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A healthy, 29-year-old male commercial airline pilot without individual or family history of skin cancer or other malignancies noticed a symptom-free movable nodular mass over the dorsal proximal phalanx of his left middle finger, near the metacarpophalangeal joint. The tumor gradually enlarged to 2 cm in diameter in two years and was associated with local erythematous change. An excision biopsy was performed by a general surgeon in a medical center. Histopathological examination revealed a nodular neoplastic lesion composed of spindle-shaped cells with frequent mitotic figures. Immunohistochemical stain was negative for actin but positive for CD34. Thin collagen fibers crisscrossing between the spindle cells stained positive with Masson trichrome. The pathological diagnosis was consistent with DFSP. Due to the close proximity of surgical margins to the tumor mass and the characterized highly recurrent nature locally of the tumor, a wider excision was strongly suggested by the general surgeon. The pilot visited the plastic surgery outpatient clinics in another hospital 3 weeks later for a second opinion. A wide excision and split-thickness skin graft with donor from left palm hypothenar region were done. Width of the surgical margin was not mentioned in the medical record. A pathology report revealed residual DFSP in the lower dermis and subcutis region of the skin surrounding the previous wound. Two weeks after his second surgery, he was admitted to the previously-mentioned medical center where a plastic surgeon carried out a wide excision of the skin and soft tissue around the previous wound. About 1 cm margin around the lesion was excised. The depth of the defect was 0.5 cm, subcutaneous tissue was involved, but tendons were spared. In order to make sure the surgical margins are free from tumor invasion, even with the frozen section, the reconstruction was delayed until definitive pathology report. The defect over the left middle finger was transiently covered with a cadaveric skin graft after confirming free of tumor invasion over surgical margins and base with intra-operative frozen section analysis (). Functional reconstruction was achieved 1 week later by tissue coverage, using a superficial palmar branch of the radial artery (SPBRA) free flap []. The SPBRA bifurcates from the main trunk of radial artery about 2 cm proximal to the distal wrist crease. Usually, one or two concomitant veins accompanied the SPBRA. After marking the SPBRA, an elliptical shaped 35 × 25 mm flap over the volar surface of distal forearm was designed to facilitate donor site closure (). A proximal incision was made to explore the SPBRA after confirmation by Doppler flowmetry. The flap was elevated, the SPBRA and its two concomitant veins were anastomosed to the digital artery and digital dorsal veins, respectively, under microscope. The flap was harvested as a sensate flap by incorporating palmar cutaneous branch of the median nerve into the flap. The donor site was closed without complication or obvious scarring. The recipient site achieved a full range of motion and showed a good contour. Both dynamic and static two-point spatial discriminations were tested and adequate protective sensation was attained.\nThe pilot did not disclose the whole process of tumor evaluation and management until his next annual aircrew physical examination. Upon doing so, he was grounded immediately. After reviewing pertinent medical records and being closely followed-up for 9 months without recurrence since the last operation, a waiver was granted and the pilot returned to flight status. To date, there has been no evidence of tumor recurrence 4 years after a complete surgical resection. |
A 40 year old female, suffering from hypothyroidism for 6 years, presented to our outpatient department with a gradually progressing large abdominal lump for 1year associated with bilateral pedal edema and difficulty in breathing for 1 month. She had had a similar large lump in 2013 and 2017, and had twice undergone excision of the tumour elsewhere. Biopsy revealed a well differentiated liposarcoma. She received 6 cycles of chemotherapy after the second surgery and her last cycle was in March 2018. She had not had radiotherapy. She was well till November 2018 when she again noticed a lump in the lower abdomen which gradually increased in size occupying her entire abdomen. There were no symptoms suggestive of bowel or urinary bladder involvement and no history of jaundice, back pain or headache.\nOn examination, she was moderately built and nourished with weight of 83 kg, height of 161 cm and body mass index (BMI) of 32. She had a distended abdomen with a midline scar from a previous laparotomy. Firm non-tender mass felt all over abdomen with edema noted all over abdominal wall and bilateral lower limbs. Her bowel sounds were heard in the left upper quadrant of the abdomen. On digital rectal examination, a mass was felt anteriorly compressing the rectum. Her all lab parameters were within normal limits except for raised thyroid-stimulating hormone that was managed by increasing the dose of thyroxin from 25mcg to 50mcg once daily. She was evaluated with a PET CT () which showed a mildly FDG avid, large heterogeneously enhancing lesion with a predominantly fat component occupying almost the entire abdominopelvic cavity with displacement of the other intra-abdominal organs. No other significant FDG avid lesion was seen elsewhere in the body.\nAs it was a second recurrence of the tumour and the patient refused neo-adjuvant therapy, it was decided to relieve her symptoms by surgical excision. On exploration by a senior consultant in surgical gastroenterology and liver transplantation department in this tertiary care center, a huge 50 × 40 × 40cm yellowish encapsulated multilobular retroperitoneal tumour mass was found extending from the diaphragm to the pelvis (). The entire small bowel and right-sided colon were pushed to the left hypochondrium with minimal interloop adhesions. The liver and right kidney were pushed cranially and medially. The tumour was completely excised without removing any other abdominal organ. The total weight of the excised tumor specimen was 18.55kg.\nHer post-operative course was uneventful. At the time of discharge, 1 week after surgery, her weight was reduced to 61 kg with BMI of 23.5. The final histopathology report was suggestive of large grade 2, dedifferentiated liposarcoma (DDL) with undifferentiated pleomorphic sarcoma (UPS) features (), with less than 50% necrosis and a mitotic rate of 5–6/10hpf. pT4N0Mx (stage 3B according to AJCC staging system 8th edition). She is now under close follow up with no recurrence detected on a CT scan at 12months. |
A 3-year-old boy was brought into hospital because of developmental regression. His medical history revealed little problems, except for a bronchiolitis caused by respiratory syncytial virus, for which he had been in hospital as a toddler. Uptill a few months earlier his neuromotor development had always been on schedule. Six months before admission to our hospital he was hospitalized in a different clinic with convulsions, thought to be caused by a viral infection with enterovirus. Afterwards he progressively developed constipation, limping, and an inability to play in his normal manner. The boy is the firstborn son of two nonconsanguineous parents of Afro-Caribbean origin. The mother and maternal grandmother of the boy are known to have ROWD. A maternal uncle was diagnosed with systemic lupus erythematosus.\nDuring the diagnostic workup in a neighbouring general hospital an MRI scan of the spinal cord was performed (). It showed a spinal vascular malformation with a large aneurysm at the level of the lower thoracic spinal cord, causing massive compression of the lumbar spinal cord. The boy was transferred to our university hospital for further diagnosis. Spinal angiography (under general anaesthesia) identified the vascular malformation as a spinal arteriovenous fistula with an associated large venous aneurysm at the level of the fistula. The dilated arterial feeder as recognized from MRI originated from the intercostal artery at T9. It was thought to be a single fistula. Due to the low weight of the boy, only a limited amount of contrast could be administered and more distal thoracic levels were not checked. An embolisation of this AVF at T9 was carried out, using a coil and a liquid embolic agent (). The idea was that the aneurysm would gradually shrink in time, whereas initial aneurysm occlusion would result in an oedematous reaction with increase in spinal cord compression. Postoperative high-dose dexamethasone was given to prevent oedema of the spinal cord. The boy recovered well with spontaneous movements of the lower limbs and preservation of sensibility. Because of his symptoms and the family history, genetic testing was started up to try and confirm the diagnosis of ROWD in the boy.\nA week after discharge he was readmitted with severe pain in his back, stiffness of the neck, and an inability to walk. A complication of the embolisation was suspected. A second MRI scan revealed an intraspinal epidural haematomata expanding caudally from level L1, at the site of the known venous aneurysm that had also increased in size (). A new spinal angiography, because of the acute state now covering more thoracolumbar levels, demonstrated several other arterial feeders of the AVF. During the same session, coiling of the aneurysm and the fistulas was performed. Afterwards the paraplegia of the lower limbs was more significant and the mental state of the boy deteriorated. Again, corticosteroids were administered to reduce oedema. However, a new MRI scan showed increased oedema of the spinal medulla (). A surgical laminectomy was performed, the haematoma was drained, and the coiled aneurysm was removed to release the spinal compression. Due to the long-standing compression the spinal cord was split and very thin at the level of the aneurysm.\nAfter the operation the boy recovered remarkably well. He stayed in our hospital for a month. During that period of time his mental state completely normalised and he was able to start walking again. He did however develop a hypertonic bladder, for which he has to be catheterised. An MRI scan performed two months later showed decrease of oedema of the spinal medulla (). Genetic testing did confirm the diagnosis of ROWD. Further rehabilitation is tended to at home by a paediatric physiotherapist. |
A 27 -years old male sustained transverse fracture of the patella with gross displacement while playing football. The fracture was subsequently stabilized with tension band wiring with two Kirschner wires (K-wire) & figure of eight stainless steel wire. The immediate post operative period was uneventful. He was discharged after stitch removal with knee support and was advised partial weight bearing with knee bending exercises in between. However, he indulged in heavy manual work including bicycling after 15 days of surgery. This led to loosening of implants and failure of reduction. He reported after 2 months of failure with pain, swelling and stiffness of the knee joint. X-rays revealed wide displacement of the fragments with loose implants ().\nThe options for such a case were either patellectomy or apposing the fragments by some means. Patellectomy would lead to difficulty in apposing the ligaments as there were gross displacements of the fragments leading to contracture of soft tissues on either side of the patella. Apposing the fragments would require extensive soft tissue dissection and lengthening of the quadriceps tendon resulting in extensive scarring and stiffness. As we were accumulating experience by using Ilizarov in various situations, we opted for it to mend the difficult situation in this case. We felt gradual docking with slow stretching of the soft tissue without any dissection would be the perfect choice for the case. After removing the implants, the fracture margins were cleared of fibrous tissue taking care not to remove any bone. As acute docking was not possible, sub-acute docking was contemplated on the table. Opposing olive wires, 2 in number on either fragments (total 4 in number), attached to traction units were passed through the fragments which were mounted on two full rings on either side (joining two half rings). The rings were fixed to distal femur and proximal tibia by wires and interconnected with threaded rods. The fragments were brought together as close as possible on the table by turning the nuts on the traction units (sub-acute docking); subsequently gradual docking was done with the help of traction units till X-ray showed complete contact. The traction unit consisted of slotted threaded rod with mounted K-wire which was held in place by nuts []. These units were mounted on the ring by male post. After docking, as confirmed by X-Ray, compression was applied across the fracture site at the rate of 1/4th turn every 3rd day till one millimeter of compression was achieved (). Full weight bearing was allowed as pain permitted. Patient was followed up every 2 weeks looking for pin site infections and loosening of the compression achieved. Assembly was removed when X-ray showed complete healing. |
A 9-year-old boy was brought by his father due to disturbed behaviour with attempts to run in front of traffic over the 2 days preceding the presentation. He was overactive and aggressive, hitting and biting others. His sleep was disturbed.\nHe has been well until 2 months ago, at which time he refused to go to school citing somatic symptoms. He later reported being physically punished by a school teacher which appeared to have led to the school refusal. During this period, he was irritable and anxious. He reported suicidal ideation and threatened to jump into their well on one occasion, following an argument with his mother. He was socially withdrawn. His sleep was disturbed and he had poor appetite. He was diagnosed as having a depressive episode and commenced on sertraline 25 mg mane 3 weeks prior to the current presentation. His father reported some improvement with this in terms of his activity and dose was increased to 50 mg 2 weeks later. After about 5 days, he became very disturbed, attempting to run off. His father brought him to the hospital as they could not safely contain him at home.\nHe was the older of 2 siblings and lived with his parents and younger sister. There was a family history of bipolar affective disorder in one of his first cousins. His parents were supportive, but there were marital conflicts and he reported witnessing domestic violence between them. His birth and development history were normal and past medical and psychiatric history were unremarkable. His school performance has been average. Although his parents reported him as being hyperactive and stubborn, his school teachers claimed he was a well-behaved child who could concentrate and completed the tasks he was given. There was evidence of inconsistent parenting styles with his father being authoritarian and mother being very permissive.\nOn mental state examination, he was an average built boy dressed casually. During the initial interview, he attempted to run off and was restrained physically by his father. He was angry and screamed using obscene words. He was admitted to the in-patient unit. Sertraline was ceased. Clonazepam was used for sedation. As his agitation reduced, he was noted to be socially disinhibited. He had pressure of speech. He did not have flight of ideas. He was extremely irritable. But at times he sang and danced in the ward. There was no suicidal ideation. He expressed self-expansive ideas. He did not have any delusions or hallucinations. He was oriented in time, place, and person. He was distractible and could not engage with cognitive testing. He had poor insight. Physical examination including cardiovascular, respiratory, and nervous systems and the abdomen was unremarkable. He did not have any abnormal movements and bilateral fundi were normal.\nInvestigations including full blood count, C reactive protein, and thyroid function tests were normal. Electroencephalography recorded in the alert state was normal for the age. Contrast enhanced computerized tomography of the brain was normal.\nHis presentation met criteria for treatment-emergent mania []. He was commenced on risperidone and dose increased to 2 mg twice daily at which point he developed extrapyramidal side effects. As his symptoms persisted beyond one week and there was a positive family history, a diagnosis of bipolar affective disorder, currently manic episode without psychotic symptoms, was made. Sodium valproate was added and dose increased up to 200 mg twice daily. Risperidone was changed to olanzapine after 3 weeks as he continued to have significant emotional and behavioural disturbances; he was extremely irritable and physically aggressive. He showed slow improvement in his mental state after increasing olanzapine to 5 mg twice daily. Following 4 weeks of treatment with olanzapine and sodium valproate, he was discharged home after discussing extensively with his parents regarding the diagnosis, risks, and treatment.\nUpon review after 1 week, his parents reported further improvement in his irritability and overactivity and he was continued on the same medication. He was reviewed every 2 weeks for the next month and continued to show improvement in mental state. However, he showed significant weight gain while on treatment. Metabolic screen was done at 4 weeks and investigations were normal. Dietary advice was provided and physical activities were encouraged. Switching to aripiprazole was discussed; however it is not available in the public hospitals in Sri Lanka and parents were not able to afford it. Olanzapine dose was slowly reduced. He then had a relapse of manic symptoms and was commenced on lithium carbonate. Sodium valproate was tailed off. The treating team continued to support parents and liaised with school to ensure smooth transition back to school. His symptoms improved and he was able to go back to school. Olanzapine was tailed off and lithium dose was optimized. |
A 64-year-old man was brought to the emergency department of our hospital due to gross hematuria and high fever. He was diagnosed with septic shock and, thereafter, admitted to the intensive care unit and intubated. Non-contrast-enhanced CT of the abdomen revealed hematoma in the right renal pelvis and bladder (Fig. ). In parallel with intensive care, bladder hematoma was cleared, and continuous bladder irrigation commenced. He had a history of rectal cancer and received neoadjuvant chemoradiotherapy followed by low anterior resection 12 years before the presentation. He developed acute renal failure due to bilateral ureteral strictures presumably caused by radiation 8 years before the presentation. Subsequently, he underwent bilateral ureteral stenting and regularly visited our hospital for stent exchange every 3 months. Ten days after the admission, he developed hemorrhagic shock due to a sudden massive gross hematuria. On suspicion of a right UAF, emergency angiography was performed; however, it was not able to identify the source of bleeding. Prophylactic embolization of the right renal artery was executed on an equivocal suspicion of renal hemorrhage. Eighteen days after the admission, he again developed hemorrhagic shock due to a sudden massive gross hematuria for the second time. However, contrast-enhanced CT and angiography could not identify the source of bleeding either. He underwent prophylactic right nephrectomy. Severe adhesion due to prior abdominal surgery, inflammation, and radiotherapy resulted in major bleeding and precluded dissection of the right distal ureter. Twenty-eight days after the admission, he developed hemorrhagic shock for the same massive gross hematuria again for the third time. Contrast-enhanced CT suggested a small pseudoaneurysm in the right external iliac artery at the iliac-ureteral crossover. Based on UAF diagnosis, he underwent emergency angiography and endovascular treatment. Under local anesthesia, the 4-Fr angiographic sheath was inserted via the left femoral artery. An angled guidewire and angiographic catheter were advanced across the aortic bifurcation into the right common iliac artery. UAF was confirmed by angiograms. Coil embolization of the right proximal internal iliac artery was performed to secure an adequate distal landing zone for stent graft placement. Direct probing of the ureter was performed with a hydrophilic guidewire and microcatheter under fluoroscopic guidance (Fig. ). Percutaneous balloon-expandable covered stent graft (Viabahn®; Gore, Flagstaff, AZ, USA) was used to treat the fistula. The 12-Fr angiographic sheath was placed through the right femoral artery. After systemic heparinization with a bolus dose of 3000 U, two stent grafts (distal stent, 8 × 50 mm; proximal stent, 10 × 50 mm) were deployed to cover the entire lesion (Fig. ). Occlusion of the ureteral segment using n-butyl cyanoacrylate was performed subsequently. The final angiogram confirmed the appropriate placement of stent grafts at the target lesion. The patient had no further episodes of gross hematuria after the endovascular treatment. However, he went on chronic hemodialysis due to an exacerbation of chronic kidney disease. He also suffered from disuse syndrome resulting from multiple intensive therapy. Furthermore, he developed an adjustment disorder and anorexia. Seven months after the endovascular treatment, he died of acute respiratory failure due to massive transudative pleural effusion caused by malnutrition. |
A 27-year-old female patient was admitted to our gastroenterology clinic with complaints of abdominal pain and diarrhea of more than 3 months duration. The colonoscopic exam revealed inflammatory changes of the colonic mucosa suggesting inflammatory bowel disease. The computerized tomography showed a solid lesion measuring 2 cm in the left ovary in addition to dilatation of the small bowel segments. Hence, the patient was diagnosed as Crohn's disease and medication with salofalk and steroid treatment was introduced to treat the acute inflammatory attack. However, during her hospitalization period, she began to display progressive nausea and vomiting, suggesting that a small bowel obstruction had developed due to a stricture as a complication of the Crohn's disease. After consultation with the general surgery department on the patient's ileus, it was decided to perform an explorative laparotomy. The patient was explored and dilated small bowel segments, which ended 10 cm proximal to the cecum because a stricture was found (). Multiple lymph nodes with a slightly thickened mesoperitoneum at the strictured ileal segment were palpated. Furthermore, an endometrial cyst 2 cm in diameter, originating from the left ovary, was also detected. The strictured ileal segment was resected and end-ileostomy was performed. Anastomosis was avoided because of the excessive dilatation of the proximal part of the ileum and suspicion of an inflammatory bowel which carries high risk for anastomotic leakage. The endometrial cyst was aspirated and a biopsy was taken from the cyst wall. Macroscopic examination of the resection specimen revealed dilated areas with normal bowel thickness and other areas that are firm and thickened. Microscopic examination revealed nests of endometriotic glands and stroma lying in the muscularis propria with regional lymph node involvement (Figures and ). The overlying mucosa was intact. Both endometrial epithelial and stromal cells were positive for estrogen receptor (ER) and progesterone receptor (PR) within ileal wall and lymph nodes (Figures and ). Stromal cells were also immunohistochemically CD10 positive. The histology of the ovarian cyst also showed endometriosis with endometriotic surface epithelial lining, cystically dilated endometrial glands, and numerous pigment laden histiocytes. The patient's postoperative period was uneventful, and after discharge she was referred to the gynecology outpatient department on medication for endometriosis. |
A 62-year-old male presented with painless gross hematuria for 2 years. The patient reported hematuria after activity including exercise and sexual intercourse. Cystoscopy was performed by the referring urologist, which revealed a bladder mass in the left anterior wall of the bladder. Biopsies were obtained by the referring urologist, with equivocal pathology analysis revealing atypia. The patient denied any pelvic pain, flank pain, or dysuria. He denied any unintentional weight loss, fevers, chills, shortness of breath, chest pain, neurologic deficits, headaches, or gastrointestinal disturbances. The patient was eventually referred to us for further evaluation and definitive treatment of the bladder mass.\nThe patient had no significant medical history, except remote history of left inguinal hernia surgery at 3 months of age and a left open inguinal hernia repair with mesh at age 47. There were no prior operative reports available to determine which type of mesh had been used for these repairs. There were no pertinent findings on physical examination. All laboratories, including a complete metabolic panel and a complete blood count, were within normal limits. The patient had a CT of the abdomen and pelvis that showed a mass on the left anterior bladder wall ( and ).\nGiven the concern for malignancy and severity of symptoms, the patient ultimately underwent blue light cystoscopy and was found to have a large lesion in the left dome of the bladder. The lesion had a blackened appearance and was found to be blue light negative ( and ). Closer inspection of the lesion revealed the lattice meshwork, suggestive of an eroded mesh plug. Multiple biopsies were taken to rule out any associated malignancy. The final pathology analysis revealed surgical material consistent with the mesh, as well as benign urothelial mucosa with squamous metaplasia.\nWe discussed the treatment options with the patient, including the rationale for excision, and the patient opted to proceed with surgery. Surgical excision of the mesh plug was achieved using the robot-assisted laparoscopic approach with the use of the four-arm Da Vinci Si robot. Port placement was similar to transperitoneal robot-assisted radical prostatectomy. A total of five ports were used. A 16F Foley catheter was placed at the beginning of the case. Initially, the sigmoid colon was mobilized out of the pelvis. The bladder was then dropped from the anterior abdominal wall in the usual manner. The mesh plug was transected from the abdominal wall so that the bulk of the mesh remained over the bladder. The bladder was then filled and a partial cystectomy was performed to remove the entirety of the mesh plug, excising a 1-cm margin around the plug. The specimen was removed in an EndoCatch™ bag and the bladder was closed in two layers using absorbable sutures. A 19F Blake drain was placed at the end of the case.\nThe postoperative course was unremarkable and the patient was discharged on postoperative day 1. A cystogram was obtained on postoperative day 5 and there was no evidence of contrast extravasation and the foley catheter was removed without difficulty. The final pathology analysis again confirmed mesh fibers with chronic fibrosis and inflammation of bladder mucosa. |
A 9-year-old male patient with no significant medical history reported to the Department of Pedodontics and Preventive Dentistry with a chief complaint of swelling in the left cheek since 1 month. The onset of swelling was associated with fever. It was initially of pea size and rapidly increased to the size of a marble, over a period of 1 month. It was not associated with pain or discomfort.\nOn extra-oral examination, the mass measured 3 × 3 cm and was located at the junction of middle and lower third of the face, 2 cm lateral to the angle of the mouth. The mass was freely movable and no ulceration was observed on the overlying skin. Intra-orally the swelling involved the buccal mucosa at the occlusal plane and extended from the distal aspect of first primary maxillary molar to the distal aspect of permanent maxillary first molar. Bi-digital examination revealed that the swelling was firm in consistency, mobile, and appeared to infiltrate the surrounding soft tissue. The mucosa overlying the swelling was intact. Intraoral examination also revealed dental caries in relation to mandibular left primary second molar.\nAspiration of the swelling did not show any contents. A radiograph of the intra-oral swelling, taken by placing an intra-oral film between the buccal mucosa and the posterior buccal surfaces did not show any radiopacity. Intra-oral periapical radiograph in relation to mandibular left primary second molar revealed deep dental caries involving the pulp. Ultrasonography of the left cheek was carried out. This showed a well demarcated solitary isolated tumor involving the buccal mucosa.\nSurgical excision of the lesion was planned under general anesthesia. Prior to surgery routine blood investigations were carried out. After achieving general anesthesia with oral intubation, infiltration was given over and around the swelling with local anesthetic containing 2% adrenaline. A horizontal incision was made anteroposteriorly using electrocautery along the buccal mucosa and over the most prominent part of the swelling. The swelling was relieved all around from its mucosal attachment including the buccal pad of fat. The lesion was removed in toto using allies forceps. The excised mass was a pinkish white, nodular, nonencapsulated and measured 2 × 2.5 cm. Hemostatsis was achieved and the surgical site was closed with resorbable sutures. Post-operative instructions regarding the diet and oral hygiene practice were given.\nHistopathological examination showed predominately spindle cells arranged in a nodular contour and appearing whorled. Individual cells showed vesicular nuclei with mild degree of pleomorphism and occasional mitotic figures. Also seen were diffusely scattered lymphocytes, polymorphs, and good number of congested blood vessels with plenty of extravasated red blood cells [Figures –].\nBased on the history, clinical picture, and histopathological examination, the lesion was diagnosed as nodular fasciitis.\nDental treatment included oral prophylaxis, sealant application, and root canal treatment in relation to mandibular left primary second molar, followed by restoration with a stainless steel crown. |
A 47-year-old male reported to the outpatient Department of Prosthodontics and Crown and Bridge, Maulana Azad Institute of Dental Sciences, New Delhi, with the chief complaint of difficulty in chewing food due to loss of teeth 5 years ago. History revealed that reason for loss of teeth was aggressive periodontitis with 36 and 46 teeth being removed at a very young age of 35. History of bidi smoking was also present for 10–15 years but he left the habit 5 years ago after the loss of teeth. He was a first-time denture wearer. Intraoral examination revealed completely edentulous arches with severely resorbed lower residual ridge with body prominence in the mid symphyseal region and depressed areas with respect to 36 and 46 region (Figures and ). Medical history did not reveal any significant findings. Fabrication of complete dentures was planned for the patient.\nMaxillary and mandibular complete dentures were fabricated in the conventional manner (). Selective pressure impression technique was used for mandibular final impression and semianatomic posterior teeth were used to reduce the stresses on the edentulous ridge at the time of try-in.\nFollow-up was done after 24 hours of denture insertion and further after 3 weeks and 3 months. Even after 3 months of denture wear with all the instructions followed by the patient, he could not adjust with his new dentures with complains of sore mouth and ulceration along with pain specially in the elevated midline area and depressed 36 and 46 regions although occlusion was satisfactory. Pressure indicating paste was used in 2 consecutive sittings which could provide only temporary relief for few days. After 2 months of adjustment, patient then reported after a gap of 6 months again with the same problem in the same areas. Adjustment was done again and patient remained asymptomatic for the next 4 months. Thus, when it was seen that even after 1 year of denture wear patient is not fully satisfied, going for permanent soft reline was decided as the mucosa in the symptomatic areas was fragile, thin, and not firmly attached to the periosteum. Patient did not have any other problem or difficulty with the dentures while chewing.\nPressure indicating paste (COLTENE) revealed pressure spots in the anterior, 36 and 46 region (Figures and ), which were marked with a pencil and trimmed till the time patient was fully asymptomatic. A wash impression was made using noneugenol based zinc oxide paste (CAVEX) () after making a uniform space of 1 mm approx. for the wash impression.\nBeading and boxing of impression were done; new master cast was poured in dental stone and directly invested (). Dewaxing was done, and denture was cleaned thoroughly using the steam cleaner and intraoral sandblaster. After that 1.5 mm of uniform reduction was done on the tissue surface to accommodate the silicone liner. Uniform holes of 1 mm diameter were made on the undersurface using a carbide round end bur to improve the surface area for bonding of the liner.\nPrimer/adhesive was applied on the surface and was allowed to dry (). After that packing of the silicone liner was done in the similar manner as done for heat cure resin. Flask was placed in cold water and slowly heated up to 100°C and polymerisation in boiling water continued for approx. 2 hours. Flask was allowed to cool down slowly taking care not to “shock-treat” it by rinsing with cold water immediately. Denture was retrieved, finished, and polished following the same steps as discussed in the first case report.\nThe relined lower denture was inserted and was checked for any pain or discomfort. Adjustments were done and postinsertion instructions were given (Figures and ). After the patient became fully asymptomatic, follow-up was done at intervals of 6 months for 1 year. The patient had adapted well to the relined dentures without complains of sore mouth as it was before. The mucous membrane overlying the residual alveolar was healthy without the signs of any inflammation or soreness. The soft liner material was also soft and did not show any sign of tear or detachment. |
A 53-year-old, right-handed woman with severe pain and loss of active abduction presented to our hospital with complaints that had started 1 year ago after an open acromioplasty procedure performed for impingement syndrome in another clinic. At that time, radiological studies had revealed an intact bony structure with a type III acromion and no tear had been noted in the rotator cuff in the MR images. A standard open anterior acromioplasty was performed under general anesthesia; the surgeon had not mentioned any perioperative complication or signs of any problem during surgery. An aggressive physical therapy protocol had been prescribed, and active and passive free range of motion was allowed immediately after surgery. A month after the operation the patient started complaining of weakness of her shoulder, especially with regard to her ability to abduct her arm. Physical therapy was continued for 3 months following surgery, after which the patient stopped attending the sessions. She consulted specialists at several different institutions and all advised conservative therapy. Conservative therapy continued unsuccessfully until the patient was referred to the senior author's institution for further evaluation.\nAt the time of presentation to the senior author's institution, 1 year after the index operation, the patient complained of excessive pain that awakened her from her sleep and severely limited her daily activities. On physical examination of the right shoulder, an unconventional matured incision scar was visible []. Her right acromion was readily palpable and the bulk of the deltoid muscle could be easily palpated over the superior portion of the arm with attempts at shoulder abduction. The active range of motion (ROM) of the right shoulder was severely limited: active scapular abduction was 50° and both active external and internal rotations were limited to 10° each. Her passive scapular abduction was 120° and passive external and internal rotations were 25° and 20°, respectively. Impingement sign could not be evaluated due to the overall painful condition of the shoulder.\nBased on the findings on physical examination and the history, rotator cuff tear, subacromial impingement syndrome, calcific tendonitis, axillary nerve palsy, and deltoid muscle detachment were all considered in the differential diagnoses. Careful review of the plain radiographs taken between the index and the second surgeries gave valuable information regarding the progress of the pathology. A plain anteroposterior radiograph of the right shoulder which was taken 1 month after the index surgery showed evidence of partial lateral acromionectomy, with the deltoid muscle retracted to the level of the greater tuberosity. The magnetic resonance imaging (MRI) showed that the deltoid muscle mass had retracted about 3 cm distal to the greater tuberosity which was additionally marked by an ossified tissue. We were not able to see the rotator cuff tear and the calcific tendonitis. Electromyographic (EMG) studies of the right upper extremity muscles were all normal except in the case of the deltoid muscle. The right axillary nerve conduction study showed that the distal latency was 2.8 msec (normal) and the compound muscle action potential amplitude was 4.5 mV (normal). The study was interpreted as decreased recruitment in the deltoid muscle. The diagnosis was made based on history, physical examination, the radiological studies, and the EMG study. The patient underwent a delayed primary repair of the deltoid muscle detachment, which had resulted from the excessive acromioplasty.\nThrough a standard modified acromioplasty incision, which extended from a point over the medial and inferior part of the coracoid to a point lateral to the acromion, the skin and the subcutaneous tissues were carefully dissected. There were extensive adhesions and fibrosis of an abnormal scar tissue that did not represent muscle or tendon tissue. After debridement of the scar tissue, the acromion could be visualized. The deltoid muscle that is normally encountered at this stage of the dissection was absent. A mass of a tissue lying deep in the wound was assumed to be the deltoid muscle. Because the scar tissue had extensively covered the deltoid musculotendinous origin, this structure could not be differentiated. The dissection was extended over the acromion posteriorly until the point where healthy attachments of the deltoid muscle to the acromion were seen. The deltoid muscle tendon was then traced to exactly locate the portions detached away from the acromion. Detached parts of the tendon and the muscle mass had loosely adhered to the proximal humerus distal to the greater tuberosity. We carefully dissected away the useless scar tissue at the origin of the muscle before performing a thorough examination of the rotator cuff by rotating the humerus internally and externally until every part of the rotator cuff was visualized. The rotator cuff looked continuous and healthy. Multiple Mason-Allen sutures were passed through the deltoid muscle-tendon junction to get a good hold of the muscle []. While holding on to the sutures, the adhesions between the muscle and the humeral bone were separated by gentle blunt dissection. During the separation, the axillary nerve was identified and all care was taken to avoid damage to it. Ethibond sutures were then passed through the remaining acromion so that the deltoid origin would be approximated to the superior part of the acromion [Figure and ]. The sutures were tied with the arm in 90° abduction.\nPostoperatively, the arm was immobilized in 90° abduction for 3 weeks with a custom-made, adjustable arm holder. Starting at the third week, the arm holder was adjusted at weekly intervals, reducing the amount of abduction by 15° every week. Passive abduction was allowed for the remaining abduction range of motion. Active or passive elbow and wrist motion was allowed, starting from postoperative day 1. At 6 weeks postoperatively, aggressive physical therapy and rehabilitation was started to regain range of motion of the shoulder joint and strength of the arm muscles.\nAt the postoperative third month, the patient was able to perform her activities of daily living and by the sixth month she reported that her shoulder was almost back to normal. At the latest follow-up (25 months postoperatively), she had no functional limitation, was fully involved in her daily household activities, and could take care of her grandchildren []. The MR images taken 2 years after the second operation showed anatomical healing of the proximal deltoid muscle onto the acromion. |
A 40-year-old right-handed Portuguese man was brought to our Emergency Department 10 minutes after sustaining a stab wound to the base of his left axillary region after being mugged. His past medical history was unremarkable.\nOn observation, a profuse acute venous type bleeding was present at the wound site. The wound was located in the middle of his left axilla. It measured approximately 3 cm in length and was oriented in an anterior–posterior axis. A compressive dressing was applied at the entry point of the stab wound. As a result of refractory hypotension after initial management with vigorous fluidotherapy, he was immediately carried to our operating theatre.\nDuring the course of transportation, it was possible to clinically assess his left upper limb in a summary fashion. Pinprick and light touch sensory examination revealed hypoesthesia of the medial aspect of his arm and forearm from the axillary crease to the palmar wrist crease, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits (Fig. ). All other areas of his left upper limb showed a normal sensory response.\nA motor examination revealed that he was not able to actively flex the joints of his middle, ring, and little fingers nor to adduct or abduct any of the fingers of his left hand (Fig. ). Moreover, he was not able to adduct his wrist. The remaining motor examination of his left upper limb showed no deficits.\nThe clinical presentation enabled us to promptly locate the nerve injury between the anterior division of the lower trunk of his BP and the proximal portion of his following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve (Figs. and ).\nSurgical exploration revealed a longitudinal laceration of the posterior aspect of his axillary vein, as well as a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve (Fig. ). A surgical approach was made under surgical loupes’ magnification. It began with vessel repair using an interrupted 8/0 Nylon suture, followed by direct end-to-end repair of the severed nerves using 8/0 Nylon simple stitches. Fibrin glue was applied around the repaired nerves.\nHis postoperative period was uneventful. He started an intensive physiotherapy program after hospital discharge, which occurred 3 days after surgery. The physiotherapy was aimed at maintaining joint mobility and at strengthening the paralyzed muscles, as reinnervation occurred. Physiotherapy was performed daily for the first year after surgery and three times a week for the following year. In the postoperative period, he also started swimming following the attending physician’s advice.\nOne year after surgery he resumed his employment. Three years after surgery, even though there was a slight atrophy of the intrinsic muscles of his hand, he presented a good overall function of his left upper limb (Figs. , , and 9). At the last evaluation, 3 years after the accident, his motor function was M4 in all the previously paralyzed muscles according to the Medical Research Council Scale (muscle strength was reduced but muscle contraction could still move joints against resistance) []. Moreover, according to this scale [], his sensory recovery was defined as S3 (return of superficial cutaneous pain and tactile sensibility without over-response) at the medial aspect of his arm and forearm, and as S2 (return of superficial cutaneous pain and some degree of tactile sensibility) at the ulnar side of his hand and at the palmar aspect of the last three digits and at the dorsal aspect of the last two digits.\nThis case report portrays a rare clinical situation in contemporary times: a major vascular lesion associated with a BP lesion in a conscious patient []. At present, this situation is rare because BP lesions are increasingly less frequent in most countries []. In addition, open BP injuries account for only a small percentage of all BP lesions [–]. In most cases of open BP wounds associated with major vascular bleeding, patients are too unstable for even a summary neurological examination to be made prior to transportation to the operating room. Most commonly, patients are carried to the emergency room already under sedation and ventilated. The patient presented in this case report was fortunate enough to have been close to the hospital at the time of the lesion. Therefore, despite the severe vascular damage, he did not yet have changes to his consciousness when he arrived at the trauma room. All these improbable events allowed a summary physical examination to be performed immediately before the emergency surgery. This in turn permitted a prompt diagnosis of the location of the nerve lesions, based solely on the physical findings and knowledge of anatomy.\nIn 2002, Dubuisson and Kline described 23 open BP injuries in 100 consecutive cases of BP lesions []. In 2003, from a total of 1019 patients with BP injuries, Kim et al. reported only 19% with open injuries, of which 7% involved lacerations and 12% were gunshot wounds []. Lacerations involving the BP may occur secondary to sharp instruments such as knives and glass, or from blunt trauma following animal bites or automobile accidents [, , , –]. These sources of injury most probably lead to neurotmesis (according to Seddon’s classification), which is the most severe type of injury to the peripheral nerves in which all the nerve layers are disrupted [, ].\nFigure illustrates the BP and the muscles innervated by each of its nerve branches. In most cases the convergence of the anterior rami of the spinal nerve roots from C5 to T1 forms the spinal nerve roots, the trunks, the divisions, the cords, and the terminal branches of the BP []. The terminal branches of the BP are responsible for most of the sensory, motor, and autonomic innervation of the upper limb (Fig. ).\nA classical aphorism in neurological diagnosis is to try to attribute all signs and symptoms to a single lesion whenever possible [].\nAs can be seen in Fig. , the fact that our patient’s stab wound was at the base of his axilla, thereby inferior to his clavicle, suggested that the lesion was probably located at the level of the divisions, cords, or terminal branches of his BP [].\nThe hypoesthesia of the medial aspect of his arm, forearm, and hand (Fig. ) could be explained by: (a) a section of the anterior division of the lower trunk of his BP; (b) a complete section of the medial cord of his BP; (c) a complete section of his medial brachial and medial antebrachial cutaneous nerves, and his ulnar nerve, and a partial section of his median nerve (or medial root of his median nerve) [, , , , ].\nFurthermore, paralysis of his flexor carpi ulnaris, medial part of his flexor digitorum profundus, third and fourth lumbricals, both palmar and dorsal interossei, adductor pollicis, abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi muscles, indicates complete dysfunction of his entire ulnar nerve. The paralysis of the muscle bellies of his flexor digitorum superficialis and flexor digitorum profundus for his third finger suggests partial median nerve dysfunction. Once more, this motor dysfunction could be caused by: (a) a section of the anterior division of the lower trunk of his BP; (b) a complete section of the medial cord of his BP; (c) a complete section of his ulnar nerve, and a partial section of his median nerve (or medial root of his median nerve) [, , , , ].\nA less likely cause of all these signs and symptoms could be either a lower trunk lesion or a lesion of the C8 and T1 roots of his BP. However, in either case, compromise of the nerves arising from his dorsal cord, namely of his radial nerve, causing motor dysfunction and sensory changes in the territory of this nerve at the level of his forearm and hand would be present. In addition, sharp injury to the T1 root seemed unlikely, as this root is very close to the T1 sympathetic ganglion, whose lesion would produce Horner’s syndrome ipsilaterally (meiosis, ptosis, enophthalmos, and facial anhydrosis) [, ].\nWith all these data taken into consideration, the region of the lesion of his BP could be safely pinpointed to the region between the anterior division of the lower trunk and the proximal portion of his ulnar, medial cutaneous nerves of his arm and forearm, and the medial aspect of his median nerve (Figs. and ). This in turn allowed a prompt planning of the surgical approach, and no doubt contributed to the good functional result observed 3 years after the surgery. |
A 26-year-old man was admitted to our hospital with an aching pain in the left knee due to a crash injury. The pain had persisted for 1 month, and the patient had experienced no symptoms before the injury. Physical examination revealed a positive hyperextension test result, and the range of motion was 0° to 140°. He felt pain during terminal extension and could not endure overextension. There was no swelling or tenderness of the knee. The results of a McMurray test, an anterior drawer test, and a lateral stress test were negative. In the right knee, the results of these tests were also negative and the range of motion was normal.\nA radiograph of the knee was normal. T2-weighted magnetic resonance imaging (MRI) showed hypointense cord-like tissue in the anterolateral side of the ACL (), a cyst in front of the tibial insertion site of the ACL (), and hypertrophy of the anterior horn of the medial meniscus (). We suspected that this deformity was symmetrical and therefore performed an MRI examination of the contralateral knee. The right knee was similar to the left, with hypointense cord-like tissue in front of the ACL, hypertrophy of the anterior horn of the medial meniscus, and a cyst in front of the tibial insertion site of the ACL (); however, the cyst was smaller than that in the left knee ( and ).\nArthroscopic examination of the left knee revealed a cyst anterior to the ACL tibial insertion site, an anomalous insertion of the medial meniscus that ran from the anterior horn to the lateral femoral condyle (), and abnormal hypertrophy of the anterior horn of the medial meniscus (). No traumatic changes, such as bleeding, were present around the synovial cyst or the anterior horn of the medial meniscus. When the knee was extended, the cyst and the anterior horn were compressed by the femur and tibia (Video 1). We therefore completely excised the cyst with a shaver and trimmed the anterior horn of the medial meniscus (). However, we did not treat the anomalous insertion; instead, we only obtained a tissue sample for pathological examination. Hematoxylin–eosin staining revealed that the anomalous insertion comprised fibrocartilage and collagen fibers (), the region of hypertrophy comprised fibrocartilage (), and the cyst was a synovial cyst (.\nAfter surgery, the patient used a disposable knee supporter for 3 days and was encouraged to perform range-of-motion exercises and quadriceps exercises. Full range of motion was achieved within 2 weeks of the arthroscopic surgery.\nMRI re-examination 6 months after surgery revealed that the anterior horn of the medial meniscus was smaller than before surgery () and matched the femoral condyle. Additionally, most of the anomalous insertion was preserved and the cyst had been completely excised (). Eighteen months after the operation, the patient had no pain and the hyperextension test was negative. No significant muscle atrophy was present, and the patient experienced no lifestyle restrictions, including when practicing sports. |
A 10-year-old girl presented to the ophthalmic department with right eye drooping and double vision for 1 day. She had headache for 1 week. She had a history of suffering headaches about four to five times a year since age 2 years; her headaches caused a dull pain sometimes accompanied by nausea and vomiting. Because of the recurring headaches, she had undergone MRI of the brain in the pediatric department 1 year ago, which had revealed no evidence of abnormality. Her mother reported that this was not the first time she was experiencing ocular movement limitation during headache. A similar ocular motility disorder had developed when she was 2 years old and lived in the United States at that time. She had been diagnosed with a typical cranial neuropathy in the right eye, which had improved after administration of a steroid. The visual acuity was 20/20 in both eyes. The right pupil was poorly reactive to direct and consensual stimulus. The ocular motility examination showed a limitation of ocular movement except abduction in the right eye []. There was no ocular injection, chemosis, or pain on eye movement. The fundus showed normal appearance of the optic disc in both eyes. All serologic tests, including tests for thyroid function and anti-acetylcholine receptor antibodies, were within normal range. Thin-section cranial MRI with MRA of the brain was performed and it revealed a 6-mm nodular enhancement located within the cisternal segment of the right oculomotor nerve, suggesting oculomotor nerve schwannoma without any vascular malformation [Fig. and ]. Although the MRI of the brain performed 1 year earlier had failed to reveal any abnormal lesion at the time, we reviewed the images and found a 3.7-mm thickening lesion of the cisternal segment of the affected oculomotor nerve on the constructive interference in steady-state axial T2 MRI []. Therefore, we concluded that the schwannoma, which had been 3.7 mm in size 1 year earlier, had gradually increased in size and led to oculomotor nerve palsy. The neurosurgeon recommended gamma knife radiosurgery to remove the tumor; however, the patient's mother refused it due to the risk of permanent sequelae on the oculomotor nerve. She was empirically treated with oral prednisone and 1 week after treatment, her ptosis and headache improved; however, she was lost to follow-up. The patient presented to the ophthalmic department again after a year for checkups. On her follow-up brain MRI, the size of schwannoma had not changed and there was no newly developed lesion. Because her recurrent headache improved, her mother still did not want her to undergo brain surgery. However, exotropia with limitation of ocular movement remained, and therefore, her mother is considering strabismus surgery for her cosmetic reasons. |
A 59-year old male patient was referred to our hospital after suffering a VF attack and was successfully treated with defibrillation. At his initial evaluation, the patient's mind was clear and his hemodynamic parameters and other physical examination findings were normal. His electrocardiogram results indicated a sinus rhythm with a rate of 60 bpm, there was no significant ischemic finding, the QT interval was normal and there was no suggestion of Brugada syndrome or arrhythmogenic right ventricular dysplasia (). Biochemical tests including cardiac troponin, serum potassium and magnesium levels were all normal. His previous medical history indicated that there had been two syncopal episodes within the last 2 months. There were no specific triggers for these episodes, but the patient described anginal chest pain immediately before the syncopal attacks. He had experienced no exercise-induced angina, and there were no instances in his family history of sudden death of unknown origin. His echocardiogram results showed that the cardiac chambers were of a normal size, there was normal systolic function of both left and right ventricles, and the wall thickness was also normal. Coronary angiography was administered and a moderate lesion was detected in the middle portion of the right coronary artery (RCA) (). This lesion was evaluated with fractional flow reserve (FFR) using 200 µg and then 300 µg intravenous adenosine injections. The FFR ratio was found to be 0.86. Amiodarone perfusion was administered at the time of his first medical contact, and this treatment was continued for 24 h. The day after hospitalization he experienced another VF episode and was successfully treated with defibrillation. His monitor records detected an ST elevation in inferior leads a few seconds before the VF (). Vasodilator treatment including nitrate and calcium channel blockers (nifedipine, isosorbide mononitrate) was added to his therapy. Despite vasodilator therapy being applied, he experienced a similar episode 1 day after (), and therefore an ICD was implanted in the patient. Intravenous nitrate infusion commenced and was titrated to the maximum dosage that the patient's blood pressure would allow. In addition, the nifedipine dosage was increased to 60 mg/day. A second calcium channel blocker agent was not added. Over the following 2 days, the ICD device shocked the patient due to similar episodes (). As the vasodilatator therapy alone failed to prevent the VF attacks, the decision was made to stent the suspected culprit lesion. A provocation test was not performed due to the risk of severe vasospasm and a fatal arrhythmic storm. A long-length new-generation drug-eluting stent (DES) (Xience V 3.5 × 28 mm) was preferred to completely cover the vasospastic segment in the RCA (). Vasodilatator therapy was continued with both 60 mg of isosorbide-5 mononitrate and 60 mg of long-acting nifedipine administered once a day. After the coronary stenting, VF attacks did not reoccur, and the patient has now been free from any anginal and VF attacks for 2 years. |
A 33-year-old male presented to the First Affiliated Hospital of China Medical University with leg pain and was unable to extend his knees. His injury occurred when he suddenly twisted his body. He had a known history of chronic kidney disease and had received regular haemodialysis in our hospital for 9 years.\nThe physical examination showed that both of his knees had massive suprapatellar swelling and that there was apparent depression of the soft tissue above the bilateral patella. Both knees were very soft and could touch the area over the suprapatellar region, and the patella could move freely over a larger range of motion than normal. Upon palpation, the continuity of the quadriceps tendons had defects. In addition, the patient could not complete knee extension adequately.\nAn X-ray of the knees showed that the superior pole of the patella moved downward, and there were calcified deposits in both quadriceps tendons. An MRI scan showed that the continuity of both quadriceps tendons was interrupted at the superior pole of the patella. The patient was diagnosed with bilateral quadriceps tendon rupture.\nThe patient underwent bilateral quadriceps tendon suture surgery under combined spinal and epidural anaesthesia (Fig. ). In the operating room, the patient was placed in the supine position. The surgical area was cleansed and draped, and the same operation was performed on both legs. A longitudinal incision of approximately 8 cm was made on each knee to expose the bilateral quadriceps tendon and the proximal patella. After the haemorrhage and blood clots were cleaned, complete rupture of the quadriceps tendon at the patella superior pole extending to the quadriceps muscle was observed, and the tissue stump appeared dark brown. The surface of the patella was smooth, with no residual tendon tissue attached. We used a spherical burr to roughen the upper pole of the patella after cleaning the inactivate quadriceps tendon tissue and implanted two anchors into the patella. Krackow’s suture technique was used to place two pairs of non-absorbable and heavy sutures through the quadriceps tendon. The knee could be bent to 120° during the operation without straining the sutured tendon.\nAfter an extended knee fixation period of 4 weeks, continuous passive exercise was performed, and auxiliary physical therapy was administered to exercise the extensor function (Fig. ). We used a flexion and extension angle of < 60° to improve the range of motion. At 8 weeks after the operation, the joint mobility of the patient was 0–130°. At the 12-month follow-up visit, he had regained full mobility of the knee joint and was able to take part in various activities in daily life. |
A 40-year-old female operated and diagnosed case of the right parietal anaplastic astrocytoma presented to us with recurrence of symptoms after being lost to follow-up after the first surgery performed 1 year back. The latest magnetic resonance imaging (MRI) revealed a recurrence in the parietal region that was reaching up to the ventricular surface. Apart from the parietal lesion, a fresh signal change could be observed in the right MTL suggestive of a separate temporal glioma [-]. The surgical options included excision of parietal recurrence through the previous incision and removal of temporal glioma through a separate temporal approach [] or excision of both the lesions through PTVa using the previous incision []. It was decided to excise both the lesions through PTVa only. Apart from the advantage of targeting both lesions through a single approach, there was an added advantage of lesser chances of developing visual field deficits through PTVa. The preservation of temporal neocortex was another added advantage.\nThe patient was positioned prone with head turned slightly toward the right side. Through the scalp incision, the previous parietal craniotomy flap was raised. The parietal tumor was completely resected. At the end of the resection of parietal tumor, the ventricular cavity was entered as the tumor was extending till and bulging into ventricles. The retraction was applied using the Leyla retractor system so as to get a view of the atrium and the temporal horn. The normal anatomical landmarks, including thalamus, choroid plexus, fimbriae, and body of fornix, were identified. There was no continuity between the parietal and medial temporal tumors confirming the two being concurrent tumors. The enlarged hippocampus was seen along its entire length, except the region of amygdala, that was not in the line of vision. The orientation of hippocampus/parahippocampus was along its anteroposterior axis []. The choroid plexus at the posterior limit of resection was reflected medially and fimbriae were dissected to expose the hippocampal fissure [ and ]. The posterior disconnection was then performed at the posterior-most extent of the tumor. As the hippocampus/parahippocampus was bulky, the tumor was debulked using a Cavitron ultrasonic aspirator. The tumor decompression was done both superior and inferior to the hippocampal fissure to remove completely both hippocampus and parahippocampal gyri, taking care not to breach the arachnoid medially. The dissection was advanced gradually anteriorly. As the tumor was debulked, the choroid plexus just anterior to the already removed hippocampus was reflected medially and the fimbriae were dissected to expose the immediate anterior part of the hippocampal fissure and further tumor debunking was done both superior and inferior to the hippocampal fissure. In this manner, the hippocampus/parahippocampus with the tumor was completely removed except for a tumor involving the amygdala that was hidden from view and was inaccessible through this approach []. Hemostasis was achieved. The patient made an uneventful recovery without any postoperative deficits. Postoperative imaging revealed complete excision of the parietal tumor and near-total excision of the medial temporal tumor with a residual tumor only in the region of superomedial amygdala [-]. |
A 51-year-old man was diagnosed with underlying esophageal squamous cell carcinoma with multiple metastatic lymphadenopathy at the right neck, right axillary region, and bilateral supraclavicular fossa 17 months ago. He had received a complete course of concurrent chemoradiotherapy and all lesions disappeared. Recently, he complained of general weakness and dyspnea and was sent to our emergency department. Laboratory data showed severe anemia (hemoglobin level 6.8 g/dL) and leukopenia (2900 103/μL), but no fever or other signs of infection were identified. Panendoscopy was arranged to evaluate the anemia and revealed an 8 mm irregular ulceration with pigmentation at the distal esophagus (Fig ). A biopsy was performed and the pathological report suggested melanoma. Chest CT was arranged for tumor staging and revealed a 4 cm distal esophageal mass and multiple pulmonary nodular lesions (Fig ). Considering the underlying esophageal squamous cell carcinoma and newly diagnosed esophageal melanoma, this patient was referred to the Department of Radiology for CT-guided lung tumor biopsy in order to confirm which was the advanced malignancy and to decide the treatment protocol.\nAfter reviewing the chest CT images, two small 1.2 cm nodules close to each other in the left basal lung were targeted for the biopsy. The patient was placed in the prone position. After CT localization and local anesthesia, a 17 gauge localization needle was inserted via the intercostal space in the left of the back until the tip of the localization needle reached the posterior superior margin of the nodules (Fig a,b). Biopsy was performed six times using an 18-gauge biopsy needle. Post-biopsy CT revealed regional pulmonary hemorrhage and mild pneumothorax (Fig c). The patient complained of severe pain at the biopsy wound but no hemoptysis or dyspnea was found. The patient was sent back to the general ward with a routine order of close monitoring of vital signs every two hours.\nThe patient complained of chest pain at the biopsy site for two hours. Although his blood pressure and heart rate were stable, he felt some dyspnea. Emergency chest plain film was arranged and showed diffuse haziness in the left lung (Fig ). The patient soon developed tachycardia, shock status, loss of consciousness, and then pulseless electrical activity. Under the suspicion of massive hemothorax, cardiopulmonary resuscitation, fluid resuscitation, blood transfusion, vasopressors, endotracheal tube insertion, and left chest tube insertion were all attempted. Massive blood was drained from the chest tube. Eventually the patient expired as a result of uncontrolled bleeding in the left pleural cavity. The final pathological report of the lung nodules was metastatic squamous cell carcinoma.\nAfter multidisciplinary discussion and review of the CT images, the cause of hemothorax was concluded as a complication of the lung tumor biopsy and likely intercostal artery injury during needle insertion because the images showed the needle insertion course was close to the infracostal location, with bleeding into the pleural cavity. |
This case involves a 50-year-old HIV-positive man who presented to his family physician in 2006 with extreme discomfort in his right knee.\nThe patient was diagnosed with HIV in 1990 and had been taking combination antiretroviral medication since 1995. Five years prior to the incident of right knee pain, he was diagnosed with osteonecrosis of the left lateral tibia. His rheumatologist prescribed Celebrex which managed the left knee pain well. However, the following year, the patient was diagnosed with cirrhosis of the liver resulting from his antiretroviral medications. Celebrex was discontinued because of the contraindication with liver disease, and Tylenol was initiated for his left knee pain. The patient considered this management plan to be acceptable, particularly in light of his life-threatening liver disease, which became his focus of care. His liver disease had stabilized, and his left knee pain was well managed when the current incident of right knee pain struck.\nThe patient presented with severe pain in his right knee and was unable to weight bear with his leg fully extended. Bone scan in February 2006 revealed osteonecrosis of the right knee, osteopenia in both hips, small fractures bilaterally in the second and third metatarsals, and osteonecrosis of the right medial femoral condyle. The endocrinologist prescribed weekly Fosimax, plus a high dose of calcium and vitamin D and K supplements. The patient preferred not to take Tylenol because of his liver disease, and so his rheumatologist prescribed Tramidol taken at night to relieve morning joint pain.\nNearly one year later, MRI showed osteonecrosis and a medial meniscal tear of the right knee (see ), and the patient was referred to an orthopedic surgeon to explore surgical options. The surgeon advised that minor debridement was not an option because of the lack of healthy bone, and that a total knee arthroplasty would likely be advised within the next two years. The patient was resistant to the surgical option because of his advanced liver disease and concern for potential complications under anesthesia.\nThe orthopedic surgeon referred the patient to a physiatrist to fit an unloader brace. The unloader brace, designed to lift the femur off of the tibia for pain relief, was worn for six months, followed by a neoprene brace for six more months. Shortly after fitting the unloader brace, the patient began a one-month course of twice weekly physical therapy for postural retraining and exercises to address the patient's altered knee biomechanics. The physical therapist also delivered manual therapy techniques to resolve the patient's recent onset of left shoulder pain that had resulted from the use of canes for mobility.\nOver the next 18 months, the patient engaged in a combination of nonsurgical approaches to manage the pain, limited mobility, and decreased range of motion related to the osteonecrosis of his right knee. First, he began using Nordic walking poles to assist with walking. Nordic walking is an aerobic activity that involves walking with two specially designed poles, similar to cross-country skiing. Evolved from off-season skitraining, Nordic walking simultaneously combines the upper and lower body; the user applies a force through the poles with each stride engaging arm, shoulder, upper chest, back, and core postural muscles. The patient began a daily routine of Nordic walking for 1 kilometer, which took approximately 1 hour. He also initiated a programme of therapeutic yoga 2–3 times per week for 90 minutes for alignment, balance and stability. The yoga instructor, who was also a physical therapist, guided the patient through a combination of stretching and strengthening of his postural muscles. Later that year, the patient began hydrotherapy involving deep-end walking for 30 minutes performed 2-3 times each week. The patient perceived benefits of hydroptherapy during the early phases of his recovery when pain was greatly limiting his abilities to mobilize on land; however, he discontinued this intervention after approximately three months once his function had improved. As a former competitive swimmer, his tendency was to re-engage in more active swimming techniques but he found the whipkick aggravated his knee pain.\nAt the end of this 18 month period, the patient was able to walk 5 kilometers pain-free without a brace, with the Nordic walking poles within 1 hour. Atrophy in his right quadriceps and gastrocnemius that was present after using the braces one year earlier had resolved. Most importantly, the patient reported greatly reduced knee pain and disability. A repeat MRI taken in 2008 showed that the degeneration of the right knee had stabilized. Discussions of total knee arthroplasty were discontinued. |
A 32-month-old boy presented to our pediatric urology center with multiple episodes of urinary retention in the previous month. He was otherwise healthy and did not have any history of previous surgical or medical conditions. Physical examination revealed a large nontender mass in the lower abdomen. Routine laboratory data were all within normal limits. Plain radiography of pelvis showed a mass composed of soft tissue and calcifications in its lower part, as well as a short sacrum. Ultrasonography (US) revealed a pelvic mass with both cystic and solid components and also bilateral hydronephrosis.\nComputed tomography (CT) was taken in the district hospital before patient's admission to our center. It confirmed previous findings but it did not delineate the exact relationship of the mass with spinal column to narrow down the differential diagnoses. MRI and MRU were performed to investigate the characteristics of the mass and its possible connection to the spinal cord. MRI showed a 144 × 63 mm2 large presacral mass with septated cystic and solid components arising from coccygeal area without any connections to spinal canal. The lesion caused complete displacement of the bladder anteriorly and to the left side. The right ureter had an S-shaped course around the inferior portion of the mass to enter the shifted bladder (). Voiding cystography also confirmed bladder dislocation to the left lower part of the abdomen and did not show any vesicoureteral reflux.\nSurgical resection of the tumor was recommended. Prior to incision, a urinary catheter and a rectal tube were fixed to guide the surgeon. First, in prone (jack-knife) position a posterior sagittal incision was made. With guidance of rectal tube the mass was carefully separated from rectum, but due to its large volume complete excision through posterior sagittal incision was not possible. Subsequently, the patient's position was changed to supine and an anterior midline incision was made to access the tumor from abdomen and to complete the excision (). Components of the large cystic mass, including a turbid fluid () and hairs, were carefully evacuated by suction to avoid tumor rupture and spillage of components in the surgical field. Tumor adhesion to different organs especially the sacrum was finally released and the tumor was resected completely (). Meticulous approach was used without using unipolar electrocauter to avoid damage to sacral plexus.\nHistopathological investigations of the mass showed a cystic neoplasm composed of various mature tissue components including skin, pilosebaceous glands, well-developed respiratory and gastric epithelium, and glial tissue with numerous psammoma bodies. Based on pathological studies the final diagnosis was confirmed as mature type IV SCT. |
A 36-year-old male visited of our facility complaining air bubbles during voiding. He had a past history of conservative management in another hospital for 1 month due to in-car traffic accident 4 months ago. On the radiologic examination in the previous hospital, there was only left renal injury (grade IV/V) and perirenal hematoma with no evidence of renocolic fistula () and mild hemothorax.\nThe physical examination and laboratory findings were not specific for the renocolic fistula. He had no intestinal or urinary disturbances except air bubbles in the urine over several days.\nOn the cystoscopy, we found a diffuse mucosal edema suggesting cystitis and an air bubble jetting in the left ureteral orifice, but fecal materials were not seen in the bladder and around the left ureteral orifice (). On the radiologic examination, an accumulation of contrast medium was seen in the left colon on intravenous pyelography. On the antegrade pyelography through percutaneous nephrostomy, the left ureter showed a normal feature but there was contrast congestion in the splenic flexure of the colon (). Computed tomography (CT) of abdomen and pelvis revealed multiple gas shadows in the left renal pelvis and the bladder associated with a fistula tract between the lower area of the left pelvis and the splenic flexure of the colon with inflammatory changes () The right kidney showed normal contrast enhancement without any abnormality.\nWith a diagnosis of renocolic fistula, the patient was subsequently explored through a left 11th transcostal flank incision with transperitoneal approach. The splenic flexure and the descending colon were tightly adherent to the kidney around the fistula. The fistula was identified between the left renal pelvis and splenic flexure of the colon. Partial colectomy was performed. There was no evidence of foreign body involving in the formation of the fistula. The lower part of the kidney revealed the necrotic change, and the renal parenchyma was replaced by the yellowish inflammatory tissues. Because of severe adhesion and scarring around the renal hilum and the renal pelvis, left nephrectomy was performed.\nThere were severe inflammatory changes around the resected colon and the kidney on the pathologic examination. The patient is presently doing well for 12 months without any complications after the operation and shows normal renal function. |
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was treated in a moon walker boot and 5mg of intravenous Zolendronic acid as a bolus dose. She was asked to continue with oral Alendronic acid 10mg on alternate days for 12 weeks. The patient was reviewed at 12 weeks. There was no tenderness around the talus or calcaneus. A repeat radiograph showed that the fracture of the talus had healed (). She has been on yearly review since. |
A 64-year-old female complaining of unrelieved chest pain for 2 days was admitted to the Emergency Room of the Beijing Anzhen Hospital, Beijing, China on 31 October 2016. Evaluation of an electrocardiogram with her laboratory examinations and symptoms clearly indicated the diagnosis of acute non-ST segment elevation myocardial infarction. She was then admitted into one of our cardiology general wards.\nTen years previously, the patient underwent PCI (one coronary stent in the left anterior descending branch, and another in right coronary artery), and about 2 years ago, the patient underwent PCI again (one stent in the posterior branch of the left ventricle) because of similar symptoms. Throughout the last 10 years after the first surgery, she suffered from intermittent chest pain, which had become more intense in the last 3 months. The patient also had a history of high blood pressure for 30 years and had been receiving regular drug therapy during the last 10 years. Her blood pressure was usually controlled at approximately 140/80 mmHg during a resting state. She was never definitely diagnosed with type 2 diabetes mellitus or other diseases.\nAfter admission onto the ward, bedside echocardiography was performed and showed acceptable cardiac function with mild mitral regurgitation. Routine laboratory investigations also eliminated liver and kidney dysfunction. With complete preoperative preparation, the patient underwent coronary angiography (CA) and PCI that night. The CA was performed smoothly and showed a 95% in-stent stricture in the remote area of the right coronary artery (RCA) (). During PCI, right after embedding the stent in the distal area of the RCA, we observed by CA that contrast agent was stranded in the proximal area of the RCA and spread outside of the aortic wall. At this time, the patient immediately felt a foreign body sensation in the throat with mild chest tightness, and thus, a coronary and aortic dissection was suspected (). Cardiologists immediately controlled her blood pressure with an intravenous method and gave her analgesic treatment and rehydration therapy. At the same time, another smaller stent was immediately embedded in the proximal area and plunged into the ascending aorta by 2 mm, with the intention of covering the tear of the dissection. Repeat CA showed that a 40% stricture of the distal RCA remained (the real degree of stricture may be higher than this because of coronary aortic dissection) and that there was less contrast agent extravasation (), demonstrating that there was no expansion of the dissection. The symptoms of the patient were also markedly relieved. During the entire process of the operation, the patient’s blood pressure fluctuated from 140/70 mmHg to 150/90 mmHg, the heart rate was approximately 70 beats/minute, and oxygen saturation was approximately 100% throughout the procedure.\nIn case of worsening of the dissection, the interventional physicians asked for immediate consultation for cardiac surgery. An urgent bedside transthoracic echocardiography was also performed, and the aortic valve showed a mild regurgitation without pericardial infusion. Urgent aortic computed tomography angiography (CTA) showed that the dissection expanded to the ascending aortic artery and innominate artery, but no other part of the aortic arch was involved ( and ). The above-mentioned results led to a diagnosis of ‘acute aortic dissection (Stanford A)’. When the patient was taken back to the ward and the clinical consultation proceeded, the patient started to feel an unrelieved thoracic backache again, followed by a discontinuous fall of blood pressure, and the effects of rehydration and cardiac therapy gradually became worse. The patient was then transferred to the Department of Cardiac Surgery, Beijing Anzhen Hospital, Beijing, China during that night, then received an emergency operation. Transoesophageal cardiography was performed during surgery, and the result was consistent with the preoperative echocardiogram. We established a cardiopulmonary bypass, took out the right coronary stent and performed right coronary artery bypass grafting and ascending aorta replacement surgery. The surgery was rather difficult because the haemostatic process was complicated by the excessive weight of the patient and preoperative dual anti-platelet therapy. However, cardiac function during the operation was acceptable, which may have been due to the immediate stent implantation. The patient woke up 7 days after surgery with stable blood circulation and without definite neurological lesions in a head computed tomography scan. We speculated that her delayed awakening might have been related to the untreated innominate artery. After staying in the intensive care unit for 14 days, she was returned to the general ward. Subsequent echocardiography and aortic CTA did not show any abnormalities (). Finally, the patient was discharged with a small amount of bilateral hydrothorax, moderate malnutrition oedema and iron deficiency anaemia 18 days after the surgery. |
This is a case of a 66-year-old man who presented with bright red blood per rectum for approximately two months. He has a past medical history significant for benign prostatic hypertrophy and obstructive sleep apnea, and his only surgery was a vasectomy. He reported being a social drinker and previously smoked but quit more than 30 years ago. The patient was adopted; however, he is aware of his biologic mother who had an unknown gynecological cancer resulting in death. He also has multiple maternal uncles who died from cancer of an unknown etiology with the earliest death between 30 and 40 years of age. His physical exam was normal. A recent colonoscopy demonstrated a 3 cm friable mass in the transverse colon at approximately 70 cm. There was a polyp in the cecum which measured 4 mm, polyps in the ascending colon measuring 1.5 cm and 4 mm, and a polyp in the sigmoid colon measuring 8 mm. Histologically, he had an invasive adenocarcinoma arising from a tubular adenoma in the transverse colon. There were findings of tubular adenomas with high grade dysplasia in the descending colon as well as tubular adenomas in the sigmoid and ascending colon. A carcinoembryonic antigen level was normal, and a CT scan of the chest, abdomen, and pelvis was only significant for circumferential wall thickening in the transverse colon. The patient underwent a subtotal abdominal colectomy, removing all lesions. The pathological evaluation identified moderately differentiated adenocarcinoma of the transverse colon with twenty-three benign lymph nodes.\nDue to the patient's cancer in the transverse colon, with another synchronous high grade dysplastic lesion in the descending colon, and a maternal history of a young gynecologic cancer, genetic analysis of the patient's germline and tumor was performed. Results were obtained from the Molecular Oncology and Cancer Genetics Laboratory, Huntington Medical Research Institute, Pasadena, CA. DNA sequencing of the patient's germline identified a cytosine (C) to thymine (T) transition at codon 414, exon 9, and c.1240 C > T, heterozygous in one allele of the APC gene. The C to T transition at codon 414 is predicted to convert an arginine residue to a cysteine. This result was confirmed by analysis of duplicate samples and by sequencing in both directions. DNA sequence analysis identified a guanine (G) to adenine (A) transition at codon 2502 (c.7504 G > A, heterozygous). The G to A change at codon 2502 is predicted to convert a glycine to a serine residue; it is considered a polymorphism and the frequency of the variant p.2502S allele is estimated at 2.8% []. The final interpretation of the germline genetic analysis identified two variants: APC gene unclassified variant p.R414C; c.1240 C > T and APC polymorphism: p.G2502S (c.7504 G > A). The patient tested negative for MYH gene coding regions and for Lynch syndrome. To further elucidate the potential deleterious effects of this variant on the formation of FAP associated colorectal cancer, sequence analysis of the patient's adenomas and tumor tissue was performed. Analysis of the adenoma demonstrated the presence of the p.R414C variant; however, tumor tissue analysis demonstrated loss of heterozygosity. The tumor had lost the allele carrying the p.R414C variant and retained only the normal allele. |
A 61-year-old male was diagnosed with renal cell carcinoma of the right kidney, which was resected in 1994. In 2005, a single 2 cm hypervascular tumor was detected in the head of the pancreas on computed tomography (CT). We suspected that the lesion was the result of pancreatic metastasis of the renal cell carcinoma and performed pancreatoduodenectomy with pancreaticogastrostomy reconstruction. Informed consent was obtained prior to operation. A pathological examination showed that the resected tumor was a metastatic lesion of renal cell carcinoma (data not shown). In April 2011, another single 2 cm hypervascular tumor was detected in the tail of the pancreas on follow-up CT (). Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed no significant FDG accumulation in the tumor of the pancreas compared to the normal pancreatic tissue and no accumulation was detected in other organs (data not shown). The patient had no past history other than that described above and no abnormalities were detected on regular preoperative examinations, including blood tests of the fasting blood sugar and hemoglobin A1c (HbA1c 5.7%) levels. The patient was diagnosed with recurrent pancreatic metastasis of renal cell carcinoma based mostly on his clinical course and preoperative images.\nThe tumor was located 5 cm away from the site of anastomosis of the previous pancreaticogastrostomy. Therefore, we planned to perform distal pancreatectomy in order to preserve the middle portion of the remnant pancreas. The preservation of the spleen was also considered. However the splenic vein was close to the tumor as shown in the CT (); we decided to remove the spleen together. In June 2011, we performed laparotomy with an upper median incision and the adhesion was first dissected. The tumor was located 5 cm from the site of anastomosis in the pancreas and stomach; therefore, we decided to preserve the body of the remnant pancreas as planned (). After the spleen and tail of the pancreas were mobilized from the retroperitoneum, the splenic artery and vein were ligated and divided at the same level at which the pancreas was transected. The dorsal pancreatic artery was preserved. The remnant pancreas was dissected approximately 2 cm distal to the tumor and the tumor on the tail of the pancreas was resected. The pancreatic resection margin was histologically negative. As a result, approximately 3 cm of the middle portion of the pancreas measured from the site of anastomosis in the pancreas and stomach was preserved. The main pancreatic duct was ligated and the stump of the remnant pancreas was closed, resembling a fish's mouth. The operative time was 145 minutes and the amount of intraoperative blood loss was 107 mL.\nThe tumor was diagnosed pathologically as reflecting pancreatic metastasis of renal cell carcinoma (Figures and ). The patient's postoperative blood glucose level was well controlled only with oral medicine (the HbA1c level three months after the operation was 6.0% without the use of insulin) and he had no other postoperative complications, such as malabsorption and diarrhea caused by the decrease of exocrine pancreatic function. He was discharged from the hospital on postoperative day 22. Fortunately, after two years of follow-up after surgery, the patient was found to be doing well and had no tumor recurrence. |
An 11-year-old girl presented with increasing headaches that had started approximately 4 weeks earlier. These headaches of high intensity occurred on a daily basis and were predominantly located in the left frontal region. The patient reported an episode of severe pain at night, with a state of disorientation and limited motor control that had first occurred 2 weeks prior to admission. An electroencephalography (EEG) was performed at that time and did not reveal any pathological findings. Neither nausea nor vomiting occurred at any time.\nOn admission the clinically and neurological examinations were strictly normal. Brain magnetic resonance imaging (MRI) showed an intraventricular mass lesion (Figs. , and ). The indications for tumor resection were established at the weekly interdisciplinary tumor board meeting.\nThe operation was performed applying intraoperative neuronavigation, intraoperative ultrasound and intraoperative neuromonitoring. Despite an initially unremarkable course of surgery, the first operation for tumor resection had to be aborted shortly after dural opening due to a newly occurring epidural hematoma. Postoperatively a new visual field loss occurred; otherwise no new neurological deficit was encountered. The second operation for tumor removal was performed 8 weeks later. After opening of the dura a soft predominantly greyish tumor with a sharp border to the surrounding ependymal lining, especially in the direction of the cella media of the left lateral ventricle was developed. In a rostral direction a sharp border to the thalamus was visible. A larger tumor node was visualized in the direction of the temporal horn of the left ventricle which appeared to be covered by a thin layer of parenchyma. After fenestration of the parenchyma under neuronavigation, the greyish tumor of soft consistency could easily be separated from the surrounding tissue and was removed. Finally, the tumor portion directed to the midline, adjacent to the internal cerebral veins was prepared. Here, the tumor borders seemed less well defined. The consistency of the tissue appeared hardened and was of more diffuse yellowish-greyish appearance. Altered tissue was removed via a cavitronic ultrasonic surgical aspirator (CUSA), under neuronavigation and electrophysiological monitoring. Due to increasingly diffuse tumor infiltration and no indication of clear tumor residues, resection was stopped and wound closure accomplished. The postoperative course was uneventful and the patient was discharged home in good clinical condition. |
The patient is a 56-year-old male, who presented to our facility with complaints of left upper quadrant abdominal pain. His past medical and surgical history was significant for diverticulosis, appendectomy and pilonidal cyst resection. One month prior to his presentation, the patient experienced mild diffuse abdominal pain but denied weight loss or night sweats. His family physician started him on a course of antibiotics for suspected diverticulitis, which improved his symptoms. After 2 weeks, his symptoms returned and a computed tomography (CT) scan of the abdomen showed a possible splenic hematoma as described by the outlying hospital radiologist and he was prescribed a new course of antibiotics. Of note is that the patient was not on any anticoagulation therapy nor had any recent trauma. His symptoms continued thus his representation.\nOn arrival the patient had moderate left upper quadrant tenderness without peritonitis and mild leukocytosis. A repeat CT showed a 7.6 cm splenic abscess with extravasation contrast from the adjacent colon []. Based on these findings the patient was started on intravenous antibiotics and a CT-guided drain was placed in the abscess cavity, subsequently, being discharged home on broad-spectrum oral antibiotics. His drain contents became enteric, consistent with a moderate output fistula. Over the next several weeks, he continued to have moderate output from the drain and worsening abdominal pain. Since this continued to be a moderate output fistula it was decided to proceed with resection.\nApproximately 8 weeks after his initial presentation, the patient underwent a laparoscopic left hemicolectomy and splenectomy converted to open due to inflammatory process involving the spleen, distal pancreas and colonic. We performed a left hemicolectomy, splenectomy and distal pancreatectomy to remove this mass en bloc. The patient's postoperative course was uncomplicated.\nPathology results showed a 10 cm diffuse large B-cell lymphoma of colon with colonic perforation and infiltration into the spleen and pancreas. One of 19 regional lymph nodes was positive. Postoperative additional staging studies including a CT scan of his chest, positron emission tomography (PET) scan, which did not show any associated lesions. Patient was seen again in our office following discharge and he was recovering appropriately. |
A 60-year-old female presented with swelling in the left gluteal region for the last 2 years. The patient also complained of pain in the swelling for the past 6 months. Additionally the patient gave history of pain in the left lower limb for the past month with blackening of the toes of left lower limb for the past week ().\nThe patient was found to be hypertensive on general examination. Fine needle aspiration cytology was attempted at a peripheral health centre, and on aspiration of blood, patient was urgently referred to our hospital.\nLocal examination revealed a swelling of about 6 × 6 cms in the left gluteal region. The swelling was cystic in consistency with ill-defined margins and was visibly pulsatile. Additionally, there were ischemic changes in the left lower limb with gangrene of the 1st and 2nd toes. Arterial examination revealed a cool left lower extremity with severely diminished femoral pulse, a normal popliteal pulse, and absent anterior tibial and dorsalis pedis pulse. The arterial pulses on the right side were normally palpable.\nA duplex ultrasound of the left gluteal region revealed a deep-seated swelling with a marked arterial Doppler signature (see the video in the Supplementary Material available online at ). A CT angiogram was ordered. The angiogram revealed a remarkably large left internal iliac artery with fusiform aneurysmal dilatation ().\nThis artery was determined to be the PSA because of its continuity with the internal iliac artery, its course which was dilated and tortuous through the lateral thigh, and finally its distal run-off into the popliteal artery ().\nThe left superficial femoral system was hypoplastic and the superficial femoral artery ended distally in the thigh with no connection to the popliteal artery. The opposite limb had normal arterial anatomy ().\nThe patient underwent a femoropopliteal bypass followed by a peripheral angiography and embolization of the left PSA aneurysm. After embolization, no flows were seen in the aneurysm. Left anterior tibial and posterior tibial arteries were normally palpable at the ankle. Due to the gangrene of the toes, patient underwent left forefoot amputation 1 week later. The postoperative period was uneventful and patient remains symptom-free with no evidence of ischemic changes till one year of followup. |
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.\nFor the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a careful conversation with the patient, she decided to undergo BRAF inhibitor therapy.\nA treatment regimen with vemurafenib 960 mg PO twice daily was started on October 4, 2016. Prior to the initiation of therapy, a new MRI performed on September 24 revealed a lesion measuring 24 × 21 × 19 mm. After 2 weeks of therapy, the patient was asymptomatic and was not using any analgesic medication. During the course of therapy, she experienced grade one anorexia, nausea and fatigue, without any severe therapy-related adverse events. MRI performed in April 2017 revealed stable disease (24 × 18 × 15 mm), and her last MRI performed in September 2017 evidenced a reduction of the lesion size (18 × 13 × 14 mm) (Fig. ). The patient currently remains asymptomatic with excellent tolerance to the medication. |
The current case is a 45-year-old man who developed a subdural hemorrhage due to an injury from a fall, and who had maintained a comatose state for more than three months following craniotomy. In addition, the patient also had a loss of the right temporal area of the cranium and a scalp defect 4×3 cm in size in the posterior area and 6×5 cm in size in the anterior area, each of which were tunneled and connected. There was an exposure of the artificial dura graft that had been previously performed, which was accompanied by a chronic infection (). To cover this large scalp defect vulnerable to infection, we needed a broad, not thin, and blood flow-rich muscle flap; thus we used a latissimus dorsi muscle free flap. Intraoperative findings showed that there was a severe injury to the right superficial temporal vessel because neurosurgical operations had been performed several times before and there were no available according recipient vessels. The right facial artery and vein were prepared as a recipient vessel. Consequently, there was a defect of 15 cm in length between the facial vessels and the pedicle of a latissimus dorsi muscle free flap, which was harvested. We used a vascular pedicle of an anterolateral thigh flap as an interposition artery and vein graft. For the vascular graft, an incision was made on the right thigh. Then, the descending branch of the lateral circumflex femoral artery and two venae comitantes, a vascular pedicle of the anterolateral thigh flap, whose length was 15 cm, were concurrently harvested. This was followed by an end-to-end anastomosis of the vascular pedicle, graft vessel, and recipient vessel of a free flap in the corresponding order (, ). Insetting of the muscle flap was done for the defect site, on which a split thickness skin graft was performed.\nPostoperatively, all the flaps survived well and the skin graft was successful. Besides, there were no further infection signs (). Furthermore, there were no notable complications at the donor site of the flap and the vessel, which suggested a successful healing process (). |
A 57-year old male presented to the emergency room with high grade fever and chills.
The patient was known to suffer from metastatic colon cancer. Following positive occult blood in his stool he was diagnosed in 2010 with colonic adenocarcinoma, involving the cecum, without any evidence of distant metastasis. A laparoscopic right hemicolectomy was performed. His final pathology revealed a T3N1 tumor. He received a FOLFOX adjuvant systemic chemotherapy.
The patient recovered well and proceeded with standard regular oncologic follow up including interval abdominal CT and PET scans as required.
About 3.5 years after the index operation several new lesions, suspicious of secondary spread were revealed. A lesion in the upper lobe of his right lung was resected thoracoscopically. Another lesion caused a significant obstruction of the right kidney that resulted in nephrostomy tube insertion.
The patient was offered a cytoreductive surgery with heated chemotherapy (HIPEC) with curative intent. At surgery HIPEC was performed as planned after resection and excision of all the abdominal load of metastases except for a solid lesion involving the IVC and the 3rd part of the duodenum, deemed unresectable. Due to its presumed irresectability the site was marked with metallic clips for later irradiation.
After surgery the patient underwent a targeted irradiation to the marked site and received additional course of systemic chemotherapy. He underwent further follow up with PET scans, revealing three main lesions with a high uptake on PET, at the previous anastomosis of the transverse colon with small bowel, in the omentum next to the anastomtic site and the metastsasis revealed at previous surgery involving the inferior vena cava, near the entrance of the right renal vein and the third part of the duodenum. There was no evidence of neither liver nor other distant metastasis.
The patient remained in a good general condition and performance status up to his presentation with fever and fatigue on 6 month after the second operation. His blood tests revealed anemia, high white blood count and CRP.
Blood cultures were taken |
A 51-year-old female, field worker, fair in complexion, and resident of the hilly region of Kumaun, India reported in March 2009 with a gradually enlarging mass in lateral portion of the right lower lid for last five years. The mass had rapidly increased in size in the three months prior to presentation. The patient also gave a history of itching, and occasional bleeding from the mass. There was a past ocular history of a similar mass in the left lower lid in an identical position, which appeared when she was around 20 years of age. It was excised at the age of 25 years for cosmetic reasons when it was pea-sized. Histological examination was not done at that time. After excision, the mass again recurred at the same location, continued to increase in size, and was associated with itching and occasional bleeding. Excision of mass with cheek rotation flap was done in 2001. Histological examination of this tissue revealed pigmented nodular variety of BCC of left lower lid.\nThe patient had been diagnosed with hypertension and diabetes three years back and was on irregular treatment. Family history of skin carcinoma was negative.\nExamination of the right lower eyelid revealed an approximately 25 × 30 mm, pigmented ulcerated, and nodular mass in the lateral half. It was painless, firmly adherent to the lid, and restricting the active movements of lower lid. The lower lid was slightly everted due to weight of this mass []. Clinically there was no evidence of regional lymphadenopathy. Examination of the left eye revealed loss of most of the lower lid with scar tissue in the infraorbital and temporal part of the left cheek. Some redness was noticed in conjunctiva adjacent to this region due to incomplete lid closure [].\nSystemic examination was unremarkable. Routine investigation revealed raised fasting and postprandial blood sugar levels, a normal hemogram, liver and kidney function tests. Chest X-ray and ultrasonography of abdomen did not reveal any abnormality.\nAn incisional biopsy was performed prior to definitive excision to confirm the clinical diagnosis of a periocular malignant mass. Histological examination of the tumor in the right eyelid revealed solid nests of darkly staining cells extending into the dermis. All the cells were similar to the basal cells (basaloid) of the epidermis and few nuclei showed abnormal mitotic figures, which took up an in-tensely dark blue stain with hematoxylin. The cells at the periphery of the solid masses showed a typical palisade arrangement []. These features led to the diagnosis of BCC of right lower lid.\nClinically, a rough estimate of tumor margins were made with the skin of the right lower eyelid on stretch using the following guides - transition in surface contour; altered vascularization (fewer capillaries and more telangectasia); altered skin color; tumor depth was judged by the lesion’s mobility over underlying tissues. Standard surgical excision with frozen section control was done. A two-staged lower eyelid reconstruction was done with tarsoconjunctival flap and full thickness skin graft taken from the thigh []. The tumor was excised with 2 mm margins, and repair delayed for two days, providing time for histological confirmation of complete excision with formal paraffin sections.[] |
A 45 years old male patient, attended the neurology emergency department on 3rd January 2016 due to right limb numbness for 6 days and convulsive seizure for 3 days. Six days before the hospital visit, the patient experienced numbness in the right upper limb and instability while holding without obvious incentive but did not seek immediate medical intervention. Three days before admission, the patient experienced convulsive seizure in the right upper limb while remaining conscious, which was relieved after 1 min. Similar attacks occurred intermittently on six further occasions. The patient had a 3-year history of hypertension with the highest blood pressure being 180/110 mmHg. He also had a history of smoking and drinking lasting more than 30 years. He was born and has always lived in Beijing, with no history of contact with infested water, infectious zone, other radioactive substances or toxins. Upon admission, the patient was examined to be obese with no subcutaneous nodules. Neurological examinations showed full level muscle strength in the right upper limb, accompanied with diminished needling response. Emergency head CT scan (2016-1-1) showed lower density in the left parietal lobe. As the patient manifested as an acute onset of right limb weakness and hemiparesis,with low density lesions in the left occipital lobe on CT and a history of hypertension, the patient was hospitalised with a preliminary diagnosis of acute stroke and secondary epilepsy.\nAfter hospitalisation, head MRI scan (2016-1-4) displayed a lesion in the left parietal lobe of unknown nature. After enhancement in the magnetic field, a larger area of oedema was found around the lesion in the left parietal lobe which could indicate glioma or other inflammatory diseases. Since the nature of the brain lesion did not match the characteristics of common cerebrovascular diseases, intracranial angiography DSA was used but found no obvious vascular abnormalities or stenosis. Further examinations including lumbar puncture, immune rheumatoid factors and parasite antibody detections were carried out. A raised cerebrospinal fluid pressure was found to (215 mm H2O) with no red or white blood cells present. After consultation within the neurology department, intracranial tumor was considered and therefore prepared for stereotactic biopsy of the brain. At this point, pathology results came back positive for Spirometra mansoni IgG. On further questioning the patient admitted that he had drank tap water and eaten frogs when travelling in another province during June–September 2015. Given his medical history, and results from head MRI and blood tests, the patient was considered to be infected with Spirometra mansoni and surgical intervention or antihelmintic chemotherapy was recommended .\nThe patient accepted pharmaceutical treatment and was given praziquantel (1600 mg, 20 mg/kg) 3 times a day for 10 days. During these 10 days, the patient reported occasional headache and was treated for dehydration before discharge from the hospital. The patient was also administration oral sodium valproate 500 mg 3 times a day to control seizures.\nThe patient was hospitalised again in March and July 2016 and treated with praziquantel (1600 mg,20 mg/kg) 3 times a day for 10 days. His headaches were eased with intravenous infusion of 20% 250 ml mannitol twice a day.\nLumbar puncture (Table Examination of cerebrospinal fluid), head MRI, blood biochemistry, conventional blood analysis and parasite antibody examinations (Table Spirometra mansoni IgG antibody) were also carried out on both occasions. On 13th Jul 2016, the patient was free from numbness and seizures in the upper limb.\nTable displays the laboratory results of lumbar puncture performed on the three occasions when he was admitted to hospital and during the 1-year follow-up appointment. CSF analysis showed normal results except for a few white and red blood cells during his second hospital stay most likely resulting from the procedure itself. Table shows the Spirometra mansoni IgG result on three occasions. Note that the IgG result became negative during his third hospital stay following three courses of praziquantel treatment.,.\nEnhanced head MRI scans were performed during the three hospital stays in January, March, and July 2016. Figure A-A3display head MRI scans performed on 8th January. The scans showedan abnormal horseshoe signal in the left parietal lobe with a low T1WI signal and a high T2WI + FLAIR signal. Enhanced scan showed irregular wreath in the lesion without enhancement in the surrounding. This type of abnormality in the left parietal lobe may indicate glioma. During the second hospital stay, the MRI scan carried out on 17th March showed abnormal small stripes of signal shadow in the left parietal lobe with a decreased range. It also showed clearer abnormal veil-like signal shadow in the left parietal lobe as compared to the previous MRI scan. These results may indicatethe presence of Spirometra within this area of the brain. During the third hospital stay, MRI scan on 7th July detected only minor abnormalities in the bilateral frontal lobes and parietal lobes indicating that the lesions has reduced significantly or resolved. The follow-up on 12th December showed no abnormality in the head MRI scan. MRI scans from each hospital visit are shown in Fig. . |
A 61-year-old female with the past medical history of recurrent pancreatitis, pancreatic stricture, with a history of pancreatic stent placement was admitted secondary to recurrent abdominal pain. Patient had a complicated hospital course at another facility approximately 10 weeks prior to admission to our facility. Patient had a history of a 14 cm pancreatic pseudocyst seen on a CT in addition to necrosis involving the neck and the body of the pancreas.\nShe had undergone a EUS-guided cystogastrostomy by another endoscopist approximately 6 weeks prior to admission to our facility. The EUS revealed that a large pseudocyst close to 14 cm in size replaced the pancreas. Patient then underwent the placement of two double pigtail 7 F 4 cm stents. Several days after this procedure patient also underwent laparoscopic cholecystectomy and J tube placement at the other facility before being discharged.\nPrior to being admitted to our facility patient started developing abdominal pain, was subsequently admitted to another facility and was transferred to our facility for a higher level of care. CT scan at the transferring facility showed a large pancreatic pseudocyst with necrosis. Patient was noted to have a WBC of 13, 000, and increased anion gap with lactic acidosis at the time of hospitalization. Critical care consult was obtained; patient became septic and was admitted to ICU.\nThe patient was taken to endoscopy suit for EUS-guided cystogastrostomy. The two previously placed pigtail stents were visualized. The cyst was punctured via the transgastric approach using a 19-gauge needle; a 0.035 jag wire was then inserted into the cyst under fluoroscopic guidance. The cystotomy was performed using a cystotome from cook endoscopy. We then dilated the tract using 15 mm balloon. We then placed a 10 mm × 6 cm fully covered SEMS. The cyst was then irrigated using 100 cc of saline resulting in the irrigation of the cyst and drainage of a large amount of pus into the stomach. Patient reported immediate improvement of abdominal pain with further gradual improvement in symptoms during the remainder of the hospital stay.\nPatient was started on a liquid diet and advanced to full. Patient was discharged 10 days after admission to a rehab facility for further recovery on broad spectrum antibiotics ().\nApproximately 6 months later the patient was re-admitted to the hospital with the chief complain of abdominal pain. Patient denied any fever and laboratory values were within normal limits. Patient underwent a colonoscopy which was positive for mild diverticular disease. CT of the abdomen was obtained which showed a 3 cm pseudocyst in the tail of the pancreases as such patient underwent an ERCP which did not reveal the cyst to be communicating. Furthermore the previous SEMS stent placed 6 months earlier was in good position and remained patent and as such we then proceed with another cystogastrostomy with the placement of a 10 F 5 cm double pigtail catheter into the cyst, which drained clear fluid with no pus. |
A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.\nHis blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.\nA specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.\nIn addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.\nHe underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.\nNine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).\nThis procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.\nAfter 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .\nAt 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual. |
A 10-year-old male patient came to the Trauma Project clinic at the Federal University of Rio of Janeiro with the complaint of a fractured tooth. The patient had been seen initially at the emergency department of a nearby general hospital where anti-inflammatory medication was prescribed. No treatment was given for the fractured tooth or for the laceration of the lower lip. Also, the dental fragment embedded in the lower lip went unnoticed. The mother reported that the child had sustained an orofacial trauma 2 days ago due to a fall during a soccer game on asphalt. The medical history was non-contributory and all the recommended vaccines had been taken.\nDuring the extraoral and intraoral examination, soft-tissue edema and laceration involving the lower lip alerted the possibility of the presence of a tooth fragment in the soft tissue. Palpation of the lower lip revealed a hard mass and the patient complained of pain in the region. Intraoral examination showed an enamel and dentin crown fracture without pulp exposure of the upper left permanent central incisor [] that was sensitive to thermal stimulation.\nA radiographic film was placed between the lower lip and mandibular incisor to verify the presence of an object. The radiographic exposure dose was 25% of that used for standard periapical radiographs. This radiographic exam revealed a large radiopaque foreign body suggestive of the coronal fragment of the fractured incisor []. There was no evidence of root fracture, pathological periapical lesion or periodontal ligament tissue injures of the upper anterior teeth [].\nThe patient remained 1 week under anti-inflammatory and antibiotic medicines to reduce the swelling and risk of infection. After this, he was submitted to a surgical excision of the fragment under local anesthesia []. The fragment was stored in a saline solution.\nAfter 8 days, the lower lip was healed. The fragment and the fractured tooth were etching with phosphoric acid 37% for 20 s, washed with water, and curing adhesive under rubber dam. The fragment was positioned on the tooth with a nano-hybrid resin layer and the excess was removed before photopolymerization []. After, a mouth-guard was made, which was recommended to use during sports practice to protect against any new traumas []. The patient is attending follow-up visits to accompany the tooth both clinically and radiographically. |
A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.\nHis blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.\nA specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.\nIn addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.\nHe underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.\nNine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).\nThis procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.\nAfter 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .\nAt 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual. |
Our case is that of a 43-year-old primiparous woman. She was diagnosed with Behçet disease at the age of 34 years; she presented with recurrent oral ulceration, recurrent genital ulceration, and pseudofolliculitis with characteristic acneiform nodules. She had no eye lesions. Her condition was well controlled with prednisolone (PSL) 8 mg/day oral dose. She fell pregnant spontaneously and visited our perinatal center for her prenatal care. As she was detected with hypertension at her first visit, we recommended that she check her blood pressure regularly at home. She developed fever, oral ulcers, and arthralgia at 16 weeks of gestation, due to which a relapse of Behçet disease was suspected. Because her condition was controlled well with PSL, the daily oral dose of PSL was increased from 8 mg to 10 mg. At this time, ulceration and pain of the vulva were not observed. She visited our outpatient clinic for a regular prenatal examination at 18 weeks and 4 days of gestation, which was when an ulcer localized in the vagina was incidentally observed (). The ulcer was painless and the patient had no symptoms in the vulva either (). Chlamydial and gonococcal infection were not detected, and cytology of the vaginal wall showed no findings suggesting malignancy. As the other symptoms of Behçet disease were resolved after the dose of PSL had been increased, the same dose was maintained. At the next prenatal care visit, at 22 weeks and 4 days of gestation, the vaginal ulcer had disappeared and other symptoms of Behçet disease were not seen. At 28 weeks and 0 days of gestation, atypical genital bleeding and vaginal ulcer recurrence were observed (). At the same time, recurrence of the oral ulcer and arthralgia as well as a mild increase in the fever were observed; based on these symptoms, she was diagnosed with a relapse of Behçet disease and the daily dose of PSL was increased from 10 mg to 15 mg. The vaginal ulcer disappeared at 29 weeks and 2 days of gestation (). Thereafter, there was no relapse of the symptoms of Behçet disease.\nAt 33 weeks and 0 days of gestation, her blood pressure had increased, due to which she was admitted to the hospital. She was diagnosed with severe preeclampsia superimposed. Induction of labor was conducted but it was not effective, and we performed cesarean section at 37 weeks and 6 days of gestation. She delivered a male infant weighing 2002 g. There were no complications in the postoperative course, and she was discharged with her baby at 7 days after cesarean section. No recurrence of the vaginal ulcer and other symptoms of Behçet disease were seen on subsequent follow-up examination at 1 month after delivery.\nThe patient was explained about the possibility of publishing this case as a case report and the accompanying images. She provided consent. |
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.\nFor the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a careful conversation with the patient, she decided to undergo BRAF inhibitor therapy.\nA treatment regimen with vemurafenib 960 mg PO twice daily was started on October 4, 2016. Prior to the initiation of therapy, a new MRI performed on September 24 revealed a lesion measuring 24 × 21 × 19 mm. After 2 weeks of therapy, the patient was asymptomatic and was not using any analgesic medication. During the course of therapy, she experienced grade one anorexia, nausea and fatigue, without any severe therapy-related adverse events. MRI performed in April 2017 revealed stable disease (24 × 18 × 15 mm), and her last MRI performed in September 2017 evidenced a reduction of the lesion size (18 × 13 × 14 mm) (Fig. ). The patient currently remains asymptomatic with excellent tolerance to the medication. |
A 61-year-old male presented with backache for 3 months. A soybean-sized mass accompanied by pain and numbness was found on the front and back of the left ear in October 2015, the left corner of the mouth was skewed and the left eye was partially closed. The patient was diagnosed with facial paralysis at the local hospital and his symptoms did not respond to acupuncture treatment. The mass on the patient’s ear had grown to the size of a pigeon egg by 2017. The swelling, pain, numbness, skewing of the left corner of the mouth, and the left eye insufficiency were also aggravated. There was no fever or weight loss during the course of the disease. The patient had no history of tumours or autoimmune diseases and had no family history of tumours. A physical examination revealed several slightly enlarged lymph nodes under the left ear and in the jaw. The largest node was 1.5 cm in diameter and had a tough texture, good mobility and no tenderness. A hard, slightly tender mass approximately 2×1.8 cm in size was noted below the front of the left ear with poor mobility, no redness or swelling of the local skin, and a low skin temperature. Computer tomography (CT) of the parotid gland identified a mixed tumour that had undergone malignant transformation ( and ). A fine-needle aspiration examination of the left parotid gland revealed that the tumour was of epithelial origin. The diagnosis of reactive lymphoid tissue hyperplasia was determined by a left ear lymph node puncture smear. No distant metastases were found in other organs. The clinical stage was estimated to be T4aN0M0.\nThe primary surgical treatment consisted of a total parotidectomy conserving the facial nerve with a modified ipsilateral radical neck dissection preserving the branches of the temporal and facial trunk and removing part of the zygomatic and buccal branches of the facial nerve. Post-operative pathology indicated that the patient had duct carcinoma of the parotid gland () with invasion to surrounding soft tissues. Tumour thrombus and nerve invasion could be seen. The pathologist identified twenty-one lymph nodes, consisting of parotid gland-adjacent lymph nodes (1/6), submandibular and upper deep cervical lymph nodes (0/14) and cervical lymph nodes (0/1). On immunohistochemistry, the tumour demonstrated strong or weak positive staining for CK, CK7 (weak), CK8/18, EMA, Cam5.2, CK (high) and Ki-67 (10%), and was negative for CK20, CEA, Vimentin, S-100, Calponin, CD117, P63 and Dog-1. The final pathological staging was pT4aN1M0. Three weeks after surgery, postoperative radiation therapy (66 Gy; 2.2 Gy once a day, five days a week) was applied to the surgical bed and the left neck area due to the aggressive nature of the tumour. No tumour recurrence or metastasis was found at follow-up until May 2020, when the patient’s serum CA724 levels were found to be greater than 300 U/mL. Emission computed tomography revealed multiple bone metastases involving the spine, ribs, and pelvis (). No other metastases were found in the neck, lungs or liver. The patient was diagnosed with bone metastasis of parotid gland cancer based on his previous medical history.\nSubsequent treatment for the recurrent lesions included radiotherapy (40 Gy; 2 Gy once a day, five days a week) for the spine bone metastases due to bone pain and the risk for pathological fractures, and bisphosphonates (once every 4 weeks) to prevent bone destruction. While the patient was receiving treatment, his previous surgical specimens were taken for genetic testing, and the tumour was found to have mutations in HRAS (exon 3, p. Q61K) and PIK3CA (exon10, p.E545K). No gene amplification of HER-2 or mutations in other related genes were observed. In addition, immunohistochemistry showed strong positive staining for androgen receptor (AR) expression (). Finally, we chose androgen deprivation therapy that targeted the AR as a first-line therapy because no other drugs were available. The anti-AR endocrine therapy administered to the patient consisted of bicalutamide (50mg; once a day) and leuprolide (3.75mg; once every 4 weeks). Leuprolide was first administered one week after bicalutamide treatment; subsequently, the two drugs were administered in combination. After 7 months of combined androgen blockade (CAB) therapy, the patient’s backache symptoms had resolved, positron emission tomography and computed tomography (PET-CT) showed no significant evidence of bone metastases ( and ), and his serum CA724 levels had returned to near-normal levels. The patient is currently alive with a progression-free survival (PFS) of over 7 months to date.\nThroughout the endocrine therapy, the patient reported that he tolerated the treatment well, did not experience any significant adverse events, and found it convenient to receive treatment in an outpatient setting. |
A 45 year old female presented with complaints of irregular bleeding per vaginum off and on since the last two months. The general condition of the patient was stable. Per speculum examination revealed a large, firm mass protruding out from the cervical os. Ultrasound scan of the pelvis showed an enlarged uterus with a well defined heterogenous and hypoechoic mass lesion in the posterior lower uterine wall and extending to the posterior cervix, measuring 96 × 62 mm []. Both ovaries could not be localized because of the large uterus and the overall impression was that of a uterine fibroid. The patient was then taken up for surgery and hysterectomy with bilateral salpingo-oophorectomy was done in view of the enlarged left ovary. Peritoneal washings were also taken.\nA specimen of uterus with cervix and bilateral adnexa was received in the laboratory. Gross examination showed a firm, globular mass which had widened and distorted the cervix. It measured 9 × 6 × 6 cm, cut surface was firm with a whorled appearance and was attached at the isthmus. The endometrial thickness was 4 to 5 mm and no evidence of adenomyosis was seen on gross examination []. The left ovary was enlarged and measured 6 × 4 × 5 cm with a smooth external surface. The cut section was firm with multiple cysts ranging from 1to 3 mm in diameter filled with brownish colored fluid []. The right ovary measured 2 × 2 ×1.3 cm with a smooth external surface and was cystic on cut section. Microscopic examination confirmed the firm, globular mass to be leiomyoma with areas of myxomatous degeneration. Endometrium was in proliferative phase with no evidence of endometrial hyperplasia. No foci of adenomyosis were seen. The right ovary showed a benign follicular cyst with histologically normal fallopian tubes. Peritoneal washings were negative for malignant cells.\nThe enlarged left ovary showed a solid tumor comprising of glands with intervening fibrous stroma. The glands were of varying sizes from small round to large tortuous, serrated and cystically dilated with areas of confluent epithelial proliferation which were less than 5mm in diameter. They were lined by tall columnar cells with coarse nuclear chromatin and nuclear stratification resembling those of proliferative phase endometrium []. Glandular complexity was evident, however no stromal invasion was seen. The intervening stroma was cellular and compact, composed of spindle cells and no associated endometriosis was noted. The tumor was limited to the left ovary and the capsule was intact. The histological diagnosis was Atypical Proliferative Endometrioid Tumor of the ovary, Pathologic Stage IA. The patient has been on regular follow up which was uneventful including serial imaging findings i.e. CT scans, were found to be unremarkable. |
An 84-year-old woman with a history of syncope was referred to a general hospital by her primary doctor. Sick sinus syndrome was diagnosed and a ventricular demand pacemaker was implanted via the left axillary vein. The tip of the implanted lead (5076-52 cm, Medtronic, Minneapolis, MN) was a screw type. The lateral chest X-ray film obtained just after pacemaker implantation demonstrated that the tip of the lead was in the correct position () and the pacemaker threshold was normal. Two days after implantation, she complained of the sudden onset of pain in the left precordial region. On the fourth day after implantation, a bulge appeared in the left sixth intercostal space at the site of the pain. A lateral chest radiograph obtained on the same day demonstrated displacement of the pacemaker lead (). Transthoracic echocardiography did not identify a pericardial effusion, but the position of the lead tip could not be seen accurately. Computed tomography (CT) confirmed penetration of the lead though the RV into the subcutaneous tissues of the left thoracic cavity (). There was no pericardial effusion, pneumothorax, or pleural effusion. The patient was sent to our hospital for emergency treatment. Because transvenous removal of the pacing lead was thought to be risky, surgical removal and RV repair were performed. Median sternotomy was chosen as the approach because it would be easy to establish cardiopulmonary bypass if required. There was no pericardial effusion, but the pacing lead was seen protruding through the anterior wall of the RV apex and penetrating the pericardium (). When the left pleural cavity was opened, the pacing lead was found to be embedded in the anterior visceral pleura, but the left lung was not injured in agreement with preoperative CT findings. A purse string suture was placed around the lead in the RV wall and a pledgetted mattress suture was added for reinforcement. Then the part of the lead protruding from the RV was grasped with forceps and cut in the pericardial cavity. Next, the pacing lead and generator were extracted from the left subclavian wound without any resistance. At the same time, the purse string suture and then the mattress suture were tied in this order, and the remaining part of the lead was extracted from the pleura with little resistance. There was no bleeding at the site where the lead had pierced the pleura. A temporary pacing wire was placed on the RV wall intraoperatively. Ten days after surgery, a new permanent pacemaker was inserted, with the tip of the lead being placed at the ventricular septum via the right axillary vein without any problems. |
A male patient, aged 8 years, suffered a traumatic injury in the area of the chin and mandibular right and left central incisor and mandibular right lateral incisor after he had been pushed against a wall by a friend at school. The child was referred to the dentist one hour after trauma, reporting intense pain in the traumatic area. At extraoral clinical examination, the presence of contusion lesion and abrasion on the chin was observed (). Considering the traumatic impact on the chin and the possible damage to the temporomandibular joint (TMJ), a panoramic radiograph was taken to evaluate this area. The radiographic image indicated normal TMJ structures, without injury (). Thus, extraoral injuries treatment was restricted to the cleaning and disinfection of the damaged soft tissue.\nIntraoral examination revealed the presence of lateral luxation towards the lingual surface of mandibular right lateral incisor (without mobility) and alveolar fracture of the area of teeth mandibular right and left central incisor with lingual displacement (). When mobility was checked, alveolar process showed movement as a unit of the displaced segment, which characterizes the alveolar bone fracture. The alveolar fracture was not visualized on radiographs, since they were taken only after dental trauma treatment. The preoperative radiograph was not taken because the child was in pain and the image was not necessary for the choice of treatment.\nAlthough the traumatic impact caused two injury types to teeth and supporting tissue (lateral luxations and alveolar fracture), the management performed was the same for both situations. After anesthesia with local and intraligamentary infiltration of the displaced teeth, using a full cartridge of 2 percent lidocaine with 1 : 100,000 epinephrine, the mandibular right lateral incisor and the bone segment of mandibular right and left central incisor were repositioned by digital pressure. The bone fracture reduction was difficult to execute because of its extension (). Next, a splint made with resin composite (Filtek Z350 XT, 3M ESPE) and 0.7 mm orthodontic wire was placed onto the labial surface of the teeth involved and the immediately adjacent teeth (not injured) (). At the periapical radiographic examination of the injured area, the image showed the presence of open axes in the three teeth affected by trauma ().\nThe patient was instructed about oral hygiene and the importance of follow-up appointments. The use of 0.12% chlorhexidine solution for application on injured site was recommended, twice daily during the first week after the dental trauma. Paracetamol was prescribed to be used while the patient was in pain and was used only in the first day (24 h). Amoxicillin was prescribed for use during 7 days, once the child fell in school, a possibly contaminated area.\nAfter one week, the splint loosened probably because of the difficulty in controlling the moist from the injured tissue at the emergency appointment and failure of the bonding system of the resin composite. The splint was again installed because the teeth still showed mobility. The patient was followed up at every week. After 6 weeks, the splint was removed and the clinical () and radiographic () findings indicated normality of soft and hard tissues with no pulp and periodontal pathologies. At three months after trauma, the patient was followed up at every two weeks, followed by two-month intervals to monitor the teeth involved in the trauma. After six months, the patient returned with a broken leg due to fall, but without involving the maxillofacial area. The follow-up radiographic examination evidenced the continuity of the closure process of the apexes of the traumatized teeth (). The 5-year follow-up indicated the presence of normal clinical aspects (). All teeth exhibited pulp vitality to Endo Frost Roeko cold spray test. Radiographically, the full closure of the apexes followed by a marked obliteration of the root canal lumens could be verified (). |
We report a 73-year-old woman, who presented with a sacral fracture that had already been diagnosed in an outpatient setting. In addition, there was strong evidence of a renal cell carcinoma of the right kidney. Despite sufficient pain treatment and accompanying physiotherapy, the patient's mobility was severely restricted by pain at the time of presentation. The patient rated her pain as 9 on a visual analogue scale (VAS) with 10 as the maximum value. Osteoporosis was also suspected and confirmed by bone density measurement, so therapy with bisphosphonates was started in accordance with the guidelines (). In the preinterventional CT of the pelvis and abdomen, a bilateral fracture line running sagittally through the lateral mass of the sacrum could be seen ().\nOn the left, the fracture line traverses the transforaminal zone at the level of the second sacral vertebra. Both in this examination and in an additionally performed MRI, no metastases of the suspected renal carcinoma were observed in the areas of the body examined. The morphology of the sacral fracture was also most consistent with an insufficiency fracture. In order to enable the further therapy of the renal tumor and to achieve sufficient pain reduction, in an interdisciplinary tumor conference, it was initially decided to treat the sacral fracture by CT-assisted balloon sacroplasty. In order to avoid further fracturing and prolonged hospitalization of the patient, we decided on simultaneous treatment of the bilateral fractures. In addition, a biopsy was to be taken for histopathological analysis for definitive exclusion of metastasis. The intervention was performed under intubation anesthesia and anesthesiological monitoring. The patient was placed in the prone position in the CT scan machine. As is routine practice, a single-shot antibiotic was administered (cefazoline 2 g IV). The short axis of the sacrum was selected as the entry plane. Access to the fracture zones was established from dorsal to ventral by two Kirschner wires, which can be directed and angulated easily without causing further damage in the osteoporotic bone. Along the Kirschner wires, two hollow needles were then placed in the fracture zone. The desired position was observed by single slice CT-images. To begin with, the bone biopsy was performed via the hollow needles. The balloon catheters (Kyphon®, Medtronic, 20 mm length, 6 cc volume) were then inserted ( and ).\nThey were inflated and deflated stepwise from the central to peripheral under CT monitoring by means of single slice images (). Cement (polymethyl methacrylate, PMMA) application was then performed in the previously prepared hollow space using the low-pressure method under CT monitoring (). The final check by thin-slice spiral-CT of the pelvis showed sufficient distribution of the cement, without leakage into the neural foramina, the iliosacral joint or the visceral surface of the sacrum ( and ). In our institution, the cement distribution is usually observed by plain radiography (not shown) to have an initial image for potential follow-up examinations. Two days post-intervention, a pain reduction to VAS 3 was observed (). The samples taken during the intervention showed no evidence of malignancy. The patient's previous pain-related restriction of mobility and her general condition improved markedly thereafter, so that the planned oncological therapy, including nephrectomy could be started. |
A 32-year-old male sustained a grade 3B (Gustilo and Anderson) open fracture of the right femur following a high-speed motor vehicle accident. A piece of bone from the femur was lost at the site of injury. He did not have any other injury except fracture of the femur. At the primary center, he received wound lavage and splinting of the limb along with systemic antibiotics. Due to lack of facility at the primary center, the patient was referred to the secondary center. After five days of index injury, the surgeon in the secondary hospital performed surgical debridement of the wound and applied external fixator. Culture reports and antibiotic profile of the index surgery are not available due to lack of documentation. The wound healed satisfactorily, and stitches were removed in two weeks. After 15 days of the first surgery (20 days from injury), the operating surgeon removed the external fixator and did intramedullary nailing of the femur without bone grafting (Figure ). The incision wound healed with routine removal of skin stitches. After three months of intramedullary nailing of the femur (nearly four from injury), a blister developed in the lower thigh, which later burst with purulent discharge. The same surgeon after culture and sensitivity of pus administered systemic antibiotics and the discharged decreased after 20 days of antibiotics. After 15 days (five months from injury), the patient presented to another surgeon with similar discharge and was administered empirical systemic antibiotics for a period of 30 days. The patient had marginal improvement with occasional fever and knee pain. Following intramedullary nailing, no further wound washout or debridement was performed by earlier surgeons. At this point (nine months after injury), the patient presented to me with complaint of pain knee, unable to walk, and discharge from the distal thigh. The patient was more than 100 kg with a BMI of 32 kg/m2 and had treatment of more than nine months with a significant psychological aspect. At this point in time, his blood parameters were within normal limits ( TLC was 12.29 x 103/cumm, neutrophil count was 78%, ESR was 6 mm per one hour, CRP was negative, and pus culture revealed no growth). The infection was not revealed due to long-term administration of antibiotics. In our first stage (nine months and 15 days after injury), we removed the intramedullary nail and put a limb reconstruction system (LRS) after thorough debridement. We removed the dead part of the bone nearly 40 mm and put vancomycin cement bead chain. Pus collected from the deeper part of the wound collected during debridement revealed Escherichia Coli and was only sensitive to colistin. The patient was treated with intravenous colistin for two weeks with regular dressing of the wound. There was no improvement in wound even after two more debridements. We had to remove the antibiotic cement bead (10 months and 10 days after injury) and found a lot of necrotic tissue at the fracture site (Figure ). After another debridement (10 months and 15 days after injury), we put an NWPT dressing at an intermittent pressure of -120 mm Hg. Surprisingly, within 72 hours, there was a significant improvement in the wound in terms of collection of debrima, wound margins, and so on. The dressing was changed every 72 hours, and after three dressings we found a healthy wound with clean wound margin and formation of granulation tissue (Figure ). We were able to close the wound with secondary suture (11 months and five days after injury) as the wound gap decreased with NPWT. The wound healed completely within three weeks (12 months after injury) without any further discharge (Figure ). The patient was put on suppressive antibiotic therapy, and the bone defect managed with corticotomy and bone transport on an LRS (Figure ) (union in progress). |
A 60 y/o female presented with Gorham’s disease in the ulna. The disease first started in the ulna and later involved the lower end of the radius and the lower humerus. The patient had referred to her doctor 9 years earlier with pain in the ulnar side of her forearm after getting hit by a heavy object. Clinical and radiographic examinations had failed to reveal any particular pathology and the patient was then referred to a physiotherapist. One year later, the patient returned to her physician with severe pain in the forearm. Plain X-rays were apparently normal, however MR imaging revealed nonspecific lesions in the ulnar bone marrow. These lesions were suspected to be chronic osteomyelitis. Radionuclide and CT scans revealed low density areas in the ulna. Laboratory, microbiological, immunological, hormonal and biochemical tests, including parathyroid tests were all within normal limits. The patient had a biopsy taken by her orthopedic surgeon. The biopsy was apparently consistent with the diagnosis of osteomyelitis, but the culture returned negative. After a while, the patient sustained a fracture in the same bone while asleep which was treated with a cast and healed without surgery. The patient has been complaining of pain and weakness in the left forearm for the past 5 years. Radiographs revealed bone absorption in parts of the ulna (). Five months ago, while attempting to lift a glass, the patient twisted her forearm and broke her radius. Her radiographs showed complete resorption of the ulna (); her arm was subsequently immobilized in a long arm cast. She came to our center and radiographs of her arm revealed non-union of her latest fracture. They also showed bony absorption of the lower end of the radius ( A,B and C). The patient's elbow ROM was nearly normal, so was the wrist ROM except for the final degression of flexion and extension. MTPs and finger motion were normal and the patient's fingers were spared.The neurovascular status had been normal from the onset of the disease and the nerves and vessels were spared. The skin was normal and no soft tissue involvement was seen. All laboratory tests including serum complement levels, vasculitis tests, parathyroid, 24-hour urinary proteins and electrophoresis of plasma proteins were normal. Based on test results and the histopathology report of dead, edematous bony tissue and an abundance of inflammatory cells with a great number of thick-walled blood vessels and no evidence of malignancy, we considered the criteria proposed by Heffez et al. in 1983 ( ) and Gorham’s disease was diagnosed. |
An 18-year-old male patient presented with symptoms of pain and swelling localized on the medial aspect of his right ankle joint, specifically at the medial malleolus. The patient noted a recent history of a twisting injury of his right ankle 6-months before presentation at our specialty orthopedic clinic. The injury occurred while playing football. Initially, he was treated by his general practitioner, who assumed it to be a severe sprain injury and had placed him on a course of ice compress and anti-inflammatory medication followed by a below knee plaster cast for a period of 3 weeks. Following this treatment protocol, the patient was able to walk but reported on-going pain while walking once the plaster cast was removed. No radiographic imaging was done at the time and was therefore not available for review and comparison.\nOn further examination, swelling was observed over the distal aspect of the medial malleolus, along with tenderness over deltoid ligament of the right ankle. There was no bone related tenderness at the distal tibia. Ankle joint movement was also observed to be normal. We proceeded with a thorough radiograph examination including standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle, which revealed the presence of a small bone fragment located anterior and distal to the medial malleolus (, ). This fragment was not free floating and rather appeared to be attached to the distal tibia. Furthermore, it was a uni-lateral presentation as the patient’s left ankle anatomy did not reveal the presence of a similar bone fragment and was rather normal in appearance (). Based on our findings as well as the findings of previously published reports on this topic, a benefit of doubt was provided, and it was assumed to be a case of acute trauma, leading to a small fracture of the anterior aspect of the distal tibia.\nAt first consultation, the patient was explained of his diagnosis and offered a conservative treatment protocol that included a compression bandage and anti-inflammatory medication. Since this had minimal effect on his symptoms, he was placed in a plaster cast for period of 6 weeks thereafter. Following removal of the cast, the patient’s symptoms re-occurred, and at that point, he had been on a conservative treatment regimen for almost 10 months with no significant clinical benefit. Based on this, it was considered that this might be a case of differential diagnosis, with the possibility of it being the case of a symptomatic Os subtibiale. At that stage, a surgery appeared to be the best option to help this patient with his symptoms. It was noted that intraoperatively, this surgery may involve either fixation of the bone fragment if it was deemed to be a fracture, or removal of the same if it appeared to be an Os subtibiale. The patient was then offered a surgical treatment option to which he consented and agreed to proceed as necessary.\nOn admission to the operating theater, the patient was positioned supine and administered general anesthesia. An upper thigh tourniquet was used on the patient’s right leg in this case. To gain access to the distal tibia, a 4–5 cm anterior mid-line incision over right ankle joint was performed (). The surrounding soft-tissue structures, superficial nerve, and vascular structures were carefully protected and retracted to gain exposure to the distal tibia, which revealed the presence of a smooth and oblong bone fragment attached to the anterior-distal aspect of the medial malleolus, as was observed in the X-ray and CT imaging (). Based on its appearance, and the lack of bony fusion like characteristics with the adjacent distal tibia, this bone fragment was deemed to be an Os subtibiale. In addition, the margins of the distal tibia marked with a surgical marker, without considering the Os subtibiale, gave the appearance of a normal medial malleolus. It was also observed that it was pressing directly on the deltoid ligament, which explained the on-going pain that the patient experienced while walking. The deltoid ligament was released and the Os subtibiale was then surgically excised using a small 3 mm osteotome and a small bone rongeur. It was measured to be approximately 2 × 11 × cm3 in size (). Following excision, the surrounding bone and soft-tissue structures were carefully examined to ensure that there were no other anatomical bone or soft tissues abnormalities that could be contributing to the patient’s symptoms. On confirmation, the surgical area was thoroughly irrigated with saline, and standard surgical procedures were used to close the incision in a layer by layer fashion. A standard surgical dressing was applied over the operated site, and the foot was placed in a heavy compressive bandage for the next 2 weeks. This was followed by ankle mobilization and stretching exercises as tolerated by the patient. At his latest follow-up of 18 months, the patient reported to be pain free and displayed normal range of motion at the ankle joint compared to his non-operated, contra-lateral left foot. He also consented to participating in this study. |
We report the case of a 52-year-old female who was referred to the surgical hepatobiliary team for assessment of a focal liver lesion found on a routine follow-up CT.\nIn 1975 (aged 15) the patient was diagnosed with an adenoid cystic carcinoma of the left submandibular gland. The primary lesion was excised followed by adjuvant chemotherapy and radiotherapy. Initial follow-up was for 10 years before discharge. In 2008 she represented with a lump at the left angle of mandible. A fine needle aspiration was suggestive of either benign pleomorphic salivary adenoma or recurrent ACC. A multidisciplinary team decision was made to treat the lesion conservatively. In 2010 the lesion had increased in size and a left total parotidectomy was attempted. Unfortunately, previous surgery and radiotherapy meant that only the superficial gland could be removed safely. Histological examination confirmed recurrence of salivary gland ACC.\nA routine follow-up CT in February 2013 demonstrated a focal liver lesion that was suspicious of metastasis. No other metastases were found on further CT scans of the brain, head, neck, and chest. An MRI of the liver confirmed the presence of a solitary lesion (see ). A biopsy of the lesion confirmed the histological appearance of a metastatic adenoid cystic carcinoma that was of identical morphology to the parotid tumour excised in 2010. This had been performed prior to the patient being referred to our unit.\nThe patient was otherwise medically fit and did not have any other significant medical history. She did not take any regular medications.\nIn June 2013 the patient underwent a nonanatomical segment V liver resection and cholecystectomy. The resected tumour measured 25 × 15 × 25 mm and demonstrated a 7 mm hepatic resection margin. The tumour was completely excised. No perineural, lymphatic, or vascular invasion was identified (). The patient made an uncomplicated postoperative recovery and was discharged home.\nA 6-month follow-up CT of the neck/chest/abdomen and pelvis was performed as part of her follow-up. This did not demonstrate disease recurrence (see Figures and ). |
A 58 year-old man in good health presented with a wart on the volar surface of the long finger of his left hand for eight months. A dermatologist recommended a new ointment containing formic acid (FA), accessible without medical prescription and authorized for use in children. This topical chemical agent was to be applied on the wart with a cotton bud, two to three times during the first week of treatment and then once a week until complete disappearance of the wart.\nUnfortunately the patient did not read the enclosed notice and applied the product to the wart for six continuous hours during the night with use of an occlusive dressing. He was awoken during the night by pain and removed the ointment. In the morning he noted a non-painful skin lesion and two days later presented to the emergency department of our hospital. He had a third degree chemical burn of the ulnar volar side of the first phalanx of the long finger with loss of sensibility on this side of the digit. This lesion presented as a dry skin necrosis of 1.8 cm in diameter with peripheral inflammation without signs of infection (Figure ). Two point discrimination of the ulnar side of the fingertip couldn’t be perceived (>14 mm).\nUnder local anesthesia the entire skin thickness along with part of the subcutaneous tissue was excised and the wound left to undergo controlled scaring (Figure ). During the next weeks the wound became atonic in its center and epithelialization started at the periphery. A flexion contracture of approximately 20° of the proximal interphalangeal (PIP) joint was observed during the scaring process. A second debridement of the subcutaneous tissue was done. The digital canal was intact but the ulnar collateral nerve was found to be exposed. Granulation was then observed during the next few days, and the wound was closed after 58 days of controlled scaring (Figure ). We decided against skin grafting to improve the aesthetic result and the wound appeared not deep enough to consider a local flap. Complete extension of the PIP joint recovered with use of a 3-point digital splint. Sensibility remained impaired at a 6 month follow-up, with neuropathic pain (tingling, stiffness, numbness) according to the pain questionnaire of Saint-Antoine (French equivalent of the McGill pain questionnaire from Melzack) (Melzack ). The assessment of axonal injury was positive: Pressure threshold 1.5 g, 2 point discrimination test 18 mm (normal 2 mm), and vibration threshold 0.220 mm (normal 0.010 mm) (Figure ). |
A forty-year-old G3, now P2012, underwent a spontaneous vaginal birth after cesarean section presented to labor and delivery in active labor at term. The patient delivered a viable female infant weighing 3757 grams with APGARs of 8 and 9 at 1 minute and 5 minutes, respectively. Following spontaneous delivery of the placenta, the fundus was noted to be slightly prolapsed through the internal os. A fourth degree laceration occurred at the time of delivery due to the emergent maneuvers utilized to replace the uterus. Brisk vaginal bleeding was noted and 500 cc of blood clot was removed the uterus. Given the patient's inability to tolerate the exam, 1000 mcg of cytotec was placed rectally and the patient was moved to the operating room where general anesthesia was administered. Manual exploration of the uterus was again performed and an additional 1000 cc of blood clot was removed and an anterior fibroid with partial prolapse of the uterus was noted. The fundus was manually replaced superiorly and attention was then turned to the 4th degree laceration which was repaired in standard fashion without complication. Following the 4th degree repair, the uterus was noted to be atonic again and uterine massage and manipulation elicited an additional 500 cc of blood clot. The patient was given two doses of hemabate 250 mcg and the uterus was noted to be firm and hemostasis was confirmed. Total blood loss at the time of delivery was estimated to be 4.5 liters and the patient received 8 units of packed red blood cells (pRBCs) and 4 units of fresh frozen plasma. The postpartum course was uncomplicated and she was discharged home on postpartum day three.\nAt seven weeks postpartum the patient presented to the local health department with complaints of persistent vaginal bleeding since delivery. Upon speculum exam, she was noted to have a 5 cm prolapsed vaginal fibroid and was referred to the local tertiary center. Initial gynecology exam confirmed a prolapsing vaginal fibroid and she was consented for a vaginal myomectomy, possible hysterectomy and blood.\nExamination under general anesthesia was performed in which rectal and bimanual examination revealed the presence of a uterine inversion (Figures and ). Vaginal attempts to evert the uterus were unsuccessful due to a tight ring of tissue noted at the cervix. The anterior compartment of the peritoneal cavity was then entered bluntly, secondary to necrotic tissue. A compression defect was noted on the posterior wall of the bladder likely secondary to the prolonged mass effect of the uterus within the vagina. Bilateral ureteral stents were then placed due to the concern for the location of the ureters. A vaginal hysterectomy was then performed. Due to complete uterine prolapse, the uterosacral ligament, cardinal ligament, and the uterine artery pedicle were clamped, incised, and suture ligated in a single pass. Good hemostasis was confirmed and closure of the vaginal cuff was then performed. A cystoscopy was performed at the end of the case which confirmed patent and functioning ureters and an intact bladder. Estimated blood loss was 600 cc and the patient received 2 liters of crystalloids, 1 unit pRBCs with pre- and postoperative hematocrit of 32.1 and 26.7, respectively. Pathology of the uterus showed degenerating endometrium with stromal bleeding and intramural leiomyoma with severe ischemic changes. The patient was discharged on postoperative day one in stable condition and was doing well at her six-week postoperative visit. |
A 39-year-old woman was transferred to our hospital after being found unconscious at home. She was confused, but was able to give a history of left-sided weakness with decreased use of her left hand and difficulty bearing weight on her left leg that had begun abruptly 3 days prior to presentation.\nShe had had one prior outside hospital admission 1 year earlier for a left middle cerebral artery stroke that presented with expressive aphasia and right arm and leg weakness. Limited MRI at that time revealed 2 areas of restricted diffusion in the left parietal lobe with increased FLAIR signal and associated cortical/subcortical enhancement. Axial T1-weighted images showed the absence of a flow void in the left internal carotid artery, while the right internal carotid artery appeared patent based on the presence of a normal flow void. Imaging showed no evidence of dissection. The patient underwent stereotactic biopsy of the left parietal lesion to rule out a neoplasm. The results showed nonspecific necrotic changes and no evidence of a neoplasm. She was discharged to inpatient rehabilitation, and over the subsequent months her speech and motor function completely recovered.\nThree years prior to her current presentation, the patient had had a miscarriage at 12 weeks’ gestation. Her history was also significant for intravenous methamphetamine use, ending 13 years prior to presentation, and an 18 pack-year smoking history. She had no history of head or neck trauma. She did not have hypertension, diabetes, or hyperlipidemia. She did not use birth control pills and did not have a history of deep venous thrombosis or pulmonary embolism. Her family history was remarkable for systemic lupus erythematosus in her father and a brother who was diagnosed with thrombotic thrombocytopenia purpura.\nOn examination, her blood pressure was 126/80 mm Hg, and her heart rate was 91 beats/min and regular. There was no cardiac murmur. She was alert and oriented to person, but not place, time, or situation. She was able to follow simple commands, but was slow to respond. Her speech was fluent, with intact repetition and naming and without aphasia or dysarthria. Cranial nerve examination was significant for a left homonymous hemianopsia and left lower facial weakness. Her motor exam revealed left hemiparesis, left hyperreflexia, and a left Babinski sign. She had intact sensation of light touch bilaterally, but extinction on the left with double simultaneous stimuli. Movements were slow on the left side, but there was no ataxia. Gait was not assessed.\nAbnormal coagulation studies included a prolonged activated partial thromboplastin time at 42.6 s (normal range 25.1–37.6 s) which did not correct with a 1:1 mix with normal plasma, a thromboplastin inhibition test that was strongly positive for lupus anticoagulant, and a dilute Russell's viper venom test that was prolonged at 64.3 s (normal 29–46 s) which corrected with the addition of phospholipids. Other coagulation studies, which included anticardiolipin and anti-β2 glycoprotein antibodies, were within normal limits. Erythrocyte sedimentation rate (55 mm/h) and C-reactive protein (5.7 mg/l) were moderately elevated, and the antinuclear antibody assay was elevated at 1:160. Anti-dsDNA was negative. Other studies were normal or negative, including complete blood count, platelet count, renal, liver, and thyroid functions, hemoglobin A1c, and LDL cholesterol. Electrocardiogram and transthoracic echocardiogram were normal.\nA CT scan showed areas of evolving infarction in the right anterior and middle cerebral artery distributions. CT angiography showed bilateral internal carotid artery occlusions extending from the level of the bifurcation to the supraclinoid segments. MRI showed areas of acute infarction within the right middle cerebral artery-anterior cerebral artery watershed territory and chronic infarcts in the left middle cerebral artery-anterior cerebral artery watershed territory (fig. ).\nConventional angiography confirmed bilateral internal carotid artery occlusions in the proximal cervical segments, with reconstitution of the carotid arteries at the supraclinoid segments via the ethmoidal branches of the distal internal maxillary arteries and the ophthalmic arteries (fig. ). Posterior communicating arteries were present bilaterally. The posterior circulation was normal, with extensive collaterals to the anterior circulation via the posterior communicating arteries. No abnormalities concerning for vasculopathy or dissection were noted in the aortic arch or in the carotid, vertebral, subclavian, renal, or femoral arteries. |
We report a case of a 46 year-old female patient, with a cataract on her right eye with a central corneal leukoma. Patient reported during one of the examination prior to the surgery that when she was 6 years old, patient had an eye injury with corn leaf. At the age of 10 year patient reported that she had another injury of the same eye with a glass. Patient also said that she wasn’t seeing quite well after that. Patient reported that she wasn’t under any medical therapy or that she was wearing contact lenses or glasses. Three years ago patient had a transplantation of amniotic membrane due ulcer on the same eye in different hospital then ours. Now she was admitted to hospital for a triple surgical procedure.\nOcular examination on admission day to hospital revealed patients best uncorrected distance visual acuity (UDVA) to be light perception on patient RE (right eye) and 1.0 with out any correction LE (left eye). Results on patient slit lamp revealed on the right eye corneal edema with a central leukoma, with a complicated cataract and partial seclusion of pupil and no pathological findings on left eye. Patients pupil size were equals. Patient ocular movements were normal in all gazes. Intraocular pressure (IOP) was also normal. Examination of the left eye was normal. The vitreous was quiet and retinal vessels were of normal caliber. Details on the founds of right eye were impossible to asses due the changes in anterior segment. We performed ultrasound examination and we performed intraocular lens calculation. Due pathological changes on the right eye we were unable to accurately measure the true corneal power values so we performed intraocular lens calculation for the left eye. Before the surgical procedure patient was treated with Prednisone 80 mg intravenous and as well systematic antibiotics with local corticosteroids and antibiotics (). The pupil was dilated preoperatively with tropicamide 1% eye drops. Before surgical procedure a good quality donor cornea was retrieved from a cadaveric transplantation.\nAfter informed consent was obtained, operation was performed in general anesthesia. After excision of the opaque recipient cornea, a cataract was seen. Before the staining of anterior capsule, surgeon performed excision of pupillary membrane and synechiolysis. The anterior capsule was initially stained with VisionBlue (Dutch Ophthalmic, USA). Cataract extraction with IOL implantation (open sky) was performed under operating microscopes Operative Microscope OPMI Visu 150 Carl Zeiss Meditec Inc, Dublin, using Alcon Infiniti® Vision System Fort Worth Texas USA, sodium hyaluronate (Provisc® Alcon) as viscoelastic and surgical instruments Alcon and Geuder AG Heidelberg Germany. After placing four cardinal sutures, the donor button was fixed to the recipient using separate 10/0 nylon sutures. (). Follow-up examinations were performed on days 1, 3, 7, and 30 days. Thirty days after surgery her UDVA was 0,5. The patients received topical antibiotic and corticosteroids. Postoperatively, if keratometric astigmatism exceeded 4.0 D, tension of the running sutures was adjusted after 1 to 2 months, and selective removal of separate sutures began after 2 months. Currently patients visual acuity is 0.6 without correction. |
A 49 year old woman presented with jaw and arm pain to her local Emergency Department. She had the pain since the previous evening, approximately 14 hours, and had initially presented to her dentist before being redirected. Cardiac risk factors included hypertension, smoking and a positive family history of ischaemic heart disease in her father. The ECG showed anterolateral ST elevation and because of this and ongoing pain, she was thrombolysed with retaplase despite the late presentation. At 90 minutes the ECG changes and pain had not resolved and therefore she was transferred to our tertiary centre for rescue angioplasty. The left anterior descending artery (LAD) was occluded with a large thrombus load. The LAD was successfully opened and a Vision 3.5 × 15 mm bare metal stent was deployed, the procedure was covered with heparin and abciximab and an intra-aortic balloon pump. There was moderate circumflex and right coronary artery disease which was not intervened upon. Cardiac enzymes were elevated with peak CK of >4000 iu/L and troponin I of 98 μg/L. A transthoracic echocardiogram the following day showed a mildly dilated left ventricle (LV) with mild hypertrophy. The anterolateral wall was akinetic with moderate to severely impaired LV function. There was no significant valvular disease and a 1 cm pericardial effusion around the posterior, inferior and lateral walls and right heart with no haemodynamic compromise. Her recovery was complicated by low-grade pyrexia and raised inflammatory markers, peak CRP 321 mg/L. Blood, urine and sputum cultures were negative however she was treated empirically for a chest infection with doxycycline. An episode of hypoxia and chest pain without gross changes on chest radiograph resulted in a CT pulmonary angiogram which did not show any evidence of pulmonary embolism but some basal atelectasis. Two weeks after admission she was asymptomatic. Prior to discharge an exercise tolerance test was arranged to assess for ischaemia in view of the moderate untreated coronary disease. She completed 6 minutes of the Bruce protocol achieving 85% of her maximal predicted heart rate, there was no pain but mild ST depression inferiorly. The test was submaximal but did not show gross ischaemia. In view of this she was discharged home with a plan for outpatient myocardial perfusion imaging.\nShe attended for a CMR stress perfusion study 5 weeks after her initial infarct. At this point she did not report any symptoms. The LV was moderately dilated with an akinetic anteroseptal wall (Additional files and ). LGE images demonstrated extensive transmural anteroseptal and apical myocardial infarction (Figure ). There was moderate functional mitral regurgitation. Stress perfusion did not demonstrate any reversible ischaemia. LGE images also showed striking global pericardial inflammation (Figure ). There was no obvious pericardial thickening demonstrable on long axis (Figure ) or short axis imaging (Figure ). |
A 41-year-old Asian man was transferred to the Center of Trauma Surgery in our hospital 6 hours after injury for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of a blasting cap. Hemostasis of the wound was achieved by applying pressure and a total of 2500 ml Ringer's solution, which is a kind of balanced salt solution, was given intravenously during the emergency. He was mildly obese, described himself as quite heathy, and had never been admitted to a hospital previously. He reported no chronic medical history, such as primary hypertension, heart disease, diabetes mellitus, an impaired immune system, malignancies, liver cirrhosis, renal failure, or hemodialysis. He also reported no history of infectious disease, such as tuberculosis, any types of hepatitis, or acquired immunodeficiency syndrome (AIDS). His medical history revealed no trauma, blood transfusion, other surgical procedures, or other serious event. He had not lived in an epidemic area and had no contact history of radioactive exposure. He denied any family history of inherited diseases. He usually did not smoke tobacco or consume alcohol and had no other unhealthy behaviors. He was a business executive and he often traveled for business.\nHis blood pressure at admission was 99/50 mmHg, pulse rate was 102 beats per minutes, and his respiratory rate was 21 breaths per minute. On examination, his mucous membrane was dry and his conjunctivae were pale. No positive signs were found during neurological, cardiopulmonary, and abdominal examinations. There was no pain around the kidney area with percussion or tenderness along the bilateral ureteral approach.\nA specialized examination revealed that the wounds were located on his right gluteal and were approximately 40 cm × 35 cm in size with a darkened appearance. The margins of the wounds were 2 cm above the bottom of iliac crest, inferior to the superior segment of back side of his thigh, 3 cm interior of the anal cleft, and external to the lateral thigh (as shown in Fig. ). The wound had hemorrhaged and contained scattered metallic foreign bodies. Most of his gluteus maximus muscle was injured and the motion of his right hip joint was limited.\nIn addition, related laboratory examinations were conducted. His complete blood count values were as follows: white blood cell count of 10,940 cells/uL, red blood cell count of 3,250,000 cells/uL, hemoglobin of 9.8 g/dL, and platelet count of 153,000 cells/uL. D-Dimer was 5678μg/L. His total protein was 45.7 g/L, among which the albumin and globulin content were 21 g/L and 24.7 g/L, respectively. The results of serology for renal function were normal. Blood and aerobic and anaerobic bacterial cultures were performed. Microorganisms were not found in the blood cultures. The secretions from injured tissue revealed that a little of the Gram-positive bacteria, Bacillus subtilis, was detected. A diagnosis of explosion injury in left gluteal region and hemorrhagic shock was made.\nHe underwent aggressive fluid administration, hemodynamic support, and intravenously administered antibiotic therapy. Debridement of his right gluteal was carried out 6 hours after the explosion under general anesthesia. Then, the wound was sutured with VSD and adhesive membrane, which finally was connected to negative pressure drainage equipment. During the operation, 800 ml erythrocytes and 400 ml plasma were infused into our patient. Three days after the first operation, he underwent a second operation. The necrotic muscles were excised and then the wound was closed with interrupted suture to shorten the defect to 12 cm × 40 cm (as shown in Fig. ). The VSD was also connected to the wound as described above.\nNine days after the second treatment, although a few scattered necrotic muscles were located in the wound, the granulation tissues were growing well. The skin around the wound was healthy, with only mild edema and migrated to the wound margins. The pinch test demonstrated that the skin had some mobility, which indicated that it could be sufficiently stretched. Under general anesthesia, the skin margins were minimally free to facilitate the insertion of intradermal needles on both sides of the wound. The wound itself was left undisturbed. Three SSDs (Life Medical Sciences, Inc., Princeton, NJ) were inspected every few hours. The healthy skin was stretched for 4 minutes, followed by 1 minute of relaxation. After stress relaxation had occurred, the tension was adjusted to 3 kg, as indicated by the tension gauge (as shown in Fig. ).\nThis procedure was repeated five times during the operation until the skin reached approximation to the wound margins. Then, the devices and the intradermal needles were removed from our patient. During this process, the granulation tissues looked good, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing to reduce the size of the defect to 5 cm × 38 cm (as shown in Fig. ). After stretching treatment, the VSD was applied again to close the wound as before.\nAfter 9 days, the size of the wound had decreased to 4.5 cm × 35 cm (as shown in Fig. ). The SSD was then applied again as before. During the last operation, the wound was thoroughly irrigated, and the stretched skin margins were closed with interrupted suturing (as shown in Fig. ). Eighteen days after this operation, there were only two small wounds that were approximately 1.0 cm × 0.8 cm without edema or inflammation. The local granulation was healthy (as shown in Fig. ). At that time, our patient was ambulatory. Although he had been in hospital for over 1 month, there was no evidence of damage to the skin margins. The timeline of the patient’s treatment is shown in Table .\nAt 3 months postoperatively the wound was healing perfectly and our patient could walk freely and do some suitable exercise. At 6 months postoperatively, he returned to business work as usual. |
A 23-year-old woman had presented with acute onset of shortness of breath. The chest radiograph findings were normal. However, contrast-enhanced computed tomography revealed a pulmonary embolism and deep vein thrombosis caused by the right posterior tibial vein aneurysm. Leg swelling and pain were not observed. No obvious right ventricular dysfunction was noted, and the pulmonary embolism was peripheral. However, the patient had presented with hypoxia and required oxygenation. Anticoagulant therapy was started, which resulted in the dissolution of the pulmonary artery embolus and posterior tibial vein thrombus. She was discharged with direct oral anticoagulant therapy (edoxaban, 60 mg/day). No venous thrombosis recurrence was noted. No history of leg trauma or injury was noted. The test results for thrombophilia and any autoimmune vascular collagen disorders were negative. Eight months later, the patient decided to undergo surgery. Ultrasound revealed a posterior tibial vein aneurysm without thrombosis. Contrast-enhanced computed tomography and magnetic resonance imaging revealed a posterior tibial vein aneurysm with no embolus in the pulmonary arteries or thrombus in the deep veins, including the posterior tibial vein aneurysm ( and ). The aneurysm was believed to be complex because the distal portion appeared to be multilocular and not a simple fusiform or saccular aneurysm. Preoperative venography demonstrated a posterior tibial vein aneurysm that had another communication with the venous circulation (). With the patient under general anesthesia, an incision was made along the medial side of the right lower extremity, and the posterior tibial vein was exposed. We had initially planned tangential aneurysmectomy and lateral venorrhaphy to reconstruct the venous communication. However, it was difficult to expose the entire venous aneurysm because of the presence of severe adhesions. We first controlled the inflow and outflow of blood to and from the venous aneurysm by clamping the respective vessels. Next, venography was performed intraoperatively (). We identified a collateral pathway connecting the distal and proximal ends of the posterior tibial vein through which the blood was transported to the venous circulation, bypassing the aneurysm. Thus, we ligated the inflow and outflow vessels of the venous aneurysm. Venography did not show any collateral veins arising from the venous aneurysm. After surgery, right lower extremity edema was not observed. Postoperative ultrasound demonstrated complete thrombosis of the posterior tibial vein aneurysm, and no thrombus was found in the other deep veins. |
A 59-year-old Caucasian female presented in April 2008 for a consultation. She had a history of osteopenia and had been treated with alendronate (Fosamax) for 3 years. Until recently, her history of dental treatment had been uncomplicated. Her third molars had been extracted and four of her permanent teeth had been restored with amalgams. Throughout her life, she had visited her general dentist for semiannual recall appointments. Her dental hygienist and dentist had recently detected periodontal pockets around her maxillary and mandibular right molars. They referred her to a periodontist, who recommended extraction of teeth 17 and 47 (FDI) and possible surgical treatment of the upper left molars. Since she had a history of bisphosphonate use, she was concerned about the potential for development of osteonecrosis of the jaw (ONJ) after the extractions []. This motivated her to seek a second opinion to explore options for nonsurgical treatment.\nThe patient brought duplicates of periapical radiographs that had been obtained one month earlier by her general dentist. The radiographs revealed the presence of moderate periodontal bone loss around teeth 17 and 16 and early to moderate periodontal bone loss around 27 and on the distal aspect of 37 (not shown). There was severe periodontal bone loss on the distal aspect of 47, which had a pronounced root dilaceration (). In addition, there was a radiopaque mass associated with the distal aspect of 47, near the level of the cementoenamel junction. The size and shape of this mass suggested that it was either calculus or a fragment of a third molar root. The patient's oral hygiene was good and clinical signs of inflammation around the premolars and anterior teeth were minimal. However, there were probing depths of 5 to 6 mm on the mesial aspect of 17 and the distal aspect of 16 and probing depths of 7 mm on the direct palatal and distopalatal aspects of 27. Tooth 47 had 5 mm depths on its distofacial and direct lingual aspects and a 10 mm depth on the distolingual. While all of these sites exhibited bleeding on probing, the distal and direct lingual aspects of 47 were the most clinically inflamed. To help determine the identity of the distal radiopaque mass, we requested all available radiographs from dentists who had previously treated the patient.\nA bitewing film of the right molars taken 13 years earlier provided evidence that the radiopaque mass distal to 47 was calculus (). At that time, the calculus deposit was considerably smaller and there were signs of early retromolar bone loss. The calculus deposit enlarged during the next two years, but there was no evidence that bone loss progressed (). During the following two-year period, there was further enlargement of the calculus and progression to a moderate degree of bone loss distal to tooth 47 (). In a periapical radiograph taken 2.5 years later (6 years prior to the initial consultation), the calculus appeared to have increased in size and distal bone loss had progressed (). A bitewing film obtained 1.5 years later suggested that the calculus had not enlarged significantly since the previous radiograph but was not useful for monitoring changes in the degree of bone loss ().\nBased on the radiographic and clinical findings and the patient's concerns about ONJ, a nonsurgical treatment plan was developed to address the patient's localized severe chronic periodontitis. There was concern about the potential for morbidity related to extraction of 17 and 47, since the roots of 47 were dilacerated. Teeth 17, 16, 27, and 37 were scaled and root planed with curettes and an ultrasonic scaler, followed by adjunctive treatment with a five-day course of systemic azithromycin. Azithromycin was prescribed to help enhance attachment gain and improve the odds of avoiding periosteum-exposing periodontal surgery. The patient was instructed to use an end-tuft brush to remove plaque from her second molars. In the event this initial treatment failed to reduce probing depths and inflammation in an acceptable manner, there was a contingency plan that included localized periodontal surgery.\nAt the reevaluation appointment five weeks later, the patient presented with a high standard of oral hygiene. There were no sites that bled upon probing or had probing depths greater than 4 mm. The 4 mm probing depths were associated with the distolingual aspect of 27 and the distofacial and distolingual aspect of 47. Given these findings, surgical treatment was not indicated. The patient was scheduled for periodontal maintenance therapy every three months after completion of active treatment. Periodontal probing depths were recorded at the 12-month and 24-month maintenance appointments. The patient's periodontal probing depths and bleeding upon probing were essentially unchanged at these visits. A follow-up radiograph taken at the 24-month recall confirmed that tooth 47 was free of visible calculus deposits and provided evidence of increased density of the bone on the distal aspect of 47 (). |
A 39-year-old man was admitted to urology department of our hospital, who had been suffering from recurrent periumbilical pain and persistent urinary tract infection. He also complained about foul smell of his urine. He had a history of acute right abdominal pain for a couple of days nearly 10 years ago but he did not receive any medical or surgical treatment. On physical examination, mild abdominal tenderness at lower quadrants was noted. Routine blood counts and biochemical analyses indicated the presence of an inflammatory condition (WBC: 13200/mm3 and CRP: 35). Urine analysis showed fecal content and increased number of bacteria accompanied with elevated WBC count in the urine sample, which suggested a possible enterovesical fistula. USG examination revealed mildly increased bladder wall thickness and accumulating sediments at the base of bladder. Appendix could not be visualized, but intraperitoneal fat planes around caecum showed increased echogenicity which suggested an inflammatory process. Ultrasound also revealed heterogeneous fluid collection which located lateral to the anterior aspect of the urinary bladder. Prostate and distal portions of the ureters were normal. We obtained an oral contrast CT scan to elucidate the underlying reason. CT examination demonstrated collection of fluid extending from the right anterolateral border of the bladder to the caecum. Outer diameter of the appendix exceeded normal limits (measured approximately 9 mm) and appendix was attached to the right anterolateral part of the bladder. Additionally, hyperdense fecalith image was seen in the distal portion of appendix; also there were 2 cm calculi in bladder (). But our CT scan was not optimal for detection of possible fistula because bladder was not fully filled during CT scan. Although CT scan is the gold standard method for diagnosis of AVF, to avoid excessive radiation exposure to our patient, MRI was performed with full bladder to see fistula tract and confirm our prediagnosis. In MRI, appendix was attached to the right anterolateral part of the bladder, and a 2 cm calculus was detected in the posteroinferior part of the bladder. MRI also showed T2-weighted hypointense air bubbles which was identified in anterosuperior part of the bladder due to gravity and these findings in MRI highly suggested a possible AVF (). To confirm the prediagnosis of AVF, the patient was referred to the urology department for cystoscopy. Cystoscopy revealed 2 cm diameter of calculi in bladder and also slit opening of fistula tract at the right lateral wall of bladder.\nAppendectomy, surgical repair of bladder and catheter drainage of the area were the preferred definitive treatment for the patient (). |
A 9 year old girl presented in the surgical outpatient department with history of a progressive swelling over right scapular region for the last three years. Swelling started as a small lump that increased in size during last six months. Swelling was not associated with fever, malaise and fatigue. There was no history of exposure to any carcinogenic agent or radiation. Past history was not significant. It was her school teacher who asked her parents to seek medical advise for the swelling, as she was facing difficulty in writing.\nThe general examination of the child was normal. Local examination revealed a globular non tender swelling over the right scapular region, measuring 40x36x38 cm, having firm to hard consistency. It was mobile with well defined margins and not attached to deeper structures. Overlying skin was mobile, shiny with multiple visible vessels and a small ulcer noted in the center of the swelling (Fig. ). There was no neurovascular deficit distal to the tumour.\nBlood complete picture revealed mild anemia. Other blood tests including renal function test, liver function test, and serum calcium and serum alkaline phosphatase were within normal limits. X-ray and CT scan of the scapular region showed soft tissue swelling without any bony involvement (Fig. , ). Fine needle aspiration suggested malignant soft tissue tumour. Incisional biopsy confirmed the diagnosis of ES. The lesion was excised and residual defect was left as such with a plan skin grafting at a later stage. The recovery was smooth and patient was discharged on fifth postoperative day. Histopathology confirmed the diagnosis of ES. All resection margins were free of tumour. Immunohistochemistry was not done. She did not report back for follow up. After three months of surgery she attended the surgical outpatient department with almost healed wound (Fig. ). She was referred to oncologist for chemotherapy. She received VAC regimen (vincristine, adriamycin and cyclophosphamide), repeated every 3 weeks for 6 cycles and local radiotherapy was also given to the excised area. The patient responded well to treatment and has not shown any recurrence after two years of follow up. |
In September 2008, a 43-year-old woman presented to the Emergency Department at Frenchay Hospital with a 3-month history of back pain, right hip and knee pain, right leg weakness, constipation and urine incontinence, altered sensation in the limbs, and visual disturbance with flashing lights in the left eye. Two weeks prior to this admission she was seen at Frenchay Hospital with cauda equina symptoms. She has had an MRI of the spine, which showed a disc prolapse but did not explain the symptoms. The patient was discharged. However, her pain continued to worsen, and sensation changes progressed across the whole of the perianal region. She was unable to sit down for 8 weeks due to pain on flexion and started using a stick as her right leg was weak.\nOn examination she had a decreased sensation in the perianal area. Neurological examination of the upper limbs revealed a slight numbness of the radial side of the forearm. Neurological examination of the lower limbs revealed the following: reduced power in the right hip flexion (1/5) and extension (2/5), the power in the left leg was 4/5, absent reflexes in both legs, reduced sensation in the right medial aspect of the distal right calf dorsum of the foot sole and the lateral dorsum of the left foot and the sole of the left foot. On examination of her visual fields, she demonstrated a loss of outer vision in her left eye.\nCT and MRI of the head showed metastases in the right parietal occipital region, together with some smaller metastases associated with the dura and skull base (fig ). MRI of the spine revealed fairly diffuse infiltrating nodules in the nerve roots of the lumbosacral plexus. Her performance status was 3 due to progressive leg weakness.\nThe diagnosis was meningeal carcinomatosis with brain metastasis from breast cancer. No other signs of metastatic breast cancer were seen on CT at this point.\nA year prior to presentation, she had been diagnosed with 4 × 3 cm grade 3 triple-negative invasive ductal carcinoma treated with 6 cycles of neoadjuvant TAC chemotherapy followed by wide local excision and axillary node clearance. None of the 10 lymph nodes showed viable cancer. She had also completed radiotherapy to her left breast in May 2008.\nThe patient was transferred to our centre and started on inpatient IT methotrexate 12.5 mg with oral capecitabine. The first 4 cycles of IT methotrexate were administered twice weekly due to deteriorating symptoms, as her left leg become weak as well. Her vision improved after 1 cycle of treatment. Other neurological symptoms improved after 3 cycles. From that point on she received weekly IT methotrexate. The 6th cycle was delayed by a week due to urosepsis and opioid toxicity. Cerebrospinal fluid was sent for analysis by cytospin before each IT treatment. She was discharged on capecitabine (1 week on and 1 week off at a 75% dose) before cycle 7 of IT methotrexate. A further cycle of IT methotrexate was not given as she was readmitted with pyrexia and pain in her lower abdomen, perianal area, and shouting/burning pains down the leg. She did not require any antibiotics, and the pain was controlled with analgesia. Her symptoms improved and she received cycle 8 of IT methotrexate as inpatient. In total, she received 8 cycles of IT methotrexate, and her neurological symptoms have improved.\nMalignant cells were still present in the cerebrospinal fluid. MRI of the head and spine after IT chemotherapy combined with capecitabine showed good response to therapy with disappearance of some of the smaller metastatic lesions and a significant reduction in the size of the larger lesions in the brain, but the spine lesions within the theca were more prominent, suggesting progressive disease.\nShe was referred for craniospinal radiotherapy and started 10 days after her last IT treatment. She received 36 Gy in 20 fractions over 4 weeks. MRI of the head/spine after radiotherapy showed significant improvement in the appearances of both intracerebral and ependymal metastases.\nIn April 2009, MRI of the head showed further involution of cerebral metastases. The posterior fossa and right frontal metastases were essentially invisible, while the right occipital metastases in the lobe showed further involution. There was no convincing focal meningeal mass. She was treated with carboplatin 6 months after completion of craniospinal radiotherapy to prevent recurrence of meningeal disease. She completed 4 cycles of carboplatin between 21/05/2009 and 10/09/2009.\nIn 2011, she had recurrent solitary right occipital metastasis, which was treated with stereotactic radiotherapy.\nIn 2012, MRI showed increasing occipital abnormality with oedema, which was surgically excised and proved to be radiation necrosis only, with no viable tumour.\nIn 2013, MRI showed no new disease, only post-surgical changes (fig ).\nIt has been 8 years since she first presented with neurological symptoms. Currently, the patient is in complete clinical and radiological remission and has recently been discharged from our clinic. |
The patient, a male 46 years old at the time of our visit, underwent surgical resection of nasal pyramid and premaxilla including the whole upper jaw teeth sparing nasal bones. When the patient came to our clinic, apart from the defect resulting from the resection, he presented with a retraction scar crossing the upper lip from the floor of the nasal defect through the filtrum. The surgical resection was performed in another clinic the previous year, and since then, the patient experienced a severe decrease in the quality of social life including the loss of job and falling into reactive depression. The histological aspect of the neoplasia was characterized by high malignancy and contraindicated a microvascular flap reconstruction in order to allow the inspection of the nasal cavity and the facial skin nearby the nasal defect during follow-up appointments.\nFurthermore, the conspicuous defect and the different kind of tissues needed would have required multiple donor sites, making the achievement of a good aesthetic and functional result quite challenging. Insofar, due to the entity of the defect, the uncertain outcome of the surgical reconstruction, time-costing evaluation and follow-up need, the patient was proposed to undergo zygoma-implant-supported prosthetic restorations.\nRadiographic examination was carried out by means of CT scans of the maxillofacial complex. After the evaluation of the residual maxillary bone, insertion of four zygoma implants was planned.\nThe surgical intervention was performed under general anaesthesia. Our surgical treatment started with an incision extended from the palatal aspect of the second molar site to the crestal aspect of the canine site bilaterally, with two posterior release incisions. A full-thickness flap was then elevated, and the anterolateral wall of the maxilla was exposed. An oval-shaped window was first drawn and was then opened trough the upper aspect of the maxillary buttress using a large round diamond bur. These windows are used to check the right direction of the zygomatic fixtures during their insertion trough the zygomatic bone. Once the maxillary buttress has been prepared bilaterally, the zygoma implant insertion could start. The preoperative planning provided the insertion of four zygomatic fixtures (Branemark System Zygoma, Zygoma TiUnite® Implant, Nobel Biocare, Goteborg, Sweden), one through the first molar area and one through the lateral canine area on both sides (Fig. ). The reflected mucoperiosteal flap was then sutured with resorbable suture (Polysorb 4.0, Covidien, Mansfield, MA, USA).\nCortical steroids were administered for the first two postoperative days. A postoperative 10-day cycle of antibiotic therapy (amoxicillin 1000 mg TID) was administered. Analgesics were administered as required. Sutures were removed 15 days after surgery. A soft diet was recommended for the first 2 weeks.\nThree months afterwards, healing abutments were connected (Fig. ) [].\nApproximately 4 weeks after healing abutment connection, intraoral defect including implant abutment and extraoral paranasal defect impressions were taken. The technician managed two different casts: one cast for nasal wax up and one cast for dental wax up. Superior implant bar supported by [] zygoma implants was designed crossing the palatal defect in order to manufacture palatal obturator at a second time. Furthermore, two metal abutments were lodged and fused on the cranial surface of the bar in order to receive epithesis attachments. The abutments acted as primary crowns and secondary crowns, press-fitted on abutments and were used to take an extraoral position impression of the abutments using the nasal wax up as an individual. In this way, the technician could connect OTK (Ball abutment) attachments on the internal surface of the epithesis and thanks to secondary crowns, the nasal prosthesis can be removed for prosthetic aftercare and follow-up inspections. OTK attachments are commonly used because of their retention in overdenture prosthetic rehabilitation. The female part of this peculiar type of ball attachment is made out of Teflon™ (politetrafluoroetilene) while the male part consisted of a titanium structure. A complete implant-supported bar with two bolt prosthesis was made in order to provide superior arch rehabilitation. At the time of delivery, the palatal defect was closed by a soft base material. The nasal epithesis was made of silicone with an acrylic resin internal plate hosting female OTK attachments, whereas male parts were on the secondary crowns.\nThe patient received an implant-supported intra/extraoral rehabilitation with nasal epithesis and overdenture connected at the same metal framework due to the presence of an oronasal iatrogenic communication (Fig. ). The nasal defect was classified into total (soft and hard tissues) rhinectomy. The palatal defect was localized at the premaxilla and was classified into “good” defect (resection margins into hard palate). Following the delivery of the prostheses, the patient showed satisfaction both for aesthetic and functional results and reverted to normal life achieving social integration (Fig. ); he also reduced anxiolithic and antidepressive drug intake according to psychiatric counselling, and he is waiting to gradually stop them definitively. The patient did not receive radiotherapy and was non-smoker, two factors that are known to influence the success of implant therapy. He started an implant and prosthetic aftercare program.\nPatients with advanced orofacial cancer may require extensive surgical resection; the wider and more evident is the amputated region, the more this condition is generating inability for patients []. Visible head site mutilation and functional impairment in speech prevent social reintegration, and abnormal self-perception leads patients to depression [].\nEven if modern surgery offers many techniques for reconstruction such as free flaps and rotation flaps, they are not indicated in all clinical cases. Because of the huge number of surgical sessions often required in reaching the wishing result, the use of local or microvascular flap could not be indicated in case of elderly patients or patients affected by cardiovascular or metabolic diseases. Moreover, a multistep surgical planning is not advisable in the absence of a complete sure compliance of the patient to the treatment []. Furthermore, recipient site complication can occur before and after harvesting or radiotherapy, when required, shall compromise the healing of the flap [].\nNowadays, prosthetic extraoral rehabilitation is effective, less invasive because no additional surgical procedure is required, cosmetically satisfying and leads patients to a precocious social reintroduction. Additionally, intraoral restoration such as palatal obturator may allow speech and swallowing which play a crucial role in the retrieval of social life [, ].\nNasal defects are classified into partial, total and extended rhinectomy referred to soft tissue resection, bone and soft tissue amputation and bone and soft tissue associated to the maxilla or orbital excision [].\nExtraoral defects are usually restored by means of silicon epithesis; intraoral ones necessitate maxillary rehabilitation. In our case, since the premaxilla was lost, no implant insertion in the anterior region was possible. The importance of anterior implant anchorage is well documented even if a higher failure rate than the ones placed in the posterior maxilla is demonstrated [, , ].\nIn palatal cleft iatrogenic defects, implants insertion depends on bone residual amount, alveolar ridge height, radiotherapy and peri-implant soft tissue conditions [, ]. In patients who undergone radical surgery, all these requirements are often unfavourable and zygoma implants represent a valid alternative in offering prosthetic anchorage [, , ].\nAs far as prosthetic design is concerned, it is mandatory to avoid or, if not possible, limit as much as possible distal cantilever: given the absence of the premaxilla, an anterior cantilever is already present. Implant splintage is recommended [, ], and the bar design must respect technical data (implant-to-implant distance, cross-arch stabilization avoiding to cover oronasal communication and shape offering nasal epithesis connection) and clinical requirements (patient’s aftercare, visible inspection for follow-up). One of the most important technical issues is about oronasal communication: if the bar crosses, it is close to the upper lip, no obturator can be manufactured and the lack of vestibular seal may cause nasal flow during beverage swallowing (Fig. ).\nThe combined zygoma-implant-supported prosthesis and nasal epithesis represents a new approach to rehabilitate wide complex midfacial defects. Nasal reconstruction, oroantral communication closure, labial competence correction and dental prosthetic rehabilitation are not commonly corrected by a unique surgical intervention or by a unique prosthetic rehabilitation. The prosthetic rehabilitation here presented allows to achieve all the above-mentioned goals by means of a single prosthesis.\nIntraoral implants offer good anchorage for palatal obturator prosthesis, and extraoral implants’ use to support facial epithesis is well documented. Dawood describes a new implant design to support nasal epithesis and upper jaw prosthesis, but he reports just a single patient treatment []. Bowden reports zygoma implant placement horizontally below orbital floors and nasal prosthesis anchorage, but we managed with combined midfacial and palatal defects [].\nProsthetic aftercare usually requires patient’s instruction about bar and implants’ daily hygienic procedures and silicone nasal epithesis cleaning [, ]. Despite careful home care, silicone facial prosthesis lifespan is 1.5/2 years on average because of discoloration, clip detachment from acrylic to silicone or acrylic carrier detachment to silicone, bad fit or silicone laceration [, ]. Unfavourable events for intraoral prosthesis are screw loosening and bar dislocation or screw fracture, obturator misfitting due to soft tissue remodelling, implant failure and prosthetic teeth fracture or excessive abrasion due to occlusal loss of balance [].\nRethinking globally of the possible indications to the adoption of this technique and its advantages compared to reconstructive microsurgery, the use of zygoma-implant-supported prosthesis may be suitable for patients whose systemic conditions are poor. The duration of surgery and of the postoperative recovery would be remarkably shortened avoiding the complications related to the harvesting of a free flap. Closely related to this aspect, the cost-benefit ratio is definitely more convenient. This technique proves itself to be more easily manageable also in non-compliant patients or in patients with limited prognosis or high risk of recurrence, allowing the clinician a more effective inspection of the resected site during follow-up consults. |
A 93-year-old woman was referred to our outpatient clinic for management of acute corneal perforation in the left eye. She had undergone surgery for pterygium of the left eye at the age of 44 years and was treated with topical MMC postoperatively, although she could not recall the MMC concentration used or the duration of administration. Cataract surgery had also been performed on the left eye at the age of 84 years. She had no history of visual problems or symptoms, and there was also no history of diabetes or collagen diseases including rheumatoid arthritis. One month earlier, she had complained of pain in the left eye and a limbal corneal ulcer had been diagnosed by her primary care physician. She was treated with topical medications, but the ulcer became progressively worse and corneal perforation occurred. At her first visit, best-corrected visual acuity was 20/60 in the right eye and counting fingers in the left eye. The intraocular pressure (IOP) was 19 mmHg on the right and 6 mmHg on the left. Slit lamp examination of the left eye revealed a corneal ulcer near the inferior nasal limbus and collapse of the anterior chamber Fig. (). In addition, the uvea near the limbus showed dome-shaped prolapse under the conjunctiva. Focal stromal scarring from previous cataract surgery was seen in the superior temporal limbus. On the next day, urgent penetrating keratoplasty was performed using a donor cornea together with vitrectomy. The graft was attached to the nasal cornea and sclera of the patient with interrupted 10-0 monofilament nylon sutures. A transfixing suture could not be placed at the site of perforation because of corneal melting and thinning. The conjunctiva had covered the exposed uveal tissue in the region of the inferior nasal scleral defect, so additional scleral patch grafting was not performed. The anterior chamber reformed on the first day after surgery Fig. (). Her postoperative course was uneventful and visual acuity of the affected eye was 20/500 at 12 months after surgery (Figs. -). |
An 80-year-old Chinese Han male with a history of recurrent renal cancer originating approximately 10 years prior was admitted to the present facility presenting a self-reported severe left forearm pain present for approximately 2 weeks. The patient reported treatment for recurrent renal cancer within the past 1–3 years, resulting in no apparent impairment to mobility or joint function. Metastasis of cancer tissue had previously been extensively observed in the patient, including brain metastasis treated with Gamma Knife procedures three times over the previous 7 years, as well as lung metastasis (Figure ) first observed 5 years prior to the appearance of the currently described ulnar metastasis. Additionally, the patient had been previously advised to initiate chemotherapeutic treatment for lung and brain metastasis, but refused treatment based on the impact on his quality of life and independent living status. The patient was thus able to remain in independent living conditions with no in-home support or care prior to admission.\nFollowing admission, the patient exhibited no abnormal vital signs. Specifically, no indication was found of hypertension, fever, dyspnea, or other abnormalities. Radiographic imaging revealed a fracture in the left proximal ulna. Coupled with the patient’s previous history of metastatic movement, these findings suggested an initial diagnosis of metastatic bone tumor and resultant pathologic fracture, a diagnosis that was confirmed prior to the procedure by routine biopsy of the affected area. Informed consent was obtained from the patient and the patient’s family for all procedures included in the current case study.\nAmputation of the affected limb was initially considered because of the extent and size of the lesion, generally considered indicative of poor reconstruction procedure outcomes resulting in limited mobility (Figures , ). The patient was advised that limb-sparing treatment was likely to increase the risk of recurrent metastasis and would likely achieve poor reconstruction outcomes resulting in only partial restoration of mobility. Upon advisement, the patient expressed an explicit preference for a limb-sparing option, resulting in a treatment designed to provide localized disease control without amputation, offering maximum preservation of the forearm and elbow functionality. This treatment, however, is not generally recommended for limiting the risk of metastasis in recurrent patients with or without a history of metastatic growths.\nThe initial preoperative reconstruction plan recommended full elbow replacement with a custom prosthesis coupled with radius neck-to-humerus trochlea transposition. The patient and patient’s family opted to reject the prosthesis but expressed a desire to move forward with radius neck-to-humerus trochlea transposition. Due to the extremely wide tissue deficit expected after full removal of metastatic osseous tissues and surrounding materials, soft tissue coverage with a myocutaneous free flap was added to the surgical plan in lieu of a prosthetic graft.\nTo ensure optimal visibility during the operative procedure, a posterior approach was applied. The initial incision was drawn along the ulnar shaft, inclusive of the biopsy site. Identification of ulnar nerve was conducted visually, and the structure was subsequently exposed within the olecranon groove. The nervous tissue was carefully protected from surgical damage in order to maintain sensitivity in the forearm. Furthermore, the adjacent portions of the median and radial nerves were identified and similarly conserved in order to prevent postsurgical sensory damage.\nDuring surgical removal of the tumor, wide en bloc excision was necessary for full removal of tumor tissues, resulting in the sacrifice of significant portions of the muscular elements attached to the tumor process. Specifically, large sections of the extensor muscle, supinator, and flexor pronator group adjacent to tumor tissues were excised, and the entire proximal half of the ulna was involved in the procedure. The margin of resection was 2 cm distal to the distal border of the tumor, as observed by T1-weighted magnetic resonance imaging, resulting in a relatively large resected area. Visual observation was used as the primary tool for resectioning of osseous and soft tissue regions, with negative margins determined according to the extent of observed malignancy. The procedure was completed in accordance with the guidelines previously provided by Enneking [], wherein complete removal of malignant tissues were ensured by the application of margins a minimum of 5 cm distal to primary malignant bone tumors and 2 cm distal to metastatic tumors. Over the course of the operation, samples were collected from marginal tissues for frozen-section examination, resulting in definitive determination that margins were negative for metastatic tissue. A total length of 10 cm of the proximal ulna and surrounding soft tissue were resected.\nThe proximal radius was circumferentially mobilized, the radial-humeral joint was disarticulated, and the radial neck was then sufficiently mobilized to allow articulation with the humeral trochlea (Figure ). The stability of the construct is considered to be highly dependent on the biceps tendon at its insertion point for normal movement, providing a mechanical purpose for soft restriction to posterior translation of the radius relative to the humeral trochlea. The triceps tendon was severed and reattached to the proximal radial head by soft tissue-to-bone repair, and the bond was further strengthened using a bone anchor.\nResultant tissue margins were examined as frozen sections, confirming the negative status for metastatic tissue.\nNotably, in cases where a small amount of the proximal olecranon can be spared in continuity with the tendon insertion, bone-to-bone repair is often successful. Reconstruction of the tendon insertion allows for subsequent extension against gravity and provides a restraint to translation of the radial neck as it articulates with the humeral trochlea. Additionally, the long-term stability of the reconstructed limb is highly dependent on the level of postoperative scar formation, which is often exacerbated by overstimulation in the weeks subsequent to surgery.\nIn order to protect the reconstructed elbow joint, 3 weeks of full immobilization with a Kirschner pin and cast at 90° of flexion were ordered after surgery, followed by an additional 6 weeks of passive- and active-assisted flexion and extension in the sagittal plane with the added protection of a hinged brace. Good upper extremity function was observed after rehabilitation (Figure ), though some tolerable discomfort was reported upon resuming normal daily activities.\nThe Musculoskeletal Tumor Society rating score for the patient after rehabilitation was 25 of 30 (83 %). The patient exhibited full sensitivity and use of the left hand, allowing the patient to successfully return to most normal activities of daily living with only moderate discomfort. Additionally, the range of the elbow movement was observed to be 10° to 90°, though supination and pronation were slightly restricted. No evidence of local recurrence or other pathological complications was observed after 1 year of follow-up. Due to the presence of stable renal cancer and concurrent lung and brain metastases, the patient remains at elevated risk for future metastatic occurrences. |
This 41-week-gestation male was born to a 30-yr-old mother with good health by normal spontaneous vaginal delivery in November 2009. His birth weight was 3,140 gm. There was no maternal complication during pregnancy. There was neither family history of congenital anomalies nor maternal exposure to drugs during pregnancy. The baby had APGAR scores of 7 and 5 at 1 and 5 min, respectively. He needed positive pressure ventilation with intubation because of progressive respiratory difficulties and hypoxia. The baby was immediately transferred to our hospital for further evaluation and management after stabilization.\nThe physical examination and laboratory findings for the baby were unremarkable on admission. He had the surfactant replacement therapy for acute respiratory failure. For the next few days, we tried extubation several times, but failed to succeed because the baby suffered from recurrent apnea and hypercarbia leading to the clinical suspicious of CCHS. On day 8 of life, a cranial ultrasound study was performed and it did not show evidence of hemorrhage or mass lesions.\nDuring the second day of life, it was noted that the patient had distended abdomen and was unable to pass meconium without rectal stimulation. A gastrografin contrast enema study showed multiple meconium plugs in the colon suggesting meconium plug syndrome (). Meconium was passed and abdominal distension was relieved after contrast study. On day 6 of life, he showed sustained abdominal distension with poor bowel movement. A barium contrast enema study was needed to rule out other causes of lower gastrointestinal obstruction. It showed a transition zone in rectosigmoid colon suggesting HD. The diagnosis was confirmed by rectal suction biopsy with acetylcholinesterase immunohistochemistry (). The infant underwent an open laparotomy on day 12. He was noted to have long segment HD with a transition zone at mid descending colon. Seromuscular biopsies of the bowel taken 3cm proximal and distal to the transition zone revealed the presence of ganglion cells in the proximal biopsy specimen only. A descending loop colostomy was done at the 2 cm from proximal biopsy site. After the diagnosis, the patient was transferred to another hospital for the treatment. The patient had a tracheostomy to provide the necessary assisted ventilation. Laparoscopic Pull through Procedure was carried out for the treatment of HD. After the discharge, he has been followed up until now.\nThe cytogenetic study was performed clinically in the infant and his parents and their karyotypes were normal. Genomic DNA of the patient and his parents was isolated from peripheral blood using the Wizard Genomic DNA Purification Kit according to the manufacturer's instructions (Promega, Madison, WI, USA). Amplification of the coding sequence of the PHOX2B gene by polymerase chain reaction (PCR) was carried out as previously described with minor modifications (). Polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) was performed as previously described (). PCR products in the patient, his parents, and normal controls were electrophoresed through 8 and 10% polyacryamide gels (). In patient, a mutant band was found, however, his parents had no mutant band. To determine the sequences of the DNA sample showing the mutant band, direct sequencing was performed by Macrogen Inc, in Korea. However, the quality of the result was not clear. To get apparent result of sequencing, PCR products were cloned by TOPO TA cloning (Invitrogen Ltd., Paisley, United Kingdom) and 10 single colonies were collected for extracting plasmid DNA. Direct sequencing revealed expanded alleles containing polyalanine 26 repeats in exon 3 of the PHOX2B gene, further supporting the diagnosis CCHS (). |
A 58-year-old woman operated with proctocolectomy and an ileal J-pouch 11 years earlier due to ulcerative colitis complicated by colonic cancer presented at a local hospital because of abdominal pain and failure of faecal evacuation. There was a previous history of similar but short and self-resolving episodes of obstruction without clear explanation. A CT-scan aroused suspicion of twisting of the pouch along its longitudinal axis causing an obstruction at the ileoanal anastomosis. An intestinal tube was passed into the pouch for decompression which resulted in relief of symptoms lasting also the day after removal of the tube. She was therefore discharged and referred to our hospital for follow-up with pouchoscopy. However, on the same day as she had been discharged, she presented as an emergency case at our hospital with identical symptoms of obstruction and was admitted to a surgical ward after the application of a tube into the pouch for deflating. Repeated CT-scans at presentation and after application of the tube showed again volvulus of the pouch, which resolved after tube insertion as did the symptoms (). Endoscopy of the pouch including 50 cm of the afferent loop was easily done with no signs of ischemia or obvious twisting. The following day a laparotomy was done in order to fixate the pouch to prevent further episodes of twisting. The pouch was found to be enlarged but in its regular position without twisting and not surprisingly there were no adhesions, either in the pelvis or in the abdomen, which made the pouch completely mobile. A loop of the distal ileum was also found to be twisted behind the mesentery of the afferent loop of the pouch as a remaining part of the volvulus (). After reduction of the distal ileum a pouchopexy was made with one row of multiple interrupted nonabsorbable monofilament sutures (Prolene) to the presacral fascia as well as closure of the open space behind the mesentery of the afferent loop in the same manner. The postoperative course was uneventful and the patient was discharged.\nTwo months later the patient presented with identical symptoms and a CT-scan showed again volvulus of the pouch. Insertion of a tube on this occasion did not fully relieve symptoms, so this led to a decision to proceed to laparotomy. A volvulus of the pouch along its longitudinal axis was found intraoperatively as well as an accompanying volvulus of the small bowel behind the afferent loop similar to the previous laparotomy (). No new adhesions had been formed since that laparotomy and all the sutures to the presacral fascia and retroperitoneum were completely detached except for one. The mildly ischemic pouch and small bowel were derotated and fixated once again to the sacral fascia and retroperitoneum but this time with two rows of continuous multifilament sutures (Ethibond) on either side of the pouch. The sutures were also extended upwards to again close the open space behind the afferent loop mesentery (). Furthermore the upper corners of the pouch were sutured to the lateral walls of the pelvis. After an uncomplicated postoperative course, the patient was discharged. At follow-up ten months later she was doing well and was free of symptoms. |
A 72-year-old woman with chronic atrial fibrillation, temporal arteritis, and avascular necrosis of the right hip requiring hemiarthroplasty that was complicated by deep venous thrombosis in the past, now presents with new onset left upper extremity clumsiness. A head computed tomography (CT) scan and subsequent magnetic resonance imaging study revealed a hemorrhage into the right parietal and occipital regions of the brain. In view of these findings, warfarin therapy was discontinued and as part of the workup a transesophageal echocardiogram (TEE) was performed and revealed a 4 × 6 mm mass on the aortic valve and a patent foramen ovale (PFO) with bidirectional shunting (right to left after the intravenous injection of agitated saline), mild bi-atrial enlargement, mildly dilated but normally functioning right ventricle, normal left ventricular systolic function and no significant valvular regurgitation. The patient was afebrile and blood cultures were negative. The patient was referred to our institution for surgical evaluation given the TEE findings and the patient clinical presentation. Surgical resection of the aortic valve mass and closure of the PFO were recommended.\nUpon examination of the aortic valve, a filamentous mass was identified on the leading edge of the noncoronary cusp midway between the ranula and the commisure. The mass was excised with sharp dissection. A second 2 × 3 mm mass was also observed on the underside of the leaflet and was excised in a similar fashion. Lesions were also observed at the commisure and on the left coronary cusp and were also excised. Pathologic examination subsequently revealed that these lesions were small fragments of myxoid tissue with hyalinization. A modified Maze procedure was also performed at the time of surgery and it required mobilization of the pulmonary veins bilaterally with application of radiofrequency lesions just proximal to the entrance of the left and right pulmonary veins. Another radiofrequency lesion was placed at the base of the left atrial appendage and this was then excised and then over sewn. Finally, the right atrium was then opened in a longitudinal fashion, the PFO was identified at the cephalad portion of the fossa ovalis and was then closed in a running fashion.\nThe patient was weaned from bypass without incident and a TEE performed in the operating room revealed no residual masses on the aortic valve or right to left shunt. However, a mild degree of tricuspid regurgitation was now identified for the first time. Both right ventricular size and systolic function remained normal. The patient was taken to the intensive care unit in stable condition and the immediate post-operative course was unremarkable. There was no need for either vasopressor or ionotropic support and the patient was extubated on the first post-operative day and subsequently transferred to a step down unit.\nThe patient did well until the night of the second post-operative day when she developed oliguria that progressively worsened followed by tachycardia and hypotension. At this time, a pronounced jugular venous distention was noted and a bedside transthoracic echo was immediately obtained to rule out the presence of pericardial tamponade. No pericardial effusion was noted; however, severe tricuspid regurgitation was now noted with dilatation and dysfunction of the right ventricle. In view of these findings, a spiral chest CT was requested but there was no evidence of pulmonary embolus; however, both superior as well as inferior vena cavae were dilated. The pericardium thickness was reported as normal. Because the clinical deterioration persisted, the patient was taken back to the operating room for mediastinal exploration; only a small amount of pericardial fluid was removed. Although the pericardial sac appeared to be under tension, no clot was found after extensive exploration.\nDespite a trial of medical management, the patient's cardiac index remained low and all facial and neck veins became progressively and markedly engorged. A repeated TEE demonstrated marked dilatation of the right-sided chambers with severe reduction in right ventricular systolic function (Figure ) and severe tricuspid regurgitation as a result of an incomplete coaptation of the tricuspid valve leaflets (Figure ). During this TEE, normal left ventricular contractility was noted with no regional wall motion abnormalities, with the exception of a paradoxical septal wall motion as expected post recent surgery, and normal left ventricular systolic function. In addition, pulsed interrogation of all four pulmonary veins showed normal velocities in order to rule out post-surgical Maze procedure pulmonary vein stenosis. No visible alteration in either the main or secondary pulmonary arteries was seen by TEE or CT. Although a clear unifying mechanism that would encompass the hemodynamic deterioration as well as the disproportionate symptoms of dyspnea with the rapidly progressive dilatation of all superficial neck and facial veins could not be given, it was clearly evident that the incomplete coaptation of the tricuspid valve leaflets, as seen on TEE, would certainly continue to further deteriorate the current clinical condition. Therefore, the patient was taken to the operating room again and upon opening the right atrium, the dilatation of the tricuspid valve annulus was confirmed resulting in failure of coaptation of the otherwise normal appearing tricuspid leaflets. Tricuspid annuloplasty with a 34 mm Cosgrove band was performed with marked improvement in cardiac output not requiring further inotropic support. A postoperative TEE revealed no evidence of residual tricuspid regurgitation and the chest was closed. The remainder of the patient's post-operative course was uncomplicated. Unfractionated intravenous heparin was started once the surgeon felt it was safe to maintain a therapeutic activated partial thromboplastin time. The pronounced engorgement of her neck and face veins resolved and she remained hemodynamically stable. After the 5th postoperative day, the patient was transferred to a rehabilitation facility. At one-month follow-up, the patient has remained in atrial fibrillation, but is otherwise doing well. |
A 59-year-old woman was referred to a gynecological outpatient clinic suspected to have an ovarian cyst. Some months earlier she had been examined at the general surgery department due to abdominal pain.\nThe patient had previously undergone a hysterectomy and was medically treated for diabetes. She was diagnosed with diverticulosis and the suspicion of a cyst in the left ovary. She had experienced constipation problems and pain in the lower left side of the abdomen. The pain increased during movement and when eating. The constipation was improved by lactulose treatment, and as a result she only suffered from abdominal pain during physical activity. Importantly, she also reported occasional incontinence, alternating with difficulties emptying the bladder.\nA gynecological examination revealed a solid mobile tumor below the symphysis, measuring 3 × 3 cm. A transvaginal ultrasound examination showed two normal ovaries and normal findings in the lower pelvis. In contrast, a tumor measuring 2.8 × 2.3 cm closely related to and intruding into the urethral wall was seen.\nA magnetic resonance imaging (MRI) revealed a sharply defined tumor, measuring 3 × 3 cm closely related to the vaginal vault (). The tumor caused an impression of the urethra, but invasive growth was not suspected. A transvaginal biopsy of the process showed smooth muscle tissue without signs of malignancy.\nSubsequently, an excision of the paraurethral tumor was carried out in collaboration between urologists and gynecologists. In the beginning of the operation a cystoscopy was performed. A little diverticel was seen in the urethra but there was no observed connection between the paraurethral tumor and the urethra. The operation was performed with only local anesthesia. Lidocaine with adrenalin was injected into submucosa in the anterior wall of vagina. The mucosa was divided lengthwise and the tumor was dissected free. During the dissection a minor lesion of the bladder occurred and lesion was sutured in two layers. Injection with methylene blue fluid confirmed no leakage in the lesion. Finally the pubocervical fascia and the mucosa in vagina were sutured. The patient was catheterized for one week and got antibiotic treatment both preoperatively and postoperatively for one week.\nThe postoperative period was characterized by urethral pain as well as vaginal leakage of urine. A subsequent gynecological examination revealed two vesicovaginal fistulas, which were sutured. Following this the leakage stopped and the patient was free of symptoms.\nThe histological examination showed a benign leiomyoma (). |
A 60-year-old Moroccan woman came to our institute 18 years ago with a history of vaginal bleeding, malodorous discharge and vaginal discomfort. Furthermore, our patient presented with a slowly enlarging skin lesion localized on the dorsum of her nose. Gynecologic examination found a 5 cm exophytic friable lesion arising from her cervix and involving the upper half of her vagina. Biopsy confirmed the diagnosis of a well differentiated squamous cell carcinoma and the absence of parametrial infiltration; neither adenopathies nor distant metastases were found. In addition, a skin inspection found a 2 cm solitary nodule on the dorsum of the nose: the lesion bled spontaneously at the examination and biopsy confirmed the diagnosis of basal cell carcinoma of the skin.\nOur patient refused the surgical excision of the nasal lesion, and so treatment consisted of radiation therapy; 30 Gy external beam radiation was delivered in 10 fractions with 3 Gy per fraction over two weeks, followed by 30 Gy delivered by brachytherapy.\nThe cervical carcinoma was treated with radiation therapy. A whole pelvic external beam radiation dose of 40 Gy was delivered in 20 fractions with 2 Gy per fraction over four weeks, followed by 30 Gy delivered by brachytherapy. In summary, she received 70 Gy total dose radiation on the cervical cancer, and 60 Gy total dose radiation on the skin cancer.\nOur patient remained in good control and free from relapsed disease over 17 years. At the age of 78 years, she presented with a rapid worsening of performance status. Gynecologic examination didn't reveal any recurrent disease or recurrent skin lesion. However, systematic liver ultrasounds showed multiple diffuse nodular lesions. We performed a computed tomography of her thorax, abdomen and pelvis. Imaging showed diffuse metastatic nodules of her lungs and liver; there was no evidence of relapsing pelvic tumor (Figure ). We performed a liver biopsy which revealed a histological diagnosis of liver metastases from a neuroendocrine carcinoma, confirmed by immunohistochemistry study with chromogranin and CD56 positive staining (Figure Figure and Figure ). There was no clinical evidence of the primary site.\nOur patient is undergoing a palliative chemotherapy based on a combination of cisplatin and etoposide. |
Miss S is a 16-year-old Chinese girl. She presented to a tertiary hospital with an initial complaint of progressively increasing pain and swelling of her right leg of 3 months duration. It was interfering with her right knee movement and walking. It was not associated with any significant trauma and started insidiously. She did not experience any loss of appetite, loss of weight or fever during and around the time of presentation. She had no other known medical conditions prior to this and was not on any medications.\nExamination of the patient showed a medium built girl with a large swelling measuring 10 cm by 15 cm over her right leg, just below the knee. She did not appear wasted and was walking with an antalgic gait. The skin over the swelling appeared shiny, indurated with visible dilated veins overlying it. Her vital signs were normal and there was no evidence of pallor. On palpation, there was a warm hard swelling arising from the proximal right tibia not crossing the knee joint. It was a smooth lobular swelling, tender on deep palpation. Range of motion for the right knee was 0° to 100° compared to 0° to 140° on the contralateral side. There was no clinical evidence of knee effusion. Examination of all other systems was unremarkable.\nPlain radiographs (Figure ) showed classical features consistent with osteosarcoma of the proximal tibia. The Magnetic Resonance Imaging showed that the tumour was limited to the proximal tibia without involvement of the knee joint and the neurovascular bundle was free from the tumour (Figure ). Computer Tomography of the chest and bone scan revealed that the tumour was localize to right proximal tibia without metastasis to the lung or other bones. The clinical examination and radiological findings were consistent with an initial diagnosis of osteosarcoma of the right proximal tibia. Histopathological findings of a large-core tissue biopsy performed showed chondromyxoid matrix and atypical chondrocytes containing enlarged hyperchromatic nuclei. There were also abnormal spindle cells producing osteoid present. These findings were consistent with chondroblastic variant of osteosarcoma.\nDuring the first encounter with the Orthopaedic Surgeon, the family members confirmed the Jehovah's Witness status of the patient. Subsequently, a meeting between the Orthopaedic Surgeon, the family members and church representatives was held. The Hospital Liaison Committee for Jehovah's Witnesses also sent representatives to provide support to the family and medical literature to the treating doctors for additional information. There was acceptance towards iron and recombinant erythropoietin. However, the family refused packed red blood cells (RBC), whole blood and fresh frozen plasma.\nShe was started on neoadjuvant chemotherapy which included doxorubicin, cisplatin and high-dose methotrexate with leucovorin (folinic acid) rescue (Memorial Sloan-Kettering protocol). The regime comprised of 6 cycles of chemotherapy. Surgery was performed after 3 cycles of neoadjuvant chemotherapy.\nBefore commencement of chemotherapy, she was started on ferrous fumarate, folic acid, vitamin B complex and subcutaneous recombinant erythropoietin 50,000 units three times a week. These measures were expected to increase her hemoglobin levels and accelerate red cell production. Immediately after her chemotherapy, she was also given neupogen (granulocyte colony-stimulating factor) to prevent chemotherapy-induced neutropenia. During the course of chemotherapy, her blood counts were stable with the range of recorded hemoglobin of 8.7 to 13.4 g/dL, white blood cell count of 1.9 to 14.8 × 109/L and platelet count of 77 to 268 × 109/L.\nFollowing three cycles of chemotherapy, clinically, there was marked reduction of the tumour mass and patient was prepared for limb salvage surgery. A standard consent for surgery and another one for anaesthesia was obtained from the parents. The parents were clearly informed about the possible risks their child may encounter because of refusal of blood transfusion and this was clearly documented in the medical notes. The patient also had a hand written note describing her religious beliefs and her refusal for blood transfusion, which she showed to all attending doctors. This we believe was because whilst the official medico legal consent form was signed by her parents, she wanted the treating doctors to know that the decision to refuse any form of transfusion was without coercion from external parties.\nThree empty blood bags containing anticoagulants routinely used for blood collection were obtained from the blood bank to be used intraoperatively.\nA standard approach was used and the proximal tibia was resected, followed by proximal tibia endoprosthesis replacement. The resected tumour bone and the endoprosthesis used to replace the defect are shown in Figure and Figure . Meticulous attention to haemostasis was of paramount importance. A tourniquet was used during the surgery which was released on and off to secure haemostasis. The patient was operated in Trendelenburg position to minimize blood loss due to high venous pressure when the tourniquet was released. Cell saver technique was not used because of possibility of contamination with malignant cells.\nGeneral anaesthesia with neuromuscular blockade and controlled ventilation was used. A 20 gauge intravenous cannula in the dorsum of the right hand was used to induce anaesthesia. After induction, an 18 gauge cannula was inserted in the right external jugular vein. The Trendelenburg position facilitated drainage of blood. Voluven (hyroxyethyl starch 6%) was infused (in a 1:1 volume ratio for blood extracted) through the right hand cannula to maintain normovolaemia. 400 ml of blood was extracted after which the flow became very sluggish. The blood bag was connected through the second port to the right hand cannula and reinfused without breaking the connection. Another 18 gauge cannula was inserted into the left internal jugular vein and a total of 600 ml of blood was extracted while maintaining normovolaemia. This bag was then inverted and reinfused through the same vein at a slower rate (Figure ). Total blood loss during surgery was 400 ml which occurred at release of tourniquet and this was replaced introoperatively.\nCore temperature as measured with an eosophageal probe was allowed to drop to 33.5°C, which is beneficial to reduce basic metabolic rate, hence, the oxygen requirement. Surgery was uneventful and took about 150 minutes to complete. Postoperatively, the limb was bandaged and elevated to minimize blood loss.\nThe remaining 600 ml of blood was transfused over 6 hours to replace ongoing blood loss as well as to maintain oxygen carrying capacity. Oxygen was administered by face mask at 6 L/min postoperatively. The patient was warmed to normothermia and shivering was prevented. Analgesia was provided by 'patient controlled analgesia' with morphine. All of the above measures reduced oxygen demand and improved oxygen delivery. Her postoperative hemoglobin on the next day was 9.8 g/dL. Meanwhile, the histopathological examination of the resected tumour showed 90% tumour necrosis following neoadjuvant chemotherapy.\nPatient was discharged after a week on full weight bearing crutches and hematinics with a hemoglobulin level of 10 g/dL, platelet count of 120 × 109/L and white cell count of 8 × 109/L. Her postoperative radiographs are as shown in figure . Adjuvant chemotherapy using the same agents was resumed 3 weeks after the surgery. She completed the remaining 3 cycles of chemotherapy uneventfully. |
A 68-year-old non-smoking Chinese woman with SIT was referred to our hospital because of an abnormal shadow on chest radiography for 4 days. Chest computed tomography (CT) showed an irregularly shaped nodule (measuring 38 × 27 mm in diameter) in the pleural area of the left lower lobe and SIT () and a 5-mm nodule in the dorsal segment of the lower lobe of the left lung (). Bronchoscopy confirmed that the left and right bronchial branches were mirror images of each other. Because we were unable to obtain a definitive diagnosis by the bronchoscopic approach, we performed CT-guided percutaneous lung biopsy and surgery was planned for diagnosis and treatment. Intraoperatively, we established that the location of the superior vena cava and azygos vein mirrored the normal distribution, and that the aortic arch was absent from the left thoracic cavity. The left lung was well lobulated into three lobes and the anatomy of the left side of the pulmonary artery had features typical of the normal right side.\nOn 9 January 2018, the patient underwent thoracoscopic wedge resection of the left lower lobe of the lung plus lymphadenectomy. The tumor was located in the lower left lobe. The location of the lesion in the basal segment was obvious and the interlobar fissure was removed. Wedge resection of the two lesions was performed to remove the lesions and they were sent for rapid pathology. Pathology showed that the tumor in the dorsal segment of the left lower lobe was adenocarcinoma in situ (0.5 cm in diameter) and the mass in the basal segment was a fusiform cell soft tissue tumor with sclerotic, slightly heteromorphic cells. These findings suggested that we should treat the lesions as borderline tumors. Precise diagnosis needed to be performed by immunohistochemistry. The lymph nodes of 11 groups were removed.\nPostoperative pathology showed that the tumor in the dorsal segment of the lower left lobe was adenocarcinoma in situ (0.6 × 0.5 cm), without invasion of the local pulmonary capsule and without involvement of the end of the lung. The mass in the basal segment was a solitary fibrous tumor (5.5 × 4×2 cm). Most of the tumor showed collagenous sclerosis, and some areas had abundant cells, active growth, and mitotic cells >4/10 high power fields. There was no clear hemorrhage and necrosis, and atypical and malignant fibrous tissue cells were found. No metastasis was found in the lymph nodes of 11 groups. Immunohistochemical results showed the following: pan-cytokeratin (−), vimentin (+), synaptophsin (−), CD56 (−), CD34 (+), CD99 (+), S100 (−), desmin (−), smooth muscle actin (−), and Ki-67 (+) 10% (). |
The patient was a 53-year-old woman with a past medical history of hypothyroidism and hyperlipidemia who presented to the emergency department (ED) with worsening bilateral upper and lower extremity weakness for three days. Two weeks prior to her presentation, she reported fever, diarrhea, nausea, vomiting, and pain on the right side of the abdomen. She had presented to the ED one week prior due to abdominal pain with a mild elevation in her liver enzymes. No acute pathology was discovered, and she was told to follow-up with her primary care physician (PCP). She then presented to an urgent care facility in which she was prescribed ciprofloxacin with eventual improvement in her diarrhea and vomiting. Three days prior to arrival, she began to note numbness and weakness of her fingers and toes. Her weakness was most noticeable in the distal aspects of her extremities, and she experienced some difficulty ambulating and a prominent decrease in her grip strength. This prompted her to schedule an appointment with her PCP. She followed up with her PCP, who was concerned for demyelinating disease. The PCP urged her to present to the ED for further evaluation. Despite not having any respiratory symptoms or fever, her PCP tested her for COVID-19 and influenza given her abdominal pain and diarrhea. Both tests returned negative.\nFurther history revealed the patient had reported a prior presentation to the ED roughly 10 months earlier for right upper quadrant abdominal pain. She was told she had elevated liver enzymes at that visit and was told to follow-up with her PCP. Her PCP had tested her for hepatitis C, which was negative, and she eventually had resolution of her clinical symptoms. She denied any recent travel, fevers, or shortness of breath. She had mostly been indoors for the past two months, without reported sick contacts.\nPhysical examination upon presentation to the ED was notable for 4/5 strength in the bilateral upper extremities with flexion and extension of the elbow and wrist. She had decreased grip strength bilaterally. Bilateral lower extremities had 3/5 strength with flexion and extension of the hip and knee as well as decreased dorsiflexion and plantar flexion of both feet. She had decreased sensation in her lower extremities with absent reflexes throughout. Initial labs were significant for a normal TSH, free T4, and a mild elevation of her liver enzymes: aspartate transaminase (AST) of 40 U/L (normal range: 8–48 U/L), alanine transaminase (ALT) of 46 U/L (normal range: 7–55 U/L), and alkaline phosphatase (ALP) of 138 U/L (normal range: 40–129 U/L). A hepatitis panel and computed tomography (CT) scan abdomen/pelvis were ordered to investigate her transaminitis. She was positive for hepatitis A IgG and IgM antibodies with no acute pathological process noted on the CT scan.\nInitial differential diagnosis included GBS versus a compressive myelopathy of the spine. Neurology was consulted with recommendations to perform a lumbar puncture and obtain further imaging of the brain and spine. A CT scan of the head was without acute abnormalities, and magnetic resonance imaging of the cervical, thoracic, and lumbar spine was negative for compressive myelopathy or acute abnormalities. A lumbar puncture was performed with an elevated total protein of 72 mg/dL (normal range: 15–60 mg/dL) and white blood cell count of 5 cells/mm3 (normal range: 0–8/mm3) suggesting albuminocytologic dissociation. The patient was diagnosed with GBS and started on intravenous immunoglobulin (IVIG) for five days. She had noticeable improvement in her distal extremity weakness following the first few doses of IVIG and was able to ambulate on her own by the end of her treatment. She was able to discharge following completion of her immunotherapy. |
The patient is a-73-year old female with an extensive past medical history. The patient first reports a diagnosis of colonic polyposis at age 48 after presenting with hematochezia. Over the subsequent 25 years, the patient had undergone repeated colonoscopy with removal of numerous polyps. By her report, some of the polyps were adenomatous, but the outside records were no longer accessible. For several years, the patient carried the diagnosis of familial adenomatous polyposis. The patient began experiencing increased weight loss and bleeding and therefore underwent subtotal colectomy with ileorectal anastomosis five years prior to this admission at an outside hospital. Pathology at the outside facility revealed approximately 50 juvenile polyps most consistent with Juvenile Polyposis syndrome. The patient's mother and half brother reportedly died of colon cancer, both in their 50s.\nThe patient presented to our hospital with recurrent melanotic diarrhea and anemia. Initial physical exam in the emergency room did not mention any alopecia, cutaneous hyperpigmentation, or dystrophic nails. A CT of the abdomen with IV and oral contrast revealed a markedly distended stomach due to mass-like fold thickening and areas of hemorrhage (). A small bowel series was also performed which showed that the stomach was markedly dilated with multiple filling defects and ulceration causing an asymmetrical narrowing of the lumen. There was no evidence of gastric outlet obstruction. Upper endoscopy showed large mucinous fungating friable folds and numerous polyps of various sizes in the fundus and proximal body of the stomach (). The masses were difficult to differentiate into separate lesions. The appearance of the mucosa of both the polyps and the polypoid masses appeared highly cystic and erythematous. There was no active bleeding during endoscopy. Sigmoidoscopy found and biopsied three rectal polyps. Biopsies of the lesions from the stomach and rectum both showed inflamed and edematous epithelium with associated prominent foveolar hyperplasia (). Upon review of the outside slides from her colectomy, taken together with the current biopsies, it was determined in retrospect that these findings were actually most consistent with polyps that arise in the setting of CCS, rather than juvenile polyposis.\nDuring her hospitalization at our institution, her diarrhea showed marked cessation after the administration of antibiotic (amoxicillin) and corticosteroid therapy and pantoprazole. Patient also received multivitamins. For her malnutrition, she was given TPN, and her symptoms improved. Surgery, although initially considered at presentation, was deferred given the patients continued improvement and the revised diagnosis of CCS. Patient was scheduled for follow-up at out polyposis clinic but did not keep her appointments and was lost to follow-up. |
A 53 year old female presented to her General Practitioner with heavy menstrual bleeding and was referred to a gynaecologist at her local hospital. Her previous medical history included one normal vaginal delivery aged 28, a Mirena IUS in situ, and, a normal cervical screening history. Drugs prescribed included ranitidine and citalopram. Family history included an identified BRCA mutation carried by her mother and aunt. She had not been genetically tested herself but underwent regular 6 monthly checks from ages 41 to 50.\nMultiple fibroids were identified on a trans-vaginal ultrasound of the pelvis. In view of her ongoing symptoms, the patient was offered a hysterectomy with a bilateral salpingo-oopherectomy.\nThe histology of the uterine specimen demonstrated one fibroid measuring 70 mm diameter and showing an abnormal focal area and central cystic necrosis consistent with a low grade leiomyosarcoma surrounded by normal tissue with no evidence of vascular infiltration. The leiomyosarcoma border was 10 mm clear of the serosal surface. A CT scan of the chest, abdomen and pelvis found no evidence of residual or metastatic disease and her case was discussed at a Gynaecologic Oncology multi disciplinary meeting (MDT). It was agreed that the likelihood of further metastasis was remote and she was discharged from follow-up.\nSix months later, the patient presented to the accident and emergency department with a complaint of numbness in her lower left lip. A full neurological examination was normal so the patient was assured it would likely resolve. However, following a consultation with her dentist, she was referred to the maxillofacial department. The patient was known to grind her teeth due to anxiety. Altered sensation over left chin was reported, followed by numbness in her left lower lip. On examination, she was found to have decreased sensitivity to soft touch in the left mental nerve distribution area and an electric shock like sensation through her lip when pressure was applied to her mental foramen. Dental pulp testing with ethyl chloride was used on her lower left second premolar but no response was recorded and on X-ray, the apex was found to be directly next to the mental foramen and an apical radiolucency was associated with this tooth. She was treated with a course of amoxicillin on the diagnosis of an apical infection affecting the mental nerve. Despite the antibiotic treatment, the numbness continued and the patient went on to develop dysesthesia of the left 4th and 5th fingers. She also experienced an episode of severe left-sided facial pain associated with difficulty in opening her jaw; the left side of her chin became swollen and rubbery to touch. Her left lower second molar was treated with a root canal filling, which also failed to improve her symptoms. Further neurological examination confirmed trigeminal motor function was unaffected and Tinel’s sign was negative in the left elbow; peripheral nerve and Electromyography (EMG) studies were also found to be normal.\nMagnetic resonance imagery of the brain and mandible along the course of the mandibular branch of the trigeminal nerve showed no evidence of metastasis. CT of the skull base, mandible and neck showed no bony abnormality and did not identify any prominent lymphadenopathy. Other investigations were undertaken, including chest X-ray, full blood count, ESR 5, clotting screen, B12 levels, plasma electrolytes, calcium, C reactive protein, angiotensin converting enzyme levels, liver function tests, thyroid function and blood sugar levels which were all normal. Tumour markers were tested and normal as well as Wassermann reaction, anti-nuclear factor, anticardiolipin antibodies, ANCA (antineutrophil cytoplasmic antibodies) screen and borrelia titres were negative, making any infective or autoimmune causes less likely. The patient declined to have a lumbar puncture (LP), instead wishing to try a course of acupuncture first. After completing her sessions of acupuncture over 4 weeks, she felt that the sensory disturbance in her left hand and left chin had improved by about 40%. She therefore decided to carry on with another four sessions of acupuncture before considering a LP. Having finished the acupuncture, the patient found her left hand sensory disturbance to be almost completely resolved and her left chin was continuing to improve. She was prescribed antibiotics by her dentist to treat an abscess of the lower left wisdom tooth however this did not resolve the problem and led to a swelling in her left cheek. The left lower third molar was removed, and while extracting the tooth, a biopsy of abnormal ‘moth eaten’ looking soft tissue was also taken.\nThe histopathology report of the biopsy revealed an undifferentiated sarcomatous malignant tumour. Immunohistochemistry staining was used to compare this specimen to the uterine LMS from the hysterectomy previously and was consistent with recurrent disease. A second CT of the neck, abdomen and pelvis performed after an interval of 6 months revealed an extensive mass lesion affecting the left jaw and soft tissue mass on both sides (Fig. ). A dental panoramic radiograph also showed a lobulated tumour within the angle of the mandible (Fig. ). The final diagnosis of metastatic uterine LMS to the left mandible and masseter was made, over 6 months after the patient had initially presented with jaw paresthesia.\nPrimary treatment was resection of the masseter, medial pterygoid and angle of the mandible. A positron emission tomography (PET) scan was suggestive of small metabolically active area in pelvis, possibly further nodal spread, but it was not macroscopically visible on CT so no further excision was recommended.\nRadiotherapy to the left mandibular lesion followed, with clinical follow-up. Further metastases subsequently developed with two lesions in the lungs, and one in the left pelvic side-wall. Diagnosis was made after a PET scan and the pelvic mass was treated with resection and radiotherapy. A pathological fracture to the humerus, secondary to the bony LMS metastasis at the site, lead to surgical correction and further radiotherapy. She later developed a metastatic lesion within the duodenum and underwent a pancreatic duodenectomy with resection of metastasis. An osteolytic mass was then identified in the right 4th rib and local palliation radiotherapy was administered. After further disease progression, 6 cycles of chemotherapy and palliative radiotherapy to the right iliac area, she died of progressive disease, 4 years following the original diagnosis of uterine LMS.\nA review of the literature was undertaken to assess frequency of mandibular metastases from uterine LMS. Databases including MEDLINE, EMBASE and google scholar were searched, the search being limited to the English language but with no time limit. Searching of the grey literature was also undertaken. Articles containing case reports of LMS metastasising to the ‘oral cavity’ were then further analysed to find cases specifically involving the mandible as a site of metastasis. From this thorough search, LMS metastasizing to the mandible was only reported in seven other cases, three from the uterus [–] as in this case, three from the lower limb [, ] and one from the abdomen (pancreas, abdominal aorta and vena cava) [] (Table ).\nThe index case is only the 4th reported case of uterine LMS metastasizing to the mandible found by this extensive search of the literature (Table ) and highlights how rare the oral region is as a metastatic site, particularly as a first site of recurrent disease. |
This case describes a 29-year-old woman who was first diagnosed with ameloblastoma as a child at 7 years old. The lesion originated in the ascending branch of the left mandible, and the first surgical procedure was performed in March 1997 followed by disease recurrence in April 1999. A second resection was performed in May 1999, and during the next 16 years, the patient underwent several surgical approaches that were consistently followed by disease recurrence. Some of the procedures were conservative surgeries, but others were radical procedures that left her with several deforming scars. She presented to our clinic in January 2015 with a new magnetic resonance imaging (MRI) that evidenced a right, triangular aspect, paracellarlesion, extending to the homolateral cavernous sinus (13 × 9 mm), which was suspected to be a residual lesion that would have achieved the cavernous sinus by contiguity growth after several surgeries. Her last surgery had been performed in April 2014 and was followed by local radiotherapy in May 2014. She was asymptomatic and not willing to undergo a new invasive procedure. She decided to be followed without further intervention.\nFor the next 18 months, she was clinically stable and asymptomatic, but she returned in July 2016 with intense pain on the right side of her face that required multiple hospital visits for intravenous analgesia. MRI revealed an extensive heterogeneous lesion with contrast enhancement centered on the right cavernous sinus anterior to the cavus of Meckel and exhibiting anterior extension towards the upper orbital fissure (measuring approximately 19 × 15 × 16 mm). To identify new treatment possibilities, we decided to perform a new biopsy and conduct molecular testing (Fig. ). A BRAF mutational analysis by the allele-specific protein chain reaction (PCR) certified test revealed the presence of a BRAF c.1799 T > A;p.V600E mutation corresponding to a V600E amino acid substitution. After tumor board discussion and a careful conversation with the patient, she decided to undergo BRAF inhibitor therapy.\nA treatment regimen with vemurafenib 960 mg PO twice daily was started on October 4, 2016. Prior to the initiation of therapy, a new MRI performed on September 24 revealed a lesion measuring 24 × 21 × 19 mm. After 2 weeks of therapy, the patient was asymptomatic and was not using any analgesic medication. During the course of therapy, she experienced grade one anorexia, nausea and fatigue, without any severe therapy-related adverse events. MRI performed in April 2017 revealed stable disease (24 × 18 × 15 mm), and her last MRI performed in September 2017 evidenced a reduction of the lesion size (18 × 13 × 14 mm) (Fig. ). The patient currently remains asymptomatic with excellent tolerance to the medication. |
Patient B lives in England and was diagnosed with reactive arthritis causing leg pain when she was 12 years old. She then developed an excruciating headache accompanied by a complete loss of balance and involuntary jerking movements, which resulted in her mother bringing her to the hospital where she was admitted for one night. She was brought back to the hospital daily for several days as increasing and intensifying symptoms developed. The first doctor to assess her wrote, “Hysteria, possible conversion disorder” in her notes. Following this impression, no relevant investigations were performed. Patient B was left deteriorating and untreated, by which time she was having constant seizures and needed a wheelchair. Her mother repeatedly told them that Lyme disease was highly suspected since the family lived in a region known to be epidemic for Lyme disease and other relatives had been diagnosed with the disease and begged them to help her daughter. These appeals were ignored. Her mother took Patient B to a private clinic where a consultant thoroughly examined her and diagnosed encephalitis and possible encephalomyelitis (inflammation of the brain/brainstem/spinal cord), probably due to Lyme disease. She was immediately put on intravenous antibiotics at the clinic for four days. In 36 hours, the seizures had stopped, and her headache slowly improved. Her blood tests came back positive for Lyme disease. The hospital admitted their error and gave an unreserved apology. On instructions from the consultant, Patient B had a further three months of daily intravenous antibiotic treatment at a National Health Service Hospital. After about two months, Patient B was able to walk again, but when the antibiotics were stopped, the seizures and other symptoms returned. The family raised funds to take Patient B to the United States for treatment by a physician who had experience with such cases. The treatment stabilized her condition and brought great improvement to some of her symptoms. However, due to the treatment delay, she still had some persistent health issues, including severe headaches, joint pains, extreme fatigue, cognitive dysfunction, and other symptoms. |
A 38-year-old male presented with silent jaundice, without any other complaints. His medical history consisted of CF and segmental intestinal resection due to small bowel obstruction in his first year of life. In 2009, he developed both exocrine and endocrine pancreatic insufficiency, necessitating pancreatic enzyme replacement and the use of insulin therapy. A continuing deterioration of his lung function resulted in the need of a bilateral lung transplantation in 2018 from which he recovered clinically well. Recently, he was analyzed because of jaundice. We saw a slightly icteric man with a body mass index of 21 kg/m2 and a serum bilirubin of 56 µmol/L. Abdominal ultrasound revealed dilated intrahepatic bile ducts and common bile duct. CT confirmed an ampullary tumour of 30 mm with extension into the duodenum (Fig. ). There were no regional lymph node or signs of distant metastases. A particular finding on the preoperative CT scan was the replacement of the entire pancreas with fat (Fig. ). The pancreatic duct could not be visualized. Biopsy of the ampullary tumour revealed an intestinal type adenocarcinoma and therefore our patient was scheduled for a pancreatoduodenectomy. The patient received a single dose of long acting somatuline (120 mg) preoperatively. During the operation, we noticed a lipomatosed pancreas and following transection of the pancreas we could not identify a pancreatic duct in the fatty pancreatic tissue. Taking into consideration that there was no possibility to anastomose the pancreatic duct to the jejunum in a patient using immunosuppressive medication in whom we could not permit pancreatic leakage, and pancreatic insufficiency, which was already known before the operation, we decided to perform a total pancreatectomy with sparing of the splenic vessels. The postoperative course was uneventful and on the 9th postoperative day, the patient was discharged in a clinically good condition, with stable glucose levels and no change in his need for insulin. Pathological examination showed a microscopically radical resection of a pT3bN2(5/16)M0 carcinoma of the ampulla of Vater and a pancreas completely replaced by fat with only some leftover islets of Langerhans. The pancreatic duct could not be detected (Fig. , ).\nAfter multidisciplinary considerations, it was decided to not administer adjuvant chemotherapy. Follow-up at our department consists of CT of chest and abdomen once a year. Furthermore, a colonoscopy will be performed because of the known higher incidence of gastrointestinal malignancies in transplanted CF patients. |
A 68-year old lady was referred by her general practitioner to the orthopaedic clinic with complaints of right heel pain for one year. The presenting complaints started about a year back as insidious onset of heel pain which was constant aching in nature and aggravated by periods of prolonged walking and standing. There was no history of trauma. She was a known seropositive rheumatoid arthritis patient on Hydroxychloroquine, Sulphasalazine and Methotrexate for 20 years. She was under the care of a rheumatologist and had steroid injections in the right heel for plantar fasciitis in the past. On examination there was diffuse tenderness around the heel with full range of ankle movements but painful limitation of subtalar joint movements. There was no hind foot malalignment evident on weight-bearing radiographs of foot and ankle (). But that of the ankle revealed a sclerotic line with areas of osteolysis suspicious of a fracture of the calcaneus (). An MRI scan of the ankle with T2 weighted images showed linear high signal intensity in the body of the calcaneus suggestive of an insufficiency fracture of the calcaneus (). The patient was treated with moon walker boot and commenced on oral Alendronic acid 10mg on alternate days for eight weeks with Calcichew and Vitamin D tablets. The patient was advised to use the moon boot while weight bearing and remove at bed time. At the eight weeks follow-up she was completely pain free and able to fully weight bear. The radiographic examination showed the fracture had healed ().\nThe patient was referred back to our orthopaedic clinic after two years by her general practitioner with complaints of recurrence of right heel pain with no history of trauma. On clinical examination there was tenderness around the talus and painful restriction of ankle and subtalar movements. Radiographic examination revealed a fracture of the talus (). An MRI scan of the foot and ankle showed insufficiency fracture of the head of the talus (). She was treated in a moon walker boot and 5mg of intravenous Zolendronic acid as a bolus dose. She was asked to continue with oral Alendronic acid 10mg on alternate days for 12 weeks. The patient was reviewed at 12 weeks. There was no tenderness around the talus or calcaneus. A repeat radiograph showed that the fracture of the talus had healed (). She has been on yearly review since. |
A 3-year-old girl accidentally fell from a chair while playing with her brother; she had been holding a pencil in her hand. She was found lying on the floor with the pencil sticking out from just below her right ear. She removed the pencil immediately by herself and subsequent oozing stopped spontaneously. Her mother reported that the pencil had been fully intact upon removal, and thus it was presumed that it had been completely removed from her neck.\nOn admission, she was alert and crying while seen by the physician. Physical examination revealed a 5 mm laceration accompanied by a small hematoma in front of her right ear lobe []. No other injuries were found. However, her facial movement was asymmetric while she was crying, with no movement of the corner of the mouth and brow on the right side []. In addition, she could not close her right eye tightly. Those findings suggested a right facial nerve injury, which could be either central or peripheral. To rule out intracranial pathology, a CECT was performed. No evidence of intracranial injury or cranial bone fracture was found. CT revealed swelling of the right parotid gland with heterogeneous enhancement and free air just in front of the right carotid sheath [], which suggested that the object penetrated through the parotid gland to that depth. No extravasation was noted.\nA clinical diagnosis of peripheral facial nerve injury was made. It was thought that the facial nerve was damaged just outside of the stylomastoid foramen due to her clinical manifestations. Conservative management was chosen because impalement injuries have the aspect of blunt injuries, and we did not believe that the facial nerve was transected. In addition, surgical intervention would have required a large incision to her face, which may have been associated with cosmetic problems later. She was admitted for observation and intravenous antibiotics. She had an uneventful course. But her facial nerve paralysis did not recover, and she was discharged 4 days after her injury. She is still being followed in an outpatient clinic, and gradual neurologic improvement has been observed at 3 months after discharge. |
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 ().\nThe 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.\nThe 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.\nThe 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. |
A 45 years old male patient, attended the neurology emergency department on 3rd January 2016 due to right limb numbness for 6 days and convulsive seizure for 3 days. Six days before the hospital visit, the patient experienced numbness in the right upper limb and instability while holding without obvious incentive but did not seek immediate medical intervention. Three days before admission, the patient experienced convulsive seizure in the right upper limb while remaining conscious, which was relieved after 1 min. Similar attacks occurred intermittently on six further occasions. The patient had a 3-year history of hypertension with the highest blood pressure being 180/110 mmHg. He also had a history of smoking and drinking lasting more than 30 years. He was born and has always lived in Beijing, with no history of contact with infested water, infectious zone, other radioactive substances or toxins. Upon admission, the patient was examined to be obese with no subcutaneous nodules. Neurological examinations showed full level muscle strength in the right upper limb, accompanied with diminished needling response. Emergency head CT scan (2016-1-1) showed lower density in the left parietal lobe. As the patient manifested as an acute onset of right limb weakness and hemiparesis,with low density lesions in the left occipital lobe on CT and a history of hypertension, the patient was hospitalised with a preliminary diagnosis of acute stroke and secondary epilepsy.\nAfter hospitalisation, head MRI scan (2016-1-4) displayed a lesion in the left parietal lobe of unknown nature. After enhancement in the magnetic field, a larger area of oedema was found around the lesion in the left parietal lobe which could indicate glioma or other inflammatory diseases. Since the nature of the brain lesion did not match the characteristics of common cerebrovascular diseases, intracranial angiography DSA was used but found no obvious vascular abnormalities or stenosis. Further examinations including lumbar puncture, immune rheumatoid factors and parasite antibody detections were carried out. A raised cerebrospinal fluid pressure was found to (215 mm H2O) with no red or white blood cells present. After consultation within the neurology department, intracranial tumor was considered and therefore prepared for stereotactic biopsy of the brain. At this point, pathology results came back positive for Spirometra mansoni IgG. On further questioning the patient admitted that he had drank tap water and eaten frogs when travelling in another province during June–September 2015. Given his medical history, and results from head MRI and blood tests, the patient was considered to be infected with Spirometra mansoni and surgical intervention or antihelmintic chemotherapy was recommended .\nThe patient accepted pharmaceutical treatment and was given praziquantel (1600 mg, 20 mg/kg) 3 times a day for 10 days. During these 10 days, the patient reported occasional headache and was treated for dehydration before discharge from the hospital. The patient was also administration oral sodium valproate 500 mg 3 times a day to control seizures.\nThe patient was hospitalised again in March and July 2016 and treated with praziquantel (1600 mg,20 mg/kg) 3 times a day for 10 days. His headaches were eased with intravenous infusion of 20% 250 ml mannitol twice a day.\nLumbar puncture (Table Examination of cerebrospinal fluid), head MRI, blood biochemistry, conventional blood analysis and parasite antibody examinations (Table Spirometra mansoni IgG antibody) were also carried out on both occasions. On 13th Jul 2016, the patient was free from numbness and seizures in the upper limb.\nTable displays the laboratory results of lumbar puncture performed on the three occasions when he was admitted to hospital and during the 1-year follow-up appointment. CSF analysis showed normal results except for a few white and red blood cells during his second hospital stay most likely resulting from the procedure itself. Table shows the Spirometra mansoni IgG result on three occasions. Note that the IgG result became negative during his third hospital stay following three courses of praziquantel treatment.,.\nEnhanced head MRI scans were performed during the three hospital stays in January, March, and July 2016. Figure A-A3display head MRI scans performed on 8th January. The scans showedan abnormal horseshoe signal in the left parietal lobe with a low T1WI signal and a high T2WI + FLAIR signal. Enhanced scan showed irregular wreath in the lesion without enhancement in the surrounding. This type of abnormality in the left parietal lobe may indicate glioma. During the second hospital stay, the MRI scan carried out on 17th March showed abnormal small stripes of signal shadow in the left parietal lobe with a decreased range. It also showed clearer abnormal veil-like signal shadow in the left parietal lobe as compared to the previous MRI scan. These results may indicatethe presence of Spirometra within this area of the brain. During the third hospital stay, MRI scan on 7th July detected only minor abnormalities in the bilateral frontal lobes and parietal lobes indicating that the lesions has reduced significantly or resolved. The follow-up on 12th December showed no abnormality in the head MRI scan. MRI scans from each hospital visit are shown in Fig. . |
A 70-year-old, African male cadaver (height 175 cm, weight 69 kg) showed another type of unilateral variation of the length (elongation) and course (looping) of the middle portion of the cervical part of his right ICA. The cause of death for this patient was an advanced prostate cancer with numerous retroperitoneal metastases in the region of the posterior abdominal wall. There was a significant hypertrophy of the urinary bladder (capacity of it was more than 1 liter) distention of both ureters and hydronephrosis of both kidneys with the renal failure. We did not notice any signs of other diseases or pathological conditions during the process of anatomical dissection of this cadaver.\nThe right ICA of this patient arose from the CB of the right CCA at the level of the middle third of C3 vertebra (symmetrical to the left ICA). The cervical part of the right ICA (diameter 6 mm) first ascended 40 mm from the site of bifurcation of the CCA (width of CS was 14 mm) in front of the transverse processes of C3, C2 and C1 vertebrae. At the level of C1 the ICA started a looping course (Fig. ) where it sharply turned downwards making the upper bend and descended 22 mm along the anterior surface of the ICA. This part of the right ICA has formed a descending limb of its loop (Fig. ). At the level of the upper border of the body of C2 vertebra the ICA sharply curved upwards making the lower bend and ascended 22 mm along the medial surface of the ICA thus forming an ascending limb of its loop. This limb crossed the level of the upper bend thus forming a complete loop and continued ascending 13 mm more upward and anterolaterally on the lateral wall of the pharyngeal recess toward the external opening of the CC, which it entered obliquely. Due to anterolateral direction of the ICA approaching the external opening of the CC, it entered this canal obliquely (similarly as in the first case) making with the plane of the inferior surface of the cranial base a sharp angle open posteromedially. The course of the petrous part in the CC was first upwards and anterolaterally and then, after its sharp bend in the genu, horizontally and anteromedially. The diameter of the fourth part of the right vertebral artery was about two times larger of its fellow on the left side.\nThe looping of the right ICA was located at the level C1 – C2 vertebrae anterolaterally to the longus capitis muscle. The VN and the IJV were located posterolateral to the loop. The latter was tightly packed within the carotid sheath and before its dissection the thickening of the carotid sheath was observed and interpreted as an arterial aneurism or a tumor. Even it resembled a large lymph node rather than the ICA itself. This thickening bulged the right wall of the nasopharynx inward and was located below and posteriorly to the nasopharyngeal opening of the auditory tube in the region of the palatopharyngeal sphincter (ridge of Passavant). The left wall of the nasopharynx did not have any bulging. The upper end of the right SCSG was located just posteroinferiorly to the lower bend of the loop (Fig. ). The ICA below its loop was surrounded by two nerves the jugular and internal carotid originating from the upper end of this ganglion. The jugular nerve ascended to the cranial base on the posterior surface of the loop and on the highest portion of the cervical part of the ICA, whereas the internal carotid nerve crossed the artery medially and ascended on the anterolateral surface of the loop and on the upper portion of the ICA toward the CC. Anteriorly, this loop related to the connective tissue space containing the ascending pharyngeal artery, the pharyngeal venous plexus, the levator tympani and the lateral pterygoid muscles. The occipital artery, stylopharyngeus muscle and glossopharyngeal nerve related to the lateral aspect of the arterial loop. The isolated specimen of the right ICA with the loop, which shows all its parts and the ruler, is presented in Fig. .\nThe loop has significantly increased the total length of the cervical part of the right ICA, which constituted 97 mm. The course of the petrous, cavernous and cerebral parts of the right ICA was identical to the course of the left ICA and it corresponded to the common standard. The left ICA had its width at the beginning of the CS 14 mm, length of the cervical part 50 mm and diameter 6 mm. Apart from the above two cases of the unilateral elongation of the cervical part of the ICA its length in all other cadavers was more or less symmetrical on both sides ranging from 48 to 66 mm. The ICA ascended to the CC by a spiral course and was entering it obliquely in anterolateral direction forming with the plane of the cranial base an angle open posteromedially. The size of this angulation was a subject of individual fluctuation. The level of CB was mainly opposite the middle third of C3 vertebra. The size of the fourth part of the right and left vertebral arteries was also more or less identical. |
A 32-year old manual laborer, right-hand-dominant man presented in the Orthopaedic Outpatient Clinic of the local hospital with a two-year history of numbness and tingling sensation in the palmar surface of left hand and fingers. During the last six months the patient reported also burning pain in the same area – causing him to wake up frequently during the nightime hours – and progressive inability to perform his regular occupation. No episode of trauma or other medical problems were mentioned. All the symptoms were attributed to carpal tunnel syndrome and the diagnosis was confirmed with median nerve conduction study (NCS). Through a classical open palmar approach subsequent release of the transverse carpal ligament was performed. According to surgeon's operative report, there wasn't any reference for any pathology in the dissected area except from the severely compressed median nerve. However, postoperatively, the patient experienced only partial and temporary relief of his symptoms without improvement of hand function.\nThree months after the surgical procedure, the patient was referred to our department for further investigation. On physical examination, the palmar aspect of the left hand and the area of the previous incision were tender to palpation and swollen while a slight atrophy of the thenar muscles was apparent. There was a sensory loss in the area innervated from the median nerve as compared with the controlateral hand and Tinel's sign was evoked over the median nerve at the wrist. The patient had decreased grip strength while passive flexion and extension of fingers were painful. As a result, additional investigation was deemed necessary and magnetic resonance imaging (MRI) was selected for delineating any potential pathology in the carpal tunnel or the surrounding tissues. MRI showed a misdiagnosed, volarly placed soft tissue mass with well-defined margins and an ovoid shape which was in direct contact with the flexor tendons (Figure ).\nBecause of the persistent symptoms and the radiographic abnormalities, surgical exploration and tumor resection were scheduled. Under axillary block a well-circumscribed, encapsulated mass in the deep palmar tissues was identified causing significant compression of the median nerve. The tumor was adhered to the third flexor digitorum tendon superficialis and it was moving within the tendon during flexion or extension of the middle finger (Figure ) (See additional file ). No vascularity or connection with the deep volar arch was evident. The mass was completely removed from the adjacent tissue and the histological examination of the surgical specimen revealed spindleshaped cells arranged in fascicles with cigar-shaped nuclei and eosinophilic cytoplasm. The smooth muscle nature of the tumor was confirmed immunohistologically by a strong reactivity against smooth muscle actin (SMA) and a negative reaction against S-100 and epithelial membrane antigen (EMA). No significant cellular pleomorphism or mitotic activity was noted. The above findings were compatible with leiomyoma (Figure ).\nAt the two-year follow-up evaluation, the patient showed no evidence of recurrence of the mass and no pain or sensory dysfunction. He had a significant improvement in hand grip strength and he returned to his previous occupation. |
A 57 year old Hispanic male who smoked for one year initially presented with lower back pain that eventually progressed to increasing upper back pain. An orthopedic surgeon performed an MRI scan which revealed multiple metastases to the thoracic spine. An initial CT scan revealed a right lung mass and a subsequent bronchoscopy revealed a non-small cell lung cancer consistent with poorly differentiated adenocarcinoma. For first line therapy, he received one cycle of carboplatin and docetaxel which was tolerated well with only mild nausea. He completed four cycles of chemotherapy and a pathology report identified an EGFR exon 19 deletion. The patient started on erlotinib, an EGFR inhibitor, at 150 mg capsule per day taken by mouth without food or on an empty stomach 1 h before or 2 h after food. Patient was also advised to avoid sunlight while on therapy due to skin toxicity. He tolerated it well and had clinically responsive disease as well as a decrease in primary mass from 5 cm to 2.8 cm on CT scan for over a year until he had started developing worsening back pain and complications caused by papulopustular lesions as well as paronychia and xerosis. He also developed a Klebsiella folliculitis which necessitated discontinuation of the trimethoprim-sulfamethoxazole that he had been taking for the acneiform lesions and a brief course of ciprofloxacin that had led to the resolution of the papulopustular eruption.\nHe also started to have persistent elevation of carcinoembryonic antigen (CEA) level from 5.4 ng/ml rising steadily to 13.4 ng/ml and eventually rising exponentially to 24.3 ng/ml but continued on erlotinib, dose reduced to 100 mg one capsule per day, due to stable MRI scans. Patient was evaluated for a possible surgery on the spine but was unfortunately not a surgical candidate. A CT of the chest with and without contrast reported significant primary site progression of bilateral varying size small lung nodular lesions, consistent with metastatic. The right infrahilar nodular mass also increased from 2.1 × 1.5 cm to 2.8 × 2.4 cm. Clinically he was progressing and he underwent a fine needle biopsy on the right lung mass and pathology reported moderately differentiated metastatic adenocarcinoma. Tissue was sent for molecular testing via next generation sequencing with CLIA-certified Foundation Medicine multi-gene assay and a blood draw was performed for liquid biopsy utilizing the Guardant 360 platform, which are both comparable to the cobas EGFR tissue test and plasma ctDNA test in the AURA3 trial. While awaiting the results, erlotinib was stopped and he was given one cycle of carboplatin AUC 5 and pemetrexed 500 mg/m2. Soon afterward liquid biopsy report returned and was shown to be positive for a T790 M mutation that is a mechanism of acquired resistance to EGFR tyrosine kinase inhibitor (TKI) therapy. Liquid biopsy utilizing the Guardant 360 platform also detected ten other mutations; EGFR exon 19 deletion, TP53 R196Q mutation, FGFR3 L406R mutation, VHL S65A mutation, RHOA E47K mutation, APC D1512N mutation, NTRK1 T360 T mutation, PDGFRA I497I mutation, FGFR2 E767K mutation, BRCA1 E962K mutation.\nBased on the T790 M mutation he was started on osimertinib, at 80 mg tablet per day taken by mouth, and tolerated it well. A few weeks into the osimertinib treatment the tissue biopsy test reported five mutations, CDK4 amplification, MDM2 amplification, FRS2 amplification, GLI1 amplification as well as the EGFR exon 19 deletion and nine variants of unknown significance; EP300 M2372 V, GNAS P345R and P349_I357del, IRF4 A341V, MED12 Q2120_Q2121 > HQQQQQ, MET D1373H, MLL A53V, SMARCA4 A1186_Q1187del, SOX9 A481T, SPTA1 R1077C. However, tissue biopsy test did not detect a T790 M mutation showing discordance between the tissue biopsy and the liquid biopsy. He continued on osimertinib treatment and a Chest CT (Fig. ) scan ten months into the treatment showed a decrease in the right lower lobe mass and numerous bilateral pulmonary nodules had either significant decrease or resolved. There were also stable widespread osseous metastases. This was noted to be a partial response and it was decided that the patient will continue on osimertinib. He has tolerated osimertinib well with only symptoms of a mild rash and low platelets which quickly stabilized without dose adjustment. |
A 66-year-old female was referred to our hospital with a 9-month history of left knee pain. The patient recalled no trauma about the affected knee. She had felt a soft mass gradually growing around the posteromedial aspect of her left knee 3 months before her initial visit. She was 154 cm in height and body weight of 50 kg with negative findings from blood and urine examinations. Clinical examinations of the left knee revealed a palpable elastic soft mass that measured around 4 cm × 3 cm with tenderness of the posteromedial aspect of the knee. The range of motion was full but painful snapping of the hamstrings could be reproduced over the mass on active flexion and extension in an arc of 30 to 60 degrees (Video 1 in Supplementary Material available online at ). No swelling, warmness, erythema, tenderness, or hydrops was found other than the medial mass about the knee. A McMurray test elicited pain over the medial aspect of the joint line. No instability was found. Plain radiography revealed grade II osteoarthritis by Kellgren-Lawrence classification in the medial compartment of the left knee. On magnetic resonance images (MRIs), a voluminous lobulated mass measured 40 mm × 23 mm × 20 mm with low intensity on T1 weighted images and high intensity on T2 weighted images was noted just under the flattened sartorius muscle on the posteromedial aspect of the knee (). Multiple small cysts extending from the major cyst to the posterior and anteromedial aspect of the knee were also noted (). A horizontal tear of the middle and posterior segment of the medial meniscus with a communicating tract to the cyst were identified (Figures and ). A diagnosis of a medial meniscal cyst communicating with the horizontal medial meniscal tear with clinical presentation of snapping by the sartorius muscle over the cyst was made.\nArthroscopic surgery was performed under general anesthesia after informed consent was obtained from the patient. Anterior and posterior cruciate ligaments, cartilage in the lateral compartment, and lateral meniscus were normal. Cartilage of both the medial femoral condyle and tibial plateau had degenerated to grade II by Outerbridge classification. Extensive horizontal tear of the middle and posterior segments of the medial meniscus was identified (). Partial meniscectomy of the torn meniscus was performed until the medial capsule was exposed. Viscous reddish intracystic fluid was aspirated through the 16-gauge introducer needle inserted to the capsule between the upper and lower leaf of the horizontally torn meniscus. A small channel was created at the site where the introducer needle was inserted; creation of the small channel caused a massive amount of bloody viscous fluid to explode into the intra-articular cavity, enabling the medial large mass to disappear (Figures –). Arthroscopic procedure for cyst decompression was provided in Video 2. Full weight bearing gait and full range of motion of the knee were allowed with an elastic bandage on the knee from 1 day postoperatively. The patient's postoperative course was uneventful. Snapping around the medial aspect of the knee disappeared completely immediately after the operation. Magnetic resonance images taken 9 months after the operation revealed all cysts including the medial large one and posterior and anteromedial multiple daughter types disappeared completely (Figures and ). The patient felt slight pain from the medial joint space during gait but she had no difficulty with activities of daily living 2 years postoperatively. |
A 64-year-old male who presented with constipation and diarrhea for 2 days was admitted to our hospital in order to investigate sudden fresh blood in stool around 1,000 mL prior to 1 h. At the same time, he was associated with dizziness and fatigue. The patient was diagnosed as acute pancreatitis and was treated conservatively with good outcome 3 years previously. He was a chronic alcohol abuser, consuming about 200 mL of alcohol daily for the preceding 30 years. On physical examination, his heart rate was 90 BPM and blood pressure was 100/70 mm Hg. He appeared pale and there was no abdominal mass found on palpation. Blood routine examination showed decrease of the hemoglobin values down to 8.4 g/L, a clue of the presence of active bleeding. Intravenous fluid administration and whole blood transfusion of 400 mL were administered. During 12 h of hospital stay and bowel preparation for colonoscopy, the patient had experienced six episodes of hematochezia approximating 1,700 mL. Six units of packed red cell transfusion and intravenous fluids were given following these events. Emergent colonoscopy showed a lot of blood clot at the location of colonic splenic flexure 70 cm distal to anus and the colonoscopy was difficult to pass it, but there was no mass or ulcerative lesions detected. Subsequent emergent DSA of superior mesenteric artery and inferior mesenteric artery did not reveal any abnormalities (). Angiography of celiac trunk was neglected because of suspicious bleeding source from lower gastrointestinal tract. Then abdominal contrast-enhanced CT scan was required for searching the source of gastrointestinal bleeding. Axial CT images and its reconstructed images after contrast injection revealed pancreatic pseudocyst and splenic arterial pseudoaneurysm within it (), an uncommon complication of chronic pancreatitis. Simultaneously, partially ill-demarcated margin with colon and presence of scattered air bubbles within pseudocyst were also seen, a direct evidence suggesting communication between pancreatic pseudocyst and splenic flexure of colon (). So, exploratory laparotomy was necessary to be performed immediately.\nIntraoperative findings showed cystic and solid mass at the tail of pancreas with irregular shape measuring 10 × 8 × 7 cm. The mass had partially well-circumscribed margin and the rest was adhering to splenic hilum and adjacent segment of transverse colon. The cyst was dissected and was found to communicate with colon. Meantime, there was also opening of splenic artery rupture about 0.2 cm and distal splenic arterial pseudoaneurysm. So, splenectomy, pancreatic tail resection and splenic flexure resection were performed together. Histopathological examination showed pancreatic pseudocyst with chronic inflammation, multiple colonic ulcers and a perforation between pseudocyst and colon (). Post-operative course was uneventful and the patient was discharged from hospital on the postoperative 2 weeks. The patient was free of disease on the 2 years follow-up. |
A 15-year-old male patient visited our hospital with complaints of limitation of ROM in the left knee and inability to walk for 9-months. Nine months prior, he visited a local hospital after a motorcycle traffic accident and was diagnosed with an open fracture of the left femur shaft and an intra-articular fracture of the proximal tibia. He underwent an operation using the Ilizarov external fixator at the femur and tibia. Two months after the first surgery, the Ilizarov fixator was removed and changed into a monoaxial external fixator for the left femur and converted to internal fixation with a screw for the left tibia. One month later, he underwent an operation for conversion to internal fixation with intramedullary nailing of the left femur. At that time, he underwent manipulation of the knee joint for ankylosis. On physical examination at the initial visit to our hospital, he had tenderness and dimpling in the superior aspect of the patella and markedly decreased mobility of the patella (including mediolateral and superoinferior translation). He had quadriceps atrophy (a 3-cm decrease in mid-thigh circumference as compared to the contralateral limb). His left knee ROM was between flexion contracture of 30° and further flexion of 90°. On plain radiographs, nonunion of the left proximal tibial fracture and femur shaft fracture were shown. The lateral radiograph revealed a fracture in the superior pole of the patella and patella infera (). The ultrasound showed discontinuity of the quadriceps muscle fiber and hypoechoic hematoma ().\nUnder the presumptive diagnosis of a chronic quadriceps rupture with a patellar superior pole avulsion fracture of the left knee and nonunion of the left proximal tibia fracture, we performed quadriceps reconstruction using tibialis anterior allograft tendon and additional screw fixation. Initially, after removal of the fibrotic nonunion site, 2 cannulated screws were used to fix the nonunion fragment of the proximal tibia at full flexion of the knee (). The fracture site was stable enough not to need any procedure such as additional plating and bone grafting. The quadriceps rupture was repaired via primary end-to-end repair using heavy nonabsorbable sutures placed in running locked fashion using a Krackow technique in both the proximal and distal ends of the tendon. Suture ends are then tied together with the knee in full extension. Thus, proximal and distal ends of the ruptured quadriceps tendon was approximated with Ethibond (Ethicon, Somerville, NJ, USA) suture and additionally fixated with a roll wire to augment tendon repair. Drilling and insertion of a Steinmann pin through the patella was done and a 7-mm diameter tibialis anterior allograft was inserted through the holes. The ends of the allograft were pulled into the holes in the patella and finally augmented at the proximal end of the quadriceps tendon while the leg was in full extension ().\nAt 3 weeks postoperatively, the patient participated in gentle ROM exercises and quadriceps and hamstring exercises were concomitantly applied. Three months after surgery, the left knee ROM was between 5° of flexion and further flexion of 60°, and bony union was obtained. Partial weight-bearing was allowed after postoperative 5 months, and progressive improvement of knee motion was observed. At the 12-month follow-up, he could walk without aid. On the last outpatient follow-up at postoperative 30 months, the left knee ROM was between 5° of flexion and further flexion of 130° with persistent mild quadriceps atrophy and 1-cm leg length discrepancy ( and ). |
A 82- year old male patient, with the only known comorbidities being hypercholesterolemia and sigmadiverticulosis, presented to a nearby hospital with productive cough and progressive dyspnea in the last 14 days. Chest x-ray showed a right lung opacification with pleural effusion. Subsequent chest CT scan revealed a 180° degree counterclockwise torsion of the whole right lung with partial atelectasis of the lower lobe and middle lobe as well as venous congestion and complete atelectasis of the upper lobe (Fig. ). The patient was then transferred to our thoracic surgical unit for further treatment. Upon arrival in our department a chest tube was placed on the right side and 1 l of pleural fluid was evacuated. Furthermore bronchoscopy was performed, showing torsion of the right mainstem bronchus with complete obstruction of the upper lobe. The intermediate bronchus showed even more profound rightward torsion with partial obstruction of the middle and lower lobe orifice (Fig. ). After drainage 12 h later a follow-up CT scan was performed, which showed complete evacuation of the pleural effusion with better ventilation of the middle and lower lobe but persistent lung torsion with suspected pulmonary venous occlusion and venous congestion of the upper lobe. A tumor was not suspected, but could not be excluded due to massive congestion of the whole upper lobe. Therefore the patient was taken to the operating room for diagnostic thoracoscopy. As suspected, the entire right lung was torqued in a 180-degree counterclockwise direction. Since thoracoscopic detorsion could not be achieved and the whole upper lobe showed hemorrhagic infarction, we converted to thoracotomy and performed anatomic resection of the right upper lobe (Fig. ). The upper lobe vein was centrally compressed by a tumor resulting in venous congestion and finally hemorrhagic infarction of the entire upper lobe. This finding was also confirmed by the pathologist who diagnosed a central bronchial adenocarcinoma in the upper lobe with compression and invasion of the upper lobe vein and additional hemangiosis carcinomatosa. The patient had an uneventful post-operative course and was discharged home in good condition on postoperative day 6. Because of concomitant malignant pleural effusion an adjuvant chemotherapy was recommended.\nUnfortunately the patient died 2 months later due to rapid tumor progression. |
Patient is a 52-year-old white female with newly discovered breast cancer. The breast tumor was discovered incidentally. Surgery was performed to remove the tumor and patient was scheduled to see the pharmacist for a PGx consult the next day. Previously, her surgeon enrolled her in a PGx study and ordered PGx testing to assist in pain management post-surgery. (Table I) This surgeon is an institution PGx champion and has discovered panels are useful in pain management post-op and in the discovery of unrelated, actionable medication related problems (MRPs). The ordering of the panel testing begins with an order being placed in the electronic medical record (EMR). The patient then either goes to the onsite lab to provide a cheek swab DNA sample or a lab kit is sent to the patient’s home for them to provide the cheek swab sample there to mail back to the lab. If the sample is obtained at home, a return envelope is provided the patient in the lab kit so they can return the sample to the lab. Onsite lab results are available in as little as eight days, kits sent to the patient’s home usually takes two to three weeks. This patient was enrolled in a pain study and the incidental findings of this case occurred when the patient was interviewed as a study patient.\nA PGx panel of 27 genes was utilized and findings reviewed with the patient by the PGx pharmacist. A sample of what such a panel would look like is provided. () Though there were no significant gene-drug interactions associated with pain management, significant, incidental findings were discovered relating to other current and potentially future therapies. Notably after PGx panel testing, the patient was found to be at increased risk of thrombosis associated with Factor V Leiden (F5). Intermediate CYP2C19 status indicated poor conversion of clopidogrel to the active form to prevent clotting with clopidogrel treatment. Upon interacting with the patient it was also discovered she had clot formation after a previous surgical procedure.\nPGx panel testing indicated she is an extensive (normal) metabolizer of CYP2D6. CYP2D6 is the primary gene that produces the enzyme converting tamoxifen from the inactive form to the active form endoxifen. This active form competes with estrogen for receptor sites in certain breast cancers to block the proliferative effect on cancer cell growth. Tamoxifen is standard therapy in patients who have had breast cancer surgery and/or radiation treatment. It is typically taken for 5 years after initial treatment for cancer PPx to prevent the cancer from recurring. CYP2D6 normal metabolizers metabolize tamoxifen normally so there is usually no reason to not use tamoxifen cancer recurrence PPx. |
An 81-year-old Japanese male visited our hospital with chief complaints of a palpable mass and dull pain in the left upper quadrant, loss of appetite, and weight loss of 5 kg within two months. He started noticing the mass in the left upper quadrant and the other symptoms in late July 2017. He was admitted to our hospital for detailed examinations and treatment in August 2017.\nHe had high blood pressure and chronic kidney disease. He had a clear sensorium. His body temperature was 36.7 °C. He showed no yellowing of the bulbar conjunctiva, palpebral conjunctival pallor, or abnormal findings in the skin and intraoral mucosa. There was a palpable elastic, soft mass in the left upper quadrant. Although he felt a dull pain in that area, there was no obvious tenderness. There were no palpable superficial lymph nodes nor abnormalities in the extremities. His laboratory findings on admission are shown in Table .\nBecause the results of biochemical tests indicated renal damage, plain abdominal computed tomography (CT) was performed. An irregular tumor of approximately 130 mm × 120 mm × 80 mm in size was observed in the left upper quadrant, which corresponds to the transverse colon. No intestinal distention was observed on the oral side of the tumor. Moreover, the tumor was in close contact with the pancreatic body and tail, and the gastric corpus greater curvature, suggesting invasion into nearby organs. Also, mildly enlarged lymph nodes were observed at the periphery of the tumor (Fig. a and b).\nThe total colonoscopy (TCS) performed six days after his first visit revealed a tumor with a circumferential ulcer covered with a thick slough in the splenic flexure of the transverse colon. Moreover, the marked thickening and inflammatory changes of the surrounding mucosa made it difficult for the endoscope to pass through, although the lesion had not yet developed into an intestinal obstruction (Fig. a and b). Histopathological analysis of several specimens of the tumor was performed, but the findings at that time were only erosion of the mucosa with moderate inflammatory cell infiltration and regenerative changes in the mucosal epithelium. Although a definitive diagnosis was not yet made at that time, we recommended an exploratory laparotomy because of intestinal stenosis. However, he requested a second opinion. While undergoing tests to obtain a second opinion from another hospital, he became aware that the palpable mass decreased in size. Furthermore, a follow-up CT performed after he obtained a second opinion (36 days after the first CT) showed that the tumor had regressed spontaneously and the swelling of small lymph nodes around the tumor had disappeared (Fig. c and d). Therefore, TCS was reperformed 41 days after his first visit to our hospital. The tumor had decreased in size and the inflammatory changes in the surrounding mucosa tended to improve; however, tightening of the surrounding mucosa due to scarring (Fig. a) and the continuous narrowing of the intestine over a length of approximately 30 mm were observed (Fig. b). Histopathological analysis of a biopsy specimen of the periphery of the tumor showed widespread erosion of the mucosa and the formation of granulation tissue with marked infiltration of inflammatory cells consisting of small lymphocytes, plasma cells, histiocytes, and medium-size atypical nucleated cells in the mucosal tissue. Some of the B-lymphocyte antigen CD20-positive B cells (CD20-positive B cells) identified by immunohistochemical analysis were also found to be positive for Epstein–Barr virus (EBV)-encoded small RNA (EBER)-1 by in situ hybridization (ISH), suggesting the high possibility of EBV − positive mucocutaneous ulcer (EBV-MCU) (Fig. a, b, and c). Forty-eight days after his first visit, while he was being prepared exploratory laparotomy, he started to suffer from constipation and intermittent abdominal pain. Because plain abdominal CT revealed intestinal distention on the oral side of the narrowed area in the transverse colon, the patient was diagnosed as having intestinal obstruction and underwent decompression by transanal ileus tube insertion (Fig. e and f). Therefore, although the definitive diagnosis was not yet confirmed histopathologically, transverse colon segmental resection was performed with the patient’s fully informed consent. The resected specimen showed an ulcer of 35 mm × 25 mm in size with narrowing of the intestine (Fig. d). The histopathological analysis of the specimen revealed marked inflammatory cell infiltration and fibrosis in all layers of the colon wall. Most of the infiltrating cells were lymphocytes and plasma cells. Also, Hodgkin and Reed–Sternberg (HRS)-like multinucleated large B cells were found scattered (Fig. e and f). A large proportion of CD20-positive B cells identified by immunohistochemical analysis were also found to be positive for EBER-1 by ISH, similarly to the postoperative immunohistochemistry test. No apparent clonal growth of lymphocytes was shown by the flow cytometry of the resected specimen. No dividing cells were identified by G-banding differential staining. Taking these findings together, he was finally diagnosed as having EBV-MCU. No recurrence was observed 20 months after the surgery. |
Our patient is a 48 year old woman with a screen-detected left breast cancer. She was found to have an abnormal bilateral screening mammogram which demonstrated a suspicious area of architectural distortion in the right breast and an obscured nodule in the left breast. This prompted further imaging with diagnostic mammogram and ultrasound. This was especially concerning for a solid microlobulated nodule in the left breast measuring 7 mm in size at 3:00 and a persistent suspicious area of architectural distortion in the right breast with two adjacent simple cysts. Bilateral breast biopsy was performed. Ultrasound guided core biopsy of the suspicious right breast lesion was consistent with sclerosing adenosis with usual ductal hyperplasia. No atypia or malignancy was noted. Ultrasound guided core biopsy of the left breast lesion was consistent with grade 2 invasive ductal carcinoma, ER 10%, PR 0%, Her2/neu negative (1+), Ki 67 1%. Bilateral breast MRI was performed which showed no suspicious lesions in the right breast and a 2–3 mm ovoid rapidly enhancing nodule with plateau kinetics reflecting a portion of the originally biopsied cancer. No other suspicious lesions were noted within the left breast, left axilla, or internal mammary chain. Her case was reviewed, and the multi-disciplinary decision was to proceed with breast conservative surgery first. She was taken for right partial mastectomy and left partial mastectomy with sentinel node biopsy. Final pathology of the right breast did not show any evidence of malignancy. Initial pathology of the left breast was initially concerning for a biologically unfavorable invasive ductal carcinoma, NOS type. However, further pathologic review revealed that the patient had a grade 2, 8 mm secretory carcinoma. The diagnosis of secretory carcinoma was suspected based on histologic findings which included a microcystic and tubular growth pattern with luminal secretions. The tumor cells were polygonal with eosinophilic to foamy cytoplasm, round nuclei with inconspicuous nucleoli. Mitotic activity was minimal. The morphologic findings of a likely secretory carcinoma were confirmed by FISH studies demonstrating a ETV6-NTRK3 translocation. A healing biopsy site was noted within the specimen. There was no associated DCIS. No LVSI was noted. The margins were widely negative (closest margin was 7 mm from the posterior margin). Five sentinel nodes were sampled of which none contained metastatic disease. The tumor was ER 5%, PR 0%, HER2/neu negative (1+), Ki 67 <10%. She was staged as a pT1bN0(sn). |
A 68-year-old woman was referred to our department in February 2008 for a second opinion regarding a metastatic urothelial carcinoma. Her history began six months prior to her visit when she presented with recurrent urinary tract infections. A cystoscopy and TUR revealed a high grade infiltrating urothelial carcinoma in the lateral right wall of the bladder (T2a). Staging CT scans were performed and showed metastatic disease mediastinal and hiliar lymph nodes, multiple and bilateral lung nodules, and metastases located in the internal iliac lymph nodes. The patient was initially treated with six cycles of chemotherapy with gemcitabine 1200 mg/m2 on day 1 and 60 mg/m2 cisplatin on days 1 and 8 every 21 days, showing a partial response after three cycles. The disease was followed up until January 2009, when imaging studies demonstrated the presence of a single metastatic lesion in the left lower lung lobe. A second line of chemotherapy using carboplatin AUC = 3 on day 1 and 1500 mg/m2 gemcitabine on day 1 every 15 days was initiated, and after eight cycles, new progression of the described lung lesion was documented. A third line of chemotherapy was proposed, and in June 2009, the patient was started on cisplatin 60 mg/m2 and pemetrexed 500 mg/m2 day 1 every 28 days. She had a partial response after two cycles, and after four cycles of chemotherapy, a slight increase in the size of the left lower lung nodule was revealed on the CT scan, although a bone scan was negative.\nWith the diagnosis of a recurrence of a single lung metastatic nodule measuring 56 × 53 × 51 millimeters, in October 2009, a hypo-fractionated course of SBRT was delivered to the lung nodule. This patient was placed in a supine position and was immobilized using an alpha cradle device to improve the reproducibility of the setup during daily treatments. A planning CT scan was performed. A combination of three sets of CT scans obtained during free breathing, deep inspiration and deep expiration were used to generate an internal target volume (ITV) that accounts for respiratory motion. The gross tumor volume (GTV) was the lung nodule, and the clinical target volume (CTV) included the ITV with a symmetric 0.5 cm margin. Respiratory tumor movement was observed under fluoroscopy. The delimited organs at risk (OARS) and the applied constraints are listed in Figure .\nA 3D-conformal multifield technique was used with six coplanar and one non-coplanar statics beams. SBRT was delivered by a linear accelerator (Oncor, Siemens, Palo Alto, California, USA) with 6-MV photons. A total dose of 48 Gy in three fractions over six days was prescribed to the 95% of the CTV (Figure ). Patient positioning and isocenter verification were checked using cone beam CT. |
A 60-year-old woman, gravida 3 para 2, presented with a growing mass at the left side of a cesarean section scar (lower abdominal longitudinal incision). She had no relevant medical history and had undergone cesarean section twice, the first in 1977 due to breech presentation and again in 1979. She had no pertinent family history other than breast cancer diagnosed in her sister and had experienced menopause at 50 years of age.\nThe patient noticed the nodule near the abdominal operation scar with no tenderness 4 years before presentation. The nodule grew quickly in size with no significant pain, even during menstruation. Physical examination revealed a smooth mass measuring 4 cm in diameter on the middle-left side of the cesarean median scar (). A biopsy of the mass showed atypical cells, and subsequent pelvic magnetic resonance imaging (MRI) showed two lesions, measuring 2.5 × 3.3 cm and 3.3 × 4.0 cm along the abdominal scar (). The mass located at the right side of the scar consisted of solid components, while that on the left was polycystic. There were no obvious mass-like lesions in the intraperitoneal cavity or any of the abdominal or pelvic lymph nodes. Laboratory tests revealed no increase in the serum levels of tumor markers (CEA, CA19-9, and CA125). Radical resection of the abdominal wall mass was performed with adequate margins under general anesthesia. Histopathological examination showed clear cell adenocarcinoma (), suggesting malignant transformation from endometriosis of the abdominal wall. Positron emission tomography (PET) showed no evidence of malignancy, including in the uterus, bilateral ovaries, and pelvic lymph nodes. Considering these findings together, we diagnosed clear cell adenocarcinoma of the abdominal wall arising from endometriosis after cesarean section. Eight months after the resection, a nodular lesion appeared in the patient's abdominal scar again. MRI and PET scan showed local recurrence, and she was hospitalized for resection of the recurring tumor and abdominal wall reconstruction. Histopathological examination showed the lesion to be clear cell adenocarcinoma. At 15 months after the second operation, there was no further evidence of the disease on imaging studies or clinical examination. |
We report a 12 year old girl, who first presented at the age of 8 years for evaluation of recurrent episodes of chest pain not associated with exercise and lasting for several minutes. Echocardiography showed AAOLCA from the right aortic sinus (Fig. 1-3). The coronary artery took a caudal course below the right ventricular outflow tract. In the absence of signs of myocardial ischemia and since the episodes of chest pain had the characteristics of idiopathic chest pain [] we decided to monitor the patient in the first decade without invasive diagnosis. When she was referred again at the age of 12 years she still had short episodes of chest pain but otherwise she was asymptomatic. To exclude possible myocardial ischemia in the presence of the coronary anomaly we now proposed a full cardiac work up. Cardiac MRI showed normal cardiac function. Treadmill testing revealed good exercise capability without signs of myocardial ischemia while bicycle-stress echocardiography showed normal left ventricular function without any regional wall motion abnormalities. 48-h Holter-monitoring showed sinus rhythm without any arrhythmias. Selective coronary angiography, performed under deep intravenous sedation, confirmed origin of the left coronary artery from the right aortic sinus (Fig. 4-5). The left coronary artery did not take an interarterial but rather an inferior, subpulmonic course. This was further clarified by contrast-enhanced computed tomography (Somatom Force, Siemens) which clearly demonstrated the intramuscular nature of this coronary arterial course (Fig. 6-9, ). Furthermore the CT-scan revealed that the anomalous left coronary artery had neither a slit like opening nor an acute angle of take-off from the aorta which have been identified as possible risk factors for myocardial ischemia in patients with interarterial course []. Since the episodes of chest pain had the characteristics of idiopathic chest pain [] and since prophylactic surgery appeared not justified in the absence of documented ischemia we opted for a conservative approach without restriction of exercise or sports activities and recommended annual follow-up visits []. During a follow-up of 2 years the patient remained asymptomatic. |
A 72-year-old Caucasian male patient was admitted to our hospital for excision of the metastatic adenocarcinoma of the skull vertex. It was diagnosed at an outside facility as carcinoma of unknown primary. He was initially diagnosed four years ago, when he presented to his primary care physician for worsening left hip pain, which was accompanied by mild muscular atrophy. A computerized tomographic (CT) scan demonstrated mixed sclerotic and lytic lesions in the left iliac wing. A bone scan demonstrated increased activity in the left sacroiliac joint. Magnetic resonance imaging (MRI) of lumbar spine showed abnormal signal in the left sacrum and ilium, consistent with metastatic disease. This area was biopsied and showed a metastatic poorly differentiated carcinoma, diffusely positive for widespectrum cytokeratin and negative for TTF1. Restaging studies did not demonstrate any other lesions. He was subsequently evaluated by radiation oncology and underwent radiation therapy to the left hip. The patient did well over the next 18 months, when he returned with an enlarged skull mass and received site directed radiation therapy. No biopsy of the skull mass was performed at this visit. He presented again in 6 months with a left tibial lesion for which he was treated with palliative radiation. A biopsy performed at this presentation did not demonstrate any neoplasm. Six-months later, he presented with increasing size of the skull mass and was initiated on chemotherapy with a regimen consisting of carboplatin and etoposide. He did have a moderate response to treatment. However, on follow-up, he was noted to have CT evidence of invasive and enlarging osseous metastasis measuring six centimeters (cm) involving the right frontal bone along with mild localized mass effect on the right frontal lobe. Consequently, he underwent another series of treatment with radiation therapy to the skull mass with a total dose of 35 grays (Gy). Despite an initial response to therapy, he subsequently had further progression of the calvarial mass including cutaneous breakdown, and presented to our institution for care.\nA nuclear medicine PET/CT of trunk showed an intensely FDG avid mass in the posterior left pelvis involving soft tissue and left iliac bone. Additionally, he underwent a subtotal resection of the skull mass, demonstrating anaplastic meningioma (). A CT guided biopsy of left iliac mass also revealed metastatic anaplastic meningioma. An octreotide scan () was performed revealing significant uptake in the left hip and right distal femur for which palliative radiation therapy was recommended, which was administered locally. However, he presented to a local ER soon after completion of radiation therapy with worsening left-sided weakness with CT evidence of cerebral edema. MRI revealed enhancing mass at the site of prior partial resection consistent with progressive disease (). He was no longer a candidate for surgery. Salvage radiation was attempted, but the patient continually to decline, and was ultimately enrolled in hospice for end of life care. |
A 59-year-old Asian male presented to the gastroenterology office for a follow-up of a previously found duodenal lesion. He had an EGD at an outside facility 2 years earlier for evaluation of abdominal pain which showed a 1.2 cm duodenal polypoid lesion in the second portion of the duodenum. Pathology of the polyp revealed heterotopic gastric mucosa with benign lobules of gastric glands. He also was found to have chronically active H. pylori gastritis with numerous Helicobacter organisms and atrophic gastritis with patchy areas of intestinal metaplasia. At that time, he was instructed to follow up for a repeat endoscopy for surveillance in two years. As recommended, two years later he presented to our office for surveillance of his duodenal lesion. Due to his history of atrophic gastritis and a large duodenal lesion, we performed an upper endoscopy that showed atrophic gastritis, duodenitis, and a single 10 mm polyp in the second portion of the duodenum. The duodenal polyp was biopsied. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypia including nuclear enlargement, stratification, nucleoli, and few mitoses. The patient was referred for endoscopic ultrasound to further characterize the lesion and complete resection. Several weeks later he underwent an endoscopic ultrasound that revealed a 13-mm pedunculated and sessile polyp on the lateral wall opposite to the major papilla in the second portion of the duodenum (). The polyp was removed en bloc using a hot snare following a 4-mL saline lift. Two endoclips were placed for hemostasis. Pathology revealed a pyloric gland adenoma (Figures , , and ) with predominantly low grade dysplasia (Figures and ) and some small areas of focal high grade dysplasia. The slides were read by the in-house pathologist and were also reviewed by a GI expert pathologist at the University of Michigan. The patient was recommended to follow up for surveillance upper endoscopy in 6 months due to the areas of high grade dysplasia found on pathology. He was lost to follow-up for over one year. Fifteen months after the PGA was removed, the patient did follow-up for a surveillance upper endoscopy. A duodenal scar was found at the site of the PGA and a biopsy was taken from the site. There was no evidence of residual pyloric gland adenoma. The patient was then recommended to follow up for surveillance endoscopy in 5 years in accordance with the ASGE guidelines for surveillance of gastric adenomatous polyps. |
A 43-year old, asymptomatic woman was admitted to our hospital by her family doctor after receiving a chest-x-ray during routine clinical examination. The x-ray showed a mediastinal mass overlapping the aortic arch region (Fig. ). For verification a computed tomography (CT) was performed and revealed incidentally a type B dissection, which was most likely chronic without information of the index date, originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm (Fig. ). The left renal artery, the coeliac trunc and the main part of the superior mesenteric artery branched from the false lumen without a sign of malperfusion of the organs. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Before intervention the patient got a blood pressure adjustment by ACE inhibitor. Betablocker was not necessary because of a resting pulse under 60 beats per minute. For neurological online monitoring, sensitive and motor evoked potentials were monitored. Spinal drainage was installed 1 day before the procedure. Surgical access was carried out through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space (Hemi-Clemshell). Simultaneously to the preparation of the aneurysm, partial cardiopulmonary bypass was installed in the left groin by cannulation of the femoral artery and vein under echocardiographic guidance. During selective ventilation of the right side, the left lung was mobilized by transsection of the Ligamentum pulmonale and preparation of the perianeurysmatic tissue and adhesions. After identification and preparation of the recurrent and phrenic nerve and the supraaortal branches, the descending aorta was clamped and a distal anastomosis performed with a straight graft (20 mm). The visceral arteries partially branched from the false and true lumen without a sign of malperfusion. Before the final distal anastomosis, we performed a fenestration of the dissection membrane about a length of 5 cm to keep the perfusion of both lumina. The left carotid artery originated from the aortic arch with a distance of only 1 cm from the aneurysm. The left axillary artery branched directly from the aneurysm and was dissected and reimplanted with a separate 8 mm sidegraft to the 20 mm straight graft between the distal arch and proximal descending aorta. (Fig. ). The procedure was performed with partial cardiopulmonary bypass (CPB) of 87 min, aortic clamp time of 62 min under normothermic condition. The patient was extubated on first postoperative day and recovered well.\nBiopsy of aortic tissue showed a picture consistent with arteriosclerosis and loss of smooth muscle cells, rupture of the elastic fibres and fibrosis of the media. The intima could not be visualized in detail.\nThe patient was discharged to cardiac rehabilitation at 13th postoperative day and recovered well. Last follow up with computed tomography was performed 3, 5 years after initial operation with a good and stable result of the dissection membrane and a perfusion of both lumina. The patient is able to resume a normal life without limitations. |
A 24-year-old man was referred to our gastroenterology department for the specialized management of persistent symptoms such as intermittent epigastric and lower abdominal pain that had begun approximately 7 months earlier. The pain had developed gradually and tended to aggravate after meals.\nOne month prior to his referral to our department, the patient had visited a primary outpatient clinic several times and was administered medication to control symptoms, but his symptoms did not improve. The patient was later admitted to a primary hospital for 1 week, where gastroduodenoscopy, colonoscopy, abdominal sonography, and laboratory testing was performed to identify the cause of the symptoms. On the basis of these examinations, he was diagnosed with IBS and administered medication. However, because of poor symptom control, the patient was referred to our hospital for specialized management of IBS. The patient had no medical history, including drug history, and had lost approximately 5 kg over the previous 7 months. The patient had a history of 5 pack-years of smoking and social alcohol consumption. The patient's father was diagnosed with pulmonary tuberculosis 1 month earlier and was receiving medication. The patient was employed as a cell phone salesman, but helped with work on his father's farm every weekend. His associated symptoms were frequent nausea with vomiting and diarrhea-like loose stools.\nPhysical examination findings were nonspecific and he showed chronic rather than acute illness. He had no tenderness or rebound tenderness on his abdomen. Laboratory test results of peripheral blood, blood biochemistry, and serum electrolytes were all within the normal ranges. Urine analysis and stool occult blood test showed no abnormal findings. Because of his weight loss, we tested his glucose and thyroid-associated hormone levels. His fasting blood glucose level was 87 mg/dL and the results of the thyroid function test were normal. We reviewed the imaging studies performed at the primary hospital. Gastroduodenoscopy showed chronic atrophic gastritis with erosion, and colonoscopy showed nonspecific terminal ileitis. Abdominal ultrasonography findings were nonspecific. After referral to our hospital, we changed his drugs to control symptoms. As intermittent lower abdominal pain persisted, we considered additional examinations such as small intestine endoscopy or capsule endoscopy to evaluate the small intestine. Considering the patient's compliance and the possibility of observation of the terminal ileum, we chose capsule endoscopy. On capsule endoscopy, the terminal ileum was normal, but a whitish tubular organism suspicious of a parasite with nearby multiple erosive lesions was observed at the proximal jejunum (, Supplementary Video 1 [available online at ]). Although we had considered the diagnosis to be IBS until that point, we changed the diagnosis to parasitic intestinal infection on the basis of the capsule endoscopic images. Additional examinations for parasitic infections, including blood testing and stool examination, were performed. His eosinophil count was 120/mm3 (reference range, 50 to 500); the results of the enzyme-linked immunosorbent assay were negative for cysticercosis, Sparganum, Paragonimus, and Clonorchis sinensis; and the result of a stool parasite test was also negative. Although the additional tests did not give additional information, based on symptoms, the results of examinations, and factors such as location (proximal jejunum), morphology (whitish small tubular shape), size (<2 cm), and erosive mucosal lesions around the organism, we diagnosed the patient with parasitic infection, and more precisely hook worm (Ancylostoma duodenale) infection at the proximal jejunum. We therefore empirically prescribed albendazole (400 mg/day) for 3 days. Ten days after administration of the drugs, the patient's symptoms slowly abated, and the patient recovered with no specific symptoms. |
We report the case of a 77-year-old female who complained of a progressively enlarged left thigh in the last year (). MRI showed the presence of a hyperintense mass on T1 and T2 with suppression in T2 fat suppression and STIR projections. The radiologist reported “thigh deep lipoma in contact with the femoral vessels in the medial thigh” (Figures and ).\nTo achieve a good access both medially and externally on the thigh and avoid traction on the ends of the incision, an S shaped skin incision was performed on the anterior thigh approximately along the direction of the sartorius muscle (). Following the outer edge of the rectus anterior, the tumor was located below this muscle and both muscle and tumor were separated by blunt dissection with the finger until the distal insertion of the vastus lateralis (). At this level, the dissection was continued along the medial side of the rectus, sectioning the vastus medialis insertion but leaving enough muscle to allow for reinsertion []. This medial approach allowed a good access to the medial intermuscular septum, where possible surgical vascular injury may have required a vascular suture (). At this level we find the adductor magnus and below it the tibial nerve and popliteal artery and vein. Dissection between the tumor and the medial intermuscular septum caused no vascular injury and a lipomatous tumor weighing 2500 g formed by two masses measuring 16 × 9 cm and 26 × 13 cm could be completely removed (). Histopathological examination reported that it was a low-grade or well-differentiated liposarcoma.\nPostoperatively, the patient had difficulties in flexion and extension of the hip and knee, due to muscular atrophy she presented preoperatively. Therefore, a physical therapy program aimed at increasing the range of motion and muscle power of the hip and knee was initiated. Both parameters were normalized at the control visit at two months. At 12 months the patient was asymptomatic, with no signs or symptoms of recurrence, as well as at four-year followup. |
Our patient was a 32-year-old previously healthy female at the 39th week of gestation who accessed the first aim department of a primary healthcare centre of a peripheral hospital for severe dyspnoea and chest pain. Her past medical history did not present other hospitalizations for the same symptoms. Due to the clinical manifestations, the patient was initially treated as a case of pulmonary embolic disease and subjected to a massive anticoagulant therapy. Considering the clinical diagnosis and the child to term, an emergent caesarean delivery was performed in order to avoid foetal complications. The caesarean section was successfully performed under general anaesthesia using Stark's method due to the urgency related to the patient's clinical condition of increasing dyspnoea. Moreover, although the pAVM was still unknown at time of the caesarean section, the execution of spinal anaesthesia seems to be not indicated because of the risk of pAVM association with other AVMs, such as those located in the spinal cord, especially in case of HHT.\nThe foetal outcome showed an Apgar index of 3, 6, and 9, respectively, at minutes 1, 3, and 5; these data are in line with the administration of general anaesthesia and the acute maternal condition of severe dyspnoea.\nTaking into account the foetal weight at birth, it showed a restriction of the expected value. The child weight was in fact 2590 gr at 39 weeks of gestation. However, ultrasounds performed during the pregnancy reported a reduction of the potential foetal growth from the 33 weeks of gestation without any Doppler alteration. This phenomenon should be the result of the chronical adaptation of the pregnancy to the unknown pAVM.\nAs far as the macroscopic exam of the placenta is concerned, a percentage of cotyledons infarcts inferior than 10% was reported.\nConsidering the patient's postoperative course, it showed a subsequently worsening of the clinical conditions, resulting in an acute distress syndrome that required an immediate transfer to the Gynaecology and Obstetrics unit of our structure. Due to the critical care panel and the low clinical conditions, the patient was intubated and housed in the ICU department. Considering the acute distress syndrome, a chest CAT scan was performed highlighting the presence of a left pAVM expanded, associated with a massive hemothorax that compressed the correspondent lung. The vital signs panel showed systolic blood pressure of 70 mmHg, diastolic blood pressure of 35 mmHg, pulse rate of 150/min, pulse oximetry saturation 88% on 100% inspired oxygen, afebrile temperature, and respiratory rate of 40/min. Initial labs revealed normal platelets, normal coagulation panel, and haemoglobin of 7 gm/dL. Critical care panel showed pH of 7.4, pCO2 of 43 mm hg, pAO2 60 mmHg, and saturation of 88%. After the placement of a chest tube, 3 litres of frank blood were removed; this action resulted in a normalization of the blood pressure and improved oxygenation on the monitor. The successive management was the clinical observation of the patient's conditions as well as the vital signs and labs test in order to perform the pAVM embolization when the patient clinical conditions will be stable. After three hours from the drainage, worsening of the patient conditions was observed reporting a severe collapse of the vital signs as well as a decrease of antithrombin III, fibrinogen, and haemoglobin values, with parameters of 33%, 122 mg/dl, and 5.8 gm/dl, respectively. Moreover, considering the postoperative caesarean course, the gynaecologic clinical evaluation showed a low uterine fundus contraction and the presence of conspicuous abnormal lochia. Uterine fundal massage was performed as first approach to solve the uterine low contraction followed by Credè's manoeuvre. Due to the failure of both, a pharmacological treatment was attempted starting with a simultaneous administration of intravenous Oxytocin (10-40 UI per 1 litre saline solution) and intramuscular Methylergometrine (0.2 mg one dose). The latter pharmacological approach involves the use of intravenous Sulprostone (0.5 mg per 1 litre saline solution) that was administered within half an hour from the signs of low uterine contraction and abnormal lochia. None of the previous pharmacological treatments succeeded.\nConsidering the reproductive age of the patients, procedures as appositions of tamponade-balloon and embolization of the uterine arteries were taken into account but were not applicable in order of the unstable and precipitant parameters of the woman. Due to the patient's life-threating condition, a simultaneous surgical intervention of thoracic surgeons and gynaecologists had been necessary to solve the urgency, with the performance of a contemporaneous surgical reparation of the pAVM and resection of damaged left lower lobe (LLL) as well as a preventive hysterectomy to avoid the risk of disseminated intravascular coagulation (DIC). The surgical interventions were performed successfully but intraoperative blood transfusions and administration of antithrombin III and fibrinogen were necessary. The postoperative treatment showed a normalization of vital signs and labs panel as well as patient's clinical conditions. Due to the stable condition of the woman, the anaesthetist established the patient's autonomous breathing. After one week from the intervention, chest CT with intravenous contrast was performed showing a 4 cm area of active contrast. Pulmonary angiography confirmed the presence of a pAVM with feeding branch of a basilar left pulmonary artery supplying aneurysmal AVM and dilated draining vein. Transcatheter embolotherapy (TCE) of the culprit vessel was performed by placement of a nonadhesive liquid embolic agent (Onyx 34®). Repeated chest X-ray and chest CT after one week from TCE showed expansion of remaining left lung and signs of pAVM embolization and pulmonary resection of LLL, respectively (). The patient course was subsequently uncomplicated and the discharging home happened after 14 days. MRI evaluation was performed in order to detect any head AVM but the result was negative. The genetic testing for HHT was not performed during this hospitalization period but the genetic examination performed a few months afterwards showed no association. |
The patient is a 57-year-old female who underwent cardiac catheterization via the right common femoral artery two weeks prior to developing a large, symptomatic right common femoral artery pseudoaneurysm ().\nThe patient began complaining of groin pain two weeks after cardiac catheterization. She has a past medical history of aortic valve replacement secondary to aortic valve infective endocarditis, hyperlipidemia, and hypertension.\nShe underwent two attempts of ultrasound-guided thrombin injection of the pseudoaneurysm. On ultrasound, the size of the pseudoaneurysm was found to be 5 cm × 3 cm × 4.6 cm. The neck of the pseudoaneurysm was measured to be 0.8 cm long. The two attempts involved using a 21 gauge needle to administer 1000 units and 2000 units of thrombin, respectively, into the pseudoaneurysm under ultrasound guidance and with the assistance of compression. Due to the size of the aneurysmal cavity and a relatively large pseudoaneurysm neck, injections were found to be unsuccessful on follow-up ultrasound (Figures and ). It was then decided to attempt endovascular closure of the neck of the pseudoaneurysm. All risks were discussed with the patient.\nAfter identification by the attending surgeon, the patient was transferred to the procedure room table in the catheterization lab. The patient received IV sedation, and local anesthesia was used prior to ultrasound-guided percutaneous access to the left common femoral artery. During the procedure, vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, were monitored by an ACLS certified nurse.\nAfter a 21 gauge needle was placed into the projection of the vessel lumen, a guidewire was placed into the left iliac artery. An angiographic catheter and guidewire were used to perform selective cannulation of the contralateral right common iliac artery. Then, a 6 French long access sheath was placed to perform an angiogram. The neck of the pseudoaneurysm was visualized (), and a 0.014 guidewire was placed into the proximal portion of the neck.\nA 21 gauge needle was used to cannulate the proximal portion of the neck percutaneously from the right groin. The previously placed guidewire was used as a landmark to place the tip of the 21 gauge needle into the pseudoaneurysm. After blood return was noticed from the needle, a 0.018 guidewire was placed into the lumen of the right common femoral artery. A 6 French access sheath was placed over the guidewire. Fluoroscopy was then used to visualize the deployment of a vessel closure device (VASCADE 6 French). This was done without difficulty, and the collagen patch was positioned outside the vessel wall in the area of the pseudoaneurysm neck. Interval angiogram revealed partial occlusion of the pseudoaneurysm neck ().\nIt was then decided to place an occlusive 8 mm balloon into the lumen of the right common femoral artery to facilitate pseudoaneurysm thrombosis. The balloon was insufflated up to 8 ATM for 600 seconds. This was done twice in total. Interval angiogram then revealed complete occlusion of the pseudoaneurysm blood flow (Figures and ).\nAll wires and catheters were removed at this point, and a left common femoral artery access sheath was kept in overnight. Postoperatively, the patient had no complications, and formal ultrasound confirmed complete thrombosis of the pseudoaneurysm. The access sheath was then removed without issue. There were no ischemic complications due to balloon occlusion in the immediate postoperative period. |
A girl aged 12 years was diagnosed with a thoracolumbar kyphosis by her family doctor and was initially followed by physiotherapists to provide exercises for her abdominal and dorsal muscles. She was not referred for an orthopedic assessment until the age of 17 years and eight months when she presented in our clinic with a severe thoracolumbar SK. She was otherwise healthy but overweight with a BMI of 38. There was no history of spinal infections or injuries and no skeletal dysplasias. At presentation, the patient had complaints of persistent back pain in the thoracolumbar junction, which restricted her activities. She had no complaints of leg pain and no neurological symptoms.\nOn clinical examination, there were no neurological abnormalities and the spine demonstrated an extreme kyphosis (113°) with the apex in the thoracolumbar junction, as well as a sharply angular gibbus. She had a mild left thoracolumbar scoliosis of 15° and no spondylolysis or spondylolisthesis. There was no radiographic evidence of anterior bony fusion across the apex of the kyphosis and no bridging osteophytes. An MRI scan excluded intraspinal anomalies, and showed small disc bulges from T8 to T11 with normal spinal cord signal. It also showed no evidence of congenital vertebral anomalies.\nThe indications for surgery included chronic thoracolumbar back pain, as well as the extreme degree of deformity and potential for neurological complications.\nThe patient underwent kyphosis correction at the age of 18 years and one month when the deformity measured 115° and only corrected to 86° on supine hyperextension radiograph against the bolster. The surgery involved a single-stage posterior spinal arthrodesis extending from T2 to L4 with the use of posterior pedicle hook/screw/rod instrumentation and autologous iliac crest bone graft. During the posterior exposure, the spine was found to be spontaneously fused across the apex of the kyphosis from T9 to L1 with fused facet joints and an ossified ligamentum flavum. There was no evidence of congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T6 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilized at completion of the osteotomies. The kyphosis was corrected using a cantilever maneuver with the rods simultaneously attached from proximal to distal under intraoperative spinal cord monitoring recording MEPs, as well as cortical and cervical SSEPs. The intraoperative spinal cord monitoring remained stable throughout the procedure. An excellent correction of the kyphosis to 60° was achieved []. Autologous iliac crest graft was used to achieve a solid bony fusion across the levels of the instrumentation.\nThe patient made a good recovery and mobilized following application of a spinal brace. She was discharged 20 days after surgery. The brace remained for four months and the patient progressively returned to normal activities seven months after surgery. At latest follow-up, 2.3 years following kyphosis correction, the patient had no complaints of her back; she had normal activities and a BMI of 28. Radiographs showed no evidence of pseudarthrosis and no recurrence of the kyphosis or junctional deformity proximal or distal to the instrumented fusion. |
Subsets and Splits