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zhengyun21

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PMC-Patients

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3994695-1

noncomm/PMC003xxxxxx/PMC3994695.xml

Giant clival chordoma causing pathological laughter

A 42 year-old male patient was admitted with a history of headache, which started approximately one year ago. He had been followed in another institution as a pituitary adenoma and had not had surgery before coming to our consultation. In the past 3 months he complained of worsening of the headache, diplopia, and diminished bilateral visual acuity. He had at this time many episodes of unmotivated laugh without consciousness disruption. They were self-limited lasting for a few seconds only. At examination, an intense ataxia, global hyperreflexia, bitemporal hemianopia, and mild right VI nerve paresis were remarkable. Panhypopituitarism was evident in laboratory exams. Eletroencephalogram did not reveal seizure activity. Neuroimaging revealed a large clival mass invading the sphenoid sinus with destruction of the sella with a huge suprasellar and retrosellar extension, brain stem displacement and skull base bone destruction [Figures and ]. We performed a binostril, transnasal transphenoidal endoscopic approach with bilateral medial turbinectomy, wide opening of the anterior wall of the sphenoid sinus, and a radical resection of the lesion with partial resection of the infiltrated clival dura. Satisfactory brain stem decompression was accomplished [Figures and ]. Reconstruction of the skull base was achieved with abdominal fat, nasoseptal pediculated graft (Haddad) and fibrin glue. Postoperative period was uneventful with no cerebrospinal fluid leakage episodes and a great improvement in vision, with total recovering of the VI nerve deficit and ataxia. He has not had any paroxysm of pathological laughter since surgery. Histological examination confirmed the diagnosis of chordoma. Patient was submitted in the postoperative period to radiotherapy (IMRT) and has been asymptomatic in the past 14 months. Follow up magnetic resonance imaging (MRI) is shown in [Figures and ].

[[42.0, 'year']]

M

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{}

3994706-1

noncomm/PMC003xxxxxx/PMC3994706.xml

Simultaneous hepatosplenic T-cell lymphoma and myelofibrosis

This was a case of a 37-year-old male patient who was admitted to the hospital because of a right sided abdominal mass. On examination, he had left axillary lymphadenopathy (1 cm) and hepatosplenomegaly. The complete blood count showed mild anemia and severe thrombocytopenia []. The peripheral blood smear showed intermediate-sized atypical lymphocytes, immature granulocytes, nucleated red blood cells and tear-drop cells []. Liver function tests were mildly impaired and screening for auto-antibody as well as viral serology for hepatitis A, B and C were negative. Computed tomography (CT) scan of the abdomen showed massive hepatosplenomegaly and minimal lymphadenopathy. He underwent left axillary lymph node biopsy followed 1 week later by bone marrow biopsy.\nThe patient was given two cycles of high dose dexamethasone, cytarabine and cisplatine followed by hyper-fractionated cyclophosphamide, doxorubicin, vincristine and dexamethasone chemotherapy regimen. There was an initial dramatic reduction in the size of spleen and liver which were confirmed by abdominal CT scan. However, 2 months later the spleen increased in size and he developed severe thrombocytopenia. At 5 months after completing radiotherapy for his enlarging spleen, the patient died of complications of septicemia. No post-mortem study was done on the patient.

[[37.0, 'year']]

M

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{'7545303-1': 1}

3994707-1

noncomm/PMC003xxxxxx/PMC3994707.xml

Acinetobacter baumannii bacteremia, a rare complication of endoscopic retrograde cholagiopancreatography!

The present case report is about an 85-year-old female patient with a history of diverticular disease, hypertension, left hip arthroplasty and gout was admitted to our hospital with a 1-week history of jaundice, lethargy, confusion and multiple episodes of falls. She denied any fever or abdominal pain.\nHer initial vital signs were: Blood pressure 92/68 mmHg, temperature 98.0°F and pulse rate 86/min. Icteric sclera was noted. The rest of the physical examination including neurological system, skin, throat, chest and abdomen was normal. Murphy's sign was absent.\nSignificant laboratory findings included white blood cell count, 13,400/μL (4-11/μL) (differential counts of 81% neutrophils, 8% lymphocytes, 6% monocytes); hemoglobin, 13.8 g/dL (12-15.3 g/dL); platelet count, 268,000/mL (150-450/mL); blood urea nitrogen 39 mg/dL (6-26 mg/dL); creatinine 1.57 mg/dL (0.5-1 mg/dL); total bilirubin 6.2 mg/dL (0-1 mg/dL); aspartate aminotransferase 248 U/L (0-32 U/L); alanine aminotransferase 185 U/L (0-40 U/L); and alkaline phosphatase 617 U/L (35-104 U/L).\nA computed tomography scan of the abdomen [Figures and ] revealed a 1.8 cm obstructing stone in a distal common bile duct. The patient was empirically started on intravenous levofloxacin and metronidazole. Two days after her admission, she underwent ERCP. The procedure was terminated due to profuse bleeding following papillotomy. The stone was not extracted. Initial blood cultures did not grow any pathogen.\nAt 4 days after her hospitalization, the patient underwent a second ERCP []. Pieces of stones were extracted and a stent was placed in the common bile duct. One day later, the patient became lethargic and developed a fever of 100.8F. The next morning, the patient deteriorated further with a blood pressure of 76/46 mmHg, pulse rate of 104 beats/min, respiratory rate of 25 breaths/min and oxygen saturation was 94% on 6 L nasal cannula with other clinical evidence of shock believed to be secondary to sepsis.\nAntibiotics were switched to intravenous meropenem 500 mg twice daily with intravenous levofloxacin 750 mg. The next day, blood cultures revealed Gram-negative rods.\nOn day 9, she required intubation and mechanical ventilation for respiratory failure with the addition of maximum vasopressor support for refractory shock. Percutaneous cholecystostomy was performed on day 10 and 5 mL of thick brown fluid was aspirated.\n5 out of 5 sets of blood cultures as well as culture of biliary fluid grew A. baumannii, resistant to almost all antibiotics including piperacillin/tazobactam, meropenem and levofloxacin. Intravenous tigecycline 50 mg every 12 h was added and parenteral colistin 75 mg every 12 h replaced meropenem based on the final sensitivity reports. Blood cultures drawn after the administration of colistin remained sterile. However, the patient did not recover from septic shock. After discussing the goals of care, her family opted for withdrawing medical management and pursuing comfort measures instead.

[[85.0, 'year']]

F

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{}

3994708-1

noncomm/PMC003xxxxxx/PMC3994708.xml

Preoperative splenic artery embolization in klippel-Trenaunay syndrome with massive splenomegaly: A case report

A 29-year-old woman with a history of KTS with vascular malformations involving both legs and pelvis was admitted to the hospital for open splenectomy. She had lymphedema of the lower extremities and cutaneous port-wine stains. Seven years prior to the admission, the patient had noncirrhotic portal hypertension of unknown etiology, complicated by portal vein thrombosis, and bleeding esophageal varices. Since then, she has undergone endoscopic variceal banding and percutaneous transhepatic portal vein recanalization with stent placement. Subsequently, she developed massive splenomegaly with thrombocytopenia and a 30-pound weight loss over six months. She had left-sided abdominal pain associated with massive splenomegaly.\nHematocrit was 25.3%, hemoglobin 8.5 g/dL, and platelet count 38,000/mm3. Computed tomography (CT) of the abdomen demonstrated massive splenomegaly with innumerable, less than 1 cm, low attenuation lesions in the spleen. Magnetic resonance imaging (MRI) of the abdomen depicted a markedly enlarged spleen with similar innumerable abnormal signal structures within the spleen []. Splenomegaly and splenic involvement of KTS were delineated on both CT and MRI images. Because of the risk of bleeding, the patient underwent transcatheter splenic artery embolization, immediately prior to open splenectomy.\nAfter obtaining written informed consent, the procedure was performed on the morning of surgery. Digital subtraction angiogram of celiac trunk demonstrated a dilated and tortuous splenic artery, and an enlarged spleen with inhomogeneous parenchymal staining. Innumerable avascular lesions were seen in the splenic parenchymal phase. There was no arteriovenous shunting []. After placing a catheter distal to the origins of the caudal pancreatic and left gastroepiploic arteries, distal splenic artery embolization was performed using Gelfoam slurry (Ferrosan, Somerville, NJ), achieving occlusion of the segmental arteries. The proximal splenic artery (immediately distal to its origin at the celiac axis), measuring 8 mm in diameter was occluded using a 14 mm diameter Amplatzer Vascular Plug II (AVP II; St. Jude Medical Inc. St. Paul, MN). Follow-up arteriography confirmed optimal deployment of AVP II in splenic artery. No persistent flow, through the deployed AVP II was demonstrated on the completion celiac digital subtraction angiography (DSA) []. Selective left gastric arteriography demonstrated no evidence of collateral blood flow to the spleen.\nAfter splenic artery embolization, the patient was transferred to the operating room for open splenectomy. After careful dissection, the spleen was isolated on its hilum. The spleen was soft, secondary to the prior splenic artery embolization. Surgical ligation of the splenic artery before dissection for surgical exposure was not necessary due to prior embolization. The estimated blood loss was 100 cc during surgical splenectomy. The patient received pneumococcal and hemophilus vaccines, immediately after surgery.\nOn pathology examinations, the removed spleen measured 27.5 × 21 × 6.5 cm in size and weighed 2,935 g []. Grossly, the spleen was diffusely enlarged without any discrete lesions. Large quantities of blood exuded from its cut surfaces. Histologically, the spleen had mixed arteriovenous and lymphatic components []. Thrombocytopenia was successfully corrected after splenectomy with platelet count of 160,000/mm3 on postoperative day 5. Postoperative recovery was smooth without complications. Patient was discharged 5 days after the surgery. The patient was closely followed by the surgical and hematological services. During 6 months after the surgery, abdominal pain has improved with weaning off narcotics. The platelet count of 184,000/mm3was also noted at her 6-month follow-up visit.

[[29.0, 'year']]

F

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{}

3994709-1

noncomm/PMC003xxxxxx/PMC3994709.xml

Renal confined sarcoidosis: Natural history and diagnostic challenge

The present case report is about a 69-year-old male patient who was referred to nephrology for persistent and worsening hypertension for 2 years despite taking multiple anti-hypertensive medications. No other complaints. Past medical history included obstructive sleep apnea, diabetes mellitus type 2, atrial fibrillation, hypothyroidism, gastro esophageal reflux disease, renal cysts, fatty liver, gout, dyslipidemia and benign prostatic hyperplasia. Social history and family history were unremarkable.\nPatient had negative 24 urinary catecholamines, arterial Doppler studies of the renal arteries and renal computed tomographic angiography. Initial ancillary laboratory findings were unremarkable including renin, aldosterone, parathyroid hormone (PTH) and calcium levels. He had borderline normal renal function (serum creatinine = 1.2, glomerular filtration rate [GFR] >60). Urinalysis was normal. Blood pressure improved to normal on atenolol, nifedipine, lisinopril. Patient also demonstrated low vitamin D 25-hydroxy levels and was consequently started on replacement with ergocalciferol.\nWithin 6 months of initial nephrology work-up, the patient continued to demonstrate stable blood pressure, renal function and blood counts.\nUnexpectedly, 8 months later, the patient's GFR dropped to 58 and he had slight anemia with hemoglobin level of 12.9. Blood pressure remained stable. His calcium, PTH and vitamin D - 25 levels were all within the normal limits. Around 10 months post referral, serum protein electrophoresis demonstrated an IgG kappa monoclonal spike and GFR decreased to 55 (chronic kidney disease stage 3). His calcium and PTH were normal. Urinalysis was negative except for monoclonal IgG on immunoelectrophoresis, but no light chains detected. At this time, patient was referred to hematology-oncology specialist and a diagnosis of monoclonal gammopathy of undetermined significance (MGUS) was established through bone marrow biopsy. Final pathologic diagnosis was: A, B, C. Bone marrow, aspirate/imprint smears, clot and biopsy sections, Hypercellular marrow for age (80% cellularity) with increased myelopoiesis and mild dysmegakaryopoiesis. Absent iron stores, marrow, with decreased sideroblastic iron, compatible with iron deficiency anemia pattern. Less than 10% plasma cells with kappa excess (by CD138 and kappa/lambda immunostaining), most compatible with a MGUS.\nAt approximately 16 months later, the patient stated noticing elevated blood pressure reading and started to develop symptoms of malaise and fatigue. Within 2 months (18-20 months post-nephrology referral), the patient's renal function declined abruptly (GFR 32) and was also demonstrating bone mineral disease with worsening hypercalcemia (calcium 10.6 mg/dL) and low PTH (<1 pg/mL) [Graphs and ].\nGiven the history of monoclonal gammopathy, the concern and working diagnosis included the possibility of a plasma cell dyscrasia. However, repeat serum protein electrophoreses was not impressive and anemia was only mild (12.6). The oncologist suggested that worsening calcium levels and renal failure could represent milk alkali syndrome, given dietary history where the patient was consuming three glasses of milk per day. Within the next 3 months (21-23 months post nephrology referral), the calcium levels slightly dropped after the cessation of milk intake, but rebounded again with no identifiable cause (calcium 10.7). More importantly, the renal function showed significant aberration and decline within these months (GFR was 8); necessitating dialysis for end-stage renal disease (ESRD) and a drastic revision in diagnostic approach.\nRepeated renal ultrasound showed cortical atrophy and no hydronephrosis. Chest radiographic imaging was negative and skeletal survey was showed no lytic or other bone related lesions. Renal biopsy was ordered due to unexplained and unexpected worsening of renal function.\nH and E, periodic acid-Schiff, Lillie's allochrome and Jones' silver stained section of the renal cortex and medulla. Evaluation demonstrated diffuse tubular atrophy involving 90% of tubules examined. The luminae contained cellular debris or protein casts with cellular response [].\nMononuclear cell infiltrates with non-necrotizing granulomatous inflammation and eosinophils were noted-granulomatous interstitial inflammation with eosinophils [].\nDirect immunofluorescence with fluorescein isothiocyanate conjugated antisera (IgG, IgA, IgM, C3, C1q, albumin, fibrinogen and kappa and lambda light chains revealed no glomerular or tubulointerstitial staining. This aforementioned finding excludes immune complex glomerulonephritis [].\nAnalysis of one glomerulus selected for examination demonstrated no electron dense deposits, no amyloid type fibrils, no tubuloreticular inclusions and normal thickness of glomerular basement membrane.\nNegative stain to detect for mycobacteria or other acid fast organisms.\nThe significant finding obtained from renal biopsy revealed granulomatous interstitial inflammation with eosinophils consistent with renal sarcoidosis. His purified protein derivative skin test was negative.\nHis angiotensin converting enzyme (ACE) level was high (73 units/L) and PTH level was still low (4 pg/mL) 24 months after the initial referral. Vitamin D1/25 dihydroxy level was checked later and was elevated (148 pg/mL).\nIn light of ESRD and a conclusive diagnosis of renal-confined sarcoidosis, the patient was begun on prednisone (60 mg daily) and enrolled in a hemodialysis program. Within 1 month, the patient's hypercalcemia resolved and remained within normal values up to 3 years for a majority of the time-course. ACE, PTH and vitamin D1/25 dihydroxy improved as well. Despite the improvement of his calcium, the patient's renal function continued to be refractory to steroid treatment and remained on dialysis for persistent ESRD.

[[69.0, 'year']]

M

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{'6176294-1': 1}

3994710-1

noncomm/PMC003xxxxxx/PMC3994710.xml

A concurrent episode of two neoplasms in a toddler-age child

A 21-month-old Hispanic girl presented to the emergency room with 10 days history of progressing left periorbital swelling. She was initially treated with antibiotics without improvement. The patient did not have any fever, vomiting, cough, eye discharge or sick contact.\nOn examination, she had swelling with proptosis at the left eye without erythema. There was a localized mass that was palpable, restricting the movement of the left eye. Incidentally, the patient found to have pubic hair Tanner stage III but no breast buds or clitoral hypertrophy. The remaining physical exam was unremarkable. There was a significant past medical history of a third-line family member with a diagnosis of uterine cancer at the age of 40 years and a second-line family member with a history of recurrent thyroid nodules.\nInitial laboratory work up including complete blood count, basic metabolic panel, and liver function test were all normal. Computed tomography (CT) scan of the head revealed a single left orbital mass that has retro-orbital and postseptal extension. This mass measured 2.5 × 3.5 × 1 cm and was not associated with focal bone erosion or invasion to the optic nerve [].\nBecause the patient had evidence of precocious puberty, the differential diagnosis at this point was broadened to include rhabdomyosarcoma, neuroblastoma, germ cell tumor or concurrent episode of childhood neoplasms. The patient subsequently underwent further evaluation with whole body positron emission tomography (PET) scan that showed another mass (6 × 6 cm) in the left suprarenal area []. Bone scan, bone marrow biopsy, and urine catecholamine were all negative.\nDue to concern of adrenarche, the patient had endocrine work up that showed advanced bone age with significantly elevated dehydroepiandrosterone sulfate (DHEAS).\nThe previous finding raised the possibility that those two masses might be two different tumor entities. She underwent a subtotal surgical resection of the left retro-orbital lesion (about 75% of the tumor burden) and total surgical resection of the adrenal mass.\nThe pathologic evaluation of those masses revealed embryonal rhabdomyosarcoma from the orbital mass and a benign adrenocortical tumor (ACT) from the adrenal mass.\nThe diagnosis of LFS was suspected based on having two tumors that belong to LFS tumors spectrum that occurred before the age of 46 years. Genetic testing for TP53 mutation from peripheral blood revealed heterozygous change on the nucleotide-coding sequence c. 818G >A, which is a missense mutation in TP53 gene.

[[21.0, 'month']]

F

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{}

3994713-1

noncomm/PMC003xxxxxx/PMC3994713.xml

The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas

A 43-year-old male presented with several months of progressive dysarthria and gait imbalance. Imaging work-up including magnetic resonance imaging (MRI) demonstrated a large left medial tentorial meningioma extending along the posteromedial aspect of the temporal lobe and medial aspect of the brainstem, causing significant mass effect on these structures with early signs of hydrocephalus []. Large flow-voids within the tumor emphasized its rich vascularity [].\nFollowing modest embolization of the tumor's large feeding meningeal vessels, resection was attempted. A staged procedure for the infratentorial and supratentorial components of this tumor was considered. We decided that a SCTT route would avoid a staged operation and minimize the risk to the dominant temporal lobe. Using a paramedian incision [], we attempted a SCTT approach with skeletonization of the transverse and sigmoid sinuses. After devascularization of the tumor's base along the tentorium, the tumor's infratentorial component was removed while preserving the trochlear nerve and surrounding vasculature [].\nUsing the technique mentioned above, we incised a section of the tentorium affected by the tumor and removed the supratentorial extension of the tumor as well as the piece attached to the petrous apex. This operative corridor allowed microsurgical dissection of the tumor wall away from the cortex and adjacent distal PCA branches. A small portion of the tumor lateral and superior to the petrous apex was left behind due to its inaccessibility []. This case underlines the supratentorial limits of this approach, unless petrous apex bony drilling is attempted through the posterior fossa. Pathological examination found a World Health Organization (WHO) grade I meningioma. The patient recovered from surgery with no deficits. All his preoperative symptoms had resolved at 3-month follow-up. At the 4-year follow-up, MRI did not demonstrate any growth of the residual tumor.

[[43.0, 'year']]

M

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{'3994713-2': 2, '4968780-1': 1, '7451164-1': 1}

3994713-2

noncomm/PMC003xxxxxx/PMC3994713.xml

The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas

A 33-year-old female presented with severe headaches and an episode of receptive aphasia. MRI evaluation revealed a left medial tentorial meningioma associated with cerebral edema []. The tumor was situated completely in the supratentorial space. Angiography disclosed a relatively vascular tumor, not amenable to embolization []. Traditional subtemporal or transtemporal approaches were considered, as the vein of Labbe was posteriorly situated, but the risk of injury to the language cortex was likely due to the required brain retraction [].\nThrough a left hockey-stick incision, the SCTT route was used to remove the tumor []. The tentorium was coagulated early in the procedure and the tumor was devascularized. The anterior edge of the tentorium and the portion of the tumor protruding through the tentorial incisura were exposed during the initial portion of the operation. The early exposure of critical brainstem structures afforded by this approach allowed for early decompression of the brainstem and dissection and protection of the trochlear nerve []. The tumor was then debulked through the tentorium using an ultrasonic aspirator and microsurgically dissected from the surrounding vessels. Gross total resection was achieved and the patient did not suffer from any postoperative language or visual deficit. A 3-month MRI confirmed the intraoperative findings []. At 2-year follow-up, no tumor recurrence was present [].

[[33.0, 'year']]

F

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{'3994713-1': 2, '4968780-1': 1, '7451164-1': 1}

3995370-1

noncomm/PMC003xxxxxx/PMC3995370.xml

A Differential Diagnosis for Left Atrial Mass on Transthoracic Echocardiography: Hiatus Hernia

An 81-year-old female with a background of stable ischaemic heart disease and hypertension was referred to the cardiology department complaining of dyspnoea on exertion over a period of 12 months. This was more appreciable on inclines. She did not suffer from chest pain, orthopnoea, ankle swelling or syncope. She denied fever, weight loss, change in appetite, dyspepsia or gastrointestinal bleeding. Her medication list included aspirin, a statin, a proton-pump inhibitor and an angiotensin receptor blocker. There was no significant family history and she was a non-smoker.\nPhysical examination was normal; in particular there were no finger clubbing, no cardiac murmurs on auscultation and no signs of fluid retention such as elevated jugular venous pressure and peripheral oedema. Resting electrocardiography demonstrated normal sinus rhythm. Her haemoglobin, leukocyte count, renal and liver function blood tests were all normal. B-type natriuretic peptide was within normal limits.\nGiven her past medical history of cardiovascular disease, she was referred for echocardiography to assess for structural or functional cardiac disease possibly contributing to her unexplained dyspnoea. Transthoracic echocardiography using standard views was performed. Alarmingly, the study demonstrated a large echolucent mass with the appearance of a left atrial space-occupying lesion (fig. ). Left ventricular size and contractile function were preserved and there was no significant valvular disease. Right ventricular size and function were normal and there was no pericardial effusion.\nTo further delineate the intra-cardiac mass, the patient underwent cardiac magnetic resonance imaging (MRI). The study revealed no intra-cardiac masses, with normal heart structure and function. It demonstrated a large hiatus hernia containing food and compressing and distorting the posterior wall of the left atrium (fig. ).\nThe patient has been referred on for surgical correction of her hiatus hernia.

[[81.0, 'year']]

F

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{'2553061-1': 1, '8431984-1': 1}

3995373-1

noncomm/PMC003xxxxxx/PMC3995373.xml

Pterygium: Nonsurgical Treatment Using Topical Dipyridamole – A Case Report

A 35-year-old female Caucasian patient presented with a pterygium in her right eye. She began to notice it approximately 6 weeks prior to her visit, and it rapidly became increasingly symptomatic. She complained of a foreign body sensation, burning, and dryness, accompanied by constant and uncontrolled blinking.\nThree views of the patient's eye in its pre-treatment state are depicted in the figures [fig. , fig. , fig. (left side)]. There was a 1.5-mm area of raised conjunctival tissue that extended slightly onto the nasal cornea obstructing the limbus. The tissue was raised approximately 1 mm. There was moderate vascularity of the lesion, and the underlying scleral vessels were obscured. Moderate conjunctival hyperemia was noted both at and medial to the pterygium. There appeared to be some pigmentation at the corneal leading edge of the pterygium. The ophthalmologist performing the examination noted that the lesion invaded the cornea. The cornea was otherwise clear, and the iris was unremarkable. The anterior chamber was clear and quiet. The lids and lashes were unremarkable. Utilizing Johnston, Williams & Sheppard's comprehensive pterygium classification system [], this was graded as a stage II to III, V3, C3, K2, P1 pterygium.\nTreatment with topical steroids was recommended, but the patient declined. Instead, treatment with topically applied dipyridamole (1.68 × 10–4 M in normal saline solution) was initiated, starting with 1 drop twice daily to the affected area. Slight transient stinging was felt immediately upon application. The patient reported a significant reduction of dryness and burning within days of starting treatment. She continued applying the drops, and as her symptoms improved, she reduced the application to once daily. She continued applying the drops for 12 months with intermittent breaks of several weeks when she felt asymptomatic. The patient noticed that symptoms of dryness recurred within a few weeks, but the lesion did not increase in size. Whenever symptoms appeared, she resumed therapy. At the end of this period, the eye was reassessed. The pterygium was markedly improved. The tissue had regressed from the limbal region of the cornea, had decreased in length from 1.5 to 1.0 mm, and decreased in height from 1.0 to approximately 0.3 mm. The conjunctival hyperemia and vascularization had resolved entirely, and the underlying scleral vessels could now be visualized. At 12 months, the pterygium was graded as stage 0 to I, V0, C2, K0, P0 [fig. , fig. , fig. (right side)]. At the time of this report, the lesion is still present, but remains at the same very mild stage as was noted at the 12-month evaluation.

[[35.0, 'year']]

F

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{}

3995379-1

noncomm/PMC003xxxxxx/PMC3995379.xml

Gastric Cancer Arising from an Upside-Down Stomach through a Paraesophageal Hiatal Hernia

An 82-year-old man was admitted to our hospital because of appetite loss and anemia. His medical history included chronic obstructive pulmonary disease and dementia. On physical examination, he was 150 cm tall and weighed 45 kg. His abdomen was soft and flat and showed no palpable masses. Laboratory tests revealed hypohemoglobinemia (Hb 7.5 g/dl) and hypoproteinemia (albumin 2.5 g/dl); all other results were normal. Upper gastrointestinal endoscopy showed a type 1 hemorrhagic tumor located in the middle body of the stomach, although observation of the entire stomach was impossible because of extreme transformation. An upper gastrointestinal series showed organoaxial rotation of the body of the stomach with the entire stomach located in the mediastinum, which is indicative of upside-down stomach. The tumor was present in the upside-down stomach through a PEH (fig. ). Pathological analysis of biopsy specimens revealed moderately differentiated tubular adenocarcinoma. Coronal computed tomography images showed an organoaxial gastric volvulus and sliding up through a PEH (fig. ). A gastric tumor was detected in the upside-down stomach through the PEH and lymph node metastases were observed surrounding the stomach; however, liver metastases and peritoneal dissemination were not observed. Preoperative staging according to the TNM classification of gastric cancer was T3N2M0, stage IIIA. On the basis of the preoperative diagnosis of gastric cancer arising from an upside-down stomach through a PEH, the patient underwent surgical treatment.\nSurgery was performed via a median laparotomy incision. The entire stomach was found to be herniated through the enormously dilated hiatus into the left thorax together with the greater omentum (fig. ). The hernial orifice was approximately 5 cm in diameter (fig. ). After the incarcerated stomach had been untwisted and reduced back into the abdomen, the tumor was found to be located in the middle body of the stomach; however, the short esophagus was not found in the state of esophagus. After reduction of the abdominal contents from the thoracic cavity, a total gastrectomy with a Roux-en-Y reconstruction and dissection of the lymph nodes surrounding the stomach was performed. The crura of the diaphragm were approximated with interrupted nonabsorbable sutures for closure of the hernial orifice. The jejunum just under the anastomosis was sutured to the crus to permanently fix the esophagojejunal anastomosis in an abdominal position (fig. ). In consideration of the patient's age and preoperative performance status, a jejunostomy was constructed as a route of enteral nutrition after surgery.\nThe resected specimen revealed a type 1 hemorrhagic tumor measuring approximately 7.7 × 7.4 cm (fig. ). Histopathological examination revealed a moderate tubular adenocarcinoma with vascular invasion and metastasis in three lymph nodes surrounding the stomach, and the final clinical stage was IIIA (T3N2M0) according to the TNM classification.\nThe postoperative course was uneventful. Roentgenography showed good passage without leakage of the anastomosis, and oral intake was initiated on postoperative day 7, although no increase in food intake was achieved. Therefore, the energy deficit was supported by enteral nutrition through the jejunostomy. The patient was discharged 35 days after surgery, and there was no recurrence of cancer or hernia during 1-year follow-up.

[[82.0, 'year']]

M

{'5366328': 1, '8642755': 1, '7629956': 1, '19198995': 1, '8319166': 1, '3607726': 1, '12421872': 1, '34336347': 2, '33547758': 2, '8034939': 1, '10080844': 1, '12942560': 1, '24761138': 2}

{'8518761-1': 1, '8315875-1': 1}

3995387-1

noncomm/PMC003xxxxxx/PMC3995387.xml

Spontaneous Resolution of Long-Standing Macular Detachment due to Optic Disc Pit with Significant Visual Improvement

A 63-year-old female presented at the outpatients department complaining about blurred vision and micropsia in her left eye for 6 months. She had no other symptoms, no previous ocular history and her general health was unremarkable. On examination, her best-corrected visual acuity was 6/7.5 in the right eye and 6/24 in the left eye. Slit-lamp examination revealed immature cataract in both eyes (+1 nuclear sclerosis), and both anterior segments were normal. Intraocular pressure was normal in both eyes as well. Dilated fundoscopy revealed normal fundus in the right eye and a serous elevation of the macular region in the left eye, for which the patient was referred to the medical retina department for further investigation.\nA more detailed fundus examination of the left eye revealed a large optic nerve head and a grey pit at the inferotemporal margin of the optic disc in association with serous macular detachment. Optical coherence tomography (OCT) confirmed the diagnosis of macular schisis communicating nasally with an optic disc pit, showing a hyporeflective area corresponding to the edge of the pit where there was communication with the schisis cavity (fig. ). Fluorescein angiography (FA) and an indocyanine green angiogram excluded other causes of serous retinal pigment epithelium detachment, showing pooling in the area of serous macular detachment and no leakage from the pit even at the late stage (fig. ). Additionally, MRI was performed to rule out any other abnormalities related to optic disc pit, but it was totally clear.\nThe patient was offered vitrectomy as a treatment alternative, but taking into account the potential risks and benefits of the surgery, she declined and was reviewed routinely on a 4-monthly basis. Interestingly enough, 3 years after initial presentation, neither macular schisis nor subretinal fluid were evident on OCT (fig. ), and her visual acuity was significantly improved from 6/24 to 6/12 in the left eye, which remained stable at the 6-month follow-up after resolution of macular detachment.

[[63.0, 'year']]

F

{'27847606': 1, '7375086': 1, '21638030': 1, '4959901': 1, '12381994': 1, '32923940': 2, '18458936': 1, '22322392': 1, '2255526': 1, '26622146': 2, '30127591': 1, '2043587': 1, '22237839': 1, '15534590': 1, '26858486': 1, '454276': 1, '23623023': 1, '15359248': 1, '8644805': 1, '32691162': 1, '1765292': 1, '19253260': 1, '24761149': 2}

{'7453435-1': 1, '4640042-1': 1}

3995388-1

noncomm/PMC003xxxxxx/PMC3995388.xml

Improvement of Freezing of Gait in Patients with Parkinson's Disease by Imagining Bicycling

A 70-year-old woman noticed short shuffling steps and difficulty in turning her body while walking at the age of 67. She gradually developed difficulty walking, mainly due to FOG. Neurological findings at the age of 67 revealed a depressive state, masked face, resting tremor, cogwheel type rigidity, bradykinesia, severe FOG, postural instability, and autonomic dysfunction, such as pollakisuria, constipation, and orthostatic hypotension. After gradual increases of L-dopa/decarboxylase inhibitor (DCI; 200–900 mg/day) and L-threo-3,4-dihydroxyphenylserine (100–600 mg/day), these parkinsonian symptoms improved, except for the severe FOG and postural instability (fig. ; see online suppl. video segment ; for all online suppl. material, see ). Visual and auditory cues also did not improve severe FOG and, therefore, her quality of life was limited. When she was instructed to imagine that she was pedaling a bicycle prior to trying to initiate gait, she was able to begin walking smoothly without FOG (fig. ; online suppl. video segment ). Imagining taking a large step, climbing stairs, or stepping over regular horizontal lines did not improve severe FOG. When the patient was additionally instructed to imagine and mimic bicycling after having initiated walking, her gait was more rhythmical and without interruption (online suppl. video segment ). There was little time between the first and second video segments. After several visits, severe FOG in its normal condition without imagining bicycling and the improvement of FOG after imagining bicycling were similar to the results shown in online supplementary video segments and . Routine blood examinations were normal. The coefficient of variation of the R-R interval was reduced to 1.68%. A brain MRI showed mild chronic ischemic changes in the deep white matter. 99mTc-ECD SPECT showed mild hypoperfusion in the anterosuperior frontal and posterolateral parietal lobes. The heart-to-mediastinum (H/M) ratio in 123I-metaiodobenzylguanidine myocardial scintigraphy decreased (early H/M: 1.89, delayed H/M: 1.68).

[[70.0, 'year']]

F

{'32331349': 1, '20357278': 1, '12610686': 1, '27777809': 1, '11425939': 1, '6933218': 1, '32773398': 1, '15852404': 1, '21462254': 1, '21933951': 1, '28895316': 1, '22717367': 1, '34336183': 1, '24761145': 2}

{'3995388-2': 2}

3995388-2

noncomm/PMC003xxxxxx/PMC3995388.xml

Improvement of Freezing of Gait in Patients with Parkinson's Disease by Imagining Bicycling

A 74-year-old woman found it difficult to begin walking at the age of 64. Neurological findings at the age of 66 revealed parkinsonism, such as microphonia, cogwheel type rigidity, bradykinesia, and FOG. She gradually developed difficulty walking due to severe FOG and postural instability (fig. ; online suppl. video segment ). Although the administration of L-dopa/DCI (600 mg/day) and ropinirole (12 mg/day), and visual and auditory cues did not improve the severe FOG, she was able to walk without FOG after imagining bicycling (fig. ; online suppl. video segment ), and the gait interruptions improved when imagining and mimicking bicycling after gait initiation (online suppl. video segment ). Imagining taking a large step, climbing stairs, or stepping over regular horizontal lines did not improve severe FOG. Severe FOG in its normal condition without imagining bicycling and the improvement of the FOG after imagining bicycling were similar to the gaits shown in online supplementary video segments and after several visits. Routine blood examinations were normal. A brain MRI showed mild chronic ischemic changes in the deep white matter.

[[74.0, 'year']]

F

{'32331349': 1, '20357278': 1, '12610686': 1, '27777809': 1, '11425939': 1, '6933218': 1, '32773398': 1, '15852404': 1, '21462254': 1, '21933951': 1, '28895316': 1, '22717367': 1, '34336183': 1, '24761145': 2}

{'3995388-1': 2}

3995389-1

noncomm/PMC003xxxxxx/PMC3995389.xml

The Course of Incidental Intraorbital Cavernous Hemangioma in a Patient with Myasthenia Gravis Treated with Cyclosporine: A Case Report

A 69-year-old woman had undergone a thymectomy at the age of 59 years because of a thymoma detected by routine chest X-ray examination. At the time of the thymoma detection, she had not shown any abnormal neurological symptoms. However, she has been suffering from symptoms such as moderate bilateral ptosis, severe diplopia, and muscle weakness after 10 years of thymoma operation, despite no recurrence of the thymoma. The affected muscles were the bilateral external ocular muscles, pharyngeal musculature, neck extensor muscle, deltoid, biceps, triceps, and iliopsoas. In particular, her left eye movement was limited in all directions. The diplopia developed at approximately the same time as the onset of the ptosis, and the extremity muscle weakness occurred during the 6 months following the onset of the external ocular symptoms. MG was diagnosed by the fluctuating symptoms, the waning detected in a repetitive nerve stimulation test on the median nerve, and positive test results for the acetylcholine receptor (AChR) antibody. The patient's quantitative MG score [] was of 24 points. After plasma exchange treatment, her qualitative MG score improved to 11 points. The AChR antibody titer at the initial visit was 250 μmol/l. The antibody titer decreased to 95 μmol/l after plasmapheresis (PP) treatment. However, improvement of the left external ocular movement (EOM) without ptosis was poor compared to the improvements in the right EOM, dysphagia, and limb muscles weakness. An orbital MRI was performed because the diplopia did not respond to PP or an edrophonium test, and revealed an intraorbital tumor of 3 cm in diameter. The tumor was diagnosed as an orbital cavernous hemangioma (OCH) by the imaging characteristics (fig. ). It was followed closely without treatment because the patient did not want surgical treatments for the tumor. She was treated with cyclosporine A (CsA) at concentrations from 100 to 150 ng/ml in order to improve the MG symptoms after PP treatment. Her diplopia began to improve thereafter over the course of 6 months. A follow-up MRI showed a reduction in the tumor size. The improvement of the left eye movement was paralleled by a significant reduction of the tumor rather than a change in the AChR antibody titer, although it was further reduced to 72 μmol/l by CsA therapy. On the other hand, continuing CsA therapy at concentrations of 100 to 150 ng/ml increased her systolic blood pressure to 160 mm Hg and decreased her glomerular filtration rate to 45 ml/min. In response to these adverse effect, the CsA concentration was controlled in the range from 75 to 100 ng/ml, which maintained blood pressure within the normal range and a glomerular filtration rate over 50 ml/min. After 7 years, a follow-up MRI was performed and the AChR antibody titer was 5.0 μmol/l. The CsA concentration was kept in the range from 75 to 100 ng/ml, and the tumor was maintained at a size that does not affect the EOM (fig. ).

[[69.0, 'year']]

F

{'21440910': 1, '9551405': 1, '8394783': 1, '1335857': 1, '8182156': 1, '10891897': 1, '24761144': 2}

{}

3995393-1

noncomm/PMC003xxxxxx/PMC3995393.xml

Calcinosis Cutis Confined to the Dermis after Intravenous Administration of a Calcium Preparation: A Case Report and Review of the Japanese Literature

A 61-year-old Japanese woman presented with induration on the left forearm. The family history was not remarkable. The medical history included bladder cancer diagnosed 10 weeks earlier, which was resected surgically. Inadvertently, the left iliac artery was occluded during the operation. This was treated intraoperatively by common iliac artery bypass and intravenous infusion of 2% calcium chloride into the arm vein to induce vasoconstriction. Postoperatively, no extravasation of the injected preparation was noted on the arm, but a red flare appeared around the area of administration. The red flare gradually led to induration and ulcer formation. The patient was referred to the Department of Dermatology at postoperative week 7 for further management.\nPhysical examination showed an indurated plaque of 13 × 65 mm with linearly distributed ulcers covered by yellowish-white material, and the entire lesion was surrounded by reddish skin (fig. ). Laboratory data showed BUN 25.2 mg/dl (normal: 7.0–22.0), serum creatinine 0.97 mg/dl (normal: 0.3–0.8), serum calcium 9.3 mg/dl (normal: 8.0–10.5), serum phosphate 4.4 mg/dl (normal: 4.0–6.0), and high sensitivity-parathyroid hormone 460 pg/ml (normal: 160–520). Cultures were negative for acid-fast bacilli and fungi.\nTwo skin biopsy samples were obtained from the left forearm. The histopathological findings were similar in the two specimens and included deposition of basophilic amorphous substance in the upper and middle dermis (fig. ), but not in the subcutis. The amorphous material was eliminated transepithelially, with partial defect of the epidermis and substitution with crust. There was granulomatous infiltration surrounding the amorphous material with underlying collagen accumulation. Histiocytic infiltrates intermingled with lymphocytes and giant cells among the collagen fibers (fig. ). The amorphous substance stained black with von Kossa staining (fig. ). Based on the above clinical and histopathological findings, the final diagnosis was calcinosis cutis. The whitish chalky substance disappeared gradually within 1 month, together with healing of the ulcers within 2 months, with scar formation (fig. ).

[[61.0, 'year']]

F

{'28778861': 1, '24761140': 2}

{}

3995395-1

noncomm/PMC003xxxxxx/PMC3995395.xml

Biological Characteristics of a Cerebellar Mass Regrowing after Removal in a Patient with Lhermitte-Duclos Disease: Emission Tomography Studies

A 17-year-old man underwent a subtotal removal of a cerebellar mass lesion (Lhermitte-Duclos disease) via craniectomy []. Thirteen years later, the patient presented with headaches. Neurological examination showed a slightly ataxic gait. MRI revealed a regrowing mass lesion with an abnormal laminated pattern of cortical architecture in the left cerebellar hemisphere, extending to the vermis (fig. ).\nBrain blood flow and metabolic rate of oxygen were calculated by the steady-state method using a PET scanner and 15O-gas []. Both 99mTc-ECD and 123I-iomazenil SPECT studies were performed at 3 and 7 days after PET, respectively, using the same procedures applied in previous studies [, ]. The study protocol was approved by the local ethics committee. Written informed consent was obtained from the subject prior to undergoing these studies.\nIn the cerebellar region, increases in both blood flow and metabolic rate of oxygen were detected on 15O-gas PET imaging (fig. ). While the lesion exhibited hyperactivity on 99mTc-ECD SPECT imaging, where the contrast was similar to that of blood flow PET imaging, 123I-iomazenil SPECT showed a defect in uptake within the lesion (fig. ).\nThe lesion was partially resected through a suboccipital craniectomy. Histological examination revealed typical features of Lhermitte-Duclos disease.

[[17.0, 'year']]

M

{'21421729': 1, '9098208': 1, '3879853': 1, '8667060': 1, '28572832': 2, '19904496': 1, '18097262': 1, '11760808': 1, '8996500': 1, '17332944': 1, '24761146': 2}

{'5450341-1': 1}

3995396-1

noncomm/PMC003xxxxxx/PMC3995396.xml

Intravascular Lymphomatosis Mimicking Primary Central Nervous System Lymphoma: A Case Report and Literature Review

A 75-year-old right-handed female patient was admitted to our hospital for the evaluation of recurrent fevers. She had been well until 3 weeks before admission, when fever and fatigue developed. She had a history of cholecystectomy, spinal compression fracture, and an old cerebral infarction of the left middle cerebral artery. After the brain infarction, she developed aphasia and right hemiplegia and became dependent on a wheelchair. She showed paroxysmal atrial fibrillation, and warfarin was prescribed to prevent a second stroke.\nOn examination, her blood pressure was 150/70 mm Hg, her pulse 90 beats per minute, and her body temperature was 37.5°C. There was a small decubitus ulcer on the sacrum and a nonpitting edema in both legs. No lymph node swelling was noted. Neurological examination revealed aphasia and right hemiplegia. The rest of the examination was normal. Her white blood cell count was 11,000/mm3 (reference range 3,500–8,000/mm3). Her blood levels of lactate dehydrogenase (LDH), C-reactive protein, and soluble interleukin-2 receptor (sIL-2R) were high at 458 IU/l (normal <229 IU/l), 16.8 mg/dl (normal <0.8 mg/dl), and 3,458 U/ml (normal <515 U/ml), respectively. Her blood levels of electrolytes, glucose, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, amylase, brain natriuretic protein, and vitamin B1 were normal, as were her renal and thyroid function. Lumbar puncture was performed; there was no pleocytosis in the cerebrospinal fluid, but the protein and IgG levels were increased to 85 mg/dl (normal <50 mg/dl) and 17 mg/dl (normal <4 mg/dl), respectively. A urine culture showed no growth. Blood specimens were sent for cultures of bacteria, mycobacterium, and fungi. All results were negative. A contrast-enhanced CT of the chest, abdomen, and pelvis failed to reveal any abnormal lesions that could have caused the fever. No adrenal gland mass was noted. A brain MRI obtained 3 weeks after admission showed an old infarction but was otherwise normal. Tests for antibodies to hepatitis B, hepatitis C, human immunodeficiency virus, human T-lymphotropic virus, and the Treponema pallidum were negative. Antibiotic treatments including ciprofloxacin at 600 mg/day, panipenem/betamipron at 1 g/day, and ceftazidime at 2 g/day combined with arbekacin at 200 mg/day were undertaken, but all were ineffective. 67Ga scintigraphy showed no abnormal uptake. The fever continued for more than 3 weeks and fulfilled the criteria for FUO. Because the serum levels of LDH and sIL-2R remained high, we suspected a hematogenous tumor such as myeloma, and bone marrow puncture was performed, but the result was normal. Although there were no skin lesions, we strongly suspected IVL and thus performed a random skin biopsy. The biopsy was obtained from 1 lesion of the purpura on the abdomen and 2 regions of the skin with a normal appearance on the abdomen and left thigh. Histological examination revealed atypical cells lodged in the intravascular lumens in the subcutaneous tissue of the normally appearing left thigh region (fig. ). Higher magnification revealed vessels filled with large malignant lymphoid cells and eosinophilic nucleoli (fig. ); the cells were stained with CD20 antibodies but not with CD3 (fig. ). The patient was thus diagnosed with IVL (intravascular large B-cell lymphoma). Her consciousness deteriorated 6 weeks after admission. An MRI obtained 7 weeks after admission showed a mass lesion involving the right basal ganglia, thalamus, corona radiata, uncus, and crus cerebri (fig. ). The mass was isointense on a T1-weighted image, hyperintense on a T2-weighted image, and exhibited mild restricted diffusion on a diffusion-weighted image (DWI). The mass was homogeneously enhanced (fig. ). No definite ischemic lesions were noted. All radiological findings were compatible with those of PCNSL. The patient's status was too poor for chemotherapy. An MRI obtained 9 weeks after admission showed an enlargement of the mass (fig. ). She died 11 weeks after admission. Permission for a postmortem examination was not obtained.

[[75.0, 'year']]

F

{'1609614': 1, '2375700': 1, '1871454': 1, '15774442': 1, '18053461': 1, '19139824': 1, '28596202': 1, '21515924': 1, '9541293': 1, '3065781': 1, '33122951': 1, '7035626': 1, '21867556': 2, '7989931': 1, '27099719': 1, '7781232': 1, '11349880': 1, '24761147': 2}

{'3178486-1': 1}

3995397-1

noncomm/PMC003xxxxxx/PMC3995397.xml

Severe Gangrene Accompanied by Varicella Zoster Virus-Related Vasculitis Mimicking Rheumatoid Vasculitis

A 72-year-old male who had been under treatment for RA with methotrexate (8 mg/week), prednisolone (5 mg/day) and bucillamine (200 mg/day) developed a skin ulcer on the left fifth toe and lymphadenitis on the left inguinal region. Although Streptococcus haemolyticus was detected in the skin ulcer and systemic antibiotics were administered, the skin ulcer expanded in size and depth, exposing the extensor tendon, and another ulcer consistent with scattered necrosis subsequently appeared on the dorsum of the left foot. A microscopic test for superficial mycoses, the Tzanck test and a cultivation test for mycobacterial infection were all negative. Furthermore, subcutaneous nodules also appeared on the left patella. A biopsy specimen obtained from the skin around the ulcer and subcutaneous nodule showed necrotic vasculitis although there were no remarkable changes in the epidermis, and we were concerned that the patient had progressed to rheumatoid vasculitis. Two months later, the ulcer on the fifth toe had further expanded with surrounding small erythematous, bullous lesions, while the other ulcer on the dorsal foot had become deeper, exposing the joint capsule (fig. ). A skin biopsy of the bullous lesion revealed acantholysis and ballooning degeneration of keratinocytes. Leukocytoclastic vasculitis with fibrinoid degeneration was also seen in the reticular dermis and subcutaneous tissue as it was in the findings from the first biopsy specimen (fig. ). Immunohistochemical staining using a monoclonal antibody recognizing VZV (Novocastra Laboratories, Newcastle, UK) was positive in keratinocytes inside the vesicles, fibroblasts, inflammatory cells and endothelial cells in the underlying dermis (fig. ). VZV was identified on a virological culture of a swab.\nWe also performed immunohistochemistry for VZV in the first biopsy specimen and confirmed positive staining in the cells in the dermis and subcutaneous tissue, including endothelial cells, with negative staining in keratinocytes (fig. ). These results indicated that our patient initially developed VZV vasculitis without the epidermal involvement typical of VZV infection. We considered the possibility of repeated VZV reactivation within several months due to immunosuppression. A decreased serum IgG level was also observed on a serological examination. We stopped the methotrexate therapy and started treatment with intravenous acyclovir. The expansion of the ulcer quickly stopped, and the lesion healed within 3 months without surgical treatment.

[[72.0, 'year']]

M

{'19022529': 1, '28631066': 1, '1311486': 1, '28298208': 1, '16021111': 1, '10773714': 1, '27097818': 1, '19648728': 1, '7722056': 1, '17938360': 1, '20576219': 1, '28684923': 2, '24761143': 2}

{'5484569-1': 1}

3995400-1

noncomm/PMC003xxxxxx/PMC3995400.xml

Disseminated Cryptococcosis-Induced Skin Ulcers in a Patient with Autoimmune Hepatitis

A 68-year-old woman consulted our department for skin ulcers on her right thigh complicated with suspected RA. She had been diagnosed with type 1 diabetes and Hashimoto's disease 15 years ago, and with AIH and Sjögren's syndrome 3 years ago, and was eventually diagnosed with autoimmune polyendocrinopathy syndrome. She received prednisolone at 30 mg/day as the first treatment for AIH. The dose of the corticosteroids was difficult to taper due to arthralgia, and she continued to take medication at 20 mg/day as a maintenance dose. At her initial visit, the metacarpophalangeal joints of her bilateral forefingers and middle fingers, and her wrist joints were swollen with tenderness. She also complained that the morning stiffness of the fingers persisted for more than 3 h. One month prior to the initial visit, a skin ulcer appeared on the lateral side of the right thigh. She was hospitalized for the ulcer due to suspected RA, and high levels of serum RF and matrix metalloproteinase-III were administered.\nOn hospitalization, her vital signs were as follows: temperature 37.1°C, blood pressure 120/64 mm Hg, pulse rate 64 beats/min, and oxygen saturation 97%. She had a productive cough and her legs were edematous. The physical examination revealed some fine crackles by stethoscope. There was a painful ulcer that had round, shallow pockets with erythema and erythematous subcutaneous indurations on the right thigh (fig. ).\nThe main laboratory findings were as follows: white blood cell count 13,500/μl (normal range 3,500–9,800), creatinine 1.42 mg/dl (normal range 0.47–0.72), urea nitrogen 35 mg/dl (normal range 10–20), C-reactive protein (CRP) 4.29 mg/ml (normal range <0.03), brain natriuretic peptides 752.5 pg/ml (normal range <18.4), RF 117.0 U/ml (normal range <19), anti-CCP antibody 16.5 U/ml (normal range <4.5), CH50 58 U/ml (normal range 30–50), KL-6 257 U/ml (normal range <500) [, , ], and β-D glucan 6 pg/ml (normal range 0–11).\nBefore hospitalization, a chest X-ray and computed tomography (CT) scan revealed cardiomegaly and some old linear shadows, but no shadows suggestive of pneumonia and pleural effusion were observed. An echocardiogram showed a decline in the left heart function but no signs of heart failure. We prescribed diuretics for the leg edema.\nAlthough the characteristic features of the ulcers seemed to be different, it was possible that the cause of the skin ulcers was RA, which complicated the AIH, because the RF value was high, the anti-CCP antibodies were positive, and her articular symptoms mimicked RA.\nA blood culture was negative, but a sputum culture was positive for Pseudomonas aeruginosa and a urine culture was positive for Proteus mirabilis. A biopsy specimen showed granulomatous inflammation, degenerative necrosis, and globe-shaped organisms in the dermis and subcutaneous tissues (fig. ). We began to treat her with ceftazidime intravenously and fluconazole orally at a starting dose of 200 mg/day and decreased to 100 mg/day which was adjusted to the patient's decreased renal function. The serum latex agglutination titer to Cryptococcus, which was measured after the result from the skin biopsy, was 1:4,096. The follow-up CT scan revealed a new nodule on the lower right lung, and a small amount of pleural effusion, and the follow-up sputum culture was positive for Cryptococcus neoformans. However, the sensitivity of the antifungal drugs could not be examined because the amount of Cryptococcus detected was so small. Therefore, we diagnosed it as disseminated cryptococcosis. We asked her about having had contact with pigeons, but she denied. We got the result of the follow-up sputum culture after the start of the treatment with antifungal drugs. The detected amount of Cryptococcus in this culture was very small. Consequently, we considered that we could not get meaningful results for the further cultures under that administration. Bronchoscopy and a lumbar puncture could not be performed because her general conditions worsened. The oral fluconazole was changed to fosfluconazole intravenously at an initial dose of 200 mg/day and a maintenance dose of 100 mg/day. Her CRP levels decreased to nearly within normal limits, and the antifungal agent was changed to oral 100 mg/day fluconazole again. However, thrombocytopenia aggravated and her renal function worsened, and the agent was changed again to oral voriconazole at a dose of 600 mg/day and thereafter 300 mg/day as maintenance dose. Although repeated CT scans showed that the nodule disappeared and the CRP levels did not increase due to the skin involvements, the indurations progressed to ulcerations and their size enlarged. After she was transferred to another hospital, the drug was changed to itraconazole, which clearly reduced the skin manifestations.

[[68.0, 'year']]

F

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{}

3995401-1

noncomm/PMC003xxxxxx/PMC3995401.xml

A Rare Case of Male Bullous Lupus Erythematosus Complicated with Subsequent Annular Hypopigmentation

A 57-year-old male patient had noticed itchy erythema on the frontal chest in May 2011, and thereafter experienced disease enlargement and partial crust formation. Since no clinical effect of 10 mg/day of oral prednisolone was observed, he was referred to our hospital on July 7, 2011. In terms of the clinical findings at the first visit, symmetric red papules and centrifugal erythema, surrounded by an annular erosive crust, were distributed on the upper extremities and trunk in line with the seborrheic region. The center of the erythematous lesions in the skin tended to be notably resolved (fig. ), while the mucosal areas were intact. A fever and symmetrical bullous erythema worsened 1 week after admission (fig. ). Although his skin disease was initially suspected to be a bullous disease, neither anti-desmoglein 1/3 nor anti-BP 180 antibodies were detected.\nLaboratory tests revealed cytopenia (WBC, 10,470/μl; Neu, 72.6%; lymph, 13.0%; mono, 14.0%; eosino, 0.1%; baso, 0.3%; RBC, 3.85 × 106/μl; Hb, 12.7 g/dl; Ht, 38.5%; platelet, 180 × 103/μl), ANA (1/320, homogeneous + speckled pattern), positive anti-Sm antibodies, anti-RNP, anti-cardiolipin antibodies, and low C3 and C4 levels. Metal patch and photo tests were negative, and no internal malignancy was detected by whole-body imaging. A biopsy of the erythematous lesion showed individual apoptotic keratinocytes and liquefaction with partial cleft formation on the epidermis, and lymphocytes predominantly infiltrated in the upper dermis and perivascular area (fig. ). Pigment incontinentia was notable, along with severe inflammation (fig. ). The direct immunofluorescence findings of the uninvolved lesion were granular deposition of IgG and IgM in the basal membrane.\nThese laboratory and histological findings led to a final diagnosis of BLE type I. In an immunohistochemical analysis for immunocompetent cells, CD8+ cells, instead of CD4+ cells, and HLA-DR+-activating T cells were found to have densely infiltrated into the epidermis of the erythematous lesion. The number of CD1a+ Langerhans cells was decreased. The CD68+ macrophages densely infiltrated into the upper dermis, and there was a slight infiltration of IL-17A+ cells and Foxp3+ cells (fig. ).\nAn increased dose of oral prednisolone was effective not only for spiking fever, cytopenia and hypocomplement level, but also crusted bullae and fused erythema (fig. ). Instead, annular incomplete hypopigmentation tracing the crusted lesions was noted 1 month later (fig. ). Our histological observations of the hypopigmented lesion showed a decrease, but not total absence, of melanosomes and melanocytes detected by Masson-Fontana (fig. ) and Melan-A (fig. ) staining, respectively. In addition, an ultrastructural analysis of a hypopigmented lesion revealed attenuated melanin production, with the presence of immature melanosomes in the remaining melanocytes, whereas no disturbance of melanin transfer to adjacent keratinocytes was noted (fig. ). The hypopigmented lesions recovered 2 weeks later, without any additional treatment (fig. ).

[[57.0, 'year']]

M

{'2835778': 1, '20653856': 1, '22136309': 1, '15234014': 1, '6358284': 1, '26579826': 1, '19807822': 1, '20693193': 1, '24761141': 2}

{}

3996251-1

noncomm/PMC003xxxxxx/PMC3996251.xml

A Rare Case of Primary Squamous Cell Carcinoma of the Stomach and a Review of the 56 Cases Reported in Japan

A 69-year-old Japanese man was admitted with a 2-month history of dysphagia and tarry stools. The results of physical examination were unremarkable. Routine laboratory tests revealed leukocytosis (11,900 cells/mm3). The tumor marker levels were as follows: SCC antigen, 2.5 ng/ml (normal range, 0~0.5 ng/ml) and CYFRA 21-1, 17 ng/ml (normal range, 0~1.5 ng/ml). Upper gastrointestinal endoscopy revealed erosive esophagitis and a cauliflower-shaped protruding mass located in the gastric cardia. The mass arose from the lesser curvature (). Histological examination of biopsy specimens revealed a well-differentiated SCC. Several biopsy specimens were collected from the gastric mucosa surrounding the tumor. No Helicobacter pylori was detected, but the mucosa of the esophagogastric junction was mildly inflamed. An upper gastrointestinal barium series revealed an elevated mass arising from the lesser curvature of the gastric cardia (). Computed tomography (CT) of the abdomen with intravenous administration of a contrast dye revealed a large heterogeneous mass on the dorsal wall of the stomach, with no evidence of metastatic disease outside the stomach (). Total gastrectomy with splenectomy, distal pancreatectomy, and Rouxen-Y reconstruction was performed, together with a lower thoracic esophagectomy via a left thoracotomy. There was no evidence of regional or distant metastasis. On opening the stomach, an ulcerated mass in the cardia, measuring 7.5×9.0 cm, was observed along the lesser curvature (). Pathological examination of sections of the resected specimen stained with hematoxylin and eosin revealed a well-differentiated SCC with frequent typical keratin pearl formation, mosaic patterns of cell arrangement, and intracellular bridges (). The esophageal and pyloric margins were free of tumor involvement, but tumor cells infiltrated the serosa of the dorsal margin. No nodal metastasis was apparent. The tumor had not invaded the mucosa of the esophagogastric junction. In addition, no squamous cells were detected in the normal portion of the stomach. The clinical stage was stage IIB (T4aN0M0), according to the TNM classification, version 7. Therefore, primary SCC of the stomach was diagnosed. The patient refused adjuvant chemotherapy. However, 18-months after the operation, a CT scan revealed a metastatic tumor that was 4.0 cm in diameter in segment 6 of the liver, accompanied by para-aortic lymph node metastasis. Although the patient immediately received systemic chemotherapy with 5-fluorouracil plus cisplatin and docetaxel plus cisplatin, the recurrent tumors progressed. Liver metastases developed subsequently, and the patient died 36 months after the first operation.

[[69.0, 'year']]

M

{'3706247': 1, '27433399': 2, '31194122': 1, '21573743': 1, '11490793': 1, '7486450': 1, '12610330': 1, '34779967': 2, '3970006': 1, '5939052': 1, '10576394': 1, '32899097': 2, '28469507': 1, '26464735': 1, '27478431': 1, '30788163': 1, '30761414': 1, '26673808': 1, '29390350': 1, '19960279': 1, '26185704': 2, '26157948': 1, '5353950': 1, '29850384': 2, '31255175': 2, '24765539': 2}

{'7478421-1': 1, '8593088-1': 1, '5973482-1': 1, '4491394-1': 1, '6599270-1': 1, '4944001-1': 1}

3996252-1

noncomm/PMC003xxxxxx/PMC3996252.xml

Mixed Adenoneuroendocrine Gastric Carcinoma: A Case Report and Review of the Literature

A 77-year-old Caucasian woman was admitted to our department with nausea, anorexia, weight loss, and anemia. The medical history of the patient did not include any significant prior illness. The findings of physical examination were unremarkable. The patient's hemoglobin level (10.3 g/dl) and tumor marker levels (carcinoembryonic antigen, carbohydrate antigen 19.9, and carbohydrate antigen 72-4) were within the normal range. Esophagogastroduodenoscopy revealed a large (>7 cm) ulcerative mass (Borrmann type 3) in the greater curvature of the stomach. Biopsy showed the presence of an adenocarcinoma with moderate differentiation. Computed tomography did not show distant metastasis. The patient underwent D2 subtotal gastrectomy, with no surgical complications. Histopathological analysis showed, in agreement with the diagnosis of a mixed gastric adenoneuroendocrine carcinoma (), that 30% of the tumor area was intensely positive for chromogranin () and synaptophysin (), with part of it being tubular adenocarcinoma (G2) and of the rest being neuroendocrine large cell carcinoma (G3). The tumor penetrated the serosa, but none of the 29 regional lymph nodes showed metastasis and no distant metastasis was detected (pT4a, pN0, pM0, stage IIb according to the 7th edition of the American Joint Committee on Cancer TNM classification). The lymphatic and vascular lumina were not invaded, but perineural invasion was present. The post-operative course was uneventful. The patient underwent adjuvant chemotherapy, consisting of a combination of cisplatin, doxorubicin, and vincristine, and at the 6-month follow-up, the patient was alive without evidence of recurrence.

[[77.0, 'year']]

F

{'25337298': 1, '22076213': 2, '2599568': 1, '22423239': 1, '8562996': 1, '15737041': 1, '19886184': 1, '31169743': 1, '25823931': 1, '29732359': 2, '30800309': 2, '30212993': 2, '29780112': 1, '19945227': 1, '2171747': 1, '29984070': 2, '29390331': 1, '22740822': 1, '16758691': 1, '9809564': 1, '29164159': 2, '16218931': 1, '22324009': 1, '1898226': 1, '3969962': 1, '31929886': 1, '15792127': 1, '26913067': 2, '21424098': 1, '9221021': 1, '24765540': 2}

{'5931938-1': 1, '3204483-1': 1, '4754118-1': 1, '6026709-1': 1, '5686881-1': 1, '6378457-1': 1, '6156028-1': 1}

3996347-1

noncomm/PMC003xxxxxx/PMC3996347.xml

Literature Review and Clinical Presentation of Cervical Spondylitis Due to Salmonella Enteritidis in Immunocompetent

A 48-year-old woman was presented to our clinic with some fever and neck pains for about one month. She had no significant neck injury history. Her neck pains occurred after days of low degree fever and fatigue, with shoulder and arm pains. She rated the neck pain 7 out of 10 points (visual analogue scale). The pain, with dizziness and headaches, increased at night. Although the neck pain involved both shoulders and arms, there were no specific distributions of arm pains. She did not have any numbness in either arms. She felt a low fever everyday but denied a contact with tuberculosis. She walked normally and continued her work at home. She had no bowel and bladder problems.\nPhysical examinations revealed restricted neck rotations and obvious tenderness on her shoulders. For her neurological examination of the upper limb, no abnormality was found. Spurling signs and Lhermitte's test were not detected. Hoffman's sign and Babinski's sign were negative. Her tandem gait was normal. Her body temperature was 38.2℃.\nThe laboratory tests revealed that white blood cell (WBC) was counted as 3.8×109/L, with 57% neutrophils, and 30.1% leukocyte. C-reactive protein (CRP) level was 7.29 mg/L and erythrocyte sedimentation rate (ESR) was 28 mm/hr. Both purified protein derivative tests and tuberculosis antibody colloidal gold diagnostic tests were negative.\nLateral radiograph revealed a loss of lordosis on the cervical spine by destructions of the fifth cervical vertebrae (C5) and narrowing of the intervertebral disk space between C5 and the sixth cervical vertebrae (C6). In addition, magnetic resonance imagings (MRIs) of the cervical spine demonstrated uneven compressions of the intervertebral disk spaces between C5 and C6. Endplates and vertebrae were moth-eaten damaged. This was combined with well-defined paraspine and intraspine abnormal signals wrapped with smooth walls, all in parallel with tuberculous spondylitis which is inconsistent with the pyogenic ().\nAn empirical diagnosis of tuberculosis (TB) cervical spondylitis was made and the patient underwent classic anti-tuberculosis therapy with isoniazid, rifampicin, and ethambutol, and anti-infective treatments with penicillin and gentamicin. Yet, the chemotherapy for TB received no improvements in neck pain after 3 weeks. Repeated lab tests revealed that WBC was 7.2×109/L, with 70% of neutrophils and 17% of leukocyte, while CRP was 2.68 mg/L and ESR 23mm/hr. Based on the limited responses of anti-TB therapy, we realized that TB might not be the pathogen. Therefore, an exploration of the C4/5 through the anterior medial approach was recommended to evaluate the germ and debridement.\nIn the surgery, hypertrophic and edematous prevertebral fascia was noticed. On the right edge of C5 vertebral body, there was an abscess in the size of about 1×1×0.6 cm3. Needle puncture containing about 1 mL yellow feculent abscess was sent for culture. The abscess was drained and adjacent inflammatory tissues were removed. The C5/6 disc and its adjacent vertebral endplates were damaged. Scattered local bone destructions and hyperplastic granulations were found in C5 vertebral body. Frozen pathological section examinations of the pre-vertebral tissues revealed infiltration of neutrophils and tissue cells, but no evidences of malignancy and tuberculosis. Acid-fast bacillus test of purulent specimen smear was negative. The C5 corpectomy was then performed, and C4/5 and C5/6 discs were removed, followed by auto-iliac grafts and anterior plate instrumentations (InterTan, Smith & Nephew, Memphis, TN, USA). Gel foams filled with streptomycin were used to cover the plate and screws.\nHistological study revealed chronic infections of C5 vertebra, with apparent neutrophils infiltration and granulation tissues hyperplasia. No evidences of tuberculosis, such as epithelioid cell hyperplasia and langhan's cell, were detected. Instead, bacteriology study showed that the pathogen was SE. She was diagnosed as having cervical spondylitis caused by SE. Based on sensitivity test, levofloxacin was administrated through intravenous injection for 3 weeks, followed by oral antibiotic for another 2 weeks. At 1 month follow-up, her neck pain completely disappeared and radiography showed signs of bone growth. At 1.5 year of follow-up, C4-6 fusion was obtained. At 5-year of follow-up, she was symptoms-free and magnetic resonance showed a fine fusion from C4 to C6. However, accelerated degeneration was observed in the adjacent C3/4 discs ().

[[48.0, 'year']]

F

{'9709878': 1, '16708233': 1, '22033610': 1, '18008092': 1, '10573337': 1, '29718896': 2, '32767972': 2, '20838270': 1, '15636572': 1, '7924947': 1, '21286449': 2, '28630845': 2, '7090411': 1, '3346277': 1, '9867305': 1, '15636577': 1, '16523127': 1, '18603186': 1, '15797499': 1, '27114675': 1, '7302688': 1, '16723876': 1, '20938384': 1, '24761205': 2}

{'3030045-1': 1, '7430869-1': 1, '5458703-1': 1, '6392897-1': 1}

3996715-1

noncomm/PMC003xxxxxx/PMC3996715.xml

Left paraduodenal hernia combined with acute cholecystitis

A 74-year-old woman presented to the Emergency Department with persistant right upper quadrant pain that began 3 hours prior to presentation. She had an unremarkable medical history, but asymptomatic gallstones were detected during routine check-up. More specifically, she had no history of abdominal surgery or abdominal pain prior to this visit. Physical examination revealed a thin woman (height, 156 cm; weight, 49 kg) with a blood pressure of 110/70 mmHg, a pulse of 64 beats/min, and a body temperature of 36.6℃. The abdomen was tender in the right upper quadrant. No guarding and rebound tenderness were noted. The laboratory data showed neutrophilia (white blood cells, 9,710 / mm3 with 81.4% segmented neutrophils). Other blood chemistry parameters including liver function test were unremarkable. CT revealed multiple gallstones with gallbladder wall thickening, marked dilatation of stomach and duodenum and a sac-like mass of small bowel loops to the left of the ligament of Treitz () suggesting acute cholecystitis and left paraduodenal hernia. After performing CT, the patient developed bilous vomiting without left abdominal pain. We proceeded to perform laparoscopic exploration of the abdomen with cholecystectomy. The defect was located at the Treitz ligament where proximal jejunal loops were noted to be herniating through the defect (). About 50 cm of jejunal loops were easily reduced and the bowel appeared viable. The 3-cm defect was closed using 3-0 Vicryl intracorporeal interrupted sutures. Laparoscopic cholecystectomy was then performed. The total operation time was 105 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 4. During the 6 months follow-up period, the patient remained completely free of symptoms.

[[74.0, 'year']]

F

{'26826933': 1, '7006131': 1, '26576408': 2, '15107222': 1, '4412601': 1, '9843350': 1, '9773941': 1, '11906430': 1, '23324390': 1, '29848337': 2, '19098672': 1, '31006063': 1, '24783182': 2}

{'5977483-1': 1, '5977483-2': 1, '5977483-3': 1, '5977483-4': 1, '5977483-5': 1, '4644909-1': 1}

3996717-1

noncomm/PMC003xxxxxx/PMC3996717.xml

Bowel perforation associated sunitinib therapy for recurred gastric gastrointestinal stromal tumor

A 78-year-old woman with an abdominal mass for more than 1 month was admitted to Chosun University Hospital. Physical examination revealed a large mass in the periumbilical area. Abdominal computed tomography revealed an 18 cm abdominal mass with extensive central necrosis. She underwent complete resection of the mass, with total gastrectomy, distal pancreatectomy, splenectomy, and transverse colectomy (). Postoperative histopathologic examination showed a gastric GIST with negative resection margins and no metastatic lymph nodes. The mass was a 15 cm × 9 cm gastric GIST with 14 mitoses/50 high-power fields, and was categorized as a high-risk tumor. Immunostaining showed that the tumor was positive for C-KIT and CD34, and negative for S100 expression (). Adjuvant chemotherapy using oral imatinib mesilate was recommended to the patient. However, she declined treatment because it was too expensive.\nEight months after the operation, the patient was found to have recurrent GIST involving the hilum and subcapsular region of the right lobe of the liver and peritoneal nodules. Imatinib (400 mg/day) was started as palliative treatment (). At a 3-month follow-up, the liver masses had decreased and imatinib was found to be well tolerated by the patient, who continued on the same dose of iminitib (). Follow-up imaging 6 months later showed peritoneal seeding in the region of the distal pancreas and a small amount of left pleural effusion and ascites (). The patient refused second-line treatment, and imatinib therapy was continued despite the progression. Two months later, she was admitted because of severe dyspnea due to a large amount of pleural effusion and ascites (). She requested second-line palliative oral medication without undergoing additional diagnostic evaluation.\nBefore she received sunitinib, a complete blood count (CBC) showed the following: white blood cell (WBC) count, 2,990 × 103/µL; neutrophils, 65% (1,943 × 103/µL); hemoglobin, 9.1 g/dL; and platelets, 222 × 103/µL. Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) were in the normal range. The patient's grade I anemia and neutropenia were due to imatinib toxicity. Examination of the pleural effusion revealed the following: WBC, 1,296/m3 (polymorphonuclear cells, 60%); pH, 7.20; lactate dehydrogenase (LDH), 1,266 U/L; and atypical cells. Cultures of the pleural effusate were negative. The results of these laboratory tests suggested malignant pleural effusion.\nThe patient's therapy was changed to oral sunitinib administered at 50 mg/day in cycles consisting of 4 weeks of sunitinib followed by 2 weeks of rest. On day 7 of the first cycle of sunitinib therapy, the volume of the patient's pleural effusion was unchanged, but her dyspnea had improved, and she requested discharge from the hospital. On day 21, sunitinib was found to be well tolerated except for grade I neutropenia (WBC, 2,390 × 103/µL; neutrophils, 1,769 × 103/µL) with markedly decreased pleural effusion and ascites (). Oral sunitinib was continued at 50 mg/day.\nOn day 26 of the first cycle of sunitinib therapy, the patient had a sudden onset of sharp, generalized abdominal pain. An imaging study revealed intraperitoneal free gas with many bubbles near the distal pancreatic region, suggesting small bowel perforation (), and the patient was hospitalized. The admission CBC showed the following: WBC, 1.19 × 103/µL; neutrophils, 63%; hemoglobin, 10.6 g/dL; and platelet count, 89 × 103/µL. The PT and aPTT were 10.9 and 25.6 seconds, respectively. She was diagnosed with generalized peritonitis due to bowel perforation and grade III neutropenia (750 × 103/µL) due to sunitinib toxicity. We recommended emergency surgery; however, the patient's guardian refused consent. The patient expired the next day.

[[78.0, 'year']]

F

{'17519900': 1, '17046465': 1, '31624752': 2, '19185833': 1, '18932293': 1, '12181401': 1, '26589942': 1, '18289826': 1, '17512858': 1, '17227905': 1, '20524036': 1, '24783183': 2}

{'6795721-1': 1}

3996739-1

noncomm/PMC003xxxxxx/PMC3996739.xml

Robotic assisted excision of retrovesical angiomyxoma in a male patient

A 62-years-old male presented to us with mild obstructive lower urinary tract symptoms (LUTS) since last 1 year, with a history of acute retention of urine 3 month back with failed catheter free trial. He underwent holmium laser enucleation of prostate (HOLEP) elsewhere with histopathology reporting as benign prostatic hyperplasia. Patient failed to void after catheter removal and on further evaluation he was found to have pelvic mass. Digital rectal examination revealed a cystic mass simulating benign prostatic hyperplasia (grade 3). Transrectal ultrasonography showed a heterogeneous mass arising from prostate. Magnetic resonance imaging (MRI) pelvis revealed a well-marginated lesion within the prostate gland resulting into significant prostatomegaly with no extra prostatic extension []. Transrectal biopsy was done, which was inconclusive with no identifiable prostatic tissue. In view of discrepancy between MRI report and biopsy report we performed cystoscopy which showed a hump in the prostatic urethra extending into the trigone, with prostatic lobes not visible (because of previous HOLEP). Hence he was planned for Robotic assisted excision of the mass. Intraoperatively a globular mass was present posterior to bladder. Mass was densely adherent to the posterior wall of the bladder. Complete excision of the mass was done. Tumor was ~6 cm × 4 cm × 2.5 cm in size []. We were not able to separate the mass from bladder due to difficulty in entering into proper plane. Hence we opened bladder deliberately and resected from within the bladder, closed cystostomy and drained bladder. Histo-pathological examination [] revealed moderately cellular tumor composed of sheets of spindle to stellate shaped cells with vascular channels in between. On immunohistochemistry cells were positive for desmin, focal positivity with smooth muscle antibody (SMA), S100 and Ki-67. The results are suggestive of angiomyxoma. Patient is on regular follow-up with no recurrence until date.

[[62.0, 'year']]

M

{'16882078': 1, '16317491': 1, '19837402': 1, '9930798': 1, '28944124': 1, '16900535': 1, '15564405': 1, '12943618': 1, '30474017': 2, '24761083': 2}

{'6236091-1': 1}

3996740-1

noncomm/PMC003xxxxxx/PMC3996740.xml

Laparoscopic excision of cyst of canal of Nuck

A 28-year-old female presented with complaint of pain and swelling in her left inguinal region since 1 month. Swelling was insidious in onset, with a slight increase in the size of the swelling since its occurrence. There was no history of vomiting, bowel and bladder dysfunction. On examination, an oval, approximately 4 × 3 cm in size, tender, cystic and fluctuant swelling was present in the left inguinal region. Transillumination test was negative. Swelling was irreducible against manual pressure. There was no expansible cough impulse, peristaltic activity or abnormal vascularity-associated with the swelling. Signs of inflammation were absent. Lymph nodal examination was normal. Ultrasonography revealed left inguinal hernia, with well-defined, oval, anechoic cystic swelling within the inguinal canal measuring 4 × 3 cm []. Patient underwent laparoscopic excision of cyst of canal of Nuck with left inguinal hernioplasty. Peritoneum was opened and hernia defect was identified []. Round ligament was identified along with the hydrocele of the canal of Nuck. Cyst of canal of nuck was separated from the round ligament and excision of the cyst of canal of Nuck was carried out []. A 15 × 10 cm polypropylene (Prolene, Ethicon, Mumbai, India) mesh was placed to cover the hernia defect []. Peritoneal flaps were approximated. Post-operative period was uneventful and patient recovered satisfactorily. Histopathologic examination confirmed it as Hydrocoele of canal of Nuck. Patient is asymptomatic on follow up.

[[28.0, 'year']]

F

{'33599854': 2, '28978588': 1, '32801942': 2, '22574075': 2, '32695544': 2, '33983554': 2, '30681605': 2, '32346477': 1, '34760578': 1, '33322831': 2, '27042529': 1, '27299752': 1, '31378110': 1, '32784235': 1, '23378878': 1, '31918159': 1, '32864093': 2, '15020367': 1, '25312972': 1, '23986837': 2, '24761084': 2}

{'3738346-1': 1, '3346837-1': 1, '3346837-2': 1, '8119562-1': 1, '7892654-1': 1, '7368960-1': 1, '7410395-1': 1, '6358343-1': 1, '7446026-1': 1, '7763523-1': 1, '7763523-2': 1, '7763523-3': 1, '7763523-4': 1, '7763523-5': 1}

3996741-1

noncomm/PMC003xxxxxx/PMC3996741.xml

Laparoscopic correction of intestinal malrotation in adult

A 25-year-old female with epigastric pain on and off for 3 months was admitted with sub acute intestinal obstruction. She improved on conservative treatment. CT showed mal-rotated gut. Laparoscopic Ladd's procedure was done.\nProcedure time ranged from 25-40 min.\nAll the patients, when asked, confirmed that symptoms were present since childhood and either ignored or treated with common household remedies.\nOral liquids started after 6 h and all three patients were discharge on second postoperative day. These patient, now in more than 6 months follow up, are doing well.

[[25.0, 'year']]

F

{'9249085': 1, '16121875': 1, '33493860': 1, '17457643': 1, '29737312': 1, '8306846': 1, '24761085': 2}

{}

3996742-1

noncomm/PMC003xxxxxx/PMC3996742.xml

Laparoscopic cholecystectomy in double gallbladder with dual pathology

This was a case report of a 21-year-old male patient who presented with a history of dyspepsia and occasional right upper quadrant (RUQ) pain of 1 month duration. During that period he had two episodes of pyrexia of 100F accompanying RUQ pain that lasted for couple of days and promptly responded to oral antibiotics prescribed by family physician. An abdominal US-scan was requested on relapse of fever and pain, which showed a thick walled gallbladder with stones but no other signs of acute cholecystitis. An interesting finding of the scan was an abnormal cystic structure near porta hepatis. Common bile duct (CBD) was of normal calibre without dilatation of intrahepatic biliary radicles. Two possibilities were suggested - a double gallbladder or a choledochal cyst. On the basis of the US-scan, MRCP was requested along with liver function test (LFT) and haemogram. Though afebrile at that time, his TC was 14,000 with 84% neutrophil. His LFT was normal in all its parameters. MRCP confirmed the cystic structure at porta to be the partially intrahepatic second lobe of a double gallbladder []. It also suggested that one stone of 2 cm is in the 1st lobe and another stone at the junction of the two lobes joined at their necks, both being drained by a short cystic duct (CD) into CBD. MRCP classifies this to type-1 V-shaped double gallbladder.\nA laparoscopic exploration was performed with standard 4 port technique. The 2nd moiety was immediately visible near porta, being overlapped by the 1st and occupying the cystohepatic triangle of the first moiety and found to be partially intrahepatic and in close proximity to the right hepatic duct. Dissection started on the callots triangle of 1st moiety and a rather long CD, a solitary cystic artery (CA) of significant size was dissected free [].\nOperative cholangiogram (OC) was performed by direct puncture of the 1st lobe and a normal calibre CBD was delineated where the CD was draining in normal position. 2nd lobe of the gallbladder was not visualised and both the stones were demonstrated in the 1st lobe as filling defects. OC was then performed by direct puncture of the 2nd lobe using 28F spinal needle. The 2nd lobe was found to be blind with no flow of dye into CBD or its counterpart and no stone was in it. Both the lobes were adjacent and the infundibulum of 1st lobe was overlapping the second. There was a common serous coat for both the lobes with a branch of the main CA supplying the second lobe, which was partly intrahepatic. After division of the CD and CA the serous coat between the lobes were divided with control of the arterial branch supplying the 2nd lobe. This manoeuvre exposed the second lobe of gallbladder, which was dissected of the liver bed with careful and gentle blunt dissection with suction canula tip []. No further biliary or vascular structure was identified during this dissection. On completion of the procedure, there was no bile leak from either gall bladder fossa which was adjacent but separate. Both lobes were found to be attached only at their neck [].\nPost-extraction examination of the specimen revealed that the 1st lobe contained both the stones and had thick inspissated green bile and the second lobe did not decompress on applying manual pressure. Once a nick was made into this lobe frank pus came out without a tinge of bile. Histological report showed chronic cholecystitis in the 1st lobe and features consistent with empyema in the second. Bacteriological culture of the pus did not reveal any growth of organism.\nPost-operative recovery was excellent and the patient is doing well in the follow-up of over a year.

[[21.0, 'year']]

M

{'34984161': 2, '11429954': 1, '8779072': 1, '10227894': 1, '3895856': 1, '19468813': 1, '28101147': 1, '7482221': 1, '21170223': 2, '14571174': 1, '24761086': 2}

{'2997217-1': 1, '8714037-1': 1}

3996743-1

noncomm/PMC003xxxxxx/PMC3996743.xml

Laparoscopic extraction of fractured Kirschner wire from the pelvis

A 25-year-old male presented to the Accident and Emergency Department with an alleged history of a road traffic accident. On examination, he had a painful right hip with no other injury. On plain radiograph of both hip, he was diagnosed as having a sub-trochanteric fracture of right femur. The patient was posted for percutaneous femoral nailing. During surgery, after threading over the nail when the K wire was to be removed, it fractured and during an attempt at retrieval by the orthopaedician through the same hole, it was further pushed into the pelvis through the acetabulum plate []. The orthopaedic procedure was completed, and the patient was referred to the surgical unit for retrieval of the fractured segment of the K wire.\nAs the patient was stable, we conducted a contrast enhanced computed tomography (CT) scan of the abdomen and pelvis [], in which the broken fragment of the K wire was seen protruding through the acetabulum into the right hemi-pelvis between the bladder and rectum, without any obvious injury to surrounding structures. The patient was planned for laparoscopic retrieval under general anaesthesia with C-arm guidance, if required.\nA midline infra-umbilical 10 mm camera port was placed, and two 5 mm ports were further placed, both in the left mid-clavicular line, one at the level of umbilicus, and the other at the level of the Anterior Superior Iliac Spine. On inspection, there was no free fluid in the abdomen and no evidence of any bowel or vascular injury. The tip of the K wire was not visible either. In the pelvis, just lateral to the bladder and approximately at the level of the right Cooper's ligament, a blunt protrusion of the peritoneum was identified. The peritoneal flap was raised, and with sharp dissection, of superficial tissues, the pointed metallic K wire was seen [], and retrieved with the help of a needle holder. No bleeding was seen, and the peritoneal flap was closed. Post-operatively, the patient recovered uneventfully.

[[25.0, 'year']]

M

{'30854359': 1, '7077694': 1, '28271090': 1, '3913954': 1, '8263998': 1, '17202640': 1, '15759823': 1, '24761087': 2}

{}

3996762-1

noncomm/PMC003xxxxxx/PMC3996762.xml

Malaria masquerading as relapse of Hodgkin's lymphoma on contrast enhanced 18F-fluorodeoxyglucose positron emission tomography/computed tomography: A diagnostic dilemma

The present case report is about a 22-year-old male patient who presented with enlarged right cervical lymph node. Biopsy revealed-Hodgkin's lymphoma (mixed cellularity). 18F-FDG PET/CECT performed for staging revealed metabolically active lymph nodes on either side of the diaphragm [, broken arrows], enlarged spleen with multiple hypodense hypermetabolic, lesions [, arrow] (SUVmax= 9.4; Spleen SUVmax/liver SUVmax ratio = 3.76) and bone lesion. He was then given 6 cycles of chemotherapy and 18F-FDG PET/CECT was done for response evaluation. PET/CT showed complete metabolic response, with normal spleen uptake [, arrow] (Spleen SUVmax= 2.5, Liver SUVmax= 2.6 S/L ratio = 0.96). At 1-year later routine follow-up the patient complained of mild fever, lethargy and listlessness. In view of previous history of Hodgkin's lymphoma, relapse was suspected and 18F-FDG PET/CECT was advised. PET/CT revealed enlarged spleen with diffusely increased FDG uptake [Figure –, arrow] (SUVmax= 5.3; Liver SUVmax= 2.3 S/L ratio = 2.30). The first differential in the given clinical scenario was splenic relapse of lymphoma, however, a second differential diagnosis of some infective/inflammatory process was considered. On further evaluation, peripheral smear showed evidence of malaria parasite infection (Plasmodium vivax). The patient was then started on anti-malarials with complete clinical improvement. Follow-up PET/CT after 7 months revealed normalization of size and 18F-FDG uptake of spleen [, arrow] (SUVmax= 3.0; Liver SUVmax= 2.7 S/L ratio = 1.1). This clinical case can be easily misinterpreted as lymphoma relapse. Hence, malaria and other relevant (endemic) infective possibilities (Kala-Azar etc.) should be considered and further investigation, if warranted, should be advised.

[[22.0, 'year']]

M

{'34038421': 1, '19654562': 1, '15517141': 1, '15096977': 1, '18398739': 1, '20838282': 1, '10232468': 1, '15745681': 1, '23076270': 1, '21742419': 1, '24761064': 2}

{}

3996763-1

noncomm/PMC003xxxxxx/PMC3996763.xml

A case of dual ectopy thyroid along the thyroglossal tract demonstrated on 99mTc-Pertechnatate hybrid single photon emission computed tomography/computed tomography

The present case report is about a 10-year-old girl who presented with anterior midline neck swelling since 6 months, which was gradually increasing in size. On evaluation, she was found to have hypothyroidism without evidence of growth retardation. On local examination, a swelling 2 × 2 cm size, cystic, well-defined with a smooth surface neither compressible nor reducible was palpated just below the hyoid bone, which was moving up with protrusion of tongue and with deglutition, but was not trans-illuminant. Serum biochemistry revealed T3 = 86 ng/dL (normal, 70-200 ng/dL), T4 = 4.3 μg/dL (normal, 4.5-12.5 μg/dL) and thyroid-stimulating hormone level of 27 μIU/mL (normal, 0.5-4.7 μIU/mL). With a provisional diagnosis of sub-hyoid thyroglossal cyst, patient was referred for a technetium thyroid scan to rule out functioning thyroid tissue in the cyst. 99mTc-pertechnatate thyroid scan revealed a midline focus of tracer uptake corresponding to the palpable neck swelling suggestive of ectopic functioning thyroid tissue. No tracer uptake was noted in the region of the thyroid bed. In addition, a small linear streak of tracer activity was seen to extend superiorly [] from the ETT in the neck. SPECT/CT of the neck revealed ETT on the right side of the thyroid cartilage, in the sub-hyoid location; in addition to this another ectopic rest of thyroid tissue was noted in the midline floor of the mouth. Tracer was also seen to extend along a tract, which was well-appreciated on sagittal section []. Patient was started on thyroid supplementation therapy.

[[10.0, 'year']]

F

{'21713222': 1, '22614198': 1, '18175113': 1, '17179793': 1, '21765986': 1, '22064096': 1, '19232175': 1, '20799023': 1, '16951442': 1, '24019671': 2, '24761065': 2}

{'3764687-1': 1}

3996764-1

noncomm/PMC003xxxxxx/PMC3996764.xml

Peritoneal and mediastinal highly differentiated follicular carcinoma of ovarian origin

Here we report a gravida 3, para 2 Caucasian 70-year-old female patient who was evaluated at an outside institution for persistently elevated alkaline phosphatase levels with no clinical complaints. A bone scan was obtained at that time and demonstrated abnormal uptake in the cranium, long bones and pelvis, raising the possibility of metastatic disease and the patient was referred to our institution. The patient demonstrated an elevated thyroglobulin level of 101.5 ng/ml (normal 0-33.0 ng/ml). In addition, the tumor marker CA 15-3 was also elevated at 34.7 u/ml (normal 10-19.9 u/ml).\nContrast enhanced computed tomography scan of the chest, abdomen and pelvis demonstrated multiple peritoneal nodules, the largest of which measured 3.2 cm × 2.2 cm []. In addition, hyperenhancing epicardial nodules were also noted []. Biopsy of one of the peritoneal lesions revealed thyroid tissue without atypia and we investigated whether struma ovarii was possible. The patient had undergone an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis at age 39 years. The pathology findings were not available. The patient reported being told of a left ovarian cyst without the need for follow-up.\nGiven the number of lesions associated with the omentum, the patient underwent a diagnostic laparoscopy and partial omentectomy. Pathology from the excised omental nodules demonstrated histologically benign appearing thyroid tissue with multiple thyroid follicles of various sizes []. Pelvic washings were negative for malignant cells.\nAs part of the diagnostic evaluation a bone marrow biopsy was performed and was negative for malignancy. In addition, a thyroid ultrasound was performed that demonstrated multiple small nodules with a dominant nodule in the right upper thyroid lobe. Three of the nodules were biopsied and the cytologic findings were consistent with benign nodules.\nGiven the patient's extensive extra-ovarian struma ovarii, a total thyroidectomy was recommended prior to radioiodine therapy. Pathological evaluation of the thyroid revealed a 0.5 cm focus of well-differentiated papillary carcinoma (a microcarcinoma) without lymphovascular invasion, stage PT1 [].\nTotal body I-123 uptake scan was performed for treatment planning purposes and demonstrated innumerable areas of uptake within the chest, abdomen and pelvis []. A discussion was held regarding the appropriate I-131 treatment dose. Given concerns about bowel radiation injury, the patient was treated with 30.5 mCi of radioiodine 131.\nA follow-up I-123 uptake scan 4 months later showed resolution of the chest uptake and significant decline in the number of lesions throughout the abdomen and pelvis that were consistent with a short-term positive response []. Thyroglobulin tumor marker at the follow-up scan was elevated at 91 ng/ml. Plans were made for continued follow-up.

[[70.0, 'year']]

F

{'15350384': 1, '21151690': 2, '16714888': 1, '18753973': 1, '18317221': 1, '21632805': 1, '3297279': 1, '7608252': 1, '23568042': 1, '2738669': 1, '17365830': 1, '24761066': 2}

{'2991076-1': 1}

3996766-1

noncomm/PMC003xxxxxx/PMC3996766.xml

Rare case of trilateral retinoblastoma with spinal canal drop metastasis detected with fluorine-18 fluorodeoxyglucose positronemission tomography/computed tomography imaging

A 10-year-old boy presented with a right eye proptosis and leukocoria. He underwent magnetic resonance imaging (MRI) which showed right orbital mass lesion infiltrating optic nerve, and diagnosis of retinoblastoma was made. He was referred for fluorodeoxyglucose (FDG) PET/CT to find out the extent of the disease. Whole body contrast enhanced PET/CT [] showed abnormal FDG-uptake within right orbital mass lesion [] and suprasellar region [], sagittal fused-PET/CT showing enhancing lesion in the cervical spinal canal level [, arrows]. He was diagnosed as a case of TRb with spinal drop metastasis. He underwent chemotherapy and craniospinal irradiation.

[[10.0, 'year']]

M

{'9716194': 1, '15269048': 1, '15255112': 1, '22251556': 1, '10561222': 1, '12799253': 1, '10391573': 1, '28815312': 1, '8195959': 1, '17962617': 1, '24761068': 2}

{}

3996778-1

noncomm/PMC003xxxxxx/PMC3996778.xml

Primary central nervous system lymphoma in an human immunodeficiency virus-infected patient mimicking bilateral eye sign in brain seen in fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography

A 35-year-old female HIV patient presented with headache and altered mental status. She was referred for whole body PET/CT for detection of involvement of CNS and other sites. PET/CT showed an intense uptake in the multiple lesions noted in both the cerebrum [], with a standardized uptake value (SUV max) of 30-35. A diagnosis of primary CNS lymphoma was made and she was started on chemotherapy.

[[35.0, 'year']]

F

{'8894823': 1, '2489119': 1, '9379195': 1, '18716509': 1, '16540459': 1, '11277828': 1, '2836938': 1, '7622678': 1, '8455072': 1, '24761060': 2}

{}

3996779-1

noncomm/PMC003xxxxxx/PMC3996779.xml

18F-FDG PET/CT for initial assessment and response monitoring in a case of high grade primary lymphoma of the thyroid gland: A case report and review of literature

A 64-year-old man with a history of hypothyroidism and proven Hashimoto's thyroiditis presented with painless progressive asymmetric enlargement of the thyroid gland. Laboratory evaluation revealed an elevated erythrocyte sedimentation rate (ESR), elevated thyroid peroxidase antibody titer of 850 U/mL (normal <30 U/mL), free triiodothyronine (FT3) 2.34, free thyroxine (FT4) 0.97, and thyroid stimulating hormone (TSH) level of 22.11. A contrast enhanced CT (CECT) exam of the neck revealed a large heterogeneous mass lesion predominantly involving the left lobe of thyroid and partly involving the isthmus and anterior part of right lobe. A needle biopsy from the thyroid mass revealed features of non-Hodgkin's lymphoma (DLBCL) with the tumor cells staining positive for CD20, negative for cytokeratin (CK) and having a high proliferative index (MIB-1) of 35-40%. 18F-FDG PET/CT was performed for staging. It revealed a large heterogeneous mass lesion predominantly involving the left lobe of thyroid and partly involving the isthmus and anterior part of right lobe with intense radiotracer uptake in the thyroid mass (SUVmax-18.7) with no other abnormal identifiable areas [Figure –]. The patient underwent four cycles of combination chemotherapy (rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone) and was reevaluated with 18F-FDG PET/CT. Post therapy 18F-FDG PET/CT [Figure –] done 6 weeks after completion of chemotherapy revealed significant decrease in the size of the enlarged thyroid gland associated with no significant FDG avidity (SUVmax-2.0) of the residual thyroid mass (arrow), suggestive of complete metabolic response. The patient is in complete remission at 18 month follow-up.

[[64.0, 'year']]

M

{'28291004': 1, '15231864': 1, '21875367': 1, '12658970': 1, '15233907': 1, '17063502': 1, '20566819': 1, '10375088': 1, '17242397': 1, '17242576': 1, '34084720': 2, '18619378': 1, '5007387': 1, '3141260': 1, '15311129': 1, '15837966': 1, '20497878': 1, '17873129': 1, '17709603': 1, '18208780': 1, '19089692': 1, '24761061': 2}

{'8081108-1': 1}

3996780-1

noncomm/PMC003xxxxxx/PMC3996780.xml

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography imaging of an isolated subcutaneous loin metastasis from primary papillary carcinoma of the thyroid

This was a case report of a 45-year-old male patient who presented with subcuataneous swelling in the left loin, which on biopsy showed metastatic papillary cancer. He was referred for whole body PET/CT for detection of primary site. PET/CT showed an intense uptake in the subcutaneous soft-tissue lesion in the left loin []. Also uptake noted in right lobe thyroid nodule []. Patient underwent fine needle aspiration of the thyroid nodule which confirmed papillary carcinoma. A diagnosis of primary papillary carcinoma of thyroid with subcutaneous loin metastasis was made and he was advised total thyroidectomy and excision of metastasis.

[[45.0, 'year']]

M

{'22980131': 1, '23828437': 1, '15531474': 1, '9092737': 1, '17242580': 1, '6467135': 1, '23106056': 1, '9848721': 1, '15047753': 1, '24761062': 2}

{}

3996781-1

noncomm/PMC003xxxxxx/PMC3996781.xml

Tuberculosis the great mimicker: 18F-fludeoxyglucose positron emission tomography/computed tomography in a case of atypical spinal tuberculosis

This was a case report of a 14-year-old boy who presented with backache and difficulty in walking. Past history revealed that he had been treated for Hodgkin's Lymphoma 2 years ago and was presently in remission. Examination revealed localized tenderness in the mid-back, with decreased power in bilateral lower limbs. The patient underwent a whole-body PET/contrast-enhanced CT (CECT) scan on the suspicion of tumor recurrence. The study showed a destructive lesion of posterior elements of the sixth, seventh and eighth dorsal vertebrae which was fluorodeoxyglucose (FDG) avid []. In addition, an FDG avid peripherally enhancing collection was noted in the adjacent paraspinal muscles with extension into the spinal canal, causing encasement of the thecal sac as well. Additional sites of increased FDG avidity were noted in the mediastinal and hilar lymphnodes. A metabolically active focus was also noted in the spleen, which was seen as a subtle hypodense lesion on CECT []. Based on these findings, a diagnosis of extrapulmonary TB with Pott's spine and paraspinal abscess was made. The patient was started on antitubercular therapy and underwent posterior decompression and stabilization. Pus drained from the paraspinal abscess was positive for acid fast bacilli. Tissue biopsy revealed a histiocytic granuloma consistent with TB.

[[14.0, 'year']]

M

{'22448055': 1, '5596124': 1, '21834765': 1, '31611930': 1, '26078742': 2, '18525363': 1, '11079627': 1, '3425410': 1, '19330191': 1, '17483734': 1, '22065874': 1, '21586936': 1, '31837121': 1, '20689971': 1, '8539058': 1, '22141602': 1, '2750627': 1, '19357878': 1, '24761063': 2}

{'4464102-1': 1}

3996794-1

noncomm/PMC003xxxxxx/PMC3996794.xml

Bindi Tattoo on Forehead: Success with Modified R-20 Technique Using Low Fluence Q-Switched Nd Yag Laser: A Case Report

A 26-year-old female consulted us for removal of a green-blue bindi tattoo done on her forehead in childhood as a family ritual. After counselling, we treated her with a low-fluence Q-switched Nd YAG Laser (LFQSNYL), a machine recommended for tattoo removal. We used 1064 mode with the parameters 450 mj, every 4 weeks, spot size of 1.5 mm, pulse width 6 ns and repetition rate of 2 Hz on all the sittings. However, after eight sessions of LFQSNYL, there was no appreciable improvement []. We and the patient were disappointed. As the patient was committed, we decided to try a new R20 technique, that is repetition after 20 minutes in the same sitting. We were not sure about the results and side effects such as scarring and dyspigmentation. We administered only one additional treatment after 20 minutes, using the same parameters as earlier []. There was transient oedema, erythema and punctuate bleeding, which was symptomatically managed. She attended follow up after 4 months having received no treatment in the meantime. We were pleasantly surprised to see significant shrinkage of the size and lightening of her tattoo with only a single session of R-20 modality [].

[[26.0, 'year']]

F

{'22036610': 1, '25949016': 1, '6836297': 1, '22092752': 1, '25949019': 1, '16427505': 1, '17910671': 1, '24761103': 2}

{}

3997923-1

noncomm/PMC003xxxxxx/PMC3997923.xml

Endovascular Treatment for Ruptured Distal Anterior Inferior Cerebellar Artery Aneurysm

A 42-year-old woman with no underlying diseases was referred to our department for severe headache, nausea, and vomiting after coitus. She was drowsy with no neurologic deficit (Hunt and Hess grade 3). Computed tomography (CT) and magnetic resonance image (MRI) showed a subarachnoid hemorrhage (SAH) on the cerebellopontine angle cistern, and a small vermian intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) in the fourth ventricle (Fisher grade 4) (). There was no evidence of head injury. Digital subtraction angiography revealed an aneurysm arising on the branching point between the caudomedial and rostrolateral branch of the left distal AICA, located distally from the meatal loop. The aneurysm was associated with fenestration () and was 2.7×2.8 mm with a neck of 1.5 mm directed caudo-laterally. The diameter of AICA proximal to aneurysm was 0.8 mm on 3D rotational angiogram ().\nUnder general anesthesia, a 6F Envoy guiding catheter (Cordis Neurovascular, Bridgewater, NJ, United States) was placed on the right vertebral artery (VA) at the level of C2 vertebra. An Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA, United States) and X-pedion-14 microwire (ev3 Endovascular, Inc., Plymouth, MN, United States) were advanced to the right VA and the basilar artery. Under the roadmap guidance, aneurysm selection was tried. Even though the superselection of the AICA orifice was not difficult, aneurysm selection was very difficult due to the tortuous course of AICA and relatively small diameter of the AICA for accommodation of the microcatheter ().\nAfter failed multiple trials of selecting the aneurysm with Excelsior SL-10 microcatheter and X-pedion-14 microwire, we changed the microwire to X-pedion-10, resulting in successful distal AICA aneurysm selection. The aneurysmal sac was then obliterated completely without compromise of the AICA branch even though the second coil was extruded from the aneurysmal sac during coiling (). Postoperative CT showed slightly increased cerebellar hemorrhage, but there was no evidence of obstructive hydrocephalus. She was alert without motor weakness or brain stem sign. However, she complained of hearing loss and tinnitus despite the patent flow to left AICA. She was discharged home at two weeks with remaining sensorineural hearing loss.

[[42.0, 'year']]

F

{'13673604': 1, '12064155': 1, '17846215': 1, '7566390': 1, '6059701': 1, '6886793': 1, '12296656': 1, '19246870': 1, '7815141': 1, '31144196': 1, '16145591': 1, '5570770': 1, '27485045': 1, '25948851': 1, '12509868': 1, '20505296': 1, '10321881': 1, '19596048': 1, '51066': 1, '21045515': 1, '16841709': 1, '16362175': 1, '5164131': 1, '24765609': 2}

{}

3997924-1

noncomm/PMC003xxxxxx/PMC3997924.xml

Microsurgical Strategies Following Failed Endovascular Treatment with the Pipeline Embolization Device: Case of a Giant Posterior Cerebral Artery Aneurysm

A 51 year-old male presented to an outside institution seven years prior with chronic headaches, which began following a motor vehicle accident. He had decreased visual acuity in the left eye from a previous gunshot wound to the face. The patient was diagnosed at initial presentation with a giant, fusiform left PCA aneurysm which was partially thrombosed. It was decided at the time of diagnosis that the risk of morbidity associated with either endovascular or microsurgical treatment of the aneurysm exceeded that of conservative management. Over time, the patient's headaches progressively worsened to an average visual analog scale (VAS) score of 7/10 despite maximal medical management, and the aneurysm gradually enlarged over serial angiographic imaging. The decision was made at this time to treat the lesion via an endovascular approach with the PED (). The aneurysm was successfully treated with two telescoping PEDs, 2.5×20 mm and 3.0×30 mm in size. The patient was discharged on standard oral dual antiplatelet therapy, clopidogrel 75 mg daily and aspirin 325 mg daily, without any change in neurological function. The severity of the patient's headache remained unchanged after PED treatment.\nThe patient presented three months post-PED with progressively worsening headaches to an average VAS score of 9/10, new gait ataxia, and new temporal hemianopsia of the right eye. While the stents remained patent at six weeks, by the follow-up angiography at three months, the diseased segment of the left PCA had progressed to complete occlusion at the origin of the proximal PED (). The patient's new temporal hemianopsia of the right eye was attributed to the left PCA occlusion. However, despite occlusion of the parent vessel, the aneurysm had continued to enlarge, resulting in local mass effect and cerebral edema as well as obstructive hydrocephalus. Therefore, the decision was made to surgically resect the aneurysm. The patient was taken to the operating room for an endoscopic third ventriculostomy, which was performed in a standard fashion through a right frontal burr hole without complications. An external ventricular drain was left in the frontal horn of the right lateral ventricle for subsequent cerebrospinal fluid drainage.\nThe patient was repositioned for aneurysm excision through an infratemporal, post-auricular, presigmoid skull base approach. Electrophysiological monitoring, including motor and somatosensory evoked potentials (motor evoked potential (MEP) and somatosensory evoked potential (SSEP), respectively), was utilized. A standard temporal craniotomy and partial mastoidectomy were performed. During the craniotomy, the sigmoid sinus was breached, requiring hemostatic control with gelfoam tamponade. After dural opening, 50 mL of cerebrospinal fluid was drained from the external ventricular drain to facilitate brain relaxation. After opening the arachnoid of the ambient cistern, the PCA and superior cerebellar artery were identified along with the fundus of the aneurysm dome posteriorly.\nDue to the high degree of thrombosis, the aneurysm was firm and immobile. Therefore the aneurysm dome was opened so that the intrasaccular thrombus could be debulked. Decompression of the fundus facilitated dissection of the aneurysm from the surrounding cortex and brainstem. The proximally placed PED was identified in the lumen of the diseased PCA without evidence of endothelialization and was removed cautiously. After PED extraction from the inflow segment of the parent artery, there was brisk bleeding from the proximal PCA which controlled by clipping the P2 segment. After further debulking of the thrombus, the distal PED placed in the aneurysm outflow was identified and a clip was placed on the outflow portion of the PCA, effectively trapping the aneurysm. The entirety of the aneurysm was then excised from the PCA (). During the final dissection, the right-sided arm and leg SSEPs were lost without change in MEPs. At the end of surgery, there was no recovery of SSEPs in the right arm or leg and MEPs remained stable.\nThe patient's postoperative course was complicated by an extradural hematoma requiring surgical evacuation and thrombosis of the left transverse and sigmoid sinuses, resulting in multiple large territory venous infarcts requiring decompressive craniectomy. The extent of the postoperative infarcts was neurologically devastating, and the patient expired two weeks following the initial surgical intervention.

[[51.0, 'year']]

M

{'22282890': 1, '23910998': 1, '23624409': 1, '19343269': 1, '22738097': 1, '32411404': 1, '9867550': 1, '27114962': 2, '17053593': 1, '544122': 1, '24167807': 2, '28163518': 2, '18981833': 1, '28123471': 1, '21148256': 1, '23787883': 1, '27066443': 1, '24765610': 2}

{'5244076-1': 1, '3804665-1': 1, '4842904-1': 1}

3997925-1

noncomm/PMC003xxxxxx/PMC3997925.xml

Clipping of Incidental Aneurysm of Middle Cerebral Artery Through Small Temporal Craniotomy and Linear Skin Incision

A 60-year-old male patient presented with headache. CT angiography showed a left MCA bifurcation aneurysm; an unruptured saccular type aneurysm measuring 6×4 mm in size. The patient was treated by clipping via a small temporal craniotomy and linear scalp incision and recovered well without any complications ().

[[60.0, 'year']]

M

{'18091240': 1, '17041490': 1, '23140151': 1, '21029040': 1, '15669803': 1, '12378989': 1, '22949961': 1, '16060236': 1, '2398396': 1, '15658112': 1, '23394339': 1, '9586924': 1, '3612281': 1, '1111150': 1, '24765611': 2}

{}

3998156-1

noncomm/PMC003xxxxxx/PMC3998156.xml

Dextrocardia with Situs Inversus Associated with Non-Compaction\nCardiomyopathy

A 53-year-old male patient who, in the past 2 years, has presented brief episodes of\ncollapse and presyncope when performing daily activities, with recent worsening in the\nfrequency of symptoms. Regarding the habits of life, the patient was sedentary, smoker\nand social alcoholic. He sought a general practitioner who requested examinations for\ninitial evaluation. The resting electrocardiogram (ECG) revealed sinus bradycardia\n(heart rate - HR: 39 bpm), deviation of the electrical axis to the right and right\nbundle branch block (). The exercise test\nwas considered abnormal due to arrhythmia (ventricular extrassystoles with periods of\nbigeminy during exercise and recovery). 24-hour Holter monitoring showed average heart\nrate of 37 bpm (minimum of 25 and maximum of 81 bpm) with sinus rhythm interspersed with\njunctional rhythm. Atrioventricular conduction was within the normal range and\nintraventricular conduction revealed right bundle branch disorder. The patient presented\n11,596 pauses lasting longer than 2 seconds, rare and isolated monomorphic ventricular\nextrasystoles and an episode of non-sustained supraventricular tachycardia.\nGiven the clinical suspicion of sinus node disease, the patient was referred to a\ncardiologist, who continued the investigation. Transthoracic echocardiography was\nrequested, which revealed dextrocardia (presence of situs inversus, heart positioned in\nthe right hemithorax with apex facing right); images suggestive of trabeculations in the\nleft ventricle (LV); moderate LV diastolic dysfunction with preserved systolic function;\nleft atrial enlargement (57 mm); mild mitral regurgitation.\nFor diagnostic elucidation and evaluation of cardiomyopathy, CMRI was performed and cine\nsequences were obtained (balanced steady-state free precession - b-SSFP), anatomy with\nblack-blood turbo spin-echo sequences, with T1 and T2 weighting with and without fat\nsuppression (TSE BB-PD and STIR) and delayed enhancement (turbo-field echo with\ninversion pulse and recovery, 10 minutes after injection of 0.2 mmol/kg of gadolinium\ncontrast; TE: 6.1; TR 3.0). Besides confirming dextrocardia associated with situs\ninversus, a slight increase in the left ventricular cavity associated with excessive\ntrabeculations in the middle and apical segments of the inferior, lateral and anterior\nLV walls was observed. The non-compacted/compacted myocardium relationship was higher\n2.3 and the trabecular mass corresponded to 38% of the total left ventricular mass\ncompatible with diagnosis of non-compacted CMP. There were no direct or indirect signs\nof restriction, thrombus or pericardial abnormalities. There were no areas of fibrosis\nor infarction detectable in the sequences after gadolinium injection ().\nElectrophysiological study was performed; programmed ventricular stimulation caused the\ninduction of ventricular fibrillation (two extrasystoles).\nCardioverter defibrillator (CD) was implanted as a normal procedure. Four months after\nthe CD implantation, the patient developed deep vein thrombosis in the left upper limb.\nThe patient was anticoagulated and is currently asymptomatic, with atrial pacing in 100%\nof the time and no sustained ventricular arrhythmias, treated with amiodarone 200 mg and\naspirin 100 mg.

[[53.0, 'year']]

M

{'21285074': 1, '16504589': 1, '27423245': 1, '24714798': 1, '11711464': 1, '20089517': 1, '12714192': 1, '29445263': 1, '17993472': 1, '19746256': 1, '20865233': 1, '24030083': 2}

{}

3998184-1

noncomm/PMC003xxxxxx/PMC3998184.xml

3D Transesophageal Echo in Percutaneous Correction of Paraprosthetic\nRegurgitation

Male patient, aged 76, assisted in August 2010, complaining of progressive dyspnea on\nexertion for two years, which had worsened one month before, accompanied by episodes of\npresyncope. The patient was diagnosed with severe aortic stenosis and, in January 2011,\nhe underwent surgery for aortic valve replacement with a bioprosthesis and was\ndischarged on the seventh postoperative day, which was uneventful.\nIn April 2011, he was hospitalized with fever, dysarthria and ejection systolic murmur\nin the aortic area. The hypothesis of infective endocarditis was confirmed by\ntransesophageal echocardiography that showed an image of an abscess near the anterior\nannulus and prosthetic vegetations, and severe mitral regurgitation and mild left\nventricular systolic dysfunction. Blood cultures were positive for S.\naureus and brain computed tomography scan showed left front hypodense lesion\n(probably septic embolism). The patient received treatment with vancomycin, gentamicin\nand rifampicin. He underwent further surgery with implantation of bioprostheses in\naortic and mitral positions. He was discharged after two months of hospitalization.\nAfter four months, the patient underwent transthoracic echocardiography that revealed\nbioprostheses with anatomically normal leaflets and the presence of severe mitral\nparaprosthetic regurgitation. This finding was confirmed by 3DTEECHO, which found the\nlocation of the leak and measured the dimensions of the defect ().\nDue to the high surgical risk, percutaneous correction of the paraprosthetic\nregurgitation was chosen on November 30, 2011. The procedure was performed under general\nanesthesia and started with the puncture of the right femoral vein and left femoral\nartery. Subsequently, transseptal puncture was performed with the aid of\nechocardiography, which helped find the catheter in position in order to allow access to\nthe mitral valve. Paraprosthetic regurgitation was then found by 3DTEECHO and measured\nin its length and diameter to plan the number and size of devices to be deployed.\nSubsequently, the interventionist tried to cross the defect assisted by 3DTEECHO. At\nthis time, the echocardiography was crucial, since the natural tendency of the catheter\nis to cross the prosthesis through its center hole. Once the catheterization of the\ndefect was confirmed by 3DTEECHO, two therapeutic catheters were separately introduced\nand two AmplatzerTM Vascular Plugs III were implanted. 3DTEECHO guided as to\nthe correct position and release of the prostheses. At the end, it was demonstrated that\nthe paraprosthetic regurgitation had completely disappeared (). The procedure was uneventful. The patient was extubated\nin the catheterization laboratory and remained under observation for about two hours and\ntaken to the infirmary.\nThe patient underwent control transthoracic echocardiography after two days, which\nrevealed normal bioprostheses and no mitral regurgitation. He was discharged on the same\nday.

[[76.0, 'year']]

M

{'18237605': 1, '16112942': 1, '22078428': 1, '15223405': 1, '14594888': 1, '19914038': 1, '23917515': 2}

{}

3998211-1

noncomm/PMC003xxxxxx/PMC3998211.xml

Emphysematous cholecystitis successfully treated by laparoscopic surgery

A 78-year-old male was admitted to our hospital for an investigation of vertigo. He had past medical history of diabetes mellitus, hypertension and dyslipidemia. After admission, he developed fever and abdominal distention. A chest X-ray in the up-right position and abdominal computed tomography (CT) were performed. The chest X-ray showed the presence of gas within the gallbladder and in its wall (Fig. ). The CT scan revealed emphysematous changes in the gallbladder wall and air within the gallbladder (Fig. A and B). Therefore, a diagnosis of EC was made. The patient was referred to the Department of Surgery and emergent surgery was performed.\nBased on the hemodynamically stable status of the patient, we selected a laparoscopic approach. Exploration of the abdominal cavity revealed gangrene and necrosis of the gallbladder. To facilitate the resection, we initially punctured the gallbladder using a percutaneous needle to extract bile. Ascites surrounding the gallbladder suggested perforation. Although there was significant adhesion, we were able to safely dissect the Calot's triangle and detected a cystic duct and artery. Gallbladder resection was successfully completed without conversion to open laparotomy. His postoperative course was uneventful. A bile culture obtained during surgery revealed Clostridium perfringens, Enterobacter cloacae and Enterococcus faecalis as the causative organisms.

[[78.0, 'year']]

M

{'32953350': 2, '27858922': 2, '28367016': 1, '16381372': 1, '10521957': 1, '22007119': 1, '20887835': 1, '26869625': 1, '11998952': 1, '26393182': 1, '24876461': 2}

{'7497293-1': 1, '5591170-1': 1}

3998212-1

noncomm/PMC003xxxxxx/PMC3998212.xml

Surgical clip migration following laparoscopic cholecystectomy as a cause of cholangitis

A 42-year-old male with a history of cerebral palsy, learning difficulties and epilepsy was admitted with a 24-h history of nausea, vomiting and abdominal pain. Past surgical history included laparoscopic cholecystectomy with operative cholangiogram 9 years previously and laparotomy and drainage of a pancreatic pseudocyst 16 years previously.\nExamination revealed a midline laparotomy scar and a distended, tender abdomen.\nLaboratory tests revealed elevated liver function tests: ALP 285 U/l, ALT 465 U/l, GGT 669 U/l with a normal bilirubin. Magnetic resonance cholangiopancreatography demonstrated marked dilatation of the common bile duct to 15 mm (Fig. ). A surgical clip was noted in the distal common bile duct, presumed to have migrated from the cystic duct, which it had been used to close 9 years previously.\nThe patient had an ERCP and sphincterotomy during which the clip was removed leading to complete resolution of symptoms and return of biochemical markers to normal.

[[42.0, 'year']]

M

{'25874138': 2, '9453863': 1, '7564747': 1, '32161435': 1, '17687655': 1, '19640523': 1, '27387334': 2, '29794362': 1, '20049550': 1, '29868139': 1, '31016053': 2, '24876460': 2}

{'4385640-1': 1, '4937585-1': 1, '6444230-1': 1}

3998213-1

noncomm/PMC003xxxxxx/PMC3998213.xml

Bowel hath no fury like a gallbladder inflamed

A 73-year-old male, Mr B presented to the A&E at Whipps Cross Hospital, London with a 3-day history of suprapubic pain. It was associated with some abdominal distension and bloating, and had no aggravating or relieving factors. Additionally, Mr B reported three episodes of non-projectile, non-bilious and blood-free vomiting. He had not opened his bowels for the past 5 days, but had been passing flatus. He denied any urinary symptoms, weight loss or change in bowel habit, prior to this acute episode. He was otherwise fit and healthy, had no previous surgeries and was on no medication. On examination, he was vitally stable but appeared to be dehydrated. He was tender and had guarding in the suprapubic region. He also had increased bowel sounds and was excessively tympanic on percussion of the abdomen. An inguinal hernia on the left side was noted but was reducible and non-tender.\nHis blood on admission showed a raised white cell count of 12.5 × 103 cells/ml (with neutrophilia) and a C-reactive protein of 14.0 mg/l. His alanine transaminase was mildly raised at 79 U/l; however, his remaining liver and renal function tests were normal. His abdominal X-ray showed dilated loops of small bowel but no evidence of large bowel dilatation (Fig. ). A provisional diagnosis of small bowel obstruction was made and a computerised tomography (CT) scan of the abdomen and pelvis was ordered. The CT showed multiple dilated loops of small bowel but no focus of obstruction (Fig. a). The gallbladder wall was thickened and oedematous and there was also evidence of gas within its lumen. Air was seen under the left lobe of the liver, suggestive of a bowel perforation. Furthermore, in Fig. b, the second part of the duodenum appears to be adherent and in communication to the gallbladder. Putting all these findings together, the radiologist felt that there was acute cholecystitis leading to a duodenal perforation and paralytic ileus.\nA plan for a laparotomy was made and the patient was taken to theatre. Intra-operatively, the entire small bowel up to the ileocaecal valve was dilated with no evidence of mechanical obstruction.\nThe colon was dilated up to the hepatic flexure; from there onwards it was progressively collapsed. The hepatic flexure of the colon was adherent to a chronically inflamed and necrotic gallbladder. The gallbladder was friable and adherent to the first part of the duodenum. A subtotal cholecystectomy was performed due to the multiple adhesions of the gallbladder and when perforated and removed, multiple cholesterol gallstones were released. The cholecystitis had eroded a small perforation into the first part of the duodenum as well, which was repaired with an omental patch. The abdomen was washed out and a Robinson's drain left in situ. The patient recovered uneventfully and was discharged on the seventh post-operative day. The results of the histopathology of the gallbladder revealed inflammation and no malignant cells.

[[73.0, 'year']]

M

{'5947287': 1, '9327684': 1, '16329768': 1, '18484141': 1, '10928024': 1, '17541660': 1, '24876462': 2}

{}

3998522-1

noncomm/PMC003xxxxxx/PMC3998522.xml

Bascule caecal volvulus: a rare cause of intestinal obstruction

A 58-year-old female with a past medical history of a large intrathoracic hiatus hernia presented to her general practitioner and was subsequently referred to our surgical department with symptoms of sudden onset severe epigastric pain associated with vomiting and abdominal distension. Her abdomen was generally tender, maximally in the epigastric region, although she was not peritonitic. The admission erect chest radiograph showed a large hiatus hernia and an elevated right hemidiaphragm with a large loop of distended bowel (Fig. ). Subsequent computed tomography (CT) scan demonstrated an almost completely intrathoracic stomach with a degree of volvulus, and the liver medially displaced by a loop of large bowel felt to be caecum (Fig. ). Since the patient remained otherwise well, bidirectional endoscopy was performed, and given that a volvulus point could not be identified and the ileocaecal junction was not identified, contrast studies were requested (Figs –) which demonstrated an incomplete obstruction caused by a volved caecum rotated anteriorly and cephalad.\nAfter the contrast study partial resolution of symptoms occurred but given the development of free fluid in her contrast CT scan, the decision was taken to manage her surgically. A midline laparotomy was performed, with the finding of a freely mobile, grossly distended caecum flipped anteriorly over the ascending colon as demonstrated on her CT scan (Fig. ). This was therefore removed with a right hemicolectomy and primary ileo-colic anastomosis. Additionally, there was no evidence of a gastric volvulus (suggesting partial twisting) and since her stomach was completely intra-abdominal, there was no need to address her hiatus hernia at that point in time. The patient was admitted to the high dependency unit post-operatively, made a good recovery and was discharged home within a week of surgery.

[[58.0, 'year']]

F

{'34898880': 1, '27077698': 1, '29849249': 2, '18760397': 1, '34868549': 2, '4015215': 1, '20574094': 1, '21216326': 1, '7244217': 1, '30976371': 1, '29159782': 1, '3288449': 1, '453944': 1, '11852342': 1, '2003701': 1, '2202566': 1, '24876459': 2}

{'8634507-1': 1, '5965113-1': 1}

3998846-1

noncomm/PMC003xxxxxx/PMC3998846.xml

Intracameral air following pneumatic noncontact tonometry in a recently post–perforating keratoplasty patient

A 42-year-old man had undergone PK for keratoconus in the right eye. A 7.25 mm graft was sutured, with a 10-0 nylon running suture, into the 7.00 mm host bed. The epithelium of the graft was removed at the end of the surgery. The first postoperative day was as usual after PK; the patient had a foreign body sensation, with epiphora and photophobia. Slit lamp examination revealed a transparent graft in niveau, free of epithelium and with Descemet’s striae. The wound was closed, the running suture seemed tight enough, and the anterior chamber was deep and clear. The visual acuity was 0.04 (1.4 logMAR) with no correction. On the second postoperative day, routine tonometry was performed, by the assistant, on the operated eye. The intraocular pressure (IOP) was measured with an NCT (CT-80 Non-Contact Computerized Tonometer; Topcon Corp, Tokyo, Japan); the automatic measurement setting was used, and the measuring range was set in the initial range: 0–30 mmHg. This instrument uses nonsterile air for the measurement. Direct contact with the eye was impossible because the triple safety function of the instrument was in operation. Immediately after the procedure, the patient felt a sharp pain, experienced a deterioration of his visual acuity, and an error signal was indicated on the display. Slit lamp examination revealed that the anterior chamber was well formed, but was two-thirds filled with air. The running suture appeared intact, and no anterior displacement of the wound or anterior wound gap could be observed. A slight stromal haze was noted in the superior part of the graft; the Seidel test was negative. For this reason, we decided on no intervention but simply, close observation of the patient. On the third postoperative day, the air bubble still occupied one-half of the chamber, and the eye remained sensitive. Four days after surgery, the anterior chamber was only one-quarter filled with the air bubble (), and the photophobia had improved considerably. The visual acuity was 0.1 (1.0 logMAR), with no correction. At the 1-week control, the patient was practically free of complaints. His visual acuity was 0.25 (0.6 logMAR), improving to 0.4 (0.4 logMAR) with a +1.0 diopter sphere, and a slit lamp biomicroscopy evaluation revealed a clear cornea with Descemet’s striae, a clear anterior chamber, and a completely healed epithelium. One month postoperatively, the uncorrected distant visual acuity had gained to 1.0 (0.0 logMAR), the corneal astigmatism was 2.5 diopters, and the graft was clear. In the following 1 year, the status of the patient remained practically the same. He was treated with topical antibiotics (levofloxacin 0.5%) for 1 week, and steroid (dexamethasone 0.1%) five times a day in the first week, with the steroid drops (dexamethasone 0.1%) tapering off during the first year.

[[42.0, 'year']]

M

{'10832711': 1, '1993032': 1, '8927819': 1, '6342403': 1, '21328170': 1, '22578443': 1, '29417444': 1, '8447649': 1, '1111288': 1, '7295152': 1, '19034141': 1, '24790404': 2}

{}

3998858-1

noncomm/PMC003xxxxxx/PMC3998858.xml

Cataract surgery during active methicillin-resistant Staphylococcus aureus infection

A 69-year-old diabetic, hypertensive, dyslipidemic, morbidly obese (body mass index 40 kg/m2) housewife underwent bifrontal craniotomy in 1996 that was complicated by osteomyelitis. Several courses of combination antibiotics failed to eradicate the infection. Repeated attempts at closing the craniotomy site with flaps failed. The wound () continued to be foul-smelling. The infectious diseases team was reluctant to allow any ocular surgery. Examination revealed counting finger vision with mature cataract bilaterally. Funduscopy was negative for diabetic retinopathy. The patient was consented for surgery with the risks of endophthalmitis explained. Sequential sutureless phacoemulsification was done, with final uncorrected vision of 6/7.5 in each eye and a 5-month interval between surgeries. Surgery was carried out under topical anesthesia with xylocaine gel and without the application of topical povidone iodine that could decrease corneal clarity (due to severe dry eye povidone iodine drops were omitted to avoid corneal epithelial toxicity that would affect visualization in this very dense cataract)., The eyelid and eyebrow region was scrubbed with povidone iodine. Special attention was paid to creating elongated, three-plane, self-sealing limbal tracts (using a crescent blade), avoiding multiple entry and exit from the eye, and keeping the eye at a pressure of 25 mmHg throughout the procedure. No intracameral antibiotics were given at the end of surgery. The eye was patched with tobramycin and dexamethasone ointment for 1 hour. One hour after surgery, drops were applied every hour during waking time for 1 day with gradual taper (first week every 2 hours, second week every 4 hours, and third week every 6 hours). The postoperative regimen consisted of topical moxifloxacin along with a combination of netilmicin sulfate 0.3% with dexamethasone phosphate 0.1% drops for 3 weeks together with 5 days of oral moxifloxacin. Close observation (examination every 2 days) failed to reveal any signs of anterior chamber inflammation in the postoperative period of 2 months. The patient had no cultures (wound, nose, blood, conjunctival cul de sac), and no preoperative antibiotics.

[[69.0, 'year']]

F

{'21060676': 1, '23623773': 1, '17659970': 1, '24043270': 1, '17638197': 1, '19632455': 1, '17471350': 1, '11239872': 1, '21186193': 1, '6696033': 1, '23990980': 1, '12928904': 1, '12888053': 1, '15028481': 1, '22880135': 1, '19686592': 1, '23928948': 1, '24385282': 1, '24043228': 1, '24790402': 2}

{'3998858-2': 2}

3998858-2

noncomm/PMC003xxxxxx/PMC3998858.xml

Cataract surgery during active methicillin-resistant Staphylococcus aureus infection

A 71-year-old retired lawyer who was a known diabetic, hypertensive, heavy smoker with coronary artery disease, renal failure, and benign prostate hypertrophy (on tamsulosin) had a chronically infected sternal wound with an indwelling catheter after coronary artery bypass surgery 6 months before presentation to the eye clinic. Repeated medical attempts at sterilizing the sternal wound failed, with accompanying irreversible antibiotic nephropathy. He presented with severe visual loss to counting fingers with dense nuclear sclerosis and posterior subcapsular cataract bilaterally. The patient accepted the risks of postoperative infection as previously detailed by the infectious diseases team. The patient underwent phacoemulsification of the right eye under topical anesthesia with xylocaine gel and without instillation of topical povidone iodine (because of dry eye, risk of epithelial toxicity, and loss of clarity during surgery)., Special attention was paid to creating elongated, three-plane, self-sealing limbal tracts. The patient did not receive intracameral antibiotics or oral antibiotics because of recent antibiotic nephrotoxicity. The eye patch was placed for 1 hour and removed to allow topical therapy. He was put on topical moxifloxacin and a combination of netilmicin sulfate 0.3% with dexamethasone phosphate 0.1% drops. The drops were administered hourly on the day of surgery with taper thereafter, as in the first case. Vision in the right eye recovered to 6/6. One month later, the patient underwent phacoemulsification of the left eye with 4.5 mm anterior capsulorhexis. The foldable implant was placed in the bag under balanced salt irrigation. Excess pressure was exerted at 6 o’clock (in order to engage the superior haptic) in a thinned out capsular bag, leading to localized capsular rupture with no vitreous loss. The implant was centered intraoperatively and slowly started decentering inferiorly. He received the same topical regimen as for the right eye. Two months later, a secondary anterior chamber intraocular lens was implanted with the help of viscoelastic material (under topical anesthesia with xylocaine gel and without topical povidone iodine). Upon aspiration of the viscoelastic material, no vitreous was noted in the anterior chamber. Suturing of the three-plane, temporal 6 mm limbal incision was done with 10-0 nylon, ensuring a tight wound. The same regimen of topical drops allowed good visual recovery with no signs of inflammation on close observation (examination every 2 days) in the early postoperative period. Six weeks after the last surgery, uncorrected visual acuity was 6/12 in the left eye.

[[71.0, 'year']]

M

{'21060676': 1, '23623773': 1, '17659970': 1, '24043270': 1, '17638197': 1, '19632455': 1, '17471350': 1, '11239872': 1, '21186193': 1, '6696033': 1, '23990980': 1, '12928904': 1, '12888053': 1, '15028481': 1, '22880135': 1, '19686592': 1, '23928948': 1, '24385282': 1, '24043228': 1, '24790402': 2}

{'3998858-1': 2}

3998861-1

noncomm/PMC003xxxxxx/PMC3998861.xml

Combined Baerveldt glaucoma drainage implant surgery and surgical bleb revision for preventing a postoperative hypertensive phase

Patient 1, a 62-year-old man with open-angle glaucoma had undergone repeated trabeculectomies in the superior quadrants and had an IOP of 42 mmHg in his left eye. The best-corrected visual acuity (BCVA) was 20/40. BGI surgery was performed in the inferior quadrant where the conjunctiva was intact. Because the optic nerve damage was severe due to the prolonged duration (>2 years) of uncontrolled glaucoma, we performed BGI surgery in combination with surgical bleb revision for early IOP control.\nAfter anesthesia was induced with a peribulbar injection of 2% lidocaine, a clear corneal 6-0 polyglycolic acid (PGA) absorbable violet braided suture (Mani Inc, Tochigi, Japan) was placed in the peripheral cornea, and the area of the failed bleb in the superonasal quadrant was exposed (). The scarred conjunctiva was dissected posteriorly using blunt-tip scissors. A bare scleral flap was dissected using an ophthalmic knife until the aqueous humor egressed (). The fornix-based conjunctival flap was re-approximated to the limbus and closed with 10-0 nylon sutures at each end of the periotomy ().\nA subconjunctival space in the inferotemporal quadrant was then created, and a 350 mm2 Baerveldt implant (Abbott Medical Optics Inc., Santa Ana, CA, USA) was positioned under the inferior and temporal rectus muscles (). To minimize postoperative hypotony, the tube was tightly occluded by ligation with 8-0 PGA absorbable violet braided suture (Mani Inc) before insertion into the anterior chamber. Balanced salt solution was injected into the tube using a 27 gauge cannula to confirm that the tube was totally occluded. The plate was sutured to the sclera with 9-0 nylon sutures. The tube was then cut bevel up, and inserted into the anterior chamber via a needle track created with a 23 gauge needle (). To achieve early IOP control, a needle was used to penetrate both sides of the tube (ie, tube fenestrations were created) in three places (). A scleral graft was used to cover the outer portion of the tube (). The conjunctiva was sutured back in its original position using 8-0 silk sutures. Bleb formation was observed after irrigation with balanced salt solution through the paracentesis (). Subconjunctival injection of betamethasone and tobramycin was administered at the end of the surgery.\nAlthough a small amount of hyphema developed, probably in relation to the surgical bleb revision, it resolved within 7 days postoperatively and did not affect bleb formation.

[[62.0, 'year']]

M

{'22245458': 1, '1841559': 1, '33344189': 1, '30154645': 1, '15741807': 1, '22645934': 1, '3328315': 1, '3814422': 1, '9787371': 1, '9855154': 1, '8433833': 1, '9645718': 1, '22244522': 1, '24790406': 2}

{'3998861-2': 2}

3998861-2

noncomm/PMC003xxxxxx/PMC3998861.xml

Combined Baerveldt glaucoma drainage implant surgery and surgical bleb revision for preventing a postoperative hypertensive phase

Patient 2 was a 37-year-old man with neovascular glaucoma caused by central retinal vein occlusion. The IOP in his left eye increased markedly to 68 mmHg despite an intravitreal injection of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA, USA) and subsequent panretinal photocoagulation. The BCVA was <20/200. An initial trabeculectomy was performed; however, the bleb failed despite repeated needling. Due to extensive conjunctival scarring and severe iris neovascularization, which is likely to cause hyphema after trabeculectomy, BGI surgery was performed. To avoid the hypertensive phase, the BGI procedure was combined with surgical bleb revision. The surgical procedure was the same as that described for patient 1.\nFor comparison, we present a representative case treated with BGI surgery alone. Patient 3 was a 54-year-old woman with secondary glaucoma caused by ocular sarcoidosis. The IOP increased to 30 mmHg in her right eye. The BCVA was 20/25. She had previously undergone repeated trabeculectomies. Because of the severity of the conjunctival scarring in the superior quadrants, BGI surgery was performed in the inferior quadrant.\nNo signs of tubal obstruction were observed in any of the patients postoperatively. The changes in the postoperative IOP levels of the three patients are shown in . The postoperative IOP was controlled by postoperative bleb management in patients 1 and 2. In patient 3, the postoperative IOP remained relatively high compared to patients 1 and 2.

[[37.0, 'year']]

M

{'22245458': 1, '1841559': 1, '33344189': 1, '30154645': 1, '15741807': 1, '22645934': 1, '3328315': 1, '3814422': 1, '9787371': 1, '9855154': 1, '8433833': 1, '9645718': 1, '22244522': 1, '24790406': 2}

{'3998861-1': 2}

3998865-1

noncomm/PMC003xxxxxx/PMC3998865.xml

Djenkolism: case report and literature review

A 32-year-old man presented to our rural clinic in Borneo, Indonesia, with 10 hours of severe bilateral flank pain. Two hours after eating ten djenkol beans, the patient experienced acute, bilateral, severe (rated as 10/10), and spasmodic flank pain which radiated to the groin and was accompanied by vomiting. He also experienced difficulty with urination, hematuria, and decreased urine output (2 mL over the course of 12 hours).\nThe patient was healthy with no known medical problems. Medical history noted that the patient had experienced a similar episode as a teenager; he did not seek medical attention at that time and recovered after 14 days. The patient had consumed djenkol beans during the interval period between the two episodes without symptoms. He did not have any recent illnesses and had not taken medications prior to or since the onset of pain.\nThe patient was fully alert and in moderate distress. Vital signs were recorded at the time of treatment: blood pressure at 120/80; heart rate at 77 beats per minute; respiratory rate at 16 breaths per minute; and temperature at 36.5°C. The patient experienced approximately 2 minutes of severe spasmodic pain every 10 minutes with concurrent vomiting or syncope. Physical examination was notable for the odor of djenkol on his breath, abdominal hyperperistalsis, suprapubic tenderness, and bilateral costovertebral tenderness. Intravenous (IV) access was obtained and an indwelling urinary catheter was placed. The patient was given tramadol 50 mg IV for pain and urged to drink carbonated beverages as tolerated.\nAn ultrasound of the kidneys revealed bilateral hydronephrosis () with no stones noted. Anuria persisted and was treated with a 2.5 L normal saline bolus and furosemide 20 mg IV. The patient subsequently urinated 200 mL of bloody urine with resolution of pain. Upon microscopic exam, the initial urine sample had a specific gravity of 1.020 and 3+ blood, microscopic exam revealed many red blood cells and sediment but no crystals. The patient continued to receive pain medications and IV fluids as needed with resolution of oliguria.\nAfter four days, the patient’s other symptoms, including hematuria, resolved. A repeat ultrasound demonstrated mild right-sided hydronephrosis and a normal left kidney. The patient was discharged on tramadol as needed, encouraged to drink at least 2 L of fluid per day, and advised to avoid djenkol beans. The patient returned approximately 2 weeks later completely asymptomatic; residual right-sided hydronephrosis had also completely resolved.

[[32.0, 'year']]

M

{'34890': 1, '17337378': 1, '7810535': 1, '21911980': 1, '5662186': 1, '18408297': 1, '9171298': 1, '2042077': 1, '12563601': 1, '4274568': 1, '17699203': 1, '13339789': 1, '7886826': 1, '828979': 1, '501259': 1, '32843946': 1, '19446679': 1, '4885988': 1, '24790471': 2}

{}

3999325-1

noncomm/PMC003xxxxxx/PMC3999325.xml

Pulmonary Infection Caused by Mycobacterium neoaurum: The First Case in Korea

A 25-yr-old woman visited the Department of Pulmonology and Allergy Clinic at a university hospital to evaluate her cough and whitish sputum that began a month ago. She didn't have any history of chronic illnesses and was not on any medication. To test for common conditions, such as asthma and bronchitis, the physician arranged for allergy and induction tests, and all of the results were negative. Her initial blood cell counts were as follows: hemoglobin, 15.3 g/dL; white blood cells, 8.64×109/L (neutrophils, 66.1%; lymphocytes, 20.5%; monocytes, 10.2%; eosinophils, 2.4%; and basophils, 0.8%); and platelets, 353×109/L. There was no prominent change in the routine chemistry tests, except for mildly elevated hepatic enzyme levels (AST, 43 IU/L; and ALT, 65 IU/L). An acid-fast bacillus (AFB) smear based on auramine fluorescent stain showed trace result (1-2 AFB/300 fields) according to the Centers for Disease Control and Prevention (CDC) report system. High resolution computed tomography (HRCT) scans were arranged to further investigate the presence of pulmonary mycobacteria infection. A HRCT scan displayed a well-marginated centrilobular nodule with branching in the left upper lobe, apicoposterior segment, indicating the presence of pulmonary tuberculosis in the left upper lobe. The physician performed bronchoscopy, which revealed no specific endobronchial lesions, but cultures of bronchial washing specimens for AFB were positive. An endobronchial washing specimen culture was negative for other bacterial or fungal pathogens. On the basis of these results, the patient was thought to have a mycobacterial lung infection and was given rifampicin, ethambutol, and pyrazinamide.\nAFB was identified by an auramine fluorescent stain and further confirmed by Ziehl-Neelsen-stained smears from colonies grown on Mycobacteria Growth Indicator Tube (MGIT; Becton Dickinson, Sparks, MD, USA) liquid medium. On blood agar plates, we observed yellow colonies within 4 days after inoculation and incubation at 42℃. The results of the nitrate reduction test were negative. Cultural characteristics indicated that the organism belonged to a group of rapidly growing mycobacteria.\nThe American Thoracic Society (ATS) has suggested diagnostic criteria of nontuberculous mycobacterial lung disease, which require clinical, radiographic, and microbiologic evidence []. In our case, the pulmonary symptoms of the patient and HRCT scan findings suffice clinical and radiologic criteria. In terms of the microbiologic criteria, we obtained positive culture results for NTM from at least one bronchial washing specimen without any evidence of an M. tuberculosis complex infection.\nTo further identify the mycobacteria, reverse hybridization assays (GenoType Mycobacterium CM/AS, Hain Lifescience, Nehren, Germany) were performed. The test results were consistent with Mycobacterium celatum, but cultural characteristics and clinical features were inconsistent with this species. Therefore, full-length 16S rRNA gene sequencing was performed by Macrogen (Seoul, Korea) using the following detailed methods:\nUsing bacterial colonies grown on blood agar plates, bacterial genomic DNA samples were extracted using InstaGene Matrix (BIO-RAD, Hercules, CA, USA). The following primers were used for PCR: forward primer 27F, 5'-AGAGTTTGATCMTGGCTCAG-3'; and backward primer 1492R, 5'-TACGGYTACCTTGTTACGACTT-3'. This primer pair amplified a 1,492-bp fragment of the 16S rRNA gene of the Escherichia coli 16S rRNA gene. The PCR reaction was performed with 20 ng of genomic DNA as a template in a 30 µL reaction mixture using EF-Taq-DNA polymerase (SolGent, Daejeon, Korea). The following PCR program was used: activation of Taq polymerase at 95℃ for 2 min; 35 cycles at 95℃, 55℃, and 72℃ for 1 min; and a 10-min step at 72℃.\nThe amplification products were purified via a multiscreen filter plate (Millipore Corp., Billerica, MA, USA). Sequencing reactions were performed using the PRISM BigDye Terminator v3.1 Cycle Sequencing Kit. The DNA samples containing the extension products were added to Hi-Di formamide (Applied Biosystems, Foster City, CA, USA). The mixture was incubated at 95℃ for 5 min, placed on ice for 5 min, and then analyzed using an ABI Prism 3730XL DNA analyzer (Applied Biosystems).\nAfter sequencing, the raw sequence file (.abi) was processed using Lasergene SeqMan Pro 7.1 (DNASTAR, Madison, WI, USA) to get trimmed nucleotide sequences. We compared the obtained sequences with those deposited in GenBank (). The sequence of the 16S rRNA gene was consistent with that of M. neoaurum ATCC25796 (FJ172307.1) based on having a sequence similarity of 99.8%.\nA phylogenetic tree was generated using the Neighbor-Joining method, which is based on nucleotide sequences of the clinical isolate with those of other Mycobacteria reference strain sequences prepared from the National Center for Biotechnology Information (NCBI) database using Mega 5.0 software [] ().\nThe drug susceptibility test was performed at the Korean Institute of Tuberculosis using first-line and second-line drugs, and the minimal inhibitory concentrations (MIC) were determined using the broth microdilution method in Muller-Hinton media. MICs were interpreted based on the broth microdilution interpretive criteria for rapidly growing mycobacteria [] ().\nAfter 1 month of rifampicin, ethambutol, and pyrazinamide treatment, the patient was placed on a clarithromycin regimen for 4 months, and her symptoms improved.

[[25.0, 'year']]

F

{'3366872': 1, '12364376': 1, '17277290': 1, '17501949': 1, '15200833': 1, '19119036': 1, '24031745': 1, '28694831': 1, '32517374': 1, '17306883': 1, '18159425': 1, '21546353': 1, '19502318': 1, '20881180': 1, '22457251': 1, '11346303': 1, '24790914': 2}

{}

3999358-1

noncomm/PMC003xxxxxx/PMC3999358.xml

Simultaneous placement of an interpositional free gingival graft with nonsubmerged implant placement

A 50-year-old female patient presented to the Department of Periodontology at Yonsei University Dental Hospital, Seoul, Korea, complaining of partial edentulism in the right mandible. The patient had no contributing medical history. The mandibular right second premolar and molars had been extracted 10 years previously, and she had been wearing a removable partial denture.\nThe posterior molar site of the edentulous mandible presented a thin band (approximately 2 mm) of keratinized tissue on the ridge crest and inadequate vestibular depth (). The treatment plan included the placement of three nonsubmerged implants in the positions of the mandibular right second premolar, first molar, and second molar. In addition, simultaneous interpositional free gingival grafting was planned in the molar area to increase the amount of keratinized tissue.\nThe protocol was reviewed and approved by the Yonsei University Institutional Review Board. The patient provided written informed consent before the onset of the surgery.\nA horizontal incision was made on the ridge crest starting from the distal gingiva of the first premolar and extending to the posterior area (). The horizontal incision line of the molar area was on the mucogingival junction. Thus, the lingual flap had 2 mm of keratinized tissue. Full-thickness buccal and lingual flaps were elevated, and the keratinized tissue band of the molar area was then repositioned to the lingual flap. Nonsubmerged implants (Standard implant, Straumann, Basel, Switzerland; second premolar and first molar: diameter 4.1 mm, length 12 mm; second molar: diameter 4.1 mm, length 10 mm) were placed, and healing caps (diameter 6.5 mm, height 1.5 mm) were connected following a standardized technique.\nThe right palate was chosen as the donor site. The thickness of the palatal tissue, as measured by penetrating to the bone with a periodontal probe, was approximately 3.0 mm. A tinfoil template was used to guide the palatal incision (approximately 7 mm high and 20-mm wide). The graft contouring was performed with a fresh No. 15C scalpel to ensure close adaptation around the implant abutment and a butt-joint marginal adaptation with the lingual tissues. A presuture for the sling suture was made to adapt and fix the graft immediately, and a partial-thickness graft was harvested ().\nThe flap design of the palatal graft followed the technique for the interpositional onlay graft described by Seibert and Louis []. The E-C and CT portions of the graft were determined; the graft was rectangular in shape in the frontal view and wedge shaped in the cross-sectional view ().\nThe graft was positioned over the recipient bed, and the CT portion was inserted under the buccal flap and sutured to the buccal mucosa flap to promptly obtain a blood supply from the buccal flap and the underlying bone tissue. The presutured silk on the E-C portion was tied around the healing caps using sling sutures. The graft was then closely connected to the lingual flap by using an interrupted suture to obtain primary closure in the interproximal area. Consequently, the buccal flap was positioned apically and fixed at the inferior border level of the E-C portion ().\nLight compression was applied to the graft with moistened gauze for about 5 minutes to reduce the thickness of the blood clot and enhance fibrin adhesion. All surgical procedures were performed by one of the authors (K.S.C.).\nPostoperatively, the patient was instructed to rinse her mouth twice a day with 0.1% chlorhexidine solution (Hexamedine, Bukwang Pharmaceuticals, Seoul, Korea) for the first 2 weeks after the surgery. Antibiotic regimens were prescribed for 7 days, and the sutures were removed after 10 days. The patient was rehabilitated with a fixed partial denture after 4 months.\nThe healing was uneventful during the initial healing period, and the graft appeared well integrated with the surrounding tissues. The patient was seen at 2, 4, 6, 8, 16, and 20 weeks postoperatively, and yearly thereafter for 8 years to monitor healing and for plaque control. Clinical and radiographic examinations were carried out once or twice a year ( and ). Plaque control and oral hygiene reinforcement were performed at each visit.\nA clinical examination performed 8 years after surgery found no significant signs or symptoms of inflammation, such as bleeding on probing, gingival redness, or swelling on the keratinized tissue around the implants, and increased keratinized tissue by the creeping attachment was observed. The grafted gingiva had been well maintained throughout the healing period. lists the changes in the width of the keratinized tissue after specific periods of healing. The width of keratinized buccal gingiva had increased to 4 mm, and the buccal vestibule was deeper than in the preoperative condition.

[[50.0, 'year']]

F

{'23451989': 1, '15088886': 1, '8227448': 1, '19719741': 1, '18266873': 1, '8468089': 1, '18724848': 1, '18548930': 1, '3083006': 1, '19079234': 1, '17294229': 1, '24151824': 1, '28293441': 2, '19678861': 1, '7558662': 1, '19217009': 1, '2636223': 1, '6164778': 1, '9242099': 1, '16966901': 1, '8038340': 1, '34393404': 1, '16881810': 1, '1843462': 1, '18380550': 1, '11490405': 1, '2213310': 1, '20827329': 2, '1298429': 1, '2094653': 1, '12693424': 1, '7578788': 1, '2098350': 1, '20498767': 1, '24778904': 2}

{'5331288-1': 1, '2931308-1': 1, '2931308-2': 1}

3999441-1

noncomm/PMC003xxxxxx/PMC3999441.xml

Symptomatic Central Venous Stenosis in a Hemodialysis Patient Leading to Loss of Arteriovenous Access: A Case Report and Literature Review

We report the case of a 58-year-old male African-American patient who became dialysis dependent in 1990 after he had developed end-stage renal disease due to focal segmental glomerulosclerosis. He had received hemodialysis via a left-radial-artery-to-brachial-vein Gore-Tex graft for several years before he was noted to have poor arteriovenous access blood flow. Venography showed graft stenosis and an accompanying thrombus. Despite efforts to restore patency, the graft could not be salvaged. A tunneled left subclavian hemodialysis catheter was placed in order to continue maintenance hemodialysis. He subsequently underwent creation of a left brachiocephalic arteriovenous fistula that provided reliable vascular access for hemodialysis during several months. The patient eventually underwent a successful cadaveric kidney transplant and was emancipated from hemodialysis. Months later, he developed a remarkable enlargement of the arteriovenous fistula (fig. ) and dilated jugular veins (fig. ). Venography revealed 50% stenosis of the left brachiocephalic vein accompanied by dilatation of the ipsilateral cephalic and subclavian veins (fig. ). Retrograde flow was noted in the left internal jugular vein. After successful dilatation of the left brachiocephalic vein stenosis by balloon angioplasty, venography showed restoration of the blood flow in the central venous circulation and disappearance of the previously noted retrograde flow in the left internal jugular vein (fig. ). However, as the access arm remained massively enlarged, venography was repeated a few weeks later, revealing moderate-to-severe stenosis of the left cephalic as well as subclavian veins. Successful balloon angioplasties of both lesions were performed. Despite several interventions, the striking enlargement of the venous system persisted, and surgical ligation of the fistula was done to avert catastrophic complications.

[[58.0, 'year']]

M

{'28228889': 1, '1754109': 1, '12958674': 1, '16036153': 1, '15034155': 1, '10411674': 1, '34824675': 2, '15270954': 1, '23291234': 1, '31350227': 1, '6502910': 1, '12380764': 1, '17377181': 1, '15745139': 1, '28500364': 1, '11786113': 1, '12616419': 1, '29217877': 1, '24803921': 2}

{'8588745-1': 1}

3999451-1

noncomm/PMC003xxxxxx/PMC3999451.xml

A Case of Bladder Cancer after Radiation Therapy for Prostate Cancer

An 86-year-old Japanese male with a history of prostate cancer and cerebral infarction presented to our urology outpatient clinic. He was taking an oral anticoagulant (100 mg of cilostazol) once a day. He received external beam radiation therapy (EBRT) by means of a 4-field technique. A cumulative dose of 60 Gy in 30 fractions was delivered over a period of 5 weeks. There was no neoadjuvant and adjuvant maximum androgen blockade or chemotherapy (prostate specific antigen 8.7, Gleason score 4 + 4, cT2a) in 2001. Neither recurrence nor metastasis was detected in the following 11-year period. In the follow-up period, his PSA level was about 0.10 ng/dl.\nThe patient presented to a local outpatient clinic with the chief complaint of intermittent gross hematuria that had lasted for 2 months. Bladder irrigation was performed, and his urine became clear. However, 5 days later, he presented to our hospital complaining of gross hematuria and clot retention.\nHe did not have lower urinary tract symptoms, fever, nausea, chills, flank pain, or weight loss. However, lower abdominal distention was noted at this time. On physical examination, his eyes were anemic, but otherwise, the examination was unremarkable. Laboratory data showed marked anemia with a hemoglobin level of 7.1 mg/dl. Other data, including liver function tests and coagulation studies, were within normal limits. Abdominal ultrasonography showed clots in the bladder. He was immediately admitted to our hospital and taken off cilostazol. After insertion of a transurethral catheter, bladder irrigation was performed to remove the clots. Continuous bladder irrigation was then started, and 4 units of component blood transfusion were administered. The findings suggested the presence of bladder cancer and radiation cystitis or stone-related disease as a differential diagnosis. Cystoscopic examination was performed to determine the cause of the hematuria and revealed irregularity of the mucosa on the posterior wall and a papillary tumor with active bleeding on the left side of the posterior wall. MRI revealed non-muscle invasive bladder cancer (fig. ).\nWe performed transurethral resection of the bladder tumor (TURBT). A nodular tumor was found on the posterior wall (fig. ). The trigon, neck and two lesions in the posterior wall were reddish, which was compatible with radiation-induced cystitis. Bilateral orifices were not involved and had clear efflux of urine. There were no other notable lesions. The tumor along the posterior wall and the reddish lesion were resected and coagulated. Urine cytology was negative for bladder cancer before and after TURBT. Pathological diagnosis revealed urothelial carcinoma, G2, pTa (fig. ).\nAfter TURBT, the patient's gross hematuria resolved. The Foley catheter was removed on postoperative day 6. The patient was discharged and cilostazol administration was resumed. He is still being followed-up and there has been no recurrence of the hematuria or bladder cancer in the 12 months since TURBT.

[[86.0, 'year']]

M

{'20951450': 1, '22425074': 1, '15947588': 1, '7959285': 1, '32743414': 2, '20212517': 1, '16887293': 1, '18374503': 1, '20707727': 1, '24000900': 1, '16697804': 1, '16878323': 1, '12824899': 1, '17296367': 1, '24803918': 2}

{'7292124-1': 1}

3999573-1

noncomm/PMC003xxxxxx/PMC3999573.xml

A Case of Gingival Metastasis from Rectal Cancer in Which Immunohistochemistry and PET-CT Were Useful for the Diagnostic Procedure

A previously healthy 50-year-old man presented with an approximately 2-month-long history of lower jaw pain. He had no history of smoking and alcohol overconsumption. He first visited the dental clinic, and the dentist, suspecting gingival cancer, referred the patient to our hospital.\nOn clinical examination, an ulcerative, circumferential tumor that arose in the left lower gingiva was visible (fig. ). Physical examination of the chest and abdomen was normal. The laboratory findings were as follows: white blood cell count 6,800/mm3; hemoglobin 13.9 g/dl; LDH 326 IU/l, and increased CEA and CA19-9 levels (215 ng/ml and 339 U/ml, respectively). Other findings were within the normal limits.\nBecause biopsies obtained from the gingival tumor confirmed adenocarcinoma with a substantial gland formation, CT was performed to determine the primary and the extent of the disease. It revealed small nodular masses in the lung, liver, and spleen, all of which were round in shape, 2–3 cm in diameter, with clear borderlines, suggesting metastases. However, CT gave no clues about the primary tumor.\nOn the fifth day after the referral, the results of the immunohistochemical staining for adenocarcinoma turned out to be positive for CK20 and caudal-related homeobox transcription factor (CDX-2), and negative for CK7 and thyroid transcription factor-1 (TTF-1) (fig. ). Moreover, PET-CT showed an accumulation of 18F-fluorodeoxyglucose (FDG) with an SUVmax of 19.0 in the upper rectum (fig. ). Based on these additional findings, the patient was persuaded to undergo a colonoscopic examination, which then revealed advanced rectal cancer (fig. ). After the patient received 16 cycles of modified FOLFOX6 (fluorouracil 400 mg/m2 intravenous bolus on day 1, followed by continuous infusional fluorouracil 2,400 mg/m2 administered over 46 h starting on day 1 in combination with leucovorin 200 mg/m2 on day 1 and oxaliplatin 85 mg/m2 on day 1) plus bevacizumab treatment, the rectal cancer and the gingival metastasis disappeared, and all other metastases shrank. Since then, 12 months have passed, and he is now undergoing second-line chemotherapy with FOLFIRI (fluorouracil 400 mg/m2 intravenous bolus on day 1, followed by continuous infusional fluorouracil 2,400 mg/m2 administered over 46 h starting on day 1 in combination with leucovorin 200 mg/m2 on day 1 and irinotecan 150 mg/m2 on day 1) plus bevacizumab.

[[50.0, 'year']]

M

{'18061527': 1, '12604886': 1, '7636553': 1, '23110013': 1, '12902422': 1, '21821544': 1, '15112256': 1, '12202714': 1, '25722032': 1, '25566054': 2, '22157556': 1, '24803903': 2}

{'4280457-1': 1}

3999574-1

noncomm/PMC003xxxxxx/PMC3999574.xml

Mycophenolate Mofetil-Induced Segmental Colitis Mimicking Ischemic Colitis

A 64-year-old gentleman with a history of autoimmune autonomic dysfunction and gastroparesis on a background of type 2 insulin-dependent diabetes mellitus presented to our hospital with abdominal pain and diarrhea. He did not have any history of coronary artery disease or other cardiovascular comorbidities. The patient was initially started on MMF 1,000 mg twice daily 2 years prior for autoimmune autonomic dysfunction. This was subsequently raised to 1,500 mg twice daily 4 months preceding the patient's presentation. The diarrhea had started 2 months prior to presentation, with up to eight episodes of non-bloody diarrhea per day. Abdominal pain was of recent onset with a 4-day history of lower abdominal stabbing pain most severe in the left lower quadrant and reported as constant and progressive in nature. He also had decreased appetite, weight loss, sensation of bloating and intermittent nausea. He did not have any history of coronary artery disease or other cardiovascular comorbidities. The patient had undergone esophagogastroduodenoscopy within the past year, which had been unremarkable. A colonoscopy 5 years prior had shown diverticulosis, but otherwise been normal.\nOn examination, his vital signs were normal, and he had diffuse abdominal tenderness with increased intensity in the left lower quadrant area. Initial investigations revealed an elevated white blood cell count of 17.9 × 109 cells/l (normal 3.5–10.5 × 109 cells/l) with normal hemoglobin and platelet count. An elevated creatinine of 1.8 mg/dl (normal 0.6–1.2 mg/dl) was also noted. Abdominal X-ray showed no obstruction. Stool examination for microbiology including Clostridium difficile was negative. Initial management included hydration with intravenous fluids, empiric antibiotics and analgesia. Further work-up with CT of the abdomen and pelvis with contrast revealed segmental wall thickening and pericolic inflammation at the splenic flexure and proximal descending colon without evidence of diverticulitis. Flexible sigmoidoscopy revealed a segmental erythematous mucosa and multiple ulcers in the sigmoid colon, descending colon, splenic flexure and proximal transverse colon, suggesting a mucosal injury pattern consistent with ischemic colitis (fig. ). However, biopsies showed dilated damaged crypts, eosinophilic epithelial changes and crypt abscesses with apoptotic bodies, a pattern of injury highly suggestive of MMF-related colitis (fig. ). There was no evidence of cytomegalovirus infection.\nMMF therapy was subsequently discontinued and the patient was discharged following improvement of symptoms with follow-up in an outpatient clinic 5 weeks later. During this visit, his abdominal pain and diarrhea had improved rapidly and significantly. He is scheduled for a repeat colonoscopy in 4 months’ time to assess the extent of mucosa recovery.

[[64.0, 'year']]

M

{'14615824': 1, '11522119': 1, '11377513': 1, '21672020': 1, '15010709': 1, '8680053': 1, '11213388': 1, '3429723': 1, '28874961': 1, '23498833': 1, '32117661': 2, '12640307': 1, '10676738': 1, '21103265': 1, '24025088': 1, '8768909': 1, '21299830': 1, '24803893': 2}

{'7041651-1': 1}

3999575-1

noncomm/PMC003xxxxxx/PMC3999575.xml

Tumor Calcification: A New Response Pattern of Myxoid Liposarcoma to Trabectedin

A 63-year-old woman without any underlying disease was diagnosed with a large tumor in the posterior part of the left thigh in January 2011. The first magnetic resonance imaging showed a heterogeneous mass with a diameter of 295 mm (fig. ). The patient was initially managed by a surgeon at a tertiary center. The community center surgeon performed an open biopsy, which resulted in a wound that never healed. The diagnosis was myxoid liposarcoma associated with small round cells (MRCL). The chest and abdominopelvic CT scan revealed the presence of multiple metastases, including a mediastinal mass (38 mm; fig. ).\nBased on the metastatic spread and the nature of the disease, the multidisciplinary committee suggested the inclusion of the patient into a randomized, multicenter phase III study (ET-C-002–07 study; ClinicalTrials.gov identifier: NCT00796120) that evaluated trabectedin 1.5 mg/m2 given as a 24-hour intravenous infusion q3w versus doxorubicin-based chemotherapy as a first-line therapy in patients with translocation-related sarcomas. Once the patient signed the informed consent form, she was randomly assigned to the trabectedin arm. Before chemotherapy, the tumor was painful. That resulted in the administration of opioids and it was associated with severe asthenia. The first cycle of treatment was administered in March 2011. The patient received 14 cycles until January 2012. The treatment was then stopped due to hematological toxicity (grade 3 anemia, grade 3 thrombopenia, and recurrent infections). Throughout the trial, the tumor response was evaluated every 6 weeks. According to the response evaluation criteria in solid tumor (RECIST) guidelines, we observed a stable disease. In parallel, the pain intensity progressively decreased and the asthenia became markedly less, although the site of the open biopsy has not healed and a daily and abundant necrotic material flow continues to be observed. Since January 2012, the patient was examined regularly. During the last visit, we observed the following: excellent general condition, absence of pain, remaining necrotic material including macroscopic calcifications flows (fig. ) and calcification of the primary tumor (fig. , fig. ) and the metastasis (fig. ). Response and symptomatic improvement maintained until November 2013.\nThe patient had formally consented for the publication of the case report to be published.

[[63.0, 'year']]

F

{'19190116': 1, '26089739': 1, '20647340': 1, '34631083': 1, '17586092': 1, '20215499': 1, '27487949': 2, '24213580': 1, '19465423': 1, '21642514': 1, '19652065': 1, '33792747': 1, '32854723': 2, '24803896': 2}

{'4973031-1': 1, '7457307-1': 1}

3999576-1

noncomm/PMC003xxxxxx/PMC3999576.xml

Simultaneous Occurrence of Early Gastric Carcinoma and Mucosa-Associated Lymphoid Tissue Lymphoma of the Omentum

A 55-year-old woman was referred to our hospital with a history of appetite loss, right inguinal pain and weight loss. Endoscopy revealed a type 0-IIc tumor in the forecourt of the pylorus and entire wall thickening in the pylorus. Biopsy showed it to be signet ring cell carcinoma. H. pylori antigen in the urine was positive. Laboratory tests including blood counts, liver and renal function tests, tumor markers such as carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. Upper gastrointestinal series showed the tumor limited in the stomach. Computed tomography showed no lymph node swelling or distant metastasis. Therefore, distal gastrectomy with D2 lymph node resection was performed under the diagnosis of gastric carcinoma T1N0M0 (fig. ). During operation a mass 2.0 × 3.0 cm in size was observed in the omentum near the cecum. The mass was also resected for pathological examination. The postoperative course was uneventful, and the patient was discharged on the 16th postoperative day. Pathological review of the surgical specimen showed three independent early gastric cancer (No. 1: 0-IIc, T1b(sm), sig.; No. 2: 0-IIc, T1b(sm), sig.; No. 3: 0-IIc, T1a(m), sig.) (fig. ). No regional lymph node metastases were seen. Grossly, the peritoneal lesion showed a tumorous growth measuring 2.0 × 3.0 cm (fig. ). Microscopically, the lesion was composed of tumorous proliferation of small lymphocytes (fig. ). The lymphoid cells were composed of centrocytic and monocytic lymphoma. Little atypia was seen. A few mitotic figures were present. No lymphoepithelial lesions were seen because it was a peritoneal lesion. Plasmacytic differentiation was noted. Immunohistochemically, the lymphoid cells were positive for CD20 (+++) (fig. ), CD79a (++), CD138 (++) (fig. ), Ki67 (labeling = 10%) (fig. ), CD45RO (+), l-chain (+++), k-chain (+) and CD15 (+++), and negative for cytokeratin AE1/3, cytokeratin CAM5.2, CD3, CD30 (fig. ), CD10, CD34, CD56 and p53. The stainings of the light chains suggested positive light chain restriction. The diagnosis of primary omental MALT lymphoma was made. Due to the nature of this patient's disease, she was started on medical eradication of H. pylori.

[[55.0, 'year']]

F

{'24574742': 1, '22426602': 1, '7054024': 1, '7783535': 1, '15286744': 1, '31044268': 1, '19620164': 1, '9437071': 1, '11526388': 1, '10535873': 1, '27594756': 1, '23054813': 1, '9615278': 1, '9166827': 1, '11419851': 1, '24803894': 2}

{}

3999577-1

noncomm/PMC003xxxxxx/PMC3999577.xml

Successful Colectomy for Hemorrhagic Colitis with Hemolytic Uremic Syndrome and Acute Encephalopathy due to Escherichia coli O157 Infection

An 81-year-old man was admitted to a primary hospital with complaints of lower abdominal pain and bloody diarrhea. He had no specific past medical history. Abdominal computed tomography revealed thickness of the descending colon wall. He was given intravenous hydration and antibiotic therapy (cefotiam, levofloxacin) with a diagnosis of ischemic colitis. On hospital day 2, follow-up abdominal computed tomography showed ascites and thickness of the entire colon wall. On hospital day 4, the patient was transferred to our hospital because of renal dysfunction and a convulsion. In the first aid station, the patient's consciousness was slightly clouded; temperature was 38.0°C, blood pressure 140/92 mm Hg and heart rate 95/min. His skin was cold and moist. The abdomen was distended and tympanic, with generalized tenderness. Laboratory studies revealed severe inflammation, anemia, a low platelet count and renal dysfunction. Blood gas analysis showed hypoxemia, metabolic acidosis and a low CO2 level due to tachypnea. Colonoscopy revealed diffuse mucosal edema, ulcer formation and bleeding from the rectum to the ascending colon (fig. ). There was no evidence of free air, but the whole colon wall was markedly thickened, with huge ascites on abdominal computed tomography (fig. ). Gradually, the patient's vital signs deteriorated (blood pressure 60/40 mm Hg, heart rate 115/min), with severe disturbance of consciousness, and generalized cyanosis could be seen. He was diagnosed as having necrotic ischemic colitis with septic shock and underwent emergency surgery. The operative findings showed a large amount of ascites. From the rectum to the cecum, the colon wall was markedly edematous and sclerotic. In particular, inflammation of the transverse colon extended to the greater omentum with necrosis. An extended right hemicolectomy and ileostomy were performed. The resected specimen showed hemorrhagic necrosis of the transverse colon (fig. ). Pathological findings showed mucosal hemorrhagic necrosis with submucosal edema. There was venous dilatation and congestion of blood, which suggested ischemic colitis. In the stool culture before the operation, O157 and verotoxin were found. This case was therefore diagnosed as hemorrhagic colitis with HUS and acute encephalopathy due to O157 infection. After the operation, the patient was treated in the intensive care unit with ventilation because of delayed emergence from anesthesia due to encephalopathy and poor oxygenation. However, with intensive care, the HUS and encephalopathy improved gradually without dialysis. He was finally discharged on the 33rd postoperative day (fig. ).

[[81.0, 'year']]

M

{'15781103': 1, '9483961': 1, '8985658': 1, '19371288': 1, '23353941': 1, '2072218': 1, '7738732': 1, '422000': 1, '24803891': 2}

{}

3999578-1

noncomm/PMC003xxxxxx/PMC3999578.xml

Surgery without Blood Transfusion for Giant Paraganglioma in a Jehovah's Witness Patient

In February 2011, a retroperitoneal tumor was suspected by a health check in a 57-year-old Japanese woman and subsequent examination led to the suspicion of a right pheochromocytoma. As the patient was a Jehovah's Witness, she wished to undergo bloodless surgery and consulted our hospital in June 2011 after being refused surgery by several hospitals.\nThe characteristics of the patient recorded at the time of hospital admission were as follows: height: 154 cm, weight: 56 kg, blood pressure: 115/65 mm Hg and heart rate: 78 bpm and regular. The tumor was palpable in the right hypochondrium. There were no physical signs of Cushing's syndrome such as moon facies or buffalo hump. There were no abnormal findings in the peripheral blood and biochemical tests. Endocrine tests revealed high levels of urinary normetanephrine (1.60 mg/day). There were no abnormal findings in any other items, including blood adrenaline, cardiac function, and pulmonary function.\nAbdominal contrast-enhanced computed tomography (CT) revealed a retroperitoneal tumor (size: 12 cm) touching the upper pole of the right kidney with an uneven contrast-enhanced effect inside the tumor. The tumor had ill-defined borders with the surrounding liver, right kidney, inferior vena cava, right renal artery and vein, and left renal vein, which indicated adhesion (fig. ). There was no clear lymph node metastasis or distal metastasis on imaging. The tumor had a low signal intensity on T1-weighted magnetic resonance images and high signal intensity on T2-weighted magnetic resonance images. Marked accumulation was found on 131I-metaiodobenzylguanidine scintigraphy.\nThe above findings were suggestive of a right adrenal pheochromocytoma. Abdominal contrast-enhanced CT findings revealed that tumorectomy required a right renal combined resection, sectioning of the right renal artery and vein, left renal vein, and inferior vena cava, and detachment of the tumor from the lower hepatic surface. Despite explaining the importance of blood to the patient once again as an outpatient, she did not give consent. However, we were able to gain her consent for the use of albumin preparations, intraoperative diluted autotransfusions, intraoperative recovery-type autotransfusions, the use of a heart-lung machine, and hemodialysis. A preoperation conference was held with the four hospital departments including anesthesiology, gastrointestinal surgery (because of the detachment of the tumor from the liver), and cardiovascular surgery (extracorporeal circulation is required when sectioning the inferior vena cava). The type of surgical procedure was confirmed, and the risks involved were sufficiently discussed. Then, the patient and her friends were provided the details of the surgery. The patient also acknowledged the risk of bleeding to death because of bloodless surgery, loss of renal function because of the removal of the right kidney and left renal vein, the possibility of hemodialysis, the risk of partial liver removal, and eventual exploratory laparotomy. After the patient understood all risks and consented, a written consent and waiver of liability for blood transfusion refusal were signed. In accordance with the surgical policy, an erythropoietin preparation, iron, and doxazosin mesylate were administered prior to surgery.\nAfter the diagnosis of right pheochromocytoma, open surgery was conducted with an abdominal midline incision in August 2011. During operation, the tumor was found adhered to the peritoneum, diaphragm, lower hepatic surface, inferior vena cava, and right renal vein. It engulfed the right renal artery and vein.\nFirst, the adhesion site of the tumor was detached from the lower hepatic surface. Partial hepatic resection was not necessary. Then, the anterior surface of the tumor was detached from the left renal vein, and the left renal vein was secured. Next, the right renal artery was tied, and blood flow to the right kidney was blocked. A clamp test was performed on the inferior vena cava and left renal vein, and as there were no changes in blood pressure, the bypass was considered adequate. Next, the tumor was very carefully detached from the inferior vena cava, which was tied to protect the right renal vein as tumor detachment progressed. Lastly, the tumor vessels flowing into the inferior vena cava were tied, and both the right kidney and tumor were removed. The inferior vena cava and left renal vein were preserved. The operative times were 8 h and 18 min and blood loss was 1,770 ml.\nThe resected specimen (size: 10.5 × 11.9 cm) was macroscopically brown in appearance with multiple cysts. There was no continuity of the tumor in the normal adrenal gland, and it was diagnosed as paraganglioma (fig. ).\nOn histological findings, the tumor consisted of a hyperplasia of cells with basophilic cytoplasm and was arranged in an alveolar pattern around fibrous blood vessels (fig. ). Histologically, there was no clear continuity of the tumor in the adrenal gland tissue, and an extra-adrenal paraganglioma was diagnosed. No invasion into the right adrenal gland or right kidney was observed.\nFollowing surgery, the patient progressed without any major changes in blood pressure or other complications and the high urinary normetanephrine level returned to normal. After discharge, the patient continues to have follow-ups at her home hospital.

[[57.0, 'year']]

F

{'29108378': 1, '302345': 1, '14175533': 1, '19539876': 1, '5652362': 1, '23013647': 1, '24318363': 1, '22321490': 1, '25539891': 1, '20596878': 1, '23819364': 1, '24803901': 2}

{}

3999580-1

noncomm/PMC003xxxxxx/PMC3999580.xml

Gastroduodenal Intussusception Caused by a Gastric Collision Tumor Consisting of Adenocarcinoma and Neuroendocrine Carcinoma

A 77-year-old woman presented with vomiting for 1 month and loss of 25% of body weight during that time. She had previously visited a general practitioner for vomiting. Abdominal X-ray in that clinic had indicated gastric dilatation. She was referred to our hospital for further examination.\nOn physical examination, her abdomen was bloated without tenderness. She was 143 cm tall and weighed 30 kg. Vital signs were: body temperature 36.8°C, pulse 65 beats per minute, respiratory rate 18 per minute, and blood pressure 90/60 mm Hg. Laboratory data on admission were as follows: white blood cell count 5,800/μl, red blood cell count 326 × 104/μl, hemoglobin 10.2 g/dl, platelets 35.1 × 104/μl, total protein 4.4 g/dl, albumin 2.1 g/dl, total bilirubin 0.38 mg/dl, aspartate aminotransferase 13 IU/l, alanine aminotransferase 6 IU/l, alkaline phosphatase 68 IU/l, γ-glutamyl transferase 12 IU/l, cholinesterase 99 IU/l, total cholesterol 103 mg/dl, blood urea nitrogen 17.1 mg/dl, creatinine 0.42 mg/dl, C-reactive protein 1.20 mg/dl, Na 134 mEq/l, K 3.61 mEq/l, Cl 97 mEq/l, CEA 4.7 ng/ml, and CA19-9 7.3 U/ml. Abdominal X-ray showed gastric dilatation. Computed tomography (CT) of the abdomen revealed a duodenal giant mass spreading from the bulb to the horizontal part of the duodenum (fig. ). Upper gastrointestinal radiography with Gastrografin revealed smooth taper shape of the duodenum. No tumor was clearly detected (fig. ). A villous tumor was observed in the duodenal bulb endoscopically, but the pyloric ring was not confirmable (fig. ). There were no appearances suggestive of malignancy. The tissue obtained from biopsy did not include malignant cells. Insertion of the endoscope into the second part of the duodenum was easy.\nWe diagnosed the mass to be a huge duodenal tumor, and laparotomy was therefore performed. About one third of the stomach was invaginated through the pylorus into the duodenum (fig. ). We in vain performed manipulative reduction by Hutchinson's maneuver. Gastrotomy followed by duodenotomy was performed and revealed a villous tumor measuring 12 cm in maximum diameter. The tumor was excised and pathological examination of the frozen section showed malignant cells composed of well-differentiated adenocarcinoma and undifferentiated carcinoma. The infrapyloric lymph node was positive for metastasis. Therefore, additional distal gastrectomy with lymphadenectomy was performed. The patient made an uneventful postoperative recovery.

[[77.0, 'year']]

F

{'1712661': 1, '1456605': 1, '14695711': 1, '28560024': 2, '11777307': 1, '16183524': 1, '9158673': 1, '27688667': 2, '34222449': 2, '33585630': 2, '14716513': 1, '21327441': 1, '33915830': 1, '26445324': 2, '16861964': 1, '5433296': 1, '19945227': 1, '12679311': 1, '24803892': 2}

{'5037094-1': 1, '7852652-1': 1, '5441243-1': 1, '8223825-1': 1, '4596292-1': 1}

3999605-1

noncomm/PMC003xxxxxx/PMC3999605.xml

Unusual case of adult hemophagocytic syndrome

A 25-year-old woman admitted to our hospital (2012, Isfahan, Iran) complaining of prolonged fever without specific pattern that he had had for three weeks and did not respond to multiple courses of antimicrobial treatment after initial sepsis work up in another hospital (according to her medical discharge sheet). She also had a history of generalized maculopapular rash prominent on distal part of both her hands without pruritis or arthralgia. She did not report weight loss, sweating, productive coughs, and dysuria. She did not smoke cigarettes and did not use alcohol or illicit drugs, traveling to foreign countries or animal contact. She had a history of Raynaud's phenomenon during cold weather and history of well-controlled hypothyroidism. She was admitted in another hospital about six weeks ago due to evaluation for multiple cervical and axillary lymphadenopathies. All investigation results in her previous admission, including tuberculin test, sputum smear for tuberculosis, frequent blood and urine cultures were negative. The result of her cervical lymph node resection was not available.\nOn admission to our hospital her oral temperature was 39°C, blood pressure 105/70 mmHg, heart rate 110 beats per minute and respiratory rate 26 breaths per minute. She appeared severely ill. The results of auscultation of the heart and lungs were normal. An abdominal examination revealed a liver span of 11 cm in the right mid-clavicular line; the spleen was not palpable. Other physical examination did not show any abnormalities except posterior cervical and axillary lymphadenopathy. She also had arthritis on her metacarpal and knee joints of her both extremities. Her initial laboratory findings revealed severe pancytopenia: hemoglobin 8 g/dl (normal range between 12 and 16 g/dl), leukocyte count 3000 per cubic millimeter (52% neutrophils, 31% lymphocytes) (normal range: 30%-55%), and platelet count 10,000 per cubic millimeter (normal range: 150,000-400,000). Ferritin level was 10,180 U/ml (normal range below 200). Erythrocyte sedimentation rate (ESR) 65 mm/h (normal range below 30 mm/h) and C-reactive protein (CRP) 100 mg/dl (normal range below 8).\nSerum complement C3 and C4 levels were both decreased to 320 and 10mg/l (normal ranges 900-1800 and 100-400, respectively). Kidney function tests were normal. Coagulation tests on admission disclosed: Prothrombin time (PT) 15.5 s (normal <13 s) and activated PTT (aPTT) 35.2 s (normal below 28 s).\nAST 84 U/l, (normal 0-40 U/l); LDH 1549 U/l (normal 114-240 U/l); ALT 67 U/l, (normal 0-40 U/l). Direct Coombs test was positive. Viral markers for hepatitis B, hepatitis C, cytomegalovirus, Epstein-barr virus antibodies, and human immunodeficiency virus were all negative. Other laboratory findings, including urinalysis, urine, and blood cultures, had negative results. Her chest radiography (CXR) revealed mild pleural effusion in her both lungs. Peripheral blood smear showed hypochromic red blood cells with mild anisocytosis and minimal reduction in white blood cells and platelets counts. Her abdominopelvic sonography showed mild ascites, mild bilateral pleural effusion, and mild hepatosplenomegally. On the secondary day of her admission, she had two episodes of tonic-clonic seizures. But lumbar puncture result and brain computed tomography scanning (CT scan) and magnetic resonance imaging (MRI) all were normal.\nFinally after 6 weeks, report of right axillary lymph node resection showed HPS. Repeated rheumatologic tests showed ANA 1:160 (normal range <1:80), Anti-ds DNA antibody 125 IU/ml (normal range < 12). Both anticardiolipin and β-2 glicoprotein-1 antibodies titers were normal. Patients showed a severe hemophagocytosis in her bone marrow biopsy, while normal in bone marrow aspirate [].\nAfter establishing the diagnosis of SLE, a twice daily dose of 50 mg of prednisolone was orally administered promptly that was added with 400 mg hydroxychloroquine. Within 24 h after starting the prednisolone and hydroxychloroquine, the fever had subsided completely. Her fever markedly improved and all of the laboratory findings returned to normal values within the next two weeks.\nThe patient was discharged 15 days after completion of the initial therapy in a clinically improved state by using a maintenance dose of 30 mg of prednisolone, 200 mg hydroxychloroquine, and valproate sodium 500 mg per day. She was contacted four months after hospitalization and reported no difficulties.

[[25.0, 'year']]

M

{'1992881': 1, '225008': 1, '18782855': 1, '16575493': 1, '16034684': 1, '9338623': 1, '24778673': 2}

{}

3999606-1

noncomm/PMC003xxxxxx/PMC3999606.xml

Bone marrow abnormalities in HIV infected children, report of three cases and review of the literature

A 7-year-old boy presented with pain in limbs since two years, recurrent otorrhea since one year, cough since four months, breathlessness since eight days and edema of feet since two days. He was diagnosed as having pulmonary tuberculosis (TB) two months back and was on direct observed therapy (DOTS) for same. On examination, he was malnourished and had tachycardia, tachypnea with respiratory distress and hypotension. He had severe pallor with anasarca and clubbing Grade III with generalized papular dermatitis with left ear purulent discharge and oral thrush. Systemic examination revealed cardiomegaly with gallop rhythm, hepatosplenomegaly and decreased air entry in left infrascapular region. HIV ELISA by two different kits was positive. Hemogram showed severe anemia (hemoglobin = 1.9 gm/dl) with thrombocytopenia (30,000.cumm), normal WBC count and ESR of 130 mm at end of one hour. X-ray chest showed left midzone and lower zone haziness and sputum for AFB on smear was positive. His serum biochemistry revealed hypoproteinemia, hypocalcemia, hypokalemia. Urine examination had 2+albuminuria and urine albumin/creatinine ratio was three. Ultrasound of abdomen showed hepatosplenomegaly with multiple abdominal lymph nodes. Bone marrow examination showed hypoplastic marrow with no megakaryocytes at all. There were no malignant cells. Echocardiography was normal. He was treated with IV antibiotics, antituberculous therapy, blood transfusion and dobutamine infusion; however he succumbed to his disease after seven days of admission.

[[7.0, 'year']]

M

{'9093237': 1, '27399076': 1, '9557450': 1, '15279591': 1, '20871386': 1, '9312731': 1, '17693583': 1, '15876768': 1, '1755664': 1, '24778674': 2}

{'3999606-2': 2, '3999606-3': 2}

3999606-2

noncomm/PMC003xxxxxx/PMC3999606.xml

Bone marrow abnormalities in HIV infected children, report of three cases and review of the literature

A three and a half year old girl presented with fever, cough and breathlessness since one year and skin dermatitis since six months. Both parents were HIV infected and mother had died due to TB three months back. The child along with elder sister were diagnosed HIV infected recently by two different HIV ELISA kits. On examination, she was malnourished, had severe pallor with chalky white nails, chronic papular dermatitis and generalized lymphadenopathy. She had hepatosplenomegaly with cardiomegaly on systemic examination. Her investigations showed anemia (hemoglobin = 3.1 gm/dl) with normal WBC and platelet count. Reticulocyte count was 0.3% and ESR was 80 mm at end of one hour. Her direct Coombs test was negative. Urine showed 2+albuminuria. Bone marrow examination showed normocellular marrow with erythroid hyperplasia with mild dyserythropoiesis. She was treated with blood transfusion and advised regarding antiretroviral therapy which was refused due to non-affordability.

[[3.5, 'year']]

F

{'9093237': 1, '27399076': 1, '9557450': 1, '15279591': 1, '20871386': 1, '9312731': 1, '17693583': 1, '15876768': 1, '1755664': 1, '24778674': 2}

{'3999606-1': 2, '3999606-3': 2}

3999606-3

noncomm/PMC003xxxxxx/PMC3999606.xml

Bone marrow abnormalities in HIV infected children, report of three cases and review of the literature

A 7-year-old boy presented with injury to right elbow 25 days back while playing following which after 10 days, he developed pain in the right elbow with swelling and went to a doctor who diagnosed it to be a fracture and a plaster was applied. After two days, he had fever which subsided with Sulfamethoxazole/Pyrimethamine. At that time, his peripheral smear showed trophozoites and ring forms of plasmodium vivax. Subsequently increasing pallor was noticed was the past eight days. On examination, he was pale, had tachycardia with bilateral basal crepitations, cardiomegaly and hepatosplenomegaly with healed herpetic lesion over right groin. HIV ELISA positive and confirmed by western blot test. The child was treated with diuretics and blood transfusion. He developed severe abdominal tenderness with fever after two days. Ultrasound abdomen showed hepatosplenomegaly with splenic abscesses. CT abdomen also confirmed the same. He was treated with IV antibiotics but there was no improvement. He continued to have fever, abdominal pain and pancytopenia. His serial hemograms are depicted in . A bone marrow aspiration showed erythroid hyperplasia with increased plasma cells and biopsy showed myelofibrosis. No organisms were grown on bone marrow culture and it was negative for TEL/AMLI or MLL translocations or Monosomy 7. Hepatitis C and hepatitis B surface Antigen by ELISA were negative. He succumbed to a fatal pulmonary bleed and hematemesis.

[[7.0, 'year']]

M

{'9093237': 1, '27399076': 1, '9557450': 1, '15279591': 1, '20871386': 1, '9312731': 1, '17693583': 1, '15876768': 1, '1755664': 1, '24778674': 2}

{'3999606-1': 2, '3999606-2': 2}

3999607-1

noncomm/PMC003xxxxxx/PMC3999607.xml

Female genital tract tuberculosis presenting as ovarian cancer

A 20-year-old primiparous woman with abdominal and pelvic pain was referred to the department of gynecology at Ghaem University Hospital, Mashhad, Iran in July 2000.\nShe complained of anorexia, nausea, vomiting and urinary symptoms (dysuria and frequency) since few weeks before presentation. She had lost about four kilograms of weight since two months ago and she had a history of fever since the previous week. She had no personal or family history of TB. Upon examination, her vital signs were normal and she had no remarkable physical finding, except for a firm, fixed and tender mass in the right adnexa. Otherwise, the abdominal examination was normal and the patient had no ascites. An ultrasound study showed a 13 × 6 cm, multi-septated, mixed echogenic mass in the right adnexa and mild free fluid suggestive of a malignant process. Her biochemical profile and complete blood counts were in the normal range. There was no abnormality in chest X-ray, and her tuberculin skin test (TST) was negative.\nBased on her clinical and imaging findings which suggestive of ovarian cancer, a diagnostic laparotomy was planned. The operation revealed dense adhesions between pelvic organs, and multiple biopsies were performed. Finally, histopathological investigation revealed necrotizing granulomatous changes consistent with TB with no malignant cells.

[[20.0, 'year']]

F

{'28173770': 2, '27433397': 2, '15534923': 1, '19565253': 1, '33178178': 1, '22927283': 1, '18275578': 1, '28808611': 1, '20052396': 1, '9219793': 1, '11918456': 1, '24778675': 2}

{'3999607-2': 2, '3999607-3': 2, '3999607-4': 2, '3999607-5': 2, '5296994-1': 1, '4943999-1': 1}

3999607-2

noncomm/PMC003xxxxxx/PMC3999607.xml

Female genital tract tuberculosis presenting as ovarian cancer

A 20-year-old primiparous woman was admitted to the department of gynecology at Ghaem University Hospital, in March 2003. She complained of painful abdominal distension and weight loss of approximately nine kilograms since the previous year. She had irregular menstruation and hypomenorrhea. Her past medical history was not remarkable, except for a pulmonary TB in her brother two years earlier, for which he completed the treatment course.\nOn admission, her vital signs were normal but the physical examination demonstrated a palpable pelvic mass (22 × 24 cm) with no tenderness. Ultrasound showed multiple myoma in the uterus and a large, multi-septated mass with internal echoes in the left ovary which suggested mucinous cystadenocarcinoma. Her biochemical profile, complete blood counts and chest X-ray were normal. She had a negative TST.\nUpon laparotomy, one could not enter the abdominal cavity. There were disseminated nodules covering the peritoneum of the parietal wall. During surgery, we cannot find ovarian mass and biopsy specimens of peritoneal nodules were taken. Pathologist reported chronic granulomatous inflammation suggestive of tuberculosis. The patient was treated with standard, anti-tuberculosis treatment. One year later, she had no signs of the disease.

[[20.0, 'year']]

F

{'28173770': 2, '27433397': 2, '15534923': 1, '19565253': 1, '33178178': 1, '22927283': 1, '18275578': 1, '28808611': 1, '20052396': 1, '9219793': 1, '11918456': 1, '24778675': 2}

{'3999607-1': 2, '3999607-3': 2, '3999607-4': 2, '3999607-5': 2, '5296994-1': 1, '4943999-1': 1}

3999607-3

noncomm/PMC003xxxxxx/PMC3999607.xml

Female genital tract tuberculosis presenting as ovarian cancer

A 20-year-old virgin girl was referred to the department of gynecology at Ghaem University Hospital, in May 2005. She complained of abdominal pain and distention, as well as ten kilograms weight loss since 4 months ago. Before admission, she received multiple courses of antibiotic therapy, regarding her complaints of fever, sweat and cough.\nShe had hypomenorrhea. Her past medical history and family history of TB were negative. Physical examination revealed ascites without any palpable masses. Ultrasound study revealed a 48 × 54 cm cystic mass with internal echogenicity in the left adnexa and massive ascetic fluid. Laboratory tests showed leucopenia (WBC = 3.2 × 109 l−1) and no anemia (Hgb = 132 gl−l). The CA-125 level was elevated to 44 units per ml (normal range: 0-35 units per ml). Cytopathological study of the ascetic fluid showed no malignant cells. The acid fast staining of the ascetic fluid was also negative. Her chest X-ray and tuberculin skin test were normal. Regarding the clinical findings, an exploratory laparotomy was performed which showed abundant amount of intense adhesions between omentum, transverse colon, abdominal wall and pelvic organs. Transverse colon was ruptured due to severe adhesions and therefore got repaired and some biopsies were taken. Histological examination confirmed necrotizing granulomatous inflammation consistent with tuberculosis []. Hence, the standard anti-tuberculosis treatment was prescribed. At follow-up 2 years after the last visit, she reported that all of her previous symptoms were resolved.

[[20.0, 'year']]

F

{'28173770': 2, '27433397': 2, '15534923': 1, '19565253': 1, '33178178': 1, '22927283': 1, '18275578': 1, '28808611': 1, '20052396': 1, '9219793': 1, '11918456': 1, '24778675': 2}

{'3999607-1': 2, '3999607-2': 2, '3999607-4': 2, '3999607-5': 2, '5296994-1': 1, '4943999-1': 1}

3999607-4

noncomm/PMC003xxxxxx/PMC3999607.xml

Female genital tract tuberculosis presenting as ovarian cancer

On Jan 2009, A 47-year-old menopausal woman (gravid 8, para 8) was admitted to the department of gynecology at Ghaem University Hospital, with the complaints of gross hematuria and weight loss. She suffered from diabetes since 15 years ago. Upon physical examination, there was a palpable, firm, fixed and non-tender mass in the left lower quadrant, and ascites was also noticeable, also. An ultrasound study showed a 22 × 26 cm cystic mass with internal echoes, as well as moderate ascites. Lab tests showed anemia (Hgb = 55 gl−1), Leukocytosis (WBC = 15.4 × 109 l−1), serum creatinine level = 3.1, CA-125 = 15 units per ml. Her chest X-ray was normal and TST was negative.\nRegarding the hemorrhagic diathesis of the patient, a cystourethroscopy was performed. Further, an exploratory laparotomy showed a 3 × 4 cm mass adhered to the bladder, and biopsy specimens were taken. Pathological analysis showed mucosal ulceration with considerable inflammatory response. Ten days later, she developed a productive cough not responding to conventional antibiotic therapy. She had dehiscence and purulent discharge from incision site that was culture positive for E-coli. Follow-up chest X-ray showed pleural effusion and consolidation in the right lung. Upon further evaluation, cystoscopy was successfully performed which revealed findings suggestive of bladder tuberculosis. The patient was discharged with anti-tuberculosis standard therapy. One year later, she had no symptoms, and her CXR and abdominal ultrasound were normal.

[[47.0, 'year']]

F

{'28173770': 2, '27433397': 2, '15534923': 1, '19565253': 1, '33178178': 1, '22927283': 1, '18275578': 1, '28808611': 1, '20052396': 1, '9219793': 1, '11918456': 1, '24778675': 2}

{'3999607-1': 2, '3999607-2': 2, '3999607-3': 2, '3999607-5': 2, '5296994-1': 1, '4943999-1': 1}

3999607-5

noncomm/PMC003xxxxxx/PMC3999607.xml

Female genital tract tuberculosis presenting as ovarian cancer

A 16-year-old virgin girl with the complaints of abdominal pain and weight loss was referred to the department of gynecology at Ghaem University Hospital, in July 2009. Her symptoms began six months ago and she lost over 10 kilograms of weight during this period. Her past medical history was not remarkable, except for the diagnosis of TB in her brother and sister, for which they had been treated one year ago. On admission, her vital signs were normal, but a 7 × 8 cm non-tender firms mass was found upon physical examination. Ultrasound showed a 39 × 116 cm cystic and multi-septated mass with irregular and thickened wall in the right adnexa suggesting an ovarian cancer. She had no abnormality on chest X-ray and TST was negative. CA- 125 level was 509 units per ml. Based on the clinical findings and Lab test results, an exploratory laparotomy was performed. There were severe adhesions. The frozen section examination of biopsy materials was strongly suspicious for TB. Standard anti-tuberculosis drugs were started and the patient was discharged from hospital. Upon her visit one year later, the abdominal mass was disappeared. She had no complaints and her ultrasound study was normal.

[[16.0, 'year']]

F

{'28173770': 2, '27433397': 2, '15534923': 1, '19565253': 1, '33178178': 1, '22927283': 1, '18275578': 1, '28808611': 1, '20052396': 1, '9219793': 1, '11918456': 1, '24778675': 2}

{'3999607-1': 2, '3999607-2': 2, '3999607-3': 2, '3999607-4': 2, '5296994-1': 1, '4943999-1': 1}

3999608-1

noncomm/PMC003xxxxxx/PMC3999608.xml

Human herpes virus 8-unrelated primary effusion lymphoma-like lymphoma in a patient with hepatitis B virus-related liver cirrhosis: A case report

A 66-year-old male patient developed a rapid progressive abdominal fullness for 3 months. He had 30-year history of chronic HBV infection without family history of lymphoma and hepatitis. Three years before his hospitalization, liver cirrhosis was diagnosed through clinical, ultrasonography, and biochemical examinations. Physical inspection revealed a distended abdomen with shifting dullness. The liver and spleen were impalpable. The laboratory tests revealed impaired renal function (creatinine: 3.0 mg/dL), mild hypoalbuminemia (3.3 g/dL) and an elevated lactate dehydrogenase (LDH) serum level (750 U/L), while the liver biochemistry profile, including aminotransferases, bilirubin, and prothrombin time, were normal. Serological tests were found negative for HIV, Hepatitis C Virus (HCV) and Cytomegalovirus (CMV). Abdominal sonography confirmed the presence of cirrhosis, massive ascites, and pleural effusion. Cytological analysis of the pleural effusion demonstrated the presence of large atypical lymphoid cells with rounded nuclei, prominent nucleoli and abundant cytoplasm []. Immunocytochemistry recognized atypical CD20+ lymphoid cells []. The cells contained in the pleural fluid were negative for HHV-8 and Epstein-Barr virus (EBV). Additionally, no evidence of lymph nodes or organ involvement was found. A comprehensive treatment strategy including diuresis, antiviral therapy, prevention of infection and maintenance of vital organ function, was adopted. The patient died on the 7th day after his hospitalization due to sepsis and multi-organ failure.

[[66.0, 'year']]

M

{'20838290': 1, '17526021': 1, '19245595': 1, '22433629': 1, '17326056': 1, '19789837': 1, '11920242': 1, '20029949': 1, '8695812': 1, '32936906': 1, '21858447': 1, '14581418': 1, '19075546': 1, '17135726': 1, '23319997': 2, '11527816': 1, '18835212': 1, '15994147': 1, '27283030': 2, '18473348': 1, '29279707': 2, '29619259': 2, '24778676': 2}

{'5731153-1': 1, '5829335-1': 1, '5266403-1': 1, '3538188-1': 1}

3999609-1

noncomm/PMC003xxxxxx/PMC3999609.xml

Amyand's hernia in a neonate: A case report

A 24-day-old male neonate presented at the Department of Pediatric Surgery of The First Hospital of Jilin University in Changchun, China with right scrotal swelling for 4 days. There was no history of fever, vomiting, abdominal distension, or diarrhea. Local examination revealed a firm, tender swelling of 3.0 × 2.0 × 2.0 cm in the right inguinal region extending into the scrotum. The skin over the swelling was red and there was no fluctuation. The left scrotum and testis were normal. The neonate's total leukocyte count was increased (11.9 × 109/L). Ultrasonography detected a colon-type echo in the right inguinal canal [] measuring 30.0 × 5.0 mm. The wall of the colon-type structure measured 3.5 mm in diameter and was thickened. There were moving hyperechoes in the lumen. The right testis measured 9.9 × 5.2 mm with an anechoic region of 7.0 × 12.0 mm anterior to the right testis []. The left testis was 8.3 × 4.1 mm without any abnormalities. An ultrasonic diagnosis of right inguinal hernia and right encapsulated hydrocele of the tunica virginals was considered.\nSince the patient's presentation was not typical of a hernia, a primary clinical diagnosis of testicular tumor or epididymitis was considered. Because the neonate was considered to have epididymitis, he was started on antibiotics for 2 days. The tenderness subsided, but the right testicular swelling reduced minimally. Repeat ultrasonography showed similar features as before, including right inguinal hernia and encysted hydrocele in the right scrotum.\nThe neonate underwent surgical exploration after the second ultrasonic examination. Surgical exploration revealed swollen tunica vaginalis of the right testis. In addition, the tunica vaginalis, right testis and epididymis were found to be hyperemic and swollen with discharge of purulent material. The tunica vaginalis also contained a colon-type structure adhering to the swollen and inflamed right testis and epididymis. This colon-type structure extended into the right inguinal region and was identified as the appendix. An appendectomy was performed through the inguinal incision alone, and the right hernia sac was ligated.\nHistopathological examination of the appendix specimen revealed fibrous tissue hyperplasia in the interstitium, with acute and chronic inflammatory cell infiltration, vasodilatation, and congestion. This confirmed the diagnosis of appendicitis. The post-operative period was uneventful. An ultrasonography scan 1 week later revealed a normal scrotum and testes on both sides, and the patient was discharged from the hospital.

[[24.0, 'day']]

M

{'26034709': 1, '18970952': 1, '26023509': 1, '34656928': 1, '21520560': 1, '23331784': 1, '17024670': 1, '12820031': 1, '17001453': 1, '31681527': 1, '16351463': 1, '18405700': 1, '24778677': 2}

{}

3999649-1

noncomm/PMC003xxxxxx/PMC3999649.xml

Renbök Phenomenon in an Alopecia Areata Patient with Psoriasis

A 23-year-old female patient presented in April 2012 with a flare of psoriasis, involving the trunk, extremities and the scalp. She had a similar flare at the age of 13, and also history of patch-type scalp AA, both resolved following topical steroid treatment. Two months later, in June 2012, she experienced localized hair loss on the scalp, concomitantly with complete resolution of the psoriatic plaque in this region. On examination, a 3 cm patch of nonscarring hair loss was observed, and dermoscopic examination revealed perifollicular pigmentation, exclamation hairs and yellow dots, corresponding to AA. Interestingly, the psoriatic plaque engulfed the AA area, but sharply stopped at its border []. The patient was treated topically for her AA with clobetasol propionate, with stabilization of hair loss when the patch reached a size of 5 cm × 6 cm in September 2012. In parallel, the patient had reappearance of psoriatic plaques inside the area of hair loss, which coincided with the presence of terminal hairs localized to these psoriatic plaques [].

[[23.0, 'year']]

F

{'21623882': 1, '21712899': 2, '22150402': 1, '19874320': 1, '23947678': 1, '881091': 1, '19322214': 1, '17263782': 1, '22911207': 1, '24778529': 2}

{'3107954-1': 1}

3999650-1

noncomm/PMC003xxxxxx/PMC3999650.xml

Extensive Tonsure Pattern Trichotillomania-Trichoscopy and Histopathology Aid to the Diagnosis

A 19-year-old female presented in dermatology outpatient department (OPD) with diffuse alopecia of scalp for 4 years. The alopecia started from frontal scalp 4-years back, which gradually extended to involve the entire scalp leaving behind the margins. On direct questioning, the mother gave history of repeated hair pulling behavior of the patient. She used to pull hair mostly during study hours at home. The patient was anxious and had a guilt feeling for her hair loss. There was no obvious stress in the family. The general and systemic examination revealed no abnormality except pallor. The cutaneous examination showed diffuse alopecia of scalp with varying length of remaining few hairs. The alopecia involved the entire scalp sparing only the occiput and margins of scalp resembling tonsure pattern [Figure and ]. There were few follicular papules distributed sparsely on the scalp. There was no alopecia involving other body hair. The KOH mount for fungus was negative. The blood tests like complete blood count, liver function test, renal function test, and thyroid profile were within normal limits except for low hemoglobin. The trichoscopy showed broken hair of varying length, coiled hair, and black dots []. The histopathological examination showed disrupted hair follicles and pigment casts without any inflammation []. With the aid of trichoscopy and histopathology, the diagnosis of extensive tonsure pattern trichotillomania with pseudofolliculitis was made. The patient was referred to psychiatry OPD for further management.

[[19.0, 'year']]

F

{'21152803': 1, '8996713': 1, '17052485': 1, '18664157': 1, '24096547': 1, '25191044': 2, '1992841': 1, '10986729': 1, '21333827': 1, '2001629': 1, '30099694': 1, '24778530': 2}

{'3999650-2': 2, '4154157-1': 1}

3999650-2

noncomm/PMC003xxxxxx/PMC3999650.xml

Extensive Tonsure Pattern Trichotillomania-Trichoscopy and Histopathology Aid to the Diagnosis

A 24-year-old para-2 postpartum female was referred to dermatology OPD for diffuse alopecia of scalp. The patient's mother gave history of hair pulling by the patient. The patient developed hair pulling behavior following an incident of molestation when she was 15-years old. Though the alopecia was patchy initially, there was aggravation during both pregnancies leading to extensive tonsure pattern alopecia. She used to pull her hair both with hands and tweezers especially during leisure time. She was married for 4 years and had two children. There was no history of familial disharmony or of any significant illness in the patient. The general and systemic examinations revealed no abnormality except for pallor. On cutaneous examination, there was diffuse nonscarring alopecia of the scalp with varying length of hair in some areas [Figure and ]. There was sparing of hair on the scalp margin. The KOH mount for fungus was negative. The blood tests like complete blood count, liver function test, renal function test, and thyroid profile were normal except for low hemoglobin. Trichoscopy showed scanty hairs with varying length, few broken hair, trichoptilosis, coiled hair, and black dots []. The histopathology showed empty hair follicles, disrupted follicles with pigment casts, and no inflammation, confirming the diagnosis of trichotillomania []. The patient was referred to psychiatry OPD for further management.

[[24.0, 'year']]

F

{'21152803': 1, '8996713': 1, '17052485': 1, '18664157': 1, '24096547': 1, '25191044': 2, '1992841': 1, '10986729': 1, '21333827': 1, '2001629': 1, '30099694': 1, '24778530': 2}

{'3999650-1': 2, '4154157-1': 1}

3999651-1

noncomm/PMC003xxxxxx/PMC3999651.xml

Graham Little Piccardi Lasseur Syndrome: A Rare Case Report with Concomitant Hypertrophic Lichen Planus

A 35-year-old female patient presented with the chief complaint of multiple pruritic follicular keratotic and spinous papules initially over wrists and forearms, gradually involving whole body, sparing face, palms and soles since past 10 years, followed by appearance of hyperkeratotic violaceous itchy plaques over malar area of face with madrosis and scarring alopecia of scalp since 4 years. Multiple dilated follicular orifices plugged with keratotic debris were present on scalp with marked perifollicular violaceous hyperpigmention and complete loss of hair []. Axillary and pubic hair were sparse with history of recurrent episodic shedding since last 3 years. Violaceous pigmentation over buccal and gingival mucosae was seen along with melanonychia in fingernails. No history of photosensitivity or similar complaints in family.\nRoutine investigations including viral markers for hepatitis B and C and serum antinuclear antibody levels were normal. Histopathological examination of hyperkeratotic alopecic plaque on scalp showed dilated follicular infundibula, with basket-weave hyperkeratosis in upper portion and compact hyperkeratotic plug in lower portion. Epithelium lining the follicular infundibulum showed marked hypergranulosis along with presence of vacuolar degeneration and apoptotic keratinocytes. Moderately dense perifollicular lymphocytic inflammation, lichenoid interface dermatitis and loss of sebaceous glands with follicular scarring were suggestive of lichen planopilaris with cicatricial alopecia. Biopsy from the follicular papules on body also revealed similar histopathological features consistent with lichen planopilaris []. Patient was put on oral retinoids in form of tablet isotane 20 mg once daily with regular follow up since past 2 months.

[[35.0, 'year']]

F

{'17511945': 1, '26622157': 2, '19341936': 1, '2319020': 1, '20191185': 1, '24778531': 2}

{'4639957-1': 1, '4639957-2': 1, '4639957-3': 1}

3999652-1

noncomm/PMC003xxxxxx/PMC3999652.xml

Square Alopecia: A New Type of Transient Alopecia of the Scalp Following Fluoroscopically Endovascular Embolization

The case we present here is about a 38-year-old man who came to the emergency room in February 2013, due to nausea and diplopia of sudden onset, 1 day prior to admission. Physical examination revealed a limitation of ocular supraversion movements and bilateral absence of pupillary light reflex, consistent with dorsal midbrain syndrome. The blood analysis and blood cell count results were strictly normal. A CT scan showed a left dorsal midbrain hematoma with ventricular hemorrhage and incipient signs of hydrocephalus. Subsequently an intracranial arteriography confirmed the presence of a left posterior parasagittal AVM with contributions from posterior choroidal artery branches []. Endovascular treatment was performed with selective embolization with Glubran®20% without any complications. In May 2013, an angiographic control identified remains of the malformation, with bilateral posteromedial choroidal afferents. A new selective embolization was performed in July 2013, which achieved a complete devascularization of the AVM with excellent angiographic results.\nA month later, he presented to the Dermatology Department for hair loss localized in the occipital region of the head. Physical examination showed an alopecic square plaque of 5 cm × 5 cm with almost total hair loss, but without signs of inflammation []. Dermoscopy exam showed no exclamation mark hairs and bilateral superficial arterial pulses were normal.\nIn total, the patient was exposed to four angiographic procedures, two of them with endovascular therapy. The total radiation exposure time was approximately 150-200 min and the absorbed radiation dose after the last session was estimated at more than 4 Gy. Radiation-induced transient alopecia diagnosis was established and there was no need to start treatment. The hair grew back 2 months after the last procedure.

[[38.0, 'year']]

M

{'23031381': 1, '17689391': 1, '27610118': 1, '29440860': 2, '9606632': 1, '20038373': 1, '18718203': 1, '12124512': 1, '15672718': 1, '30034200': 1, '28074164': 2, '12860517': 1, '20093507': 1, '10434104': 1, '23180911': 1, '10606078': 1, '17107802': 1, '22677971': 1, '7972801': 1, '24778532': 2}

{'5803854-1': 1, '5803854-2': 1, '5803854-3': 1, '5198088-1': 1}

3999653-1

noncomm/PMC003xxxxxx/PMC3999653.xml

Lichen Planopilaris Versus Discoid Lupus Erythematosus: A Trichoscopic Perspective

A 27-year-old male presented with hair loss from the scalp since 6 months. Itching and slight burning sensation was present. It was progressive, covering almost entire vertex area extending to the parietal areas. Examination revealed well-defined purplish plaques with atrophy of skin [].\nTrichoscopy showed perifollicular scales (black stars), diminished follicular ostia and white dots (red stars). Blue-grey dots (yellow arrows) around the follicular structures were seen as a “target” pattern [].\nHistopathology of a lesion showed infundibular hyperkeratosis, hypergranulosis, bandlike infiltrate of lymphocytes with sparing of interfollicular areas, which are consistent with diagnosis of LPP [].

[[27.0, 'year']]

M

{'30820128': 1, '5932155': 1, '8040470': 1, '20026850': 1, '10446772': 1, '32299739': 1, '30410916': 1, '1373948': 1, '19289790': 1, '30643773': 1, '31190216': 1, '22628989': 2, '22648224': 1, '27222766': 1, '34621959': 1, '29723351': 1, '20520933': 1, '31723457': 1, '30397497': 1, '24778533': 2}

{'3999653-2': 2, '3358938-1': 1, '3358938-2': 1, '3358938-3': 1}

3999653-2

noncomm/PMC003xxxxxx/PMC3999653.xml

Lichen Planopilaris Versus Discoid Lupus Erythematosus: A Trichoscopic Perspective

A 50-year-old male presented with lesions on the scalp since 4 months. History of exacerbation of lesions on sunlight exposure was present. Examination revealed erythematous scaly plaques on the vertex and frontal areas with atrophy of underlying skin [].\nTrichoscopy showed branching capillaries (yellow diamond), white patches (yellow star), keratin plugs (red arrow), reduced follicular ostia and white dots (red stars). Blue-grey dots (yellow arrow) inside the patch of alopecia referred to as “speckles” pattern were also observed []. Histopathology showed thinning of epidermis, hypogranulosis, follicular horny plugs, vacuolar changes and necrotic keratinocytes at the dermoepidermal interface which are consistent with diagnosis of DLE [].\nSystemic examination and blood investigations in both patients were unremarkable.

[[50.0, 'year']]

M

{'30820128': 1, '5932155': 1, '8040470': 1, '20026850': 1, '10446772': 1, '32299739': 1, '30410916': 1, '1373948': 1, '19289790': 1, '30643773': 1, '31190216': 1, '22628989': 2, '22648224': 1, '27222766': 1, '34621959': 1, '29723351': 1, '20520933': 1, '31723457': 1, '30397497': 1, '24778533': 2}

{'3999653-1': 2, '3358938-1': 1, '3358938-2': 1, '3358938-3': 1}

3999654-1

noncomm/PMC003xxxxxx/PMC3999654.xml

Sweat Gland Adenocarcinoma of Scalp

A 42-year-old female presented in skin out-patient department (OPD) with history of (h/o) of pus filled lesions over scalp which ruptured leading to ulcer formation since almost 6 months. No h/o cough, cold, fever, vomiting, headache or hematuria present. No h/o weight loss, any GIT symptoms, breathlessness, chest pain or eye symptoms present. No H/o DM/HT/BT/TB/epilepsy/asthma/IHD/COPD/thyroid disease.\nOn examination single 4 × 5 cm non-tender ulcer with irregular and unhealthy margin, serous and foul-smelling discharge and slough, present over the occipital region of scalp []. Bilateral cervical lymph nodes enlarged and ruptured forming a well-defined round to oval ulcer of 2-3 cm in size with purulent discharge, rolled margin on left side and pus discharge with eschar formation on right side [].\nRoutine investigations, liver function test (LFT) and renal function test (RFT) were in normal range. Chest X-ray/ECG/USG abdomen and computed tomography (CT) brain was normal. Patient was seronegative with normal venereal disease research laboratory (VDRL). Wedge shaped biopsy done from the ulcer over scalp by surgeon, showed epidermal ulceration, malignant epithelial cells arranged in cribriform pattern, nest, cords and in strands. The cells are pleomorphic with round to oval nuclei and dispersed chromatin, have eosinophilic and indistinct cytoplasm with nuclear and nucleolar pleomorphism. Few cells have foamy vacuolated cytoplasm, zone of necrosis and abnormal mitotic figures. Intraductal necrosis was also noted []. Changes were suggestive of adenocarcinoma of sweat gland over scalp. Wide local excision of ulcer was done with rotational flap and regional lymph node dissection.

[[42.0, 'year']]

F

{'17998708': 1, '13260595': 1, '30314491': 2, '10860232': 1, '14839609': 1, '19970710': 1, '12921537': 1, '11260623': 1, '5100098': 1, '14320386': 1, '13636656': 1, '4164856': 1, '24778534': 2}

{'6186105-1': 1}

3999656-1

noncomm/PMC003xxxxxx/PMC3999656.xml

Kerion Due to Microsporum Gypseum in a 1-Month-Old Infant

A 3-month-old, otherwise healthy infant was brought with an inflamed plaque on the scalp, that had first developed when he was 1 month old. There was no history of any discomfort or pain. He had been treated with multiple courses of systemic antibiotics and a steroid-antibiotic cream topically, without response. The child had been referred to the Pediatric Surgery Department for a scalp biopsy and his parents had been advised a dermatology consultation before the procedure. His mother had a hyperpigmented annular plaque on the dorsum of the right hand, which was subsiding after application of terbinafine cream.\nOn examination, there was a round, tender, boggy plaque 7 cm in diameter on the vertex of the scalp, with almost total loss of hair, with multiple pin-head sized erosions and exudation of pus from some of the follicular orifices [].\nRoutine investigations were all within the normal limits. Wood's lamp examination of the scalp showed no fluorescence. Light microscopic examination of the scanty, easily pluckable hair on the plaque after addition of 30% potassium hydroxide (KOH), revealed small ectothrix spores. Fluorescent microscopy of the hair revealed accentuation of auto-fluorescence of the affected hair with destruction of the normal architecture of the cortex towards the hair root [Figure –].\nFungal culture in modified Sabouraud's dextrose agar medium showed brown colonies with white cottony centers, which were yellow on the reverse. Microscopic examination of the colony morphology with lactophenol cotton blue, revealed symmetrical, ellipsoidal, thin-walled, six-celled maroconidia with rounded ends [Figure –]. KOH examination and fungal culture from the mother's lesion were negative.\nA diagnosis of kerion due to M. gypseum was made. The patient was treated with ultra-micronized griseofulvin in a dose of 10 mg/kg body weight/day, in two divided doses. The lesion healed completely in 6 weeks with near complete regrowth of hair [] and a repeat fungal culture of the hair was negative.

[[3.0, 'month']]

M

{'10710583': 1, '24005974': 1, '22435373': 1, '20927231': 1, '20653852': 1, '15189191': 1, '23130263': 2, '24778536': 2}

{'3481934-1': 1}

3999657-1

noncomm/PMC003xxxxxx/PMC3999657.xml

Frontal Fibrosing Alopecia and Lupus Overlap in a Man: Guilt by Association?

A 46-year-old Caucasian male first presented with a 3 months' history of eyebrow thinning and itching. Past medical history included seborrhoeic dermatitis and rosacea. Examination showed erythematous eyebrows associated with pre-auricular and supra-auricular hair loss, deemed clinically to be non-scarring. One year later, photosensitivity at hair loss sites was noted. A left temple biopsy was consistent with scarring alopecia; direct immunofluorescence study was negative. Two years later, he developed further hair loss of scalp, eyebrows, beard, temples, [] and forearms [], and six years later complete loss of sideburns [].\nBiopsies from the scalp, eyebrow and arm showed follicular dropout and residual hair follicles with a perifollicular moderately dense lymphoid cell infiltrate with perifollicular fibrosis; consistent with LPP [Figures , and ] and in keeping with the clinical presentation of FFA. Periodic acid-Schiff stain of the scalp and eyebrow biopsies showed focal areas of basement membrane zone thickening []; direct immunofluorescence demonstrated a bright, granular-linear deposition of immunoglobulins IgM, IgG, IgA and fibrin along the basement membrane zone, consistent with a positive lupus band test []. Serological testing confirmed the presence of antinuclear, anticardiolipin, as well as lupus anticoagulant antibodies; however, he was free of systemic symptoms.

[[46.0, 'year']]

M

{'24720432': 1, '26622155': 2, '34980973': 1, '11869213': 1, '20482728': 1, '28232926': 1, '8002649': 1, '28300881': 2, '12132298': 1, '28232924': 1, '29177150': 1, '26180452': 2, '26180450': 2, '11495530': 1, '23448183': 1, '28442883': 1, '22986881': 1, '20846567': 1, '28492036': 1, '23968222': 1, '15811087': 1, '28491960': 1, '24778537': 2}

{'4639955-1': 1, '4502478-1': 1, '5324980-1': 1, '4502476-1': 1}

3999658-1

noncomm/PMC003xxxxxx/PMC3999658.xml

Nodules on the Hair: A Rare Case of Mixed Piedra

A 40-year-old married female hailing from West Bengal came with the complaints of difficulty in combing hair and blackish small nodules attached to her scalp hair. There was no history of hair loss. There was no family history of similar complaints. Patient gave a history of similar symptoms 5 years back, which had resolved by using antifungal shampoo for 3 months.\nExamination of scalp hair revealed multiple discrete firms to hard, brown to black tiny nodules attached to hair shaft. These nodules were distributed irregularly along the length of hair shaft []. When pulled between the fingers, these hairs gave a raspy sensation. Patient also had concurrent nits suggestive of pediculosis capitis. Examination of underlying scalp was normal. Axillary and pubic hair were normal. A provisional diagnosis of black piedra was made. 10% potassium hydroxide (KOH) examination was done from multiple nodules, which surprisingly revealed two different set of findings. Examination of black colored nodule revealed a concretion forming a collar around normal hair shaft, which was made up of filamentous hyphae, held together by cement like substance with spores seen at the edges of the nodule []. Crushing of nodule by gentle pressure revealed presence of brown dematiaceous closely septate hyphae with few chlamydospores on KOH mount []. Culture from black colored nodule on the Sabouraud's dextrose agar at room temperature grew small, compact, blackish conical colonies with velvety surface []. The reverse side of the colonies also revealed black color. One of the colonies, on microscopic examination revealed round, dark brown, globus ascus confirmatory for Piedraia hortae species []. KOH mount of brown colored nodule revealed nondematiaceous, loosely arranged septate hyphae with arthroconidia and blastoconidia []. Culture from the brown colored nodule grew white to cream colored, wrinkled, velvety, dull colonies with a mycelial fringe surrounding the hair shaft []. Lactophenol cotton blue mount from the fungal colonies showed multiple hyaline septate hyphae and arthrospores confirming Trichosporon sp. []. Thus microscopic and culture characteristics confirmed presence of both black-and-white piedra, i.e., mixed piedra. Presence of nits of Pediculus capitis was also confirmed on microscopy []. Patient was advised trimming of her hair and application of 2% ketoconazole lotion once a week for 3 months resulting in disappearance of the nodules. Patient was also treated with 1% permethrin (single application) for treatment of pediculosis capitis.

[[40.0, 'year']]

F

{'21860159': 1, '8776394': 1, '15196166': 1, '15891566': 1, '8186138': 1, '18949351': 1, '12196752': 1, '31007477': 2, '23786496': 1, '24778538': 2}

{'6463451-1': 1}

3999676-1

noncomm/PMC003xxxxxx/PMC3999676.xml

Bilateral diaphragmatic paralysis in an HIV patient: Second reported case and literature review

A 42-year-old HIV positive male smoker on antiretroviral therapy (stavudine, efavirenz, and lamivudine) with very poor adherence to the medication regimen was admitted because of community acquired pneumonia. Since past one year, ordinary physical activity would result in breathlessness in the patient. There was no history of thoracic trauma or preexisting respiratory or cardiac diseases.\nClinical examination showed stable vital signs. Chest examination revealed paradoxical movement of the diaphragm, during inhalation, when the patient was in the supine position and coarse crepitations near the base of the left lung. All deep tendon reflexes were normal and there were no other signs of peripheral neuropathy.\nRoutine laboratory investigations were within normal limits. CD4 cell count was 170/μl and the plasma viral load was 74,746 copies/ml. Serological tests for Chagas disease, hepatitis B virus (HBV), and syphilis (Venereal Disease Research Laboratory (VRDL) and fluorescent treponemal antibody absorption (FTA ABS)) were negative whereas imunoglobulin G (IgG) anti-toxoplasma antibodies were positive. Electrocardiogram was normal. Chest X-ray revealed the elevation of the right and left hemidiaphragms in a full inspired film [] and its immobility detected through a radioscopic examination. The cardiomediastinal silhouette was normal. There were no pulmonary infiltrates, pleural effusion, or mediastinal tumor in the computed tomography (CT) scan of the chest. The forced vital capacity in the sitting position was 1.84 L (48%) and it decreased to 1.29 L (34%) when brought to the dorsal decubitus position (change of <30%). Oxygen saturation while breathing ambient air was 96%. Transdiaphragmatic pressure was 2.99 cm H2O and confirmed the diagnosis of bilateral phrenic paralysis. During the examination, a negative deflection of the gastric pressure was observed as a sign of paradoxical movement of the diaphragm. The electromyography test showed an axonal damage to both phrenic nerves, without compromise in the other territories examined in his four limbs. Patient was started on a new scheme of antiretroviral therapy, without stavudine, and pulmonary rehabilitation exercises. Ten days later, he was discharged from the hospital in a good clinical condition. Patient was lost to follow-up.

[[42.0, 'year']]

M

{'14718726': 1, '19452391': 1, '22687801': 1, '11932984': 1, '2688182': 1, '14571455': 1, '30016248': 1, '23614993': 1, '23415009': 1, '29367364': 1, '10882161': 1, '20739800': 1, '14985569': 1, '11293804': 1, '2233481': 1, '16702753': 1, '24778479': 2}

{}

3999677-1

noncomm/PMC003xxxxxx/PMC3999677.xml

Pulmonary cryptococcosis with cryptococcal meningitis in an immunocompetent host

In September, 2010, a 36-year-old man was referred to our service for evaluation of a suspected lung cancer. He complained of dull aching pain on left anterior chest, cough with scanty sputum, loss of appetite and weight for 6 weeks. He had no fever, hemoptysis, abdominal, or neurological symptoms at presentation. He denied any preexisting lung disease, diabetes, illicit drug abuse or intake of immunosuppressive agents. He was a mason by profession and had smoked for 10 pack-years. He lives in a village in Tamil Nadu, India and had never traveled away from his native state. General physical examination was unremarkable. Chest examination revealed a dull percussion note with diminished breath sound on left hemithorax. Chest radiograph showed a large mass in the left lung []. He was hospitalized for workup of a possible lung cancer. Leukocyte count was 22,500/mm3 with a predominance of neutrophils. Serum electrolytes, liver and renal functions were normal. Serology for human immunodeficiency virus (HIV) was negative. Serum immunoglobulin levels and CD4 count (618 cells/μL) were normal. Chest computed tomography (CT) scan confirmed a large mass (11.9 cm × 8.2 cm) in left upper lobe (LUL) with central hypoattenuation []. On 3rd day of hospitalization, patient developed mild headache and nausea. He was awake-alert and had no neck rigidity or focal neurological deficit. Considering the possibility of meningitis or cerebral metastasis, immediate contrast enhanced CT brain was performed that showed mild meningeal enhancement with normal ventricles and brain parenchyma. CT guided fine needle aspiration cytology (FNAC) of the lung mass showed numerous budding yeasts resembling Cryptococcus and no evidence of malignancy. Lumbar puncture following neurologist opinion revealed clear cerebrospinal fluid (CSF) under normal pressure with pleocytosis (leukocytes 16 cells/μL, 100% lymphocytes) and stained positive for India ink preparation. Serum and CSF were positive for cryptococcal antigen by latex agglutination test. However, culture for the fungus was negative in CSF and blood. Staining for acid fast bacilli was negative in sputum, CSF and bronchial wash. Flexible bronchoscopy showed a whitish-yellow mass in LUL bronchus. Bronchial washings and endobronchial biopsy were consistent with cryptococcal infection []. He was treated with Inj. amphotericin B 50 mg/day (1 mg/kg/day) and flucytosine 4 g/day orally (in four divided doses) for initial 4 weeks. He had remarkable clinical and radiological improvement after completion of induction therapy. His renal function and leukocyte count remained normal throughout the course of therapy. Therapy was switched to oral fluconazole 400 mg/day for 8 weeks followed by 200 mg/day continued until November 2011. Complete resolution of the mass was ensured in follow-up imaging [] and he was well until last contact in March 2012.

[[36.0, 'year']]

M

{'26401280': 2, '24778470': 1, '9797753': 1, '10084485': 1, '28700464': 1, '19503836': 1, '20047480': 1, '20979679': 1, '26917800': 1, '26422166': 2, '16504989': 1, '29737452': 1, '18398126': 1, '22953139': 2, '12000513': 1, '21896527': 1, '24778480': 2}

{'4616927-1': 1, '4574791-1': 1, '3420626-1': 1}

3999678-1

noncomm/PMC003xxxxxx/PMC3999678.xml

Pleural Aspergillosis in an otherwise healthy individual

A 16-year-old Indian boy presented to the out-patient department of our hospital with complaints of low-grade fever, dry cough and left sided chest discomfort of 6 weeks duration. Cough was non-productive, non-spasmodic without postural or diurnal variation. The chest pain was worse on coughing. There was no history of similar complaints in the past. He had no history of hemoptysis, loss of appetite or weight loss. There was no history of bronchial asthma, diabetes mellitus, previous hospitalization or surgical intervention. On examination, patient was of fair nutritional status and his vitals were stable. General physical examination did not reveal any significant abnormality. On chest examination, left sided movements were decreased, percussion note was stony dull and air entry was absent. Succusion splash was also heard. On investigating, his routine hematological and biochemical parameters were normal (hemoglobin – 11 g/dl, total leucocyte count – 7600/cc, differential leucocyte count – P52 L40E8, blood sugar (fasting) – 86 mg/dl, blood sugar (post-prandial) – 148 mg/dl, T. bilirubin-0.4 mg/dl, aspartate aminotransferase - 26 IU/ml, alanine aminotrans ferase 38 IU/ml, blood.urea-26 mg/dl, S. creatinine-1.0 mg/dl). Mantoux test and serology for human immunodeficiency virus were negative. Immunoglobulin E was significantly elevated (1602 IU/ml). A chest radiograph was done, which had features of left pyopneumothorax. Air fluid level was present on the radiograph []. Diagnostic intercostal drainage revealed frank brownish pus and tube thoracostomy was performed draining 1000 ml pus on the 1st day itself. The pus and induced sputum stained negative for pyogenic organisms and acid fast bacilli (AFB). Considering the fact that the patient belonged to a high incidence area for tuberculosis, a therapeutic trial of anti-tuberculosis treatment was started. However, at the end of 2 months of treatment, his induced sputum and pleural fluid again stained negative for AFB. Culture of the sputum sample was also negative for AFB. Despite treatment and drainage with a broad intercostal drainage tube (ICD) his symptoms failed to resolve. The sputum and pus were then subjected to fungal smears and culture. The sputum smears were negative, but pus smears showed septate fungal hyphae and grew A. fumigatus in culture []. Smears from the culture showed septate hyphae and conidiophores confirming pathogenic role of the mould. Flexible bronchoscopy was done and bronchial wash was subjected to microbiological studies. Both fungal smear and culture were negative, indicating lack of pulmonary involvement. Patient was thus diagnosed as pleural Aspergillosis in the absence of invasive pulmonary Aspergillosis or any other obvious predisposing factors. He was started on voriconazole 300 mg twice-a-day. Within 4 weeks, the patient showed signs of recovery with reduction in cough and chest pain []. The pyopneumothorax showed signs of resolution and the ICD was removed after 6 weeks of starting treatment. Patient was maintained on oral voriconazole for 9 months and showed no signs of relapse 1 year later.\nWe conducted a thorough search for the source of the A. fumigatus infection in our patient and found that the boy had a carious tooth. On culture in blood agar, Streptomyces spp. was grown. In addition, the carious material was cultured in Sabouraud's Dextrose Agar medium and it grew A. fumigatus. We thus hypothesize that at some point in time the patient could possibly have aspirated the carious material, which would have infected the pleura subsequently without direct invasion of lung parenchyma. We thus, report this case in view of the extreme rarity of pleural Aspergillosis in patients with otherwise healthy lungs.

[[16.0, 'year']]

M

{'14982812': 1, '12167683': 1, '19346638': 1, '24778470': 1, '5441996': 1, '14180193': 1, '773232': 1, '28913161': 1, '10858401': 1, '32181124': 1, '12783174': 1, '24778481': 2}

{}

3999679-1

noncomm/PMC003xxxxxx/PMC3999679.xml

Delayed esophageal perforation from stereotactic body radiation therapy for locally recurrent central nonsmall cell lung cancer

An 85-year old male with medical history of hypertension, type-2 diabetes, and coronary artery disease underwent a right lower lobectomy for a T2bN0M0 Stage 1b squamous cell carcinoma of the lung. After 1 year, the patient developed a local recurrence adjacent to the inferomedial aspect of the right upper lobe. A PET scan performed showed no evidence of disease elsewhere. The patient was considered unfit for a completion pneumonectomy. The recurrence was treated by SBRT using a Cyber knife Stereotactic Radiosurgery System (Accuracy, Sunnyvale, CA) with a prescription dose of 50 Gy in five fractions given every other day. Five months after the SBRT, the patient presented acutely with an empyema of the right chest. Flexible bronchoscopy showed a well-healed lower lobe bronchus. A barium swallow showed an extravasation of the oral contrast into the right pleural space []. An upper gastrointestinal endoscopy revealed a single 2.5 cm perforation in the distal thoracic esophagus and no tumor ingrowth. The patient was treated with a Wall flex fully covered esophageal stent (Boston Scientific, Natick, MA), sealing the esophageal perforation []. The patient also needed an open drainage of his right chest. However, the patient did not do well and succumbed to the esophageal perforation.\nA 73-year old female with medical history of hypertension underwent a right lower lobectomy for a T1N0M0 Stage 1A adenocarcinoma of the lung. After 4 years, the patient developed a new primary in the right upper lobe. A completion pneumonectomy and four cycles of adjuvant chemotherapy with cisplatin and paclitaxel were given for this T2N2M0 stage 3 adenocarcinoma of the right upper lobe. The patient did well for 2 years, after which she developed a regional recurrence near the right main stem bronchus stump. The patient was given SBRT to the recurrence site with a Cyber knife Stereotactic Radiosurgery System (Accuracy, Sunnyvale, CA), with a prescription dose of 50 Gy in five fractions given every other day. Seven months after SBRT, the patient presented with a hydropneumothorax in the postpneumonectomy space on routine surveillance chest x-ray. Bronchoscopy showed a well-healed bronchial stump. The CT scan of the chest showed oral contrast extravasation into the right pneumonectomy space []. An upper esophagogastroscopy confirmed two esophageal perforations at 22 and 37 centimeters from the incisors. Both were treated with a Wall flex fully covered esophageal stents (Boston Scientific, Natick, MA), and the right chest was drained with a tube thoracotomy. The patient did well, with retrieval of the stent at 5 weeks post placement.

[[85.0, 'year']]

M

{'17050868': 1, '18954709': 1, '12826306': 1, '32095550': 1, '12694831': 1, '28861738': 2, '14605072': 1, '32420074': 1, '22265734': 1, '30713468': 1, '12182981': 1, '24778482': 2}

{'5578948-1': 1}

3999681-1

noncomm/PMC003xxxxxx/PMC3999681.xml

Imaging findings of pulmonary carcinosarcoma: A case report

A 90-years-old male patient came to our hospital with chief complaints of cough with expectoration and breathlessness for one month. There was history of treatment for pulmonary koch's for two years. Personal history revealed that the patient was heavy smoker. Chest radiograph was done and showed a large lobulated right lower lobe opacity silhouetting the right dome of diaphragm. There was blunting of right costo-phrenic angle. Multiple other rounded lobulated opacities were seen in both lung fields. Provisional diagnosis of malignant lung mass with pulmonary metastases was made [].\nComputed tomography (CT) scan of chest was done with intravenous contrast for further evaluation on Siemens Somatom perspective, 128 slice. CT scan showed a large cavitating heterogeneous mass with lobulated margins measuring approximately 8.7 × 8.2 × 7.4 cm in the lower lobe of right lung []. The mass showed inhomogeneous contrast enhancement at the periphery and decreased attenuation centrally. Ground-glass haze was seen surrounding the mass []. Coarse foci of calcification were seen within the mass. Inferiorly the mass was invading the diaphragm and infiltrating directly into the liver involving segment VII of right lobe of liver [] and [Figure and ]. Postero-laterally, the mass was invading the pleura [] and chest wall with associated pleural thickening and subtle rib erosion, which suggested the mass to be malignant. In addition, multiple bulky lobulated hypodense masses were seen in both lung fields suggesting pulmonary metastases, one of them in right para-vertebral region was invading the mediastinum. Foci of calcification were seen within the larger metastatic masses [Figure and ] and [Figure and ]. Multiple small mediastinal lymph nodes were also seen.\nSequelae to old pulmonary koch's were also seen in form of thick walled cavity and few fibrotic lesions in upper lobes and right middle lobe with foci of calcification within them.\nOn basis of chest CT findings: highly invasive bulky lobulated hypodense mass infiltrating the diaphragm and liver inferiorly and chest wall laterally along with lobulated metastases in both lung fields and coarse foci of calcification within the primary tumor and metastases.- possibility of some sarcomatous component within the primary lung tumor along with metastases was considered. These features are unusual to bronchogenic carcinoma, which usually shows spiculated ill-defined margins and does not usually infiltrate into the liver directly. Amorphous foci of calcification may be seen within the primary bronchogenic carcinoma but is not seen in its metastases.\nUltrasound-guided fine needle aspiration cytology (FNAC) of the primary tumor was done. It showed extensive necrosis and scattered squamous cells having hyperchromatic, pleomorphic nuclei along with few tadpole cells and anucleate squamous cells [] and []. So diagnosis of squamous cell carcinoma was given.\nPatient was referred to another hospital for treatment of malignancy. Fine-needle percutaneous biopsy of the primary tumor was done there under ultrasound guidance. Few neoplastic osteoids and ossification was seen in addition to necrosis and malignant squamous cells. So final diagnosis of carcinosarcoma was made consisting of mainly squamous cell carcinoma and component of osteosarcoma. Foci of calcification seen in the primary tumor and metastasis on chest CT was metaplastic osteosarcomatous component. Patient refused further treatment.

[[90.0, 'year']]

M

{'20462841': 1, '23378874': 1, '9306427': 1, '21043818': 1, '23006472': 2, '26989547': 1, '8817133': 1, '21469429': 1, '19637805': 1, '17723808': 1, '22619609': 1, '29075544': 2, '15215543': 1, '17094419': 1, '9275879': 1, '24778484': 2}

{'5623769-1': 1, '3517474-1': 1}

3999682-1

noncomm/PMC003xxxxxx/PMC3999682.xml

Hemoptysis secondary to actinomycosis: A rare presentation

A 70-year-old female patient presented to us in the early morning of January 1, 2011 with massive haemoptysis. The patient was a known case of hypothyroidism and hypertension and on regular treatment. She had been complaining of cough with expectoration and mild streaking of blood in sputum for about 3 days. On examination the pulse rate was 96/min, BP 134/76 mm Hg, RR 25/min, and SPO2 94% on 2 l of O2. Chest examination revealed bilateral vesicular breath sounds with crepts in right infrascapular and infra-axillary regions. There was no history of dental manipulation, facial lesions or trauma to mouth, aspiration, or alcoholism. Her cardiovascular, GIT, and central nervous system examinations revealed no abnormality. She was admitted in the intensive care unit and her initial investigations including ECG, ABG, CBC, KFT, LFT, and RBS were within the normal range. Her sputum was sent for AFB, gram's stain, and fungal stain along with culture and sensitivity for pyogenic organisms. Her chest X-ray revealed right mid zone homogenous opacity along with the obliteration of both right costophrenic and cardiophrenic angles []. She was started on piperacillin + tazobactum along with IV haemostatics, IV fluids, and cough suppressants. Once stabilized, she was taken for diagnostic fibreoptic bronchoscopy that revealed a cauliflower-like growth in RUL bronchus [] raising a high suspicion of malignancy. BAL was taken and bronchial biopsy for histopathology was obtained from the lesion and sent for histopathological examination. She was continued on conservative treatment and the haemoptysis stopped. BAL was negative for AFB; no organisms were seen on gram's stain and fungal stain. Pyogenic culture also did not grow any organisms. Her chest X-ray after the antibiotics showed an increase in the size of the homogenous opacity abutting the heart []. CECT thorax revealed a large heterogenous soft tissue mass measuring 7 × 5.9 × 6 cm with surrounding parenchymal infiltrates in anterior segment of upper-right lobe and medial segment of middle-right lobe. The mass was abutting the anterior segmental bronchus of upper-right lobe, medial segmental bronchus of the middle-right lobe, costal and mediastinal pleura; the patchy area of consolidation was seen in lower-right lobe limited by oblique fissure with bilateral pleural effusions, which were more on the right side []. Diagnostic pleural aspiration was done. Pleural fluid did not show any organisms on gram stain, AFB stain, and fungal stain. Pyogenic culture was sterile and malignant cells were not seen. The ADA level was 4.76 IU, thus almost ruling out TB. Bronchial biopsy showed markedly inflamed bronchial mucosa with granulation tissue and sheets of inflammatory cells, predominantly neutrophils. Bronchial biopsy was also sent for culture where occasional colonies of gram positive filamentous bacteria surrounded by neutrophils were seen. CT-guided FNAC and Trucut biopsy were done for better understanding of the lesion. On performing FNAC thick pus was aspirated out. FNAC showed sheets of neutrophils and occasional branches of filamentous bacteria with impression of suppurative pathology. Trucut biopsy showed sheets of neutrophils with colonies of filamentous bacteria and sulphur granules [] consistent with actinomycotic infection. She was started on Benzyl penicillin 20 lac units IV 6 hourly and had a dramatic response. Her symptoms disappeared and chest X-ray almost cleared []. Finally, she was discharged in a stable condition on oral amoxicillin + clavulanic acid combination. She is under regular follow up and has continued to be in a stable condition for more than a year.

[[70.0, 'year']]

F

{'27578949': 1, '9988785': 1, '24778470': 1, '34194178': 2, '10196385': 1, '30186488': 1, '1200725': 1, '12662015': 1, '9619663': 1, '24778485': 2}

{'8213083-1': 1}

3999684-1

noncomm/PMC003xxxxxx/PMC3999684.xml

A rare case of underlying pulmonary sequestration in a patient with recently diagnosed medium and large vessel vasculitis

A 25-year-old female presented with complaints of malaise, weight loss, and diffuse abdominal pain, more inthe umbilical region since 1-2 months. Pain was aggravated with meals and relieved with fasting. On examination, her blood pressure was 160/92 mm Hg in right arm and 158/90 in left arm; lower limb blood pressure was 126/80 in right lower limb and 128/82 in left lower limb. Pulse rate was 90 per minute, regular, good volume with no radiofemoral delay. A renal bruit was heard on the left side. Rest of the systemic examination was within normal limits. Complete blood count, liver function tests, kidney function tests, and urine routine microscopy were within normal limits. Erythrocyte sedimentation rate (ESR) was raised to 35 mm/hour and C-reactive protein (CRP) was more than 5 mg/L. Her chest X-ray and electrocardiogram (ECG) were normal. Her fundus examination was normal. Serology for HIV 1 and 2, hepatitis B surface antigen (HBsAg), anti hepatitis C virus (anti-HCV), venereal disease research laboratory (VDRL) test, anti-nuclear antibodies (ANA), cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) were negative. Complement levels were normal. Ultrasonography (USG) of the abdomen was normal. Contrast enhanced computed tomography (CT) scan of the thorax and abdomen was done, which revealed thickening of the descending aorta upto bilateral renal artery origin with thickening of the superior mesenteric artery. CT angiography was done, and it revealed wall thickening of the descending aorta with narrowing of lumen. There was also thickening of the superior mesenteric artery with narrowing of lumen. Pulmonary trunk and bilateral pulmonary arteries were also normal. There was evidence of a heterogeneous, hyperdense region in the left medial basal segment deriving its arterial supply separately from the aorta. There was no direct communication with the tracheobronchial tree, and the heterogeneous lung segment had no separate pleural covering. The above-mentioned findings were suggestive of an intralobar pulmonary sequestration []. Bilateral renal artery showed stenosis with involvement of the ostia and proximal segment with post-stenotic dilatation []. The other branches of the abdominal aorta were normal. The thoracic aorta and its branches were also normal in course and caliber. The findings were consistent with large vessel vasculitis.

[[25.0, 'year']]

F

{'1975175': 1, '4883836': 1, '3238668': 1, '8617101': 1, '9856886': 1, '7570424': 1, '1481189': 1, '442005': 1, '9725412': 1, '8707435': 1, '9564949': 1, '24778487': 2}

{}

1876608-1

noncomm/PMC001xxxxxx/PMC1876608.xml

Three Case Reports to Illustrate Clinical Applications in the Use of Erythrocyte Transketolase

J.S. was a 77-year-old woman. In June 2005, she came to our clinic complaining of extreme fatigue. This was severe enough to cause her to go to sleep briefly while driving. She was also experiencing occasional ‘dizziness’ on rising in the morning and severe constipation. She reported that an ophthalmologist had found increased pressure in one eye and she was using eye drops prescribed for this. Past history revealed that she had received radioactive iodine as a child and was being treated with synthetic T3. Although the TKA was in the normal range () the TPPE was 18%, indicating a mild degree of thiamin deficiency.\nShe was treated with orally administered nutritional supplements that included a multivitamin, 3 g of ascorbic acid (bowel tolerance), 300 mg of magnesium/potassium/aspartate, 250 mg of calcium with 166 mg magnesium in a combination tablet taken at bedtime, 5 mg of phytonadione (vitamin K1) because of a history of osteoporosis diagnosed elsewhere, 200 mg of lipoic acid and 150 mg of TTFD.\nTwo months later she reported that she had ‘more energy’. In spite of this the TKA was lower in concentration and the TPPE had accelerated dramatically (). Although there was no exacerbation of symptoms, 1 month later the laboratory results had deteriorated again and it was decided to provide her with a series of intravenous infusions (). Following this treatment, the laboratory test was repeated. The TKA had increased its activity and the TPPE had fallen to 3% ()

[[77.0, 'year']]

F

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{'1876608-2': 2}

1876608-2

noncomm/PMC001xxxxxx/PMC1876608.xml

Three Case Reports to Illustrate Clinical Applications in the Use of Erythrocyte Transketolase

J.K. This 72-year-old woman was first seen because of ‘flu-like’ symptoms that occurred every 2 weeks after square dancing. She would feel chilled, experience nausea and become unusually fatigued. Low-grade fever would last about 4 days. She would feel well again until after the next session of dancing. She reported recurrent sinus infections that had occurred over a number of years, each being treated with an antibiotic.\nLaboratory studies are shown in before and after 2 months of nutrient therapy. Dietary counseling and supplementation correlated with clinical improvement. Supplements included a multivitamin as a nutritional foundation, up to 3 g of ascorbic acid, depending on bowel tolerance, 240 mg EPA, 60 mg GLA, B complex with 50 mg additional pyridox-5-phosphate, 270 mg magnesium and 270 mg of potassium as magnesium/potassium/aspartate and 150 mg TFFD.

[[72.0, 'year']]

F

{'489520': 1, '5016053': 1, '4050546': 1, '18955227': 1, '712201': 1, '709859': 1, '3248678': 1, '4644937': 1, '16185141': 1, '15452061': 1, '14660498': 1, '13804447': 1, '8054263': 1, '8974393': 1, '5924757': 1, '4377016': 1, '3343477': 1, '16550223': 1, '31752901': 1, '7334740': 1, '15744136': 1, '9513798': 1, '4836950': 1, '4784014': 1, '15862294': 1, '14977409': 1, '5554200': 1, '762558': 1, '4436724': 1, '30721240': 1, '7355794': 1, '10348000': 1, '17549243': 2}

{'1876608-1': 2}

1994793-1

noncomm/PMC001xxxxxx/PMC1994793.xml

Aggressive Burkitt-Like Lymphoma of Colon in a Patient With Prior Celiac Disease

A 75-year-old man with history of celiac disease presented with pallor, fatigue, and 20-pound weight loss of three weeks duration. CD was diagnosed two years prior, at which point the patient underwent extensive evaluation for unexplained microcytic hypochromic anemia and was found to have an elevated endomysial antibody titer. A small bowel biopsy showed celiac disease. The patient was then placed on a gluten-free diet and the anemia resolved completely.\nOn physical examination, a vague non-tender mass in the right hypochondrium was found and his stools tested positive for occult blood. The laboratory values were within normal range, except for hemoglobin (11mg/dL), MCV 75, SGOT (61 IU/L) and LDH (5000 IU/L).\nCT scan of abdomen showed extensive carcinomatosis. There were also small pleural effusions and scattered lymphadenopathy. PET showed diffusely hyper-metabolic foci coinciding with CT findings. Colonoscopy revealed a friable nodular mass in the hepatic flexure and proximal transverse colon. However, histopathologically the mass consisted of a high-grade B-cell lymphoma. Flow cytometry following immunostaining reported positive CD10, CD19, CD20, CD45, CD79a, and Ki-67. FISH assay demonstrated t (14:18) translocation and bcl-2 rearrangement. The bone marrow biopsy showed evidence of disease []. The bone marrow biopsy was also positive for CD10, CD19, CD20, CD38, CD45 and HLA-DR.\nThe patient was treated with rituximab cyclophosphamide, Adriamycin, vincristine, and prednisone (CHOP-R) according to protocol, with intrathecal methotrexate prophylaxis. The patient is currently in remission.

[[75.0, 'year']]

M

{'20780486': 1, '12702783': 1, '15825131': 1, '31819338': 1, '16394801': 1, '1556401': 1, '7558926': 1, '12513011': 1, '12815137': 1, '15379837': 1, '12578508': 1, '12801951': 1, '11903028': 1, '17940628': 2}

{}

1994796-1

noncomm/PMC001xxxxxx/PMC1994796.xml

Metastatic Cervical Carcinoma to the Thyroid Gland: A Case Report and Review of the Literature

A 68-year-old woman was admitted to our department after complaining of a persistent cough over the course of a week, hemoptysis, and a temperature that would peak at 37.8°C (100°F) over the last two months. She had noticed a painless swelling in the region of the thyroid gland and a palpable mass in the right side of her neck. Four years ago, the patient had been diagnosed with squamous cell carcinoma of the cervix stage ΙΙΙΒ, moderately differentiated, for which she had received external beam radiotherapy to the pelvis and brachytherapy.\nUpon physical examination, an irregular, hard-fixed mass measuring 8.6 cm was felt in the right lateral region of the neck, along with a firm thyroid enlargement. Chest auscultation revealed altered breath sounds in the left lung, with rales and rhonchi. Her blood cell count and serum biochemistry were normal, and the rate of sedimentation was 65mm the first hour. The patient underwent a CT scan of the neck, thorax, abdomen, and pelvis that revealed a large irregular mass 9 cm in diameter in the right lateral region of the neck, enlargement of the thyroid gland, enlarged mediastinal and paraaortic nodes, and multiple patchy airspace infiltrates, without evidence of local recurrence. A bone scan was negative for metastases. Fiberoptic bronchoscopy revealed edematous and erythematous mucosa of the upper bronchus of the right lower lobe and erythematous edematous mucosa with probable subserosa infiltration of the lingual bronchus. Sputum cytology after bronchoscopy washing and brushing was positive for undifferentiated carcinoma. Since the cytology report could not establish a definite diagnosis, a biopsy of the thyroid gland was performed, which showed non-keratinizing squamous cell carcinoma compatible with primary squamous cell carcinoma of the cervix. The pathologist also reviewed slides of the cervical biopsy from four years previous and confirmed that the thyroid tumor was histologically identical to the initially documented cervical carcinoma.\nThe patient received six cycles of systematic chemotherapy with cisplatin and gemcitabine, with partial response. Subsequently, she received radiation therapy to the right side of the neck and the thyroid, with further decrease of the lymph nodes and thyroid mass. Five months after the completion of radiotherapy, the patient developed progressive disease and succumbed four months later. The overall survival after diagnosis of the thyroid metastasis was 16 months.

[[68.0, 'year']]

F

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{'4349014-1': 1, '4704422-1': 1, '8674393-1': 1}

1994805-1

noncomm/PMC001xxxxxx/PMC1994805.xml

Efficacy of Low Dose Clofarabine in Refractory Precursor T- Acute Lymphoblastic Leukemia

JK is a 35-year-old male with precursor T-lymphoblastic leukemia diagnosed in 2001 with a bone marrow blast immunophenotype of CD2+CD7+CD3+ cells with aberrant expression of CD13 and negative staining for TdT and myeloperoxidase. His karyotypic analysis was indicative of a 4;11 translocation involving the MLL gene at 11q23. He was induced and underwent allogeneic stem cell transplantation (SCT) from his HLA-identical fraternal twin brother in April 2002. He was in remission with limited skin chronic graft-vs.-host disease until January 2003, when he relapsed and was treated with ICE chemotherapy followed by a donor lymphocyte infusion. He remained in remission until February 2005, when he developed nodular violacious skin lesions which on biopsy revealed T-cells consistent with his original leukemia. Full restaging including bone marrow biopsy and cerebrospinal fluid analysis were negative, indicating an isolated skin recurrence. Re-induction therapy was initiated with cyclophosphamide and gemcitabine but was complicated by significant myelosuppression and renal insufficiency. He received a brief course of systemic retinoid therapy with bexarotene and spot electron beam irradiation for symptomatic improvement of nodular disease on his face with rapid recurrence at the completion of radiation. He then was treated with nelarabine in February 2006 and responded but developed worsening renal insufficiency.\nHe quickly developed recurrent nodular tumors over his brow, around his right ear, on his chest, and on his back and chest []. On restaging in October 2006, the patient had no evidence of lymphadenopathy or involvement of liver or spleen by CT scan. A bone marrow biopsy revealed relapse of known precursor-T lymphoblastic leukemia involving 40 percent of the marrow. The cells were CD2+ CD7+ CD34+ HLA-DR+ CD3-. Flow cytometry of the blood was negative for blasts with only occasional reactive lymphocytes. At that time, his leukocyte count was 2.0 with 64 percent neutrophils and 35 percent lymphocytes, the hematocrit was 24.5 and platelets were 52 x 10³/dl. He initiated therapy with clofarabine at 10 mg/m2 weekly for three consecutive weeks every 28 days. Treatment schedule and toxicities are shown in Table 1. There was no hepatic toxicity, and only mild fluctuations of the creatinine were noted. Treatment was held on the third week of the first two cycles due to neutropenia.\nAfter two cycles of clofarabine, the patient’s lesions regressed significantly as shown in . Cycle 3 was delayed due to a hospitalization for herpetic esophagitis, which resolved with acyclovir therapy. He remains on weekly low-dose clofarabine with ongoing response after three months. His platelet count has been stable at 99,000/mm³. An unrelated donor has been identified, and the patient will undergo a second allogeneic stem cell transplant.

[[35.0, 'year']]

M

{'12637486': 1, '14551141': 1, '12791647': 1, '16622268': 1, '15353542': 1, '15908652': 1, '17016426': 1, '16234483': 1, '1707752': 1, '16407512': 1, '17940627': 2}

{}