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patient_info_and_summary

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Amoura Tate

1998/2/14

692.324.4371

angela09@example.com

625 Natasha Overpass

A 55-year-old male patient presented to our emergency with abdominal pain, distension, and absolute constipation for two days. The patient had three similar episodes in the past, which responded to conservative management. There was no history of abdominal surgery or trauma. The abdominal examination revealed distension with rebound tenderness and hurried intestinal peristaltic sounds. On digital rectal examination, rectum was empty with ballooning. Hematological investigations demonstrated neutrophilic leucocytosis. Abdominal X-ray on erect posture revealed multiple air fluid levels with presence of valvulae conniventes. Ultrasonography demonstrated dilated bowel loops without any ascites. The patient underwent exploratory laparotomy for acute intestinal obstruction. On exploration, almost entire small gut was found to be in the left paraduodenal area enclosed in a hernial sac (). The inferior mesenteric vein was situated on the right free margin of hernia sac and at the region of ileocecal junction, it passed onto the anterior aspect of terminal ileum (). The small gut, within the sac, was distended and congested. The peritoneal attachment along the right free margin of inferior mesenteric vein was excised, and the herniated small gut was reduced beneath the inferior mesenteric vein to its normal position on the left side of the base of the mesentery of small intestine. The peritoneal attachment at the neck of the hernia sac was sutured with the retroperitoneum; thus closing the neck of the hernial orifice. The postoperative recovery was uneventful. On followup, for next one year, the patient has been free from any further abdominal problems.

Dalton Stevens

1984/7/20

001-986-493-3624x120

justinwalsh@example.com

26553 Mccarty Motorway Suite 600

A 49-year-old female patient described an episode of sudden dyspnoea that required digital maneuvers to clear the airway. She described that during the maneuver a smooth mass was detached from the pharynx and swallowed. Similar episodes were repeated in two occasions. During examination a progressive dysphagia to solids was noted. No history of loss weight, cough, or hematemesis was noted. She had no comorbidity of interest. A CT scan was performed revealing a soft tissue mass in the esophagus, extending from the level of the cervical esophagus to the lower esophagus with no clear relation to the esophagus wall. The upper endoscopy showed a sausage-shaped mass obstructing the esophageal lumen, arising from the upper esophageal sphincter and ending 13 cm below ().

Katherine Sawyer

1980/9/23

542-247-4106x66213

petersonrobert@example.net

394 John Point

A 27-year-old female reported with the chief complaint of a ?ractured filling??in her left lower back tooth. History revealed intermittent pain localized to the same tooth during mastication. The tooth was previously restored with a silver amalgam restoration 7 years back. Clinical examination revealed a silver amalgam restoration with secondary caries in the left mandibular first molar (tooth 19) which was tender to percussion. Vitality tests elicited no response. Preoperative radiographs showed widening of periodontal ligament space in relation to the mesial root apex. In addition, radiographic apical contour of the tooth suggested that there might be two distal and two mesial roots (). From the clinical and radiographic findings a diagnosis of pulpal necrosis with symptomatic apical periodontitis was made and endodontic treatment was initiated. Following endodontic access cavity preparation, two mesial and one buccally placed distal canal orifice was identified. Upon visual inspection of the floor of the pulp chamber using a dental operating microscope, a dark line was observed extending from the distal canal orifice towards the distolingual corner. At this corner, the overlying dentin was removed and a second distal canal orifice was detected. The conventional access was modified to improve access to the additional canals (). Root canal orifices were named as per the nomenclature proposed by Albuquerque et al. []. Working length was confirmed () and the canals were instrumented. Calcium hydroxide was placed as an intracanal medicament with a lentulospiral and the access cavity was sealed with Cavit G. The patient was asymptomatic at the next appointment, a week later, which allowed for root canal obturation and a coronal composite restoration ().

Jefferson Weiss

2003/3/10

+1-953-979-3639x03458

wwright@example.com

18126 Griffin Forges

A 32-year-old unmarried male, smoker, and beef eater from rural Kashmir, India presented to the surgical emergency department of a tertiary care hospital in Srinagar with features of acute abdomen. He had a three-day history of upper abdominal pain of increasing severity, nausea, and bilious vomiting with fever and chills. Previous history was suggestive of chronic acid peptic disorder. Physical examination revealed anicterus, tachycardia, temperature of 38.5簞C, tenderness, and guarding in the epigastrium and right hypochondrium. The total leukocyte count was 13.5 ? 109/L with a differential count depicting polymorphs77, lymphocytes20, monocytes02, and eosinophils01. The total bilirubin was 12.7 弮mol/L, ALP was 197 IU/L, AST was 68 IU/L and ALT was 42 IU/L. Chest and abdominal radiographs (standing/supine) were normal. USG abdomen reported free fluid in Morrison's pouch. The patient was operated with an impression of a perforated duodenal ulcer. Operative findings showed a severely inflamed gall bladder with patchy necrosis and a perforation in fundus with pericholecystic pus collection. Further exploration was interesting, and to our surprise we extricated an adult tape worm of approximately 1.7 m in length from the gall bladder which was devoid of stones (). Peritoneal mopping, closure of perforation, and cholecystostomy were done. Cholecystectomy was avoided in view of severe inflammation around the Calot's triangle. Rest of the viscera were normal. The specimen sent to the department of pathology/parasitology was confirmed to be Taenia saginata. In the postoperative period, patient had mild respiratory tract infection. Bile started draining with pus flakes from cholecystostomy tube on 5th post operative day. Cholangiogram on 9th postoperative day showed a normal anatomy and free drainage into the duodenum. Liquid orals were started on 2nd postoperative day with full orals resuming by 4th postoperative day. The cholecystostomy tube was removed on 14th postoperative day. Retrospective history was negative for jaundice or passage of worm segments. The patient was given a single dose of praziquantel: 15 mg/kg body weight. Parasitological controls (two series of three fecal samples each), performed two months later, were negative for Taenia eggs. The patient was followed up regularly, and an interval cholecystectomy was done after 6 weeks.

Lennox Vo

1979/7/5

402-786-6615x650

jessicagarner@example.org

96158 Jose Path Apt. 415

A 71-year-old woman, who underwent a total hysterectomy and oophorectomy 8 years ago for endometrial cancer, was admitted for recurrent abdominal mass detected during a routine control thoracoabdominal computerized tomography (CT) scan. CT scan revealed a 5 ? 6 cm sized cystic mass located in the left para-aortic area, at the level of the renal artery orifice of the abdominal aorta. No other metastasis had been demonstrated. In the blood chemistry, only mild elevation of CA 125 was present. The rest was unremarkable. A 6 ? 6 ? 5 cm sized tumoral mass, located between the abdominal aorta and the left renal artery, was revealed at the laparotomy. In addition, about 10 cm proximal to the ileocecal valve, a nodular soft and freely mobile mass of 3 cm diameter was observed on mesentery. A surgical resection of the para-aortic mass and an excisional biopsy of the mesenteric mass were performed. The histological evaluation of the para-aortic cystic mass revealed the metastasis of the primary endometrial serous papillary carcinoma. The histological features of the mesenteric mass were consistent with breast tissue, including lobular and ductal structures in a fibrovascular tissue (Figures and ). Immunohistochemistry with milk fat globulin protein 1 antibodies (MFGP 1) were positive for epithelial and acinar cells, consistent with mammary epithelial differentiation ().

Gordon Felix

1997/9/14

+1-545-542-3845x6904

gcastaneda@example.org

095 Linda Islands

A 55-year-old man, lawyer, was admitted to the hospital because of abdominal pain located in the epigastrium and right hypochondrium, intermittent night sweats, and 3 kg involuntary weight loss over the preceding 8 months. Approximately 5 years earlier severe aortic valve stenosis, with left ventricular hypertrophy, paroxysmal atrial fibrillation, and heart failure (class III NYHA) were diagnosed, and aortic valve replacement was performed using a biological prosthetic valve. Furthermore, the patient was an alcohol user (70 g/day) and had endoscopically diagnosed chronic antral gastritis. He lived in an urban area but, approximately 18 months before admission, he traveled to Nepal living in settings with poor hygienic standards. Daily medications included omeprazole 20 mg. Approximately one year before admission, the patient began to have intermittent, profuse night sweats associated with abdominal pain located in the epigastrium, and right hypochondrium. He reported no fever or chills. No remarks on routine physical examination performed by his attending physician were made, and summarizes the results of prescribed laboratory tests. Serologies for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and VDRL were negative. Serologies for cytomegalovirus (CMV) and Epstein Barr virus (EBV) showed past infections. Two blood cultures were negative. A transthoracic echocardiography detected hemodynamically well-functioning aortic valve prosthesis, ascendant aortic dilatation, and no valve vegetations. An abdominal ultrasound revealed a biliary cyst of the liver. His physician eventually decided to prescribe sertraline for depression. Four months before admission, the patient was still complaining of abdominal pain, with the same characteristics and was referred to our out-patient clinic. Laboratory tests were repeated (), protein electrophoresis was performed, and results were within normal range. Meanwhile, during a work trip to Brazil, the patient developed lower limbs leukocytoclastic vasculitis (). Due to worsening of intermittent night sweats, persistence of abdominal pain, and 3 kg involuntary weight loss over the preceding 8 months with no fever, the patient was admitted to the hospital. On examination, the patient was in good condition, the temperature was 37.1簞C, the pulse rate 75 beats per minute, the blood pressure was 130/75 mmHg, and respiratory rate was 15 per minute. The oxygen saturation in ambient air was 98%, good oral and dental health. There was no superficial lymphadenopathy. There was no jugular venous distension. Auscultation of the heart revealed a mechanical second heart sound, a grade II/VI systolic murmur in the aortic area. No chest rales were detected. There were no conjunctival hemorrhages, Osler's nodes, Janeway's lesions, Roth's spots, splinter hemorrhages, or peripheral edema. The electrocardiogram showed a normal sinus rhythm with nonspecific repolarization abnormalities. Routine laboratory tests () were performed and revealed hemoglobin 12.8 g/L [13.5??7.5], platelet count 139,000 per mm3 [150,000??50,000], aspartate aminotransferase (AST) 61 U/L [<50 U/L], alanine aminotransferase (ALT) 73 [<50 U/L], alkaline phosphatase (ALP) 110 [<120 U/L], ferritin 418 ng/mL [24??36], C-reactive protein (CRP) 4.1 [<5.0 mg/L], erythrocyte sedimentation rate (ESR) 15 mm/hr [<20], and rheumatoid factor (RF) 318 U/mL [<14]. Electrolyte panel and urinalyses were normal. Serologies for HIV, HBV, HCV, Schistosoma, Borrelia, Rickettsia, Leishmania, and VDRL were negative. Serologies for CMV, EBV, and Toxoplasmose showed past infections. Widal and Huddlesson reactions and research of Plasmodium sppwere negative as well. Two sets of blood culture specimens exhibited no growth. Protein electrophoresis showed IgG-K/弇 monoclonal hypergammaglobulinemia. Abdominal ultrasound detected mild hepatosplenomegaly. Thoracic-abdominal-pelvic computer tomography disclosed gastric wall calcification and confirmed hepatosplenomegaly. To rule out endocarditis, transesophageal echocardiography was performed. Two very small echodense images suggestive of surgery-related alterations versus fibrosis were detected on the aortic cups (Figures and ). Fundus examination showed no retinal abnormalities. Liver biopsy revealed infectious hepatitis without pathognomonic features () and with no fibrin ring granulomas described in Q fever. EDTA-whole blood and paraffin-included liver biopsy were then sent to CEVDI/INSA for C. burnetii laboratory diagnosis. The serologic evaluation was performed by Indirect Immunofluorescence Assay (IFA) using the commercial C. burnetii I+II IgG/A/M Immunofluorescence kit (Vircell Microbiologists, Granada, Spain). It revealed a high anti-phase I IgG with an end-point titer of 204,800 suggestive of chronic Q fever (anti-phase I IgG ??00 was the reference cut-off, for results). C. burnetii active infection was also confirmed by molecular testing. For this purpose, genomic DNA was extracted from buffy coat and liver tissue using DNeasy blood & tissue kit (Qiagen GmbH, Hilden, Germany). The presence of C. burnetii DNA was screened by polymerase chain reaction (PCR) in a nested reaction using the primers pairs Trans1-Trans2 and Trans3-Trans4 that target a transposon-like repetitive region in the agents genome []. Specific DNA was detected in liver tissue but not in blood, and C. burnetii identity was confirmed by amplicon sequencing. The quality of DNA in both samples was previously verified by amplification of human 帣-actin gene as internal control. Moreover, the absence of bacteria in blood sample was reinforced by a negative result also obtained for the isolation attempt. In fact, an additional buffy coat aliquot was inoculated in DH82 cells, routinely used in CEVDI for C. burnetii isolation, and after a standard 60-day incubation at 37簞C and 5% CO2 atmosphere in BSL3 condition, no bacteria growth could be detected. The paraffin processing of the liver sample limited its utility for agents isolation. Final diagnosis of chronic Q fever was made, with histologically documented infectious hepatitis and endocarditis by modified Duke's criteria []. Our patient met one of the major criterion of Q fever endocarditis (C. burnetii serology with anti-phase I IgG titer >800) and three minor criteria (predisposing heart condition with biological prosthetic aortic valve, immunological phenomena with RF positive, vascular phenomena with leukocytoclastic vasculitis). Furthermore, we probably may consider the valvular alterations detected by transesophageal echocardiography as a minor criterion (echocardiographic findings not meeting a major criterion). Antimicrobial therapy with doxycycline 100 mg bid, and hydroxychloroquine 200 mg tid was started and the patient became asymptomatic within 8 days. The patient is still being followed in our out-patient clinic and he is adhering to treatment. He remains well and his weight gradually returned to normal (75 kg-Bode Mass Index 23,1), 8 months after the diagnosis. The titers of antibodies to C. burnetii have been falling in response to therapy. Results of the periodical serological tests are summarized in , together with results of the laboratory tests ().

Paisleigh Hardy

1997/12/23

387-603-5208x109

taylorphillips@example.net

9279 Williams Mill Suite 450

A 70-year-old male presented to our outpatient department with anorexia and weight loss during the last three months. He was diagnosed with myelodysplastic syndrome a year ago and was treated accordingly by a hematologist. The physical examination was noncontributory. The medical history of the patient revealed right nephrectomy 22 years ago owing to renal cell carcinoma; grade 2 (according to Fuhrmann grading system) and T1b (TNM staging system for kidney cancer, 7th edition). His blood glucose was elevated. Liver function tests, serum amylase, bilirubin; CEA and CA 19-9 were within the normal limits. Ultrasound examination of the abdomen revealed a large mass at the region of the pancreatic head. Contrast-enhanced computed tomography of the abdomen was performed, which confirmed a 9 ? 5 cm lesion at the head of the pancreas (). Due to his medical history of a right nephrectomy 22 years ago owing to renal cell carcinoma, a CT scan of the brain and the thorax was performed, which was negative for metastases. The patient underwent a pancreatoduodenectomy with pylorus preserving (Longmire-Traverso) in order to remove the tumor. The postoperative period was uneventful, and the patient was released from our department 7 days after his operation. Histopathological evaluation showed a 9 ? 5 ? 4 cm solid lesion with areas of hemorrhage and necrosis (). The lesion was composed of solid sheets of cells divided by bands of fibrovascular tissue into large nests and alveoli. The cells showed moderate clear-to-granular eosinophilic cytoplasm with well-defined cell borders. The nuclei were central and pleomorphic with conspicuous nucleoli. The lesion was surrounded by a thick collagenous capsule and completely separated from the pancreatic tissue with no infiltration. The morphology was identical to that of the primary renal tumor which was reviewed. A final diagnosis of metastatic clear cell renal cell carcinoma of the head of the pancreas was reached (Figures and ). The surgical margins were free of tumor. The followup of the patient was every 6 months for the first 2 years and then annually. The patient remains free of symptoms and without recurrence of the primary tumor three years after his treatment.

Jayceon Willis

1997/11/21

2137444539

sawyersamantha@example.net

563 Solomon Greens

A 27-year-old, otherwise healthy normal male presented to the reconstructive surgery clinic of Hazrat Fateme hospital. His problem first appeared about 11 years ago, as a small pink lesion on the hard palate and a simultaneous scaly papule on the anterior chest. Several hospital admissions and therapies including antibiotics did not have any effect on the disease. The lesions grew gradually interfering with oral function and finally the diagnosis was confirmed through pathologic and mycological studies. The biopsy results are discussed later. All other test results including blood biochemistry, hematology, sexually transmitted disease (STD) serology, urine analysis and microbiology, and stool exam were within normal limits. Moreover, intact cell mediated immunity was revealed. Imaging studies showed the extent of mass growth and the involvement of surrounding bone. The mass was resected sacrificing the involved soft tissue and bone, and the palatal defect was covered by means of local tissue, only to fail. The patient received Amphotericin B and Itraconazole according to a protocol provided by clinical mycologists of the department of infectious diseases (, ). Finally, after confirming the disease free margins of the defect, the decision to employ free tissue transfer was made. To cover this 38 by 42 mm three-dimensional defect in the palate, a well vascularized thin tissue providing viable skin was needed. Along the length of the pedicle was an issue to facilitate microsurgical transplantation. Thus, a free radial forearm fasciocutaneous flap was chosen (). The patient underwent surgery once the necessary tests were run and the patency of the ulnar artery and deep palmar arch was confirmed preoperatively. The flap was dissected on the nondominant limb in a distal to proximal direction on its radial artery pedicle and venae comitantes. After preparation of the Facial vessels as the recipient vessels, the flap was harvested and transplanted. The nasal lining was restored by split thickness skin graft. The patient received postoperative care and was discharged after the donor site dressing and immobilizing splint were removed, and scheduled for several office visits. The histological finding in the biopsy specimen was that of a granulomatous reaction characterized by formation of pseudotubercles containing giant cells, and a focal round cell infiltration in the superficial portions of the specimen. The fungi appeared in clusters of brown, spherical cells with thick, dark cell walls and coarsely granular pigmented protoplasm. The cultural characteristics were also studied. The colonies produced black, slow growing, heaped-up colonies and the Cladosporium type of sporulation was noted. The last specimens obtained before the final reconstructive procedure showed eosinophil rich acute inflammation without any fungal infection. Cultures obtained as the reference method were all negative.

Alexa Kerr

1990/9/24

(771)384-2382x0558

leonardschwartz@example.org

26712 Michael Glen

A 38-year-old man reported with a swelling in the medial aspect of the right thigh for the past 10 months. The swelling was gradually increasing in size. There was no history of trauma or fever. The history of pain was present in the thigh. On the examination, a non-tender swelling felt in the subcutaneous area of the right medial aspect of the thigh. Swelling was firm in consistency, which was free from the underlying structures. Blood tests were within normal limits. Ultrasonography (USG) revealed a cystic lesion of a size of approximately 5 x 7 cm in the subcutaneous area of the right thigh (). There was evidence of multiple daughter cysts within the cystic lesion along with few floating membranes. Probable diagnosis of subcutaneous hydatid cyst was made. The rest of the organs were normal. On the computed tomography (CT) of the thigh, there was a well-defined cystic mass in the antero-medial subcutaneous area of the left thigh. Bones and muscles of the rest of the thigh were normal. The patient underwent surgery with a probable diagnosis of hydatid cyst. On exploration, a cystic mass was revealed in the subcutaneous area of the right thigh. On cut section of the cyst, its color was white. The skin was closed primarily after thorough wash. On histopathological examination, diagnosis was made as hydatid cyst. The postoperative period was uneventful and the patient was discharged on albendazole at a dose of 400 mg. In follow-up of 8 months, the patient was asymptomatic without any recurrence.

Louie McGuire

2005/5/8

325-984-9682

joshualeonard@example.com

32408 Coleman Brook Suite 248

A 10-year-old boy presented with a 2-weeks history of tenderness and induration in the medial aspect of the right knee, after a fall on his leg. Physical examination revealed a 5 cm round, mobile mass, well circumscribed, without localized pain to palpation. The patient had no symptomatology before the traumatism. An X-ray of the right knee and its laboratory values including VSH, CRP, HLG, serum calcium, alkaline phosphatase, phosphorus, magnesium, were normal (). The IRM of the right knee revealed an oval soft tissue mass (6,5/3,5/1,5cm) on the medial side of the right knee. The lesion exhibited hypointense signal on MR T1-weighted images, isointense signal on MR T2-weighted images and moderate enhancement after injection of gadolinium (). The incisional biopsy revealed multiple reddish nodules, well circumscribed. The first histopathology examination established the diagnostic of villonodular synovitis. The second look, in the other department established the diagnostic of glomangyoma. In the meantime, the tumor developed outside the skin and became mushroom-like, painless (). After 2 months, we performed a surgical excision, followed by another histopathological examination. A histopathological diagnosis of glomus tumor was made. The postoperative evolution was very good, without local recurrence after complete excision.

April Becker

1981/8/13

(234)234-9526x956

lorithompson@example.org

097 Kelli Points Suite 338

A 34-year-old HIV-1-infected woman was admitted for dyspnea and acute bilateral pneumonia. HIV-1 infection had been diagnosed 8 years earlier during pregnancy, when she received only mother-to-child antiviral infection prevention. When her virus load (VL) reached 100000 copies/ml and CD4-cell count fell to 270/mm3 HAART with efavirenz, tenofovir and emcitrabine was started on 16 July 2008. Eight days later, she complained of fever and a persistent cough. Because no clinical improvement was obtained after 5 days of self-administered amoxicillin?lavulanate and ofloxacin, she was admitted; her chest X-ray showed bilateral interstitial pneumonia. Her diagnostic work-up found polypnea, cough and fever at 41簞C, and a biologically severe inflammatory syndrome (C-reactive protein: 190 g/dL) without eosinophilia. Arterial blood-gas determination showed severe hypoxemia PO2 45.6 mm Hg. The thoracic computed tomography (CT) scan revealed multifocal areas of branched centrilobular nodules and patchy ground-glass opacities with few lobular reticulates (Fi), without cavitation, pleural involvement or mediastinal lymphadenopathy. Bronchoalveolar lavage (BAL) cytology showed 950,000 cells/ml: 33% macrophages, 16% neutrophils, 8% eosinophils, no mast cells and 43% lymphocytes, with a CD4/CD8 ratio of 0.6. Direct BAL microscopy was negative for Pneumocystis jiroveci cysts, Mycobacterium species, Candida and viral inclusions. Histological examination of bronchial biopsies showed aspecific chronic inflammatory infiltrates. At this time, her HIV-1 VL was 5,322 copies/ml and CD4 T-lymphocyte count had reached 510/mm3 (25%). Because of the worsening of the pulmonary function, the patient was transferred to the ICU and improved rapidly, when HAART was interrupted, under cotrimoxazole and steroids (1mg/kg/day) initiated for suspected IRIS, unmasking of PJP, which was subsequently confirmed, after the elimination of other possible diagnoses, by both BAL positive Pneumocystis-DNA polymerase chain reaction amplification and careful microscopic reanalysis showing a few parasitic cysts.

Lawson Gonzales

1993/1/29

641.383.9152x9050

pamelawoodward@example.com

47558 Mendez Rapids Apt. 491

A 90 days old female patient, according to information given by the mother, had shown progressive signs of difficulty in swallowing and breathing, together with repeated incidences of cough and vomiting. The constant refusal to suck the pacifier and to be breastfed, meant that it took a long time to feed the baby. The medical report informed that there was a delay in weight gain. At the first medical examination, a voluminous and mobile tumoral alteration was noticed on the dorsum of the tongue, resting anteriorly, but it wasn? possible to stipulate whether it extended to the oropharyngeal area. A new exam was set and when the computer images were obtained ??for which the patient was sedated under spontaneous breathing ??a pediculated mass with a cylindrical body could be seen (phallic). It was located longitudinally on the dorsum of the tongue, with its base placed in the median furrow, at an almost equal distance between the apex of the tongue and the foramen cecum. The lesion was mobile to any direction, composed of a soft consistency, yielding to traction and with color and texture similar to those of the oral mucous membranes (Figure ). Computed topography images were obtained. Through the use of a non ionic oral radiocontrastant a polipoid lesion was clearly distinguishable on the dorsum of the tongue, measuring 2,1cm x 0,8cm. The use of an oral radiocontrast allowed not only for the delimitation of the lesion's contours, but also, its dynamics, demonstrating its movement from the dorsum of the tongue to the oropharyngeal area, suspending the soft palate (Figure ). Surgery was performed under general anesthetic, using nasotracheal intubation. A complete resection of the pedicle was performed, involving, in depth, the fibers of the superior longitudinal muscle of the tongue. After the hemostasis, the procedure was concluded with layer sutures to isolated points. The surgical specimen was stored in a 10% buffered formaldehyde solution and sent for anatomopathological analysis (Figure ). On the macroscopic examination a polypoid fragment of light brown tissue covered by a grayish and wrinkled mucous membrane was observed, measuring 0,8 x 0,9 x 0,8 cm. At the sections, in turn, it shows a bright light brown color. The microscopic examination revealed a polipoid lesion lined with keratinizing squamous epithelium, containing stroma, besides connective and adipose tissue, smooth and striated muscle and salivary glands (Figure - a,b,c,d). The postoperative period evolved without complications. In the five-month follow up there wasn? any recurrence and the patient, therefore, was considered free from the lesion.

Hadley Reed

1980/10/3

375-425-0321x017

nkennedy@example.com

5324 Janice Park

ZM, a 37 year old multiparous woman from Northern Tanzania, presented with complaints of generalized body swelling associated with progressive weight gain for ten years. The onset coincided with her last child birth which was complicated by mild post-partum haemorrhage following which she failed to lactate. She also experienced cold intolerance, loss of libido and a complete cessation of her menses. Four years prior admission she had had a serious febrile illness following which she experienced a brief period of altered level of consciousness and transient aphasia; since then she noted slowing of speech. As part of her systems review, she reported an anterior neck swelling which increased during her last pregnancy then gradually subsided a few months later. She also reported headaches of moderate intensity but no gross visual changes; she suffered from occasional rashes in sunlight exposed areas but no mucosal ulceration. Her past medical history revealed no previously diagnosed chronic illnesses; she was sero-negative for HIV and syphilis. Her obstetric history revealed she had a parity of five with four living children (one still birth at term with no obvious congenital malformations noted). Since she had received no formal antenatal care, there were no records of blood pressure measurements during pregnancy. All were home deliveries in the absence of a qualified birth attendant. Vitals: Pulse: 70/min; BP: 102/68 mm Hg; Temp: 36.2 degrees C; Respiratory rate 14/min. Orthostatics: Supine BP 110/80 mm Hg, standing BP 95/60 mm Hg. General/ endocrine: overweight woman (BMI 29. 1 kg/m2), looking younger than her stated age. She was pale with generalized, non-pitting edema involving face and extremities. Of note she had no oral ulcers and her thyroid gland was not palpable. She had ?labaster??skin with patchy hair loss over scalp; sparse axillary and pubic hair. Cardiovascular: Regular rate and rhythm with distant heart sounds. Respiratory/Abdominal exams were unremarkable. Neurologic Exam:Higher centres: Fully oriented to time, place and person but with marked slowing of speech and mentation. Cranial nerves: Optic nerve- Visual acuity 20/30 both eyes; gross visual fields normal at bedside. Fundoscopy: no papilledema noted. Extra-ocular movements were intact. Motor: Limbs hypotonic; power reduced to grade 4/5 MRC (Medical Research Council grade) with proximal weaker than distal muscle groups. Reflexes: Ankle jerks were delayed and plantar responses flexor. Sensation was normal for all modalities tested. Please see Table . Minor field defects were noted in both temporal fields. Chest X-ray: cardiomegaly, small left sided pleural effusion; Echo: 15 mm pericardial effusion, normal left ventricular function; X-ray of Sella: no evidence of mass lesion, symmetric floor (Figure ); Non-contrast axial head CT scan: possible asymmetric density within the sella turcica (but no ?mpty sella??sign); dorsum sellae poorly visualized (Figure ). The patient was started on hormone replacement therapy including thyroxine 50 mcg daily, prednisone 5 mg AM and 2.5 mg PM and a combined oral contraceptive. During her stay in the wards the patient? condition deteriorated abruptly due to an adrenal crisis probably precipitated by the vigorous thyroid hormone replacement. The dose of thyroxine was lowered to 25 mcg daily and the patient kept on normal saline and IV hydrocortisone 100 mg 6hourly. In addition, severe hyponatremia should be managed with water restriction and hypertonic saline infusion; the latter was avoided because of the difficulty monitoring Na+ levels and the associated risk of osmotic demyelination syndrome. Upon discharge three weeks later her rate of speech, mentation and exercise tolerance was significantly better compared to admission. On a two-month follow-up visit, there was a marked reduction in the generalised edema. The thyroxine dosage was subsequently increased gradually to 100 mcg daily. Her hair pattern had normalized in three months. At her five-month follow up visit, it was noted that she had developed livedo reticularis over her lower extremities bilaterally. (Figure ) She was subsequently started on anti platelet therapy (junior aspirin 75 mg daily) and the oral contraceptive stopped. The livedo reticularis had disappeared on a subsequent visit. At 16 months, the patient was in good general health except for a headache and occasional palpitations. At this juncture, the thyroxine dose was lowered to 75 mcg daily. This patient has anterior pituitary insufficiency beginning in the post partum period. Neurohypophyseal involvement is unlikely given the persistently elevated urine specific gravity even post steroid therapy which essentially rules out diabetes insipidus. The most likely differentials are lymphocytic hypophysitis (LyHy) and Sheehan? syndrome. An underlying co-morbid auto-immune condition such as systemic lupus erythematosus (SLE) or anti-phospholipid syndrome is a relevant clinical consideration but is made less likely given her negative antibody screens. Neoplasms and other granulomatous disorders of the hypophysis (tuberculosis, syphilis, sarcoidosis and histiocytosis X) are also possibilities but would be lower on the list of differentials in the absence of appropriate clinical and laboratory evidence.

Easton Hebert

1982/3/10

001-871-481-0146

steven65@example.org

819 Kevin Drive Suite 020

A 45-year-old woman was presented at the emergency department because of respiratory insufficiency. Her past history revealed allergic asthma with recurrent bronchitis. Five days before presentation, she developed a fever and diarrhea. The day before admission, she was seen by her general practitioner who prescribed Augmentin for a respiratory tract infection. Her chest X-ray showed complete opacification of the left lung (Figure ) with a differential diagnosis of pleural effusion, pneumonia, or complete left lung atelectasis. Because of progressive respiratory failure, she had to be intubated. Bedside ultrasound with a 5-MHz probe (GE FPA 2B 5 Mhz microconvex ultrasound probe, GE Healthcare Diagnostic Imaging, Hoevelaken, The Netherlands) parallel to the ribs in the anterior lower and upper thorax was conducted (Figure ). This revealed no pleural effusion but an irregular hypoechogenic area with air bronchograms and many hyperechogenic spots. The CT scan performed afterwards showed a practically complete consolidated left lung compatible with pneumonia.

Kyleigh Barron

1994/7/23

001-526-932-3601x19663

yarnold@example.com

17361 Campbell Gardens Apt. 608

A 16-year-old man was transferred from another hospital in cardiogenic shock which resulted from idiopathic dilated cardiomyopathy. He was supported with venous-arterial extracorporeal life support (ECLS). He required therapeutic anticoagulation because of the ECLS. There were intermittent problems with oxygenation that recovered spontaneously. After a few days, he continued to have low saturation with diminished breath sounds at the left side of the chest. A chest X-ray (Figure ) showed opacification of the whole left lung with the differential diagnosis of pleural effusion or total atelectasis of the left lung. Bedside ultrasound with a 5-MHz probe (GE FPA 2B 5 Mhz microconvex ultrasound probe) parallel to the ribs of the anterior lower and upper thorax revealed total left lung collapse and a surrounding hypoechogenic area suggestive of pleural effusion (Figure ). The pleural line was not visible in the collapsed lung. This patient was treated with bronchial suction by bronchoscopy and nursing in the right-sided position. A rigid sputum plug was removed from the left main bronchus. After this, the chest X-ray appeared nearly normal, indicating that the therapy had been effective.

Dustin Dodson

1986/3/2

604-434-9553

michaelryan@example.com

866 Avery Lock Suite 865

A 60-year-old female presented with 4-week history initially of dry cough and night sweats with subsequent nausea and weight loss. Her past medical history, social and occupational history, and systematic questioning did not reveal further relevant information; neither headache nor visual disturbance was noted. Her drug history included Rosuvastatin 10 mg daily, Glucosamine 500 mg thrice daily, Ibuprofen, and Salbutamol inhaler as required. She had a temperature of 39簞C and physical examination was unremarkable. There was no temporal tenderness and no limb girdle tenderness or weakness. Fundoscopy showed normal vessels. Initial laboratory tests showed raised CRP 335 mg/L and ESR 62 mm/hr with elevated liver enzymes showing a mixed picture with total Bilirubin 8 弮mol/L, ALP 589 U/L, GGT514 U/L, ALT 112 U/L, AST 47 U/L, and albumin 36 g/L. Chest X-ray was reported as normal. Ultrasound scan (USS) of abdomen showed a stone in the gall bladder with a normal common bile duct. Magnetic resonance cholangiopancreatography (MRCP) confirmed USS findings and showed a normal biliary tree. Her atypical infective screen was negative including blood cultures, and a serologic screen for viruses, atypical bacteria, and fungi. Her liver screen including hepatitis serology and autoantibody screen was negative. CT scan of chest, abdomen, and pelvis showed a spiculated nodule in the posterior region of the apex in the left upper lobe of the lung. Bronchoscopy was unremarkable and the washings of left upper lobe lesion were negative. The lesion was considered to be longstanding and related to previous resolved inflammation. She continued to be pyrexic with worsening liver functions. She then underwent liver biopsy which showed lobular granulomatous inflammation with no significant Kupfer activity or inclusions (). A whole body positron emission tomogram (PET) showed increased metabolic activity within central large vessels; thoracic and abdominal aorta; proximal carotids and subclavian arteries (). These findings were strongly suspicious of a large vessel vasculitis. Temporal artery biopsy confirmed giant cell arteritis (). Treatment with steroids resulted in prompt resolution of her symptoms and normalizing of CRP, ESR, and liver functions. A followup PET scan in 2 months showed complete resolution of previous abnormalities confirming a positive response to treatment.

Etta Lawrence

1989/10/14

(215)235-0831

shannonweaver@example.net

9036 Mendez Forest Suite 260

A 62-year-old female with ulcerative colitis in remission was found to have a 20 mm submucosal protuberance at the appendiceal orifice during surveillance colonoscopy (). EUS (12 MHz TTS mini probe, Olympus America, Center Valley, PA) demonstrated a hypoechoic lesion with an anechoic heterogeneous center in the appendix (), suggestive of mucocele. Patient underwent a successful laparoscopic appendectomy. Histology revealed mucinous cystadenoma of proximal appendix.

Kaleb Marks

1982/6/25

001-920-430-5378x58573

sarah63@example.net

7769 Brown Bridge

A 34-year-old female undergoing colonoscopy for evaluation of bloody diarrhea was found to have mild pan colitis (biopsy revealed ulcerative colitis) with an incidental finding of a bulging appendiceal orifice (). EUS revealed an anechoic and homogeneous lesion measuring 20 mm in thickness with well-defined borders and lack of invasion to nearby structures (). The mass was suspicious for appendiceal mucocele. Patient underwent appendectomy without any complications. Histological examination of the resected appendix revealed adenomatous changes with nuclear hyperchromasia and elongation, best seen at crypt bases with abundant mucin (Figures and ). In addition, there is depletion of the normal underlying population of lymphocytes. This set of findings is consistent with the diagnosis of appendiceal mucinous cystadenoma.

Monica Greene

1981/8/30

521-625-2355

susanwagner@example.com

98082 Williams Points

A 15-year-old boy without any medical history was referred to our hospital for osteomyelitis of the sternum and a subcutaneous abscess extending over half of the anterior chest wall. The patient's chest had been elbowed by an opponent during a basketball game 19 days earlier. He stated that there were no abrasions or lacerations at the time of injury, but 10 days later, he developed chest wall swelling () and fever. He consulted a local orthopedist and underwent chest computed tomography (CT), leading to provisional diagnosis. The chest mass was punctured, and the pus was drained. Subsequently, the patient was sent to our hospital. Chest CT revealed a sternal fracture and extensive fluid collection in the chest wall (). Increased density of the region behind the sternum was also observed, but we concluded that inflammation had not affected the anterior mediastinum. Because the patient did not appear severely ill, we performed pus drainage from a minimal incision and subcutaneously applied a 19 Fr silicone drain connected to a closed drainage system (BLAKE drain and J-VAC Reservoir; Johnson and Johnson Medical, Tokyo) under general anesthesia. The drained material yielded a Staphylococcus aureus isolate on microbiological culture; this culture was sensitive to all antibiotics tested. The patient was treated by intravenous administration of sulbacillin for 2 weeks, followed by oral administration of tosufloxacin for 10 days. The drain was removed on postoperative day 14. The patient was discharged on postoperative day 26, and antibiotic therapy was discontinued. While infectious granulation was observed at the drain tube-penetrating site for a few months after discharge, complete epithelialization of the site was confirmed 4 months after the surgery. Follow-up CT performed 4 months after surgery showed disappearance of fluid collection and ossification of the fracture site (). The patient did not show any symptoms and signs of recurrence 6 months after the surgery.

Griffin Phillips

1990/6/14

7234822846

stephen55@example.org

415 Alexander Parks Apt. 634

A 39 y/o male patient presented with a 2-month history of decreased vision, halos, pain, and photophobia of the left eye. The patient was diagnosed with keratoconus at age 16, for which he used rigid contact lens in the left eye, with a best corrected visual acuity (VA) of 20/60. The patient's past medical history revealed that he had a complicated vaginal delivery with the use of obstetrical forceps. Clinical examination showed a VA of 20/400 in the left eye with a refraction of ??.00 + 5.00 ? 095 and a stable VA of 20/20 in the right eye with a refraction of ??.00 + 0.50 ? 180. Slit lamp biomicroscopy displayed corneal stromal and epithelial edema associated with centrally located parallel vertical opaque lines at the level of Descemet's membrane (). The right eye had no corneal changes and the intraocular pressure and the posterior segment examination was unremarkable in both eyes. Further studies included a corneal topography (Orbscan) that ruled out keratoconus and showed regular astigmatism of 5.7 D at an axis (097簞) that correlated with the location of the striae on slit lamp, and an anterior segment OCT that showed hypereflective linear structures protruding into the anterior chamber at the level of the posterior cornea. A diagnosis of corneal edema secondary to endothelial decompensation in the left eye secondary to forceps injury and history of Descemet's membrane break was made. The patient underwent a Descemet's stripping automated endothelial keratoplasty (DSAEK) in order to replace the diseased posterior corneal lamella that included a Descemet's membrane previously traumatized by the obstetrical forceps, and an endothelium that had undergone gradual decompensation. The stripped Descemet's membrane was submitted for histopathological evaluation. The patient had good visual outcome after DSAEK with BCVA of 20/80. Slit lamp examination revealed a well appositioned graft, and a clear cornea with minimal superficial scarring (). Mild superficial corneal scarring and preexisting amblyopia limited final visual acuity. Histological examination of the stripped Descemet's membrane revealed endothelial attenuation and a thickened PAS-positive membrane with areas of nodular thickening at the edge of the initial break composed of concentric deposits of PAS-positive material ().

Naomi Vance

1985/2/15

+1-335-805-7222x811

freemanchristopher@example.com

260 George Squares

A 54-year-old man presented with small seropurulent discharging lesion located at the junction of upper one-third and lower two-thirds of the anterior border of the sternocleidomastoid muscle (). The lesion started as a small nodule three months back which busted after two weeks and resulted in a small ulcer with seropurulent discharge. Patient did not have previous history of swelling in the neck. Examination of the oral cavity was normal. Clinically, the possibility of brachial fistula or tubercular sinus was considered. Biopsy was taken from the fistula, which revealed chronic inflammation and no evidence of tuberculosis. A fistulogram showed that the fistulous tract was communicating with the submandibular duct (Wharton's duct) (). No stone was detected on the X-ray. The diagnosis of orocutaneous fistula with communication with the submandibular duct was hence made. Excision of the submandibular gland and the fistulous tract was carried out. The tract was found to be communicating with the submandibular duct and a small stone was present in the duct just distal to the point of communication between the fistulous tract and the submandibular duct. Postoperative recovery of the patient was uneventful.

Casen French

2002/10/1

383-526-7763x218

cooksamantha@example.com

14439 Betty Locks

A 23-month-old girl presented to our facility with one week of worsening fevers, productive cough, and increased work of breathing. Over the previous 3 months, she was treated for presumed upper respiratory tract infections with inhaled beta-agonists, inhaled steroids, oral steroids, and several different oral antibiotics. Relevant medical history was significant for prematurity and severe anemia necessitating intrauterine blood transfusions, CDA diagnosed at 20 months by bone marrow biopsy and aspiration that was morphologically consistent with type II, and surgical placement of a Port-a-Cath for chronic blood transfusions. Initial vital signs were temperature 37.9 degrees Celsius, heart rate 156 bpm, respiratory rate 50/min with oxygen saturation 83% on room air and 98% on 1 LPM oxygen by nasal cannula, and blood pressure 115/61 mm Hg. She appeared in mild distress with increased work of breathing. She had moderate frontal bossing with open anterior fontanelle. Heart examination was significant for a II/IV systolic ejection murmur. Lung exam revealed diffuse rales bilaterally but no wheezing. Abdomen was not distended. The liver was palpated 4 cm below the costal margin, and the spleen palpated to the level of the umbilicus. She had no clubbing, cyanosis, or peripheral edema. Chest radiograph showed diffuse ground glass alveolar infiltrates which were chronic in nature when compared to a chest X-ray from one year prior (). Blood, urine, and respiratory cultures were sent, and the patient was started empirically on oral azithromycin and parenteral ceftriaxone. On day 3, a transthoracic echocardiogram revealed a patent foramen ovale but no cardiomyopathic process. An abdominal ultrasound confirmed hepatosplenomegaly. Repeat chest X-ray showed no changes, and chest CT was offered but the parents refused. Despite 4 days of antibiotics, the patient continued to spike intermittent fevers and was still on oxygen treatment, and there still were no changes on chest radiograph. Bronchoscopy was performed and was anatomically normal. The bronchoalveolar lavage (BAL) fluid was cloudy in appearance and revealed no evidence of aspiration or malignant cells. Grocott's methenamine silver (GMS) stain was negative for Pneumocystis jirovecii. Ziehl-Neelsen stain was negative for acid-fast bacilli (AFB). Fungal, bacterial, AFB, RSV, and influenza cultures of BAL fluid revealed no growth. Differential of the WBCs indicated 68% macrophages, 12% PMNs, and 10% lymphocytes. Light microscopic examination of BAL fluid using Periodic acid-Schiff (PAS) stain was positive for abundant amorphous material within the pulmonary macrophages and also in larger extracellular aggregates suggesting pulmonary alveolar proteinosis (). The lipid-laden macrophage (LLM) index was 120 []. On day 5, the patient's work of breathing improved, lung sounds improved, and the supplemental oxygen was decreased to 0.5 LPM by nasal cannula. Antibacterials were discontinued. On day 7, BAL fluid was positive for cytomegalovirus (CMV) by indirect fluorescent antibody testing and serum CMV IgG and IgM antibodies were detected by immunoassay, while CMV DNA of the blood remained negative. Ophthalmologic examination revealed no signs of CMV retinitis. The patient was started on parenteral ganciclovir. On day 9, the patient was weaned off supplemental oxygen to room air. She continued IV ganciclovir and was discharged from the hospital. After completion of two weeks of ganciclovir, the patient presented to her hematologist's office for scheduled followup and blood transfusion. Chest X-ray was repeated and showed minimal interval improvement in the diffuse coarse reticular opacities noted on X-ray from her most recent hospitalization. Again, the parents refused CT scan. The patient was subsequently lost to followup. Several months later she was admitted to a hospital in another state in respiratory failure. Per report, she required intubation and BAL was performed, which confirmed PAP.

Lorelai Duke

1985/4/5

813.572.8372x99775

ericreyes@example.com

54234 Waters Mills

The patient is a 55-year-old female with known stage III b serous ovarian cancer. She had undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy, followed by 6 cycles of carbo/taxol chemotherapy with complete clinical response. She was free of disease for 2 years until her disease recurred and was treated with Carboplatin and Taxol. The carboplatin was eventually switched to Doxil. However, the repeat positron emission tomography (PET) scan at that time showed progression of her disease. Thus she underwent exploratory laparotomy with removal of a splenic mass. She was noted to have peritoneal carcinomatosis at that time and was then treated with Gemzar. The patient had stable disease after this treatment. Five years after the initial diagnosis, the patient was admitted to the hospital with anemia, hemoglobin of 7.0 gm/dl, fatigue, and melena. Computerized Tomography (CT) of the abdomen without IV contrast was obtained on admission, which revealed calcified, heterogeneous, mixed intermediate and high-density deposits worrisome for peritoneal carcinomatosis (, arrows). No IV contrast was administered due to her poor kidney function. She was referred for an EGD, which showed a 7 mm erythematous lesion at the gastroesophageal junction and a 1.5 to 2 cm subepithelial mass () with a superficial overlying erosion in the antrum, but no obvious source for any active bleeding. Initial endoscopic biopsies of the gastroesophageal junction lesion showed granulation tissue polyp with foveolar hyperplasia, and the antral biopsies were normal. Due to the presence of a subepithelial lesion in the antrum, the patient was referred for EUS. Two subepithelial lesions were discovered by EUS, one in the antrum measuring 3.4 ? 3.7 cm () and one in the body of the stomach 1.2 ? 0.8 cm (). The lesion in the body of the stomach was not appreciated during the EGD. The lesions were hypoechoic masses emanating from the muscularis propria and had the typical appearance of gastrointestinal stromal tumors. FNA was performed of both masses. Both sites revealed papillary adenocarcinoma from an ovarian papillary serous adenocarcinoma primary (). Immunostains for progesterone receptor, estrogen receptor and p 53 were focally positive and confirmatory. The patient was treated with Taxol and is undergoing surveillance imaging.

Kalel Copeland

1979/3/8

913.587.9767x677

tonirogers@example.net

2805 Kurt Gateway

A twenty-year-old Cameroonian woman, gravida 1 para 0 presented at 35 weeks gestation to the antenatal consultation unit of our hospital with an unusually distended abdomen, for her first antenatal care visit. Her past medical history revealed a herniorrhaphy three years prior to this consultation, for a congenital umbilical hernia. On physical examination, the patient's general condition was satisfactory. She was afebrile with a pulse rate of 70 beats per minute and a blood pressure of 100/60 mmHg. She had moderately colored conjunctivae and her cardiopulmonary examination was normal. Her abdomen was unduly distended around the central area, with a hyperpigmented necrotic scar overlying the paraumbilical area. Abdominal palpation revealed complete absence of abdominal wall around the paraumbilical area overlying the uterus. This hernia orifice was about 15 cm by 10 cm. Most of the gravid uterus protruded via this orifice in a standing position (). The fundal height was estimated at 32 cm. The foetal lie was longitudinal, and foetal parts could easily be palpated across the herniated gravid uterus. Foetal heart sounds were regular and there was no evidence of uterine contractions. The skin around the hernial sac was hyperpigmented, necrotic, and very tense. Vaginal examination revealed a firm, long, median, and closed cervix; the rest of the clinical examination was unremarkable. Blood and urine analysis were within normal limits. Our hospital did not dispose of an ultrasound machine for further foetal evaluation. We discussed the possibility of hospitalisation and an elective caesarean section but the patient declined the proposal due to financial constraints and chose to return home against medical advice. Topical antiseptics were given to the patient to apply on the abdominal skin, and the next visit scheduled in one week. She however presented three weeks later at the maternity in active labour. Clinical evaluation revealed foetal bradycardia with a foetal heart rate at 90 beats per minute. An emergency transverse lower segment caesarean section was performed under general anaesthesia (for acute foetal distress). The incision was paramedian, avoiding the necrotic zones. Just beneath the skin was a large round umbilical hernial sac containing the gravid uterus. We found remnants of the chromic catgut sutures used to repair the umbilical hernia three years ago. We did a transverse lower segment incision on the uterus extracting a live male foetus weighing 3400 g. The APGAR scores were 5 and 7 at the first and fifth minutes, respectively. The placenta was anterior corporeal. Following satisfactory haemostasis on the uterus, we concomitantly repaired the hernial orifice. This was done by excision of all zones of necrotic tissue, reduction of the hernia sac, end-to-end approximation of the orifice borders, and reinforcement of the rectus abdominis muscles. Excess and necrotic skin was removed before closure of the skin. The surgery lasted close to two hours. The postoperatory period was uneventful; the wound healed by primary intention, and the patient was discharged on the eighth day postoperation. She was seen six weeks later during her postpartum visit. She was enjoying relatively good health, her scar was well healed, and her baby was doing well.

Dayana Robinson

1993/6/24

001-867-258-7571x21877

morganerickson@example.com

626 Bates Mews

A 23-year-old woman in her first pregnancy with an ordinary follow-up and no previous medical history attended our ultrasound unit for a 20-week scan. The sonographic findings (levorotation of the cardiac axis, pericardial effusion, large overriding aorta, perimembranous ventricular septal defect, and narrow pulmonary artery) (Figures and ) diagnosed tetralogy of Fallot. The right atrium was slightly enlarged, and the fetus presented dysplastic (multicystic) kidneys with oligohydramnios (). Due to the dreadful prognosis, the parents decided to terminate the pregnancy. The postmortem study confirmed the sonographic findings; however, it showed a right-sided aortic arch and an abnormal cloacal septation (imperforate anus with a sigmoid colon opening in the posterior side of the bladder) (Figures and ), which was not seen prenatally. Although the FISH showed only two copies of the X chromosome probe, with absence of a SRY marker, an external male genitalia with hypospadias was present (). Internally, the uterus and fallopian tubes were missing and only two small streak ovaries with oogonia at both sides of the bladder were seen. Genetic test was also performed to rule out microdeletions in the chromosome 22 and mutations in the genes causing 21-hydroxylase-deficiency. All with negative results.

Matthew Bass

1991/6/25

001-250-985-5637x645

katherinemorgan@example.net

326 Patrick Club Apt. 452

A 51-year-old female patient was attended at the Otorhinolaryngology Clinic of the University of Campinas Teaching Hospital (Campinas, Brazil) on November, 2009, for an oral cavity verrucous lesions evaluation (). Patient reported that she had the lesions since birth and they were presenting a painless progressive slow growth in the left hemiplate and bilateral superior labiogingival sulcus. Physical examination showed nasal columella involvement, extending throughout the upper lip, soft and hard palate, and oropharynx with total preservation of the facial midline. At the age of 16, patient had a left parotid gland myxoid tumor, being submitted to a partial parotidectomy surgery. After two years, the tumor returned, and she had another surgery. During the new operation, the left facial nerve was injured, resulting in an ipsilateral peripheral facial paralysis. After the procedure, patient received adjuvant radiotherapy. There are no data regarding the palate lesion pattern before or after these treatments. However, the patient and her family did not reported any lesion change during the subsequently years. After 11 years since the first procedure, the patient attended at the Otorhinolaryngology Clinic for a palate lesion evaluation. An incisional biopsy was made and the histopathological result reported presence of both gingival e palate tissues with stratified and cornified epithelium, severe hyperplasia, and mild chronic inflammatory infiltration (Figures and ). The analysis showed no signs of malignancy or external agent infections (e.g., Candida spp, HPV). The final diagnosis was oral linearepidermalnevus. The follow-up decision was to do lesions evaluations every six months. During the first period, the lesions remained the same. Patient is currently under the Otorhinolaryngology Clinic care.

Zahra Maynard

2002/5/8

(886)618-0572x2652

cherrydaniel@example.com

309 Eileen Course Apt. 827

A 26-year-old male patient was diagnosed as AML-M2 in 1995. Following an induction regimen he achieved complete remission (CR) and received an allogeneic peripheral blood stem cell transplantation from his 37-year-old HLA identical brother in 1997. The conditioning regimen consisted of busulfan and cyclophosphamide, and the GVHD prophylaxis was done with cyclosporin and short-term methotrexate. He did not develop any acute or chronic GVHD and remained in CR with complete donor-type chimerism until 2008 when he was admitted to the neurosurgery clinic with back pain. The vertebral MRI revealed a tumor invading the 6th thoracic vertebrae causing pathological fracture. The tumor was completely excised, and the pathological evaluation was consistent with CD38++ and CD117+ atypical plasma cell infiltration with kappa monoclonality. He had IgG kappa monoclonal gammopathy on immune electrophoresis and an elevated erythrocyte sedimentation rate along with a mild anemia and normal renal function tests. Bone marrow (BM) examination revealed 9% plasma cells with CD38+CD138+CD19?D56?D44+CD28?D20??immunophenotype and kappa predominance. The cytogenetic study did not detect any abnormality. Bone marrow chimerism analysis was consistent with 100% donor type in both T-and non-T-cell lineages. Chimerism study was also done with the DNA extracted from the plasmacytoma and revealed 18% donor and 82% recipient cells (). The presence of EBV could not be demonstrated in BM or plasmacytoma by in-situ hybridization for EBV early RNA as well as PCR analysis of EBV DNA. The donor was also found to be negative for signs of secretory paraproteinemia. The patient received 3000 cGy local radiotherapy to T5?7 level of the spine and high-dose oral dexamethasone. After attaining a CR, it was decided to perform an allogeneic HCT without immunosuppression, instead of the general approach of autologous transplantation, since he had complete donor type of chimerism. Following a nonmyeloablative conditioning with fludarabine and melphalan a hematologic engraftment was achieved. The BM and blood examinations revealed CR for myeloma and a continued complete donor-type chimerism. The patient developed a grade 2 acute GVHD of skin which was controlled with steroids, but acute grade 3 gastrointestinal GVHD required the addition of cyclosporin. Later immunosuppression could be tapered off completely without causing rebound GVHD. He continued in CR until one year after transplantation when he developed progressive mucor sinusitis and infectious meningitis and eventually died.

Landry Pugh

1988/9/26

(504)329-2421x7527

pdalton@example.com

381 Thomas Islands

A 39-year-old Japanese woman with a history of one miscarriage at 6 weeks' gestation had become pregnant under anticoagulation treatment of 2500 U danaparoid sodium because of her osteoporosis and osteonecrosis of femoral head and 100 mg aspirin per day from 4 weeks' gestation at Nagoya City University Hospital. She has had a 22-year history of SLE, which had been in remission for more than 4 years under a treatment of 5 mg prednisolone daily. At this point, our case was not diagnosed with APS, because she suffered from only one miscarriage. However, we planed to do anticoagulant treatment during pregnancy, because her lupus anticoagulant (LA) [] was ascertained to be strongly positive by diluted activated partial thromboplastin time (aPTT) methods and diluted Russel's viper venom time (RVVT) before pregnancy. Prednisolone therapy was interrupted before this pregnancy because the patient thought it affected infertility. Her edema and protein urea appeared at 17 weeks' gestation (). Her blood pressure was 121/78 mmHg and laboratory studies showed anti-帣2-glycoprotein I (帣2GPI) 9.4 U/mL (normal range < 1.9), aPTT 30%, LA by aPTT 30 seconds, LA by RVVT 1.47, and urinary protein 2.0 g/day at 17 weeks of gestation. At 21 weeks of gestation, she had body edema and protein urea (8.1 g/24 h). Laboratory studies were shown in . At 21 weeks of gestation she was hospitalized because of severe edema and acute renal dysfunction, and treatment of 40 mg prednisolone daily started at 22 weeks of gestation. She had developed epigastralgia and vomiting. Thrombocytopenia and hemolytic anemia together with liver and renal dysfunction and an elevated level of C-reactive protein were observed (). At 22 weeks and 6 days of gestation, emergency cesarean section was performed because of fetal distress with loss of variability and severe late deceleration, abnormal Doppler flow velocimetry waveform analysis suggestive of fetal hypoxemia, and the HELLP syndrome. The baby was weighting 414 g, and the clinical manifestations were morphologically normal. Four days after birth the baby died of pulmonary hemorrhage. Placental infarction was pathologically found. Her laboratory examinations showed liver dysfunction, and the data from coagulation studies indicated the diagnostic criteria for DIC. Intravascular infusion of nafamostat methylate together with antibiotics, gamma-globulin 15 g, and platelet transfusion gradually improved the clinical symptoms and laboratory abnormalities. The patient had no fever or persistent epigastralgia. Her blood pressure was 140/92 mmHg and pulse was 118 per min under antihypertensive therapy. Her renal biopsy showed lupus nephritis INS/RPS class IV with mesangial interposition, massive subendothelial, subepithelial and mesangial deposit, fibrinoid necrosis, karyorrhexis, swelling of endothelial cells, and foam cells. The patient was diagnosed MAPS. Then multitarget therapy (prednisolone, cyclosporine, and mizoribine) was started. Presently, the patient is now being treated as an outpatient who is asymptomatic, while continuing treatment with cyclosporine A (75 mg/day), mizoribine (100 mg/day), and prednisolone (25 mg/day). Anticoagulation with warfarin (2 mg/day) was started to a target international normalized ratio (INR) of 2-3.

Landry Cain

1996/9/3

782.573.4663x08385

donald07@example.org

2521 Ayala Trail

A 45-year-old male was transferred to our facility from an outside institution with the diagnosis of TEF and the presence of a possible foreign body seen on CT scan of his chest. The patient gave a history of recurrent pneumonia and cough in the last few months. Prior to presentation to the hospital, the patient had finished a course of antibiotics. Despite this, he complained of increasing cough over the prior week but no history of dysphagia, hemoptysis, hematemesis, or chest pain. The physical exam was unremarkable except for inspiratory crackles and diminished breath sounds heard at the lung bases. Axial CT images of the chest both with and without intravenous contrast were obtained. A small, linear, walled air collection was noted just above the carina tracking towards the esophagus, a finding suspicious for a tracheoesophageal fistula (). Under sedation and spontaneous ventilation, bronchoscopic and endoscopic examinations were performed. A hard, disc-shaped foreign body was impacted in the esophagus and was also protruding into the lumen of the distal trachea (see ). Gentle attempts to remove the FB were unsuccessful and aborted. Two days later the patient underwent a thoracotomy for foreign body removal and TEF repair. Mask ventilation was easy with low positive inspiratory pressures. A left double lumen tube was placed via direct laryngoscopy. With fiberoptic bronchoscope (FOB) allowing for direct vision, the bronchial lumen was advanced into the left main stem bronchus with subsequent deflation of the right lung. With the double lumen ETT in position, ventilation of only the left lung avoided any air insufflations through the fistula into the esophagus (due to the anatomical location of the fistula 1 cm above the carina). The patient was placed in the left lateral decubitus position and the ETT placement again confirmed with the FOB. Surgical approach was via right thoracotomy, with removal of the foreign body and primary repair of both the trachea and the esophagus. After the surgery the patient resumed spontaneous ventilation and was extubated prior to transfer to the ICU. Pathology confirmed that the foreign body was a dental plate. Later, the patient revealed that after an appendectomy 5 years ago, he could not find his partial dental plate.

Benson Tang

1979/12/22

858-879-9608x698

campbellryan@example.net

886 Lisa Forge

A 37-year-old man developed alopecia totalis, loss of eyebrows and eyelashes and widespread thinning of the hair since 31-years-old with no personal or family history of vitiligo. He had been treated with corticosteroid with diagnosis of AA with good response to the treatment but due to adverse effects, the treatment was discontinued and DPCP 0.5% for 4 months (once a week) in hair loss regions was commenced following washing the areas 5 hours later with no prior sensitization that resulted in the first sign of hair regrowth in early fourth week and nearly total hair of head with regrowth of eyebrows, eyelashes and beard at the third month. Some vitiligo patches were revealed on his scalp and arm distant from the location of DPCP application and they preceded by contact dermatitis of the scalp (Figures and ). Then dark hair in the depigmented patch was gradually replaced on the scalp with white hair. Complete blood count and biochemical profile were normal and antinuclear antibody test was negative but antithyroid peroxidase was in high range (29.7; normal ranges up to 16) in this case.

Belle Bowman

1977/11/12

+1-827-754-6966x2300

melissabaird@example.net

3420 Christopher Square

A 42-year-old woman with 25 years history of hair loss and a mean duration of 3 months DPCP therapy before the onset of vitiligo is the second case. The first presentation of the disease was generalized hair loss. She had been treated with corticosteroid with the diagnosis of AA for several years but due to low effectiveness, the treatment failed. She complained of coin shape hair loss in her scalp and body since 17-years-old. In physical examination rounded irregular patches varying from 1 to 2 cm mostly in occipital and parietal regions were observed. She had no personal or familial history of vitiligo. In our center, the patient was treated with intralesional corticosteroid and topical minoxidil but due to the remain of hair loss patches, topical DPCP 0.5% was prescribed once a week without prior sensitization. The treatment resulted in the first sign of white hair regrowth at the 6th week, and some vitiligo patches appeared on the scalp with even white and dark hair, as well as on her face, after 5 months distant to the site of application. A marked reaction with macular erythema was obvious on her scalp after the first time application of DPCP but it subsided a few days later. There has been no relapse of alopecia in several months followup after discontinuing of DCP therapy and the depigmented areas remained unchanged. A growth of dark hair within the vitiliginous patch on both patients was probably due to activation of follicular melanocytes by a nonspecific effect of contact dermatitis. Vitiliginous patches at the sites of contact with DPCP may be the consequence of postinflammatory hypopigmentation.

Francisco Evans

1998/7/9

+1-852-319-8583x425

jennifermcdonald@example.net

52480 Joseph Corners Apt. 925

A 24-year-old man presented at our clinic with a four-year history of a painful nodule in his left cheek that reoccurred after two attempted excisions in the last four months by different specialists. No biopsy result or other histological information was available. Otherwise healthy, the patient complained of pain and local tenderness. Clinical examination revealed a well-defined, round, firm nodule in the middle of the left cheek, approximately 1 ? 1 cm in size that appeared to be subdermic with no apparent fixation to the underlying tissues. The overlying skin was normal and the nodule was extremely painful on palpation. Examination of the oral cavity was normal and no neck lymph nodes could be palpated. Complete head and neck examination and laboratory tests were also unremarkable. Contrast enhanced CT (puffed cheek method) revealed a well-defined, contrast-enhanced, round soft-tissue mass of the left cheek over the buccinator muscle measuring 13.8 ? 9 mm, with no apparent relations to the surrounding tissues (). Attached to it a very small satellite lesion was noted. In the operating room under local anesthesia, a relatively wide excision in order to remove both the masses was performed. Though we were not able to demarcate the main and satellite nodules macroscopically, no evidence of residual disease was apparent. Special care was taken regarding the protection of facial nerve branches and the cosmetic result. Histological examination of the specimen was consistent with the diagnosis of glomus tumor of the solid type, with no mention of potential residual disease (). The patient reported relief of his symptoms after surgery, but at 2-month followup he complained of gradual recurrence of local tenderness at the site of the excision. Three months later, the patient had a small palpable nodule and complete recurrence of his symptoms. Under local anesthesia, a very wide excision including the previous scar (with approximately 1 cm margin around the scar) was performed. Histological examination revealed glomus tumor with solid, angiomatoid, and angiomyomatous features (). The margins of the excision were reported as free of lesion. The patient remains without any symptoms nine months after surgery.

Eliana Avalos

2001/7/4

734-239-2066

harrisdebbie@example.com

305 Mccormick Rue Suite 514

A 65-year-old woman presented with a mass 6 cm in diameter located on her right frontoparietal region. The mass had appeared approximately three months earlier and had grown rapidly. The patient's history included resected colorectal adenocarcinoma followed by general surgery and was disease-free for five years. She was referred to us because the swelling and pain indicated a sebaceous cyst or a benign soft tissue tumor (). The mass was indurated, round, and adherent to the deep planes. Mild alopecia and skin expansion due to the mass were observed on her anterior scalp. The patient complained of tenderness and mild pain when the mass was palpated. Our clinical differential diagnoses included sebaceous cyst, lipoma, or localized soft tissue tumors. But the plain radiographs and the computerized tomography demonstrated a destructive mass which was eroding the bone over the right frontoparietal region (). A transverse incision and a meticulous blunt dissection that were performed under local anesthesia exposed a rubbery soft tissue mass extending to the outer table of the skull. The mass was dissected with care. However, we noticed calvarial bone destruction with an exposed duramater and lytic lesions 2 ? 3 cm in size around the calvarial defect. The mass was completely resected. The mass was measured to be 5.5 ? 5.0 ? 2.0 cm (). The damaged bone sites were resected with a 1 cm security margin. A section of the duramater measuring 2 ? 3 cm was removed and the defect was reconstructed using a tensor fascia graft by the brain surgeons. Hemostasis was achieved using electrocautery and bone wax. A bolster dressing was applied following the primary closure of the skin incision. The specimen was sent for histopathological analysis. The patient was monitored closely for one day and was discharged the next day. Histopathologic findings revealed many low differentiated adenoid, and apoptotic and necrotic spaces lined with atypical epithelial islands with vesicular nuclei. At high-power magnification, the specimens showed cytologic atypia with pleomorphic and hyperchromatic nuclei. Immunohistochemical analysis was positive for carcinoembryonic antigen (CEA), villin, and cytokeratins 7 and 20. The specimens were negative for vimentin, chromogranin, thyroglobulin, thyroid transcription factor 1 (TTF-1), and CDX2. The final diagnosis was metastatic low-differentiated adenocarcinoma compatible with the immunophenotype of colorectal adenocarcinoma (Figures , , and ). After the histopathological evaluation revealed metastatic adenocarcinoma, the patient was referred to the medical oncology department.

Coen Carlson

2005/8/25

473.344.9274

williamfloyd@example.org

34942 Robert Roads Suite 651

A 48-year-old woman presented with epigastric discomfort. Upper gastrointestinal (GI) endoscopy revealed severe mucosal atrophy in the gastric corpus. Magnifying endoscopy of the corpus revealed closely arranged small round and oval pits with a surrounding network of capillaries. In the antrum, both conventional and magnifying endoscopy demonstrated no abnormal features, and the patient was tentatively diagnosed as having autoimmune gastritis [?. Biopsy specimens were taken from both the antrum and the corpus. The histology of the antral mucosa was normal, whereas that of the corpus exhibited severe atrophy. The serum gastrin level was 4440 pg/mL (reference range: <200 pg/mL), and the level of antiparietal cell antibody was ?160 positive. The patient was negative for anti-intrinsic factor antibody and anti-H. pylori antibody IgG, and the urea breast test gave a result of 2.2??(reference range: <2.5??. The diagnosis of autoimmune gastritis was therefore confirmed.

Kali Adkins

1992/6/14

+1-868-265-8822x726

dillonstone@example.com

6673 Robert Lane

A 72-year-old woman presented for a routine health check. Upper GI endoscopy identified severe atrophy of the mucosa in the gastric corpus (), and magnifying endoscopy showed a pattern of closely spaced small round and oval pits (). Conventional endoscopy of the antrum demonstrated no abnormality, suggesting a diagnosis of autoimmune gastritis. As this endoscopic examination was part of a routine health check, no biopsy was performed. However, serum samples revealed a gastrin level of 1800 pg/mL (reference range: <200 pg/mL) and antiparietal cell antibody ?40 positive, with negativity for anti-intrinsic factor antibody and anti-H. pylori antibody IgG. Autoimmune gastritis was therefore confirmed.

Kylo Stafford

2002/2/22

+1-861-844-4669x7855

manuel77@example.org

528 Reilly Loop Suite 202

A 58-year-old man had been found to have gastric nodules by X-ray and endoscopic examinations at another hospital. During the endoscopic examination, three nodules were biopsied and one was suspected to be a carcinoid tumor. The other two were diagnosed as atrophic gastric mucosa. A conventional endoscopic reexamination at our hospital revealed multiple nodules on the greater curvature of the corpus (), one of which was reddish ( yellow arrow). Magnifying endoscopy showed that this reddish nodule had a gyriform-like structure with an irregular vascular pattern (). Based on the magnifying endoscopy findings, the reddish nodule was diagnosed as a carcinoid tumor, and this was subsequently confirmed by histological examination of a biopsy sample. Conventional endoscopic examination of the corpus demonstrated severe atrophic gastritis (). Magnifying endoscopic examination of the other nodules revealed closely arranged small round pits () and a pattern of closely arranged small round and oval pits was also observed in the mucosa surrounding these nodules (Figures and ). Thus, magnifying endoscopy was able to show that this characteristic pit pattern was present even in the atrophic mucosa of the corpus, leading to a diagnosis of autoimmune gastritis associated with a carcinoid tumor. Analysis of the patient's serum showed a gastrin level of 2700 pg/mL (reference range: <200 pg/mL), antiparietal cell antibody ?80 positive, positivity for anti-intrinsic factor antibody, and negativity for anti-H. pylori antibody IgG. The reddish nodule and some of the surrounding nodules that showed closely arranged small round pits were treated by endoscopic mucosal dissection (ESD). The reddish nodule was 3 mm in diameter and histological examination confirmed that it was a carcinoid tumor. The other small nodules showed remnants of fundic glands within the atrophic mucosa ().

Bridget Huber

1988/12/20

(579)355-8943x6502

dgordon@example.net

4539 Joseph Bypass Apt. 951

A 58-year-old female had lumbar pain and shortness of breath at the time of admission. Medical history revealed the patient being under medical treatment for chronic obstructive lung disease. A slight limitation in lumbar movements was determined by physical examination. Routine laboratory tests were normal. Further radiological evaluation included ultrasonography (US), color Doppler ultrasonography (CDUS), thoracoabdominal magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP). The balanced turbo field echo (BTFE-BH SENSE) sequence on MRI (Figures and ) revealed following findings: the aorta, aortic arc, and apex of the heart were located on the right-hand side, and the inferior vena cava, stomach, and spleen were located on the left-hand side according to the midline. The liver was located in the midline, but it was left-dominant liver. The position of the gallbladder was right-hand sided under the liver. The pancreas was located on its normal position in the midline. The spleen had three foci (polysplenia) and was in a settled position on the left-hand side under the liver. The right renal vein which was retroaortic has passed posterior to the aorta and drained into the inferior vena cava. The small and large intestines seemed to have some degree of malrotation. It was observed that the large and small intestines were predominantly settled in lower right region and upper left region of the abdomen, respectively. Color Doppler ultrasonography showed that the inferior vena cava and aorta flows were on the opposite side of the normal location (). On MRCP, the liver was observed to be left dominant located, and common bile duct was lying towards the inferomedial from the left-hand side.

Mac Potts

2005/3/19

(393)832-6135x70628

danielhodges@example.com

20009 Chase Square Suite 279

43-year-old female, previously healthy, presented with episodic severe pain affecting her right 4th finger for many years. The involved area is specific to the extent that the patient can pinpoint the exact area. The condition provoked by pressing on that area and by cold exposure. The attack manifests with pain followed by a color change of the finger (blue then red), only at the distal phalanx, and attacks last about 10 to 20 minutes. She is a housewife with no history of trauma or paraesthesia. She is not on long-term medications and has no symptoms suggestive of connective tissue disease. On examination, skin examination was normal with no localized tenderness or swelling. Tinnel and phalen tests were negative. MRI () showed a small lesion measuring 0.6 cm ? 0.6 cm subjacent to the nail bed of the fourth finger. On T1-weighted images, the lesion appears of low signal. On T2 sequences, the lesion appears of bright signal. After i.v. gadolinium administration, the lesion appears intensely enhanced. The MRI findings were going with the diagnosis of glomus tumor. The patient referred to a hand surgeon and surgical excision, and histopathology confirmed glomus tumor. Patient recovered well, and, within 10 days, pain subsided, and Raynaud's phenomenon resolved.

Ellison McIntyre

1994/9/12

543-635-3116

alexander96@example.com

1768 Cochran Junction Apt. 165

A catheter was inserted for intravenous hyperalimentation into the right femoral vein of a 77-year-old man with a cerebral hemorrhage. Hyperalimentation was started after the position of the catheter was confirmed by a plain radiograph (). Antibiotics (PAPM/BP) had been used for the laryngitis by the otolaryngologist for 9 days and stopped. The patient developed fever, subcutaneous swelling, and redness in right lower quadrant of the abdomen 11 days later (). An axial abdominal computed tomographic (CT) scan for suspected phlebitis and cellulitis revealed that the catheter was located in the right inferior epigastric vein. Swelling of the adjacent right lower rectus abdominal muscle and subcutaneous tissue was also evident (). Intravenous hyperalimentation was stopped and the catheter was removed. Subsequently, the subcutaneous swelling and clinical redness disappeared within a few days. We did not use any antibiotics for the cellulitis.

Eliseo Hall

2004/6/14

265.710.3746

cynthia42@example.com

8933 Bean Island

A 53-year-old woman without significant past medical history developed an asymptomatic left-sided supraclavicular mass. A core needle biopsy showed sheets of large neoplastic cells that were positive for CD15 and CD30 and negative for CD45, consistent with classical Hodgkin Lymphoma, nodular sclerosis, grade 2. Imaging also revealed nonbulky disease in the anterior mediastinum, and no bone marrow biopsy was performed (). The patient declined conventional therapy, instead seeking 5 months of alternative treatments without response. Her disease remained stable, and thus she continued to decline therapy. Five years later, she developed pruritus, night sweats, and dysphagia. One year later, she developed progressively severe dysphagia with a 12 kg weight loss, significant dyspnea, productive cough, and was admitted to the hospital to receive intravenous antibiotics for pneumonia. Imaging revealed significant adenopathy in the neck, mediastinum, and abdomen, groin as well as hepatosplenomegaly (). In addition, she had partial compression of the superior vena cava and trachea by the mediastinal mass, cavitary lesion in the upper lobe of the right lung, and evidence of tracheoesophageal and tracheomediastinal fistulae (arrow in lower ). Excisional biopsy of a supraclavicular lymph node showed sheets of Reed-Sternberg cells with focal necrosis and dense but limited fibrosis. The large neoplastic cells were positive for CD15 and CD30 but negative for CD20 and CD45, consistent with classical Hodgkin lymphoma, nodular sclerosis subtype. Bone marrow examination was without disease. A bronchoscopy and barium swallow () identified fistulous tracts connecting the trachea with the esophagus and the mediastinum. A gastrostomy tube and tracheal stent (covered and self-expanding, Microinvasive, Boston Scientific, Natick, MA) were placed to minimize the risk of recurrent aspiration pneumonia. Despite requiring supplemental oxygen and weighing only 39 kilograms, therapy was initiated 73 months after her initial diagnosis with doxorubicin, vinblastine, and dacarbazine (AVD). Bleomycin was not given due to lung disease and oxygen requirement. She had minimal therapy-related toxicities which responded well to supportive care. After 2 cycles of therapy, restaging studies showed a 75% decrease of her mediastinal mass, but the fistulae remained unchanged. Her cough significantly improved and oxygen requirement normalized. She continued on therapy, completing 8 cycles and gaining over 5 kilograms. Restaging CT scans demonstrated a near complete resolution of her mediastinal disease and fistulae, and no other disease was noted. A posttreatment PET/CT demonstrated a non-FDG avid residual mediastinal mass. At restaging imaging 3 months later, the mass persisted unchanged and the patient declined biopsy or further intervention. Approximately two years after completing therapy, she remained without disease but had frequent upper respiratory infections. Her stent was exchanged, and eventually removed. After removal, her frequent infections disappeared. She remains without evidence of disease six years removed from initiation of therapy and eleven years from diagnosis.

Leah Leon

1998/3/13

001-328-676-1604x3915

christine60@example.com

860 Chapman Center

A 71-year-old female with multiple myeloma (MM) IgG/lambda stage III A (II ISS) presented to routine follow-up seven years after 3 cycles of VAD (vincristine, adriamycin, dexamethasone) induction, ciclophosphamide and stem cell harvest followed by autologous stem cell transplantation (ASCT) conditioned with melphalan 200 mg/m2, complaining of a moderate pain in her right ribs and pelvis. Radiographs showed multiple stable osteolytic lesions in her spine, pelvis, ribs, and skull, when compared to those obtained 18-month before. An MRI of her spine confirmed the stability of bone lesions compared to the previous one done one year before. Bone marrow biopsy showed 10% of monoclonal plasma cells. Serum monoclonal component was stable (IgG 0.8 g/L). CT/PET using 18F labelled with Fluorodeoxyglucose (18F-FDG) as positron-emitting radionuclide () showed three hypermetabolic focal lesions in the fifth right rib (thick white arrows), D10 vertebral body (thin white arrow), and right ischium (black arrow), with standardized uptake value (SUV) of 14.8 (normal cut off 2.5), 3.3, and 9.3, respectively. Considering the moderate pain and in order to test unique lenalidomide efficacy in bone lesions, after signed written informed consent, the patient was treated uniquely by lenalidomide (25 mg/day, 1 to 21 every 28 days, for a total of 6 cycles). We avoided dexamethasone use on purpose, as well as bisphosphonates to show drug efficacy. Six-month follow-up PET-CT showed a complete disappearance of the lesions (), that was confirmed one year later.

Marshall Enriquez

2000/8/13

796-704-6152x1632

randy45@example.net

5045 Kristen Station

In February 2010 a 48-year-old man was admitted to our hospital for fever and jaundice appeared few hours after the twelfth BCG bladder instillation because of urothelial carcinoma of the bladder diagnosed two years earlier. The patient was known to our department for a diagnosis of follicular lymphoma made ten years before, and treated with six cycles of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone) plus Rituximab (Mabthera簧-Roche), an anti CD20 antibody. At admission the patient was in fair general conditions but feverish (38,5簞C); physical examination revealed scleral and skin jaundice, painful hepatomegaly on palpation, while pulmonary examination was unremarkable and the patient had no peripheral lymphoadenopathy. Complete blood count revealed only a mild hypocromic microcytic anemia with normal platelet and WBC count. Blood chemical assays showed abnormal liver function tests (ALT 265 UI/L, ASL 406 UI/L, serum alkaline phosphatase 785 UI/L, gamma-glutamyl-transferase 370 UI/L, total bilirubin 4,71 mg/dL), elevated LDH (639 UI/L), beta2-microglobulin (6,6 mg/L) and C-reactive protein (92.4 mg/L). Tumor markers were within normal range. Routine blood and urine cultures did not yield any common pathogens and the results of serologic tests in order to assess virus and bacteria exposures were negative. An abdominal ultrasonography confirmed mild hepatomegaly in association with splenomegaly (diameter 13 cm). Chest X-ray showed diffuse bronchial walls thickening and a focal opacity with air bronchogram in the left lower lobe, expression of a possible exacerbation of a concomitant chronic obstructive pulmonary disease. Despite empirical broad-spectrum antibiotic therapy with piperacillin/tazobactam, the patient? clinical conditions progressively deteriorated and he experienced worsening of fever (40簞C), thorax pain and worsening dyspnoea requiring oxygen supply. A high-resolution chest CT-scan was carried out, that confirmed a diffuse and bilateral hazy increase of lung density (?round glass??opacity), especially in the bases, and the presence of diffuse and bilateral multiple micronodules with random distribution, with thickening of the interlobular septa and a left lower lobe consolidation (). A bronchoscopy was carried out and samples of broncho-alveolar lavage were sent for microscopy and culture. To exclude a relapse of his hematological disease, the patient underwent bone marrow trephine biopsy: no evidence of lymphoma relapse was found in his bone marrow specimen, which instead documented multiple aggregates of epithelioid histiocytes setting up for a granulomatous myelitis (); finally, because of a continue and gradual increment of liver function tests, particularly of serum alkaline phosphatase (1124 UI/L), and gamma-glutamyl-transferase (481 UI/L), a liver biopsy was performed, whose histological examination documented the presence of several non-caseating epithelioid granulomas with Langhans giant cells revealing a granulomatous hepatitis (). Because of the concomitant radiological findings documented at CT chest scan, suggestive for miliary lung involvement (), a systemic infection caused by BCG was suspected on the basis of the recent intravesical administration of BCG and the worsening patient conditions, despite several days of antibiotic treatment. An accurate research of acid-fast bacilli was performed in blood, bone marrow, urine, feces, sputum, biopsy specimens, and broncho-alveolar lavage (BAL) by cultures, PCR analysis and Ziehl-Neelsen staining, with no evidence of Mycobacterium spp. Of note a high CD4/CD8 ratio was found in BAL samples (22.73, normal value 1??); the tuberculin skin test using 2 UI of purified protein derivative (PPD) and the interferon-gamma release assay (Quantiferon) were negative. So that, although acid-fast bacilli were not elsewhere isolated and blood and bone marrow taken at the same time were PCR negative, ten days after admission an antituberculous treatment was started with isoniazid, rifampicin, and ethambutol, to which ciprofloxacin and corticosteroids were added. After 15 days of antituberculous therapy, fever and dyspnoea subsided and liver-function tests markedly improved along with the patient general well-being. The patient discharged home for the full six-month course of his treatment, at the end of which he was healthy, with complete normalization of inflammation signs and liver function tests, and disappearance of pulmonary nodules and parenchymal abnormalities and of bone marrow granulomatosis, documented at radiologic and histological exams.

Nellie Willis

1989/9/1

(475)798-7335

wmaxwell@example.com

02598 Henderson Locks Suite 701

A 54-year-old male patient was admitted complaining of fever, coughing, headache and sputum during the previous month. He had a two-week history of oral amoxicillin clavulanate (1 gr, twice daily) and ciprofloxacin (500 mg, twice daily) use. He was diagnosed with stage two chronic lymphocytic leukemia (CLL) one year prior to admission. Chemotherapy or any immunosuppressive treatment including steroids had not been administered to the patient during his follow-ups. He did not have any CLL complications. A physical examination was performed, and he had a body temperature of 38.5 繙C, a blood pressure of 135/80 mmHg and a regular pulse rate of 100 beats per minute. The pathological findings of the examination included cervical lymphadenopathy and right basal crackles upon auscultation of the lung. A neurological examination revealed a normal, oriented man without neurologic deficits. Laboratory tests revealed a hemoglobin level of 9, 3 g/dl, a white blood cell count of 58.900/mm3 (86% lymphocytes) and a platelet count of 159.000 cells/mm3. Serum glucose, electrolyte and kidney function tests were normal. A peripheral blood examination demonstrated lymphocyte predominance and the presence of basket cells. Urinalysis and urine and blood cultures were negative for any microorganism. Cefepime (2 grams, three times daily) was administered intravenous to the patient in addition to oral clarithromycin (500 mg, twice daily). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) rapidly increased, and we decided to cease clarithromycin on the first day of treatment. The patient? fever remained on the fourth day of treatment, and we replaced cefepime with vancomycin and carbapenem. Thoracic computed tomography (CT) exhibited parenchymal infiltration. A brain CT scan revealed normal findings. Due to an on-going disturbance in the liver function tests, vancomycin treatment was ceased on the second day. The patient? condition did not improve with these treatments, and he continued to have temperatures up to 39 C. In the meantime, the patient? condition was complicated with Coombs positive hemolytic anemia, and daily prednisolone was administered for two weeks (60 mg on the first three days, followed by 30mg/day). The patient? headache did not resolve during his hospitalization, and on the 21st day after admission, the patient lost consciousness. While blood cultures from the early period of hospitalization were negative, a blood culture obtained on the 18th day of hospitalization revealed mucoid yeast colonies on the 3rd day following collection. A lumbar puncture sample contained 20 leukocytes/mm3 and, 100 erythrocytes/mm3, and the protein and glucose levels were 36,2 mg/dl and 26 mg/dl respectively. Encapsulated budding yeast cells resembling Cryptococcus were observed using an India ink preparation. The blood cultures were continuously monitored using an automated blood culture system (BACTEC 9000/BD), and Sabouraud dextrose agar (SDA; 4%) and inhibitory mould agar (IMA) were used for CSF culture. Inoculated culture media were evaluated after 72 hours and morphology results from cornmeal?ween 80 agar and the API ID 32C system (bioMerieux-USA) were used for identification. Cryptococcus neoformans was identified as the offending pathogen, and it was separated from Cryptococcus gattii by growth features on canavanine-glycine-bromothymol blue (CGB) agar. Amphotericin B was started at a dose of 0,8 mg/kg. However, the patient? condition did not improve, and he died one day after treatment initiation due to respiratory failure and septic shock.

Remington Woodard

1986/8/2

274-298-4588x96125

robert63@example.org

7679 Ashley Mountains

Here, we describe a rare occurrence of PML, with a rapidly fatal outcome, in 59-year-old woman who underwent UCBT for Follicular Non Hodgkin Lymphoma in January 2011; she was in complete remission (CR) confirmed by the PET scan after 5 lines of treatment. At transplantation, no organ dysfunction was present. The reduced intensity conditioning (RIC) regimen consisted of total body irradiation (2 Gys in 1 fraction), Fludarabine at 40 mg/m2/day for 5 days, and Cyclophosphamide at 50mg/Kg/day. A total nucleated cell dose of 3.3 107/kg body weight was infused on day 0. The cord blood unit and the patient were HLA matched 4/6 with mismatch of locus A and B. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine A at 3 mg/kg/day, and Mycophenolate Mofetyl (MMF) at 500mgx 4/day, beginning on day -3. Neutrophil engraftment (>0.5 ? 109/L) occurred on day 26. On day 35, the patient presented a skin grade 2 acute GVHD reaction, without other organ dysfunction, and 2 mg/kg methyl-prednisolone was started; a rapid clinically response was observed. On day 51, the patient developed CMV reactivation detected by quantitative polymerase chain reaction (PCR) in the peripheral blood with 1359 copies; and an antiviral treatment with Gancyclovir (Cymevan) 2.5 mg/kg/day was administrated after adaptation with her renal function. On day 68, at the time of her outpatient visit, she developed confusion, short-term memory dysfunction, and altered mental status, with focal signs and abnormal Babinsky reflexes on the left, and lack of the force on the thighs lower limbs. A brain computed tomography (CT) scan demonstrated no specific findings. The patient was described as cachectic, alert, awake, and oriented to person, time, and place. Her speech was fluent; comprehension, naming, and repetition were intact. Examination of the cranial nerves showed mild drooping of the left angle of the mouth; all other cranial nerves were intact. Motor strength was 4+/5 on the left symmetrically in the upper and lower extremities and 5-/5 in the right extremities. Deep tendon reflexes were hyperactive, but no extensor plantar responses were recorded. The complete blood count and chemistry levels were normal, except for positive schizocytes. Blood urea nitrogen and serum creatinine levels were 15.9 mmol/L and 179 弮mol/L, respectively. The diagnosis of thrombotic microangiopathy was made in the presence of haemolytic anemia, thrombocytopenia, renal failure and presence of schizocytes in biological assessment. The patient received corticotherapy at 1mg/kg/day, and 5 plasma exchanges were made. The cyclosporine was discontinued and MMF treatment was continued. We assisted rapidly to a response of her haemolytic anemia, improved thrombocytopenia but without improvement of her neurological troubles. With worsening mental status on day 83, a magnetic resonance imaging (MRI) of the brain after gadolinium injection showed a non-enhancing hypo-intensity Image in (T1- sequence) beyond the white matter. However, after gadolinium injection showed an image in the axial (FLAIR sequence) showing hyper-intensity lesions in the white matter of the frontal lobes. There is no signal abnormality of the cortex. Note that there is no mass effect on the ventricular cavities or midline structures. Furthermore the MRI in B1000 diffusion sequence showed a restriction of diffusion in the damage areas of the white matter. On day 84, the patient? mental status was stable, and a lumbar cerebrospinal fluid (CSF) examination revealed a white blood cell (WBC) count of 1 cells/L, a normal Glucose level of 3.89 mmol/L and a normal protein level of 389mg/L. the mycological (aspergillosis, Cryptococcus), and Gram staining and culture were negative. A specimen was sent for polymerase chain reaction (PCR) analysis for JC virus was positive in the CSF and the serum (negative for CMV, VZV, HHV-6, EBV and herpes simplex virus by PCR). A treatment with 5 mg/kg/week of Vistid (Cidofovir) was initiated on day 86 associated with Mefloquine (Lariam簧) and Mirtazapine (Norset簧). It was around this time that the patient? general condition began to worsen. Acute deterioration of cognitive function occurred with confusion and autism. Because of CR of her GVHD; steroids were tapered and ultimately discontinued on day 97. An electroencephalogram demonstrated mild bi-frontal slowing, with diffuse brain damage, more prominent on the left than the right. Re-examination of CSF on day 93 revealed a WBC count of 3 cells/mL, a protein level of 323 mg/L, Glucose level of 5.08 mmol/L. JCV was positive in CSF by PCR. HHV- 6, CMV, HSV, VZV, EBV, enterovirus were negatives by qualitative PCR assay. PCR of the CSF for JCV conducted in the same laboratory as previously was positive, establishing the diagnosis. Throughout her hospital stay, the patient? neurologic condition continued to deteriorate. Her course was marked by an episode of altered mental status, progressive dementia, motor weakness, declining visual acuity and worsening performance status. In the light of clinical deterioration no further exams was performed in respect to the family? wish for no further intervention. She was continued to a skilled nursing facility in our unit, where she died one month after the diagnosis of PML, on day 110 after UCBT. Unfortunately we did not perform a neuropathologic examination of the brain by autopsy in respect to the family? wish.

Aubrie Waller

1993/3/13

325.478.5053x308

fischertimothy@example.net

4098 Amanda Forest Suite 668

A 25-year-old British male dived into hotel swimming pool in 1989 and sustained a C-6 fracture. Anterior fusion of the cervical spine was performed with a bone graft taken from the right iliac crest. This patient required tracheostomy for clearance of secretions. Neurological examination revealed tetraplegia at C-6 (American Spinal Injury Association Grade A). He has been managing his bladder by an indwelling urethral catheter. The catheter was changed every 4 weeks by a health professional. This patient could not recollect developing autonomic dysreflexia in the past. This patient rang the Spinal Injuries Centre on a Sunday in 2010 and informed the staff that his catheter was blocked. This patient was advised to come to the Spinal Injuries Centre immediately. This patient's brother brought him to the Spinal Unit within half an hour and he was attended to promptly. This patient looked well; he did not have sweating, headache, goose pimples or flushing of the face. He was alert and made the usual conversation about going to his favourite public houses for drinks. He was not breathless. He did not have increased spasms. This patient did not have to wait for any time. This patient's brother lifted him, put him on the bed and undressed him. The blocked catheter was removed. The external urethral meatus was cleaned with chlorhexidine prior to catheterisation. Then this patient, who was lying on the bed, said that the ceiling lights were very bright and glaring. Five milligrams of Nifedipine was given sublingually. This patient started having fits involving his head, face, neck and shoulders with loss of consciousness. A 14-French silicone Foley catheter was inserted per urethra without any delay and 300 ml of clear urine was drained. After this patient received Nifedipine, his blood pressure was 84/51 mmHg. A Venflon was inserted in his foot. Blood tests revealed: haemoglobin, 14.4 g/dl; white cell count, 11.3 ? 109/l; urea, 2.5 mmol/l; creatinine, 49 umol/l; glucose, 5.4 mmol/l. This patient recovered consciousness within 5 min. Two hundred forty milligrams of Gentamicin was administered intravenously, as spinal cord injury patients with blocked catheters are susceptible to developing urine infections. This patient recovered well and he was able to take his tea. This patient was admitted to the Spinal Injuries Centre for observation. A request was made for a brain scan for this patient. A blocked catheter and distended bladder led to autonomic dysreflexia and the patient developed convulsions. Computed tomography of the brain would show whether this patient had developed an intracranial bleed as a result of a transient hypertensive episode due to autonomic dysreflexia. CT of the brain revealed no focal cerebral or cerebellar abnormality. There was no intra-cranial haemorrhage. In order to prevent recurrence of autonomic dysreflexia due to a blocked catheter, it was decided to take possible measures to prevent blockage of the urinary catheter. He was advised to drink plenty of fluids. This patient was requested to get his catheter changed more frequently. In case of blockage of the catheter, this patient was instructed to take Nifedipine 5 mg sublingually in order to prevent a rise in blood pressure due to autonomic dysreflexia. This patient was advised to carry Nifedipine capsules with him at all times. His carers were trained how to administer Nifedipine sublingually. At present this patient was taking Oxybutynin 5 mg once a day. After discussing with him, this patient was prescribed 10 mg of modified-release Oxybutynin once a day. He was also prescribed an alpha-adrenoceptor blocking drug, Doxazosin modified-release 4 mg once a day. Doxazosin is likely to reduce the frequency and severity of autonomic dysreflexia. This patient was informed of the side effects of long-term indwelling catheter drainage. For example, long-term indwelling urinary catheters are often associated with problems such as urinary infection, blocked catheters and stones in the bladder. Intermittent catheterisation was preferable to long-term indwelling catheters. Unfortunately, this patient did not have carers who could perform intermittent catheterisations.

Marley Goodwin

2005/2/15

+1-707-749-7664x6359

elizabeth31@example.org

607 Allen Fall

A 51-year-old 75-kg man with a background history of ischaemic heart disease, chronic back pain, and depression ingested amitriptyline in excess of 43 mg/kg (> 65 ? 50-mg tablets) and unknown quantities of quetiapine, citalopram, metoprolol, quinapril, and aspirin in a deliberate act of self-poisoning. At ambulance arrival (time approximately 40 min after ingestion) he was agitated and poorly co-operative, with a heart rate of 160 bpm and blood pressure 100/70. En route to hospital he became unresponsive and then suffered a generalised seizure, which was terminated with 4 mg intravenous midazolam. On arrival to our tertiary care facility (time 60 min following ingestion), the Glasgow Coma Scale (GCS) score was three, temperature was 37.6簞C, pupils were dilated (4 mm), heart rate was 150 beats per minute, blood pressure was 112/82 mmHg, and serum glucose 14.0 mmoll-1. A 12-lead electrocardiogram (ECG; Figure ) revealed a wide complex tachycardia with QRS duration of 180 ms and a prominent R wave in aVR, supporting a clinical diagnosis of tricyclic antidepressant cardiotoxicity. One-litre 0.9% saline and 50 ml 8.4% sodium bicarbonate were administered intravenously. He subsequently underwent endotracheal intubation following administration of midazolam 5 mg and suxamethonium 100 mg. Mechanical ventilation was initiated and titrated to an end-tidal CO2 of 30 mmHg. A gastric tube was placed and 50 g activated charcoal instilled. A further 1-l 0.9% saline was administered intravenously and an additional 300 ml 8.4% sodium bicarbonate injected in divided aliquots (50 ml) to an arterial pH of 7.51 (serum bicarbonate 35.6 mmol/l, sodium 141 mmol/l, potassium 3.4 mmol/l). ECG QRS duration narrowed to 96 ms. However, despite 8 mg metaraminol delivered in 2-mg increments, the blood pressure deteriorated to 70/58 mmHg (pulse rate 130 beats per minute; Figure ) at time 115 min. Given the ongoing haemodynamic instability, a decision was made to undertake lipid rescue treatment while preparations were made for central line insertion and anticipated vasopressor infusion. At 115 min after drug ingestion, 100 ml 20% lipid emulsion (Intralipid簧, Fresenius Kabi) was injected over 1 min followed by a further 400 ml over 30 min. Following administration ECG QRS duration narrowed further to 80 ms, the heart rate was 120 beats per minute, and BP 140/80 mmHg. Serial ECG parameters (QRS duration, QTc) to 205 min are presented in Table . Thereafter the patient remained haemodynamically stable. He required no further inotropic/vasoactive medications at any point during his Emergency Department or ICU admission. Blood was drawn immediately prior to ILE administration, and at 5, 15, 35, and 90 min post ILE commencement (corresponding to 110, 115, 125, 145, and 205 min after initial ingestion) for later determination of plasma amitriptyline and triglyceride concentration. All samples were centrifuged at 3 000 g for 10 min effecting partial visual separation of more lipaemic plasma above from more aqueous plasma below. Blood was then frozen in an upright position to -15簞C before undergoing manual cleavage of separated plasma from the buffy coat and red cell mass. The upper 50% of centrifuged plasma (nominally top) was then separated from the lower 50% (nominally bottom) in an attempt to obtain contemporaneous samples exhibiting a gradient of lipaemia. All samples then underwent assay for plasma amitriptyline by high-performance gas chromatography with the mass selection method and plasma triglyceride estimation by a commercial laboratory. Plasma amitriptyline and triglyceride concentrations are presented in Table . The patient was subsequently transferred to the ICU with ongoing bicarbonate infusion. Serum lipase was 18 U/l (normal range 13-60 U/l) 24 h after lipid infusion. Electrocardiogram QRS duration was noted to have normalised completely on day 2. Extubation occurred on day 3 with ICU discharge on the same day following development of aspiration pneumonia requiring antibiotic therapy. He was discharged neurologically intact to the psychiatry service on day 7.

Shiloh Hall

1993/6/10

001-278-442-4948x61671

across@example.net

245 Christina Oval Apt. 473

The patient was a 76-year-old man whose chief complaint was difficulty in walking and pain in his right loin. His coexisting disorders included diabetes mellitus, hypertension, and alcoholic liver cirrhosis. He also had a history of gastrectomy for gastric cancer, subarachnoid hemorrhage, normal pressure hydrocephalus, and cerebral infarction. On admission, his body temperature was 35.9簞C; blood pressure, 113/80 mmHg; and pulse rate, 95 beats/min. He reported tenderness in his right loin, but there were no reddish areas or swelling. His laboratory data on admission were as follows: white blood cell count, 460 ? 102/弮l (neutrophils: 98.5%); hemoglobin, 7.5 g/dl; creatine, 3.5 mg/dl and C-reactive protein, 25.7 mg/dl. Abdominal computed tomography (CT) showed gas and fluid collection extending from the subcutaneous layer of his right loin to his retroperitoneal cavity (Fig. ). Based on these findings, we diagnosed necrotizing fasciitis. No connection was found between the necrotizing fasciitis and the gut and his appendix was not swollen. Therefore, a 10-cm incision was made in his right loin. Pus and foul-smelling gas were released, and the subcutaneous fat was debrided. Bacterial culture of the pus grew Peptostreptococcus micros, Peptostreptococcus sp., Prevotella disiens, and Escherichia coli. Antibiotic sensitivity tests for meropenem hydrate and clindamycin hydrochloride were positive. We irrigated the incised tissue and gave systematic antibiotic therapy (meropenem hydrate: 1 g/day, clindamycin hydrochloride: 1.2 g/day) for 10 days. His inflammatory response improved; however, the underlying cause of his condition could not be investigated effectively because he suffered epileptic seizures. About 3 months after his admission, sordes were discharged from the affected body part. Subsequently, an appendicocutaneous fistula was revealed by fluoroscopy-aided colonoscopy (Fig. ). An open laparotomy revealed strong adhesions between the terminal ileum and retroperitoneum. We found that the distal end of the vermiform appendix had adhered to the retroperitoneum and a fistula had formed. Thus, we performed appendectomy and fistulectomy. The pathohistological diagnosis was chronic acute phlegmonous appendicitis. His postoperative course was uneventful; however, on postoperative day 35, a urinary tract infection developed and methicillin-resistant staphylococcus aureus sepsis ensued, resulting in the death of multiple organ failure on postoperative day 48.

Thomas Richardson

1985/7/7

227.739.7230

taylor89@example.net

076 Christine Mill Suite 844

A 65-year-old man presented to the hospital in March 2006 with a rectal syndrome with minimal rectal bleeding, which had appeared two months earlier, and with an overall deterioration of health. The patient had a history of cholecystectomy. A complete proctologic examination revealed a left lateral mass 4 cm from the anal margin, with a good sphincter tone. A biopsy was performed. The anatomopathological study showed morphological and immunohistochemical aspects, suggesting a spindle cell GIST (). X-ray computed tomography (CT) of the abdomen and pelvis revealed the presence of a rectal tumour mass of 6 cm in diameter, pre-sacral and well encapsulated. Proctectomy and coloanal anastomosis were performed. After a histopathologic examination of the resected specimen, the diagnosis of malignant stromal tumour was made (intense expression of the anti-c-kit antibody; size > 5 cm; high mitotic index; mitosis > 5/50 fields). The postoperative course was uneventful. Eight months after surgery, the patient presented with multifocal, unresectable liver metastases, for which he was treated with imatinib. The hepatic lesions remained stable 12 months after treatment onset. Treatment was then suspended due to the patient's general health deterioration and tumour progression.

Allison Trujillo

1986/7/25

(245)778-5498

schneiderrobert@example.org

350 Martin Crescent Apt. 644

A 77-year-old woman without significant medical history presented to the hospital in October 2008 with rectal tenesmus and bleeding of medium abundance, which had appeared two months earlier. Digital rectal examination revealed a deep indurate sessile mass located 3 cm from the anal margin and leading up into the lower rectum. A proctoscopy revealed a tumour process extending from the dentate line and 10 cm from the anal margin. A biopsy was performed. The histopathologic study showed morphological and immunohistochemical aspects, suggesting a GIST. A colonoscopy did not reveal abnormalities in other parts of the colon. Thoracoabdominal and pelvic CT scans were then performed for staging. This examination provided an objective view of the lesion, showing a rectal tissue tumour of 8 cm in diameter, located on the posterior wall and showing an infiltration of presacral fat, but without bone involvement (). No lymph node, liver or lung injury was detected. An abdominoperineal resection was performed. The histopathologic study revealed a submucosal, ulcerated tumour, measuring 8 x 5 x 5 cm, and consisting of a rather dense fuso-cellular proliferation with fascicular architecture, a high risk of malignancy (mitosis > 5/50 fields, tumour size > 5 cm), and a complete resection. The immunohistochemical study showed a diffuse and intense c-kit and CD34 expression, confirming the stromal tumour type, whereas the other differentiation markers were negative (desmin and actin). The postoperative course was uneventful. The patient received adjuvant treatment with imatinib for a year, given the potential malignant aspect of the tumour. The evolution was good 13 months later.

Apollo Hall

1994/4/14

988.789.2589

romerodanielle@example.net

111 Vang Fall Suite 340

An 85-year-old woman with a past medical history of severe peripheral vascular disease and right below knee amputation presented to the emergency department with a 1-day history of non-positional dizziness and weakness. She denied any headache, neck pain, chest pain, trauma, or fever. Her ED vital signs were normal, and her ECG showed normal sinus rhythm with a heart rate of 91 bpm. Her physical examination was normal including a right below knee stump that was clean and dry. An MRI/MRA of the head and neck showed no new changes. The patient required intravenous access to work up her dizziness and weakness. The patient had multiple failed blind ED peripheral IV attempts performed in the past. An ED bedside ultrasound guided antecubital brachial vein was cannulated on the first attempt using the long-axis approach (see video clips in Additional files , , and .). After applying an elastic tourniquet to the patients non-dominant left arm and applying ultrasound gel, a high frequency linear array probe was used to identify an antecubital vein that was the largest in diameter, at least 3 mm or greater in diameter and a vein as close as possible to the skin surface. An augmentation procedure was performed by squeezing the patient's forearm while sampling the vessel with color Doppler and pulse Doppler. The augmentation procedure with increased Doppler flow verified the selected vessel was a vein, since an arterial vessel would produce a pulsatile Doppler flow pattern (see video clip in Additional file .). The skin was prepped with alcohol swabs, the vein verified with augmentation again, and the probe, now covered with a thin sterile plastic film dressing, was placed in the nine o'clock position to view the antecubital brachial vein in short-axis, then the ultrasound probe was turned counter clockwise to the six o'clock position to position the vein in the long-axis position (Figure ). The ED physician held the vascular ultrasound probe while resting on the patient's bed to provide stability. A 20-gauge 2-in. catheter was placed under the long-axis of the probe and vein so that direct visualization of the needle tip and catheter inside the vessel could occur (Figures and ). The catheter was flushed with saline and secured.

Leah Good

1981/4/21

620-390-4851x21136

everettelizabeth@example.org

7386 Gomez Cove

A 27-year-old man presents to the emergency department with a 1-day history of severe right upper extremity pain and swelling. The patient's status is post open reduction internal fixation for a left tibial plateau fracture, which was complicated by methicillin-sensitive Staphylococcus aureus osteomyelitis. A peripherally inserted central catheter (PICC) line was subsequently placed for intravenous antibiotic therapy. He denied any other past medical history. Aside from the pain and swelling to his right arm, the patient reports no associated shortness of breath, chest pain, or fever. His emergency department (ED) vital signs were as follows: temperature 97.1簞F, blood pressure 135/74 mmHg, heart rate 82 bpm, respiratory rate 14 bpm, and oxygen saturation 100% on room air. Physical examination result was normal except for the right upper extremity that showed surrounding edema and mild erythema by the PICC line site (Figure ). The arm had tenderness to palpation, but no significant increase in warmth was noted. On initial assessment, the triage nurse suspecting a possible upper extremity deep vein thrombosis notified the ED physician to facilitate a rapid bedside ultrasound of the right upper extremity. This ultrasound was performed (Additional files , , , and , available in the online version of this paper). Both short-axis and long-axis views of the brachial vein are shown (Figures and and Additional files , ). The short-axis view of the right axillary vein revealed a non-compressible deep venous thrombosis (Figure and Additional file ). Long-axis ultrasonographic evaluation of the axillary and subclavian veins near the PICC line tip revealed deep venous thrombosis of both the axillary and subclavian veins (Figure and Additional file ). Comprehensive radiology ultrasonography of the right upper extremity showed no flow and/or compressibility in the right subclavian vein or the right axillary vein adjacent to the PICC line, consistent with complete thrombosis. The right internal jugular vein and right brachial vein were patent and compressible, and the right innominate vein demonstrated patent flow. The patient was admitted to the hospital, and he was treated with oral antibiotics and subcutaneous enoxaparin injections.

Davian Farley

1982/5/9

840.302.1270

sosawalter@example.net

211 Mcbride Burg Apt. 327

A 58-year-old Malay woman had ulcerative colitis that was diagnosed 21 years ago when she presented with recurrent diarrhea. Five years ago, she started to develop peripheral polyarthritis. There were no other extra-articular manifestations such as uveitis or pyoderma gangrenosum. She had multiple relapses of colitis with polyarthritis and therefore had received multiple courses of tapering-dose oral prednisolone with maintenance of 1 g of mesalazine three times a day and subsequently 100 mg of azathioprine once daily. Finally, two years later, with the above treatment, the primary disease managed to be brought to remission. In spite of the clinical and histological remission of the IBD, the left knee arthritis seems to be persistent, but other peripheral joints mentioned above were in remission without any permanent deformity. A clinical assessment revealed that the left knee was swollen, warm, and tender. The inflammatory marker C-reactive protein was increased to 1.14 mg/dL (normal is less than 0.5 mg/dL). A knee aspirate revealed clear synovial fluid and did not yield any growth. She received two courses of 500 mg of intravenous methylprednisolone daily for three days followed by a tapering dose of oral prednisolone for one year for active and persistent left knee arthritis, but the effects were temporary. Mesalazine was changed to 1 g of sulfasalazine twice a day, and the azathioprine dose was subsequently increased to 150 mg once daily. Unfortunately, she developed leukopenia; therefore, the azathioprine dose had to be reduced back to 100 mg daily. Despite aggressive treatment with multiple courses of high-dose systemic and local steroid with the maximum tolerated doses of sulfasalazine and azathioprine, she still had recurrent left knee effusion and synovitis. Indeed, the disease had caused significant pain and restriction of mobility. Also, after almost two years of corticosteroid therapy, our patient has endured significant iatrogenic morbidity, including Cushingoid habitus, impaired fasting glucose, hypertension, and bilateral cataract with increased intraocular pressure. In view of persistent unbearable pain and swelling of the left knee with severe secondary osteoarthritis, a total left knee replacement was done in the same year. During the operation, there was active synovitis of the left knee, and a histopathological examination of the synovial tissue revealed 'rice bodies', which are fibrocollagenous connective tissue stroma admixed with fibrinous exudates and abundant foci of vascular proliferation, suggestive of inflammatory arthritis (Figure ). One month after the operation, the left knee effusion recurred and there was persistent elevation of the inflammatory markers. Subsequently, a left knee arthroscopic debridement and near-total synovectomy were performed five years ago. Ten milligrams of oral methotrexate weekly was added one month after the operation, on top of 1 g of sulfasalazine twice a day, 10 mg of prednisolone once daily, and 100 mg of azathioprine once daily. Unfortunately, despite the above treatment for four months, our patient continued to show poor response and persistent recurrence of knee effusion. Subsequently, 25 mg of subcutaneous etanercept twice weekly, together with the other DMARDs and azathioprine, was initiated after three months. Eventually, the joint showed resolution of knee joint swelling and synovitis at the fifth week of treatment, visual analogue scale score improved from 70 to 20 mm, and the C-reactive protein level decreased to 0.8 mg/dL. After six months of treatment with etanercept, azathioprine was stopped and sulfasalazine was changed to 1 g of mesalazine three times a day as our patient had a mild flare of ulcerative colitis with community-acquired pneumonia. The steroid was also tapered off after six months of treatment. Twenty-five milligrams of subcutaneous etanercept biweekly and 10 mg of methotrexate weekly were continued, and after 12 months of follow-up, the colitis or arthritis was in remission and no serious side effects were noted.

Wrenley Avila

2000/6/5

(724)909-3373

lparker@example.net

453 Thomas Station Apt. 126

An 83-year-old diabetic man of African descent presented with a four week history of constipation and a two week history of obstipation to our emergency department. He noticed painless increasing abdominal distension with concomitant leg edema. He denied any history of vomiting, fever or anorexia. He used several laxative concoctions with no relief. He revealed a long standing history of incontinence at night with hesitancy and poor stream but denied frequency and strangury. He had been diabetic and on treatment for 25 years with a history of diabetic retinopathy. On admission, he was tachycardic (pulse 102 beats per minute) with a blood pressure of 160/85 mm Hg and random blood glucose of 511 mg/dL (28.39 mmol/L). He had bilateral pitting edema up to mid leg. A large abdominal mass extended out of the pelvis just below the xiphisternum (Figure ). The mass was dull to percussion and tender on palpation. His bowel sounds were hyperactive. A symmetrically enlarged, smooth, rubbery prostate was felt on palpation with a bulge above the prostate. All other examinations were normal. Blood test results revealed a normochromic normocytic anemia (hemoglobin 10.4 g/dL, MCV 90.9 fL) with renal impairment (blood urea nitrogen (BUN) 30 mg/dL, creatinine 1.8 mg/dL) and a normal prostate-specific antigen (PSA) level (4 ng/mL). Computed tomography (CT) of the abdomen was ordered with a working diagnosis of bowel obstruction likely secondary to a tumor in mind. The results showed gross distension of the urinary bladder above the level of the umbilicus with marked bilateral hydronephrosis and hydroureter (Figures and ). A Foley catheter was inserted which yielded 5000 ml of clear urine. On the following day the patient passed flatus and his leg edema had decreased markedly. He passed stool on the third day with the aid of a suppository. The catheter was removed at the patient's request and he was sent home passing urine freely. His renal impairment resolved (creatinine (Cr) 1.5 mg/dL) on discharge. He was non-compliant with follow up. One week later, he returned to the emergency department with constipation and bilateral pedal edema. A Foley catheter was re-inserted and 3100 ml of clear urine was drained. The edema completely resolved thereafter and the patient was sent home with the catheter in situ.

Jaylen Swanson

1998/7/5

213-452-8728x124

elizabethsmith@example.net

9725 Willie Mews Apt. 508

In 2005, a 42-year-old Brazilian woman presented to an eye doctor with a visual impairment, and pappiledema. Upon neurological examination, she was diagnosed with communicating hydrocephalus. A ventriculo-peritoneal shunt was implanted and the hydrocephalus improved. Neuroendoscopic surgery showed multiple cysts in the subarachnoidal space, and histopathological examination indicated cestode-derived tissue. Serology for cysticercosis was strongly positive, but copro-multiplex PCR was negative for taeniasis. The patient was treated with praziquantel at first and then with albendazole. Post-treatment serology remained positive.

Helen Doyle

2002/4/29

(530)690-9009

ohubbard@example.com

64981 Crawford Points Apt. 739

A 38-year-old Japanese man expelled a single tapeworm in 2000. He was treated with pyrantel pamoate, a drug used primarily for nematode parasites. In 2004, he complained of headaches and multiple cystic lesions were found on brain computed tomography (CT). However, at this time, no medical or surgical treatment was initiated because all of the cysts were deemed dead based on the CT image and the patient's normal eosinophil value. In 2009, he complained of a narrowing field of vision. Serology showed strong positive responses, but copro-LAMP was negative. The patient was treated with albendazole in 2010, and follow-up is ongoing.

Kashton Cantrell

2002/12/25

(377)884-2296

brent33@example.org

2925 Sanchez Isle

A 31-year-old Japanese man noticed a subcutaneous nodule on his neck in December 2009. When the number of nodules increased by May 2010, brain CT and magnetic resonance imaging (MRI) showed multiple cystic lesions in the brain and serology showed strong positive responses. Tapeworm proglottids were expelled in his stools at the beginning of July 2010 and were identified as T. solium by multiplex PCR. He remembered he had found a similar white noodle-like substance in 2009, but he did not care about it. Taeniasis was treated using Gastrografin (diatrizoate meglumine and diatrizoate sodium) at Mie University hospital in Mie, Japan on 14 July, but no worms were expelled. However, T. solium infection was confirmed by copro-LAMP and Taenia eggs were identified microscopically. On July 28th 2010, the patient expelled additional worms. Then he was treated with Gastrografin and albendazole in August 2010, but tapeworm(s) were not expelled. However, it was considered that the patient became free from T. solium tapeworm after he found the worm by himself on 28th July, as copro-LAMP was negative until December 2010. In contrast, the subcutaneous and intracranial nodules disappeared within 4 weeks after the treatment. The patient's travel history indicated that he had worked for one month in a rural area 150 km from Delhi, India on 3 separate occasions. The first, second and third visits were March-April 2008, October-November 2008 and March-April 2010, respectively. Based on this information, it was suspected that he acquired the parasite during his first or second stay in India. A mtDNA gene (chromosome c oxidase subunit 1) of the obtained proglottids was sequenced according to previous research [], and was determined to be identical to the Indian haplotype of T. solium (GenBank Accession Number: ). Due to the risk of the patient contaminating his living environment with parasite eggs while infected with the intestinal form of T. solium, his wife and 4 year old son were tested serologically for cysticercosis. In addition, 41 colleagues who had also travelled to India since 2007 were tested serologically for cysticercosis, with 39 of these individuals also tested for taeniasis using copro-LAMP. To date, none of these individuals have tested positive for either cysticercosis or taeniasis. This case is notable as a rare imported case of T. solium taeniasis/cysticercosis in Japan.

Yamileth Vang

1983/1/31

375.576.2421

michaelhampton@example.net

443 Mendoza Rapids

Patient 1 is a 51-year-old Caucasian woman with acromegaly, treated with pegvisomant (Somavert, Pfizer, NY, USA) after three unsuccessful transsphenoidal endoscopic tumor resections and ineffective somatostatin analog treatment. This patient presented to the outpatient clinic of Endocrinology of Modena with the clinical suspicion of acromegaly. A hormonal analysis demonstrated raised serum levels of IGF-1 (666 ng/mL; normal range: 94 ng/mL to 267 ng/mL) and basal GH (22.1 ng/mL) and a pituitary magnetic resonance imaging (MRI) scan disclosed a pituitary macroadenoma with a diameter of 12 mm, which extended to her right cavernous sinus. Our patient underwent three transsphenoidal endoscopic pituitary tumor resections, which did not lead to complete tumor resection because of residual tissue within the right cavernous sinus. She was treated with the somatostatin analog, octreotide long-acting release (LAR) (Sandostatin LAR, Novartis Pharma AG, Basel, Switzerland), at the dosage of 20 mg intramuscularly every 28 days for three months followed by 30 mg every 20 days but this did not lower her IGF-1 serum levels (821.3 ng/dL and 741.3 ng/mL, respectively). Thus, she was started on pegvisomant treatment 13 months after the initial diagnosis of acromegaly, at a dosage of 10 mg/day delivered subcutaneously, which rapidly decreased her IGF-1 serum level (251.3 ng/mL after two months of treatment). In July 2008, our patient underwent pituitary-directed Gamma-Knife stereotaxic radiosurgery. She is still under pegvisomant treatment at a dosage of 10 mg subcutaneously, daily resulting in a good control of her serum IGF-1 (206 ng/mL).

Jimmy Correa

1991/12/25

495-416-0272x3369

sford@example.org

6790 Jordan Islands

Patient 2 is a 71-year-old Caucasian woman with acromegaly, treated with surgery 23 years before the initiation of pegvisomant treatment; the latter was administered because all previous pharmacological treatments failed. This patient came to our attention with IGF-1 serum levels higher than normal (280.1 ng/mL; normal range: 20 ng/mL to 182 ng/mL) during cabergoline treatment (Dostinex, Pfizer) at a dose of 0.1 mg twice weekly. Our patient reported a previous long history of acromegaly treated with surgery by means of a conventional transnasal transsphenoidal approach. A pituitary MRI showed a small piece of residual adenomatous tissue. Previous pharmacological treatments included bromocriptine, octreotide (Sandostatin, Novartis Pharma AG), octreotide LAR, and lanreotide (Ipstyl, Ipsen, Milan, Italy) but our patient had discontinued somatostatin and SSAs due to intolerance to the drugs; notwithstanding, they were effective in controlling the disease. As the control of the disease was suboptimal (her serum IGF-1 was constantly higher than the upper limit of the normal range) with cabergoline treatment, our patient was switched to pegvisomant therapy at a dose of 10 mg/day subcutaneously. The latter was effective in normalizing her IGF-1 serum levels (150 ng/mL after two months of treatment). After starting pegvisomant therapy, both women developed a rapid, progressive increase in subcutaneous fat depots at the site of injection in the abdominal periumbilical region. Both patients reported abdominal fat accumulation, and physical examinations performed four and two months after starting pegvisomant treatment for patient 1 and patient 2, respectively, revealed a soft, painless anterior abdominal wall swelling, consisting with a thickening of subcutaneous fat tissue. Both patients underwent detailed clinical and radiological investigations at baseline (Phase 1), after at least eight months of pegvisomant treatment (10 mg once a day) at the abdominal site, when abdominal lipohypertrophy had just started developing. Soon after the baseline evaluation, both patients switched the injection site from the abdomen to the anterior surface of both thighs. The dose of pegvisomant was not changed. A radiological evaluation was repeated after four months (Phase 2). A hormonal evaluation and study of their body composition by means of a physical evaluation, MRI of the abdomen and thighs and dual energy X-ray absorptiometry (DXA), were performed in Phase 1 and Phase 2 with the aim of detecting and quantifying changes in their subcutaneous adipose tissue. At physical examination, the abdominal wall swelling decreased progressively in both patients after switching the site of injection to the thighs. Swelling, however, developed at these new sites of pegvisomant injection in both patients within four months. The MRI images and evaluation of fat mass content with DXA (Table ) confirmed a reduction in abdominal subcutaneous fat thickness in patient 1 (Figure ) and patient 2 (Figure ), together with a concomitant increase in the subcutaneous fat at the anterior surface of both thighs in patient 1 (Figure ) and patient 2 (Figure ). Body fat thickness also increased in the flanks and back areas (only in patient 2; Figure ) and the posterior surface of the thighs in both patients (Figures and ). A tendency for a reduction in IGF-1 and IGF-binding protein 3 and a better control of the disease was documented, especially in patient 2 (Table ). Neither patient experienced other side effects; in particular, no enlargement of the pituitary residual tumor was recorded. Notwithstanding advice by us about the benefits of the treatment and the importance of continuing pegvisomant administration, patient 2 decided to stop pegvisomant because of the discomfort related to lipohypertrophy. In patient 2, pegvisomant withdrawal resulted in a progressive disappearance of the lipohypertrophy. Patient 1 was asked to rotate the site of injection over several districts (thighs, abdomen, arms and buttocks). As a consequence, a minimal swelling developed at these sites, without affecting self-image and patient's compliance to the treatment.

Valery Brown

1986/10/24

(572)385-4725

destinyaguilar@example.org

06893 Jackson Divide

EB is a lively and cooperative 58 year-old, right-handed woman. Two years previous to testing she suffered a large ischemic stroke involving the insular, frontal and temporal regions of the right hemisphere (see Figure ). Sensory and motor functions were briefly assessed through the standardized neurological examination by Bisiach et al. (). With this test both functions are examined according to a three-point scale ranging from score 0 (absence of deficit) to score 3 (maximum deficit). At the time of testing EB presented with left spastic hemiparesis (score 2 for the lower and 3 for the upper limb) and left hemianopia (score 3 for both quadrants). She also presented with USN and tactile extinction, as described below. Tactile sensation and extinction were tested in the baseline assessment and in the experimental evaluations by computer-controlled devices (Foreman & Co., UK) producing single silent and invisible touches of 100 ms duration. The stimulators were taped on the distal pad of the forefinger of each hand while EB rested the hands on her lap and fixated a central mark placed on the table in front of her. Each testing session comprised the following stimulus types: 12 unilateral left, 12 unilateral right and 24 bilateral, plus 12 catch trials (no stimulation), for a total of 60 trials, delivered in random order within a single session. After each trial the examiner verbally prompted the patient to report the presence and the side of any perceived stimulus, recorded EB's response and started the following trial. USN was formally tested in the baseline assessment and the experimental sessions, through common standardized tests, namely letter cancellation (Diller and Weinberg, ), star cancellation (Wilson et al., ), figure and shape copying test (Wilson et al., ), and sentence reading test (Pizzamiglio et al., ).

Elijah Giles

1985/3/22

(430)856-9272x13233

patrick28@example.org

17400 Michael Springs

A 48 year-old woman with several discrete granular corneal deposits visited our clinic with her daughter for evaluation of corneal dystrophy. Her 23 year-old daughter, determined to be a GCD2 R124H heterozygote, had best corrected visual acuity (BCVA) 20/20 in both eyes and showed no corneal deposit (). The patient had no history of glasses or contact lens wear. Upon reexamination six months later, the daughter showed one small corneal deposit in the right eye (white arrow, ) and none in the left ().

Bailee Bowman

2005/6/29

-3254

hernandezolivia@example.org

7246 Angela Manor Apt. 983

A 28 year-old man was evaluated for corneal dystrophy because his older sister was diagnosed as being a GCD2 homozygote. He had used glasses for eight years. Upon initial examination, granular deposits or diffuse haziness were not observed in either eye (data not shown). Upon reexamination two years later, due to DNA analysis that showed him to be a GCD2 heterozygote, a newly developed, faint granular deposit was observed in each eye (data not shown).

Francisco Ford

1981/6/1

(621)250-3649

tammy73@example.org

4170 Tran Keys

A 45-year-old man sustained blunt compression injury to his abdomen while working under a van. He was immediately extricated and presented at a referring hospital 24 hours later with mild abdominal fullness and pain. Upon transfer to our hospital, he had developed worsening abdominal pain and one episode of nonbilious emesis. He was tachycardic (120 beats/min) with mildly elevated blood pressure (140/80). His abdomen was distended, diffusely tender; and without signs of external trauma. Abnormal laboratory studies included WBC 19?103/弮L, ALT 86 units/L, alkaline phosphatase 136 units/L, and total bilirubin 3.7 mg/dL. Contrast-enhanced computed tomography (CT) of the chest/abdomen/pelvis revealed free fluid around the liver and right pericolic gutter () without evidence of extraluminal air or solid organ injury. Clips from a laparoscopic cholecystectomy (performed three years earlier for acute cholecystitis) were visualized in the hepatic fossa. Given the high suspicion for bowel and/or bile duct injury, he was taken to the operating room for exploratory laparotomy. Exploration revealed bilious fluid that tracked into the right pericolic gutter and retroperitoneum. No injuries were detected in any solid organs or hollow viscera. Medial rotation of the right colon and duodenum did not reveal injuries in the lesser sac or retroperitoneum. The hepatic hilum was bile stained and dissection of the hepatoduodenal ligament demonstrated complete avulsion of the hepatic duct at the confluence. The left hepatic duct and the right posterior and anterior duct junctions were visualized (). The common hepatic duct stump was oversewn and a single-layer hepaticojejunostomy was created using a retrocolic Roux-en-Y limb (). A stapled side-to-side jejunojejunostomy was performed and two closed suction drains were placed at the biliary-enteric anastomosis. The patient was discharged home with a single closed suction drain that was removed six weeks postoperatively. He has continued to do well at over three months after injury.

Alexandra Bullock

1987/5/2

289.246.7760x97863

brianstone@example.net

35176 Hartman Oval

A 77-years-old female was referred to our clinic for evaluation of worsening heart failure. She had no history of international travel. During etiological evaluation of heart failure, echocardiography revealed an ejection fraction of 40% with a multilobular cystic structure localized to intramyocardial left ventricular apex (). Computed tomography confirmed the diagnosis () and screening of other organ involvement including brain, lung, and liver were negative for cystic echinococcosis. Serum indirect hemagglutination assay test for Echinococcus granulasus was positive. Thus, diagnosis of isolated cardiac apical cystic echinococcosis was confirmed. The patient was recommended surgery, however, patient refused the surgical operation.

Ben Edwards

1989/4/30

2945978421

leonjeff@example.com

04445 Kenneth Mews

A 28-month-old girl was admitted to the Pediatric Department with a five-day history of pain in the left hip, limpness, and fever. The girl had a pelvic trauma one day before the onset of the symptoms. Examination showed an irritable girl with temperature of 39簞C. A general examination was normal. Although the girl kept antalgic position (semiflexed of the left leg) with pain in left groin, hyperextension of the hip, forced abduction, and external rotation of the left hip were limited and painful. Plain radiograph of the pelvis and ultrasonography of the hips were normal. Laboratory findings on admission showed a white blood cell count of 11600/弮L, erythrocyte sedimentation rate (ESR) of 110 mm/1st hour, and C reactive protein (CRP) of 69 mg/L. A bone scan (99 mT-MDP) performed two days after admission revealed increased uptake in the left sacroiliac joint. A CT scan performed four days after admission showed pinching of the left sacroiliac joint without effusion in this joint and thickening of the left iliacus muscles. The sacral and iliac cortices were regular along the sacroiliac joint. The left hip joint was normal without effusion. The diagnosis of pyogenic sacroiliitis was suspected, and intravenous treatment with oxacillin and gentamycin was started. MRI of the pelvis performed ten days after admission revealed on T2-weighted images an increase of the signal intensities of the left sacroiliac joint and increase of the signal of the iliacus and gluteal muscles. Also there was a little effusion in the left sacroiliac joint (). All radiologic findings (bone scan, CT scan, and MRI) suggested a left sided sacroiliitis. Blood cultures were negative. On intravenous antibiotherapy, pain decreased, and mobility improved after three weeks. The girl was discharged after three weeks of intravenous oxacillin and continued oral oxacillin for three weeks. Followed up six months later, the girl improved well without sequelae.

Ivy Conley

2004/5/8

+1-246-528-5844x53896

davidhess@example.com

2149 Jensen Spring Apt. 398

A previously healthy 13-year-old girl was admitted to the Pediatric Department presenting with fever and inability to walk. Sudden right hip and buttock pain with fever up to 40簞C had developed in the patient three days before admission to the hospital. The pain had gradually progressed to the point that she was unable to walk. The patient had no history of prior trauma but she had a skin infection in her right foot secondary to tattooing. On admission to the hospital, the patient had a temperature of 39簞C and marked pain on motion of the right hip with limitation of right hip movement. Physical examination revealed exquisite tenderness on palpation of the right hip and the right sacroiliac joint. Laboratory findings on admission included a white blood cell count of 31200/弮L with 80% polymorphonuclear leukocytes, ESR of 110 mm/1st hour, and CRP of 213 mg/L. A roentgenogram of the pelvis showed no abnormalities, and ultrasono-graphic of the hips was normal. The admitting diagnosis was septic arthritis of the right hip or right pyogenic sacroiliitis. Empiric intravenous antibiotherapy (oxacillin gentamycin) was started. On the second day of admission, CT of the pelvis was performed; it revealed apparent widening of the right sacroiliac joint with infiltration, edema of the soft tissue surrounding the joint, and presence of microabscess in the right iliacus muscle. All these findings suggested right pyogenic sacroiliitis joint (). An isotope bone scan was performed two days after admission, showed increased uptake in the right sacroiliac joint. Three days after the onset of antibiotherapy, the patient did not respond to treatment, continued to have fever, groin pain, and since blood cultures have identified Proteus mirabilis, than antibiotherapy was switched to the association of Cefotaxime with fosfomycin intravenously. Over the next 48 hours, apyrexia was obtained and symptoms gradually improved. CT of the pelvis was performed fifteen days after the first CT; it showed signs of right sacroiliitis with infiltration and microabscess of the soft tissue, surrounding the joint with erosions of the subchondral iliac bone (). The patient responded promptly to 25 days of intravenous antibiotherapy followed by an additional two weeks of oral antibiotherapy (ofloxacin). Followed up six months later the girl improved well without sequelae.

Marvin Cochran

1983/3/15

808-282-7935

oliverkathleen@example.com

8299 Wade Falls Suite 297

The clinical history of an Italian female patient of 43 years old with a height of 1,50 cm, begins at two years when after a normal postnatal development, was admitted the first time to a children's hospital because of a delay in growth and difficulty walking but with no mental retardation. At the age of 7 years, she had the second admittance to the hospital for a diagnostic setup, because the growth retardation was apparent, and she referred joints stiffness; physical examination showed muscular weakness, pectus carinatum, stubby neck, genu valgum, joints out of proportion to her age, and globose abdomen. The urine test was positive for the presence of keratan sulfate and fibroblasts cultures obtained from skin biopsies showed a deficiency of beta galactosidase activity confirming the diagnosis of type IVB Morquio syndrome. At the age of 11 years, she underwent tibial varus osteotomy of the left knee, while at 29 years she underwent arthroscopy of the left knee for a medial meniscus regularization procedures, cartilage debridement, and removal of an osteochondral fragment. At 35 years, she underwent surgery for uterine fibromyoma. The patient did not follow any supportive measures or rehabilitation protocol to treat the skeletal manifestations of her disease. At the age of 40 years till now, the physical conditions of the patient have worsened for a further deterioration of her joints, with difficulty walking and recurrent pain. The neurological examination revealed hyporeflexia either at superior or at inferior limbs, paresthesias, and muscles fasciculations. With the aim to evaluate the locomotor system conditions of the patient, a full skeletal radiographic survey has been obtained (standing anterior posterior (AP) and lateral views of the entire spine, standing pelvis view, PA view of the chest, standing AP views of the knees). MR study with a 1,5 T superconducting system (Magneton Symphony, Siemens AG, Erlangen, Germany) of the entire column, hip, knees, and ankles was also performed, including coronal, sagittal and axial views. The radiographic and MRI assessment refers to a patient who did not undergo any other surgical procedures except for those carried out at 11 and 29 years. The AP radiographic view of the spine showed a mild thoraco-lumbar right scoliosis; the lateral view demonstrated a slight thoraco-lumbar kyphosis with irregular, flat and antero-posteriorly enlarged vertebral bodies particularly in mid-thoracic region, thoraco-lumbar junction and distal lumbar spine, produced by partial ossification of cartilaginous vertebral body (Figures , , and ). The cervical tract showed wedge shape of the vertebral bodies and an hypoplasia of the odontoid process (). Roentgenographic findings of the chest included a relatively small size of her chest with oar-shaped ribs, (widening ribs anteriorly and narrowing posteriorly). The iliac wings of the pelvis were flared, with short femoral necks, flattered femoral epiphysis, and marked degenerative changes of the hip joints (). In the lower extremity, the lower ends of the femur and the upper ends of the tibia were large with an evident genu valgus deformity. Severe degenerative changes of the knee joints were present with the signs of the previous left tibial osteotomy (). MRI due to its multiplanar features confirmed radiographics findings adding further information on the degenerative alterations of the joints. Sagittal view of cervical and thoracic spine showed either the morphological alterations of the vertebral bodies or the hypoplasia of the odontoid process with a mild narrowing of the spinal canal and cord compression at the level of C2-C3 (Figures and ). On dorsal tract platyspondyly, end plate irregularity, and anterior beaking of the vertebral bodies characteristics of dysostosis multiplex, were present. MRI of the pelvis in coronal view showed multiple abnormalities including oblique acetabular roof with, flattening of the femoral heads, and severe degenerative changes in the hip joints confirmed by axial views (Figures and ). In addition to a genu valgus deformity, widening of the metaphysis and epiphyses, severe bilateral involvement of knees articular cartilage with multiple osteoarthritic changes were also detected. (Figures , , and ) Similar findings were also carried out on ankle joints, in particular at the level of tibial epiphysis and talar dome ().

Alma Barajas

1991/9/19

+1-400-955-7721x617

kristen41@example.com

698 Herrera Alley Suite 607

An 8-year-old boy presented to the Department of Pedodontics of Dr. HSJIDS with the chief complaint of swelling and pain in the lower right posterior region since 3-4 days. Intraoral examination revealed a fractured filling, grade 1 mobility of the tooth, tenderness on percussion, and abscess in relation to tooth 85. An intraoral periapical radiograph was advised; it revealed the presence of a sharp radiopaque material present in relation to the external surface of the mesial root (). Extraction of the involved tooth was done, and the foreign object was removed that was found out to be a sharp tip of the metallic compass (). On further questioning, it was told by the patient's parents that the child frequently used to use a metallic compass to take out the impacted food from the fractured filling.

Brennan Huff

1981/5/28

(922)637-5875

jessica17@example.net

998 Anderson Village

An 11-year-old boy was brought to the Department of Pediatric Dentistry with the chief complaint of pain and swelling in the maxillary anterior region. He had suffered dental trauma a year back. Intraoral examination revealed fractured 11 with the slit-like opening involving the pulp chamber of tooth 11 (). The tooth exhibited the following clinical features: swelling in the labial vestibule, grade 1 mobility, and tenderness on percussion. An intraoral periapical X-ray of the region was advised. The radiograph revealed a stapler pin in the pulp chamber of 11 (). History revealed that the child had the habit of playing with the stapler; the pin got stuck in his tooth. Attempts by him to remove it were futile. The incident was concealed from his parents as he feared a reprimand or admonishment. A tetanus vaccine booster dose was administered to the patient in the very first appointment. The timing of presentation enabled us to solve the problem by removing of the stapler pin from the tooth () by making a conventional access cavity followed by copious irrigation of the pulp chamber to remove the debris present; routine endodontic procedure was followed by placement of dressing of nonsetting calcium hydroxide. Once the tooth was asymptomatic, it was obturated.

Karsyn Cisneros

1988/9/18

001-595-624-9870

christopher75@example.org

17252 Casey Dam

An 28-year-old male patient reported to the Department of Oral Medicine and Radiology with a complaint of dull pain in upper right back region. The patient was an air conditioner mechanic and had met with an accident two months back; while repairing the air conditioner, it suddenly burst and he got severe injuries on his face and one of the fragments of the air conditioner got embedded in oral cavity. On examination, there was a fibrous swelling palpable in the vestibular area of the upper right premolars. An OPG radiograph was advised (). The radiograph revealed a rectangular radiopacity in the premolar region. The area was explored under local anesthesia, and a rectangular copper strip approximately 0.7 ? 1 cm was removed ().

Alden Terry

1998/1/16

655-590-5542x188

diana00@example.com

75237 Knight Greens Apt. 277

An 20-year-old male patient reported to the department with a history of breaking a sewing needle in upper right back area two days back while trying to remove the food debris (). An IOPA radiograph was advised, and it revealed a radiopaque object that was the broken needle on both sides of 17. Under local anesthesia, the two fragments were removed ().

Wren Wiggins

1994/7/1

(312)411-2734

hammondamanda@example.com

62052 Walter Ville

A 19-year-old male patient was referred to the Department of Oral Medicine and Radiology for treatment. Patient gave a one-month history of a mild pain and swelling in the right posterior mandible. Pain is intermediate and usually seen on mastication. Initially, the swelling was small in size and showed a gradual increase to its present dimensions. Clinical examination revealed a firm, non-tender swelling expanding the buccal and lingual cortices of the mandible, extending from right first premolar region to third molar region, and it obliterated the buccal vestibule. The skin over the swelling was normal, and there was no history of paresthesia (Figures and ). The panoramic radiograph showed a large well-defined, sclerotic margined, multilocular radiolucent lesion with ?oap bubble??appearance extending from the lower right canine to 1 cm distal to the third molar and also showed first molar mesial root resorption (). The right mandibular lateral occlusal radiograph showed multilocular radiolucent lesion with expansions of buccal and lingual cortices (). Fine needle aspiration was performed to rule out odontogenic cysts, and results were negative. Benign odontogenic tumors were considered, and incisional biopsy was made and a histopathological examination of the tissue sample exhibited rounded, stellate, and spindle-shaped mesenchymal cells arranged in a loose, myxoid stroma with few collagen fibrils (). These results were suggestive of OM. Segmental resection of the right side mandible was performed under general anesthesia (). Reconstruction was done by microvascular iliac bone grafting, and fixation was achieved with titanium plates (). Postoperative complications included iliac bone graft rejection, and sequestrated bone graft was removed 3 months later. 30 months after the surgical procedure, there were no radiographic or clinical signs of recurrence and patient was not interested for rehabilitation.

Azariah Hawkins

1999/2/27

7564449986

kylecollins@example.org

461 Nelson Mount

A 29-year old male living in a rural area of Southern Sudan has been maintained on continuous ambulatory peritoneal dialysis for two years. He presented to our center in May 2010 complaining of fever, dry cough, shortness of breath, and abdominal discomfort of four days duration. He was very ill, pale, and dehydrated. His temperature was 38.4簞C, respiratory rate 30 per min, pulse rate 120 beats per minute, and blood pressure 70/50 mmHg. There were enlarged tender submandibular lymph nodes, but no mouth ulcers or other palpable lymph nodes. Chest and precordium examination was unremarkable. Abdominal examination revealed bilateral loins tenderness but no guarding. There was no palpable organomegaly, and the peritoneal catheter exit site showed no signs of inflammation. The skin was intact and there was no arthritis. Neurological examination revealed no abnormality. The patient was admitted and rehydrated. The peritoneal effluent was inspected and found to be clear. Investigations revealed WBCs count of 13,100/弮L with 90% polymorphonuclear cells, hemoglobin 5.6 g/dL, platelets 160,000/弮L, ESR > 150 mm/hr, serum albumin 1.9 mg/dL, blood urea 168 mg/dL, serum creatinine 9.2 mg/dL, and normal liver enzymes and electrolyte levels. Peritoneal effluent contained 50 WBC/弮L. Blood film for malaria was negative as were serological tests for Brucella and Salmonella. We sent blood and peritoneal effluent samples for culture and started empiric antibiotic treatment with ceftriaxone, and ciprofloxacin. He also received 4 units of blood to correct his anemia. Peritoneal effluent cultures remained negative after three days of incubation. Blood samples were cultured in Brain heart infusion (BHI) broth and Thioglycollate broth. After five days of incubation, the aerobic BHI broth showed increased turbidity and gram stain revealed tiny gram negative pleomorphic bacilli. Subcultures were performed in three solid media; blood agar, chocolate agar, and McConkey agar. Forty eight hours later the subcultures showed non hemolytic mucoid gray white colonies on the chocolate agar, very faint growth was detected on the blood agar, and no growth noticed on the McConkey agar plate. Giemsa stain smear revealed a bipolar organism. The isolated organism tested negative for oxidase, urease, motility and fermentation of lactose, and other sugars. A battery of chemical tests was performed utilizing two analytical profile index kits (API, bioMerieux) for identification of gram-negative rods; API-20E and API-20NE. Both failed to identify the organism but confirmed that it did not belong to hemophilus, actinobacillus, cardiobacterium, ekinella or kingella species. Thus, the organism was identified as Francisella tularensis. Further investigations to determine antimicrobial sensitivity were not done due to inadequate lab safety facilities. The patient's condition was generally better but he was still running on and off fever. We started him on a ten-days course of gentamicin. The patient improved dramatically after receiving gentamicin and was discharged in good condition. He remained asymptomatic two weeks later when he presented for followup. No similar condition emerged in his family or contacts including the medical and laboratory personnel. To the best of our knowledge, this is the first reported case of Francisella septicemia in our area and, may be, in Africa.

Ariel Hartman

1989/8/17

001-364-502-1252x527

brittany34@example.net

1346 Webster Plain Suite 995

A 63-year-old man was referred to the Department of Prosthodontics in the Faculty of Dentistry at Isfahan University of Medical Sciences, Iran, for prosthodontic treatment. The patient's chief complaint was the restoration of worn teeth, in addition to the replacement of unacceptable restorations and missing teeth. An initial evaluation of the patient indicated a history of depression, and also, parafunctional habits of bruxism and clenching. Oral hygiene was fair, and there was no periodontal problem. Clinical and radiographic examinations and diagnostic casts revealed severe attrition, especially on anterior teeth and an uneven occlusal plane (). The causes of the severe wear were parafunctional habits, unsuitable restorations, and a lack of stable posterior occlusion. After oral hygiene instructions, making impressions and diagnostic workup, removable provisional prostheses were fabricated with correct occlusal plane and adjusted clinically for achieving good aesthetics, phonetics, and OVD. This removable prosthesis was used to evaluate the OVD and patient tolerance (). An ITI implant (4.8 ? 10) (Straumann, Basel, Switzerland) was inserted in right first lower molar region after precise clinical and radiographic evaluation and diagnostic waxup using surgical stent. Root canal therapy (RCT) of anterior worn teeth and retreatment of teeth with unacceptable RCTs were performed, and casted posts and cores were fabricated (). Fixed and removable provisional restorations were inserted and adjusted until patient acceptance achieved. These restorations were fabricated according to the diagnostic waxup (), for which the Broadrick flag analyzer was used to determine the curve of occlusal plane. Impressions were made from provisional restorations, and casts were transferred to the Denar Mark II articulator (Teledyne Water pik, Fort Collins, CO, USA) using the Denar Slidematic facebow (Teledyne Water pik, Fort Collins, CO, USA). Then, an anterior guide table was customized by pattern resin (Duralay, Reliance Dental MFG Co., Worth, CO, USA). After completion of teeth preparations, the final impressions were made with silicon impression material (Speedex, Coltene AG, Alstatten, Switzerland/impergum, 3 M ESPE), and metal-ceramic restorations were fabricated. In the maxillary restorations, rest seats, guide planes, and retentive undercuts were formed in the RPD abutments. A Kennedy class II mode 1 maxillary RPD was fabricated and delivered (). Finally, the occlusion of restorations was adjusted so that equal-intensity centric contacts were established on all teeth (), and anterior guidance discluded all posterior teeth in eccentric jaw movements. A maxillary occlusal splint was fabricated for protecting the restorations from patient's parafunction. The smile view of patient after treatment is shown in . One-year followup showed no problem in teeth, restorations and temporomandibular joints and show the panoramic image after this period.

Baker Crosby

1985/7/6

397-241-2653x1017

larsontodd@example.net

94875 Brandon Throughway

A 75-year-old male referred to the eye clinic of Erciyes University Medical Faculty with the complaint of vision loss and conjunctival hyperemia of the left eye. He had a history of trauma to his left eye four days ago. Magnetic resonance imaging (MRI) of the orbits showed bilateral proptosis which was significant on the left as well as edema and inflammation at the anteroinferior part of the left bulbus oculi. He was referred to our clinic to investigate the etiology of the proptosis. His past medical history included hypertension which was regulated with an oral antihypertensive agent. Visual acuity was counting fingers on the right eye and 5/10 Snellen lines on the left. He had nuclear cataract, and minimal proptosis on the right eye, conjunctival hyperemia, chemosis, nuclear cataract and moderate proptosis on the left eye. The intraocular pressure and fundus examinations were within normal limits for both eyes. Hertel exophthalmometer measurements were 21 mm on the right and 24 mm on the left. Ocular ultrasonographic (USG) examination of both eyes were normal. The patient was hospitalized for the differential diagnosis of orbital pseudotumor, orbital cellulitis, retrobulbar tumor, intraorbital foreign body, thyroid ophthalmopathy, and carotid-cavernous fistula. The patient received oral flurbiprofen (100 mg, t.i.d) and ciprofloxacin (750 mg, b.i.d), topical moxifloxacine and dexamethasone 6 times daily and cold compresses as an initial treatment. Orbital computerized tomography showed no foreign body, and there was no murmur on auscultation of the glob. The proptosis was not pulsatile. The visual acuity on the left eye decreased to 4/10 Snellen lines one day after the hospitalization although the other ocular signs remained the same. After the consultations with the departments of infectious diseases and endocrinology, the diagnosis of orbital cellulitis and/or thyroid ophthalmopathy was not considered. An oral steroid (fluocortolone 1 mg/kg,) and preventive treatment for the gastric mucosa (ranitidine HCL, b.i.d) were added to the treatment because of the possible diagnosis of orbital pseudotumor. On the second day of the hospitalization, vesicular and pustular lesions occurred around the left eyelid and forehead, and the diagnosis of HZO was made (). The visual acuity of the left eye rapidly decreased to counting fingers from 3 meters, and a punctate keratopathy was detected on slit-lamp examination. After the consultation with the department of dermatology, oral corticosteroid treatment was stopped, and the patient was commenced on a treatment of oral valacyclovir (1 g, t.i.d. for 7 days), vitamin B1 (250 mg, b.i.d), vitamin B6 (250 mg, b.i.d), and dressing with ethacridine lactate for the skin lesions. The visual acuity of the left eye decreased to hand motions one day after the initialization of this treatment. Total ophthalmoplegia and ptosis of the left eye were detected (). There were dendritic lesions on the cornea (). Since a brief period of disorientation and a syncope was developed, a diagnosis of OAS and a probable cranial involvement was considered and the patient was referred to the department of infectious diseases. The patient was commenced on intravenous ampicillin sulbactam (2 gr, t.i.d.) and acyclovir (750 mg, t.i.d.) for 14 days, topical acyclovir ointment 5 times, moxifloxacin and polyacrylic acid 6 times, and a fixed combination of dorzolamide HCL and timolol maleate 2 times per day. Two days later uveitis with cyclitic membrane and hemorrhage in the anterior chamber were developed (). Topical cycloplegic drops and hot eye compresses were added to the treatment 5 times per day. Topical steroids were not considered because of the diffuse corneal epithelial defects. MRI examination showed an enlargement of the extraocular muscles and an increase in the amount of the soft tissues around the preseptal area; both of the cavernous sinuses were normal. Both of the superior orbital veins were dilated, which were more significant on the left. There was a choroidal detachment and an intraocular hemorrhage on the left eye. Diffusion MRI showed a deficiency of the diffusion on the right frontal and frontoparietal regions. When the acute clinical signs of HZO were regressed, the patient was commenced on a tapering dose of oral prednisolone (1 mg/kg per day) to accelerate the recovery of the total ophthalmoplegia, proptosis, and ptosis. Topical cortisone treatment (dexamethasone) 8 times was added after the recovery of the corneal epithelial defects. At the end of 5-month follow-up period, the visual acuity of the left eye was counting fingers from 1.5 meters. Anterior segment examination showed an epithelial defect at the inferior half of the cornea, posterior synechiae at the pupillary area, fibrinoid reaction in the anterior chamber and mature cataract. The intraocular pressure of the left eye was 4 mmHg (applanation). The USG examination of the left eye revealed a choroidal detachment. The corneal sensation, ocular motility, and the ptosis showed partial improvement at the end of five months ().

Keily Potts

1980/10/21

-3236

jennifermeyer@example.net

38499 Blevins Garden Apt. 690

A nineteen-year-old female patient who had severe facial trauma was referred for dental rehabilitation after a series of esthetic surgery operations. The patient's history revealed a blow to her face after falling off a cliff during mountain biking. Her initial evaluation in Emergency Service reported that her general condition was poor, and her hemoglobin value was 6 mg/dL with severe maxillofacial trauma and bleeding. The patient had an emergency consultation at the Department of Plastic and Reconstructive Surgery after a rapid hemodynamic stabilization and CT scans. According to the medical records obtained from her physician, she had a severe soft tissue injury and accompanying comminuted bone fractures on bilateral maxilla, zygoma, periorbital area, mandible, and nasal bones. Bone fragments were fixed with titanium plates and screws without bone grafting. There was also a posterior vertical split fracture on the hard palate extending anteriorly to both sides creating a mobile free bone fragment on the anterior maxilla. Those fractures were also fixed after reconstruction and then soft tissue repair was done. Complications were not seen in the early postoperative period; however, followup of the patient indicated bone necrosis on the anterior maxilla including the alveolar process extending to the palate. After debridement of the necrosis process, the defect was reconstructed with mucosal flaps and bony reconstruction was postponed. The patient refused the bone graft surgery planned for the repair of the defect on the anterior maxilla and had been consulted for prosthetic treatment. Her clinical examination showed soft tissue defects on the face particularly eye area and dysmorphic appearance (). The panoramic radiograph demonstrated mini plates and screws used for fixing fractured zygomatic arch, orbital, and maxillary sinus walls. Intraoral examination revealed the absence of the anterior maxillary alveolar ridge and bone until the apex line; both maxillary central and lateral incisors and right canine teeth were lost as a result of traumatic injury (). The patient had an Angle Class I occlusion with an acceptable vertical and horizontal overlap prior to the accident. Because of the loss of premaxillary segment, the patient experienced speech problems and had difficulty in biting and swallowing (). In addition, the maxillary lip had lost support and was depressed into the defect area. The mandible was overclosed, resulting in a decrease of the vertical facial height. The temporomandibular joints were asymptomatic and jaw movement was in normal limits. The patient has complained of her inability to communicate, emotional disturbance of her appearance, and anxiety about the restoration of her teeth. After her extensive surgical procedures, initially temporary acrylic prosthetic rehabilitation was applied approximately one year later after trauma in order to restore her oral and dental function (). As a treatment method, the zirconia-based crown bridge prosthesis had been planned and applied between right first molar teeth through left second premolar teeth for the replacement of the missing teeth (). A new centric relation was made to transfer the articulator and shade was selected. This prosthesis was combined with gingiva-colored porcelain (Noritake Super Porcelain; Noritake, Nagoya, Japan) to compensate for the loss of hard and soft tissue on the anterior maxillary area and lip support. The zirconia framework was veneered by feldspathic porcelain and occlusion balance was checked. Definitive zirconia_crown bridge prosthesis was fabricated using computer aided design/computer-assisted manufacturing (CAD/CAM) system (Procera, Nobel Biocare). The patient was given home oral health care instructions, including use of dental floss, interproximal brushes, and an oral mouth rinse. The advantages of combined prosthesis included esthetic and biocompatible restoration with zirconia prosthesis. A satisfactory esthetic and functional result was achieved after fixed denture adjustments (). After the 1st, 3rd, 6th, and 12th months recall visit, the patient was satisfied with her new appearance and had no functional difficulties during eating, chewing, or swallowing. Speech impairment was eliminated considerably and the patient's profile was improved to a certain degree. In a followup of 5 years period, the prosthesis was stable and there was no evidence for relapse or dysmorphology was found.

Alfred Bell

1978/11/12

(896)232-7339x8427

pmoore@example.org

653 Cox Route Suite 122

A 21-year-old, 31-week pregnant, gravida 1, para 0 case was confused with a moderately poor general condition and was admitted to the obstetric clinic. When the patient came to the hospital, her arterial blood pressure was 210/130 mmHg, and anamnesis from her relatives revealed that she had a generalized seizure 1 hour prior to admission. On bed-side ultrasound, normal amniotic fluid volume and one viable fetus with a body size consistent with 29 weeks were found. The patient had 4+ proteinuria and was diagnosed as eclamptic and given a loading dose of magnesium sulphate (4 grams). Three minutes after magnesium sulphate was administered, the patient had another generalized convulsion and was given diazepam (10 mg i.v.). The patient had respiratory distress and was intubated orotracheally and taken to the operating room for an emergency Cesarean section. Thiopental sodium (250 mg, Pental) and cisatracurium (4 mg, Nimbex) was administered for induction of anesthesia followed by 50% O2 + 50% N2O and 0.75% MAC isoflurane. One viable female baby in breech presentation was delivered by Cesarean section. The baby's birth weight was 1100 gr and height was 36 cm with a 1-minute APGAR score of 7. After the operation, the patient, still entubated, was taken to the intensive care unit, and mechanical ventilation was initiated (SIMV, f: 12/min, FiO2: 60, TV: 500 mL, I : E = 1 : 2). In the intensive care unit, her blood pressure tended to increase (180/110 mmHg) so nitroglycerin (10 弮g/kg/h) and magnesium sulfate (2 gr/h) infusion was continued. The patient was administered dexamethasone (32 mg/day) and an oral antihypertensive amlodipine (Norvasc 10 mg/day). As she regained consciousness and spontaneous breathing, the patient was extubated. But 15 min after extubation, the patient had another convulsion and was reintubated. Biochemical values of the case were as follow: Hb: 13.5 gr/dL, Htc: %37, WBC: 16590/mm3, PLT: 50.000/mm3, AST: 375 U/L, and ALT: 183 U/L, LDH: 1213 U/L, and her coagulation parameters were Prothrombin time (PT): 52,1 secs, activated prothrombin time (APTT): 25,2 secs, INR: 1,44. With these findings, the patient was diagnosed as having HELLP syndrome and eclampsia, and neurologic examination showed no lateralization. The patient was administered Thiopental sodium (100 mg bolus followed by a continuous infusion of 250 mg/h i.v.), and her convulsions were reduced considerably. Therefore, first day after surgery thiopental sodium was stopped, and after approximately 6 hours, the patient was extubated. Magnesium sulfate infusion was continued. The patients, postoperative first-day MRI showed increased intensity lesions on sequences T2, FLAIR, DAG, and ADC in bilateral basal ganglia, at the level of centrum semiovale on the frontal areas, bilateral parietotemporal, occipital regions, and left cerebellum (). The patient was diagnosed as having PRES. The patient was treated with magnesium sulfate for 48 hours, and her platelet counts were 44,000/mm3 on the first day after the operation. Her liver enzyme and LDH levels were elevated. As her general condition improved, the patient was taken to the obstetric clinic on the second postoperative day. Her liver enzyme and LDH levels started to decrease starting from the second postoperative day. Her platelet counts were 97,000/mm3 on the second day after surgery. Her drains were removed on the third day after the surgery and sutures were removed on the 7th postpartum day. The patient was discharged with suggestions after that. Her MRI was taken after a month and was totally normal ().

Melody Rios

2004/9/24

+1-934-953-1770x37549

emartinez@example.net

9922 Calvin Union Suite 762

A 45-year-old female presented to the emergency department with a 1-day history of new onset abdominal pain. The abdominal pain was described as severe and sharp. It localized to the epigastric, right upper, and right lower quadrants as well as radiated posteriorly. She had nausea, as well as multiple episodes of nonbilious vomiting. The past medical history was significant for breast cancer, and the past surgical history was significant for a c-section, bilateral mastectomy, and bilateral tubal ligation. On admission, her temperature was 97.8簞F and hemodynamically stable. Her exam was significant for epigastric tenderness, as well as a positive Murphy's sign, and tenderness over McBurney's point. She had no peritoneal signs, and a negative psoas, obturator, and Rovsing's sign. Clinically, her general appearance was not consistent with sepsis or bacteremia. Her white blood cell count was 8 K/弮L with a hematocrit of 37.8%. Her admission chemistry was normal, but her hepatic profile revealed an elevated total bilirubin of 1.4 mg/dL, a direct bilirubin of 0.5 mg/dL, and normal transaminases and alkaline phosphatase. The urinalysis revealed 3+ occult blood. CT abdomen and pelvis with contrast revealed cholelithiasis with the possibility of cholecystitis, as well as a dilated (9 mm) fluid filled appendix suggesting the possibility of early appendicitis (). An abdominal sonogram was performed, which confirmed the acute cholecystitis with cholelithiasis with the common bile duct size of 4 mm but did not visualize the appendix. The patient was brought to the operating room where a laparoscopic cholecystectomy and appendectomy was performed. The appendix intraoperatively appeared to be an early appendicitis, nonperforated. The abdomen was accessed via a single 12 mm port and five additional 5 mm ports (). The surgery time was 2 hours and 3 minutes. The final pathology revealed both acute and chronic cholecystitis with cholelithiasis, as well as nonperforated acute appendicitis with periappendicitis. The patient was discharged home on postoperative day 2 and made an uneventful and full recovery.

Israel Franklin

1986/8/13

5385247140

julie36@example.net

14023 Johnson Forest Apt. 754

A 51-year-old type II diabetic gentleman had been under our care for one year with recurrent high-grade superficial transitional cell carcinoma (TCC) of the bladder. This had been treated with TURBTs and subsequent six instillation courses of intravesical mitomycin-C and BCG. He had, on three occasions, tumour in the prostatic urethra which was resected and then treated with three instillations, at three-week intervals, of mitomycin-C gel (20 mg Mitomycin-C in 5 mL water for injections and 5 mL Instillagel, that is, 2 mg繚mL??). Treatment was given for one hour, and the gel was retained with the assistance of a penile clamp. After the first treatment, the patient complained of severe dysuria, but after three weeks, continued with treatment. When readmitted for a check cystoscopy, he complained of continuing dysuria and deterioration in urinary flow. At cystoscopy he was found to have a very dense, almost impassable, distal urethral stricture which was eventually dilated using S-curve dilators over a guide wire up to 20 French to allow passage of the cystoscope. Cystoscopy demonstrated the stricture to be approximately 2.5 cm long and corresponded to the site and size of the penile clamp. There was no further stricturing and no evidence of urethral tumour recurrence proximally. Following a period of one month with an indwelling urethral catheter, his catheter was removed and he voided satisfactorily. He awaits further cystoscopic surveillance.

Angela Huerta

1990/3/6

(523)349-6862x131

dillonpamela@example.org

436 Rodgers Route

A 28-year-old female was referred to our practice complaining with recurrent urinary symptoms such as dysuria, burning, pollakiuria, and urinary urgency. Neither personal nor familiar medical history of interest was reported. Periodical urocultures resulted negative. Yeasts and Koch's bacillus were also excluded. Intravenous urography (IVU) revealed a left double excretory system, without any other relevant findings. A CT scan showed an unspecific bladder wall thickening. A subsequent cystoscopy revealed a whitish thin plaque covering the whole bladder surface with the exception of the trigone area. Underneath this whitish plaque, the mucosa appeared erythematous and bled easily during the examination (). Random biopsies reported a keratinizing squamous metaplasia of the bladder (). Due to the age and mild symptoms of the patient, we agreed on a conservative management and proposed annual cystoscopy with random biopsies combined with annual upper urinary tract imaging (CT scan or IVU). After a two-year followup, the patient is felling generally well with occasional urinary symptoms but no evidence of disease progression.

Douglas Aguirre

1984/12/22

3403205506

rachel93@example.net

5191 Jones Drive

A 68-year-old Caucasian male with a history of multiple myeloma on lenalidomide/dexamethasone, diabetes, and end-stage renal disease on hemodialysis was admitted to the hospital for severe diarrhea and dehydration. On physical examination, he was found to be afebrile with benign abdominal exam. His white blood cell count (WBC) was normal. Fecal leukocytes were detected. Stool ova and parasites and bacterial stool cultures were negative. A computed tomography (CT) of the abdomen and pelvis showed diffuse thickening of the colon wall involving the entire colon and rectum consistent with infectious colitis. With the high suspicion of Clostridium difficile associated colitis, metronidazole 500 mg orally every 8 hours was empirically started. The cytomegalovirus serum polymerase chain reaction (PCR), enzyme immunoassay (EIA) for C. difficile toxin A/B and C. diffile PCR were all negative. Despite metronidazole treatment, his diarrhea persisted and on the 7th hospital day, he had a temperature of 101.8簞F and rifaximin 550 mg orally twice daily was added. He responded rapidly to the combination treatment and the diarrhea and fever resolved by the 14th hospital day and he was discharged on metronidazole for 14 days. However, a week later the patient was readmitted to the hospital with diarrhea, nausea and abdominal pain. On physical examination, he was afebrile and appeared to be in mild distress with right-lower quadrant and suprapubic tenderness on palpation. His leukocyte count was 6,200 cells/弮L and a repeat abdominal CT showed changes of pancolitis consistent with an infectious process. Metronidazole was continued and cefepime 1 gram intravenously every 24 hours was added. Stool culture showed only normal fecal flora and blood cultures were negative, however; the EIA C. difficile toxin stool assay was positive. His therapy was changed from metronidazole and cefepime to vancomycin 250 mg orally every 6 hours, as his symptoms restarted within 5 days of receiving rifaximin and while on metronidazole. Over the following nine days, the patient showed little response to therapy, averaging six loose bowel movements a day along with persistent abdominal tenderness and distention. He had a WBC count of 5,000 cells/弮L with 32% bands, and a lactate level was elevated at 4 mmol/L. An abdominal X-ray showed no bowel distention. By the 10th hospital day, the patient developed leukocytosis with a WBC count of 17,200 cells/弮L and was now considered to have failed vancomycin treatment. Tigecycline 100 mg intravenously once, followed by 50 mg every 12 hours and rifaximin 550 mg orally every 12 hours, was added to the vancomycin. Though the patient's leukocyte count peaked at 19,900 cells/弮L (during 2nd day of modified therapy), he responded well with a gradual decrease in leukocytosis, diarrhea, and abdominal pain. He was discharged on the 16th hospital day with resolution of symptoms after 4 days of tigecycline, rifaximin, and vancomycin treatment. He was continued on this antibiotic regimen for an additional ten days. One month after finishing antibiotics, the patient was free of symptoms.

Ariah Warren

1984/3/18

-5861

jasonlin@example.net

904 Henson Islands

A 34-year-old female, without a familial history of neurofibromatosis, presented with left hearing disturbance. Magnetic resonance imaging (MRI) in 2004 showed VS at left cerebellopontine angle. Two times of left retrosigmoid approach with partial tumor removal were done during 2004. Pathological report was schwannoma WHO grade I. At 1 year after the second surgery, SRT, hypofraction was given due to regrowth of the tumor. Linear accelerator base system (6 MV dedicated Linac, Varian; with X-knife planning system version 3&4, Radionics) was used for SRT treatment. Four isocenters with total average dose of 30 Gray in 6 fractions prescribed at 80% isodose line were given to the patient during 2 weeks period. The tumor volume was 4.8 cc. The tumor had been well controlled for 6 years after SRT. revealed the MRI Axial and Coronal showing a left VS at the time before SRT. The patient presented with left facial palsy, dysphagia, and right hemiparesis 6 years after SRT. Computer tomography revealed marked progression in size with cystic and hemorrhagic changes of the preexisting tumor at left CPA with new obstructive hydrocephalus (). Craniotomy with tumor removal was done immediately. MRI was performed at 3 weeks after operation, and the study shows small residual tumor at the left internal auditory canal with the cluster lesions at the superior aspect of the surgical site that is compatible with the resolving hematomas (). The patient had improvement of her neurological symptom after surgery. The pathological report was malignant peripheral nerve sheath tumor arising on schwannoma, with heterogenous mesenchymal rhabdomyoblastic and chondroblastic differentiation, WHO grade IV. Because of malignant histology and small residual tumor, the patient underwent postoperative radiation therapy with 3-dimensional conformal radiation therapy (3D-CRT). A total dose of 54 Gray in 27 fractions was planned for the patient. After 20 Gray in 10 fractions of 3D-CRT, the patient developed deterioration of consciousness. CT emergency was done and showed progression of residual tumor with internal bleeding (). Obstructive hydrocephalus was more severe. Ventriculoperitoneal shunt was performed immediately. After VP shunt, the patient still had no cooperation and showed no response to deep pain. Because the prognosis of the patient was poor, we discussed with her husband about the end of life care. Finally, the patient was discharged home for best supportive care 1 month later. The two pathological specimens were examined in two occasions as shown in . The first specimen reveals low cellularity spindle cell tumor with minimal nuclear atypia and fibrillary cytoplasm that are compatible with schwannoma (). The second specimen was performed after irradiation and composed of markedly hypercellularity and hyperchromatic spindle cells growing in fasciculated pattern. The cytoplasm is typically light staining and indistinct (). A few areas of markedly pleomorphic nuclei, brisk mitotic activity, and round cells epithelioid appearance are also seen (Figures and ). The capacity of MPNST to undergo focal mesenchymal differentiation is well known. Rhabdomyosarcoma is most frequent. The other sarcomatous component may be present such as chondrosarcoma and osteosarcoma. In this case, pluridirectional differentiations are observed as chondrosarcomatous component () and rhabdomyoblastic component (). Immunohistochemically, S-100 is negative () and confirms rhabdoid/skeletal muscle differentiation with positive staining with sarcomeric actin (). The high proliferative index (Ki 67) is also seen supporting malignant behavior ().

Abel Enriquez

1997/8/28

(825)777-6488

dicksontiffany@example.org

5370 Coleman Plains

The patient is a 68-year-old male with history of untreated hypothyroidism, untreated hypertension, and no medical care for over the last 10 years who presented to hospital with complaints of nausea, vomiting, and lower extremity weakness. Patient had called 911 two weeks prior for an episode of chest pain that felt like he was having a heart attack. When emergency medical service (EMS) arrived, chest pain had resolved and patient refused to come to hospital. A similar episode of severe chest pain occurred the following week, for which he called 911, but again refused transfer. On the day of admission patient called 911 again, but this time for nausea, vomiting, and weakness. When EMS arrived, they noticed he had slurred speech, a left-sided facial droop, and, therefore, transferred him to the hospital with concerns for stroke. In the emergency room, physical exam was most remarkable for all the classic signs of hypothyroidism including hypothermia at 35.8簞C, periorbital edema, puffy facies, macroglossia, hoarse voice, and delayed relaxation of deep tendon reflexes. His electrocardiogram (EKG) showed low voltage and sinus bradycardia with a rate in the 40 s. He did have left-sided facial droop and dysarthria, which was found to have been present for many years according to his family, and strength was 5/5 throughout his upper and lower extremities. No other focal neurological deficits were appreciated. Head CT without contrast indicated there was no acute intracranial pathology, brain MRI without contrast showed extensive chronic microvascular ischemic disease, as well as remote microhemorrhages in the right occipital and left cerebellar hemisphere. Lumbar spine MRI without contrast showed multilevel degenerative changes, most pronounced at the L5-S1 with a diffuse disc bulge, moderate-to-severe left and right neural foraminal stenosis, but no central canal stenosis. Initial laboratory data was significant for a TSH of 63.4 IU/mL, creatinine of 1.9 mg/dL, hemoglobin of 7.3 gm/dL, and a normal white blood cell count. Patient was given two units of packed red blood cells, which improved his anemia to 9.7 gm/dL. He was admitted to general medicine service for further management of his severe hypothyroidism and workup for his anemia of unknown etiology. The following morning repeat labs showed further decline in his kidney function, with a creatinine of 3.1 mg/dL, and potassium of 5.1 mMol/L. There also was new leukocytosis of 15 (?109/L) with a 94% left shift, a new thrombocytopenia of 131 (?109/L), down from 225 (?109/L) at admission, and an elevated creatine phosphokinase (CPK) of 500 IU/L. A portable chest X-ray did not show any obvious sings of widened mediastinum but did show a left lower lobe consolidation consistent with a pneumonia for which he was started on IV azithromycin and ampicillin/sulbactam. Nursing staff noted stool incontinence, for which a rectal exam was performed showing good rectal tone, and a positive guaiac. In addition, despite receiving aggressive fluid resuscitation, patient continued to be in auric renal failure. Patient then received 3 more liters of fluid throughout the day, a Foley was placed, and bladder scans showed a total of 48 cc of urine, enough to send urine studies. Urinalysis was negative for any signs of infection, and urine electrolytes indicated a fractional excretion of sodium (FeNa) of 0.96% looking initially like a prerenal process. Labs were again repeated that evening, with a rising creatinine to 4.1 mg/dL, a lactate of 3.7 mMol/L, and patient still had no urinary output. Nephrology and endocrinology specialists were consulted, and the thought process was that his renal failure was likely stemming from his severe hypothyroidism causing a low flow state. He was started on levothyroxine (T4) and liothyronine (T3) and continued to get intravenous fluids. The third day after admission morning laboratory data showed further increase in his creatinine to 6.1 mg/dL, a worsening leukocytosis to 16.7 (?109/L), an improved lactate of 2.2 mMol/L, and a worsening thrombocytopenia of 92 (?109/L). Thrombotic thrombocytopenia purpura (TTP) and HUS were also considered on the differential, given the anemia, and high LDH of 1014 IU/L. However, the smear did not have significant amounts of schistocytes, and the haptoglobin was normal; thus making it less likely. Patient began complaining of abdominal pain and in the setting of an increasing leukocytosis and diarrhea, an abdominal CT without contrast was performed. This showed colitis, which looked either infectious or ischemic, as well as, a possible aortic dissection. A CT angiogram of the chest, abdomen, and pelvis was subsequently performed STAT, which showed a large type B dissection starting in the descending thoracic aorta just past the origin of the subclavian artery, extending into the abdominal aorta, with near complete collapse of the true lumen at the level of the renal arteries, with extension of the dissection into the common iliac arteries bilaterally, and ending at the level of iliac bifurcation (see Figures ??. Following is a discussion on the presentation of this case of severe hypothyroidism and long-standing hypertension who presented with anuria/renal failure. Through the case, we highlight the importance of having aortic dissection as an important differential in patients presenting with anuria who have a long-standing history of uncontrolled hypertension.

Nellie Duarte

2001/1/30

292-331-4231

wilsontaylor@example.com

1316 Ruiz Garden Suite 219

In March 2011, a 35-year-old man was admitted to the Institute of Infectious Diseases, ?aolo Giaccone??University Polyclinic in Palermo, because of intermittent fever, arthralgias, and sweating for two months. He also reported a one-week history of intermittent pain in his left arm. He was employed at a slaughterhouse and regularly ate unpasteurized cheese. On admission, physical examination showed hepatosplenomegaly and on cardiac auscultation a 3/6 systolic murmur was heard all over the precordium. Laboratory test results revealed an increase in aspartate aminotransferase (98 U/L, upper normal limit 37 U/L), alanine aminotransferase (200 U/L, upper normal limit 41 U/L), and C-reactive protein (1.6 mg/dL, upper normal limit 1 mg/dL). Electrocardiogram (ECG) showed normal sinus rhythm. A transthoracic echocardiogram was performed and showed mild aortic and mitral insufficiency. A rapid agglutination test (Rosa Bengala Test) and Wright's serum agglutination were performed and they were both positive. Brucella melitensis was isolated from blood culture. The patient was treated with oral doxycycline (100 mg twice a day for 6 weeks) and intravenously (IV) rifampin (450 mg twice a day for 3 weeks). Oral rifampin at the same dose was administered for a further three weeks after hospital discharge. Fifteen days after the end of treatment, the patient had a recurrence of fever, asthenia, and hiporexia. The physical examination did not show remarkable changes. Echocardiogram showed an aortic valve vegetation (1.4 ? 0.9 in diameter) with eccentric jet of insufficiency, mitral valve with minimal prolapse of the anterior flap, mild mitral, and tricuspid insufficiency. Laboratory test results revealed a total white blood count of 3830 cells/mm3, haemoglobin 11.8 g/dL (normal range 13??7 g/dL), platelet 163000 cells/mm3 (normal range 150??00 ? 103/mm3), erythrocyte sedimentation rate 6 mm/h (upper normal limit 15), C-reactive protein 4.68 mg/dL, and lactate dehydrogenase 634 U/L (normal range 240??80 U/L). Brucella melitensis was isolated from blood culture. PCR assay on blood for detection of Brucella was positive. A treatment with IV rifampin (450 mg twice a day) and oral doxycycline (100 mg twice a day) was resumed and IV amikacin (1 gr once a day) was started. Nine days after admission, the patient experienced acute left upper limb pain. Decreased pulses and decreased skin temperature of the arm were noticed. Echo Doppler showed thrombosis of the left subclavian artery. The CT scan showed axillary artery filling defect with side calcification. Heparin (25000 U/24 h) was administered for ten days and the patient underwent an aortic valve replacement surgery with prosthesis implantation. The treatment with IV rifampin (450 mg twice a day), IV amikacin (1 gr once a day), and oral doxycycline (100 mg twice a day) was stopped after 45 days. Oral rifampin and doxycycline, at the same dose, were administered for further 45 days with complete resolution of symptoms. Blood cultures became negative after ten days of triple therapy.

Abdullah Simmons

1977/11/25

001-612-780-3318

richardsonkimberly@example.net

8026 Tina Crest

A 28-year-old male patient reported to the department of oral and maxillofacial surgery at people's dental academy complaining of asymmetry of the face and scar in the mandibular angle region on the left side since 3 years. The patient gave a history that he had tripped and fallen down 3 years back and he had a laceration on the left side of the face that developed in to a scar. The patient's chief complaint was left side facial growth without pain. The patient had no history of systemic diseases. Extraoral examination showed an obvious unilateral swelling centered over the mandibular angle. Palpation indicated that the swollen tissue was normal in tone and nontender. Mandibular movements were in the normal range. When the patient was asked to clench, the swelling became more prominent and firm. The patient said that he uses the left side of the jaw more while chewing food. There was no history of temporomandibular joint clicking, and no family history of masseter hypertrophy. Physical examination revealed that the patient had unilateral masseter muscle bulging, with a prominent mandibular angle at the lower border. Intraoral examination revealed distoangularly impacted 38 and 48. OPG showed a prominent mandibular angle. Data from clinical and radiographic examination led to the diagnosis of unilateral masseter muscle hypertrophy (Figures , , , , , and ). Nonsurgical options such as botox therapy and the advantages and disadvantages of both surgery and botox treatment were discussed with the patient. The patient opted for surgical option as he wanted to get rid of the scar immediately and we told him that we can do the correction of masseter hypertrophy and scar revision through one incisional approach only. A combined reduction of the mandibular angle and shaving of the masseter muscle was planned. The surgery was done under general anesthesia with nasotracheal intubation. Xylocaine 2% with adrenalin was infiltrated in the angle of the mandible. An elliptical incision was placed around the hypertrophic scar and the scar was removed (). The marginal mandibular nerve was identified and protected. Debulking of the masseter muscle was performed as the patient was very worried about the asymmetry of the face (). The muscle was incised approximately 5 mm above the mandibular basilar. The entire ascending portion of the masseter muscle was detached, and a vertical internal muscle band equivalent to two third of the thickness of the muscle was resected. After the muscle was resected, the remaining external third was sutured to its site of origin onto the muscle stump inserted in the mandibular basilar. The bony deformity was trimmed and removed in the angle of the mandible with surgical bur (). Sharp margins were trimmed with a bone file. The shaved masseter muscle and the resected excess mandibular angle was sent to oral pathology department in 10% formalin (Figures and ). Primary closure was done with 5-0 prolene suture (). After 1 week, the prolene sutures were removed and the wound healed uneventfully.

Reagan Franco

1983/4/29

+1-289-510-1020x6482

tinamoore@example.com

4198 Davis Haven

A 9-year-old girl was referred for neurological examination due to sudden onset of diplopia. The patient affirmed that after waking up on that morning, she started to feel visual impairment in which an object was seen as two while having both eyes open. She also said that the distance between the two objects enlarged when looking to the left. Her past medical and familial history was unremarkable for any degenerative or neurological disorder. General clinical assessment of the patient was found within normal limits. Neurological examination revealed convergent strabismus and no movement of the left lateral rectus muscle. The remainder of the exam was essentially normal, including visual fields and routine ophthalmoscopy. Blood laboratory exams and electrocardiogram were found to be normal. Magnetic resonance imaging (MRI) of the brain showed multiple lesions affecting the periventricular, juxtacortical and infratentorial regions (Figures , , and ). Brain MRI also showed gadolinium-enhancing and nonenhancing lesions (). A cerebrospinal fluid analysis was unremarkable. As no other structural abnormalities were identified, a diagnosis of multiple sclerosis (MS) was made and the neurological symptom was attributed to it. Based on this diagnosis, we started pulse corticosteroid therapy with methylprednisolone during three days. The girl did not recover after 6 months of the diplopia and is currently being followed on outpatient appointments.

Gage Frost

1995/6/28

(337)426-6055x682

jillstone@example.org

89205 Chapman Ford

A 60-year-old white male presented to hematology/oncology clinic for a routine followup visit. The patient was complaining of mild shortness of breath on exertion. His past medical history consisted of hypertension and a left upper extremity necrotic mass, 4.4 ? 3 ? 3 cm, that was resected 5 weeks ago (). Pathology revealed high-grade soft tissue undifferentiated sarcoma/pleomorphic malignant fibrous histiocytoma with clear resection margins tumor cells restricted to the dermis () without evidence of lymphovascular invasion. Giant malignant cells on an inflammatory background were identified on H&E stain (.) Immunohistochemistry of the pathology specimen was positive for CD 68 and CD 99 (Figures and ) and negative for S-100, HMB-45, SMA, pan-keratin, factor 13-A, and desmin. At the time, a chest X-ray was negative for metastatic disease (). A chest X-ray and CT scan of the thorax both revealed numerous bilateral pulmonary nodules (Figures and ) suspicious for metastasis with left axillary and left superior diaphragmatic lymphadenopathy with splenomegaly and bilateral adrenal nodules. Routine blood work revealed a white blood cell count of 109.4 K/mm3 with absolute bands of 25 K/mm3 and an absolute neutrophil count of 64 K/mm3 (). C-reactive protein was 14.8 mg/dL. A peripheral blood smear showed presence of mature granulocytes with toxic granulations and vacuolizations and a significant left shift with excess of bands and occasional metamyelocytes and myelocytes. PCR for BCR-ABL fusion transcript was negative. His vital signs were as follows: pulse 123, BP 119/60, temp. 99.1簞F, and RR 26??0. The patient was in mild respiratory distress. Head and neck examinations were unremarkable. Bilateral crackles were heard on lung auscultation. On cardiovascular exam, the patient was tachycardic, S1 and S2 were noted. The abdomen was soft, distended with mild diffuse tenderness, and present bowel sounds. Splenomegaly was noted on palpation. Blood cultures were drawn, which remain negative. Based on physical examination and data mentioned above, the patient was diagnosed with metastatic cutaneous IMFH associated with a leukemoid reaction. The patient was treated with supportive measures and broad spectrum antibiotics. Unfortunately, his breathing became increasingly labored, he failed several trials of BiPAP and was intubated. He remained tachypnic and became hypotensive. The patient did not receive vasopressors as per the family's wishes. The following day, the patient went into asystole and expired. Death occurred less than 45 days after initial diagnosis.

Paula Kline

1998/6/20

871-614-3672x6846

jesserogers@example.net

66382 Mcintosh Plains Apt. 630

A 42-year-old man appeared with melena and underwent several examinations, including esophagogastroduodenoscopy (EGD), colonoscopy, and abdominal CT with a contrast agent. Abdominal CT scan revealed a wall thickness in the small intestine (Figures and ). The patient was referred to our hospital. His hemoglobin level was 11.8 g/dl (normal range 11.3??5.5 g/dl). We conducted a capsule endoscopy and found part of a tumor in the small intestine, suggesting small bowel tumor (). In particular, the mucosal contrast of the tumor was enhanced by the effect of the spectral specification of flexible spectral imaging color enhancement (FICE) settings 1 and 2 (Figures and ). In order to investigate the small bowel tumor, antegrade spiral enteroscopy (SE) was conducted []. SE showed a multinodular polyp (type Ip) 20 ? 15 mm in diameter located about two meters distal to the ligament of Treitz (). Biopsy specimen revealed an atypical epithelium. We considered that the lesion was located within the mucosa and decided to perform EMR. We used a DBE (EN-450T5/W, FUJIFILM Medical Co., Ltd., Japan)with an overtube (TS-13140, FUJIFILM Medical Co., Ltd., Japan) and a transparent cap (D-201-11304 Olympus Co., Ltd., Japan) attached to the endoscope tip, which is useful in the colon by pushing draped folds aside or helping luminal orientation at bends by keeping appropriate distance between lens and mucosa []. In order to reduce intraluminal gas, a CO2 insufflation pump was used during the procedure.It took 12 min to approach the jejunum polyp. Hyaluronic acid at 0.12% (MucoUp, Johnson & Johnson K.K., Japan) was injected into the submucosal layer to lift the surrounding mucosa using a 25-gauge needle (TOP Corp., Japan). A 15 mm electrosurgicaldiameter snare (Snare-Master, Olympus Medical Systems Corp., Japan) was placed around the lifted area. The lesion was strangulated and resected en bloc using blended electric current (Endocut 2 mode ICC200, ERBE, Germany). The electric current output was increased from 60 to 100 W for final resection. Histological examination showed adenocarcinoma (). The invasion depth of the carcinoma was limited to the mucosal layer. There was no lymphovascular invasion of carcinoma cells. The lateral and vertical margins of the specimen were negative. The patient was discharged seven days after EMR without any complications, such as perforation and bleeding. Follow-up endoscopy and abdominal CT scan four months after EMR showed no local or remote recurrences.

Ramon Zamora

1996/5/15

7675841002

shahshelley@example.org

5351 Kathryn Roads Suite 331

A 30-year-old, gravida 1 lady, of 39 weeks' gestation, presented to an outside hospital with acute severe epigastric pain, shoulder-tip pain, and severe intravascular volume depletion. An emergency lower section caesarian section was performed, and a healthy female was delivered. During the procedure, the blood was noted to be of ?trawberry milkshake??consistency. Blood drawn for analysis precipitated into two layers. The upper two-thirds of the sample, constituting the plasma component, was lipid in nature. The laboratory was initially unable to process the sample, although an amylase of 900 U/L was obtained (reference range: 28??00 U/L). The patient had no significant medical or family history, and her pregnancy was previously uncomplicated. A clinical diagnosis of acute pancreatitis was made based on the revised Atlanta Classification of Acute Pancreatitis [], most likely secondary to extreme gestational HTG, and the patient was transferred to our institution one day after caesarian section. Initial examination following transfer revealed a markedly unwell and tachycardic (140BPM) patient with gross abdominal distension and a rigid, tender abdomen. Further investigations demonstrated a leukocytosis (20.5 ? 109/L, reference: 3.5??1 ? 109/L), elevated random cholesterol (Chol, 20.3 mmol/L, reference: desirable <5.2 mmol/L) and triglyceride (TG, 45.29 mmol/L, reference: 0.15??.8 mmol/L) levels, and a prothrombin time (PT) of 20 seconds. Lipase (148 U/L, reference: 13??0 U/L), amylase (495 U/L), and C-reactive protein (CRP, 420.0 mg/L, reference: 0??.0 mg/L) were all elevated. Given the high lipid content of the patient's blood at initial presentation, neither the Ranson or Glasgow scoring systems could be utilised. A contrast-enhanced CT abdomen and pelvis was performed, which found moderate volumes of ascites, small bowel dilatation consistent with ileus, and bilateral pleural effusions with associated atelectasis. There was no radiological evidence of any pancreatic pathology at this stage. As a result, mild acute pancreatitis was predicted as per the Modified CT Severity Index []. Despite aggressive resuscitation, the patient remained haemodynamically unstable after transfer (tachycardic and hypotensive), requiring significant vasopressor support. As a result of the associated pulmonary oedema and inotropic dependent cardiac failure, she developed type 1 respiratory failure necessitating intubation and ventilation. In addition, a persistent oliguria secondary to acute renal failure was noted with concomitant metabolic acidosis, and it was felt that dialysis would be appropriate. As a result of this multiorgan failure, the patient was transferred to the intensive care unit. In spite of this, she demonstrated persistent organ failure during her ICU stay []. Three sessions of plasmapheresis were performed during a progressive deterioration in the patient's condition, using 5% human albumin solution as replacement fluid. She rapidly improved, both clinically and biochemically (random Chol: 3.1 mmol/L, TG: 6.4 mmol/L), was extubated and maintained on supportive care (gastric decompression, jejunal feeding tube, total parenteral nutrition, and haemodialysis), returning to the ward nine days after admission. Once the patient was stabilised, she continued to experience intermittent temperature spikes. Blood cultures were positive for Staphylococcal and Candida spp. Interval imaging over four weeks showed an evolving ascites () and loculation. No evidence of pancreatic or peripancreatic collections or necrosis was noted during this period. Samples of the ascitic fluid obtained under ultrasound guidance grew Escherichia coli. After detailed discussion with the microbiology service, appropriate parenteral antibiotics and antifungals were commenced. The ascitic collections were not amenable to radiological drainage due to their highly loculated nature. A decision was made not to proceed to laparotomy and surgical drainage, as the ascites promptly resolved, and her inflammatory markers quickly fell with the commencement of targeted antimicrobial therapy. The patient's clinical condition continued to improve until the time of her discharge.

Sierra Barker

1987/5/15

(889)402-0139x3340

katherinelong@example.org

395 Gloria Curve Apt. 626

A 43-year-old man was referred to our department complaining of a mass in the right preauricular region, which had been developing painlessly over 1 year. The physical examination revealed a hard mass approximately 2 cm diameter in the right preauricular region. Otoscopy showed swelling of the anterior wall in the right external acoustic meatus, covered by normal skin. There was no temporomandibular joint (TMJ) pain, trismus, or hearing loss, and there was no history of facial trauma. The general physical examination did not disclose any abnormalities. Magnetic resonance imaging (MRI) revealed a solid lobulated lesion in the right preauricular region, which was proximate to the capsule of the right TMJ (). The lesion was isointense relative to muscle on T1-weighted images, hyperintense on T2-weighted images, and partially enhanced after gadolinium injection. A benign tumor in the right TMJ was suspected clinically. The lesion was removed surgically via a preauricular incision under general anesthesia to determine the histopathological diagnosis. The lesion was independent of the parotid gland and was not in contact with either the TMJ or the cartilage of the acoustic meatus (). Although the lesion was attached to the surface of the temporal bone, there was no invasion of the temporal bone, and the lesion was removed easily by en bloc excision. The specimen was a 2.5 ? 2 ? 1.5 cm, well-circumscribed, nodular, white-grey, hard, elastic mass. Histopathologically, the tumor was well circumscribed and encapsulated by thin fibrous connective tissue. The tumor comprised mainly of hyaline cartilage, which contained chondrocyte with chondrocytic lacunae, with collagenous fibrous tissue in the center of lesion (). The tumor had low cellularity, with no evidence of atypia or mitotic figures. Immunohistochemically, the chondrocytes expressed S-100 protein and vimentin, but were negative for epithelial cell markers. These histopathological findings revealed the diagnosis of chondroma. The postoperative period was uneventful, and there was no evidence of recurrence at the 2-year followup.

Kade Jenkins

1987/9/12

(301)479-9255x36034

christinemcfarland@example.net

194 Holly Mission

A 9-year-old boy was admitted to the emergency department with abdominal pain from 3 days ago. The pain was colicky in nature and 3 episodes of biliary vomiting were reported. Simple abdominal radiography indicated loop distention in the small intestine with air-fluid levels (). The child was submitted to laparotomy: we found severely distended intestinal loops in jejunum and ileum, with the distension proceeding as far as a Meckel's diverticulum (). A hard mass was palpated at some 5 cm after the Meckel's diverticulum, suggesting that obstruction originated at some point after the diverticulum. Enterotomy produced a round mass measuring 4 ? 5 cm and brown in color. Sectioning the mass demonstrated lumps of meat, forming bezoar (). Histopathologic studies of the diverticulum reported ectopic gastric tissue. A history obtained after surgery indicated that the child had consumed meat a week ago.

Rylee Hicks

2002/10/30

(930)227-3964

lwilliams@example.com

2668 John Oval Apt. 529

A 5-year-old boy referred to the pediatric gastroenterology clinic, complaining of colicky abdominal pain and 5 episodes of vomiting from yesterday. No history of surgery or disease was mentioned. Simple abdominal radiography depicted signs of intestinal obstruction. The patient was admitted to the operating room with a diagnosis of acute appendicitis. The appendix was found to be normal. Severe loop distention was observed as far as 3-4 cm after a Meckel's diverticulum. Enterotomy revealed a quantity of orange impacted at the diverticulum, extending as far as 5 cm after the diverticulum and causing obstruction at this point (). Histopathology reported no ectopic tissue. After the surgery, the parents mentioned that the child had eaten large quantities of orange 2 days ago. In both cases there were no preexisting motility disorders or predisposing factors. Except Meckel's diverticulum any histopathologic problems such as changes in number of ganglions or neuromotor units were not seen.

Maddox Cantu

1989/7/25

001-661-511-4538

xalexander@example.net

7535 Carpenter Green

The patient is a Caucasian female (Fig. ), who was born to a 32-year-old mother and 34-year-old father after a third full term uneventful pregnancy. Her birth weight was 2700g, length 40 cm, head circumference 35 cm. The patient has two healthy half-siblings from the mother? first marriage. Analysis of the family history did not reveal previous bone disorders in the other family members. Bone dysplasia was considered as a diagnosis due to the short stature of the newborn, however, no radiographs were taken at that time. The patient? motor development was delayed; she started to walk at the age of 2 years. At the age of 3 years she was referred to the Ambulant Centre for Defects of Locomotor Apparatus in Prague. At that time her height was 62 cm (-8.8 SD), upper segment/lower segment = 39.7 cm (-.5 SD)/22.3 cm (-10.1 SD), arm span 63 cm, head circumference 48.6 cm (between 25-50 centile) and her weight was 8 kg. The patient had a genu valgum deformity and a waddling gait was observed. Her hands and feet were relatively long. At the age of 4 years, patient was able to walk only for short distances. At that time she developed recurrent paroxysmal attacks of impaired consciousness with succession of muscular spasms. The cause of her seizures was hypertension secondary to a right dysplastic kidney. After right nefrectomy, her seizures disappeared and the blood pressure returned to normal. Bracing was used as a treatment for patient? severe scoliosis at the age of 4 years. Radiographs taken between 2 and 6.5 years documented lack of ossification of the capital femoral epiphyses, severe metaphyseal changes, scoliosis convex to the left, and delayed carpal/tarsal bone age (Fig. ). At 6.5 years her height was 72 cm (-9.2 SD) and her weight was 11 kg. The patient? thickness of skin folds was normal and her muscle development correlated with the length of her extremities. Her mental development, vision and hearing were normal. At the age of 9 years the patient? height was 78.8 cm (-9.2 SD), the upper segment/lower segment ratio was 47 cm(-10.2 SD)/31.8 cm(-9.4 SD), span 86 cm, weight 13.3 kg and the head circumference 51.6 cm (33rd centile). At 10 years her height was 80 cm (-10 SD) and her weight was 14.5 kg (Fig. ). There was an increase of her spinal deformity (dextro-convex scoliosis of the thoracic spine and sinistro-convex scoliosis of the thoraco-lumbar spine with marked hyperextension), (Fig. ). Her mobility was limited; she was walking by taking short steps. Radiographs taken between 6.5 and 11 years of age documented progress of spinal scoliosis and increased genu valgum deformity. Ossification of the capital femoral epiphyses was absent and the carpal/tarsal bone age was delayed (Fig. ). Bilateral release of tractus iliotibialis and osteotomy of the left fibula, with corrective osteotomy of proximal metaphyses of the left tibia, were performed at the age of 8.5 years. At 9.5 years of age bilateral partial medial epiphyseodesis of distal femora was performed. Valgus deformity of the knees decreased after these surgeries.

Galilea Cisneros

1984/1/8

(312)487-7624x8215

richelizabeth@example.com

1643 Nicole Fall Suite 043

A twenty-seven-year-old woman presented with intermittent hematuria and a mass coming out from the vagina. On examination, she was found to have a fleshy mass at the urethral meatus (). She did not have any voiding symptoms or perineal pain. On urethroscopy, the mass was occupying the mid and distal urethra from 10 o?淆lock to 6 o?淆lock position. Cystoscopy was normal. The urethra could be calibrated up to 18 Fr. The mass was excised and the proximal urethral mucosa was mobilized and approximated with the distal edge. After excision of the tumor, the urethra could admit a 30 Fr dilator. Patient was catheterized for 48 hours and voided well on catheter removal. Histopathological examination revealed an encapsulated tumor composed of spindle-shaped smooth muscle fibers arranged in a whorling pattern. On immunohistochemical examination tumor was positive for vimentin and smooth muscle actin. A diagnosis of leiomyoma was made ().

Alden Rowe

2004/7/2

001-492-878-0899x163

wrightsarah@example.org

124 Jennifer Forge Suite 185

A 27-year-old G11 P2262 female with no significant past medical history had a routine prenatal ultrasound at 35 weeks gestation. The ultrasound showed a 4.0 cm cystic lesion in the right ovary of the fetus. The remainder of the pregnancy was uneventful. The female neonate was delivered vaginally without any complications. A pelvic ultrasound was performed one day after birth to follow up on the ovarian cyst seen in utero. Ultrasound showed a 5.8 ? 4.0 ? 4.3 cm cystic mass with internal hemorrhage. There was a smaller cyst internally measuring 0.8 ? 0.9 ? 1.0 cm (). An MRI was recommended for further characterization, which was performed on the same day. MRI showed a 4.5 ? 5.6 ? 4.5 cm cystic mass with layering hemorrhage or proteinaceous elements. A 1.0 cm nodular cyst was present against the inner wall of the larger cyst (). The size of the ovarian cyst had increased in size with morphologic changes since the prenatal ultrasound. Suspicion for ovarian torsion was high and the female newborn underwent oopherectomy on the seventh day of life. Imaging findings of ovarian torsion with internal hemorrhage were confirmed in the surgical pathology report.

Matilda Wu

1983/6/19

001-407-529-8628x53647

elizabethtodd@example.org

888 Torres Road

A 45-year-old male Moroccan patient presented to the emergency department with gross rectal bleeding and hematuria secondary to a stab wound to the perianal area. The patient was admitted four hours after his knife stabbing. On physical examination, the patient looked well and was stable hemodynamically. He had mild suprapubic tenderness and the rectal examination revealed evidence of rectal bleeding together with a 2 cm wound, located 1 cm laterally to the anal opening (). A proctosigmoidoscopy performed on the patient revealed two defects of the posterior and the anterior walls of the rectum. An emergency cystogram CT was done through a urethral catheter under screening, and the rectum was also filled with the contrast in order to improve its evaluation. This clearly showed an extraperitoneal contrast extravasation associated with an anterior rectal wall defect () and two bladder wall defects located in the posterior wall and the dome of the urinary bladder (). The CT showed no abnormalities in the nearby organs. The rectal injury treatment consisted of distal rectal washout, transanal rectal wound repair that was protected by a diverting colostomy and the bladder injury was managed by a urethral catheter drainage. Three months later, the colostomy was reversed without other sequela. The urethral catheter was left in place for 30 days, and the patient was put on oral broad spectrum prophylactic antibiotics. A retrograde cystogram was done 30 days later and showed no further evidence of extravasation. After a one-year followup, the patient is healthy and totally asymptomatic.

Kyson Hawkins

1997/7/12

(557)353-4184

patrickjoseph@example.com

72807 Wade Ford Suite 224

A 61-year-old male presented with a history of hypertension and years of hyperuricemia and gouty arthropathy. He consulted for 4 small lesions present on a raised, irregular, erythematous penis that caused him pain during erection. The lesions were not adherent to deep planes, and the largest lesion was 2.5 cm, suggestive of gouty tophi. The patient also exhibited similar lesions of various sizes on his hands, feet, and elbows, which did not cause symptoms. He was treated with allopurinol and NSAIDs, but despite treatment, the lesions did not disappear. The patient's analytical findings showed only a mild renal insufficiency (creatinine of 1.5 mg/dL) and hyperuricemia of 9 mg/dL. We performed a surgical excision of the tophi from the penis, without incident (Figures and ). The excised fragments were sent to pathology, confirming the gouty tophi (based on monosodium urate levels). The patient was asymptomatic for 9 months after surgery.

Ariel Owen

2000/11/23

001-568-693-5687x2251

gcarter@example.org

15335 Barnes Club

At April 2008, an 18-year-old man was referred by a neurologist to our department with 6-day history of progressive deteriorating neurologic symptoms and an abnormal brain magnetic resonance imaging (MRI). His problem has begun with weakness and paresthesia in the right upper extremity with gradual extension to left arm and both lower limbs. On the third day, he felt haziness of vision in his right eye and pain on lateral gaze. In the same day, he also experienced few attacks of grand mal seizure. On neurological evaluation upon admission, he was well-oriented gentleman looking apprehensive and concerning about his symptoms. He was afebrile with normal general physical examination. Positive findings in neurological evaluation included visual acuity of 20/200 in right eye, with central scotoma and signs of papillitis on fundoscopy, jerk nystagmus on lateral gaze, decreased power in extremities (3/5 in right and 4/5 in left), +1 deep tendon reflexes, bilateral Babinski sign, and mild ataxic gait with normal superficial and deep sensations. While patient was started on Valproate- (Depakine Chrono 500 mg twice per day) obtained lab data revealed below results: CBC, blood sugar (BS), serum electrolytes, liver and kidney function tests, and urine analysis all were normal and ESR was 15 mm. Serology for HIV, HCV, EBV, HZV, borrelia, and toxoplasma was negative so was a tuberculosis skin test and collagen vasculitis work up. Chest X-ray was normal. Cerebrospinal fluid (CSF) analysis showed 2 RBC, 0 WBC, protein of 125 mg/dL, sugar 50 mg/dL (BS: 110), LDH: 43 U/mL, and positive oligoclonal band (OCB). Visual-evoked potentials (VEP) test was prolonged in right eye so was the left-sided sensory-evoked potentials (SEPs). Brain MRI revealed multiple large round-shaped lesions with central low T1, high T2 signal high-intensity signals and marginal low T2, iso T1 signals in right centrum semiovale, and perileft occipital horn white matter extending to splenium of corpus callosum, which were associated with sever peripheral vasogenic edema but no mass effect and no midline structural shift (Figures ??. In postcontrast T1W images, heterogeneous enhancement was noted in lesions (Figures ??. Result of cervical MRI was normal. These findings brought several differential diagnoses such as acute disseminated encephalomyelitis, multifocal glioma, metastasis, vasculitis, lymphoma, lymphoproliferative diseases, and TMS under consideration. At this stage for proper management of the patient, a biopsy was suggested which was refused by the patient and his parents, so we decided to treat the patient empirically with the diagnosis of TMS in spite of clinical (seizure) and MRI red flag signs []. This decision was made on the basis of the presence of papillitis, normal blood tests, prolonged VEP and SEP, presence of OCB, and no shift in midline structure in spite of large lesions. He received a 7-day course of 1 gr daily intravenous methylprednisolone (IVMP). This was followed by further 2 weeks of 75 mg daily oral prednisolone (OPN) with tapering and discontinuation of the drug in the third week. From the third day of IVMP, he begun improving and discharged by the end of OPN therapy with mild right-sided weakness. Thirteen months later he was returned with left optic neuritis, received 5-day course of IVMP, and with respect to 2nd MRI done at August 2008, he was discharged on weekly intramuscular injection of Interferon beta1a (Avonex). So far, he has been stable and no further relapse has been reported. Two further MRI studies were performed at August 2008 (Figures ?? and August 2011 (Figures ??. They demonstrated sequelae of previous lesions as high T2 signal intensities with resolution of their peripheral vasogenic edema. The lower row is postcontrast axial T1W images (g and h), which show no enhancement in lesions and no abnormal signal intensity can be detected in cervical cord.

Cannon David

2004/9/23

383.375.3681

rayyoung@example.com

546 Turner Shore

We present herein the case of a 34-year-old Caucasian patient G1P0 that was referred to our department for ?locked atrial bigeminy with pseudobradycardia??detected elsewhere at 33 of weeks of gestation. Furthermore, a placenta previa was diagnosed. The patient was scanned at our department at 37 weeks of gestation. An echocardiography showed during all the examination an arrhythmia that in M-mode resulted in being a blocked atrial trigeminy with a mean fetal heart rate (FHR) of 100 bpm (Figures and ). A female neonate of 2770 gr and Apgar score 9/10 at 1/5簞 minutes, respectively, was born by cesarean section at 38 weeks because of the placenta previa. An ECG performed at birth revealed blocked supraventricular extrasystoles (). Instead, successively at cardiomonitoring, no extrasystoles were registered. An ECG the day after did not register any extrasystole. On day 3, an ECG showed no atrial extrasystoles and a normal QTc interval at upper limits. An echocardiography performed the same day showed a small patent FO with moderate left-to-right shunt and a trivial tricuspid regurgitation with an indirect estimate of pulmonary artery pressure of 35 mmHg. To our surprise, on day 11, ECG revealed supraventricular trigeminy and episodes of paroxystic supraventricular tachycardia (). A treatment with Lanoxin syrup 0.25 mL twice a day was started. A control on day 17 showed a paroxystic supraventricular tachycardia interrupted by some sinusal beats (). Digoxinemia level was at 1.4 ng/mL, and therapy with Sotalol hydrochloride 2 mg/kg twice a day was started. On day 18, an episode of PSVT that needed a ?iving reflex??maneuver was registered. The same day, a cardiomonitoring showed extrasystoles and episodes of bradycardia with a heart rate of 80 bpm. A 24 hr ECG/Holter monitoring on day 20 recorded a sinusal rhythm with a mean heart rate at lower limits for age, some blocked supraventricular extrasystoles, and 3 isolated and monomorphic ventricular extrasystoles. During sleep, some episodes of 2nd-degree AV block Mobitz type I and Mobitz type II were recorded. Interventricular conduction was regular. There were no significant alterations of the ventricular repolarization. After consulting 24 hr ECG monitoring, we decided to gradually suspend Lanoxin. Currently, the little girl is administered Sotalol hydrochloride 2 mg/kg twice a day and she is doing well.

Haylee Blankenship

1992/4/3

(600)734-5993

michael40@example.com

857 Rojas Run

A 49-year-old Iraqi male presented in February 2011 to the American University of Beirut Medical Center (AUB-MC) with fever, chills, chest pain, anorexia, and weight loss after being operated on for a presumed malignant thymoma in India. His initial history goes back to May 2010 when he was diagnosed with myasthenia gravis in Iraq and was started on prednisone 60 mg orally and mestinon 60 mg orally three times per day. A computed tomography (CT) of the chest done in Iraq showed a cystic mediastinal mass abutting the right ventricle described as thymoma (images not available) but very similar to the CT done at our institution later. No interventions were undertaken in Iraq. He was then referred for right lateral thoracotomy in India in November 2010. Pathology revealed malignant thymoma. The patient remained hospitalized in India for 3 weeks where he reported chills, weight loss, and sweating without any documented fever. He was started on chemotherapy (unknown regimen) and was discharged home on levofloxacin 500 mg orally daily for ten days. No microbiological work-up was initiated in India to try to detect an underlying infectious process. The period from December 2010 until February 2011 in Iraq was characterized by recurrent chest pain, fever, chills, sweating, cough, and greenish sputum production. Blood tests at that time showed a WBC of 26,000/弮L. Repeated CT of the chest showed multiple cystic masses impinging on the right ventricle and left atrium described as metastasis in concordance with his history of malignant thymoma (). At a local hospital, he received blood transfusion, fluconazole, and cefotaxime both at unknown frequency and dosage without improvement. He then had a PET scan in Lebanon showing cystic masses in the chest with necrosis and invasion of the pericardium described as metastasis. He presented to our institution where echocardiography showed two large anterior fluid collections one of which was compressing the right ventricle with a third cyst behind the left atrium (). Pericardiocentesis was performed and yielded 90 mL of greenish yellow purulent fluid. The Gram stain showed Gram-positive branching rods, and the recovered Nocardia spp. was identified in Laboratories Cerba France as N. asiatica (). The susceptibility testing (Cerba, France) revealed susceptibility to all tested antimicrobials except macrolides, clindamycin, colistin, and aztreonam. A median sternotomy was performed and debridement of the abscesses in the anterior mediastinum as well as biopsy of suspicious tissue was performed. The pathology did not reveal any malignancy. The posterior abscess could not be drained without instituting cardiopulmonary bypass and so was left to be drained with the help of endoscopic ultrasound via the esophagus. CT scan of brain showed multiple cystic lesions so the patient was diagnosed as having disseminated Nocardia asiatica infection and was started on imipenem, amikacin, and trimethoprim sulfamethoxazole (TMP-SMX) to be given for at least 9??2 months. At five months of followup, the patient is doing well clinically and radiographically.

Ernesto Dorsey

1987/11/29

+1-986-402-6816x1943

davissteven@example.com

45332 Warren Causeway Suite 875

A male 32-year-old patient, who lives in Campinas, S瓊o Paulo, Brazil, was admitted to a private hospital in his city. He had traveled on vacation to the state of Bahia, (Northeastern Brazil) Barra Grande city, on New Year's Eve 2008. After approximately one month of return, the patient reported a sudden onset of symptoms and the clinical pattern at admission to hospital included fever (39簞C), fatigue, malaise, persistent and nonproductive cough, and diarrhea. The patient was examined by a physician and, after a chest radiography, the putative diagnosis at that time was pneumonia and antibiotic treatment was started at home. One week after the treatment the patient remained with continuous lassitude and diarrhea with some blood and persistent cough and was examined by other physicians that reported the same symptoms. Routine laboratory examinations were performed: complete blood count (n = 3) in alternate days for one week and one stool parasitological examination for screening intestinal parasites. The only alteration detected in the blood count was eosinophilia, which showed a gradual increase once every two days: 816, 1,232, and 1,408 cells/弮L percentage corresponding to 8.0%, 14.0%, and 16.0%, respectively, of total leukocytes (normal range 0??.0% or ??00 cells/弮L). The parasitological investigation?resh stool examination?evealed trophozoites of Entamoeba histolytica/Entamoeba dispar. The patient was treated with secnidazole, 2,000 mg at that moment and 2,000 mg after 14 days. About two weeks after the treatment, the patient remained with the same signs and symptoms exhibited before the diagnosis of pneumonia and amebiasis and his clinical pattern worsened: very strong cough, progressing to dyspnea, generalized rash, and marked weight loss (about 8 pounds since the onset of symptoms). One week later, a new routine laboratory investigation showed leukocytosis, presence of atypical lymphocytes, normocytic-normochromic anemia, and high eosinophilia: 4,560 cells/弮L??0.0% of total leukocytes. The patient was hospitalized and submitted to infectious diseases screening, which revealed positive serology to Epstein-Barr virus (EBV), cytomegalovirus (CMV) and hepatitis A virus (IgG-ELISA) for all viruses, data consistent with past infections. Serology for hepatitis B and C viruses, HIV types I and II, Toxoplasma gondii, and Toxocara canis was all negative. The stool parasitological examination evidenced the presence of Entamoeba coli and Endolimax nana, and hemocultures were negative. After the inconclusive diagnosis and a suspicion of infection with helminths, the patient was referred to the Department of Animal Biology, Sector of Parasitology, of Biology Institute in State University of Campinas. The patient showed all the exams and was interviewed about his signs and symptoms and about information regarding travel history. Important epidemiological data and clinical pattern were obtained from that holiday: the patient had gone through a small dam to get to a beach (Taipus de Fora) rarely explored by tourists and often frequented by autochthonous population; the exposure time was approximately five minutes. The patient also recalled that he had a localized pruritic rash in both legs?ercarial dermatitis?fter crossing the weir. Prior parasitological stool testing was negative on prior days until the one done at 70 days. The Kato-Katz method [] as well as the flotation procedure of Willis and spontaneous sedimentation method was applied in the Sector Parasitology in the State University of Campinas to search for helminthes. The coproparasitological analysis showed many Charcot Leyden crystals, and the Kato-Katz method showed the presence of Schistosoma mansoni eggs with typical lateral spine (). The quantitative analysis revealed the presence of 240 eggs per gram of stool. The patient was treated with Oxamniquine (Mansil)?ingle dose of four tablets of 250 mg, according to the weight of the patient. The control of cure was performed for four successive months after the treatment using the Kato-Katz method to search for eggs. All stool samples were exposed to light for about 2 hours to stimulate eclosion of the miracidia. The monitoring of the control of cure to search for eggs or larvae was all negative for Schistosoma mansoni, and the result of the treatment was favorable.