6 months, showed a satisfactory outcome.
Conclusion:
Floating knee injuries further complicated by the presence of the previous implant in a polytrauma situation poses a unique challenge which requires meticulous surgical planning and prolonged rehabilitation to achieve satisfactory outcome.
Image Caption and Description:
Image caption: Floating Knee with bent implant in situ
Image description: A locking distal femoral locking plate was present and had bent (Fig. 1).
Image caption: (a-c) Floating knee with knee-spanning fixator in situ.
Image description: As per records, he had 3*2cm wound on anterior aspect of thigh which was thoroughly washed, debrided, and sutured and damage control surgery was done in the form of knee-spanning fixator (Fig. 2)and the patient was put on intravenous antibiotics.
The right lower limb X-rays revealed knee-spanning external fixator with fracture of lower end femur and proximal end tibia with bent implant in situ (Fig. 2).
Image caption: (a-e) Chest, cervical spine, and pelvis X-rays as a part of routine trauma protocol.
Image description: As a part of repeat evaluation, all his necessary X-rays were retaken(Fig. 3)which revealed resolution happening in bilateral hemothorax.
Image caption: (a and b) Skin incision used for fixing the fractures.
Image description: The distal femur was opened through lateral approach using liberal skin incision(Fig. 4).
Image caption: (a and b) Immediate post-operative X-rays.
Image description: Immediate post-operative X-rays revealed satisfactory alignment of both fractures, (Fig. 5).
Image caption: (a and b) Distal radius fracture.
Image description: We could not ambulate the patient as he had another fracture in the wrist in the recent past, (Fig. 6).
Image caption: (a and b) X-rays at 6 weeks.
Image description: An X-ray was taken at 6 weeks post-operative which revealed satisfactory alignment(Fig. 7) and toe touch weight-bearing with long knee brace was started under supervision of trained physiotherapists.
Image caption: (a-d) Solid union at the end of 6 months.
Image description: At the latest follow-up of 6 months, the patient had radiological and clinical evidence of union (Fig. 8).
Image caption: Knee range of motion.
Image description: The foot drop was also recovering and there was no extension lag and knee flexion was upto 90 (Fig. 9).
Case Report:
A 56-year-old diabetic, hypertensive man on antipsychotic medications who jumped from about 30 feet height, sustained polytrauma and was admitted in a local hospital. After initial resuscitation and advanced trauma life support (ATLS) care, he was intubated and put on ventilator support. He was diagnosed with bilateral hemothorax and his right lower limb X-rays showed fracture lower one-third femur with extensive metadiaphyseal comminution and fracture ipsilateral proximal tibia extending to metaphysis. A locking distal femoral locking plate was present and had bent (Fig. 1). As per records, he had 3*2cm wound on anterior aspect of thigh which was thoroughly washed, debrided, and sutured and damage control surgery was done in the form of knee-spanning fixator (Fig. 2)and the patient was put on intravenous antibiotics. He stayed in the intensive care unit (ICU) for 7 days, after which he was shifted to our center. As a part of repeat evaluation, all his necessary X-rays were retaken(Fig. 3)which revealed resolution happening in bilateral hemothorax. The right lower limb X-rays revealed knee-spanning external fixator with fracture of lower end femur and proximal end tibia with bent implant in situ (Fig. 2). The patient was kept in the ICU till he was fit for subsequent intervention and appropriate treatment in the form of intravenous antibiotics and deep vein thrombosis prophylaxis was given. During this period, the patient had low-grade fever, but his inflammatory markers were normal and the wound over the thigh was healthy. On the 8thday, he was taken up in the operation theater with intubation on. Before removing external fixator, the wound present on anterior aspect of distal thigh was again debrided and found to be clean; then, the decision to proceed further was made and the external fixator was removed. The distal femur was opened through lateral approach using liberal skin incision(Fig. 4). After splitting the distal part of tensor fasciae latae, the distal locking screws were removed. Since the plate was bent, a bone hook was used to pull out the proximal end of plate laterally. Now, the position of the proximal screws was marked under C-arm control using an artery forceps. Each screw head was cleared causing minimal muscle damage and they were removed in a minimally invasive fashion, thus preserving the biology of zone of comminution and the plate was gently levered out. Following implant removal, we identified that there was another fracture line in coronal plane just posterior to plate application in the articular block which was identified as lateral condyle Hoffa fracture. The articular reconstruction was first done and the Hoffa fracture was fixed using single partially threaded cancellous screw. Manual linear traction was applied to the limb after reconstructing articular block and grossly comminuted fragments were seen to be aligned, so no attempt was made to open the comminuted area. The length of the limb was maintained by giving linear traction and an electrocautery was used to ensure that the center of femoral head, patella, and second toe lie in same line and checked under C-arm to maintain the correct rotation of the limb. The longest available distal femur locking plate (A.O SYNTHES) in the set was slid in a MIPPO fashion bypassing the zone of comminution after reconstructing the articular block. Same incision was extended below knee to expose proximal tibia and the longest available lateral tibia locking plate(A.O SYNTHES) was slid in a MIPPO manner bypassing the comminution. Now, after fixing both the fractures, the knee was examined for ligamentous instability and it was found to be globally unstable in both the planes. Considering the gross comminution in both femur and the tibia, and the being an open fracture, it was decided to wait for ligamentous reconstruction till bony union was achieved. Wound was sutured in layers over negative drain and a long knee brace was given to the patient since the knee was unstable in both the planes. The patient was shifted out of theater in an intubated state. Immediate post-operative X-rays revealed satisfactory alignment of both fractures, (Fig. 5). During the next 7 days, the patient remained intubated and during this period, the passive movement of joints was given, the limb was elevated and the stitch line was carefully monitored. Once the patient was extubated on the 8th day, it was found that there was an associated foot drop which was missed preoperatively since the patient was in an intubated state. The foot drop splint was applied accordingly and physiotherapy in the form of guarded ROM and muscle strengthening exercises was started. We could not ambulate the patient as he had another fracture in the wrist in the recent past, (Fig. 6). The wound healing was bit delayed but it was ultimately uneventful. An X-ray was taken at 6 weeks post-operative which revealed satisfactory alignment(Fig. 7) and toe touch weight-bearing with long knee brace was started under supervision of trained physiotherapists. The patient was further followed up at 1 month interval and during this rehabilitation period, special attention was given to his psychiatric care. At the latest follow-up of 6 months, the patient had radiological and clinical evidence of union (Fig. 8). At the last available follow-up, the ligamentous instability still persisted, and with long knee brace, he was able to stand and walk. The foot drop was also recovering and there was no extension lag and knee flexion was upto 90 (Fig. 9). At this moment, he was properly counseled and explained in detail about all the available options in the form of arthrodesis, hinged knee arthroplasty, and ligamentous reconstruction, but the patient opted for non-operative management in the form of long knee brace for the time being.
OUTPUT:
| PMC6742877 |
MultiCaRe_Reasoning79 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Male
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Somatically, the patient had no significant medical or surgical history, and in particular no documented drug allergy or AE. He had grade 1 obesity (99 kg, 180 cm, BMI: 30.56), was an active smoker, and had a history of addiction (cannabis) from which he had been abstinent for several years.
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning80 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 19.0
Sex: Unknown
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Psychiatrically, the patient had a history of schizoaffective disorder diagnosed at the age of 19 (illness duration of 10 years) according to DSM5 criteria, in combination with antisocial personality disorder and substance use disorder. Illness recurrences came in the form of acute manic psychosis, which were often triggered by a discontinuation of treatment and required multiple psychiatric hospitalizations (5 within the past 2 years), the most recent of which were by involuntary care.
Therapeutically, the initiation of long-acting injectables (LAI) in the form of Risperidone extended-release (ER) (50 mg/14 days) first of all ensured an initial period of clinical stability. However, 2 years before the onset of the current episode, a decompensation while on a single antipsychotic agent had motivated the initiation of a mood stabilizer (Valproate semisodium, 2,000 mg/d, with serum valproate concentration of 62 mg/L, within the therapeutic range of 41-100 mg/L) combined with antipsychotic treatment with paliperidone ER (100 mg/28 d). This dual therapy was then replaced by a combination of valproate semisodium (2,000 mg/day) and Risperidone (4 mg/d) in a context of absenteeism from outpatient follow-up. Six months prior to the onset of the current episode, dual therapy with valproate semisodium (2,000 mg/d) + paliperidone ER (100 mg/28 d) was re-initiated, with a well-tolerated dosage increase (to 2,500 mg/d and 150 mg/28 d, respectively, accompanied by an elevation in serum valproate levels from 67 mg/L before to 97 mg/L after drug dosage increase) without any further adjustment in the 4 months preceding this episode.
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning81 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Male
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
After a short period of clinical stability however, a further interruption of both outpatient follow-up and drug treatment was accompanied by an increase in both manic (elated mood and psychomotor agitation) and psychotic symptoms (delusions of grandeur and persecution) leading to behavioral disturbances and hetero-aggressive threats against his neighbors. After police intervention, the patient was transported to the psychiatric emergency services for medical assessment, and hospitalized without consent in a psychiatric care unit, where further examinations were performed.
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning82 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Due to a relapse with a serum valproate level suggestive of drug non-compliance on admission (serological concentrations of valproate measured at 23 mg/l on admission, below the therapeutic range), the drug was re-prescribed at the usual doses and supplemented with diazepam, a benzodiazepine drug, and levomepromazine, a phenothiazine antipsychotic with tranquilizer properties. When clinical deterioration (acute manic psychosis with grandiose delusions and psychomotor agitation) again occurred under effective treatment [i.e., despite a serum valproate level within the therapeutic range (91 mg/l)], a change in mood stabilizer was proposed in an overlap-and-taper strategy, after pre-therapeutic assessment (with no outstanding features). Considering that the patient had many illness recurrences of manic polarity with psychotic symptoms, as well as a high metabolic syndrome risk valproate was replaced with lithium as mood stabilizer, which was initiated (day 0) at 400 mg/d. However, after the third administration of slow-release lithium salt, signs of fluctuating temporal disorientation signaled the onset of an acute confusional syndrome (d3). An iatrogenic etiology was immediately suspected, which led to the discontinuation of lithium the same day (d3) and the confusional syndrome was etiologically assessed.
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning83 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Clinically, the patient presented with psychomotor retardation, disorders of alertness and global cognitive impairment [Mini-Mental State Examination (MMSE) score of 15/30; Frontal Assessment Battery (FAB) score of 3/18 ] with no clinical signs on general or neurological examination). Biological examinations (complete blood count, electrolytes, liver, kidney, thyroid, coagulation and vitamin workup) revealed no significant abnormality (day 3). The brain computed tomography (CT) scan (day 5) showed nothing abnormal. The electroencephalogram (EEG) (d5) showed no seizure activity but presented a pattern indicating encephalopathy (fluctuating and slowing background activity with theta/alpha and delta waves, predominant in the posterior regions, reactive to verbal stimulation and with the change to eyes-open). Pharmacologically, serum lithium level measured 24 h after the third intake (day 3) showed subtherapeutic doses (undetectable <0.05 mmol/l; N: 0.8-1.2 mEq/l), whereas the serum valproate level was consistent with an overdose (130 mg/l) and was accompanied by a threefold elevation in serum ammonia level (182 mumol/l; N: 16-60). In addition, the blood toxicology screen showed cannabis use (THC-COOH: 16.9 ng/l) but did not suggest associated substance use.
The diagnosis of drug-induced hyperammonemic encephalopathy (HAE) was therefore proposed, and the valproate semisodium dose was decreased under clinical supervision (2,000 mg/d on day 4, 1,500 mg/d on day 6). The neurologist recommended no other urgent course of action.
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning84 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Dose reduction resulted in rapid neurological improvement, both clinically and on the electroencephalogram [check on day 7, i.e., 3 days (steady-state) after the first valproate semisodium dose reduction], associated with normalization of serum valproate (79 mg/l on day 7; 5 mg/l on day 10) and serum ammonia (66 mumol/l on day 7; 32 mumol/l on day 10) levels. However, regression of the encephalopathic condition quickly gave way to the reappearance of psychiatric symptoms due to the lack of effective treatment, which justified a re-increase in valproate semisodium dosage (2,500 mg/d on day 12, 5 days after the regression of the neurological disorders) and a monthly injection of paliperidone, which once again stabilized the patient without any clinical or biological adverse effect observed in 1 month (serum valproate level: 61 mg/l and serum ammonia level: 27 mumol/l on day 38, on valproate semisodium 2,500 mg/d).
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning85 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Unknown
Title: Case Report: A Case of Valproic Acid-Induced Hyperammonemic Encephalopathy Associated With the Initiation of Lithium: A Re-duplicable Finding
Keywords: encephalopathy; hyperammonemia; interaction; lithium; pharmacokinetic interaction; valproate sodium;
Abstract:
Introduction:
Hyperammonemic encephalopathy (HAE) is a serious adverse effect of valproate semisodium, which is facilitated by the potential for drug interaction. However, despite frequent co-prescription of valproate semisodium and lithium, the role of this combination in the occurrence of HAE has not been defined in the literature. This case report concerns the occurrence of HAE concomitant with the initiation of lithium in a 29-year-old patient who had been placed on valproate semisodium for a schizoaffective disorder.
Case report:
Due to a relapse while on a combined antipsychotic and mood-stabilizing therapy (paliperidone palmitate and valproate semisodium), a cross-taper from valproate semisodium to lithium was proposed. The initiation of lithium was accompanied by an acute confusional syndrome, an elevated serum valproate level and hyperammonemia suggestive of drug-induced HAE. The discontinuation of lithium and reduction of valproate semisodium led to neurological improvement, until a recrudescence of psychiatric symptoms justified a rechallenge of the combination within the framework of a new cross-taper. As soon as Lithium was re-initiated, an increase in the serum valproate level and hyperammonemia were again noted.
Discussion:
The mechanisms of valproate-related HAE involve various metabolic pathways. In this case, exploration of the iatrogenic hypothesis focused on the imputability of concomitant cannabis use and co-prescriptions of benzodiazepines, antipsychotics, and in all likelihood, mood stabilizers.
Conclusion:
Therefore, this case study suggests that Lithium plays a role in serum valproate level elevation, and supports the hypothesis of an association between an elevated serum valproate level, hyperammonemia and reversible encephalopathy. A more in-depth pharmacokinetic exploration would provide a better understanding of the mechanisms of these interactions and support for the benefit-risk balance associated with this frequent co-prescription.
Image Caption and Description:
Image caption: Management summary: therapeutic strategy, clinical course and diagnostic tests. EEG, electroencephalogram; ER, extended release; NA, not administered; N, normal values ; CT, computed tomography (brain) scan; T, abnormal; ?, normal, within normal limits; , elevated value, within normal limits; , elevated value, above normal or supratherapeutic; , decreased value, within normal limits; , decreased value, below normal or subtherapeutic; : discontinued; Normal values: serum lithium level: N = (0.84-1.2) mg/l; serum valproate level: N = (41-100) mEg/l; serum ammonia level: N = (16-60) mumol/l.
Image description: The rechallenge of the combination long after the first episode then enabled a more objective examination of another increase in the serum valproate level, with more moderate hyperammonemia (without encephalopathy or associated clinical signs), concomitant with the re-initiation of lithium, despite a progressive decrease in the doses of valproate semisodium administered (Figure 1).
Case Report:
After requesting an opinion from a pharmacology specialist:and in the absence of documentation in the literature regarding the possibility that lithium may have contributed to the picture presented, a change in mood stabilizer was again considered at day 46 (day 0') according to the same modalities. lithium was initiated at 400 mg/d, valproate semisodium was progressively decreased (2,000 mg/d on day 0', 1,500 mg/d on day 3' [...] discontinuation on day 12') and the patient was reassessed daily. No clinical adverse effects were reported. However, biologically, the results of the test done on day 6' showed an infratherapeutic serum lithium level (0.26 mEq/l with 400 mg/d of lithium) and a 6% increase in serum valproate level compared to the test done 2 weeks earlier (89 mg/l on day 6' compared to 61 mg/l on day 38), despite a 40% decrease in the valproate semisodium dose administered since the last test (1,500 mg/d on day 6' compared to 2,500 mg/d on day 38). In addition, this elevated serum valproate level was again associated with hyperammonemia (90 mg/l), with no proven consumption of toxic substances (negative urine toxicology screen).
The first administration of lithium salts was temporally related to an elevation of valproate serum levels, which was in turn associated with hyperammonemia and signs and symptoms of encephalopathy, which resolved after lithium discontinuation and progressive reduction of valproate semisodium dosage. The rechallenge of the combination long after the first episode then enabled a more objective examination of another increase in the serum valproate level, with more moderate hyperammonemia (without encephalopathy or associated clinical signs), concomitant with the re-initiation of lithium, despite a progressive decrease in the doses of valproate semisodium administered (Figure 1).
OUTPUT:
| PMC9108155 |
MultiCaRe_Reasoning86 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 21.0
Sex: Male
Title: Campylobacter jejuni-Associated Hemophagocytic Lymphohistiocytosis and Guillain-Barre Syndrome: A Case Report
Keywords: campylobacter jejuni; guillain-barre syndrome; facial paralysis; hemophagocytic lymphohistiocytosis; ophthalmoplegia; peripheral nerve injury;
Abstract:
Campylobacter jejuni (C. jejuni), a Gram-negative bacterium, belongs to microaerobic bacteria. We reported a 21-year-old male patient diagnosed with hemophagocytic lymphohistiocytosis (HLH) due to C. jejuni infection, who presented with multiple clinical manifestations of peripheral nerve injury, such as ophthalmoplegia, facial paralysis, and urinary retention during the treatment. Electromyography showed neurogenic injury and the final diagnosis was Guillain-Barre Syndrome (GBS). After treatment of dexamethasone combined with immunoglobulin, the patient was discharged from the hospital with partial recovery of neurological symptoms.
Image Caption and Description:
Image caption: Abdominal and computed tomography (CT) revealed splenomegaly.
Image description: Plain CT scan of the thoracoabdominal basin showed mild fatty liver and splenomegaly (Figure 1).
Case Report:
The patient, a 21-year-old Uygur male, had a history of fever and diarrhea for 8 days, with the highest body temperature of about 38.6 C, accompanied by chills, and sparse watery stool several times, without abdominal pain. Due to the intermittently increased temperature after taking non-steroidal anti-inflammatory drugs (NSAIDs), the patient was treated in the fever clinic but got a poor treatment effect, therefore he was admitted to the emergency department on October 10, 2021.
Physical examination on admission showed a body temperature of 38 C, pulse of 102 times/min, respiration of 23 times/min, and blood pressure of 125/72 mmHg, with clear consciousness, palpable spleen under the ribs. No other significant abnormalities were found in other physical examinations.
Emergency laboratory analysis in the emergency department indicated the following: white blood cell count decreased from normal range to 1.56 x 109/L (reference value, RV 3.5-9.5 x 109/L), hemoglobin was 166 g/L (RV 130-175 g/L), platelet decreased from normal range to 74 x 109/L (RV 125-350 x 109/L), aspartate aminotransferase was 150u/L (RV 15-40 u/L), lactate dehydrogenase was 1249 u/L (RV 109-245 u/L), triglyceride was 2.29 mmol/L (RV 0.45-1.7 mmol/L), sodium was 124.2 mmol/L (RV 137-147 mmol/L), fibrinogen decreased from normal range to 1.27 g/L (RV 2-4 g/L), sCD25 was 25,398 pg/mL (RV < 6,400pg/mL), ferritin was 3671u g/L (RV 30-400ng/mL), natural killer cell activity was 18.48% (RV >= 15.11%). G-test (serum (1,3)-beta-D-glucan test) was positive, GM-test (galactomannan test) was negative, and blood culture, procalcitonin, c-reactive protein, erythrocyte sedimentation rate and T-SPOT.TB test were all negative. Mycoplasma pneumoniae antibody IgM (Passive Particle Agglutination, FUJIREBIO) was 1:80 positive (RV < 1:20), Legionella pneumophila antibody IgM (ELISA, Euroimmun) was 0.82 positive (RV < 0.8). The detection of Cytomegalovirus (CMV), Epstein Barr virus (EBV), Adenovirus and Coxsackievirus were all negative (real-time PCR). The oncological and immunological indexes were normal. Plain CT scan of the thoracoabdominal basin showed mild fatty liver and splenomegaly (Figure 1). There are many small lymph nodes in the hepatogastric space and retroperitoneal space.
Referring to HLH-2004 diagnostic criteria, the patient met the following conditions: (1) Temperature > 38.5 C for more than 7 days; (2) Hemocytopenia (WBC <10 x 109/L, PLT <100 x 109/L, hemoglobin 166 g/L); (3)Splenomegaly; (4)Low fibrinogen (FIB <1.5 g/L) and high triglycerides (2.29 mmol/L), although not meeting the diagnostic criteria (3 mmol/L); (5)Ferritin > 500u g/L;(6)sCD25 > 6,400 pg/mL. Considering the definitive diagnosis of HLH, the patient was treated with 20 g immunoglobulin QD (8 days) and 0.5 g imipenem cilastatin sodium Q8H, and his leukocytes, platelets, and fibrinogen gradually returned to normal levels. However, on day 14 after his onset, the patient developed a series of symptoms of peripheral nerve involvement, as shown in Table 1.
Lumbar puncture was performed on the 16th day. Cerebrospinal fluid showed a low pressure and turbid appearance, containing 150 white cells/muL (90% lymphocytes, 10% neutrophils), protein 1.09 g/L, glucose 2.37 mmol/L, and chlorine 100.6 mmol/L; Bacteria, fungi, cryptococcus, and Mycobacterium tuberculosis were all negative; Rubella virus, CMV and EBV IgM antibody and DNA were later reported as negative. CSF and serum albumin data: CSF and serum albumin was 3.27 and 37 g/L, respectively (October 19); while 1.09 and 32.6 g/L, respectively (October 22). The albumin quotient (albumin in CSF/albumin in serum) indicated that an increased permeability of the blood-brain. No abnormality was found in CSF next-generation sequencing technology (NGS) implemented by Biotechnology Co., Ltd. Briefly, they optimized the internal index adapter and real-time analysis pipeline, established the optimal threshold for pathogen identification, and performed rapid metagenomic-NGS analysis. Peripheral neuropathy, demyelination, paraneoplastic tumor, autoimmune brain-related antibodies, serum antibodies IgM and IgG of C. jejuni were positive by enzyme-linked immunosorbent assay (ELISA), performed by Dr. Hao from the first hospital of Peking University, The values of IgM and IgG were greater than the negative control values (the cut-off values were 0.08 and 0.16 respectively) even after 1:160 dilution. Given the clinical presentation and CSF findings, based on intravenous dexamethasone of 20mg QD, the treatment regimen was adjusted to meropenem 1000 mg Q8H combined with acyclovir 60 mg Q8H and Mecobalamin 500 ug QD. On the 18th day, the patient's body temperature dropped to normal. On the 19th day, the lumbar puncture was performed again, and the cerebrospinal fluid became clear. CSF laboratory examination showed white blood cell count of 91/muL (92% single nucleus, 8% multiple nuclei), protein level of 3.27 g/L, normal glucose and chlorine, as well as negative NGS. Electromyography (Table 2) and cranial MRI were generally normal.
Considering the peripheral nerve injury and cerebrospinal fluid protein cell separation, GBS secondary to C. jejuni infection was specifically classified as Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis. On the 23rd day of onset, the diameter of the right pupil gradually recovered to 4 mm the pupillary light reflex, and the closing function of the right upper eyelid gradually recovered. On the 26th day, dexamethasone was reduced to 10 mg QD. On the 27th day, the left pupil diameter recovered to about 4 mm, and the pupillary light reflex recovered. On the 28th day, the patient defecated autonomously. On the 41st day, spontaneous urination recovered, and the patient was hospitalized for 42 days. Before discharge, the patient had left bilateral facial paralysis and mild diplopia in both eyes. One month after discharge, the patient was followed up, leaving slight facial paralysis, and other symptoms returned to normal.
OUTPUT:
| PMC9302883 |
MultiCaRe_Reasoning87 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 44.0
Sex: Male
Title: Achromobacter xylosoxidans/denitrificans bacteremia and subsequent fatal Escherichia coli/ Streptococcus anginosus pleural empyema
Keywords: None
Abstract:
Achromobacter xylosoxidans, a gram-negative bacillus with low virulence has rarely been reported to cause clinically significant infections. We report an unusual case of MDR Achromobacter xylosoxidans/denitrificans bacteremia from a peripherally inserted central catheter (PICC) and subsequent fatal pleural empyema due to MDR Escherichia coli and Streptococcus anginosus. A 44-year-old male presented to the hospital with chief complaints of chest tightness associated with a productive cough. He was found to have pleural empyema secondary to MDR E. coli and S. anginous. Three months prior to current presentation, he had a history of MDR A. xylosoxidans originating from a PICC. The patient expired even after appropriate management. Thoracic empyema continues to cause significant morbidity and mortality despite the improvement of antimicrobial therapy and the existence of multiple options for drainage of the infected pleural space. The bacteriology of thoracic empyema has been changing since the introduction of antibiotics. Typical antibiotics used to treat these MDR pathogens have become obsolete. Therefore, physicians should be aggressive in their diagnostic approach to pleural empyema, since the isolation of MDR aerobic gram-negative bacilli or multiple pathogens from the pleural fluid is associated with a poor prognosis and indicates a need for more aggressive antimicrobial chemotherapy. Also, the association of indwelling medical devices and MDR Achromobacter bacteremia should be known.
Image Caption and Description:
Image caption: Initial axial Computed Tomography of the chest showing a right upper lobe wedge-shaped peripheral ground glass and cavitary opacities consistent with pulmonary infarcts.
Image description: The patient's clinical condition was initially improving but after an extensive hospital stay he subsequently died after a cardiac arrest (see Fig. 1, Fig. 2, Fig. 3).
Image caption: Repeat Computed Tomography of the chest showing right lower lobe consolidation with small right pleural effusion, right upper lobe consolidation with partial ground glass opacity and a right upper lobe cavitary lesion measuring 3.5 x 2 cm.
Image description: The patient's clinical condition was initially improving but after an extensive hospital stay he subsequently died after a cardiac arrest (see Fig. 1, Fig. 2, Fig. 3).
Case Report:
A 44-year-old male presented to the hospital with chief complaints of right foot pain, swelling and inability to ambulate. Medical history was significant for type 2 diabetes mellitus, diabetic foot ulcer, and osteomyelitis of right foot status post intravenous antibiotics through a peripherally inserted central catheter (PICC). On physical examination, the patient was noted to have bilateral lower extremity edema and a right foot plantar ulcer associated with erythema and warmth. Magnetic Resonance Imaging of right foot showed hallux Metatarsophalangeal (MTP) plantar soft tissue ulcer with gas locules at hallux MTP joint associated with Hallux metatarsal/proximal phalangeal osteomyelitis with septic arthritis. The patient underwent a right foot partial first ray amputation. Also, a Computed Tomography of chest obtained for shortness of breath revealed an incidental segmental and subsegmental bilateral upper lobe pulmonary emboli and a right upper lobe wedge-shaped peripheral ground glass and cavitary opacities consistent with pulmonary infarcts.
Cultures were obtained from peripheral blood and PICC line. Both grew Achromobacter xylosoxidans/denitrificans which was resistant to meropenem, cefepime, piperacillin/tazobactam aztreonam, gentamicin, and tobramycin and sensitive to ciprofloxacin, levofloxacin, and Bactrim. A. xylosoxidans was considered MDR and the PICC was considered the primary source of bacteremia. Repeat blood cultures after three days of empiric antibiotic therapy were negative. The PICC was removed and a new PICC was placed and the patient was subsequently discharged on intravenous ciprofloxacin and vancomycin for six weeks. Also, a transesophageal echocardiogram was negative for vegetation and endocarditis was ruled out.
Three months later, the patient was readmitted for chest tightness associated with a productive cough and nausea which were present for four days prior to presentation. On physical examination, the patient was noted to have right sided crackles, bilateral lower extremity edema, and a right foot plantar ulcer. The patient was tachycardic with a heart rate of 112 and afebrile. Laboratory studies revealed an elevated leukocyte count of 17 k/ul with a neutrophil predominance of 79% and low hemoglobin of 8.5 g/dL. He had normal electrolytes, normal kidney function and normal liver enzymes. Initial imaging with chest x-ray showed right lung opacity with lower lobe predominance. On further imaging with a Computed Tomography of the chest revealed no evidence of PE and showed right lower lobe consolidation with small right pleural effusion, right upper lobe consolidation with partial ground glass opacity and a right upper lobe cavitary lesion measuring 3.5 x 2 cm. The effusion and consolidations were new whereas the cavitary lesion was thought to be secondary to ischemic necrosis of previous pulmonary infarction at the same location.
A diagnostic thoracentesis was done which showed turbid fluid with a total nucleated cell count of 36034/muL with 67% segmented granulocytes and many bacteria seen on gram stain. The Pleural fluid cultures grew E. coli which was resistant to ampicillin, gentamicin, levofloxacin, and ciprofloxacin and sensitive to ceftriaxone, Bactrim, aztreonam, cefepime, meropenem, imipenem, piperacillin/tazobactam and S. anginosus which was pan-sensitive to ceftriaxone, clindamycin, vancomycin, levofloxacin, erythromycin. E. coli was considered MDR and the patient was started on intravenous zosyn and a video-assisted thoracoscopic surgery with decortication was done for right pleural empyema. The patient's clinical condition was initially improving but after an extensive hospital stay he subsequently died after a cardiac arrest (see Fig. 1, Fig. 2, Fig. 3).
OUTPUT:
| PMC6205350 |
MultiCaRe_Reasoning88 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 62.0
Sex: Female
Title: Gordonia sputi-associated bloodstream infection in a renal transplant patient with chronic indwelling central venous catheter: a case report and literature review
Keywords: 16s rrna; actinomycetes; gordonia; central line-associated bloodstream infection;
Abstract:
Introduction:
Although rare, human infections caused by Gordonia spp. have been reported, especially within the immunocompromised population and those with long-term indwelling devices. We report a case of Gordonia spp. bacteraemia in a renal transplant patient and present a literature review on microbiological identification methods of this organism.
Case presentation:
A 62-year-old female renal transplant recipient admitted to hospital with a 2-month history of dry cough and fevers occurring weekly when receiving electrolyte replacement infusions via a Groshong line. Over 2 weeks, blood cultures repeatedly isolated a Gram-positive bacillus solely in aerobic bottles, and this was initially reported as Rhodococcus spp. by the local microbiology laboratory. Chest computed tomography (CT) showed multiple ground-glass lung opacities suggestive of septic pulmonary emboli. As central line-associated bloodstream infection was suspected, empirical antibiotics were initiated and the Groshong line was removed. The Gram-positive bacillus was later confirmed by the reference laboratory as Gordonia sputi via 16S rRNA sequencing. Vancomycin and ciprofloxacin for a duration of 6 weeks were completed as targeted antimicrobial therapy. After treatment, the patient remained symptom-free with marked improvement on repeat CT chest imaging.
Conclusion:
This case illustrates the challenges surrounding identification of Gordonia spp. and other aerobic actinomycetes. 16S rRNA gene sequencing may be a preferred identification method, especially when initial workup of a weakly acid-fast organism fails to make an identification or shows discrepant results using traditional diagnostic modalities.
Image Caption and Description:
Image caption: Chest computed tomography (CT) findings with contrast axial views. Yellow arrows: new ground-glass changes, anterior left upper lobe (a); solid to ground-glass opacity, posterior left upper lobe (b); subpleural ground-glass changes, anterior right lower lobe (c).
Image description: Chest radiograph followed by whole-body computed tomography (CT) scan revealed multifocal ground-glass opacities suspicious for pulmonary septic emboli, without cavitary lesions (Fig. 1).
Image caption: Colony morphology on sheep blood agar plate post-incubation. Beige non-haemolytic colonies, sheep blood agar, 115 h of incubation, 35+-2 C.
Image description: Subsequent repeat blood cultures collected both from peripheral draw and tunnelled Groshong line over a 2 week period continued to isolate Gram-positive bacilli only in aerobic bottles (Figs 2 and 3).
Image caption: Gram stain of blood culture sample. Demonstration of Gram-positive coccobacilli under light microscopy, 100x.
Image description: Subsequent repeat blood cultures collected both from peripheral draw and tunnelled Groshong line over a 2 week period continued to isolate Gram-positive bacilli only in aerobic bottles (Figs 2 and 3).
Case Report:
A 62-year-old female renal transplant recipient was admitted to hospital on 20 August 2021, with a 5 week history of recurrent fevers and progressive dry cough without haemoptysis or dyspnoea. She did not report any unintentional weight loss, night sweats, fatigue or altered mentation. She had no recent sick contact exposures (including no prior risk of exposure to tuberculosis) or significant travel history. Her past medical history included deceased donor renal transplant in October 2012, stable on tacrolimus and mycophenolate mofetil without any history of rejection. Other medical and surgical history included workup for chronic hypophosphataemia and hypocalcaemia requiring weekly electrolyte replacement infusions via Groshong line (inserted March 2021), prior hemicolectomy for diverticular disease and parathyroidectomy.
On examination, she was haemodynamically stable with blood pressure of 151/67, pulse rate of 69 beats min-1 and body temperature of 36.8 C. Lung auscultation was normal without any bilateral adventitious sounds, and cardiovascular examination did not reveal any murmurs or other stigmata of infective endocarditis. Groshong line site did not demonstrate purulent discharge or overlying cellulitis. Laboratory investigations showed a peripheral white blood cell count of 5.1x109 l-1 (normal range 4.5-11.0x109 l-1) with a neutrophil count of 3.4x109 l-1 (normal range 2.0-8.0 x 109 l-1). Inflammatory markers were elevated with C-reactive protein of 23.2 mg l-1 (normal <3.1 mg l-1).
Chest radiograph followed by whole-body computed tomography (CT) scan revealed multifocal ground-glass opacities suspicious for pulmonary septic emboli, without cavitary lesions (Fig. 1). Transthoracic and subsequent trans-oesophageal echocardiography were negative for vegetations or haemodynamically significant valvular dysfunction.
In the context of recurrent fevers occurring in temporal relation to weekly electrolyte infusions, outpatient blood cultures were initially obtained 2 weeks prior to admission and Gram-positive bacilli were only isolated from the aerobic bottle. The patient was initiated on intravenous (IV) vancomycin. Questions remained as to whether the positive blood culture was attributable to contamination and initially the organism was not identified using MALDI-TOF VITEK MS V3 (bioMerieux, Marcy L'Etoile, France). Subsequent repeat blood cultures collected both from peripheral draw and tunnelled Groshong line over a 2 week period continued to isolate Gram-positive bacilli only in aerobic bottles (Figs 2 and 3). The organism showed beige, non-haemolytic colonies that were mucoid in appearance and adherent to media, catalase-positive and partially acid-fast. In our local microbiology laboratory, API Coryne system (bioMerieux, Marcy L'Etoile, France) gave an identification of Rhodococcus spp.
Inoculum was prepared from blood agar after incubating the isolate for 3-5 days at 35 C (+/- 2 C), with suspension made to 0.5 McFarland standard. The minimum inhibitory concentrations (MICs) were determined using E-test gradient strip (bioMerieux, France) as part of non-standardized susceptibility testing for this isolate. Findings were interpreted as per Clinical and Laboratory Standards Institute (CLSI) M24. The results showed susceptibility to amoxicillin/clavulanate, azithromycin, ciprofloxacin, linezolid, penicillin and vancomycin; it was intermediate to doxycycline. Hence, oral ciprofloxacin 500 mg twice daily was added to the patient's regimen on the third day of admission as combination antimicrobial therapy. As her Groshong line was the suspected source of bacteraemia, it was subsequently removed and the catheter tip bacterial culture isolated Gram-positive bacilli after 4 days of incubation. Repeat blood cultures after 5 days of antibiotics (1 day post-line removal) were negative.
OUTPUT:
| PMC10323808 |
MultiCaRe_Reasoning89 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 19.0
Sex: Male
Title: Spontaneous Rupture of Rhabdomyosarcoma of the Testis With Unilateral Ptosis: A Case Report and Literature Review
Keywords: case report; rhabdomyosarcoma; spontaneous rupture; testis; unilateral ptosis;
Abstract:
Spontaneous rupture of testicular rhabdomyosarcoma is very rare. We report a case of spontaneous testicular rupture that was pathologically confirmed as rhabdomyosarcoma with unilateral blepharoptosis. The patient, a 19-year-old male, and his father had weakness of the left eyelid muscle. The patient was suspected to have a right inguinal hernia by a family doctor but was not treated further. 2 days later, there was skin itching in the right inguinal area, accompanied by redness, swelling and discomfort of the right scrotum, and the patient went to the local hospital again. Ultrasound examination showed that a contusion of the right testis may have been complicated with orchitis. Oral levofloxacin was ineffective. In addition, the swelling of scrotal increased significantly. He came to the emergency room of our hospital and also was treated with levofloxacin, but the pain was still not relieved. CT and ultrasound examination could not identify the cause of the disease. Exploration of the right scrotum was performed under general anesthesia and confirmed that the right testis had spontaneously ruptured. The pathological diagnosis was rhabdomyosarcoma of the right testis. Testicular rhabdomyosarcoma is clinically rare, and spontaneous rupture is even rarer. The pathogenesis of the disease needs to be further studied, and the diagnosis should be made on a case-by-case basis. Overall, the prognosis of testicular rhabdomyosarcoma is poor. As seen in this case, further study is required to determine whether there is some association between testicular rhabdomyosarcoma and ptosis. Unfortunately, the patient's family rejected a genetic examination because of financial difficulty. We only report a single case of this rare phenomenon here.
Image Caption and Description:
Image caption: Father had weakness of the left eyelid muscle.
Image description: Both the patient, a 19-year-old male who was previously healthy, and his father had weakness of the left eyelid muscle (Figures 1, 2), although their vision was normal.
Image caption: Patient had weakness of the left eyelid muscle.
Image description: Both the patient, a 19-year-old male who was previously healthy, and his father had weakness of the left eyelid muscle (Figures 1, 2), although their vision was normal.
Image caption: Enhanced CT scan show that the spermatic vessels.
Image description: In addition, there were some secondary changes in the spermatic vessels, and the spermatic vessels could be seen more clearly (Figure 3).
Image caption: Surgical specimen: the rupture of testicular tunica albuginea.
Image description: The whole testicular boundary was unclear, the epididymis was enlarged, and the tunica albuginea had a visible tear of approximately 1.5 cm in length (Figure 4).
Image caption: He x 20: The tumor cells were arranged in fascicles, and some were nestled in some areas. The nucleus was fusiform and oval, and the cytoplasm was rich and acidophilic.
Image description: Haematoxylin-eosin staining (Figure 5).
Image caption: Desmin x 20, +, more cytoplasmic staining of Desmin-positive tumor cells can be seen.
Image description:
Image caption: Myod1 x 20, +, nucleoprotein staining showed diffuse expression of Myod1-positive tumor cells.
Image description:
Image caption: Myogenin x 20, +, visible nuclear protein staining Myogenin positive tumor cells partially expressed.
Image description:
Image caption: Ki-67 x 20, +, visible nuclear protein staining Ki-67 positive tumor cells diffuse expression, positive rate of 80%.
Image description: TLE1 (-), Ki-67 (80%+, Figure 9).
Case Report:
Both the patient, a 19-year-old male who was previously healthy, and his father had weakness of the left eyelid muscle (Figures 1, 2), although their vision was normal. The patient's mother and sister were in good health. After lifting heavy objects, the patient presented with intermittent distending pain and discomfort in the right inguinal region, he did not pay attention to these symptoms and did not seek medical treatment. As the patient's symptoms worsened, a right inguinal hernia was suspected and diagnosed by the family doctor but was not treated further. 2 days later, there was skin itching in the right inguinal area, accompanied by redness, swelling and discomfort of the right scrotum, and he went to the local hospital again. Ultrasound examination showed that a contusion of the right testis may have been complicated with orchitis (no specific medical data). Rest was recommended. The pain was not relieved by oral levofloxacin but resolved on its own 3 days later; nevertheless, it became aggravated and unbearable after exercise. At the same time, the scrotal swelling had significantly increased. He came to the emergency room of our hospital, where a plain CT scan showed scrotal enlargement of unknown cause. Upon admission, the right scrotum was obviously enlarged and tender. It had a high surface temperature, normal skin color, negative scrotal elevation test, negative light transmission test, normal sex hormones and normal tumor markers (including Alpha-fetoprotein, chorionic gonadotropin, carbohydrate antigen-199, carbohydrate antigen-125, serum ferritin, and carcinoembryonic antigen). After admission, the patient was treated with levofloxacin, but the pain was still not relieved. On the second day after admission, ultrasound showed heterogenous echo of the right testis. Considering the possibility of inflammatory lesions, neither testicular tuberculosis nor a tumor could be ruled out. A plain + enhanced abdominal CT scan suggested that inflammatory lesions of the testis with necrosis were possible. In addition, there were some secondary changes in the spermatic vessels, and the spermatic vessels could be seen more clearly (Figure 3). After communicating with the patient and his family, he gave informed consent for exploration of the right scrotum, which was performed under general anesthesia.
We made a right groin incision and cut the skin subcutaneously and each layer of muscle in turn, exposing the spermatic cord. We observed hyperaemia and oedema of the spermatic cord blood vessels and surrounding tissue. We rotated the testis approximately 90 degrees, lifted the testis out of the scrotum, opened the testicular sheath, and observed a small amount of bloody fluid within. We opened the tunica albuginea, where we observed a large amount of bloody fluid and a fish-like tissue bulge. The whole testicular boundary was unclear, the epididymis was enlarged, and the tunica albuginea had a visible tear of approximately 1.5 cm in length (Figure 4). Radical orchiectomy was performed on the right side, the spermatic cord was resected in a high position, and the incision was sutured step by step.
Haematoxylin-eosin staining (Figure 5). Immunohistochemistry results: Desmin (partly +, Figure 6), SMA (-), MyoD1 (+, Figure 7), Myogenin (+, Figure 8), CD34 (1), STAT-6 (1), S-100 (-), SOX-10 (-), CK (-), EMA (-), TLE1 (-), Ki-67 (80%+, Figure 9). The pathological diagnosis was rhabdomyosarco-ma of the right testis. The postoperative chromosome karyotype analysis showed that there was no Y chromosome microdeletion. Positron emission tomography (PET) examination showed no systemic metabolic abnormalities and no systemic metastasis. These findings suggested that the patient should be treated with a VAC regimen (vincristine, doxorubicin, cyclophosphamide). The patient refused further systemic treatment for personal reasons and is currently under follow-up.
OUTPUT:
| PMC9273775 |
MultiCaRe_Reasoning90 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Male
Title: Primary adenosquamous carcinoma of ampulla of Vater-A rare case report
Keywords: adenosquamous carcinoma; ampulla of vater (amv); pancreaticoduodenectomy (pd);
Abstract:
Introduction:
Primary adenosquamous carcinoma (ASC) of the ampulla of Vater (AmV) is extremely rare. Carcinoma of the ampulla of Vater tends to manifest early due to biliary outflow obstruction, as opposed to pancreatic neoplasms that often are advanced at the time of diagnosis. Periampullary carcinomas are treated by pancreaticoduodenectomy (PD). Adenosquamous carcinoma carries very dismal prognosis.
Presentation of case:
Here we present a case of 58-year-old male who was presented with abdominal pain, jaundice and anorexia with no history of (h/o) pruritus and clay colored stool. All blood investigations were normal except liver function tests (LFTs). Ultrasonography (USG) of abdomen suggestive of periampullary mass with dilated pancreatico-biliary tree. Endoscopic retrograde cholangiopancreatography (E.R.C.P.) demonstrated large deformed and bulky papilla with ulcerated lesion with infiltration in to duodenum. Exploratory laprotomy proceeds Whipple's pancreaticoduodenectomy done. Histopathology revealed adenocarcinoma of the ampulla of Vater. Immunohistochemistry was confirmatory of adenosquamous carcinoma.
Discussion:
Adenosquamous carcinoma (ASC) is defined as a tumor in which both glandular and squamous elements are histologically malignant. Compared to adenocarcinoma, ASC of the AmV is a rare malignancy. Preoperative diagnosis is difficult because of the lack of defining characteristics in imaging studies and the difficulty in acquiring both malignant components by limited biopsy. Periampullary carcinomas are treated by pancreaticoduodenectomy.
Conclusion:
Adenosquamous carcinoma is a very rare form of cancer of the AmV. Pancreaticoduodenectomy is the treatment of choice though early recurrence and distal metastasis may be encountered after surgery. Follow-up should be more frequent to detect possible early recurrence and distal metastasis.
Image Caption and Description:
Image caption: Photograph showing pancreaticoduodenectomy specimen with mass in the periampullary region indicated by the arrow.
Image description: The gross specimen revealed a growth of 4 x 3 cm in the AmV (Fig. 1).
Image caption: Microphotograph of H&E staining showing both (a) adenomatous, (b) squamous component.
Image description: Histopathological report was of adenosquamous carcinoma of the AmV (Fig. 2).
Image caption: Microphotograph of immunohistochemistry showing co-expression with p63 in areas of squamous of differentiation.
Image description: Immunohistochemistry was planned which confirmed adenosquamous carcinoma (Figs. 3 and 4).
Image caption: Microphotograph of immunohistochemistry showing co-expression of CK5&6 in areas of squamous differentiation.
Image description: Immunohistochemistry was planned which confirmed adenosquamous carcinoma (Figs. 3 and 4).
Case Report:
A 58-year-old male presented with abdominal pain, jaundice and vomiting for one month. He also had associated history of weight loss and anorexia with no h/o pruritus and clay colored stool. Clinical examination revealed no abnormality except icterus. The laboratory examination revealed a serum total bilirubin level of 6.7 mg/dL, an aspartate aminotransferase (SGOT) level of 102 IU/L, an alanine aminotransferase (SGPT) level of 92 IU/L and an alkaline phosphatase of 250 U/L. USG abdomen was suggestive of periampullary mass with dilated pancreatico-biliary tree. E.R.C.P. demonstrated large deformed and bulky papilla with ulcerated lesion with infiltration in to duodenum causing 1st and 2nd part of duodenal (D1D2) stenosis. Biopsy revealed squamous cell carcinoma. Metastatic work-up did not reveal any other primary focus of disease. Contrast enhanced computed tomography scan (CECT) of the abdomen revealed a soft-tissue mass in the periampullary region with dilated distal portion of the common bile duct (CBD) and main pancreatic duct.
E.R.C.P. guided stent inserted in CBD. Liver function tests were repeated till the total serum bilirubin level normalized. Exploratory laparotomy proceeds Whipple's pancreaticoduodenectomy done.
On exploration there was a growth at the ampullary region with involvement of CBD leading to grossly dilated CBD and main pancreatic duct. The gross specimen revealed a growth of 4 x 3 cm in the AmV (Fig. 1). Portal vein and superior mesenteric vein and artery were separate from the growth. Histopathological report was of adenosquamous carcinoma of the AmV (Fig. 2). Immunohistochemistry was planned which confirmed adenosquamous carcinoma (Figs. 3 and 4). The postoperative course was uneventful.
OUTPUT:
| PMC4064426 |
MultiCaRe_Reasoning91 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 31.0
Sex: Male
Title: Pleurisy secondary to nonthrombotic pulmonary emboli in a patient with intravenous drug use
Keywords: ntpe; nonthrombotic pulmonary emboli; pwid; patients with injection drug use; septic emboli;
Abstract:
Patients with injection drug use can have nonthrombotic pulmonary emboli (NTPE) of foreign insoluble particles that are either parts of the equipment used or mixed with the drug as an additive. These foreign particles can become a nidus for infection and inflammation. We present a case of a 31-year-old man with active intravenous drug use who initially presented with signs and symptoms of pleurisy and was found to have NTPE of septic refractile crystalline material as seen on bronchial wash and brush biopsy. We believe our patient likely had embolism of either crack particles, needle fragments or cotton-wool fragments that led to a localized inflammatory reaction and infection. This highlights the importance of obtaining detailed history and diagnostic workup. Once the diagnoses of bacterial endocarditis and thrombophlebitis are ruled out with blood cultures, transthoracic echocardiogram, trans-esophageal echocardiogram and/or CT scan (depending on the suspicion), NTPE should be considered and bronchoscopy with bronchoalveolar lavage with biopsy should be performed.
Image Caption and Description:
Image caption: Chest X-ray showing patchy increased density in the left lower lobe, lingula, and right middle and lower lobes.
Image description: Chest X-ray indicated a patchy increased density in the left lower lobe, lingula, and right middle and lower lobes (Fig. 1).
Image caption: CT angiography of the chest showing multiple, fluffy, nodules of varying size and ill-defined margins throughout both lungs.
Image description: However, multiple, fluffy, nodules of varying size and ill-defined margins were seen throughout both lungs (Fig. 2).
Image caption: High resolution CT of the chest remonstrating the nodules with feeding vessel sign.
Image description: Pulmonology was consulted and, based on the findings on high resolution CT scan of the chest (Fig. 3), the decision was made to perform navigational bronchoscopy to obtain endobronchial and transbronchial lung biopsies.
Image caption: Crystalline refractile foreign body fragments (arrow and arrowhead) with surrounding dense neutrophilic infiltration.
Image description: Moreover, approximately 55 cc of thick pale orange fluid was obtained via bronchial wash of right lower lobe which showed scattered refractile material surrounded by dense neutrophilic and mononuclear infiltration (Fig. 4, Fig. 5).
Case Report:
A 31-year-old man with a past medical history of intravenous drug use (IVDU), specifically heroin and cocaine, and untreated hepatitis C virus infection presented to the emergency department for the evaluation of chest pain. The patient's chest pain began approximately 5 days prior to presentation as a sharp, non-radiating, persistent pain, which was worse with inspiration and on movement. The pain progressed to 10/10 in intensity below the nipples bilaterally. Our patient endorsed exertional dyspnea mostly because of the inability to inspire without significant pain and subjective fever. He also reported worsening cough productive of light green sputum and, at times, a scant amount of blood. Moreover, approximately a week prior, the patient missed a vein while injecting the drug in the right side of his neck which led to swelling and redness of the area. The remainder of the review of systems was noncontributory. As for his past medical history, our patient reported being informed he was positive for hepatitis C 10 years prior, but he did not seek treatment nor did he follow up with medical providers for the same. The patient has a smoking history of 15 pack years and has been injecting "speedball", a mixture of cocaine and heroin, almost daily for the last 10 years. Our patient reported using "a bundle and a half" of heroin together with "few grams" of cocaine in powder form with water daily. When the patient was not able to acquire cocaine, he used crack which comes in solid "rock" form. He reported crushing the rock form and diluting it with vinegar. He heated the mixture after filtering through cotton-wool before injecting himself using a syringe. The patient generally uses his neck and left arm veins to inject drugs. Our patient used the same syringe for up to a month. He reported that, at times, the needle tip would break off in tiny fragments and it would become difficult to acquire access through it. The patient's last use of these drugs was the day of admission. Our patient admitted to being homeless and has been living on the streets for the last 3 years.
Initial vital signs demonstrated a temperature of 98.7 F, pulse of 135/min, respiratory rate of 19/min and blood pressure of 108/72 mmHg. He appeared to be in mild distress, with poor inspiratory effort due to pain. Physical examination was significant for poor dentition including a few chipped and missing teeth but no oral lesions or thrush. There was an area of erythema, induration and tenderness on the right side of the neck, about 4 x 10cm in size. Lungs were clear to auscultation bilaterally. Cardiac auscultation revealed normal S1 and S2, with no murmurs, rubs or gallops. Examination of the extremities revealed track marks on left antecubital fossa and onychomycosis of the nail beds. Stigmata of bacterial endocarditis were not seen.
Initial laboratory data was significant for a normal white blood cell (WBC) count of 8.5 K/muL, hemoglobin of 10.2 gm/dL and platelet count of 106 K/muL. The patient's mean corpuscular volume (MCV) was 73.6 fL, with red cell distribution width of 15.3%. Serum sodium was 129 mEq/L, with otherwise unremarkable basic metabolic panel. Serum lactic acid was 1.2 mmol/L (normal 0.5-2.2 mmol/L) and D-dimer was 1197 ng/mL (normal 0-230 ng/mL). Erythrocyte sedimentation rate (ESR) was 95 mm/hr (normal 0-15 mm/hr) and C-reactive protein (CRP) was 15.2 ng/dL (normal <1.0 ng/dL). Urine drug screen was positive for cocaine and opiates but negative for amphetamines. Chest X-ray indicated a patchy increased density in the left lower lobe, lingula, and right middle and lower lobes (Fig. 1). Given a significantly elevated d-dimer in the setting of tachycardia, CT angiography of the chest was performed which excluded pulmonary embolism. However, multiple, fluffy, nodules of varying size and ill-defined margins were seen throughout both lungs (Fig. 2). Some of these nodules were cavitary. Larger coalescent areas were seen in the left lower lobe and the lingula. These findings were concerning for septic emboli or metastatic disease. As a result, CT abdomen and pelvis with contrast was performed which did not show any masses. The only finding was splenomegaly, measuring 18cm in length. Furthermore, given the findings of tenderness on the right side of the neck, CT of the neck with contrast performed to exclude septic jugular vein phlebitis or Lemierre's syndrome was unremarkable.
Meanwhile, blood cultures were drawn and our patient was empirically administered intravenous (IV) Vancomycin 1 g and Piperacillin-Tazobactam 3.375 g. Emergent transthoracic echocardiogram (TTE) was performed which did not show valvular vegetation or abscess. Given a high suspicion of bacterial endocarditis (BE), trans-esophageal echocardiogram (TEE) was performed which also did not show any vegetations or abscess. Piperacillin-tazobactam was changed to IV Cefepime 2 g every 12 hours. IV Vancomycin was continued to achieve a therapeutic vancomycin trough level. Pulmonology was consulted and, based on the findings on high resolution CT scan of the chest (Fig. 3), the decision was made to perform navigational bronchoscopy to obtain endobronchial and transbronchial lung biopsies. Specimens were obtained from the right lower lobe using a needle biopsy, and near the pleura using the forceps. A few specimens were also obtained using triple needle brush. In addition, specimens from bronchial washings were sent for cytologic analysis, routine cultures, acid-fast bacilli (AFB) culture and fungal culture.
Additional diagnostic evaluation included HIV testing, QuantiFeron TB, hepatitis panel, rapid plasma reagin (RPR), antinuclear antibody (ANA), anti-double stranded DNA (DsDNA) antibody, anti-glomerular basement membrane (GBM) antibody, anti-neutrophil cytoplasmic antibody (ANCA) and complement levels. Results were unremarkable.
Histopathology report of right lower lobe biopsy specimen was normal with no mononuclear infiltration. A brush tip specimen was also obtained from right lower lobe. Moreover, approximately 55 cc of thick pale orange fluid was obtained via bronchial wash of right lower lobe which showed scattered refractile material surrounded by dense neutrophilic and mononuclear infiltration (Fig. 4, Fig. 5). Gomori methenamine silver (GMS) stain for Pneumocystis jirovecii was negative.
The patient's maximum temperature was 100.1 F five days after the admission on antibiotics. The patient's heart rate normalized to 70-90/min and WBC count remained in between 6 and 8 K/muL throughout admission. The patient's chest pain improved over the course of days but mild discomfort with breathing persisted. Blood, respiratory and bronchial wash cultures for bacteria, AFB and fungi remained negative. Because of ongoing concern for bacterial septic emboli, the patient was continued on IV Vancomycin and IV Cefepime for a total of 6 weeks. The patient completed the final 3 weeks of antibiotics at a sub-acute facility.
OUTPUT:
| PMC10415754 |
MultiCaRe_Reasoning92 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 32.0
Sex: Female
Title: Ectopic Premolar Tooth in the Sigmoid Notch
Keywords: None
Abstract:
Impaction of a mandibular premolar is relatively uncommon. Ectopic placement is more unusual and there has been no discussion in the literature of an ectopic mandibular premolar in the coronoid process. In this case report, we present an impacted ectopic mandibular permanent premolar in the sigmoid notch (incisura mandibulae) region. Etiology of the tooth and treatment options are discussed and illustrated by Cone Beam Computed Tomography (CBCT) images.
Image Caption and Description:
Image caption: Panoramic radiograph showing an ectopic tooth located in the left mandibular ramus.
Image description: After intraoral examination, panoramic radiography showed an ectopic premolar located in the left mandibular ramus (Figure 1).
Image caption: (a, b) CBCT scans show that the premolar is located in the sigmoid notch. (a) Panoramic radiography reconstructed by CBCT and (b) MPR-CBCT: (I) axial slice, (II) coronal slice, and (III) sagittal slice.
Image description:
Case Report:
A 32-year-old female patient visited the Department of Dentomaxillofacial Radiology, complaining of pain in the right mandibular second premolar tooth. After intraoral examination, panoramic radiography showed an ectopic premolar located in the left mandibular ramus (Figure 1).
To identify the exact location of the tooth, Cone Beam Computed Tomography (CBCT) was taken, showing the premolar in the mandibular sigmoid notch in a vertical position (Figures 2(a) and 2(b)).
Surgical treatment was not seen as necessary for this patient because there were no symptoms related to the ectopic tooth. The patient was informed of the ectopic tooth and directed to clinical endodontics.
OUTPUT:
| PMC4980514 |
MultiCaRe_Reasoning93 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 63.0
Sex: Male
Title: Obstructive jaundice as an initial manifestation of non-hodgkin lymphoma: treatment dilemma and high mortality
Keywords: None
Abstract:
Introduction. Non Hodgkin lymphoma (NHL) presenting with obstructive jaundice is a rare occurrence. Because of rarity of combination, it is seldom considered in differential diagnosis of patients presenting with obstructive jaundice. It is considered treatable due to the chemosensitive nature of the disease and the recent advances in chemotherapy. Case Series. We present a case series of 2 patients with NHL presenting with obstructive jaundice as an initial manifestation. Both patients presented with obstructive jaundice and were diagnosed by CT guided liver biopsy. One patient died of sepsis and multiorgan failure before initiating chemotherapy and the second patient did not choose to undergo chemotherapy. Conclusion. Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma.
Image Caption and Description:
Image caption: Case 1:MRI abdomen pelvis revealed 5.5 x 5.4 x 4.9 cm mass and biliary ductal dilatation from extrinsic compression (black arrow).
Image description: Magnetic resonance cholangiopancreatography (MRCP) revealed 5.5 x 5.4 x 4.9 cm mass and biliary ductal dilatation from extrinsic compression (Figure 1).
Image caption: Case 1:hematoxylin and eosin stain of liver biopsy showing cells with large, hyperchromatic nuclei with scant cytoplasm and mitosis (black arrow).
Image description:
Image caption: Case 1:percutaneous trans-hepatic cholangiography (PTC) with 8-French internal and external biliary drains.
Image description: Percutaneous transhepatic cholangiography (PTC) was performed with successful internal and external biliary drain placement (Figure 3).
Case Report:
A 63-year-old male with history of untreated Chronic hepatitis C and alcohol abuse was admitted to the Internal Medicine Department with 4-day history of nausea, diffuse abdominal pain, and jaundice. On physical exam he was jaundiced with scleral icterus. The abdomen was diffusely tender with guarding. Laboratory data revealed total bilirubin 16.9 mg/dL (normal: <1.0), Alkaline phosphatase 243 IU/L, aspartate transaminase (AST) 97 IU/L (normal: <35), alanine transaminase (ALT) 69 IU/L (normal: <35), alpha fetal protein: 3.0 IU/mL, lactate dehydrogenase (LDH) 267 IU/L, albumin 2.7 g/dL (normal: 3.2-4.6), total protein 5.7 g/dL (normal: 6.4-8.3), blood urea nitrogen (BUN) 14 mg/dL (normal: 8-23), creatinine 0.85 mg/dL (normal: 0.80-1.30). CBC showed white cell count (WBC): 6.3 K/muL (normal: 5-10.2), hemoglobin 13.7 g/dL (normal: 13.5-17.5), and platelet 117 K/muL (normal: 150-450). Liver ultrasound showed a mass-like structure around gallbladder fossa, and common bile duct (CBD) diameter was 6 mm. Computed tomography (CT) of the abdomen and pelvis showed a large irregular mass at the porta hepatis. Magnetic resonance cholangiopancreatography (MRCP) revealed 5.5 x 5.4 x 4.9 cm mass and biliary ductal dilatation from extrinsic compression (Figure 1). Pathology of fine needle biopsy of mass (Figure 2) showed diffuse large B cell lymphoma, positive for CD20, BCL2, BCL6, CD79a, and PAX5 and negative for CD3, CD5, CD10, CD23, CD138, cyclin D1, CK7, CK20, and p63. Positron emission tomography (PET) scan showed multiple liver lesions and right lower lung nodule, without involvement of mediastinal lymph nodes or peritoneum. Bone marrow biopsy was negative for lymphoma. Endoscopic retrograde cholangiography (ERC) was performed for biliary decompression but CBD could not be cannulated, and limited cholangiogram showed distal CBD stricture. Percutaneous transhepatic cholangiography (PTC) was performed with successful internal and external biliary drain placement (Figure 3). His ECOG (Eastern Cooperative Oncology Group) score was 3 and chemotherapy was planned. After few days he was readmitted with acute renal failure (BUN/Cr: 100/4.1), WBC 25.1 K/muL, total bilirubin 6.4 mg/dL, intractable nausea and vomiting, and hypotension with multiorgan failure. He was found to be in septic shock. The patient died even before starting chemotherapy.
OUTPUT:
| PMC3683444 |
MultiCaRe_Reasoning94 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 80.0
Sex: Female
Title: Obstructive jaundice as an initial manifestation of non-hodgkin lymphoma: treatment dilemma and high mortality
Keywords: None
Abstract:
Introduction. Non Hodgkin lymphoma (NHL) presenting with obstructive jaundice is a rare occurrence. Because of rarity of combination, it is seldom considered in differential diagnosis of patients presenting with obstructive jaundice. It is considered treatable due to the chemosensitive nature of the disease and the recent advances in chemotherapy. Case Series. We present a case series of 2 patients with NHL presenting with obstructive jaundice as an initial manifestation. Both patients presented with obstructive jaundice and were diagnosed by CT guided liver biopsy. One patient died of sepsis and multiorgan failure before initiating chemotherapy and the second patient did not choose to undergo chemotherapy. Conclusion. Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma.
Image Caption and Description:
Image caption: Case 2:CT scan abdomen pelvis with infiltrating ill-defined liver mass involving the portal confluence and spleen mass (black arrows).
Image description: CT abdomen was done revealing infiltrating liver mass involving the portal confluence with intrahepatic biliary dilatation, lesion in spleen, and absence of lymphadenopathy (Figure 4).
Image caption: Case 2:hematoxylin and eosin stain (H&E) of liver biopsy (40X resolution) revealing diffuse large B cell lymphoma with pleomorphic cells with scant cytoplasm.
Image description: CT guided liver mass core biopsy (Figure 5) reported diffuse large B cell lymphoma with stains positive for CD20 and CD79a and negative for CD10, cyclin D1, CD138, cytokeratin AE1/AE3, and S 100 protein.
Case Report:
A-80-year-old nursing home female resident was admitted to internal medicine service with diffuse abdominal pain of 2-3 days duration, poor oral intake, nausea, and dark urine. PMHx was significant for dementia, hypertension, and hypothyroidism. She had cholecystectomy done at 55 years of age. She did not have history of tobacco or alcohol abuse. Physical examination revealed conjunctival icterus, confusion, tenderness in right upper quadrant, and epigastrium. No lymphadenopathy or hepatosplenomegaly was appreciated. Initial laboratory data revealed total bilirubin 12.0 mg/dL, alk phos 659 IU/L, AST 112 IU/L, ALT 86 IU/L, ammonia 35 mumol/L, LDH 650 IU/L, BUN 10 mg/dL, creatinine 0.68 mg/dL, sodium 130 mmol/L, chloride 98 mmol/L, albumin 2.4 g/dL, total protein 6.4 g/dL, prothrombin time 12.7 sec, INR 1.1, partial thromboplastin time 31 sec, and WBC 15 K/muL. Viral hepatitis panel, alpha-fetoprotein, and carcinoembryonic antigen were negative. CT abdomen was done revealing infiltrating liver mass involving the portal confluence with intrahepatic biliary dilatation, lesion in spleen, and absence of lymphadenopathy (Figure 4). The patient underwent percutaneous cholangiogram showing marked narrowing of biliary tree and unsuccessful attempt to insert drain. She underwent endoscopic retrograde cholangiopancreatography (ERCP) which showed distal common bile duct stricture secondary to extrinsic compression with dilated CBD up to 15 mm and intrahepatic ductal dilation. Biliary sphincterotomy was performed and plastic stent was placed for biliary decompression. CT guided liver mass core biopsy (Figure 5) reported diffuse large B cell lymphoma with stains positive for CD20 and CD79a and negative for CD10, cyclin D1, CD138, cytokeratin AE1/AE3, and S 100 protein. Her ECOG score was 4. Chemotherapy was not given because of patient's poor general condition. Patient's family decided to make her comfortable under hospice care and she succumbed within 3 months of diagnosis.
OUTPUT:
| PMC3683444 |
MultiCaRe_Reasoning95 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 20.0
Sex: Male
Title: Mechanical thrombectomy in a young stroke patient with Duchenne muscular dystrophy
Keywords: None
Abstract:
Background:
Duchenne muscular dystrophy (DMD) is an X-linked recessive skeletal muscle myopathy which is caused by mutations in the dystrophin gene. Lack of dystrophin also results to cardiomyopathy, which raises significantly the stroke risk in DMD-patients. However, data about therapeutic opportunities in the acute setting are scarce in literature. So far, only two cases receiving IV thrombolysis are described, one of them with fatal outcome.
Method:
Case report of a case of successful mechanical thrombectomy (MTE) in an acute ischemic stroke (AIS) patient with DMD and associated dilatative cardiomyopathy.
Results:
A 20-year old DMD-patient was transferred at 08:56 h to our department due to wake up stroke with severe right-sided hemiparesis and aphasia (NIHSS=20). Last-seen-normal was at 03:00 h. Cerebral CT-scan revealed only slight early ischemic changes (ASPECT-Score=8). CT-angiography detected occlusion of left middle cerebral artery (LMCA). MTE started rapidly at 9:23 h and using direct thrombus aspiration (Penumbra System®) complete recanalization was achieved 20 min later (TICI-grade 3). Considering the specific risks of general anesthesia in DMD, the procedure was performed with propofol, remifentanil and rocuronium. The patient recovered quickly from the acute symptoms, due to preexisting hypotonic tetraparesis his NIHSS-score at discharge was 12 points.
Conclusions:
To the best of our knowledge, this is the first report on MTE in a patient with DMD related cardioembolic stroke. In contrast to the few reports with IV thrombolysis, MTE seems to represent an optimal treatment option. Specific characteristics of DMD-patients like anesthetic regimen should be taken into account.
Image Caption and Description:
Image caption: Initial CT scan showing the hyperdense media sign (a), proximal occlusion of LMCA (b), MT before aspiration of the thrombus (c) and after aspiration (d). Follow-up CT scans showed a hypodensity in the left area of the basal ganglia with a mild edema (e and f).
Image description: CoaguChek (Roche Diagnostics) in the emergency room. Cerebral CT scan revealed only slight early ischemic changes in the LMCA territory (ASPECT-Score = 8 points) but with hyperdense media sign on the left (Figure 1(a)).
Subsequent CT angiography confirmed a proximal occlusion of the LMCA (Figure 1(b)).
Shortly after successful recanalization (Figure 1(c-d)) and directly after recovering from anesthesia, the half-sided motoric worsening of the preexisting hypotonic tetraparesis improved, but the aphasia persisted to a reduced extent (NIHSS score of 14 points).
Follow-up CT scans revealed a demarcation of the ischemia in the left area of the basal ganglia with a mild edema (Figure 1(e-f)).
Case Report:
A 20-year old male patient with genetically confirmed DMD with known associated dilated cardiomyopathy was transferred to our supraregional stroke unit due to a wake-up stroke with severe right-sided sensomotoric hemiparesis and aphasia as he was right-hand dominant. Due to status post detection of a thrombus in the left ventricle in August 2015, the patient was on an anticoagulation regime with low molecular weight heparin (LMWH), which was interrupted in error because of a misapprehension the day before. In addition to LMWH, the patient was treated with bisoprolol, magnesium and vitamin D. A moderate- to high-grade hypotonic tetraparesis due to the DMD-related muscle weakness was already known. The acute presentation of the patient was due to a substantial worsening of the preexisting weakness on the right side, including a new facial weakness and aphasia, resulting in a formal NIHSS score of 20 points. The time at which the new symptoms were recognized was 08:15; last-seen-normal (LSN) was about 03:00. Initially the patient was brought by paramedics to the pediatric hospital at which he is best known. An immediate transfer to our department was performed, and the patient arrived at 08:56 in our emergency room.
Vital parameters were stable, the international normalized ratio was 0.9 measured by CoaguChek (Roche Diagnostics) in the emergency room. Cerebral CT scan revealed only slight early ischemic changes in the LMCA territory (ASPECT-Score = 8 points) but with hyperdense media sign on the left (Figure 1(a)). Subsequent CT angiography confirmed a proximal occlusion of the LMCA (Figure 1(b)).
Patient education took place, including the patient's mother as his legally authorized representative, so MT started quickly at 09:23 (door-to-groin time = 27 min). Considering the specific risks of general anesthesia in DMD, the procedure was performed with propofol, remifentanil and rocuronium. At 24 min after groin puncture, the recanalization was successfully completed (TICI grade 3) by direct thrombus aspiration using the Penumbra System (Penumbra Inc. Alameda, CA, USA). Since the patient formally exceeded even the extended time window of 6 h after LSN, no additional IV thrombolysis was performed.
Shortly after successful recanalization (Figure 1(c-d)) and directly after recovering from anesthesia, the half-sided motoric worsening of the preexisting hypotonic tetraparesis improved, but the aphasia persisted to a reduced extent (NIHSS score of 14 points). With logopedic speech therapy, the aphasia resolved almost completely in the further course of his hospitalization. The daily NIHSS score showed an improvement up to 12 points within 9 days.
Transthoracic and transesophageal echocardiography revealed no evidence of an intracardial thrombus, but a relevant reduced ejection fraction. No atrial fibrillation was detectable via prolonged ECG monitoring. Laboratory investigations found high creatine kinase at 1883 U/L (38-174), high lactate dehydrogenase at 321 U/L (135-225) and a high creatine kinase-muscle/brain at 144.5 U/L (<24). Due to the low muscle mass, creatinine serum level was extremely low at 0.25 mg/dl (0.70-0.12), so it could not serve as a reliable kidney retention parameter in this case. Consequently, we determined the kidney function via cystatin C, where a concentration of 1.10 mg/L (0.61-0.95) with a resulting glomerular filtration rate of 83 ml/min (>=90 ml/min) was shown. Further hemostaseological investigations revealed no thrombophilia.
Follow-up CT scans revealed a demarcation of the ischemia in the left area of the basal ganglia with a mild edema (Figure 1(e-f)). After discussing the specific considerations of indicated anticoagulation with the patient and his mother, oral anticoagulation with dabigatran (150 mg bid) was initiated for secondary prophylaxis.
At discharge from our stroke unit and transfer to a rehabilitation center after 9 days of hospitalization, the patient showed a complete recovery from the ischemia-induced central hemiparesis. Only a slight aphasic component was present, resulting to an NIHSS score of 12 points at discharge, which was mainly due to his preexisting DMD symptoms.
OUTPUT:
| PMC5846908 |
MultiCaRe_Reasoning96 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 83.0
Sex: Male
Title: BRCA2 mutation in advanced lung squamous cell carcinoma treated with Olaparib and a PD-1 inhibitor: a case report
Keywords: brca2 mutation; olaparib; pd-1 inhibitor; case report; lung squamous cell carcinoma;
Abstract:
Background:
Mutations in the human breast cancer susceptibility gene 2 (breast cancer 2, BRCA2) increase the risk of breast, ovarian and other cancers. Olaparib, an oral poly[adenosine diphosphate (ADP)-ribose] polymerase (PARP) inhibitor, is usually prescribed to treat BRCA mutated tumors, especially breast and ovarian cancers. Programmed cell death-1 (PD-1) inhibitors have revolutionized the treatment of lung cancer and many other cancers by destroying the interaction between receptors with ligands in the tumor-immune microenvironment and enabling T cells to recognize and attack cancer cells.
Case description:
In our study, we report a patient with advanced BRCA2 lung squamous cell carcinoma who received platinum-based chemotherapy combined with paclitaxel. Seven months later, the disease progressed. BRCA2 mutations were detected in peripheral blood by next-generation sequencing. After 2 months of treatment with Olaparib combined with Cindilimab, the patient was in partial remission and the progression-free survival (PFS) lasted for 6 months, but the patient developed immune renal damage.
Conclusions:
This study adds to the clinical data for the treatment of BRCA2 mutant non-small cell lung cancer by demonstrating that lung squamous cell carcinoma has a good response to PARP inhibitors. It also serves as a reminder that there may still be some negative effects from targeted superimposed immunotherapy.
Image Caption and Description:
Image caption: (A) Fiberoptic bronchoscopy shows cauliflower-like new organisms blocking the left main bronchus and oozing blood on the surface of the new organisms. The pathological classification of lung squamous cell carcinoma was confirmed by multi-biomarker immunohistochemistry. (B) HEx100, (C) HEx400, (D) ki-67, (E) P40, (F) TTF-1.
Image description: This location was the site of the biopsy, which revealed lung squamous cell carcinoma ( Figure 1A ).
TTF-1 (-) ( Figures 1B-F ) in immunohistochemistry. The patient ceased chemotherapy because he could not endure the adverse effects of nausea and vomiting after one cycle of perfusion chemotherapy (40 mg nedaplatin via bronchial artery infusion administration) and paclitaxel systemic intravenous treatment.
Image caption: The clinical course schedule of this patient includes the treatment plan received by the patient and the chest CT of the disease response on each treatment route.
Image description: The therapy options, disease response, and PFS for each treatment line are summarized in Figure 2 .
Case Report:
An 83-year-old male patient had no family history of hypertension, chronic obstructive pulmonary disease, or malignancy. He smoked for 40 years and had a smoking index of 20 pack-years. He was admitted to the hospital for a physical examination, during which a chest computed tomography (CT) scan revealed a left hilar occupancy measuring approximately 5.9x3.6 cm, obstructive atelectasis in the left lung field, and a small pleural effusion. Further fiberoptic bronchoscopy revealed that the left main bronchus was blocked by new organisms, the surfaces of which oozed blood. This location was the site of the biopsy, which revealed lung squamous cell carcinoma ( Figure 1A ). P40 (+), CK56 (-), ki-67 > 25%, TTF-1 (-) ( Figures 1B-F ) in immunohistochemistry. The patient ceased chemotherapy because he could not endure the adverse effects of nausea and vomiting after one cycle of perfusion chemotherapy (40 mg nedaplatin via bronchial artery infusion administration) and paclitaxel systemic intravenous treatment. After 7 months, the patient developed hemoptysis with a daily volume of about 10-20 mL, and chest CT scan revealed a left deviation of the mediastinum, left lung consolidation and atelectasis, a soft tissue mass in the left hilum with a size of about 8.1x4.6 cm, left main bronchial obstruction, and enlarged lymph nodes in the left cervical root and mediastinum. No obvious metastatic lesions had been found after head MRI, whole-body bone imaging, whole-abdomen enhancement CT. We took the disease's progression into consideration (Clinical Stage, cT4N3M1a, stage IVA). Subsequently, the BRCA2 EXON15 G25085 mutation was detected by blood next-generation sequencing, and the tumor mutation load TMB was 5.98 mutations/Mb. Based on the sequencing test results, we immediately started aggressive treatment and decided to use the PARP inhibitor Olaparib (300mg twice a day) with the PD-1 inhibitor Cindilimab. After one week, the patient's hemoptysis stopped. A repeat chest CT revealed that the left hilar mass was substantially smaller than before, with a long diameter of around 4.5 cm, and that the left lung was recruiting and the pleural effusion was absorbed after receiving Olaparib for two months and PD-1 inhibitor for two immunotherapy sessions. At this time, the patient appeared new symptoms, puffy eyelids, decreased urine volume, and generalized weakness. In further testing of common serological indicators, we found that blood creatinine increased from normal value at the beginning of the disease to 163.90mumol/L. Meanwhile, urine precipitation microscopy showed urine protein (+) without a tubular pattern. Routine blood, liver function, inflammation indicators, tumor indicators were normal, and autoantibodies were negative. Following the multidisciplinary team's discussion, we took into account the kidney damage caused by immune checkpoint inhibitors, which was graded as 2, and stopped using the PD-1 inhibitor in accordance with the Chinese Society of Clinical Oncology (CSCO) 2022 recommendation. One month after quitting the PD-1 inhibitor, the serum creatinine level was back to normal. Six months after starting Olaparib monotherapy, the patient was more advanced. The therapy options, disease response, and PFS for each treatment line are summarized in Figure 2 .
OUTPUT:
| PMC10228719 |
MultiCaRe_Reasoning97 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 67.0
Sex: Female
Title: Rare metastasis of gastric cancer to the axillary lymph node: A case report
Keywords: axillary lymph node metastasis; gastric cancer; immunohistochemical staining; radical total gastrectomy; tumor markers;
Abstract:
Lymph node metastasis of gastric cancer is more common, metastatic lymph nodes are often around the stomach, and metastasis is carried out in a certain order, but gastric cancer metastasis to axillary lymph nodes is very rare. Due to the small number of patients with this kind of metastasis, its clinical features and treatment are not very clear. We initially thought that the enlarged axillary lymph nodes were inflammatory lesions. Axillary lymph node biopsy was later diagnosed as gastric cancer metastases to axillary lymph nodes. The patient refused further treatment and died 11 months after the second operation because of multiple systemic metastases. We believe that metastasis of gastric cancer to axillary lymph nodes is rare and the prognosis is poor. In clinical work, the possibility of metastatic lymph nodes should be considered in patients with a history of gastric cancer with enlarged axillary lymph nodes.
Image Caption and Description:
Image caption: Abdominal enhancement CT showed obvious enhancement of the edge of the tumor in the arterial phase (A); Abdominal enhanced CT showed enlarged retroperitoneal lymph nodes (B); 18F-FDG PET-CT showed that the left axillary lymph node was enlarged, and the mass uptake of FDG increased slightly, but it was considered as an inflammatory lesion (C).
Image description: The abdominal enhanced CT shows multiple lymph nodes enlargement in the abdominal and retroperitoneum in the outpatient clinic of our hospital ( Figures 1A, B ).
After the end of neoadjuvant chemotherapy, we performed a PET-CT examination for the patient. 18F-FDG PET-CT showed that the mass showed changes after chemotherapy, slight thickening of the lesser curvature of the stomach, the mass did not significantly absorb FDG, and it was found that the left axillary lymph node was enlarged, and the mass uptake of FDG increased slightly, but it was considered as an inflammatory lesion ( Figures 1C ).
Image caption: Pathological picture after radical total gastrectomy (A); Pathological picture after radical axillary lymph nodes (B); Immunohistochemical staining showed axillary lymph node tumor cells express CDX2 (C); Immunohistochemical staining showed axillary lymph node tumor cells express CK20 (D); Immunohistochemical staining showed some axillary lymph node tumor cells express SATB-2 (E).
Image description: Lauren's classification was the diffuse type ( Figure 2A ).
Pathology showed that the tumor cells were poorly differentiated adenocarcinoma. immunohistochemical staining showed that most of the tumor cells expressed Caudal-type homeobox 2 (CDX2), CK20, GATA binding protein 3 (GATA-3), and a small amount of sequence-binding protein (SATB) 2 and Mucin-5AC (MUC5AC), but no expression of CK7 and TTF-1 was found ( Figures 2B-E ).
Image caption: Axillary ultrasound showed enlarged axillary lymph nodes (A); The mammary gland molybdenum target X-ray was not found obvious breast mass (B, C); No obvious mass was found in whole-body bone scintigraphy (D).
Image description: Ultrasound examination of the bilateral breast and axilla showed that there was no obvious mass in the bilateral breast, and several hypoechoic lesions were found in the left axilla, the size of which was about 4.3 x 1.9cm, the boundary was clear, the cortex was thickened, the medulla was eccentric and the blood flow signal was abundant ( Figure 3A ).
No obvious abnormality was found in mammary gland molybdenum target X-ray ( Figures 3B, C ), mediastinal and supraclavicular enlarged lymph nodes were not found in CT, and no obvious bone metastasis in whole-body bone scintigraphy ( Figure 3D ).
Image caption: CEA, CA19-9, and CA72-4 increased gradually after radical axillary lymphadenectomy.
Image description: The patient received docetaxel and fluorouracil chemotherapy after radical axillary lymph node dissection, and a progressive increase in CEA, CA19-9, and CA72-4 was found ( Figure 4 ).
Case Report:
A 67-year-old female patient was admitted to the local hospital because of epigastric pain and discomfort for one month. She was diagnosed as a malignant tumor of the gastric body by electronic gastroscopy and biopsy pathology. The abdominal enhanced CT shows multiple lymph nodes enlargement in the abdominal and retroperitoneum in the outpatient clinic of our hospital ( Figures 1A, B ). The patient received six cycles of chemotherapy in another hospital (SOX regimen for 1 cycle; S-1 and oxaliplatin. Paclitaxel, oxaliplatin, S-1, and Sintilimab for 5 cycles). After the end of chemotherapy, the effect of chmotherapy was evaluated as partial remission (PR). The patient asked for surgical treatment in our hospital. Physical examination showed that the abdomen was flat, the abdominal muscles were soft, the upper abdomen was mild deep tenderness, there was no rebound pain, and there was no obvious abdominal mass. Laboratory results showed that hemoglobin content decreased: 97g/L (normal range 110-150g/L). CA72-4:4.90U/mL (normal range 0-6.9U/mL), AFP: 1.30ng/mL (normal range 0-8.1ng/mL), CEA:1.13ng/mL (normal range 0-10ng/mL), CA199:17.71U/mL (normal range 0-37U/mL), CA125:2.85U/mL (normal range 0-30.2U/mL). There was no significant increase in serum tumor markers. After the end of neoadjuvant chemotherapy, we performed a PET-CT examination for the patient. 18F-FDG PET-CT showed that the mass showed changes after chemotherapy, slight thickening of the lesser curvature of the stomach, the mass did not significantly absorb FDG, and it was found that the left axillary lymph node was enlarged, and the mass uptake of FDG increased slightly, but it was considered as an inflammatory lesion ( Figures 1C ). After multidisciplinary tumor consultation, we decided to perform the radical total gastrectomy on the patient, and regular examination of the enlarged lymph nodes in the left axilla. After obtaining the consent of the patient and her family, the patient underwent radical total gastrectomy (Roux-en-Y digestive tract reconstruction) in August 2021. Postoperative pathology showed that the area of ulcerative gastric cancer was about 4 x 3cm. The main tumor cells were poorly differentiated adenocarcinoma, local invasion of the deep muscular layer of the gastric wall, and tumor cells can be seen in the lymphatic vessels but no definite nerve invasion. Lauren's classification was the diffuse type ( Figure 2A ). Only one of the 21 lymph nodes had metastasis, which was located on the lesser curvature of the gastric wall, and no obvious tumor metastasis was found in the rest of the lymph nodes (ypT2N1M0 IIA). Immunohistochemical staining showed that tumor cells expressed CK8/18, individual cells expressed Syn, and did not express CgA, CD56, SALL4, Oct3/4, C-erb-B-2, and Ki-67 proliferative index was approximately 90%. The patient recovered smoothly without obvious postoperative complications and was discharged 13 days after radical total gastrectomy.
One month after radical total gastrectomy, the patient found that the left axillary mass grew faster than before and was accompanied by the limitation of left upper limb movement. Physical examination showed that the left axillary mass was about 4 x 2cm in size, hard, had an unclear boundary, and had a poor range of motion. Ultrasound examination of the bilateral breast and axilla showed that there was no obvious mass in the bilateral breast, and several hypoechoic lesions were found in the left axilla, the size of which was about 4.3 x 1.9cm, the boundary was clear, the cortex was thickened, the medulla was eccentric and the blood flow signal was abundant ( Figure 3A ). No obvious abnormality was found in mammary gland molybdenum target X-ray ( Figures 3B, C ), mediastinal and supraclavicular enlarged lymph nodes were not found in CT, and no obvious bone metastasis in whole-body bone scintigraphy ( Figure 3D ). The patient underwent the axillary lymph node biopsy in October 2021. During the operation, the enlarged lymph nodes were located next to the axillary vein, fused into clumps, hard texture, and closely combined with the surrounding tissues. Intraoperative frozen sections showed that there were 5 lymph nodes in the left axilla, and all of them had cancer metastasis. After that, we performed radical axillary lymph node dissection and 14 of the 18 lymph nodes had metastases. Pathology showed that the tumor cells were poorly differentiated adenocarcinoma. immunohistochemical staining showed that most of the tumor cells expressed Caudal-type homeobox 2 (CDX2), CK20, GATA binding protein 3 (GATA-3), and a small amount of sequence-binding protein (SATB) 2 and Mucin-5AC (MUC5AC), but no expression of CK7 and TTF-1 was found ( Figures 2B-E ). After communicating with pathologists, considering the immunohistochemical results and the history of gastric cancer, we considered that the left axillary lymph node tumor was metastasized by gastric cancer.
The patient received docetaxel and fluorouracil chemotherapy after radical axillary lymph node dissection, and a progressive increase in CEA, CA19-9, and CA72-4 was found ( Figure 4 ). Three months after the second operation, the MR examination of cervical and thoracic vertebrae due to back pain revealed secondary malignant tumors of the spine, but the patient refused to undergo whole-body bone imaging. CT of the chest and abdomen showed double clavicular and mediastinal enlarged lymph nodes, considering the malignant tumor. But the patient refused any treatment and died 11 months after the second operation.
OUTPUT:
| PMC9641636 |
MultiCaRe_Reasoning98 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 41.0
Sex: Female
Title: Educational Case: Hemolysis elevated liver enzymes and low platelets (HELLP syndrome)
Keywords: female reproductive system; hellp syndrome; organ system pathology; pathology competencies; preeclampsia; pregnancy;
Abstract:
Recommended management of patients with preeclampsia starts with a comprehensive clinical maternal and fetal evaluation, including maternal complete blood count, platelets, creatinine, LDH, liver enzymes, and urine test for proteinuria, along with fetal ultrasonographic evaluation and fetal antepartum testing.7 Subsequent management depends on the results of this evaluation and on gestational age. Continued observation is recommended for a woman with a preterm fetus if she has gestational hypertension or preeclampsia without severe features, until delivery at 37 weeks of gestation in the absence of abnormal antepartum testing, preterm labor, premature rupture of membranes, or vaginal bleeding.7 There are numerous conditions precluding such expectant management including severe hypertension refractory to treatment, persistent headaches refractory to treatment, epigastric or right upper pain refractory to treatment, visual disturbances, motor deficit, altered sensorium, stroke, myocardial infarction, new or worsening renal dysfunction, pulmonary edema, suspected acute placental abruption, vaginal bleeding in the absence of placenta previa, eclampsia, or HELLP syndrome.7.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 41-year-old woman presents to a small rural hospital emergency department at 03:00, with the abrupt onset of severe acute epigastric pain. The pain is constant; it does not radiate outside of the mid-upper abdomen. The patient is pregnant, at 35 weeks gestation, with normal prenatal examination and blood pressure each visit through 34 weeks, and this is three days after the last prenatal examination. The patient has a past medical history of asthma, a remote appendectomy, a left oophorectomy for a cyst, a pre-term vaginal delivery at 34 weeks gestation 21 years ago, and no history of hypertension. Her asthma is quiescent, not requiring medication.
OUTPUT:
| PMC9512840 |
MultiCaRe_Reasoning99 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Female
Title: The first case of transcatheter device closure of perimembranous ventricular septal defect in Nigeria: a case report
Keywords: nigeria; transcatheter closure; case report; interventional paediatric cardiology; ventricular septal defect;
Abstract:
Ventricular septal defect (VSD) is the most common congenital cardiac anomaly with a prevalence of 1.17 per 1000 live births. Haemodynamically significant VSDs require closure either surgical or transcatheter. We report a case of transcatheter device closure of a moderate-sized perimembranous ventricular septal defect (PmVSD), the first of its kind in Nigeria. The procedure was performed on a 23-month-old female weighing 10 kg who had presented with a history of frequent pneumonia and poor weight gain and signs of heart failure. The procedure was uncomplicated, and she was discharged 24 hours after the intervention. She had been followed-up two years post-procedure without complications and she had achieved appreciable weight gain. This non-surgical option was effective in this patient and provided the advantage of limited hospitalization, accelerated recovery, and intervention without the need for blood products. Such interventions should be scaled up in Nigeria and other sub-Saharan African countries.
Image Caption and Description:
Image caption: pre-procedure echocardiogram
Image description: Echocardiography showed a 7mm perimembranous ventricular septal defect partially restricted by the tricuspid valve septal leaflet aneurysm, shunting left to right (Figure 1).
Image caption: left ventriculogram
Image description: A left ventriculogram done in left anterior oblique (LAO) 400 cranial 200 view using a 5Fr pigtail catheter confirmed the echocardiography findings (Figure 2).
Image caption: ventricular septal defect device post-release
Image description: TTE guidance and released (Figure 3). The procedure time was 77 minutes and the fluoroscopy time was 24.3 minutes.
Image caption: post-procedure echocardiogram
Image description: Post-deployment TTE showed the device in a stable position with no residual shunt and no aortic valve regurgitation (Figure 4).
Case Report:
Patient information: a 23-month-old female child had been diagnosed to have a moderate-sized PmVSD at four months of age.
Clinical findings: she presented with fast, laboured breathing and poor growth and a history of three previous episodes of chest infections. She had also been delivered at a birth weight of 1.05 kg on account of a twin-twin transfusion.
Timeline of the current episode: she had presented a year earlier at 11 months of age for pre-surgical evaluation for a moderate-sized PmVSD and had been receiving oral diuretics since diagnosis. Dietary counsel was given, medications optimized, and parents were counselled for early closure of the VSD. She presented for the procedure a year after, and parents were counselled regarding the benefits and risks of transcatheter closure as compared to the surgical option and the family opted for the former. A written and signed informed consent was obtained.
Diagnostic assessment: physical examination revealed no evidence of dysmorphism, no obvious respiratory distress, cyanosis or peripheral oedema. She weighed 10.0 kg which was 85% of her expected weight. The pulse rate was 116 bpm and pulses were normal volume, regular, synchronous, and well felt in all peripheries. Her precordium was active with the apex beat localised to the fourth left intercostal space lateral to the midclavicular line. Blood pressure was 100/49mmHg (90th centile for both systolic and diastolic pressures) and first and second heart sounds were normal with a grade 3/6 pan systolic murmur at the mid left sternal border. Oxygen saturation by pulse oximetry was 98% in room air, respiratory rate was 48 per minute and breath sounds were vesicular. She had a soft, smooth, non-tender hepatomegaly, 4cm below the right costal margin and no other abdominal organ was palpably enlarged.
Diagnosis: electrocardiography revealed sinus rhythm with a heart rate of 112 bpm, QRS axis of +300, predominant left ventricular forces and an incomplete right bundle branch block. Echocardiography showed a 7mm perimembranous ventricular septal defect partially restricted by the tricuspid valve septal leaflet aneurysm, shunting left to right (Figure 1). The peak interventricular pressure gradient was 80mmHg and the left atrium, left ventricle and pulmonary arteries were dilated with good biventricular function.
Therapeutic interventions: the child underwent successful transcatheter VSD device closure with a 0608 Lifetech CeraTM duct occluder (Lifetech Scientific Corporation, Shenzhen, China) under general anaesthesia using a laryngeal mask airway. Both arterial and venous femoral accesses were obtained, and 100 units/kg of intravenous heparin was administered. The intravenous antibiotic was administered as per the institution's protocol. Pre-procedure transthoracic echocardiography (TTE) showed a PmVSD measuring 7.0mm and was restricted to 4.0mm by the tricuspid septal leaflet aneurysm. A left ventriculogram done in left anterior oblique (LAO) 400 cranial 200 view using a 5Fr pigtail catheter confirmed the echocardiography findings (Figure 2). The VSD was crossed retrograde from the aorta with a 5F Judkins Right catheter and 0.035" 260cm Terumo wire combination and the wire manoeuvred into the superior vena cava and then the innominate vein. It was then snared using a 4F 10mm LifetechTM snare catheter (Lifetech Scientific Corporation, Shenzhen, China) and exteriorised from the right femoral vein forming an arteriovenous (AV) loop. The femoral venous short sheath was exchanged for a 6F Steer Ease introducer sheath (Lifetech Scientific Corporation, Shenzhen, China) which was passed antegrade over the venous limb of the AV loop and the sheath tip placed in the left ventricle. The duct occluder device was prepared, loaded in the delivery sheath, and deployed across the PmVSD under fluoroscopic and TTE guidance and released (Figure 3). The procedure time was 77 minutes and the fluoroscopy time was 24.3 minutes.
Follow-up and outcome of interventions: there were no procedural complications. Post-deployment TTE showed the device in a stable position with no residual shunt and no aortic valve regurgitation (Figure 4). Post-procedure electrocardiography showed normal sinus rhythm. The child was discharged 24 hours after the procedure in good health. Oral Aspirin 5mg/kg was prescribed for 6 months. By the third month following the procedure, activity had significantly improved, and she had gained 1.0 kg. She has been seen severally on follow-up; the last being two years post-intervention and has no complications.
Patient perspective: "we are happy that our child can now live a normal life after this procedure". The parents expressed profound gratitude to the entire health team and were grateful to have had the benefit of state-of-the-art cardiovascular care in the country.
Informed consent: written and informed signed consent to publish de-identified data of the child was obtained from both parents.
OUTPUT:
| PMC10182372 |