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primary cutaneous tuberculosis results from the direct inoculation of mycobacterium tuberculosis into the skin of a person with no previous history of tuberculosis infection 1 . cutaneous tuberculosis is considered predominantly an occupational disease and is a challenging diagnosis to make , especially in low - income countries due to a wide array of differential diagnoses , for example , fungal infections , leishmaniasis 2,3 . a 27-year - old previously healthy african male medical intern sustained a needle - stick injury from a wide bore needle ( gauge 18 ) to his little finger while performing a lumbar puncture on a hiv - infected patient . he sustained a small lesion that bled a little and he immediately washed it with water and soap . he was immediately started on postexposure prophylaxis anti - retroviral drugs ( arvs ) : zidovudine , lamivudine and kaletra for 28 days as per the kenya national aids control program protocol . his initial rapid hiv test ( determine ) test was negative and so was a pcr done on completion of the arvs . the patient source , an african female , was who clinical stage 4 , not on arvs and was being investigated for meningitis died soon the lumbar puncture and her results were not followed up until several months later . two weeks after the injury , the intern had swelling of the little finger associated with a persistent dull ache for which he sought surgical intervention . pus was aspirated from the finger and incision and drainage were done under local anesthesia . culture of the pus grew staphylococcus aureus sensitive to flucloxacillin on which he was started . his little finger now had an open wound that persisted for several months despite debridement and different antibiotic regimens : levofloxacin , clindamycin , ceftriaxone , and vancomycin . for the next 6 months , there was persistent swelling of the little finger which seemed to be spreading to the hand ( fig.1 ) . this was accompanied with low - grade fever , night sweats , and subjective weight loss . he underwent a surgical debridement 6 months after the injury and was started on levofloxacin . serial blood counts done in the course of illness showed persistently elevated lymphocytes and a raised esr . ten months later and with no improvement of symptoms , he underwent yet another surgical debridement . histological examination of the tissue taken revealed a chronic inflammatory process ( fig.2 ) , granulomatous tubercles with epithelioid cells ( fig.3 ) , giant cells of langerhans ( fig.4 ) , and a mononuclear infiltrate but no acid - fast bacilli ( afb ) were demonstrated on ziehl nelson stain . he was started on rifampicin , isoniazid , pyrazinamide , and ethambutol for duration of 2 months to be followed by a 4-month course of rifampicin and isoniazid . a rapid hiv test done at the end of the anti - tb treatment was negative . tuberculosis continues to pose a significant public health problem and kills about 3 million people annually 4 . it is largely an airborne infection , but skin manifestations may be caused by hematogenous spread or contiguity from foci of infection which may be active or latent . primary inoculation , another mode of transmission 5 , results from direct inoculation of m. tuberculosis into the skin of a person who has no previous exposure and subsequently no immunity to the organism 6 . cutaneous tuberculosis is rare and accounts for 0.1% of dermatology cases and only 1.5% of extra pulmonary tuberculosis cases 7,8 . once the traumatized skin of a previously uninfected person is inoculated with m. tuberculosis , a tuberculous chancre develops at that site within 3 weeks . a painless regional lymphadenopathy becomes prominent 36 weeks after inoculation , and a previously negative , intradermal , intermediate - strength purified protein derivative ( ppd ) test converts to a positive test 1 . cutaneous tuberculosis is commonly seen amongst young adults because of their likelihood to sustain workrelated injuries and inoculation of tubercle bacilli 9 . the diagnosis of tuberculosis in this case was masked by an initial culture growth of s. aureus which led to a delay in diagnosis and several months of morbidity for the medical intern . on tuberculous arthritis of the knee with staphylococcus super infection in which a delay in the diagnosis led to adverse outcome 12 . diagnosis requires correlation of clinical and histopathologic findings but a mycobacterial culture is the most reliable method of detecting mycobacteria and monitoring treatment response . an absolute diagnosis can be made when afb is visualized on a ziehl nelson - stained slide of a smear prepared from material from lesions 13 . cutaneous tuberculosis that occurs by direct inoculation is a paucibacillary disease , sparse bacilli seen on histology and microorganisms are difficult to isolate 2 . smears , ziehl nelson staining , and mycobacterial cultures in lowenstein jensen and bactec media are frequently negative 14 . typical features of a tuberculous chancre of tuberculosis include granulomatous tubercles with epithelioid cells , langerhans giant cells , and a mononuclear infiltrate 15 . useful diagnostic tools in the diagnosis of cutaneous tuberculosis include histopathologic findings of tubercles , isolation of m. tuberculosis in cultures of biopsy material , or by polymerase chain reaction 16 . management of cutaneous tuberculosis is the treatment with four - agent regimen given for 2 months followed by a two - drug regimen for the next 4 months as per tuberculosis treatment guidelines for tuberculosis in other organs 13 . primary cutaneous tuberculosis is rare and should be suspected in all patients who present with skin lesions that do not respond to antibacterial treatment . . a high index of suspicion is required to make the diagnosis of cutaneous tuberculosis because diagnostic methods are not sufficient and may lead to a delay in starting appropriate methods . complete microbiological tests | key clinical messagethe authors report a case of cutaneous tuberculosis in a 27-year - old african male medical intern who contracted primary cutaneous from a needle - stick injury .
cultures of pus aspirated from the finger initially grew staphylococcus aureus that led to a delay in the diagnosis . |
one of the most frequently asked questions to those of us at june is what kinds of manuscripts are appropriate for inclusion in the journal . any manuscript with the aim of enabling others to enhance their teaching of neuroscience to undergraduates is appropriate ; those with empirically - tested protocols of innovative pedagogy are particularly welcomed and prioritized for publication in june . beyond manuscripts devoted to new classroom approaches and laboratory exercises , a variety of manuscripts in other aspects that are relevant to undergraduate neuroscience education are welcomed , such as :
editorials . june welcomes book reviews ranging from popular press volumes relevant to neuroscience to textbooks.media reviews . june welcomes reviews of media such as films , television shows , websites , and software that may have particular value to neuroscience education.commentaries . june welcomes reviews of media such as films , television shows , websites , and software that may have particular value to neuroscience education . manuscripts must be properly formatted according to the instructions to authors available at the june website ( http://funjournal.org ) . manuscripts should be carefully proofread , and attention should be given to both the flow and appearance of information and positioning of tables , figures , and captions . to facilitate indexing , authors are welcome to provide a list of suggested reviewers , which may or may not be used in the review of their article . the first step in the process is an initial screen by the editors to ensure that the manuscript is appropriate for the journal . if not , a notification indicating why the manuscript does not fit the criteria for inclusion in june is sent to the author(s ) . sometimes , an editor may provide suggestions of how the manuscript may be modified to better fit the criteria . once the initial reviews are received , the editors make a decision to accept , request revisions and resubmissions , or reject . often times the difference between acceptance and rejection hinges on a few key issues . in the case of manuscripts detailing innovative approaches to teaching , contentions of effectiveness need to be supported with discussion of appropriate methods of assessment and supporting evidence provided by the results obtained . in some cases , an author may inadvertently fail to obtain permission to use and discuss copyrighted material . in all cases if an author has been asked to revise portions of their manuscript , a cover letter indicating how each of the reviewer s comments and concerns have been addressed should be included in the resubmission . one of the most frequently asked questions to those of us at june is what kinds of manuscripts are appropriate for inclusion in the journal . any manuscript with the aim of enabling others to enhance their teaching of neuroscience to undergraduates is appropriate ; those with empirically - tested protocols of innovative pedagogy are particularly welcomed and prioritized for publication in june . beyond manuscripts devoted to new classroom approaches and laboratory exercises , a variety of manuscripts in other aspects that are relevant to undergraduate neuroscience education are welcomed , such as :
editorials . june welcomes book reviews ranging from popular press volumes relevant to neuroscience to textbooks.media reviews . june welcomes reviews of media such as films , television shows , websites , and software that may have particular value to neuroscience education.commentaries . june welcomes reviews of media such as films , television shows , websites , and software that may have particular value to neuroscience education . manuscripts must be properly formatted according to the instructions to authors available at the june website ( http://funjournal.org ) . manuscripts should be carefully proofread , and attention should be given to both the flow and appearance of information and positioning of tables , figures , and captions . to facilitate indexing , authors are welcome to provide a list of suggested reviewers , which may or may not be used in the review of their article . the first step in the process is an initial screen by the editors to ensure that the manuscript is appropriate for the journal . if not , a notification indicating why the manuscript does not fit the criteria for inclusion in june is sent to the author(s ) . sometimes , an editor may provide suggestions of how the manuscript may be modified to better fit the criteria . all manuscripts that are deemed appropriate for the journal are sent to reviewers . once the initial reviews are received , the editors make a decision to accept , request revisions and resubmissions , or reject . often times the difference between acceptance and rejection hinges on a few key issues . in the case of manuscripts detailing innovative approaches to teaching , contentions of effectiveness need to be supported with discussion of appropriate methods of assessment and supporting evidence provided by the results obtained . in some cases , an author may inadvertently fail to obtain permission to use and discuss copyrighted material . in all cases if an author has been asked to revise portions of their manuscript , a cover letter indicating how each of the reviewer s comments and concerns have been addressed should be included in the resubmission . there is a range of ways readers of june can contribute to the journal beyond the submission of manuscripts . one very important way is to use the journal as a resource in your own teaching and to encourage your colleagues to do this as well . in addition , you can promote june to other neuroscience educators , encouraging them to read the journal and to submit manuscripts discussing their own approaches and innovative techniques for teaching neuroscience . it s important to support june in another way as well by joining and holding membership in fun . while june is an open - access journal and free to all , june does cost money to publish . fun members , through a portion of their very reasonable annual dues , provide critical support for june . consider also being a reviewer for june . one is to become an ad hoc reviewer ; to do so , simply send the editor in - chief a short email message expressing your willingness to review articles , indicating your particular areas of expertise . while review board members are regularly called on to complete reviews , such service is typically limited to two or three reviews per year . review board members are also considered to fill vacancies that happen periodically on the editorial board . to be considered for service on the june review board , please contact the june editor - in - chief regarding a possible appointment . june has come a long way since being founded in 2002 . through the efforts of our contributing authors , reviewers , and the entire editorial board , june has contributed to the success of undergraduate programs and neuroscience education around the globe . an important milestone for the second decade of june will be the successful completion of our efforts to become indexed across major databases and services , including psych info , scopus , the national science digital library , the directory of open access journals , medline and pubmed ( grisham , 2012 ) . at this writing , only indexing in medline and pubmed remain to be accomplished , and the application process is partially completed . as technology changes and new avenues for electronic communication become available , expect june to change as well , adding new features or altering existing ones to reflect latest developments . with support from fun members , the undergraduate neuroscience educational community will continue to have a readily available venue for learning about the latest innovations in laboratory exercises and improved teaching approaches . be sure to visit june online at ( http://funjournal.org ) , in person at the fun and at the society for neuroscience annual meetings , or both . publish in , and review articles for june and join in the fun of promoting undergraduate neuroscience education and research . | in the fall of 2002 , the faculty for undergraduate neuroscience ( fun ) began publication of its flagship journal , the journal of undergraduate neuroscience education ( june ) .
for the past ten years , june has been a major forum for the free exchange of information among undergraduate neuroscience educators .
numerous articles on laboratory exercises , media , pedagogy , curriculum , and issues pertinent to neuroscience educators have been published in june during the past decade .
given the vast expertise in pedagogy amongst the fun membership and within the undergraduate neuroscience education community at large , we strongly encourage all fun members and june readers to become actively involved in june by contributing manuscripts and/or by offering your services as a reviewer . |
syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is a common cause of hyponatremia . although it has been associated with different pulmonary infections , there have been only few case reports describing the association of siadh with influenza . we report a case of siadh in a patient with influenza who was successfully treated with fluid restriction . it is essential for clinicians to be aware of the association between influenza and siadh . syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is one of the most common causes of hyponatremia in hospitalized patients , with a prevalence as high as 35% . it is characterized by the impairment of urinary dilution in the absence of any renal disease or any identifiable nonosmotic stimulus that induces antidiuretic hormone ( adh ) release . although siadh has been known to be associated with different pulmonary infections , only rarely has it been reported with influenza . we present a case of hyponatremia associated with influenza , which was subsequently diagnosed as siadh . a 65-year - oldmale presented to the emergency department with low - grade fever and productive cough for 2 days . he did not have any neurological symptoms , abdominal pain , nausea , vomiting , change in bowel movements , or loss of appetite or weight . he did not have any history of recent surgery , central nervous system disorders , malignancy , or known pulmonary disease . on examination , he had a temperature of 102.4f , heart rate 120/min , respiratory rate 24/min , blood pressure 110/60 mmhg without orthostatic vital signs , and oxygen saturation 96% on room air . laboratory examination revealed a serum sodium of 122 meq / l ( 135 - 145 ) , blood urea nitrogen ( bun ) 11 mg / dl ( 8 - 24 mg / dl ) , creatinine 1.35 mg / dl ( baseline 1.2 - 1.3 ) , plasma osmolality 276 mosm / kg ( 280 - 290 ) , urine specific gravity of 1.029(1.002 - 1.030 ) , urine osmolality 777 mosm / kg , urine sodium 63 meq / l , thyroid - stimulating hormone ( tsh ) 3.011 iu ( 0.5 - 5.0 mu / l ) , and random serum cortisol 20.2 g / dl ( 7 - 25 g / dl ) . the chest x - ray did not show any infiltrate , consolidation , or mass . the nasal swab polymerase chain reaction was positive for influenza a. urinary antigens for legionella , mycoplasma , and streptococcus were negative . a diagnosis of siadh was made and his hyponatremia was corrected gradually in 3 days with fluid restriction o less than 800 ml / day . at 2 weeks thus , a careful history to rule out other causes like malignancy , pulmonary conditions , central nervous system lesions , and medications is essential in the evaluation of any patient suspected with siadh . it has been reported in many pulmonary infections including asthma , atelectasis , acute respiratory failure , and pneumothorax . influenza has been implicated as a cause of siadh previously , but there is no published data regarding the actual incidence of siadh in these patients . our patient was diagnosed with siadh based on :
hypoosmolar hyponatremia;urine osmolality > 100 mosm / kg;urine sodium concentration > 40 meq / l;euvolemic state ; andnormal renal , thyroid , and adrenal function . hypoosmolar hyponatremia ; urine osmolality > 100 mosm / kg ; urine sodium concentration > 40 meq / l ; normal renal , thyroid , and adrenal function . failure of improvement of serum sodium with intravenous normal saline further confirmed the diagnosis of siadh . although the exact pathogenesis for siadh in influenza is unknown , it is thought to be related to the secretion of proinflammatory cytokines . interleukin ( il)-2 , il-6 , il-1 , and tumor necrosis factor ( tnf)- have been reported to stimulate parvocellular and magnocellular neurons to secrete more adh ; thus causing siadh . fluid restriction is the main treatment modality in siadh , with a suggested goal intake of less than 800 ml / day . further treatment options depend on the severity of hyponatremia and the presence of other related symptoms . in the presence of severe or symptomatic hyponatremia , hypertonic saline goal should be to raise serum sodium less than 10 - 12 meq / lin 24 h to ovoid the potential complication of osmotic demyelination with rapid correction . oral salt tablets and loop diuretics may also be added if optimum response is not seen with fluid restriction alone . our patient 's siadh was thought to be secondary to influenza , which was treated with oseltamivir and led to steady improvement in the patient 's serum sodium levels . in conclusion , clinicians should be cognizant of the association between influenza and siadh to allow for accurate diagnosis and treatment of this condition . further studies are needed in future to find out the incidence and pathogenesis of siadh in patients with influenza . although treatment depends on the severity of hyponatremia and associated symptoms , fluid restriction remains the cornerstone of therapy . | context : syndrome of inappropriate secretion of antidiuretic hormone ( siadh ) is a common cause of hyponatremia .
although it has been associated with different pulmonary infections , there have been only few case reports describing the association of siadh with influenza.case report : we report a case of siadh in a patient with influenza who was successfully treated with fluid restriction.conclusion:it is essential for clinicians to be aware of the association between influenza and siadh . |
injury to intraperitoneal organs is unusual during percutaneous renal surgery . we report a splenic injury during upper pole percutaneous renal access for nephrostolithotomy that was managed conservatively . a 52-year - old male with left upper pole renal stones associated with a narrow upper pole infundibulum underwent upper pole renal access prior to percutaneous nephrostolithotomy ( pcnl ) . the access was performed in the 10th to 11th intercostal space , and the patient underwent pcnl with stone clearance . on postoperative day 5 , the patient was evaluated for persistent flank pain and bleeding from the nephrostomy tube . the patient was admitted to the hospital , and the general surgery service was consulted . a pullback nephrostogram revealed no perirenal leak , and no evidence was present of acute bleeding . follow - up computerized tomography on the same day revealed no evidence of acute bleeding . the patient was discharged without further complications and remains stone free at 1-year follow - up . a transsplenic renal access that was dilated and through which a successful left percutaneous nephrostolithotomy was performed is a highly unusual complication related to upper pole left renal access . percutaneous nephrostolithotomy is the treatment of choice for most large renal stones , and the success of the procedure is critically dependent on obtaining an access with optimal angles for lithotripsy and stone removal . while thoracic entry and pneumothorax is a known complication with intercostal renal access , injury to intraperitoneal organs is unusual . we report the successful conservative management of a splenic injury resulting from transsplenic access and tract dilation in a patient undergoing pcnl . a healthy 52-year - old male presented with left upper pole renal stones associated with a narrow infundibulum ( figure 1 ) . due to stone location and related renal anatomy , the upper pole approach was preferred , and upper pole renal access through the 10th to 11th intercostal space was obtained in interventional radiology prior to pcnl . the access was successful , and the patient underwent balloon dilation of the tract and pcnl with complete stone clearance . nephrostogram during initial puncture demonstrates upper pole calculi with a narrow , tortuous infundibulum . on postoperative day 3 , the patient was evaluated in the emergency room due to flank pain and bleeding through the nephrostomy tube . on postoperative day 5 , he was reevaluated for persistent bleeding from the nephrostomy tube and flank pain . computerized tomography of the abdomen and pelvis was obtained , revealing transsplenic percutaneous renal access ( figure 2 ) . in consultation with interventional radiology and general surgery , a decision was made to leave the nephrostomy in place for 2 weeks after surgery . nephrostomy tube found to traverse the spleen on computerized tomography without hematoma . at that time follow - up computerized tomography on the same day revealed no evidence of acute bleeding . splenic portion of the nephrostomy tract as seen by fluoroscopy ( a ) and computerized tomography ( b ) . most complications are related to percutaneous renal access , with bleeding and pneumothorax being most common . when supracostal puncture is performed , the risk of pneumothorax or pleural effusion requiring drainage is 4% to 12% . splenic injury may require surgical management . however , conservative management with splenic preservation is feasible as demonstrated here . the risk of splenic injury during pcnl has been estimated by hopper and yakes , who used ct to analyze the relationship of the kidney , spleen , and lower ribs . their analysis noted that splenic injury is highly unlikely if an 11th or 12th rib supracostal approach is made during expiration . the risk increases to 13% if this approach is taken on inspiration and may be as high as 33% if a 10th to 11th approach is used for access . splenic injury in our patient was most likely due to supra-11th puncture at the skin level . access was quite oblique with the needle directed caudally and , in retrospect , transperitoneally . the advantages of upper over lower pole access include direct access along the long axis of the kidney and to the ureteropelvic junction , usually allowing for less torque of the rigid nephroscope and less bleeding . we feel that the upper pole should have been accessed given the patient 's anatomy . however , this may have been achieved at the 11th to 12th intercostal space , thus lessening the risk of transsplenic puncture and splenic injury . | introduction : injury to intraperitoneal organs is unusual during percutaneous renal surgery . we report a splenic injury during upper pole percutaneous renal access for nephrostolithotomy that was managed conservatively.methods:a 52-year - old male with left upper pole renal stones associated with a narrow upper pole infundibulum underwent upper pole renal access prior to percutaneous nephrostolithotomy ( pcnl ) .
the access was performed in the 10th to 11th intercostal space , and the patient underwent pcnl with stone clearance .
plain film radiography after percutaneous access and pcnl revealed no pneumothorax or hydrothorax .
the patient was discharged on postoperative day one with the nephrostomy tube in place.results:on postoperative day 5 , the patient was evaluated for persistent flank pain and bleeding from the nephrostomy tube .
computerized tomography revealed a transsplenic percutaneous renal access .
the patient was admitted to the hospital , and the general surgery service was consulted .
the patient was placed on strict bedrest .
his hematocrit was within normal limits and remained stable .
the nephrostomy tube was kept in place for 2 weeks .
a pullback nephrostogram revealed no perirenal leak , and no evidence was present of acute bleeding .
follow - up computerized tomography on the same day revealed no evidence of acute bleeding .
the patient was discharged without further complications and remains stone free at 1-year follow-up.conclusions:a transsplenic renal access that was dilated and through which a successful left percutaneous nephrostolithotomy was performed is a highly unusual complication related to upper pole left renal access .
we were able to manage this complication with conservative measures . |
pneumomediastinum is defined as air or free gas in the mediastinum , which invariably arises from the alveolar spaces or the conducting airways and has a multi - factorial aetiology . it is a benign and self - limiting condition that usually affects young males ( 1 ) . although uncommon , this condition is increasingly seen in emergency departments owing to the epidemic rise of substance abuse ; an effect which is thought to be related to the mechanism of intoxication rather than pharmacology of the offending compound ( 2 ) . we report here an interesting case of cocaine induced pneumomediastinum . a fit and healthy 27 year old gentleman presented to the accident and emergency department complaining of severe sharp central chest pain and vertigo . there were no other symptoms of note and his past medical history and family history were unremarkable for respiratory or cardiovascular disease . on examination his blood tests showed a crp 36 , with all other hematological and biochemical parameters within normal levels . an electrocardiogram and serum troponin were unremarkable . a chest x - ray ( fig . he was admitted and transferred to the care of the surgical team with a diagnosis of suspected bronchial or oesophageal perforation . 2 ) confirmed the presence of a pneumomediastinum extending from the lower neck at the level of c6 to the diaphragmatic hiatus . there were no visible mediastinal collections and no evidence of pulmonary /airway disease with intact pulmonary vessels . an oesophageal perforation was suspected but not shown on a water - soluble contrast swallow . reassessment of the patient 's personal history revealed that he had nasally inhaled powdered cocaine prior to the onset of his symptoms . he denied the use of other recreational substances although he admitted to a significant history of smoking and alcohol use . the patient was managed conservatively during the course of his admission with simple analgesia and iv maintenance fluids . an upper gi endoscopy revealed oesophagitis for which he was commenced on a proton pump inhibitor . therefore with the low probability of lung injury , a possible diagnosis of micro - perforation of the oesophagus was made . once again , the patient was managed conservatively and was discharged a few days later symptom free . its occurrence secondary to cocaine inhalation has been reported in the literature as a known but uncommon event . the presumed patho - physiology of acute cocaine medicated lung injury is believed to arise from a sequence of events that begin with inhalation induced bronschospasm , increased alveolar pressure followed by alveolar rupture leading to interstitial emphysema and pneumomediastinum ( 3 ) . patients are generally young and present hours after cocaine inhalation with symptoms of acute onset chest pain , neck pain and surgical emphysema . their vital signs will reveal a high respiratory rate and low oxygen saturation . in some institutions the term crack lung is more commonly used to identify this phenomenom ( 4 ) . feliciano et al have reported cocaine induced gastro - intestinal perforations and these events are said to be due to co - existing h.pylori infection leading to mucosal weakness , which is then exacerbated by valsalva action ( 5 ) . our case report demonstrates evidence of inflammation of the oesophagus , and low probability of a lung injury in the setting of pneumomediastinum secondary to cocaine use . indeed we postulate that oesophagitis may also contribute to mucosal weakness leading to microperforation of the oesophagus and thereafter pneumomediastinum . however with no signs of lung injury on examination or investigations , microperforation in the setting of oesophagitis seems to be the most likely cause . his continued use of cocaine despite counseling and community support is likely to place him at risk of recurrent episodes . repeat microperforations on the background of oesophagitis may predispose this patient to an oesophageal catastrophe with mediastinal contamination and sepsis . the use of a proton pump inhibitor to promote oesophageal healing may be important in preventing such an outcome . | we describe an interesting case of pneumomediastinum secondary to cocaine abuse .
the patient presented with severe chest pain following nasal inhalation of a large quantity of cocaine .
investigations revealed no chest injury ; however oesophagitis was proven leading to a possible aetiology of oesophageal microperforation .
after conservative management there was spontaneous resolution of the pneumomediastinum . |
temporal bone metastasis of hepatocellular carcinoma ( hcc ) has rarely been reported.1 only one case of facial nerve palsy due to temporal bone metastasis of hcc has been reported and it was detected by autopsy.2 we encountered a case of metastatic hcc to the temporal region of the skull that initially presented as facial nerve palsy and was incidentally found during the diagnostic work up . a 61-year - old man visited our hospital because of progressively worsening right facial pain and numbness over a 6-month period . he could not make abrupt facial expressions on the right side of his face for seven days before he came to our hospital . , he had paresthesia and hypesthesia over all territories of 3 branches of the trigeminal nerve , facial palsy in the right side of his face , and hearing loss without tinnitus in his right ear . in nasopharyngeal magnetic resonance image ( mri ) , a 5-cm , heterogeneously enhancing tumor was found in t1 weighted image ( fig . the tumor was located in the masticator space and right middle cranial fossa , abutting the right cavernous sinus and extending intracranially to the right ipsilateral infratemporal fossa . the tumor was hypermetabolic in positron emission tomography ( pet ) study using c-11-methionine , which suggested that the tumor might be a malignant lesion ( fig . bony destruction of the anterior wall , which was adjacent to the anterior genu portion of the facial nerve , was suspected to be the cause of facial nerve palsy . his laboratory findings were as follows : white blood cell count was 6,900 per mm , hemoglobin was 15.3 g / dl , platelet was 152,000 per mm , serum albumin was 3.4 g / dl , total bilirubin was 1.1 mg / dl , alkaline phosphatase was 134 iu / l , aspartate aminotransferase was 97 iu / l , alanine aminotransferase was 192 the serologic finding revealed positive for hepatitis b surface antigen ( hbsag ) , antibody to hepatitis b envelop antigen ( hbeag ) and antibody to hepatitis c virus ( anti - hcv ) . his serum hepatitis b virus dna level was 97,200 iu / ml . serum alpha - fetoprotein was 5,200 ng / ml and des - gamma - carboxy prothrombin was 17,268 nau / ml . endoscopic surgical biopsy with sphenoidotomy via the right nasal cavity was performed by an otolaryngologist . during surgical biopsy , immunohistochemical findings of the biopsy specimen revealed positive staining for alpha - fetoprotein , which was also consistent with metastatic hcc ( fig . 4 ) . other metastases were found in lumbar spines ( l1 , l2 ) and right femur in bone scan . radiation therapy was performed for the tumor in the masticator space and right middle cranial fossa and for the metastatic lesions in lumbar spines and right femur . after radiation therapy was finished , his facial pain subsided significantly and his facial nerve palsy was partially relieved . facial pain did not occur again and facial nerve palsy did not progress until 7 months later . to evaluate the primary hcc in liver , abdominal computed tomography ( ct ) was performed . a 5-cm - sized , fat - containing , ill - defined and subtly enhanced mass lesion was found in segment 8 in the cirrhotic liver ( fig . 5 ) . although repeated transarterial chemoembolization ( tace ) was tried 3 times over 7 months to treat this tumor , only marginal lipiodol uptake was observed with each tace . seven months after initial diagnosis of metastatic hcc , back pain occurred over 2 weeks . as no therapy remained for the multiple spinal metastases , the patient was transferred to a hospital near his home for supportive care . temporal bone metastasis of hcc has rarely been reported.2 though hcc commonly metastasizes to bone , metastasis of hcc to skull is uncommon.3 facial palsy due to hcc was reported once in an advanced cirrhotic patient after autopsy.2 therefore , our report might be the first case report of metastatic hcc to the temporal region of skull involving the facial and trigeminal nerve , as confirmed by surgical biopsy.2 metastatic hcc was diagnosed by surgical biopsy in this case . even if hcc had been found in liver prior to performing the biopsy of temporal metastatic lesion , tissue confirmation of the lesion in temporal area would have been done for proper management because exact diagnosis was needed for proper management and because the lesion could have been an isolated double primary tumor such as schwannoma . as far as temporal bone metastasis of malignant tumors , bilateral temporal bone involvements are more common than unilateral involvement , but in this patient and the previous autopsy - proven case of temporal bone metastasis of hcc , the lesions were only on the right side.2 hearing loss without vestibular manifestation was reported as the most common symptom of temporal bone metastases in a retrospective study of 47 autopsy cases , which was consistent with this case.4 in the case of facial palsy secondary to metastasis , involvement of other cranial nerves was more common than involvement of the facial nerve alone , which was also consistent with this case.4 radiological investigation is strongly recommended if the facial nerve palsy is clinically associated with other neurological signs.5,6 bone and brain metastases of hcc have been treated with palliative radiation therapy and pain relief has been observed in about 78% of patients , suggesting good responsiveness to radiation.7 therefore , we performed radiation therapy for the metastatic lesion in the temporal area and the pain completely subsided . our case may suggest that temporal bone metastasis of hcc is also a very good indication for radiation therapy . hepatic dysfunction is known to be the main prognostic factor in patients with hcc , even in patients with extrahepatic metastasis . the major survival factor for our patient might also be the progression of hepatic dysfunction.8,9 sorafenib treatment might have been considered in this patient because the intrahepatic hcc progressed despite repeated tace ; however , sorafenib was not available during our caring for him.10,11 in summary , we encountered a very rare case of histologically proven temporal bone metastasis of hcc that was found during the evaluation of a patient who presented with trigeminal , facial and auditory nerve dysfunction and who was positive for both hbsag and anti - hcv but without previous history of illness . our case suggests that hepatologists may consider metastatic hcc as a rare cause of new onset cranial nerve palsy in patients with chronic viral hepatitis , and radiation therapy may be considered for the treatment of temporal bone metastasis of hcc with cranial nerve involvement . | facial nerve palsy due to temporal bone metastasis of hepatocellular carcinoma ( hcc ) has rarely been reported .
we experienced a rare case of temporal bone metastasis of hcc that initially presented as facial nerve palsy and was diagnosed by surgical biopsy .
this patient also discovered for the first time that he had chronic hepatitis b and c infections due to this facial nerve palsy .
radiation therapy greatly relieved the facial pain and facial nerve palsy .
this report suggests that hepatologists should consider metastatic hcc as a rare but possible cause of new - onset cranial neuropathy in patients with chronic viral hepatitis . |
a 53-year - old lady , of height 152 centimeters and weighing 45
kilograms diagnosed with rheumatoid arthritis was first seen
by us in april 2003 for a pre - chloroquine workup . she was seen at six - monthly intervals and advised
amsler grid self - evaluation between her scheduled eye
examinations . in april 2006 , the vision in her left eye dropped to 20/30
n8 with no subjective change in vision . a clinically
detectable rpe disturbance was noted , more prominent in
her left eye [ figures 1 , 2 ] . amsler grid evaluation was
normal , but hfa 10 - 2 revealed , repeatable superior paracentral defect
in both eyes [ figure 3 ] . fundus fluorescein angiography
( ffa ) revealed rpe defects in the macular region in both
eyes . a recommendation to the treating internist four months later , she reported distortion of vision in both
eyes , which was reflected as a small blurred area in the center
of the amsler grid and vision in both eyes of 20/30 n8 optical coherence tomography ( stratus 4 oct ; carl zeiss
meditec , dublin , calif ) revealed a marked retinal thinning of
the parafoveal region [ figure 4 ] . the internist was informed and hydroxychloroquine was
replaced by methotrexate . since then , her vision has remained
stable at 20/30 n8 . chloroquine , and more recently , the apparently less toxic
hydroxychloroquine , is used for long periods of time for
treatment of various autoimmune disorders . cambiaggi
first described the classic rpe changes in 19571 and hobbs
in 1959 established a definite link between long - term use
of chloroquine and subsequent development of retinal
pathology.6 early chloroquine retinopathy though still inadequately
described , is defined as an acquired paracentral scotoma
on threshold visual field testing , with no detectable retinal
findings , while advanced retinopathy has associated parafoveal
rpe atrophy.7 chloroquine and its metabolites have been found
in the pigmented ocular structures at concentrations much
greater than in any other tissue in the body , which may explain
its toxic properties in the eye.3,8 animal studies have
suggested that ganglion cell damage occurs early with choloroquine.4,8 human pathological studies are however limited to patients
with advanced maculopathy.3 detection of resultant thinning of the ganglion cell and
nerve fiber layer ( nfl ) would be useful in demonstrating
the initial stages of toxicity , perhaps at a stage when further
damage can be halted by stopping the drug at this point . the nfl measurements of the peripapillary region in
patients on antimalarials by scanning polarimetry have
indeed shown a significant thinning of the nfl which was
dose and duration - dependent.4 however , the ganglion cell
population is the densest in the macular region , and hence ,
toxicity of the drug would be greatest at this location . the
fact that the first functional change is a paracentral scotoma ,
and the first observable rpe changes are seen in this area
supports this assumption.7 thus retinal thickness and volume
measurements in this area may give more accurate and earlier
predictions of chloroquine toxicity , perhaps even before the
scotoma develops . the oct , with its high resolution provides
measurements of the retinal thickness and volume , both in
the peripappillary area as well as at the macular region . it
also gives information on the status of the retinal pigment
epithelium , clearly revealing rpe defects . in addition , the
limitations of the scanning laser polarimeter with respect
to inaccuracies related to corneal and lens birefringence are
not present . a recent study using a research prototype of a high - speed
ultra - high - resolution oct reported discontinuity or loss
of perifoveal photoreceptor inner segment / outer segment
junctions and thinning of the outer nuclear layer in 15 patients
receiving hydroxychloroquine.5 this instrument is however not
available as yet for general clinical use . in our patient [ figure 2 ] , the fovea ( central circle ) is of
normal thickness while the perifoveal ( inner circle ) and
peripheral ( outer circle ) , are thinned mainly temporally and
inferiorly . this is in agreement with the universally accepted
early superior paracentral scotoma , also seen in this patient
[ figure 1 ] . although reports in the older literature on chloroquine
toxicity had suggested that the cumulative dose of chloroquine
was the critical factor for toxicity , current evidence suggests
that cumulative dosage and duration of therapy are relatively
unimportant and that the crucial index is daily dosage
normalized by lean body weight.7,9 in this patient , the
dose of chloroquine she was on clearly exceeded the recommended
daily dose of 4 mg / kg / day.10 this is probably why she
developed maculopathy just 36 months after starting the
chloroquine therapy for her rheumatoid arthritis . long - term prospective studies may determine when retinal
thinning starts in patients on antimalarials , and whether
irreversible paracentral field defects could be prevented if
antimalarials are stopped on first detection of thinning . | we herein report the optical coherence tomography ( oct )
findings in a case of chloroquine - induced macular toxicity ,
which to our knowledge , has so far not been reported . a 53-
year - old lady on chloroquine for treatment of rheumatoid
arthritis developed decrease in vision 36 months after initiation
of the treatment .
clinical examination revealed evidence of
retinal pigment epithelial ( rpe ) disturbances .
humphrey
field analyzer ( hfa ) , fundus fluorescein angiography ( ffa )
and oct for retinal thickness and volume measurements at
the parafoveal region were done .
the hfa revealed bilateral
superior paracentral scotomas , ffa demonstrated rpe loss and
oct revealed anatomical evidence of loss of ganglion cell layers ,
causing marked thinning of the macula and parafoveal region .
parafoveal retinal thickness and volume measurements may be
early evidence of chloroquine toxicity , and oct measurements
as a part of chloroquine toxicity screening may be useful in early
detection of chloroquine maculopathy . |
from 1994 through 2005 , epidemiologic data on animal - related injuries and associated postexposure prophylaxis ( pep ) treatment were prospectively collected for marseille rabies treatment centre patients . only patients who had been injured in france were selected ; rabies pep for travelers who were injured abroad is detailed elsewhere ( 6 ) . of the 4,965 eligible patients , 4,367 were outpatients or inpatients ( 192488/year ) , and from 2001 through 2005 , a total of 598 were managed by teleconsultation only because their exposure risk was considered to be zero . the number of inpatients and outpatients decreased markedly from 1999 to 2001 ( figure 1 ) , which is consistent with the general decrease in the number of pep treatments in france after the elimination of terrestrial mammal rabies ( 7 ) . furthermore , prescreening of persons by telephone also contributed to this decrease . the increase observed during 20042005 is likely an effect of the international alert in relation to the cases of rabid dogs imported from morocco ; these cases were intensively reported by the french media . the proportion of animal - related injuries tended to increase in late spring / early summer ( figure 2 ) , probably as a result of increased outdoor activities in southern france , which makes contact with animals more likely . number of injured patients per year seeking care for rabies postexposure prophylaxis , marseille centre , marseille , france , 19942005 . average proportions of injured patients seeking care for rabies postexposure prophylaxis , by month , marseille centre , marseille , france , 19942005 . the overall annual incidence of injured patients seeking care for rabies pep was 16/100,000 , which is consistent with incidence recently reported in united states ( 8,9 ) ( where rabies is enzootic in bats and raccoons ) but far less than that reported in recently available studies from the canine rabies endemic countries of turkey ( 467/100,000 ) ( 10 ) and india ( 1,700/100,000 ) ( 11 ) . the overall mean annual incidence in our study was 20/100,000 before 2001 and 11/100,000 after 2001 . by contrast , a recent study on pet demographics in france indicated that dog and cat populations are nearly similar at 8.51 million and 9.94 million , respectively ( 12 ) . this finding suggests that dogs , more often than cats , are responsible for severe injuries that lead persons to seek care for rabies pep . the mean annual incidence of animal - related injuries was lower in rural than in urban communities ( technical appendix ) . because an estimation of the dog population in france indicated that 41% live in urban areas ( 12 ) , our results suggest that a high human population density increases the probability of human dog interactions and risk for injuries . among patients seeking care for rabies pep , most were male ( male : female ratio 1.49 ) and mean age was 31.5 ( median 29 , range 096 ) years . the likelihood for animal - related injuries among male patients was also dependant on the animal species involved ; dogs , bats , and monkeys accounted for most injuries ( technical appendix ) . in contrast , female patients were more likely to be injured by cats , a finding consistent with previous reports ( 13 ) . the mean time between injury and consultation was 2.6 days ( range 0365 days ) and did not statistically vary by sex or age group . time was longer in patients who were injured by bats ( p<10 , online technical appendix ) , probably because most bat bites are nonpainful and considered benign by patients who ignore the risk for rabies after bat contact . most injured persons experienced severe contact with animals ( 95.1% ) , categorized by the world health organization ( who ) as category iii ( 14 ) . rabies testing of animal is not available in southern france , and animals from this region should be sent to the rabies laboratory at the pasteur institute in paris , which was done for 89 cases , of which 20 cases were related to a confirmed rabid source from africa or the middle east ( table 1 ) . imported from morocco ( 187 treatments were given in france ; most in bordeaux centre ) . the proportion of patients who received treatment increased from 42% during 19942000 to 84.3% during 20012005 ( p<10 ) as a result of prescreening by telephone ( table 2 ) . since 2001 , when the animal was not available for surveillance by a veterinarian ( which includes numerous cases in which the animal was available for observation by its owner ) , complete treatment was given to most ( 89% ) patients . rabies immunoglobulin was provided to 3.2% of these patients , most of whom were injured by bats or severely injured by domestic animals when the owner was not identified or when surveillance of the responsible animal was not possible . * pep , postexposure prophylaxis ; rig , rabies immunoglobulin ( % as proportion of treatments including rabies pep ) . animal not available for observation by a veterinarian ( including cases where animal was available for observation by its owner ) . animal proven to be rabid by laboratory testing or considered rabid upon clinical criteria . animal proven to be not rabid by laboratory testing or after 2 weeks of observation by a veterinarian . our rabies pep data are consistent with data from the national french referral center ( 7 ) . the therapeutic approach in france is partly in accordance with who general recommendations that in rabies - free areas where adequate rabies surveillance is in effect , rabies pep may not be required , depending on the outcome of a risk assessment conducted by a medical expert ( 14 ) . systematic rabies pep is cost - effective and safe but should not be used if the biting animal is unlikely to be rabid . furthermore , treating a patient with only vaccine when the animal is under observation could reduce the benefit of further administration of rabies immunoglobulin if the time between vaccination and rabies immunoglobulin injection is > 7 days ( 15 ) . if the treatment can not be delayed , it should include both vaccination and rabies immunoglobulin in cases of category iii injury . from 2001 through 2005 , not vaccinating the patient when the animal was under observation by its owner or a veterinarian would have represented an overall savings of 177,600 euros . to minimize overprescription of vaccination for rabies pep when treatment may be unjustified , we recommend delaying the initiation of rabies treatment in injuries involving an apparently healthy indigenous dog or cat that can be kept under veterinary or animal - owner observation for 2 weeks , which is the maximum rabies incubation time in these animals . however , when animals are not available for observation , complete rabies pep treatment should be initiated . given the risk for importation of rabid animals from nearby rabies - endemic countries , immediate rabies pep treatment according to who guidelines should be given when the following are involved : indigenous bats ; animals illegally imported from rabies - endemic countries ; or animals found in railway stations , trains , or other ports of entry . if the animal is suspected of being rabid at the time of exposure , confirmatory testing should be conducted ( technical appendix ) . all travelers visiting countries where rabies is enzootic should be informed about the risks of bringing animals back to their home country and about the who recommendations regarding rabies vaccination of imported animals ( 14 ) . | the administration of human rabies postexposure prophylaxis near marseille ( southern france ) has changed since the eradication of terrestrial mammal rabies in 2001 .
most injuries were associated with indigenous dogs ; rabies vaccine was overprescribed .
we suggest that the world health organization guidelines be adapted for countries free of terrestrial mammal rabies . |
unique to this case , the foley catheter beats the odds and traversed the fistulous tract . we outline the presentation , identification and accepted management for surgical treatment of vesicouterine fistulas . a 28-year - old g1p1 was referred to our fistula hospital with a 5-month history of leaking urine per vagina . the leakage was intermittent , and immediately followed caesarean delivery of a stillbirth after labouring 3 days . additionally , she had 5 months of amenorrhoea but cyclic haematuria accompanied by cramping pains . the genital examination was unremarkable , with no leakage of dye following retrograde filling of the bladder . given her complaints , she was scheduled for an exploratory laparotomy for suspected vesicouterine fistula . a foley catheter passed immediately before surgery was noted to have no urine drainage , but the examination confirmed proper transurethral placement . on surgical exploration , the bladder was identified , but the foley bulb was curiously absent . dissecting the bladder completely free from the uterus revealed the problem . surrounded by dense scar tissue was the missing foley catheter , traversing the fistulous tract ( fig . 1 ) . vesicouterine fistula clearly demonstrated the catheter found passing through the bladder ( reflected to the right by babcock clamps ) to the uterus . vesicouterine fistula clearly demonstrated the catheter found passing through the bladder ( reflected to the right by babcock clamps ) to the uterus . urogenital fistula continues to be a major problem in developing countries , primarily due to obstructed labour . in recent decades , however , there has been an increase in fistula cases resulting from caesarean section . while most obstetric fistulas are vesicovaginal , this case highlights the vesicouterine type , one recognized to occur most often secondary to caesarean delivery [ 13 ] . youssef described a common presentation to vesicouterine fistula of amenorrhoea , cyclic haematuria ( which he termed menouria ) and urinary continence . since then , case and series reports have demonstrated a variable presentation to this problem . some report urinary incontinence , which is commonly intermittent , while others present with no urinary leakage . it is believed that the passage of menses through the fistula is due to differences in the pressure gradients between the uterus and bladder , which also explains the lack of urinary leaking except when the pressure of the bladder is raised sufficiently , such as with micturition or valsalva . surgical management is the mainstay of treatment for vesicouterine fistula , though some consider hormonal attempts using ocps . transperitoneal access to the fistula was employed in this picture , with dissection of the uterus from the bladder , closure of the uterine rent , then opening the bladder and repairing its fistula using a modified o'connor technique . the follow - up at 3 and 10 months confirmed the resolution of this patient 's symptoms . similarly , published success rates for surgical management of this type of fistula are high . the authors attest to having obtained written consent from the patient whose case is reviewed in this report . | a 28-year - old g1p1 presented complaining of urine leakage per vaginum following caesarean delivery , accompanied by amenorrhoea , cyclic haematuria and cyclic pelvic pain .
examination findings were suggestive of vesicouterine fistula and the patient was taken for exploratory laparotomy , during which the foley catheter could not be identified within the bladder . during separation of the bladder from the uterus ,
the catheter was found to be traversing the fistulous tract into the uterine cavity .
vesicouterine fistula is a fairly uncommon type of urogenital fistula that is frequently associated with caesarean section .
surgical treatment remains the mainstay and successfully cured this patient . |
it is a benign locally aggressive tumor usually involving the distal end of the femur , proximal tibia and distal radius in young adults . the main variables to be considered for planning treatment include the site of involvement and campanacci stage of the tumor . different treatment options are available which include intralesional curettage , extended curettage , wide resection and reconstruction . functional and oncological outcome of these treatment options varies widely , the predominant detrimental factor being tumor recurrence rate . reconstruction of endoprosthesis after wide excision of the tumor offers good short - term and mid - term functional and oncological outcomes as established by previous studies . this study was conducted to evaluate the long - term outcome of 11 patients with gct who underwent wide excision and customized endoprosthetic replacement . this study included 11 patients ( eight men and three women ) aged 2448 ( mean 32 ) years with primary gct of proximal femur campanacci stage - iii who were available for mean follow - up duration of 10.6 ( range 10.214 ) years . the definite diagnosis was established on histopathological confirmation with incisional biopsy . computed tomography scan of chest and bone scan none of the patients had pulmonary metastasis , and all the 11 patients had a solitary lesion in the proximal femur . these patients underwent wide resection of the tumor using postero - lateral approach to the proximal femur . the proximal femur was reconstructed using a customized , titanium , cemented endoprosthesis [ figure 1 ] . hip abductors , short external rotators and iliopsoas tendon were secured onto the prosthesis and hip capsule repair was performed . postoperative rehabilitation protocol included nonweight bearing and abduction splinting of the limb for 6 weeks followed by nonweight bearing crutch walking for another 6 weeks . once the hip abductors and quadriceps strength was regained weight bearing was allowed . long - term functional outcome was evaluated at minimum 10 years duration using revised musculoskeletal tumor society rating scale . ( a ) radiogragh showing giant cell tumor of proximal femur in a 34-year - old man . ( b ) magnetic resonance imaging showing giant cell tumor of proximal femur with soft tissue extension . there were no instances of prosthesis related complications like aseptic loosening or dislocation . at the end of mean 10.6 years six patients had good hip function without any restrictions , four patients had intermediate functional restriction whereas one had the recreational restriction of function . nine patients enthusiastically accepted the outcome of the procedure whereas two patients had satisfactory emotional acceptance . eight patients were walking without any support with unlimited walking abilities whereas three patients were using a cane for support while walking . the mean is revised musculoskeletal tumor society score was 26.8 out of 30 [ table 1 ] . traditional treatment of gct has been a difficult problem in orthopaedic oncology owing to high recurrence rates following conventional treatment with curettage or extended curettage . ideally treatment currently with improvement in reconstructive surgical techniques and availability of high quality biomechanically designed megaprosthesis , wide resection of tumor with proximal femur endoprosthesis replacement is being considered as a treatment option for campanacci stage - iii lesions in proximal femur with extensive osteolysis and soft tissue extension . it offers good local control of s with least recurrence rate and favorable functional outcome . the previous studies have shown satisfactory short- and mid - term functional and oncological outcomes . this study shows good long - term functional , and oncological outcomes of the procedure and hence the authors recommended as an endoprosthetic replacement for advanced gct of the proximal femur . furthermore , randomized control trials are required to established this modality as a standard treatment . | introduction : giant cell tumor ( gct ) of bone is locally aggressive benign tumor involving the epiphysis of long bones in young adults . various treatment options include intralesional curettage , extended curettage , wide resection , resection and reconstruction and amputation .
the main variables to be considered for planning treatment include the site of involvement and campanacci stage of the tumor .
functional and oncological outcomes of these treatment options vary widely , the predominant detrimental factor being tumor recurrence rate.aim:a study was conducted to evaluate the long - term oncological and functional outcome of patients with gct of the proximal femur that underwent tumor resection and endoprosthetic replacement.materials and methods : eleven patients with campanacci stage - iii gct of proximal femur who underwent wide excision of tumor and endoprosthesis replacement with a mean follow - up the duration of 10.6 years were assessed using standard proforma .
the treatment outcome was evaluated using the revised musculoskeletal tumor society rating scale for the lower extremity.results:at mean follow - up the duration of 10.6 years , none of the cases had tumor recurrence , infection , prosthesis loosening or dislocation .
all the patients were community ambulators among whom eight patients were walking without support while three patients were using a cane for support .
the mean total musculoskeletal tumor society score was 26.8 out of 30 indicating the good outcome.conclusions:the authors recommend that wide resection and endoprosthetic replacement should be considered as a preferred treatment option for proximal femur gct as the functional , and oncological outcome is satisfactory with this modality of treatment . |
coronary arterial fistulas are rare cardiac anomalies that create new pathways of blood flow between coronary vessels and thoracic vasculature or chambers of the heart . although generally asymptomatic , patients can develop complications of thrombosis , congestive heart failure , rupture , endocarditis , and arrhythmias . here , we describe a patient with acute decompensated heart failure and transient left bundle branch block ( lbbb ) , found to have an underlying left anterior descending ( lad- ) to - pulmonary artery ( pa ) fistula . this case illustrates the potential of coronary fistulas to induce a clinical presentation of cardiac ischemia via a coronary steal mechanism . a 64-year - old man with a history of congestive heart failure and stage iv chronic kidney disease secondary to uncontrolled hypertension and diabetes mellitus presented with three days of orthopnea and one night of intermittent left shoulder pain radiating to the back . physical examination revealed a heart rate of 99 beats per minute and blood pressure of 149/71 mm hg with an oxygen saturation of 94% on 4 liters of oxygen . laboratory analyses were significant for a hematocrit of 24% and creatinine of 3.8 mg / dl . twelve - lead electrocardiography ( ecg ) revealed sinus rhythm at 94 beats per minute and a new lbbb . an acute myocardial infarction was suspected and the patient was taken for emergent cardiac catheterization , which showed stenosis of up to 40% of the mid - lad coronary artery and mild disease in other vessels . in addition , a fistula was identified connecting the lad to the distal main pa ( figures 1(a ) and 1(b ) ) . transthoracic echocardiography demonstrated moderate global systolic dysfunction with a left ventricular ejection fraction of 40% as well as a moderate - sized pericardial effusion without echocardiographic evidence of increased intrapericardial pressure . a regadenoson nuclear perfusion stress imaging study performed after 4 days of diuresis and a blood transfusion was negative for inducible ischemia . furthermore , an ecg on the day of the stress imaging study showed resolution of the lbbb , and one week later the patient 's ecg showed recovery to near normal left ventricular ejection fraction and decrease in size of the pericardial effusion . we hypothesized that the small lad - pa fistula was not the sole cause of heart failure symptoms but was a contributor to the patient 's clinical presentation and ecg findings . the small fistula in this case steals from the lad - supplied myocardium , including the left bundle . by itself , the fistula was not sufficient to manifest clinically . however , in the setting of increased oxygen demand and decreased oxygen supply during the heart failure exacerbation , this coronary steal likely decreased the total oxygen supply in the lad territory enough to cause additional transient ischemia and lbbb . since he was previously asymptomatic without objective evidence of ischemia in the absence of myocardial oxygen supply and demand mismatch , we elected to continue close observation rather than closure of the fistula . coronary arterial fistulas are rare communications between coronary vasculature and thoracic vessels or cardiac chambers . the most frequent sites of drainage include the ventricles , pulmonary arteries , the coronary sinus , the superior vena cava , or the pulmonary veins . of the different types of fistulas , 42% originate from the left coronary tree and 17% drain into the pulmonary artery . fistulas are generally congenital in origin , but they can also arise from cardiac trauma , chest irradiation , cardiac surgery , coronary angioplasty , and endomyocardial biopsy . while fistulas are usually asymptomatic , their natural history can be variable . adult patients who develop symptoms often do so in the 5th or 6th decade [ 1 , 2 ] . common clinical presentations include dyspnea , congestive heart failure , angina , aneurysm , or myocardial infarction . whether or not a patient will develop symptoms is determined by the degree of fistula - induced volume overload , as well as the severity of left - to - right shunting secondary to fistula size and location . transesophageal echocardiogram may be useful in delineating the origin , course , and drainage of a fistula . therefore , in the presence of large shunts or even in asymptomatic patients , surgical or transcatheter ligation may be considered to prevent long - term sequelae such as steal , spontaneous rupture , heart failure , or myocardial ischemia [ 6 , 7 ] . transcatheter closure is first - line therapy in suitable anatomic cases due to lower cost , shorter recovery time , and reduced hospital stay . although coronary steal may have contributed to ischemia of the left bundle as evidenced by subsequent ecg findings , we can not exclude a rate - related bundle branch block . however , this is less likely since an ecg tracing 5 months earlier , at the same heart rate , revealed a normal qrs duration as did subsequent ecg tracings at similar heart rates . a right heart catheterization was not performed to assess filling pressures or to calculate a shunt fraction . even without direct measures of these pressures , it was still evident that the patient was in congestive heart failure by history and physical exam findings . he improved significantly with diuresis , suggesting elevated filling pressures also contributed to the supply - demand mismatch . the left ventricular systolic function may have also appeared decreased at presentation because of the septal motion abnormality from the lbbb . our patient , who presented with orthopnea , shoulder pain , and a new lbbb , illustrates that even a small coronary fistula may steal enough blood flow to mimic the symptoms of an acute myocardial infarction in the setting of a transient oxygen supply - demand mismatch . a coronary fistula , therefore , may not be the sole culprit lesion or an innocent bystander , but an accomplice in causing signs and symptoms of acute heart failure . the authors have no disclosures or financial conflicts of interest relevant to this paper to report . | coronary arterial fistulas are rare communications between vessels or chambers of the heart .
although cardiac symptoms associated with fistulas are well described , fistulas are seldom considered in the differential diagnosis of acute myocardial ischemia .
we describe the case of a 64-year - old man who presented with left shoulder pain , signs of heart failure , and a new left bundle branch block ( lbbb ) .
cardiac catheterization revealed a small left anterior descending ( lad)-to - pulmonary artery ( pa ) fistula .
diuresis led to subjective improvement of the patient 's symptoms and within several days the lbbb resolved .
we hypothesize that the coronary fistula in this patient contributed to transient ischemia of the lad territory through a coronary steal mechanism .
we elected to observe rather than repair the fistula , as his symptoms and ecg changes resolved with treatment of his heart failure . |
the most common primary cardiac tumor is myxoma a benign neoplasm usually located in the left atrium . the most common malignant cardiac tumor is angiosarcoma , which can usually be found in the right atrium . due to scarce symptoms the factors which impede complete tumor removal include tumor location and growth causing infiltration of the right ventricle , the tricuspid valve , and the right coronary artery . the 40-year - old female patient was referred to the clinic with the diagnosis of a right atrial tumor . one month before , during a routine gynecological examination , the patient was diagnosed with a uterine tumor . after preliminary diagnostics , the patient underwent hysterectomy with adnexectomy . based on the histopathological examination of the removed material , angiosarcoma was diagnosed . control abdominal ultrasonography revealed a tumor focus in the liver , while echocardiography revealed a tumor in the right atrium . two days after the procedure , the patient was admitted to the clinic of cardiac surgery to undergo heart surgery . echocardiography performed at admission revealed a tumor in the right atrioventricular furrow 43 20 18 mm in size , infiltration of the right atrium and right ventricle with possible involvement of the right coronary artery , and fluid in the pericardial sac . further preoperative diagnostics included magnetic resonance of the heart , which revealed a right atrial tumor involving the atrial wall , infiltrating around the right coronary artery , and herniating into the lumen of the right atrium , as well as fluid in the pericardium ( fig . 1 ) . magnetic resonance of the heart the procedure was performed via median sternotomy , in normothermia , with the use of extracorporeal circulation . after the pericardial sac was incised , the pressure pushed out 300 ml of bloody fluid . the opening of the pericardial sac visualized a large tumor growing out of the right atrial wall ( fig . a substantial portion of the tumor was removed from the right atrium . a fragment of the lesion , approx . 10 20 mm in size , was left in the vicinity of the right coronary artery due to the infiltration of the coronary artery and the right atrium . the defect of the atrial wall was reconstructed with a fragment of the pericardial sac 5 5 cm in size . a pericardial patch was sutured onto the resected tumor fragment to prevent bleeding . despite the use of 4.0 sutures and teflon patches , the prevention of bleeding was not successful due to the delicate structure of the neoplastic tissue . in order to stop further bleeding , a 4.8 4.8 cm dressing covered with human blood coagulation factors ( tachosil , manufactured by the swiss company nycomed ) hemostasis monitoring revealed that another fragment of the tumor remained unsecured , and another tachosil dressing ( 3 2.5 cm in size ) was placed over this fragment . control cardiac echo performed before discharge revealed a small amount of fluid in the pericardial sac with no signs of compression , considerable saturation of the right atrial wall , and contractility disorders of the right ventricle . histopathological examination revealed the same histological type of the removed tumor fragment as in the uterus angiosarcoma . the late detection of the neoplastic lesions precluded a complete resection of the tumor from the myocardium . if the resected tumor mass had not been secured correctly , the patient would have faced the risk of a dangerous hemorrhage and cardiac tamponade . the delicate structure of the tumor precluded the provision of efficient hemostasis with traditional surgical methods . when they come in contact with the patient 's blood , these substances form a fibrin network which makes the sponge adhere to the bleeding surface . the dressing has found a wide spectrum of applications in many fields of general surgery ( inhibiting bleeding from parenchymal organs ) , thoracic surgery ( preventing not only bleeding , but also pleural adhesions and air leaks ) , and cardiac surgery [ 6 , 7 ] . based on our observations , tachosil may be used to control the hemostasis of delicate vascular structures that can not be removed completely . | primary malignant cardiac tumors are rare and are usually detected at an advanced stage of disease .
their location and infiltration often hinder surgical resection .
tissue sarcomas , especially angiosarcomas , are composed of irregular and delicate vascular tissue .
the resection of such tumors from the heart is associated with a high risk of life - threatening bleeding that can not be stopped with traditional surgical methods .
we present a case report of the application of a dressing containing human fibrin and thrombin in order to prevent bleeding during the partial resection of advanced cardiac angiosarcoma in a 40-year - old patient . |
mycotoxins are secondary metabolites of molds which are associated with certain disorders in animals and humans . in addition to being acutely toxic , some mycotoxins are now linked with the incidence of certain types of cancer , and it is this aspect which has evoked global concern over feed and food safety , especially for milk and milk products . aflatoxin m1 ( afm1 ) is a hepatocarcinogen found in milk of animals that have consumed feeds contaminated with aflatoxin b1 ( afb1 ) , the main metabolite produced by fungi of the genus aspergillus , particularly a. flavus , a. parasiticus , and a. nomius . about 0.36.2% of afb1 in animal feed serious health concerns , many countries have set maximum limits for aflatoxins , which vary from country to country . the european community prescribes that the maximum level of afm1 in liquid milk should not exceed 50 ppt . however , according to the us standard , the level of afm1 in liquid milk should not be higher than 500 ppt . there have been several studies on afm1 concentration in milk samples in different regions of the world and also in iran , but this study was done to evaluate the occurrence of afm1 in milk distributed in mashad in northeast of iran in order to evaluate the potential of changing the regional standard on afm1 contamination of milk . in this study the afm1 content of pasteurized milk samples in retail stores in mashad ( northeast of iran ) was determined in fall 2011 . forty - two pasteurized milk samples ( 1000 ml milk packets , heat treated at 7274.4 for 1520 ) from different brands were collected by simple random sampling method . the samples were transported to the laboratory in an insulated container at about 4c and analyzed upon arrival . most of the reagents used to detect afm1 were contained in the ridascreen test kit , which included microtiter plate coated with capture antibodies , afm1 standard solutions used for the construction of the calibration curve ( 1.3 ml each 0 , 5 , 10 , 20 , 40 , and 80 ppt ) , peroxidase - conjugated afm1 , substrate ( urea peroxidase ) , chromogen ( tetramethylbenzidine ) , and stop reagent contains 1n sulphuric acid . the quantitative analysis of afm1 in pasteurized milk samples was performed by competitive elisa ( ridascreen afm1 , r - biopharm ) procedure as described by r - biopharm gmbh . prior to analysis of the samples , the elisa method was validated to ensure data quality . validation of elisa was carried out by determination of recoveries and the mean variation coefficient for fresh milk spiked with different concentrations of afm1 ( 5 , 10 , 20 , 40 and 80 ppt ) . the upper creamy layer was completely removed by aspirating through a pasteur pipette and from the lower phase ( defatted phase ) 100 l was directly used per well in the test . one hundred l of the afm1 standard solutions ( 100 l / well ) and test samples ( 100 l / well ) in duplicate were added to the wells of microtiter plate and incubated for 60 min at room temperature in the dark . after the washing steps , 100 l of the enzyme conjugate was added and incubated for 60 min at room temperature in the dark . fifty l of substrate and 50 l of chromogen were added to each well and mixed thoroughly and incubated for 30 min in the dark . following the addition of 100 l of the stop reagent to each well , the absorbance was measured at 450 nm in elisa reader ( elx-800 , bio - tek instruments , usa ) . according to the ridascreen kit guidelines , the absorbance values obtained for the standards and the samples were divided by the absorbance value of the first standard ( zero standards ) and multiplied by 100 ( percentage maximum absorbance ) . therefore , the zero standard is thus made equal to 100% , and the absorbance values are quoted in percentages . the values calculated for the standards were entered in a system of coordinates on semilogarithmic graph paper against the afm1 concentration in ppt ( figure 1 ) . the equation of the trendline in figure 1 is as follows :
( 1)y=0.016x21.940x+91.34 . data were analysed using excel 2007 and results reported as mean sd . the calibration curve and trendline equation prepared using excel 2007 . the standard solutions of concentration from 5 to 80 ppt afm1 were used to find calibration / standard curve . figure 1 gives the calibration curve of standard solutions of afm1 with concentrations of 5 , 10 , 20 , 40 , and 80 ppt by elisa analysis . analytical results showed that the incidence of afm1 contamination in pasteurized milk samples was low . although 97.6% of the samples were contaminated with afm1 , the toxin concentration was lower than iranian national standard and fda limit ( 500 ppt ) and only in three ( 1.6% ) of the samples afm1 concentration was greater than the maximum tolerance limit ( 50 ppt ) accepted by european union and codex alimentarius commission . the minimum and maximum contamination level of afm1 was found to be 6.4 and 71.4 ppt , respectively . the mean sd afm1 level in the analyzed samples of pasteurized milk was 23 16 ppt . the mean afm1 concentrations in milk in european , latin american , and far eastern diets have been reported by the joint fao / who expert committee on food additives to be 23 , 22 , and 360 ng / l , respectively . thus , the observed mean afm1 concentration in mashad milk samples was as high as the european and latin american and much lower than those reported for the far eastern diets . on the other hand , several studies have been done to determine afm1 contamination of milk in iran ( table 3 ) . the incidence of afm1 observed in the present study was lower than the incidence of afm1 reported by other authors [ 817 ] , yet , in all studies , the averages of toxin concentrations are below 100 ppt . the variations may be attributed to differences in region , season , and especially analysis method . based on the above results , especially later studies in mashad , the present situation is hopeful and might represent the possibility of altering standard limit of afm1 concentration in milk in iran . we suggest reduction of the limit as low as 100 ppt for raw milk . | the aim of this study was to detect the amount of aflatoxin m1 ( afm1 ) in pasteurized milk samples in mashad in northeast of iran . for this purpose , 42 milk samples were collected from retail stores during fall 2011 and analyzed for afm1 by enzyme - linked immunosorbent assay ( elisa ) technique .
all the analyses were done twice .
results showed presence of afm1 in 97.6% of the examined milk samples by average concentration of 23 16 ppt and contamination level ranging between 6 and 71 ppt .
the concentration of afm1 in all the samples was lower than the iranian national standard and food and drug administration limits ( 500 ppt ) , and , only in 3 ( 1.6% ) samples , afm1 concentration was more than the maximum tolerance limit ( 50 ppt ) accepted by european union and codex alimentarius commission . according to our findings and previous studies , afm1 contamination of milk is not a concern in this region , and the regional standard of afm1 contamination in milk might be changed to lower than 100 ppt . |
mycosis fungoides ( mf ) is a cutaneous t cell lymphoma ( ctcl ) characterized by infiltration of skin with patches , plaques and nodules composed of t - lymphocytes . it has various stages , premycotic , patch , plaques , nodules , tumours and erythroderma . tumour demblee is a variant of tumour stage , which develops from normal skin without prior patch or plaque stage . a 55-year - old hindu male , tobacco farmer by occupation , presented with multiple infiltrated plaques and nodules of 3 months duration over the face and scalp . the nodules started from ears and spread all over the face and scalp , increasing in size and number . patient had a history of severe itching episodes for past three years which were not relieved by antihistaminics . there was history of episodes of fever , weight loss , anorexia , and nausea for the past 2 months . multiple infiltrated plaques and nodules with few erosions and foul smelling superficial ulcers were present over face and scalp . the infiltrated skin over forehead , nose and ear lobules and loss of eyebrows gave a leonine face appearance [ figures 1 and 2 ] . the nodes were discrete , non - tender , mobile , and firm in consistency . loss of hair was seen on scalp , eyebrow , and axillary region . nodules plaques and erosions over face investigations revealed a hemoglobin level of 8.6% gm and the erythrocyte sedimentation rate ( esr ) of 110 mm / hour . chest x - ray , lymph node aspiration cytology and bone marrow examination did not reveal anything abnormal . ultrasonography of abdomen and pelvis and computed tomography ( ct ) scan of head and neck , chest , abdomen , and pelvis were normal . histopathological examination of the excision biopsy from a nodule over face showed a lymphocytic infiltrate in the papillary dermis and around the hair follicle and pilosebaceous unit . epidermotropism was noted with formation of well defined pautrier 's microabscess at places [ figure 4 ] . biopsy showing epidermotropism ( h and e , 40 ) biopsy showing clusters of atypical lymphocytes within the epidermis ( pautrier microabscesses ) ( h and e , 400 ) immunohistochemistry showed positive cd3 and lca markers as and cd 30 and cd 20 negativity . he termed it mycosis fungoides because of the resemblance of the lesions to mushrooms . in 1885 , vidal and brocq described mycosis fungoides d emblee for a patient presenting with skin tumours not preceeded by patch or plaques . in this type of mf mf is the most common type of ctcl and accounts for almost 50% of all primary cutaneous lymphomas . however other lymphoproliferative disease also involve the skin including ki-1 + anaplastic large cell lymphoma , peripheral t - cell lymphoma , cutaneous b - cell lymphoma , adult t - cell leukaemia/ lymphoma , t - cell lymphoid leukaemia and cutaneous hodgkin 's disease . incidence of mf has been estimated to range from 0.06 to 0.1 per 10,000 cancer cases per year in the usa . the term tumour d emblee is now falling into disrepute and these tumors may , in fact , be pleomorphic cd 30 negative cutaneous t - cell lymphoma ( peripheral t - cell lymphoma ) , which have undergone large cell transformation . many of these cases are likely to be classified by immunophenotyping as various types of non - mf t - cell lymphoma or even b - cell lymphoma of the skin . such type of mf d emblee has been reported rarely in past.[1214 ] many cases described as the demblee variant in the past may have represented other types of lymphomas . the cd 30 negative large ctcl and small/ medium sized pleomorphic ctcl have been described in literature to be presenting with tumors without prior or concurrent patches or plaques along with histological presentation sometimes similar to that of mf . the cd 30 negative large ctcl ( 5 year survival of 15% ) has a poor prognosis compared with small/ medium sized pleomorphic ctcl ( 5 year survival of 60% ) . usually the mean interval between appearance of skin lesions and definite diagnosis by histopathology is approximately 6 years , however , in our case it was only 3 - 4 months . the patient was treated with chop regimen [ cyclophosphamide , hydroxydaunorubicin ( doxorubicin ) , oncoverin ( vincristine ) , prednisone ] plus methotrexate . taking into account that this case of tumour d emblee also showed typical histopathological changes along with cd30 negativity and the eventual death of the patient within short span of time after the diagnosis , it is possible that the patient had cd 30 negative large ctcl , which could not be confirmed owing to limited resources in our hospital set up . this case is reported because of an acute and masquerading presentation of mycosis fungoides reiterating the fact that ctcl can pose an enormous diagnostic challenge . | mycosis fungoides is a cutaneous t - cell lymphoma characterized by infiltration of skin with patches , plaques , and nodules composed of t - lymphocytes .
it is the most common type of cutaneous t - cell lymphoma and accounts for almost 50% of all primary cutaneous lymphoma .
tumour d emblee is the term used for the patient presenting with skin tumors not preceded by patches or plaques .
we report a rare case of mycosis fungoides d emblee variant with tumors of only 3 months duration without any preceding skin lesions . |
pulmonary calcification , typically asymptomatic , can be caused by a number of diseases , most common being end - stage renal disease . we describe a case of pulmonary calcifications associated with chronic kidney failure , which has been improved by medical treatment . a 21-year - old man with a 4-year history of end - stage renal disease , on hemodialysis ( three 4-h sessions / week ) , secondary to untreated bilateral vesico - ureteral reflux and neurogenic reactive bladder . the patient was referred for a bone scan because of osteoarticular complaints , especially at the elbows with limited mobility , and he reported mild and nonspecific symptoms , especially no significant dyspnea . patient had high creatinine ( 428 mol / l ) ; serum phosphorus ( 4.51 mmol / l ) ; total alkaline phosphatase , 108 u / l and serum parathyroid hormone level was 1700 pg / ml . whole body bone scintigraphy images [ figure 1 ] , showed a diffuse uptake in both lungs , more intense in the right one , suggesting an extra - osseous pulmonary calcification and an increased radiotracer uptake in the soft tissues of the left arm and in the periarticular soft tissues surrounding the elbows . whole body bone scintigraphy with anterior and posterior projection performed 2 h after the injection of 18 mci ( 666 mbq ) of tc - methylene diphosphonate which showed a diffuse uptake in both lungs and an increased radiotracer uptake in the soft tissues of the left arm and in the periarticular soft tissues surrounding the elbows ( the hand positions are due to the limited mobility of the elbows ) chest radiograph performed in the light of the data of bone scan parathyroidectomy was declined by the patient . the medical therapeutic was chosen with dietary phosphorus restriction , noncalcium phosphate binders , calcimimetics , optimal control of secondary hyperparathyroidism , and intensive hemodialysis with a low - calcium dialysate . second bone scan was done 3 months later [ figure 3 ] revealed a significant decrease , without disappearance , in the lung 's uptake . second whole body bone scintigraphy with anterior and posterior projection performed 2 h after the injection of 18 mci ( 666 mbq ) of tc - methylene diphosphonate revealed a significant a decrease in the lungs uptake ( the hand positions are due to the limited mobility of the elbows ) uremic tumoral calcinosis predominates in periarticular soft tissues with preservation of the bone and joint structures . the clinical symptoms of mpc are usually mild that 's why this pathology is rarely diagnosed and patients with extensive calcification may be asymptomatic . chest x - ray findings in mpc are nonspecific and they are frequently normal . the diagnosis is confirmed by biopsy , but can be suspected by typical findings on a tc-99m - methylene diphosphonate bone scan , which is a sensitive and specific method for diagnosing . that why , some authors have recommended the use of bone scan in hemodialysis patients with pulmonary symptoms . finally , low glomerular filtration rate can cause hyperphosphatemia and an elevated calcium - phosphorus product . for patients with hyperparathyroidism , our patient declined parathyroidectomy and was treated medically with a significant regression of scintigraphic abnormalities . | pulmonary calcification is a subdiagnosed metabolic lung disease that is commonly asymptomatic and frequently associated with end - stage renal disease .
we report a case of a 21-year - old man with a 4-year history of end - stage renal disease without respiratory symptoms .
we discover incidentally on a bone scan a pulmonary calcification .
parathyroidectomy was refused by the patient .
after 3 months of medical treatment , a second bone scan was done , and we found a partial response . |
healthy oral mucous membrane is normally of varying shades of red . when either the patient or the clinician notices areas of pigmentation , there is often an element of increased concern . focal lesions usually need an in - depth examination to exclude a melanoma , while diffuse lesions often have no specific histological features and do not generate prognostic perplexity . however , diagnosis of these lesions is important because they could be a sign of diseases with systemic implications such as peutz - jeghers syndrome or adrenal insufficiency . melanin is produced by melanocytes in the basal layer of the epithelium and is transferred to adjacent keratinocytes via membrane - bound organelles called melanosomes . the term melanoacanthoma was first used by mishima and pinkus in 1960 to describe a benign mixed skin tumor composed of basal and prickle cell keratinocytes and pigment - laden dendritic melanocytes . oral melanoacanthoma ( oma ) is a rare , benign pigmented lesion , brown to brown - black , well circumscribed , characterized by hyperplasia of spinous keratinocytes and dendritic melanocytes . we present a rare case of diffuse oral pigmentation which led us to diagnose it as oma . a 22 year old female patient came to our institution vaidik dental college and research centre , daman with a complaint of black pigmentations in the mouth since 2 months . patient reported that she was apparently alright 2 months back when she noticed black pigmentations in the mouth . the patient was concerned whether it was normal or some disease and so the patient reported to our institute . intraoral examination revealed brown black macular pigmentations widespread along the posterior part of left and right buccal mucosa [ figure 1 ] . it also showed involvement of retromolar areas , hard palate , soft palate and fauces . there was marked acanthosis with diffuse distribution of dendritic melanocytes in suprabasal layers of epithelium [ figure 2 ] . immunohistochemistry revealed diffuse nuclear and cytoplasmic immunoreactivity with for s-100 protein [ figure 3 ] . diffuse pigmentation involving hard palate , soft palate , bucal mucosa and retromolar areas marked acanthosis ( hematoxylin and eosin . the differential diagnosis of diffuse oral pigmentation include peutz - jeghers syndrome , addison 's disease , pigmentation due to smoking and medications , laugier - hunziker syndrome and oma . peutz - jeghers syndrome is an inherited , autosomal dominant disorder with variable inheritance , characterized by hamartomatous polyps in the gastrointestinal tract , mostly in the small bowel , and pigmented mucocutaneous lesions . in the present case , the patient had no previous or family history of any kinds of pigmented lesions or gastric intestinal polyposis . diffuse pigmentation of the oral mucosa and/or skin secondary to systemic drug administration is a well - recognized phenomenon . the patient did not give any history of medications including oral contraceptive and anti - malarial drugs . laugier - hunziker syndrome is an idiopathic macular hyperpigmentation of skin characterized by brownish black spots on oral mucosa including lips associated with longitudinal melanonychia of nails . although the pigmentation was diffuse and macular , the nails did not show any abnormalities . oma is a benign pigmented disorder of the oral mucosa , characterized by simultaneous proliferation of both melanocytes and keratinocytes . to emphasize the non - neoplastic nature of the disease , tomich and zunt suggested the term melanoacanthosis while reserving the designation melanoacanthoma for cutaneous tumors . the intra - oral site most commonly affected in oma is the buccal mucosa but involvement of other sites such as the mucosa of the lip , palate , gingiva and alveolar mucosa has also been reported . the clinical presentation is a brown to brown - black macular lesion , predominantly solitary , encountered in the younger age group with a distinct female predilection . oma is considered to be a reactive phenomenon and it has been suggested that masticatory and frictional trauma may play an etiological role . microscopically oma is characterized by the presence of numerous benign appearing dendritic melanocytes scattered throughout an acanthotic and mature squamous cell epithelium . in addition inflammatory cells with eosinophils may be present in the subjacent connective tissue stroma . an immunohistochemical analysis with melanocytic marker ( s-100 protein ) is an additional way to confirm . it is a benign condition and once the diagnosis is confirmed no treatment may be required . oma is a rare benign condition which must be distinguished from other diffuse pigmentations like peutz - jeghers syndrome , addison 's disease , pigmentation due to medication and laugier - hunziker syndrome . there is usually no treatment required in such cases and there have not been any cases of malignant transformation reported till date . | the clinical presentation of diffuse pigmentation can be alarming to the patient as well as the clinician .
a histopathologic examination of a pigmented lesion is necessary in most of the cases in the oral cavity .
oral melanoacanthoma is a very rare diffuse pigmentation with no specific treatment required .
it shows increased number of dendritic melanocytes in an acanthotic epithelium .
we present a rare case of diffuse pigmentation in the oral cavity whose diagnosis was done on the basis of clinical presentation and histopathology .
also immunohistochemistry was done . |
their occurrence was first described in 1670 by thilesus . however , at that time fistulas were a common complication of chronic and untreated cholecystitis . according to a 2005 study , 226 cases have been reported in total , with fewer than 25 in the last 50 years . the reduced incidence in current times can be attributed to more rapid diagnosis and treatment with antibiotics or surgery . although occurring in acalculous cholecystitis and carcinoma of the gallbladder , fistulas are still most commonly associated with gallstones [ 3 , 4 ] . obstruction of the cystic duct leads to an increase in gallbladder pressure and reduced perfusion with necrosis , which consequently causes gallbladder perforation . the contents of the gallbladder may then empty into the peritoneal cavity and an abscess may form or a fistula may develop through adherence to the duodenum , colon or abdominal wall , often via the fundus of the gallbladder . the right upper quadrant is the most common location for the exit tract of the fistula , but locations such as the gluteal region , umbilicus and right groin have also been documented . cholecystocutaneous fistulas are most often seen in elderly women over the age of 60 , likely due to coexistent disease and non - specific symptoms interfering with diagnosis . a white 85-year - old female with hypertension and a previous history of breast biopsy underwent endoscopic retrograde cholangiopancreatography with sphincterotomy after initially presenting on may 3 , 2011 with common duct stones . the patient was initially seen in the emergency department complaining of a 3-day history of sharp intermittent epigastric and right upper quadrant pain radiating to the central back . mild scleral icterus was noted , but there were no signs of jaundice or lymphadenopathy . her abdomen was soft , non - distended and mildly tender to palpation with a positive murphy 's sign . routine blood work demonstrated an elevated white blood cell count of 16.1 , no abnormalities on sma7 , elevated lipase > 3,000 , and elevated liver function testing including an alkaline phosphatase of 215 , a bilirubin of 41 , an ast of 100 , a ggt of 305 and an alt of 194 . clinical evidence of mild jaundice accompanied by blood work abnormalities and positive radiological signs led to the diagnosis of acute calculous cholecystitis , common bile duct stones up to 7 mm in size and biliary gallstone pancreatitis . she was treated conservatively with intravenous antibiotics and underwent endoscopic retrograde cholangiopancreatography with sphincterotomy for removal of several stones of various sizes . percutaneous cholecystostomy was then carried out for drainage of the gallbladder after development and medical control of atrial fibrillation . on june 1 , 2011 she was re - admitted to the hospital with a left lower lobe pulmonary embolism . on june 27 , 2011 the percutaneous drain was removed at her request . in early august 2011 , she re - developed right upper quadrant discomfort ; furthermore , she noted some purulent drainage from the percutaneous drain site and extrusion of approximately 30 gallstones . she had several follow - up ultrasounds which identified a fistulous tract measuring 0.78 cm in diameter communicating with the external opening in the right upper quadrant ( fig . an irregular hypoechoic area just inside the subcutaneous tissue measuring 4.1 2.7 cm was presumed to represent a contracted gallbladder . plans were made for laparoscopic cholecystectomy and management of her cholecystocutaneous fistula on february 22 , 2012 , once she finished her coumadin regiment . in the morning of the operation , on february 22 , 2012 , the patient 's inr was still elevated at 1.8 and the surgery was re - scheduled for a month later . on april 18 , 2012 the patient underwent laparoscopic cholecystectomy and fistula division ( fig . 2 ) . three additional gallstones were found in the gallbladder at the time of the operation . we present the case of an 85-year - old white female who was diagnosed with a cholecystocutaneous fistula that developed as a complication following removal of a percutaneous drain that was used to treat her acute cholecystitis . re - occurrence of her cholecystitis after drain removal and the presence of gallstones promoted the production of a fistula along the pre - existing tract of the drain . her concurrent treatment with anticoagulants for a pulmonary embolism delayed the definitive management of her cholecystitis and fistula . fortunately , the patient remained in reasonably good health throughout the waiting period from time of fistula diagnosis to surgery . more conservative approaches such as percutaneous cholecystotomy have been used in high - risk patients , leading to spontaneous closure of the fistula . however , in this case the fistula developed through the old drain tract , so surgical intervention was employed . as with uncomplicated cholecystitis , laparoscopic techniques are favorable compared to open surgery and thus a laparoscopic cholecystectomy was undertaken in this case . the gallstones removed during cholecystectomy were of orange - brown color consistent with cholesterol stones . although fistula formation is now a rare complication of cholecystitis , it remains a possibility and should be considered in the differential diagnosis of any fistulous tract in the right abdominal wall . we have demonstrated that previous percutaneous drainage of an acute gallbladder infection can promote the formation of such a fistula if the infection is not properly dealt with or re - occurs . physicians should be prepared to recognize this complication in patients after drain removal and prior to definitive surgery . | cases of cholecystocutaneous fistulas are now a rare occurrence as a result of rapid diagnosis and treatment .
we present a case of cholecystocutaneous fistula developing after the removal of a percutaneous drain for the treatment of acute cholecystitis .
re - occurring infection and presence of gallstones led to fistulization of the gallbladder fundus and the development of a tract along the path created by the drain . the patient presented with re - occurring right upper quadrant abdominal pain , purulent discharge from the fistulous opening and expulsion of multiple gallstones .
she underwent laparoscopic cholecystectomy and fistula excision . |
a 56-year - old man was hospitalized because of pain and numbness in his left hand since he slipped a week earlier . , we found that the motor and sensory functions of his left hand were normal . his laboratory data , including anti nuclear antibody , anti - neutrophil cytoplasmic antibody , and rheumatoid arthritis factor , were within normal limits . however , the laboratory analysis showed decreased protein c and s concentrations ( protein c antigen , 57% ; protein s antigen , 19% ) . the diagnostic work - up to determine the degree of lesion included a computed tomography ( ct ) angiography , which showed an intraluminal lesion of the left upper extremities vessel . in the ct scan , coincidently , we stumbled across a mass lesion on the aortic arch . for the evaluation of the incidental mass lesion , we performed a chest ct scan and transthoracic echocardiography . the ascending aorta and the aortic arch had intact intima and a normal size ( fig . 2 ) . in transthoracic echocardiography , we found a floating mass in the lesser curvature of the aortic arch ( fig . 3 ) . we decided to surgically remove this floating mass because of the risk of peripheral embolization , including thrombectomy for the brachial and radial artery occlusion of the left arm . a median sternotomy was performed , a venous cannula was inserted in the ra auricle , extracorporeal circulation was begun , and the central temperature was decreased to 25. the patient was then in total circulatory arrest . an incision was made in the aortic arch , and the 3.0-cm intraaortic mass was completely removed ( fig . the mass had no definite stalk , and its attachment site in the aorta was relatively normal . we also removed the thrombus of the left upper extremities through the brachial artery . in the postoperative peripheral angiography , one week later , the patient recovered without complications and was discharged on the regimen of warfarin . aortic thrombi , however , are another important cause of arterial thromboembolism . factors related to an arterial thrombus are arteriosclerosis , arterial dissection , trauma , malignant tumor , and hemostatic disorder . in this case , the patient had protein c and s deficiency , which induced a hypercoagulable disorder . the presence of pedunculated thrombi in the aortic arch as in this case is rare . the incidence of embolic events from mobile aortic thrombi is 73% . in this case , the patient had a thrombus in his left arm . they occur more commonly in patients of advanced age and those with several cardiovascular risk factors . in our case the most frequent location of thoracic aorta thrombi is the region of the aortic isthmus and the portion distal to the aortic arch , at the side opposite to the origin of the subclavian artery . ct and echocardiography can be used for the diagnosis of aortic thrombi . in particular , transthoracic and transesophageal echocardiography have high diagnostic accuracy and allow the assessment of the size , morphology , and anchoring site of the thrombus , as well as the characteristics of the aortic wall . further , to determine the cause of the thrombus , we should consider a survey for hypercoagulable disorder . a definite diagnosis requires histological and immunohistochemical studies . in a differential diagnosis with other mass lesions , such as tumors , the treatment of aortic thrombi is considered necessary because of the risk of a massive systemic embolization . thrombolysis can be a possible treatment , but there is a risk of thrombolytic agents selectively lysing the stalk of the lesion , releasing the bulk of the lesion into the systemic blood stream . we believe that in selective patients with acceptable surgery for cardiopulmonary bypass and definite systemic embolic events due to highly mobile aortic thrombi , surgical treatment has been successful . this case is reported in order to inform the readers of a rare case where floating thrombi in the aortic arch of patients with embolization were successfully treated surgically . | floating thrombi in the aortic arch are very rare and an unusual source of systemic embolism . herein , a case of a 3-cm thrombus in the aortic arch is reported .
it was a floating , highly mobile thrombus attached to the lesser curvature of the aortic arch .
the patients had a hypercoagulable disorder induced by protein c and s deficiency .
the thrombus was operatively removed with a favorable outcome . |
it is a benign melanocytic lesion typically < 2 mm in thickness , with an annual malignant transformation rate of one in 8,845.1 polypoidal choroidal vasculopathy ( pcv ) is a recurrent and relapsing chorioretinopathy characterized by grape - like subretinal vascular lesions associated with retinal pigment epithelium detachments ( peds).2 indocyanine green angiography ( icga ) is the gold standard for pcv diagnosis . however , patients with pcv are often mistaken for patients with exudative age - related macular degeneration and typical choroidal neovascularization ( cnv ) . we previously reported the first case in the literature of a stable pcv associated with nevus , which was managed conservatively.3 in this article , we performed a retrospective chart review following the written informed patient consent of a 78-year - old caucasian female , who had active , symptomatic pcv secondary to nevus , and was successfully treated with photodynamic therapy ( pdt ) . this case involved a 78-year - old caucasian female with a stable left - eye superotemporal extrafoveal pigmented nevus for 20 years . funduscopy showed a pigmented lesion measuring 4.83.2 mm in basal dimensions with overlying clumped soft drusen at the posterior pole along the 2 oclock meridian ( figure 1a ) , corresponding to a nevus at 2.0 disc diameters from fovea . a discreet orange nodule adjacent to the pigmented lesion on the nasal aspect and associated subretinal fluid ( srf ) was noted . optical coherence tomography ( heidelberg engineering , heidelberg , germany ) showed typical features of a flat nevus with ped associated with an underlying discreet polyp - like lesion at the nasal edge of the nevus and extensive srf ( figure 1d ) . fluorescein angiography ( figure 1b and c ) and icga ( heidelberg engineering ; figure 2a and b ) demonstrated early filling of a grape - like structure suggestive of pcv with leakage in the late phase . icga also revealed an associated small branching vascular network ( bvn ) in both early and late phases ( figure 2a and b ) . a diagnosis of pcv adjacent to nevus was made . due to the peripheral location of pcv and the presence of srf threatening the fovea intravenous verteporfin ( 6 mg / m ) was followed by standard - fluence pdt ( 50 j / cm ) at the center of the pcv with a spot size of 1,600 m over 83 seconds from a 689 nm laser . following treatment , srf was absent ; however , a persisting small ped was observed ( figure 1f ) . icga at 7 months showed an absence of leakage , with complete regression of the polypoidal lesion ( figure 2c and d ) . no active polyp could be detected on icga at 2 years , with a stable best - corrected visual acuity of 6/6 ( 0.0 logmar ) . studies have found that patients with choroidal nevus may develop typical cnv.47 however , pcv secondary to nevus has rarely been reported . we previously reported a case of a quiescent pcv arising from a stable choroidal nevus where the polyp was located above the nevus , however , between the retinal pigment epithelium ( rpe ) and bruch s membrane . this location of the pcv corresponded to a study by uyama et al on icga findings of japanese patients with pcv , in which they proposed that pcv may be a peculiar form of cnv beneath the rpe and above the bruch s membrane.8 similar to this , histopathological examinations revealed that vessels found at the margins of type-1 choroidal neovascular membranes tend to be matured and dilated , and therefore , pcv seemed to originate from longstanding type-1 ( occult ) cnv above bruch s membrane and is not a primary choroidal vascular disorder.9 we postulated that a choroidal nevus may cause chronic inflammatory or degenerative changes overlying rpe , which may result in the growth of type-1 cnv and eventually lead to pcv lesions developing adjacent to the nevus.3 in our case , optical coherence tomography and angiography revealed a discrete orange grape - like lesion below the ped with early filling and leakage in the late phase associated with a bvn and an srf , which were more typical of active pcv . some may argue the current case to represent malignant transformation of choroidal nevus , since srf was observed with an orange structure , which could be interpreted as pigment associated with choroidal melanoma . however , the pigmented lesion was flat , and the orange structure was adjacent to , not overlying , the lesion . moreover , our case responded well to pdt being applied at the center of the pcv , not over the pigmented lesion , and has remained stable for 2 years post - pdt . these features support our case to be pcv secondary to choroidal nevus rather than malignant transformation . various treatments including thermal laser therapy have been used for pcv.1015 icga - guided pdt was found to be effective in treating cnv associated with choroidal nevus ; however , variable outcomes have been reported.11 pdt is also one of the most effective treatments for pcv , resulting in acuity improvement , leakage reduction , and complete pcv regression.13,14 however , a high recurrence rate and minimal bvn regression have been documented , with possible complications such as subretinal hemorrhage and rpe tears.16 the favorable outcome of pdt in our case was most likely due to the extrafoveal location of pcv and the patient s good initial acuity . in pcv patients , vascular endothelial growth factor ( vegf ) was found to be elevated in rpe and vascular endothelial cells.17 intravitreal anti - vegf injections for pcv have been shown to be effective in reducing srf and improving vision ; however , vascular abnormalities have often persisted.12,15 a previous study reported that combination treatment with pdt and anti - vegf resulted in better acuity outcomes and a lower risk of developing pdt complications than photodynamic monotherapy.15 lowering vegf levels after pdt may be the key to preventing pcv recurrence and cnv development . however , koh et al reported that in follow - up visits of up to 6 months , although pdt combined with ranibizumab was superior to ranibizumab monotherapy in achieving complete regression of pcv , no difference was found between the combination treatment and the photodynamic monotherapy.12 in this report , we present the case of a caucasian female who developed symptomatic , active pcv at the edge of a stable choroidal nevus , which was successfully treated with one session of pdt , resulting in improved symptoms and fluid resolution , and no further treatment was required . icga is invaluable for diagnosing pcv and differentiating pcv from typical cnv , as pcv is a highly variable disorder . further studies are required to understand the mechanisms of pathogenesis and evaluate optimal treatment options . | we report a case of a caucasian female who developed active polypoidal choroidal vasculopathy ( pcv ) at the edge of a stable choroidal nevus and was successfully treated with verteporfin photodynamic therapy .
no active polyp was detectable on indocyanine green angiography 2 years after treatment , and good vision was maintained .
indocyanine green angiography is a useful investigation to diagnose pcv and may be underutilized . unlike treatment of choroidal neovascularization secondary to choroidal nevus , management of pcv
secondary to nevus may not require intravitreal anti - vascular endothelial growth factor therapy .
photodynamic monotherapy may be an effective treatment of secondary pcv . |
the utilization of multiple pharmacologic agents is an essential component of modern day anesthetic practice . while there have been numerous advancements in recent years in both analgesic and amnestic medications available for an anesthesiologist to use in clinical practice , the cadre of neuromuscular blocking agents available in the united states has been stagnant . the ideal neuromuscular blocking agent is one that is rapidly acting , has minimal to no adverse effects , is independent of end organ metabolism , and allows for rapid and complete reversal of neuromuscular blockade . first , the deleterious effects of residual neuromuscular blockade in the postanesthetic care unit have been well studied and are clinically relevant . emphasis on operative efficiency and patient discharge has also been widely identified as an area for potential cost saving measures in modern healthcare settings . novel drug development has been proven to be a difficult and timely process as it has been over 20 years since a new nondepolarizing muscle relaxant has been introduced for clinical use . this paper will highlight some of the latest pharmacological advancements in the area of neuromuscular blockade . the enantiomers gantacurium and cw002 are two of the most recent neuromuscular blocking agents that have shown potential for clinical application . the appeal of these molecules is the ultra - rapid reversal of neuromuscular blockade via cysteine adduction and minimal systemic hemodynamic alterations with administration . gantacurium is an asymmetric alpha - chlorofumarate and is classified as an ultra - short acting nondepolarizing neuromuscular blocker . its pharmacologic properties have been established using both animal and human models with its ed95 found to be 0.19 mg / kg . maximum neuromuscular blockade using gantacurium was found to be within 90 s following administration of 1.5 ed95 with even faster onset at higher doses . this pharmacologic profile is comparable to that of succylincholine and could eventually serve as a replacement for a rapid depolarizing muscle relaxant . gantacurium chemical structure cw002 differs in structure from gantacurium by being symmetrical and lacking a chlorine at the fumarate double bond . these properties give cw002 a greater potency than gantacurium and an intermediate duration of action of approximately 30 min . using both animal and human models , , cw002 has minimal to no hemodynamic effects at administered doses well above its documented ed95 . the first is a slow ph - sensitive hydrolysis at the ester linkages of the molecules . this results in a t of 56 min and 495 min for gantacurium and cw002 , respectively . the second pathway for inactivation is much more rapid and has the greatest clinical implications . l - cysteine adduction results in a byproduct of extremely low potency that also subsequently undergoes hydrolysis to form inactive molecules . furthermore , of importance is that unlike conventional neuromuscular blockers , this pathway allows for complete reversal at any time after bolus administration of neuromuscular blockers . l - cysteine adduction terminates the relaxants action via inactivation and not by overcoming competitive inhibition . advancements in neuromuscular blocking agents have the potential to have significant impact on anesthetic care in the united states . the ability to rapidly and reliably induce and reverse favorable conditions for tracheal intubation and surgery can profoundly impact anesthetic care in ambulatory , inpatient , and emergent settings . all anesthesia providers will need to consider some of the advantages and potentially disadvantages of these new drugs in their practice in the future . this paper details some of the promising medications on the horizon for clinical use . continued research is needed in the most important area of neuromuscular modulation in clinical practice . | pharmacological advances in anesthesia in recent decades have resulted in safer practice and better outcomes .
these advances include improvement in anesthesia drugs with regard to efficacy and safety profiles .
although neuromuscular blockers were first introduced over a half century ago , few new neuromuscular blockers and reversal agents have come to market and even fewer have remained as common clinically employed medications . in recent years , newer agents have been studied and are presented in this review . with regard to nondepolarizer neuromuscular blocker agents ,
the enantiomers gantacurium and cw002 , which are olefinic isoquinolinium diester fumarates , have shown potential for clinical application .
advantages include ultra rapid reversal of neuromuscular blockade via cysteine adduction and minimal systemic hemodynamic effects with administration . |
the ingestion of instruments or materials used in various dental procedures may occur accidentally in dentistry . foreign bodies vary in size and shape and range from burs , posts , root pieces , teeth , orthodontic brackets , endodontic instruments ( files , broaches ) , impression materials , implant components , and restorations [ 1 , 2 ] . some objects are made of materials that lack radiopacity , which makes them impossible to identify and locate ; diagnostic bronchoscopy / endoscopy or computed tomography for localization is then required [ 3 , 4 ] . foreign body ingestion is a commonly seen accident in emergencies , usually in children ( 80% ) , elderly , mentally impaired , or alcoholic individuals ; whereas it may occur intentionally in prisoners or psychiatric patients [ 58 ] . rarely foreign body ingestion results in serious complications , such as intestinal perforation , bleeding , obstructions or impactions . the patient position in the dental chair as well as the patient s medical history is important in preventing serious complications . usually instruments entered the gi tract pass asymptomatically and atraumatically within 2 days to 4 weeks . however there are many potential sites for impactions , among them the ileocecal valve is the most common site . approximately seventy five percent of perforations occur at or near this site or at the rectosigmoid junction [ 6 , 9 ] . only 1 percent of ingested foreign bodies cause an intestinal obstruction requiring surgery [ 10 , 11].the aim of this article is to document implant screwdriver ingestion along with its consequences and to offer guidance for prevention and management . a 69 year - old male patient presented with a chief complaint of missing upper left second molar and mandibular left first molar teeth ; for which implant placement was planned . implant placement was done successfully and patient was recalled after 4 months for second stage surgery . during second stage surgery while placing a gingival former on the implant in the region of upper left second molar , the screw driver accidentally slipped from the operator s hand . the operator made an unsuccessful attempt to retrieve the instrument by making the patient spit . the case was attended by a gastroenterologist and immediately pa chest and abdominal radiograph were taken confirming the screwdriver to be in stomach ( fig 1 ) . an endoscopy was planned , which was performed under local anesthesia but the instrument could not be retrieved . patient was kept under observation and advised to consume fiber - rich food to enhance intestinal motility and to regularly examine his stools . on the second day again radiographs were repeated and this time screwdriver was located in the intestine ( fig 2 ) ; the very same day the patient passed the ingested screwdriver in his stool ( fig 3 ) . it must be emphasized that preventing complications of foreign body ingestion and aspiration is of great importance . this applies to the identification of at risk patients by means of comprehensive clinical examination and thorough patient history taking . in our case the patient was senile and apprehensive ; there was difficulty in screwing the gingival former in the maxillary posterior region of upper left second molar , from where the instrument slipped . as the patient was in the supine position direct access to oropharynx was eminent although rare , ingestion / inhalation of a foreign body may lead to serious complications ; therefore , immediate radiographic evaluation is a must including pa / lateral chest , lateral neck and abdominal radiographs . usually , most ingested foreign bodies are expelled in stools without causing any complications in several days to several weeks ; for which conservative management of serial radiographs and fiber rich diet is an initial protocol [ 14 , 15 ] . if serial radiographs depict the same location of foreign body or there is a sign of abdominal tenderness or hemorrhage then most likely there is retention , obstruction or intestinal perforation for which an invasive procedure is indicated and has to be done as early as possible through gastroscopy for its retrieval . the mallampati score is assessed by asking the patient ( in a sitting posture ) to open his / her mouth and protrude the tongue as much as possible .the anatomy of the oral cavity is visualized ; specifically , whether the base of the uvula , faucial pillar and soft palate are visible . depending on whether the tongue is maximally protruded and/or the patient asked to phonate , the scoring may vary . class iv : only hard palate visible it is emphasized that all practitioners should take preventive steps during treatment like placement of gauze screen across the oropharynx , tying ligature ( dental floss ) to instruments , adjusting chair position ( sitting position prevents aspiration / ingestion and supine position increases the risk of swallowing ) and should be able to manage the patients in emergency situations . sending a patient home in the belief that a foreign body that slipped into the oropharynx has been swallowed and should a foreign body be ingested / aspirated , the patient must be examined clinically and radiographically ; diagnosis must be performed immediately by a specialist and patient and his family members must be informed . class iv : only hard palate visible it is emphasized that all practitioners should take preventive steps during treatment like placement of gauze screen across the oropharynx , tying ligature ( dental floss ) to instruments , adjusting chair position ( sitting position prevents aspiration / ingestion and supine position increases the risk of swallowing ) and should be able to manage the patients in emergency situations . sending a patient home in the belief that a foreign body that slipped into the oropharynx has been swallowed and will pass through the gut may be associated with complications and lead to litigation . should a foreign body be ingested / aspirated , the patient must be examined clinically and radiographically ; diagnosis must be performed immediately by a specialist and patient and his family members must be informed . this case report illustrates a case of foreign body ingestion in an anxious senile patient having mallampati class 1 , during implant restoration in the posterior maxilla ; proper preventive measures may prevent such complications . | one of the complications during a routine dental implant placement is accidental ingestion of the implant instruments , which can happen when proper precautions are not taken .
appropriate radiographs should be taken to locate the correct position of foreign body ; usually the foreign body passes asymptomatically from gastrointestinal tract but sometimes it may lead to intestinal obstruction , perforations and impactions .
the aim of this article is to report accidental ingestion of 19 mm long screw driver by a senile patient . |
non - hodgkin 's lymphomas ( nhl ) primarily involving the orbit , is relatively uncommon . we report a case of orbital lymphoma in a 62-year - old male with rare histopathological findings secondary to transformation of once cell type into another . tissue diagnosis and molecular studies led to revelation of diffuse large b cell lymphoma evolving from malt lymphoma . proliferation of two morphologically and phenotypically different b cells resulting in malignancy has not been found in the orbit so far . the orbit is a rare primary site for non - hodgkin 's lymphoma ( nhl ) , accounting for 1% of primary presentations and an estimated 5 - 14% of all extra nodal presentations . however , lymphomas are the most common primary orbital tumor in adults 60 years of age and older . transformation from marginal zone mucosa - associated lymphoid tissue ( malt ) lymphoma to a different form of lymphoma is a very rare occurrence , and has not been previously described in orbital lymphomas . we present a case of bilateral orbital malt lymphoma that transformed into a diffuse large b - cell lymphoma ( dlbl ) , both of which were incidentally found to be coexistent at the time of diagnosis . a 62-year - old caucasian male with a past medical history of hypertension and diabetes , presented with bilateral eye protrusion since 1 week . he had been experiencing double vision and throbbing frontal headaches for the past 2 weeks . physical examination was remarkable only for bilateral exophthalmos [ figure 1a ] , without any palpable lymphadenopathy . magnetic resonance imaging ( mri ) of the orbit revealed 3.8 3.0 1.5 cm enhancing orbital mass involving the lateral and superolateral aspect of the peripheral right orbit as well as an irregular 1.1 1.1 2.4 cm mass along the inferior aspect of left orbit [ figure 1c ] . also noted were abnormal signal enhancements within the lesser sphenoid wing and the anterior body of the mandible on the right . given this constellation of findings , there was suspicion for lymphoma or other metastatic disease . ( a ) photograph of the patient showing bilateral swelling and proptosis of the eyes , more prominent on the right side . ( b ) photograph of the patient after 1 month of chemotherapy , showing significant improvement on both sides . red arrows showing lateral hyperintense infiltration in both orbits biopsy of right eye mass was done that revealed extensive soft tissue involvement by two separate lymphomatous populations [ figure 2a and b ] , comprising small and large neoplastic lymphocytes . the large cells were positive for cd20 b cells with co - expression of cd10 bcl6 and mum-1 . by corresponding flow cytometry the small lymphoma cells were cd20 + b cells with co - expression of bcl2 and aberrant cd43 and partial cd5 . b cell immunoglobulin gene rearrangement by polymerase chain reaction ( pcr ) was done to detect clonality . peaks migrating at 318 , 255 , and 274 bases were present on b - cell immunoglobulin heavy chain ( igh ) . in addition , there were peaks present migrating at 195 and 273 bases on b - cell immunoglobulin kappa light chain ( igk ) . gene rearrangement studies were also done on the different aberrant lymphocyte population with diagnosis of malt lymphoma . those areas also shared common peaks at 318 and 255 bases in igh as well as 273 bases in igk light chain . ( a ) low magnification view of lacrimal gland histopathology , showing two morphologically different lymphocytes . ( b ) high power magnification shows malignant large lymphocytes in the lower half with abundant cytoplasm , round nuclei with prominent nucleoli and occasional mitoses . seen in the upper half of the figure are small lymphoid cell with a narrow rim of clear cytoplasm and condense chromatin . this is consistent with malt lymphoma metastatic work - up with computed tomography ( ct ) scans and positron emission tomography ( pet ) scan was negative . he was started on rituximab and cyclophosphamide , doxorubicin , vincristine , and prednisone ( chop ) . by the time of his 1-month follow - up , the orbital swelling had disappeared repeat pet is negative for any metastatic disease , and only residual disease is present in the orbit . orbital lymphomas ( ol ) usually present with eyelid swelling , palpable eyelid mass , diplopia , proptosis , and lid erythema . the most commonly infiltrated structures are found within the superior - lateral quadrant , such as the superior rectus muscle , lateral rectus muscle , lacrimal gland , and eyelid . systemic lymphoma has been diagnosed in 67% of patients with bilateral orbital tumor and in 34% with unilateral orbital tumor . majority of the ol are malt type lymphomas , accounting for 40% to 70% of the cases . although initially described in gastric mucosa and in association with helicobacter pylori infection , malt lymphomas have subsequently been observed to arise in other epithelial structures , including the thyroid , parotid gland , lung , uterus , and breast , as well as in the orbit . age greater than 60 years , elevated lactate dehydrogenase ( ldh ) , and coexistent other malignancies , have been identified as independent risk factors for transformation into aggressive lymphomas . management of orbital lymphoid tumors includes surgical excision , chemotherapy , immunotherapy , or radiotherapy , depending on the size , shape , location , and grade of the lesion and on the systemic status of the patient .. some aggressive tumors may require chemo - immunotherapy as in this case . what is unusual about our case is that it combines two morphologically and phenotypically different mature b - cell lymphomas arising in the same tissue . in the pathological sample it may represent either two different co - existent lymphomas or a transformation from one to the other . in this case , immunoglobulin gene rearrangement studies revealed common peaks at 318 bases and 254 bases in the igh , and 273 bases peak in the igk light chain , in both malt lymphoma as well as dlbl . these findings suggest a common initial clonal process evolving from malt lymphoma to a diffuse large b cell lymphoma with light chain switch ( from lambda to kappa ) . transformation of malt lymphoma is a rare event , and there are only a few cases of this occurrence that have been reported , but to our knowledge , no such pathological transformation has been identified in the orbit . | context : non - hodgkin 's lymphomas ( nhl ) primarily involving the orbit , is relatively uncommon . rarely two pathologically different nhl cell types have been found to be coexistent.case report : we report a case of orbital lymphoma in a 62-year - old male with rare histopathological findings secondary to transformation of once cell type into another .
tissue diagnosis and molecular studies led to revelation of diffuse large b cell lymphoma evolving from malt lymphoma.conclusion:proliferation of two morphologically and phenotypically different b cells resulting in malignancy has not been found in the orbit so far .
they are usually aggressive tumors and require chemo - immunotherapy . |
a 64-year - old male was admitted with sudden onset of right - sided hemiparesis , headache , gait disturbance , and recurrent vomiting . the patient regularly took amlodipine besylate ( 5 mg once a day ) for his blood pressure , but nothing for his diabetes . on examination , his pulse was regular , his blood pressure was 160/100 mmhg , and his temperature and respiratory rate were normal . a neurological examination revealed right - sided hemiparesis ( mrc grade : upper / lower , iv / iv ) , right horner syndrome , and ataxia of his right limbs . on sensory examination , pinprick and temperature sensations were decreased on the right side of his face and the left side of his body . position and vibration senses were also decreased on the right side of his body . on the second day in hospital , his right side became hemiplegic ( upper / lower , ii / ii ) with flaccid tone and hyporeflexia . during the next 7 days , his tone returned , the deep tendon reflex increased , and he developed a right - side babinski response . diffusion - weighted and t2-weighted brain mri performed 24 hours after the onset of his condition revealed a high - intensity area in the right lateral medulla extending from the rostral medulla to the upper cervical cord , and in the right cerebellum in the territory of the medial branch of the posterior inferior cerebellar artery ( pica ) ( fig . 1 ) . mr angiography disclosed suspicious narrowing of the proximal and distal portions of the right vertebral artery and hypoplasia of the left vertebral artery ( fig . low - dose aspirin ( 100 mg once a day ) and clopidogrel ( 75 mg once a day ) were initiated for secondary prevention . on the basis of the mr angiography findings , we recommended digital subtraction angiography and angioplasty , but the patient refused any other treatment modalities . the patient was discharged 36 days after the ischemic accident with hemiparesis ( upper / lower , iii / iii ) , ataxia of his right side , and residual sensory impairment . ipsilateral hemiparesis with symptoms and signs of lateral medullary infarction were first described by opalski in 1946.1 he reported two patients with ipsilateral hemiplegia , ataxia , horner syndrome , diminished facial sensation , and diminished superficial sensation of the contralateral side . pathologic and neuroradiologic findings have identified the causal lesion of opalski 's syndrome.2,3 in the present case , the lesion causing ipsilateral hemiparesis was located in the upper cervical cord , also involving the corticospinal tract below the decussation . the arterial supply of the medulla arises from the vertebral artery , pica , and anterior and posterior spinal arteries . the pica and vertebral artery supply the lateral medullary area , and branches of the vertebral artery are distributed to practically the entire lateral medullary region between the medullary pyramids and the fasciculus cuneatus at the caudal medullary level . norrving and cronqvist examined the pattern of vascular occlusion in lateral medullary infarctions , and found that the most common vascular lesions involved the vertebral arteries.5 the relative sizes of the vertebral arteries vary considerably , and in approximately 10% of cases one vessel is so small that the other is essentially the only artery supplying the brainstem and cerebellum . when the one vertebral artery responsible for supplying the major source of the blood flow is occluded , the resulting infarction is more severe than in the case of bilaterally competent vertebral arteries.6 therefore , in the present case we may consider that the right vertebral artery was responsible for supplying the major source of blood flow and that an artery - to - artery embolism with right vertebral arterial atherosclerosis resulted in coexisting cerebellar and medullary lesions extending to the rostral cervical cord . several previous reports of opalski 's syndrome2 - 4 attributed these clinical observations to observed focal ischemic lesions of the medulla . dhamoon et al . reported one autopsy case with severe atherosclerosis and thrombosis in the proximal and distal sections of the right vertebral artery in opalski 's syndrome.2 in the present case , acute ischemic lesions extended to the rostral medulla and encompassed the medial pica territory of the cerebellum , and mr angiography showed suspicious severe stenosis or near occlusion of the right vertebral artery , and hypoplasia of the left vertebral artery . conventional angiography and angioplasty could not be performed due to patient 's refusal . in addition , considering that intrinsic pica ( in situ branch artery ) disease can also cause lateral medullary lesion with multiple cerebellar involvement,7 we can not exclude the possibility of in situ pica occlusion . | a 64-year - old man presented with sudden onset of right - sided hemiparesis , headache , gait disturbance , and recurrent vomiting .
a physical examination revealed right - sided hemiparesis , right horner syndrome , ataxia of the right limbs , and diminished sensation on the left side of his body .
diffusion - weighted mri revealed an acute right lateral medullary infarction extending from the rostral medulla to the upper cervical cord , and an acute cerebellar infarction in the territory of the medial branch of the posterior inferior cerebellar artery .
magnetic resonance angiography revealed suspicious severe stenosis or near occlusion of the proximal and distal parts of the right vertebral artery , and hypoplasia of the left vertebral artery .
we diagnosed ipsilateral hemiparesis with lateral medullary infarction ( opalski 's syndrome ) and concomitant cerebellar infarction . |
accidental ingestion of foreign bodies like coins , fish bones , plastic toy parts , batteries and needles are common in toddlers and pre - school children . the battery cells are potentially hazardous as they cause chemical mucositis and because of their capability to generate electric current . the mucosal damage starts early and may lead to life - threatening complications in long - standing cases . a male child aged 1 year and 9 months was brought to our center by the caregivers with history suggestive of accidentally swallowing a computer battery cell at home 4 h before . the parents provided the history of living in a one - roomed dwelling of a slum , which also served both as a computer hardware assembling and repairing workshop of the father and , usually , was cluttered with computer accessories . history suggested that the child had ingested a battery cell while playing in the vicinity of the dismantled spares of computer sets and started retching , vomiting , coughing and choking and turned pale soon after swallowing something . the father had brought along with him a sample of the battery cell to support the suspicion , which resembled a five rupees coin with smooth edges . a high - risk informed consent was taken after counseling the caregivers for the procedure , explaining in detail the risks with the advantages and disadvantages involved in anesthesia and the course of actions of further interventions . in the preliminary history and clinical examination , the child had dehydration and mild stridor , but showed no batter marks on the body to exclude a case of child abuse . x - ray pa view of the chest and neck was performed immediately in the emergency room , which confirmed the impaction of the foreign body [ figure 1 ] . x - ray ( pa view ) showing foreign body the toddler was rushed to the observation room of the emergency services at our center . a fluid line was promptly started with ringer lactate and a bolus dose of hydrocortisone and ceftriaxone was administered with adequate precautions , while the preparation was pursued to shift the child to the emergency operation theater . a pediatrician was called without delay to assess the clinical status , including hemodynamic stability of the child . the pre - operative logistics was in favor of general anesthesia on the anticipation of use of rigid endoscope if flexible endoscopy fails and a tracheostomy in case of respiratory distress . the child was intubated orally by the anesthesiologist and the pediatric flexible esophagoscope was negotiated . the battery cell was noticed to be impacted in the cricopharynx , which is the most common site of impaction for foreign bodies . because of limited edematous and congested space , instrumentation was difficult and the single battery slipped repeatedly due to smooth surface , but was removed safely without trauma to the surrounding structures . an infant feeding tube was inserted immediately under direct supervision . on inspection , the foreign body was found to be discolored , with corrosion of one surface , as we could remove it before it could cause severe reaction to the tissues [ figures 2 and 3 ] . extracted foreign body opposite side of the corroded foreign body the child was kept in the pediatric intensive care unit to observe for immediate complications like dysphagia , odynophagia , mucositis causing stridor and aspiration in cases of delayed intervention . antibiotics , steroids and anti - inflammatory drugs were given as a 5-day course and a nasogastric tube was left in situ for a week , after which the patient could swallow well before discharge . the child was followed - up for the last 1 year and was free of long - term complications . foreign bodies in the esophagus are a routine emergency dealt by the otolaryngologist in daily practice . more the delay in extraction of the leaking battery cells , greater is the damage due to liquefaction necrosis of mucosa and the chance of stricture and pressure necrosis . there were no major complications after endoscopic removal . in the turkish retrospective study on the ingested foreign bodies in children having endoscopic removal , general hospital poison control center , of 25 patients with button battery ingestion , it was noted that impacted cell needed immediate esophagoscopic removal . at the department of radiology , klinikum rudolf virchow , charlottenburg , frg , button - type batteries ingested were removed from the esophagus and the upper gastrointestinal tract of 13 children by means of the fe - ex ogtm - technique . in all cases , the button cells were easily detected and retracted under fluoroscopic control with the magnet without post - operative setback . litovitz in his review of 56 cases advocated immediate removal of cells to prevent further complications and use of nasogastric tube to prevent strictures . still , the researchers are of the opinion that the management of ingested foreign bodies in children is not standardized . in the present case , the accidental battery cell impaction was referred to a teaching hospital emergency within 4 h. the kid was examined and diagnosis was confirmed promptly . the narrow inlet of cricopharynx was the site of impaction for this type of larger foreign bodies . primary outcome measure was immediate endoscopic removal with non - invasive technique as the utmost priority to prevent known secondary complications by the prompt extraction . the strength of the study is that the case of foreign body impaction had undergone optimum management within the resource constraint set up of eastern indian tertiary care hospitals . further , the case has been reported with precise details , including the follow - up . to the horizon of our knowledge , no previous study had been reported of children with computer battery cell in the cricopharynx of a toddler in eastern india . foreign bodies are dealt with by different authors differently , but the basic method is prompt endoscopy and atraumatic removal . further , controversies move around the logistics of general anesthesia , use flexible or rigid endoscope and a tracheostomy in case of respiratory distress . future research directions should move around research collaboration in this part of the country for the underlying mechanisms of foreign body ingestions by socioclinical research . the caregivers need to be educated on the art of rearing of children by continuing parent education to prevent all the domestic and peridomestic accidental occurrences . they should be taught on the early identification of ingested foreign bodies , and the optimum intervention is by prompt endoscopic removal of foreign bodies under general anesthesia as the safe and effective method in children to prevent erosion and perforation of the gastrointestinal tract . training of the primary health care staff with clinical audit are needed for handling such emergencies without referring them to other centers , which can save morbidities with long - term complications . | a computer lithium battery cell was impacted in the cricopharynx of a 1 year and 9 month - old child .
the battery cell was safely removed with the pediatric flexible oesophagoscope under anesthesia without trauma to the surrounding structures .
the lithium battery cell is potentially dangerous due to its ability to cause chemical damage to the mucosa and cause early inflammation and edema leading to dysphagia and respiratory obstruction .
hence , it should be promptly extracted without delay to prevent catastrophe .
the toddler recovered uneventfully in the immediate post - operative period and was followed - up for the last 1 year without any complication . to the horizon of our knowledge , no previous case
was reported with computer battery cell in the cricopharynx of a toddler in eastern india . in conclusion ,
parent education is important in the early detection of foreign bodies and their interventions . |
although many case reports have described the presence of a variety of abdominal organs found in spigelian hernias , there are no reports of an incarcerated appendix repaired laparoscopically . the use of laparoscopic technique in this case provided easy identification of the incarcerated structure and allowed us to perform an appendectomy without a large incision and with minimal dissection of the abdominal wall . a 71-year - old female presented to our clinic with a 10-year history of right lower quadrant pain . multiple imaging studies over this time period , including ct and mri , failed to reveal the etiology of her symptoms . in the week prior to presentation , the patient noticed a new bulge at the site of her chronic pain . the patient was taken urgently to the operating room for a laparoscopic spigelian hernia repair . upon laparoscopy , she was found to have an incarcerated appendix in the hernia ( figure 1 ) . after the appendix was carefully reduced , it was noted that the tip of the appendix was necrotic and an appendectomy was performed . the fascial defect was quite small and could be closed in a tension - free manner . due to the inflammation present and the appendectomy performed , the hernia was therefore repaired primarily with nonabsorbable monofilament sutures and buttressed with a biological mesh underlay . postoperatively the patient made good progress and was discharged on postoperative day 5 after return of bowel function . the patient was seen in outpatient clinic twelve days after discharge from the hospital and remains pain - free six months later . the incidence of spigelian hernias is low , but they are the most common type of spontaneous lateral ventral hernia . they are defined by protrusion of the peritoneal sac , an organ , or preperitoneal fat through the spigelian aponeurosis which is located between the semilunar line laterally and the lateral aspect of the rectus muscle medially . ( 1 ) the most common presenting symptoms are pain and the presence of a lump . however , these are notoriously difficult to diagnose on physical exam given that they are often obscured by abdominal fat and the external oblique aponeurosis . ( 2 ) spigelian hernias can be repaired in a traditional open fashion or laparoscopically , but the basic tenets of hernia repair must be applied in both situations . laparoscopic repair of spigelian hernias has been shown to be a viable option in the setting of elective repair , although one study recommended extraperitoneal repair in cases in which there is no known incarceration . ( 3,4 ) laparoscopy has also been reported as a method of diagnosis of spigelian hernias in cases where preoperative workup did not provide a definitive diagnosis . additionally , the use of laparoscopic repair with mesh has been reported for repair of an incarcerated small bowel . ( 5 ) multiple intra - abdominal organs have reportedly been found in spigelian hernias , but the presence of an appendix is very rare . ( 6,7,8 ) all prior reports of appendix - containing spigelian hernias have repaired the defect using open technique . in this case , the use of intraperitoneal laparoscopy allowed easy identification and subsequent management of the incarcerated appendix with minimal dissection of the abdominal wall structures . | spigelian hernias are rare , making up only 1 - 2% of all hernias . like other hernias
, they may contain abdominal contents but are more likely to be incarcerated due to the small size of the fascial defect.(1 ) we describe here the case of a 71-year - old female with a 10-year history of right lower quadrant pain that remained undiagnosed despite multiple imaging studies .
prior to presentation the patient developed a new bulge and increasing pain at this site ; an ultrasound revealed the presence of a bowel - containing hernia .
the patient was taken urgently to the operating room for a laparoscopic spigelian hernia repair , and was found to have an incarcerated appendix in the hernia . after the hernia was reduced , an appendectomy was performed and the hernia was repaired with biological mesh .
postoperatively , the patient did well , and her pain resolved . |
white cottony mycelia formed on the stems of the diseased plants , which became tough and formed abundant amounts of brown spherical sclerotia on the surface of the mycelial mat . initially , stem rot disease affected only a small number of garlic plants ; however , the disease gradually spread and caused large - scale damage . the symptoms of the disease began in may , when the canopy of the garlic plant became densely covered , blocking air flow and light . in late may , relatively high air temperatures and frequent rain fall favored disease development . according to farmers who had experience with this disease , the disease becomes troublesome only when environmental conditions favor disease development . stem rot disease of garlic is a soil - borne disease , the inoculum potential of which increases in continuously mono - cropped areas . it is presumed that the debris of infected plants is main inoculum source of the disease . abundant sclerotia are formed on the stems and bulbs of infected plants , and the sclerotia are overwintered and invade the root , crown , and stem when garlic is planted ( fig . the causal organism of garlic stem rot was isolated from the sclerotia formed on the stems of the infected plants . the surfaces of the collected sclerotia were disinfected with a 1% naocl solution for 1 min , rinsed with sterilized water 3 times , and blotted with 5 layers of flame - sterilized filter papers ( 90 mm ) . the surface - sterilized sclerotia were placed on potato dextrose agar ( pda ) medium and incubated at 25 for 4 days . the fresh mycelia grew out from sclerotia on agar surface were cut with spatula and transferred to new pda and incubated at 25. the causal organism was cultivated in pda for 3 wk , and the morphology of the hyphae and clamp connection structure and sclerotia formation were examined under light microscopy ( table 1 ) . the mycelia were white and grew fast and prosperously on the surface of the pda and had a cottony appearance . 1d ) , were tan to brown in color , and were generally spherical , although some were irregularly shaped . after a 4-day incubation period on pda at 25 , a typical clamp connection structure was observed in the hyphae ( fig . the diameter of the hyphae ranged from approximately 4 to 8 m , and the optimal temperature for growth of the fungus was 30. the causal organism of stem rot disease in garlic and the associated symptoms agreed with the findings of kishi , and the mycological characteristics of the fungus agreed with those reported by mordue . the pathogenicity of the fungus was examined in a garlic plant grown in 1/5000a wagner 's pots . three bulbs of health garlic were planted in wagner 's pots ( 10 replication ) in october 2008 . the inoculum of the fungus was prepared by mixing fungal mycelia and soil 5 kg of sandy loam soil was sieved and autoclaved at 121 for 30 min . and repeatedly autoclaved 3 times at 5-day intervals . the mycelial mat of the test fungus grown on pda for 7 days was harvested . the harvested mycelial mat from 30 petri dishes ( 9 cm in diameter ) was mixed thoroughly with 5 kg of sterilized soil in a plastic container ( 56 35 13 cm ) . the mixture containing the mycelial mat and the soil was dried in the shade for 15 days and then powdered . the powdered mixture was preserved in a green house and used as inoculums ; 200 g of soil inoculum was placed on top of the wagner 's pots . after infestation of inoculum , 500 ml of tap water was added to each pot and covered with one layer of newspaper to maintain sufficient soil moisture . the inoculated pots were kept separately in a green house and were observed for disease symptoms . seven days after inoculation , white mycelia on the stems of the garlic and premodia of sclerotia were observed . as time progressed , the premodia of sclerotia developed into typical brownish sclerotia , and the white mycelia on the stem and soil surface had typical stem rot symptoms ( fig . , many diseases caused by sclerotium rolfsii in various crops have been reported [ 3 - 6 ] . the disease described in this article and the mycological characteristics of the causal organism were in line with these reports . on the basis of the results obtained in this study , the author suggested that the disease observed was stem rot of garlic caused by s. rolfsii saccardo . the isolate obtained from garlic in this study was deposited in the korean agricultural culture collection and was assigned the registration number kacc no . | stem rot disease was found in garlic ( allium sativum l. ) cultivated from 2008 to 2010 in the vegetable gardens of some farmers in geumsan - myon , jinju city , gyeongnam province in korea .
the initial symptoms of the disease were typical water - soaked spots , which progressed to rotting , wilting , blighting , and eventually death .
white mycelial mats had spread over the lesions near the soil line , and sclerotia had formed over the mycelial mats on the stem .
the sclerotia were globoid in shape , 1~3 mm in size , and tan to brown in color .
the optimum temperature for growth and sclerotia formation on potato dextrose agar ( pda ) medium was 30. the diameter of the hyphae ranged from approximately 4 to 8 m .
typical clamp connection structures were observed in the hyphae of the fungus , which was grown on pda medium for 4 days . on the basis of the mycological characteristics and pathogenicity of the fungus on the host plants , the causal agent was identified as sclerotium rolfsii saccardo .
this is the first report of stem rot disease in garlic caused by s. rolfsii in korea . |
a 10-year cohort study found a 1.33-fold relative risk of death in a schizophrenic population compared with a control population ; the leading cause of death was cardiovascular disease . in patients with myocardial infarction and cardiac failure , reduced heart rate variability is one of the predictive factors of increased risk of cardiac death ; this reduced heart rate variability might be due to the anticholinergic effects of psychotropic drugs . thioridazine , an old and widely prescribed neuroleptic drug which was recently withdrawn , was associated with 75 % of 49 deaths in a patient group taking a single antipsychotic drug regimen ; its potential for qt prolongation had already been reported in 1963 . unexplained sudden death in young adults has been linked to the prescription of antipsychotics other than thioridazine . electrocardiographic modifications due to psychotropic drugs include prolongation of the pq interval ( atrioventricular blocks of different degrees of severity ) , widening of the qrs interval ( bundle branch block ) , st - segment changes ( repolarization disturbances ) , and prolongation of the qt interval . drug - induced long qt syndrome is an underestimated adverse drug effect : morbidity and mortality associated with a prolongation of the qt interval currently constitute the most frequent cause of drug withdrawal from the market or in 1920 , bazett found that the repolarization phase was related to ventricular systole , and that its duration was mainly influenced by the heart rate . bazett 's formula corrects the qt interval with an approximation for a rate of 60/min as follows : qtc = qt/rr , expressed in seconds ( figure 1 ) . prolongation of the qt interval is considered to be a surrogate marker for the risk of developing a particular type of ventricular tachyarrhythmia called torsades de pointes ( tdp ) , which may be recognized on the electrocardiogram ( ecg ) as a twisting of the qrs axis ( figure 2 ) . prolongation of the qt interval was reported in 8 % of 495 psychiatric inpatients . in an unpublished study in 1 000 inpatients under 65 years of age , serious cardiac events and sudden death occured more often at high doses of haloperidol , droperidol , sertindol , and methadone ; hence , drug - induced qt interval ( repolarization phase ) prolongation is mainly considered as a dose - dependent adverse reaction . psychotropic drugs block several potassium currents ( eg , iks and ikr ) during repolarization ( phases 2 and 3 during the action potential ) , resulting in a prolonged qt interval on the ecg with an increased risk of developing tdp similarly , eight phenotypes of the congenital long qt syndrome are recognized . the most frequent phenotypes are for potassium channels kcnq1 ( or kvlqt1 ) coding long qt type 1 ( lqt1 ) and kcnh2 coding lqt2 ; for sodium channels , scn5a is responsible for the lqt3 phenotype . drugs such as methadone , amitriptyline , haloperidol , and sertindole promote qt prolongation by blocking the herg potassium channels . as for class ic antiarrhythmic drugs , such as flecainide and propefanone , haloperidol also blocks sodium channels , and displays a quinidine - like effect by slowing sodium influx into myocytes . all drugs enhancing the qt interval prolongation should not be prescribed in patients with congenital long qt . furthermore , several psychotropic drugs block in vitro calcium channels of the l - type and may cause bradycardia and heart block through negative inotropic effect . in contrast to low - voltage calcium ion channels ( t - type ) located in pacemaker cells , highvoltage channels of the l - type modulate conduction through the sinoatrial pathway and the atrioventricular node . this mechanism may explain the unusual occurrence of second - degree sinoauricular ( mobitz type ii ) or atrioventricular block during clozapine prescription ( figure 3 ) . moreover , atrial fibrillation is also reported as an unusual adverse reaction during clozapine treatment .
inherited defects of ion channels responsible for congenital long qt syndrome ( which are not always apparent on the ecg ) , polymedication , methadone maintenance , hypokalemia , hypomagnesemia , and history of cardiovascular disease are risk factors that increase the clinical consequences of the ion - channel effects of psychotropic drugs . however , age as a single factor does not seem to contribute substantially to the risk of cardiac adverse drug reactions . besides the qt interval prolongation and other major ecg modifications such as atrioventricular block and intraventricular conduction delay of different degrees of severity , other serious cardiovascular adverse reactions which are not dose - dependent are associated with psychotropic drugs . several deaths , from myocarditis and cardiomyopathy during clozapine therapy were reported in physically healthy young adults . the who database shows that clozapine is significantly more frequently reported in relation to cardiomyopathy and myocarditis ( figure 4 ) than other drugs . myocarditis and cardiomyopathy were also associated with chlorpromazine , lithium , fluphenazine , risperidone , and haloperidol , but these associations need to be further investigated in order to establish whether they are causal . the above information indicates that ecg monitoring should be performed during hospitalization and ambulatory treatment , at least when multiple psychotropic drug regimens , methadone maintenance treatment , and other predisposing factors for qt prolongation are present at admission . we particularly recommend regular cardiac and ecg monitoring in patients receiving clozapine , high - dosage antipsychotics , tricyclic antidepressants , drug regimens with potential interactions , or in clinical situations recognized as promoters of qt prolongation . further electrocardiographic studies in psychiatric patients , systematic recording of case reports , and data mining in pharmaco vigilance systems will help establish the magnitude of cardiac adverse reactions to psychotropic drugs . | rates of cardiovascular morbidity and mortality in psychiatric patients are higher than in the general population : it is estimated that those who suffer from schizophrenia have a life expectancy approximately 20 % shorter than those who do not , and this difference is not fully accounted for by suicide or accidental death.1 cardiovascular adverse effects of psychotropic drugs are common , and potentially harmful.2 the most serious cardiovascular consequences of psychotropic drugs are arrhythmias and sudden death , which principally result from torsades de pointes following progressive qt intervall prolongation .
less severe cardiac adverse drug reactions are extremely common .
orthostatic hypotension , vasodilatation with transient collapse , and reflex sinus tachycardia due to 1-adrenoceptor blockade and to anticholinergic effects occur at therapeutic dosages of several psychotropic drugs .
postural hypotension was found in 77 % of patients receiving antipsychotic medication versus 15 % receiving placebo , and a correlation was found with drugs dosage.3 furthermore , antipsychotic drug is associated with an increased risk of hip fracture with a relative risk of 2 ( confidence interval [ ci ] , 1.6 to 2.6 and accounts for a third of all falls in nursing homes.4,5 |
an 18-year - old caucasian male was admitted for headache and abdominal pain , without diarrhea , of 3 weeks duration . the diagnosis of burkitt s lymphoma , stage d , noncleaved diffuse type was established ( figure 1a ) . chemotherapy was initiated with cyclophosphamide , oncovin , methotrexate , and prednisone ( comp ) . computed tomography ( ct ) scans with and without contrast and magnetic resonance imaging ( mri ) of the head was obtained secondary to the presence of headache in order to evaluate for central nervous system involvement . cerebrospinal fluid ( csf ) analysis revealed normal protein and glucose levels with 220 wbc s per high - powered field , which exhibited malignant morphologic characteristics . the csf tested negative for cryptococcal antigen and venereal disease research laboratory ( vdrl ) test , with no growth on bacterial and fungal cultures . subsequent bone marrow biopsy and hiv testing were also negative . based on elevated opening pressure and the presence of hydrocephalus on neuro - imaging , the patient underwent ventricular - peritoneal shunting . despite improvement in the hydrocephalus , ten days after the shunting procedure the patient developed diplopia for which the ophthalmology service was consulted . on examination patient had hypertropia of the right eye ( figure 1b ) , maximal on left gaze with beilschowsky test positive confirming right superior oblique palsy . visual fields , color vision and optokinetic nystagmus were normal . pupils were 3 mm , equal , and reactive to light ( figure 2a ) . his general condition deteriorated and fourteen days later he developed a right 3rd cranial nerve palsy and expired two days later . the patient s symptom of diplopia can be attributed to the palsy of the right superior oblique muscle . the long intracranial course of the trochlear nerve renders it vulnerable , which in this case was most likely affected by the elevated intracranial pressure . incidently , the patient had no pupillary constriction on near gaze with preserved accommodation and convergence ; the light reflex , however , was also maintained . these reflexes are mediated by the oculomotor nerve and associated parasympathetic fibers originating from the edinger - westphal nucleus ( bron et al 1997 ) , however , the basis of this finding is difficult to explain . it has been suggested that neurons in the primate pretectal olivary nucleus are solely related to the pupillary light reflex and that the cortical projections to this pretectal nucleus are related to this reflex and do not play a role in the pupillary near response ( zhang et al 1996 ) . the differential diagnosis of this finding is difficult , as iarp itself is a rare clinical entity . csf testing confirmed the absence of neurosyphilis and meningitis , leaving the presence of malignant - appearing white blood cells ( wbcs ) as the primary abnormality in addition to the elevated opening pressure . thus , we propose that infiltration from the burkitt s lymphoma and/or increased intracranial pressure due to hydrocephalus may have caused compression over the anatomical pathway serving the efferents of the near pupillary reflex . the elevated intracranial pressure was most likely secondary to impaired csf absorption at the arachnoid villi , which is most likely related to the presence of malignant wbcs in the csf . an autopsy on this patient could have assisted in clarifying the pathology behind this manifestation . | we present a case of an 18 year old white male with burkitt s lymphoma who was operated on for hydrocephalus and subsequently referred for evaluation of new onset diplopia . on examination ,
his visual acuity ( va ) was 20/20 in both eyes with a right superior oblique palsy .
his pupillary reaction to light was intact while on near gaze there was no constriction of the pupils , bilaterally .
the other two responses of the near gaze triad ie , convergence and accommodation were present .
these findings were suggestive of an inverse argyll robertson pupil ( iarp ) , a rare entity in the literature .
we could not find a specific cause attributable to this manifestation in this patient , though we feel it may be secondary to infiltration from burkitt s lymphoma and/or compression from elevated intracranial pressure of the efferent pupillary near reflex pathway . |
for successful endodontic treatment , thorough knowledge of root canal morphology along with its variation is mandatory . the main objective of endodontic therapy is to prevent and when needed to cure endodontic disease and apical periodontitis . to achieve these goals , locating , cleaning and shaping ingle lists the most frequent cause of endodontic failure as apical percolation and subsequent diffusion stasis into the canal.1 variations in form of aberrant canal configurations , accessory canals , bifurcation , isthmuses , and anastomoses are often difficult to identify , thus creating a problem for endodontic treatment . inadequate knowledge regarding variations of root canal system may be a major cause of the failure of root canal system . endodontic treatment of single rooted teeth is usually simple as these teeth usually have single root canal . many studies have examined the root canal systems of these single - rooted teeth , confirming that it is not as simple as it may appear to be on standard periapical radiographs.2 however variations in form of presence of extra canal in mandibular incisors have been documented by various researchers in the past . vertucci in 1974 classified the canal configuration of mandibular incisors into four types:3
type i : single canal is present from the pulp chamber to the apex.type ii : two separate canal leaves the pulp chamber , but join short of the apex to form one canal.type iii : one canal leaves the pulp chamber , but it divides into two within the body of the root , the canals merge again to exist as one canal.type iv : two separate and distinct canals are present from the pulp chamber to apex . type ii : two separate canal leaves the pulp chamber , but join short of the apex to form one canal . type iii : one canal leaves the pulp chamber , but it divides into two within the body of the root , the canals merge again to exist as one canal . type iv : two separate and distinct canals are present from the pulp chamber to apex . various investigators have studied root canal system in mandibular incisors and reported following findings:4 although some of the morphological variations may depend on different ethnic backgrounds , two canals should be expected in about one - quarter for mandibular incisors . this proportion is not found clinically by practitioners during root canal treatment due to the failure of the dentist to recognize the presence of the second canal.5,6 the case report presented here has a striking feature of presence of extra canal in all the mandibular incisors in the same patient . a 45-year - old male patient reported to the department of conservative dentistry of chatrapati shahu maharaj shikshan sanstha dental college , aurangabad , from maharashtra state in india with the chief complaint of pain with lower anterior region . history revealed that the patient had a dull aching , intermittent pain mainly at night hours since 1 year . on clinical examination edge to edge the incisal bite with severe attrition was seen associated with mandibular anteriors . the intraoral periapical ( iopa ) showed a loss of lamina dura with 31 and 41 and periodontal space widening with 32 and 42 suggesting chronic apical periodontitis ( figure 2 ) . non - surgical endodontic treatment was planned with exploration , cleaning , shaping and filling of the root canal of all the mandibular incisors . root canal access opening was prepared through incisal edges initially with round diamond bur and later with round - end cutting tapered diamond in an oval shape with larger labio - lingual extension in an isolated condition with application of rubber dam . all the incisors when endodontically explored were found to have two separate canal orifices extending into two canals and joining short of the apex to continue as one ( vertucci s type ii canal morphology ) , thus showing one apical opening . the working length was determined for all the canals with apex locator as well as radiographically . complete chemo - mechanical preparation of all the teeth was done by hand instrumentation and use of 3% sodium hypochlorite irrigation . all the canals were then filled with intracanal calcium hydroxide for 1 week . on the next appointment , the intracanally placed calcium hydroxide was removed and obturation done with gutta - percha by lateral condensation technique . post - treatment radiographs were taken with conventional radiograph as well as orthopantomogram , cone beam computed tomography ( cbct ) technique with the consent of the patient ( figures 3 - 6 ) . dr . hermann prinze wrote object of the clinical dentistry is to institute preventive measures to relieve suffering , and to cure disease . to gain this goal clinician should have sound knowledge of dental anatomy , differential diagnostic modulates.7 during interpretation of diagnostic radiographs if there is sudden change in canal radiodensity , narrowing of canal space , abrupt disappearance of canal space , this gives us a clue for need of one extra angulated radiograph to diagnose an extra root or canal.8 uma et al . studied 50 extracted mandibular incisor for canal and isthmus morphology radiographically and concluded that type i and type iii canal configuration are much commoner than type ii canal which are rarely found.9 sinzianna scarlatescu et al . studied 32 extracted mandibular incisors in a south eastern romanian population by using color detector and a tooth - clearing technique . they concluded that type i root canal configuration ( 65.5% ) , type iii was found in 25% cases , type ii in 6.3% and type vii in 3.1%.10 mandibular incisor root canal system has either ovoid or ribbon shaped with a single canal in the range of 71.8 - 73.6% and double canal in the range of 26 - 28.1% . hence to achieve success in endodontic therapy it s important to locate , shape and obturate these extra canals . a common reason for not locating a second canal in mandibular incisors is an inadequate access opening into the tooth that leaves a lingual shelf of dentine over the second ( usually the lingual ) canal.11 therefore , it may be necessary to modify the conventional access preparation to permit better visualization and instrumentation of additional canal even at the emphasis of compromising the crown structure.12 this case report highlights the importance of thorough knowledge of root canals and its variations . extra canals in mandibular incisors are not a rare entity as suggested by few investigators . detailed knowledge and at times the modification of access opening is needed . the practitioners should be aware of how many canals to expect , their location , length and relationship to each other . wilson and henry have suggested that the access opening must be widened labio - lingually as well as inciso - gingivally to locate the extra canal , if any.13 it s also emphasized that radiographs taken from different angles are a must to anticipate the presence of extra canal . | single rooted tooth are considered to be the easiest for root canal treatment .
the literature has documented cases with single rooted tooth showing more than single canal .
understanding of root canal morphology thus is an important aspect to be considered for successful endodontic treatment .
the case presented here shows a rare entity of having double canals in all the mandibular incisors in a single patient . |
external ventricular device ( evd ) is useful in monitoring intracranial pressure ( icp ) in patients with severe traumatic brain injury and abnormal computed tomography ( ct ) scan of the head . however , the presence of evd is a well - known risk factor for infection of central nervous system ( cns ) with the incidence of 118% . acinetobacter baumannii has emerged as an important nosocomial infectious agent due to its ability to tolerate desiccation and to accumulate diverse mechanisms of resistance . there are few reports of successful use of tigecycline for treatment of multidrug resistant ( mdr ) a. baumannii meningitis . colistin is potentially nephrotoxic , which increases with higher cumulative dose and in patients with preexisting renal impairment . here , we report a successful microbiological cure of evd - associated mdr acinetobacter ventriculitis using intravenous and intraventricular colistin together with intravenous tigecycline . a 75-year - old patient presented with the history of decreased level of consciousness and weakness in left half of the body following trivial fall . glasgow coma scale ( gcs ) was 7 ( e1v1m5 ) with bilateral equal and reacting pupils . after 3 days , patient had progressive drop in gcs to 4 ( e1m3vt ) . evd was in proper position and functioning . on the day 4 , he developed high - grade fever ( up to 103f ) . analysis of cerebrospinal fluid ( csf ) sample revealed total count of 630 cells / mm with 90% polymorphs with sugar of 20 mg / dl and protein of 180 mg / dl . csf sample was sent for culture and sensitivity which revealed a. baumannii sensitive only to colistin and tigecycline and resistant to all other antibiotics including carbapenems . intravenous colistin was started at the dose of 2 million iu 8 hourly together with 200,000 iu through intraventricular route daily . tigecycline was administered intravenously at a loading dose of 100 mg followed by 50 mg twice daily . csf culture after 3 days of starting colistin and tigecycline was negative with decrease in cell count to 25 cells / mm . worsening of renal function , intravenous dose of colistin was decreased to 2 million iu 24 hourly on the day 5 when creatinine reached 4 mg / dl . intravenous colistin and tigecycline was continued for 14 days when the family members of patient decided to withdraw the support due to anticipated poor neurological outcome despite microbiological cure of ventriculitis . possess an impressive armamentarium of resistance mechanisms rendering it resistant to almost all commercially available antibiotics . colistin is widely used for the treatment of infections by mdr gram - negative rods . however , intravenous administration of colistin is associated with a very low cns transfer of only around 5% . a concomitant intraventricular administration is required for treatment of severe ventriculitis in patients with evd . the literature review suggests a minimum intrathecal dose of 125,000 iu daily as suggested by the guidelines of infectious disease society of america and may possibly increase to 250,000 iu daily . duration of intraventricular treatment < 7 days is possibly associated with higher mortality . in our case , it was administered for 8 days . combination of intraventricular and intravenous therapy was chosen as intraventricular therapy alone is not sufficient to treat evd - related ventriculitis due to mdr gram - negative pathogen . kidney injury is related to total cumulative dose and duration of therapy . as in our patient , older and more severely ill patients are at higher risk for nephrotoxicity , and it independently predicts higher mortality . tigecycline has demonstrated good in vitro activity against mdr a. baumannii , but current evidence does not support its use as monotherapy . hence , tigecycline was used as a component of multidrug and multi - route therapy for our patient . despite successful microbiological clearance , the bundle of measures such as education of intensive care unit personnel , meticulous intraventricular catheter handling , and csf sampling only when clinically necessary routine replacement of drainage catheter on the 7 day is associated with significantly decreased incidence of evd - associated infection . intraventricular and intravenous colistin combined with intravenous tigecycline may be effective in microbiological clearance of bacteria . bundle of measures should be implemented in all patients with evd and at risk of mdr infection to prevent the disastrous outcomes . | acinetobacter baumannii is an important cause of nosocomial ventriculitis associated with external ventricular device ( evd ) .
it is frequently multidrug resistant ( mdr ) , carries a poor outcome , and is difficult to treat .
we report a case of mdr acinetobacter ventriculitis treated with intravenous and intraventricular colistin together with intravenous tigecycline .
the patient developed nephrotoxicity and poor neurological outcome despite microbiological cure .
careful implementation of bundle of measures to minimize evd - associated ventriculitis is valuable . |
in 1997 , nozaki et al . ( 1 ) described subdiaphragmatic intrasellar meningiomas that originated from the sellar turcica ; two of which only originated from the floor of the sellar turcica . since then , only one case of intrasellar meningioma from the sellar floor has been reported in the english literature ( 2 ) . the pituitary gland is reported to be covered by two distinct structures : the capsule and dura ( 3 ) . although meningiomas can originate from anywhere in the sella turcica , subglandular meningiomas are extremely rare ( 1 ) . we report a case of subglandular meningioma probably originating from the floor of the sella turcica along with a review of the pituitary fossa anatomy . the imaging revealed an intrasellar mass measuring approximately 1.8 1.7 cm with a slightly upward bulge , homogenous isointense signals on t1- and t2-weighted images , and a focal inhomogenous signal on t2-weighted images ( fig . on contrast - enhanced t1-weighted images , the lower portion of the sellar mass was greatly enhanced , and the upper portion , lesser enhanced ( fig . initially the upper portion was thought to be a pituitary adenoma and the lower portion , normal pituitary gland . when an endonasal transsphenoidal operation was performed to remove the tumor , a bulging tumor on the sellar floor the normal pituitary gland was elevated and shifted to the left anterolateral side by the mass . after the tumor was removed , the diaphragma sellae was identified at the top of the sellar turcica . on histological examination , the low - lying intrasellar lesion was confirmed as a meningioma , while above it was the normal pituitary gland ( fig . in 1969 , hardy and robert ( 4 ) described a separate type of intrasellar meningioma originating from the inferior aspect of the diaphragma sellae . in 1985 , al - mefty et al . ( 5 ) proposed that diaphragmatic meningiomas and a tuberculum sellae meningiomas were separate entities . in 1995 , kinjo et al . ( 6 ) classified diaphragm sellae tumors according to their site of origin from the diaphragm : type a originated from the upper leaf of the diaphragma sellae anterior to the pituitary stalk ; type b from the upper leaf of the diaphragma sellae posterior to the pituitary stalk ; and type c from the inferior leaf of the diaphragma sellae . in 1997 , nozaki et al . ( 1 ) summarized observations in the literature on 18 operatively confirmed pure subdiaphragmatic intrasellar meningiomas originating from the dura of the sella turcica . they included type c diaphragma sellae meningiomas according to kinjo 's classification and intrasellar meningiomas from the other side of the sella , such as the floor and anterior or lateral wall . they established the origin of 9 meningiomas ; 6 from the inferior leaf of the diaphragma sellae ( the same as type c diaphragma sellae meningiomas ) , 2 from the floor of the sella turcica , and only one from the anterior wall of the sella turcica . one further example from the floor of the sella has been reported since then ( 2 ) . to the best of our knowledge , only three cases of intrasellar meningiomas originating from the floor of sella turcica have been reported . it is important to differentiate a diaphragm sellae meningioma from a pituitary macroadenoma because they require different surgical approaches . ( 7 ) emphasized that , most of the intra- and suprasellar macroadenomas could be approached by the transsphenoidal route , while diaphragma sellae meningiomas might require a craniotomy . for diaphragma sellae meningiomas , the transcranial - transsphenoidal approach is preferred for a type c meningioma and the cranio - orbital approach for type a and type b meningiomas ( 6 ) . on the other hand , the transsphenoidal approach is advocated for all subdiaphragmatic meningiomas ( 8) , or should be tried first , irrespective of whether the lesion is a meningioma or a pituitary adenoma ; even if it has a small suprasellar extension ( 2 ) . according to cappabianca et al . ( 7 ) , it is essential for the diagnosis of type c meningiomas that the diaphragma sellae be displaced upwards with the normal pituitary gland visible below . our case also showed upward bulging of the complex of the diaphragma sellae and pituitary gland , with the meningioma located below the pituitary gland with a broad - based attachment to the sellar floor . the pituitary gland is reported to be covered by two distinct structures ; a capsule and the dura in the pituitary fossa ( 3 ) . at each inferolateral edge of the pituitary fossa , the thick dura of the inferior wall splits into two thinner layers that form a y shape . one of the arms of the y forming the lateral wall of the pituitary fossa is directed superiorly , while the other arm continues as the sphenoidal part of the medial wall of the cavernous sinus and extends to the lateral limit of the sinus ( 3 ) . it is difficult to differentiate intrasellar meningiomas from intrasellar tumors , which can include pituitary adenoma , pituicytomas , intrasellar germinomas , craniopharyngiomas , aneurysms , and metastases . calcifications are a feature of intrasellar meningiomas , craniopharyngiomas , and aneurysms , but they are not typical features of adenomas . necrotic or cystic changes can be found in most types of intrasellar tumors except for meningiomas . meanwhile , imaging findings on the angioarchitecture of aneurysms allow them to be differentiated from other tumorous lesions . the intrasellar mass in our case was treated by the transsphenoidal approach because our preoperative diagnosis was a pituitary adenoma . during the operation , the lower part of the intrasellar mass was found to be subglandular meningioma following a frozen biopsy , which was successfully removed , while leaving intact normal pituitary gland in the upper part of the intrasellar mass . in conclusion , they probably originate from the dura in the sellar floor , while most intrasellar meningiomas that are located in the subdiaphragmatic and supraglandular area originate from the diaphragma sellae . we report a case of intrasellar and subglandular meningioma along with a review of the literature . | most intrasellar meningiomas are located in the subdiaphragmatic and supraglandular region because they originate from the diaphragma sellae .
subglandular meningiomas located under the pituitary gland are extremely rare .
intrasellar meningiomas in the subdiaphragmatic and subglandular region probably originate from the dura in the sellar floor .
we report a case of a subglandular meningioma along with a review of the literature . |
isolated iliac artery aneurysms are extremely rare , representing only 0.03% of a series of 26 251 autopsy patients , mostly associated with atherosclerosis and with other aetiological factors including trauma and infection . presentation is variable including incidental findings during surgery , abdominal or rectal examination , acute rupture , ureteric obstruction , sciatic nerve compressive neuropathy or pelvic vein compression . gluteal artery aneurysms are also rare , more commonly affecting the superior gluteal artery in association with penetrating trauma , with those of the inferior gluteal artery usually associated with pelvic fractures [ 3 , 4 ] . although often asymptomatic , presentations may include progressive gluteal swelling , a mass mimicking a gluteal abscess , a tumour or be associated with sciatic nerve compression symptoms . a 67-year - old , non - communicative man was referred to plastic surgery with a right - sided subcutaneous gluteal haematoma and low haemoglobin after a minor fall 28 days previously . despite there being no obvious bleeding points after two surgical haematoma evacuation procedures , interspersed with days of haemodynamic stability , the patient required repeat blood transfusions . on saturday ( day 2 ) , a 500 ml haematoma was evacuated at our institution under general anaesthesia via a 4 cm incision . there were no identifiable bleeding points and he was transfused 2u of packed red cells peri - operatively , increasing his hb to 8.7 g / dl . the patient was haemodynamically stable , throughout sunday ( day 3 ) , with no clinical features of recurrence . on monday ( day 4 ) , the haematoma recurred and his hb dropped from 8.7 g / dl to 4.9 g / dl , prompting a second transfusion of 4 units of packed red cells , increasing his hb back to 8.7 g / dl . on tuesday ( day 5 ) , a further hb drop to 6.4 g / dl prompted transfusion of 2u of fresh frozen plasma 3u of red cells and surgical haematoma evacuation ; however , there was no identifiable active haemorrhage . gastroscopy and colonoscopy were performed due to a past medical history of haematemesis ; however , no recent / active bleeding was identified . the patient continued to be haemodynamically stable throughout thursday ( day 7 ) , abdomen and pelvis contrast ct indicated two bleeding sites arising from the internal iliac artery region . one was identified arising from the posterior division of the right internal iliac artery , at the inferior gluteal artery ( fig . less prominent bleeding point was noted at the division level of the internal iliac artery into its anterior and posterior branches , anterior to the sacroiliac joint ( fig . selective angiography was also performed , identifying a large pseudoaneurysm arising from the inferior gluteal artery and endovascular repair was undertaken ( fig . the right common iliac artery was accessed via a left common femoral artery puncture and a combination of five 2 5.0 mm figure 818 pushable coils and two vortx-18 pushable coils of 3 2.5 mm and 4 4.0 mm respectively ( boston scientific , massachusetts , usa ) were deployed to embolize the inflow and outflow vessels ( fig . a further 200 mls of blood were evacuated from the right buttock wound post - embolization . haemostasis was achieved successfully and wound closure undertaken on the following monday ( day 11 ) . ( b ) second site of haemorrhage at the level of division of the internal iliac artery into its anterior and posterior branches , anterior to the sacroiliac joint .
figure 2:interventional angiogram : deployment of seven coils to embolize the inflow and outflow vessels of the inferior gluteal artery pseudoaneurysm . ( b ) second site of haemorrhage at the level of division of the internal iliac artery into its anterior and posterior branches , anterior to the sacroiliac joint . interventional angiogram : deployment of seven coils to embolize the inflow and outflow vessels of the inferior gluteal artery pseudoaneurysm . we present a diagnostically challenging case of recurrent subcutaneous gluteal haematoma , uniquely associated with 2 bleeding points relating to the internal iliac system . at surgery internal iliac and gluteal artery aneurysms are extremely rare , often traumatic in origin and predominantly classified as pseudoaneurysms [ 1 , 3 , 4 ] . they may be slow - growing and present late either as an incidental finding or with gluteal swelling and bruising , compressive neuropathy or compression of surrounding structures . radiological investigations including duplex , ct and mri may facilitate bleeding course identification , shape , size and position relative to surrounding structures . angiography however is diagnostically invaluable in delineating the anatomy of the arterial branches involved and in facilitating intervention [ 5 , 8 ] . aneurysms of the internal iliac artery and branches have a poor prognosis if left untreated . estimated mortality ranges between 50% and 75% , when in isolation , due to rupture and fatal haemorrhage [ 1 , 5 ] . traditional treatment includes open surgical artery ligation both proximal and distal to the aneurysm to minimize recurrence risk due to collateral circulation . due to the potential difficulty in identifying sites of haemorrhage , such as in our reported case , endovascular angiographic repair using embolization although this carries the incontestable advantage of being minimally invasive over surgery , embolization alone may be insufficient for pseudoaneurysm treatment as it is less likely to relieve exerted pressure on surrounding structures , while coils and stents may dislodge and migrate . this case uniquely reports recurrent gluteal haematoma in a non - communicative patient which manifested 28 days following minor , non - penetrating and non - fracture - associated trauma . furthermore , although the rare internal iliac artery system pseudoaneurysm has been reported , no similar report exists in the literature with two bleeding sources and with this mechanism of injury . despite repeated requirements for low hb associated blood transfusions , albeit interspersed with days of haemodynamic stability , exclusion of relevant history - related bleeding sources , and by endoscopy and two surgical explorations , it was only until contrast ct scanning was requested that two separate bleeding sources were identified and successfully treated by endovascular coil embolization . this report provides an important variant and lesson to supplement current literature and understanding of more diagnostically challenging cases of an extremely rare presentation ; it highlights the importance of maintaining a high index of suspicion and investigating the possibility of multiple bleeding points in cases of subcutaneous gluteal haematoma , even when the presentation is several weeks following minor non - penetrating and non - fracture - associated trauma . this research received no specific grant from any funding agency in the public , commercial or not - for - profit sectors . | isolated iliac artery aneurysms are extremely rare .
gluteal artery aneurysms are also rare , more commonly affecting the superior gluteal artery in association with penetrating trauma , with those of the inferior gluteal artery usually associated with pelvic fractures .
we discuss a diagnostically challenging presentation of recurrent subcutaneous gluteal haematoma due to two separate internal iliac artery - associated bleeding points .
a 67-year - old man was referred , from a peripheral hospital , with a right - sided subcutaneous gluteal haematoma .
this manifested 28 days following minor non - penetrating , non - fracture - associated trauma . despite repeat blood transfusions , albeit interspersed with days of haemodynamic stability , and despite exclusion of relevant bleeding sources at endoscopy and two surgical explorations , it was only until contrast ct scanning was requested that both bleeding sources were identified and successfully treated by endovascular coil embolization .
this provides an important variant and lesson to supplement current literature and understanding of more diagnostically challenging cases of an extremely rare presentation . |
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