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163,100 |
3764954-2
| 24,019,771 |
noncomm/PMC003xxxxxx/PMC3764954.xml
|
Coxsackievirus A6 and Hand, Foot and Mouth Disease: Three Case Reports of Familial Child-to-Immunocompetent Adult Transmission and a Literature Review
|
Case 2: A 37-year-old woman, sister of the patient described above, clothing store manager, with an unremarkable past medical history, was admitted to our outpatient clinic in the middle of October 2012, with a 1-day history of characteristic palm and sole rash. The symptoms were preceded by a sore throat and low-grade fever. Ten days before the onset of the first symptoms, she had contact with her brother, who at the time of the meeting was asymptomatic. The day after, the male patient developed symptoms of HFMD. He was infected by his niece suffering from HFMD 1 week before the siblings’ meeting. The female patient was absent from the family party, where the child suffering from HFMD was present. Physical examination revealed singular erythematous macular and papular lesions on the patient's soles and palms. The oral cavity was spared. No other diagnostic exam was executed due to the patient's refusal. Considering characteristic clinical manifestations and recent contact with a person suffering from HFMD, the diagnosis of HFMD was made. No treatment was prescribed as the patient did not complain of any disturbances. Complete resolution of the disease was observed within 2 weeks.
|
[[37.0, 'year']]
|
F
|
{'28413820': 1, '33574876': 1, '10568570': 1, '33101238': 1, '25636654': 1, '25742504': 1, '23800163': 1, '8133108': 1, '14722149': 1, '28168168': 1, '16891480': 1, '33274234': 1, '25774239': 2, '20189452': 1, '26203408': 2, '30760232': 2, '22762340': 1, '22456122': 1, '12643822': 1, '10720980': 1, '19788821': 1, '28352303': 1, '5694203': 1, '30425589': 1, '23732432': 1, '33743167': 1, '20548919': 1, '26975350': 1, '11760019': 1, '26155357': 2, '24019771': 2}
|
{'3764954-1': 2, '3764954-3': 2, '4483348-1': 1, '4333364-1': 1, '4504872-1': 1, '4504872-2': 1, '4504872-3': 1, '4504872-4': 1, '4504872-5': 1, '4504872-6': 1, '4504872-7': 1, '4504872-8': 1, '6373151-1': 1}
|
163,101 |
3764954-3
| 24,019,771 |
noncomm/PMC003xxxxxx/PMC3764954.xml
|
Coxsackievirus A6 and Hand, Foot and Mouth Disease: Three Case Reports of Familial Child-to-Immunocompetent Adult Transmission and a Literature Review
|
Case 3: A 21-year-old man, student, with irrelevant medical history, was admitted to our Dermatology Department in April 2013 in compromised physical condition, with a 2-day deteriorating papular and vesicular skin rash accompanied by a 3-day high fever, chills and malaise. Two weeks before developing the symptoms, during a family meeting, the patient had contact with a niece suffering from HFMD. Physical examination showed numerous erythematous papular and vesiculobullous lesions spread throughout the perioral and perinasal zones, oral cavity, on his palms and soles, as well as on the distal lower extremities, up to the knees (fig. , fig. ). A complete blood count revealed lymphocytopenia (1.29 g/l), and the erythrocyte sedimentation rate was increased to 26 mm/h. Blood chemistry tests showed an elevated CRP level (56 mg/l). Syphilis, HIV, Epstein-Barr virus, cytomegalovirus, measles and rubella serologies were negative. The PCR assay confirmed Coxsackievirus A6 both in plasma and in plantar vesicle fluid. Only symptomatic treatment was introduced. After a 3-day hospitalization, the patient's conditions as well as inflammatory parameters improved and he was discharged. After 2 weeks, all the lesions resolved completely. During a 2-month follow-up, no complications were observed.
|
[[21.0, 'year']]
|
M
|
{'28413820': 1, '33574876': 1, '10568570': 1, '33101238': 1, '25636654': 1, '25742504': 1, '23800163': 1, '8133108': 1, '14722149': 1, '28168168': 1, '16891480': 1, '33274234': 1, '25774239': 2, '20189452': 1, '26203408': 2, '30760232': 2, '22762340': 1, '22456122': 1, '12643822': 1, '10720980': 1, '19788821': 1, '28352303': 1, '5694203': 1, '30425589': 1, '23732432': 1, '33743167': 1, '20548919': 1, '26975350': 1, '11760019': 1, '26155357': 2, '24019771': 2}
|
{'3764954-1': 2, '3764954-2': 2, '4483348-1': 1, '4333364-1': 1, '4504872-1': 1, '4504872-2': 1, '4504872-3': 1, '4504872-4': 1, '4504872-5': 1, '4504872-6': 1, '4504872-7': 1, '4504872-8': 1, '6373151-1': 1}
|
163,102 |
3764955-1
| 24,019,793 |
noncomm/PMC003xxxxxx/PMC3764955.xml
|
Orbital Inflammation Developing from Epidemic Keratoconjunctivitis in an Adult
|
A 67-year-old man was referred to Oculoplastics after suffering from conjunctival injection and chemosis in the right eye for 4 days. Previously being diagnosed with EKC by another ophthalmologist, the patient had been treated with levofloxacin eye drops (Cravit®, Santen Pharmaceutical Co. Ltd., Osaka, Japan) and fluorometholone 0.1% eye drops (Flumetholon 0.1®, Taejoon Pharm Co. Ltd., Seoul, Korea). However, his symptoms were worsening even on medication, so orbital cellulitis was suspected and he was referred to our clinic. The patient had an ocular history of cataract operation – phacoemulsification and posterior chamber intraocular lens implantation – in both eyes 9 months ago. When he had a check-up 1 month ago, his corrected visual acuities were 20/20 in both eyes. He had a medical history of diabetes, but there was no other clinical evidence of any other systemic disease or a trauma.\nAt the point of referral, the patient's corrected visual acuities were 20/50 in the right eye and 20/20 in the left eye. His right eye was almost closed due to severe erythematous lid swelling, and he had marked conjunctival injection and chemosis. He complained of limited extraocular motility in horizontal gaze and diplopia in lateral gaze in the right eye. There was no relative afferent pupillary defect in the right eye. Intraocular pressure (IOP) was 22 mm Hg in the right eye and 9 mm Hg in the left eye by Goldmann tonometry. Slit lamp examination of the right eye showed diffuse bullous conjunctival chemosis, hyperemia, corneal edema, and mild anterior chamber reaction. Examination of the left eye was unremarkable (fig. ). A non-contrast orbital computed tomography (CT) scan displayed right periorbital infiltration and swelling, thickening of the right lateral rectus muscle, and mucoperiosteal soft tissue attenuation in the left maxillary sinus, leading to a diagnosis of right orbital cellulitis (fig. ). The patient was given intravenous cefmetazole (Cefmetazole®, SCD Pharm Co. Ltd., Seoul, Korea) 500 mg twice a day; oral amoxicillin 500 mg/clavulanate 125 mg (Augmentin®, Ilsung Pharmaceuticals Co. Ltd., Seoul, Korea) 3 times a day; levofloxacin (Cravit) eye drops, and fluorometholone 0.1% (Flumetholon 0.1) eye drops. His body temperature was 36.6°C, i.e. he was afebrile.\nFive days after the onset of symptoms, and 1 day after the systemic antibiotic treatment, anterior segment conditions and extraocular motility in the right eye did not improve. IOP increased to 32 mm Hg in the right eye, but it was normalized after using a topical IOP-lowering agent. Six days after the onset, and 2 days after the treatment with systemic antibiotics, chemosis and conjunctival injection were seen in the contralateral, left eye, while symptoms in the right eye did not improve.\nThree days after the treatment with systemic antibiotics, there was no improvement in the right eye. We started to consider the possibility of idiopathic orbital inflammation. As infection could not be excluded completely, the patient was given 1 dose of intravenous methylprednisolone 250 mg (solu-Medrol®, Pharmacia and Upjohn, USA) per day with systemic antibiotics. Eight days after the onset, and 1 day after the treatment with systemic steroid, there was improvement in lid edema, conjunctival injection, and chemosis in the right eye. Yet, no changes were seen in the left eye.\nSystemic antibiotics were discontinued because the possibility of an infection now seemed low. The patient continued on intravenous methylprednisolone 250 mg (solu-Medrol) per day and started on 20 mg oral prednisolone (Nisolone®, Kukje Pharm, Korea) twice a day. Nine days after the onset, 2 days after the treatment with systemic steroid, there was significant improvement in the lid swelling of the right eye, and conjunctival injection and chemosis in both eyes. His corrected visual acuities went up to 20/25 in the right eye and pseudomembranes were seen in both eyes. Oral prednisolone was continuously tapered by 10 mg per 2 days.\nTwo weeks after the onset, lid swelling of the right eye, conjunctival injection, chemosis, and corneal edema in both eyes were all gone. The patient's corrected visual acuities recovered to 20/20 in the right eye. The patient's limited extraocular motility in the right eye and diplopia also resolved (fig. ).
|
[[67.0, 'year']]
|
M
|
{'8739689': 1, '21670070': 1, '10428409': 1, '2795411': 1, '25943049': 1, '8852918': 1, '19264216': 1, '22391741': 1, '678780': 1, '7835456': 1, '11117957': 1, '31856790': 1, '16234700': 1, '17019419': 1, '33995773': 1, '1460272': 1, '10387481': 1, '13649019': 1, '10690844': 1, '24019793': 2}
|
{}
|
163,103 |
3764956-1
| 24,019,783 |
noncomm/PMC003xxxxxx/PMC3764956.xml
|
Disease Flare after Discontinuation of Crizotinib in Anaplastic Lymphoma Kinase-Positive Lung Cancer
|
A 50-year-old male former smoker was found to have a left lung nodule, 25 mm in size, and chest computed tomography (CT) revealed lymph node metastases in the left hilum and mediastinum. Endobronchial ultrasound transbronchial aspiration demonstrated adenocarcinoma, and he was diagnosed with lung cancer (T1bN2M0). Two cycles of cisplatin and vinorelbine chemotherapy were administered concurrently with 50 Gy thoracic irradiation. He underwent left lower lobe resection and then received 4 cycles of adjuvant chemotherapy with carboplatin and paclitaxel; however, a single pulmonary metastasis was detected in the right lower lobe, and he received 48 Gy stereotactic radiotherapy. Subsequently, he developed mediastinal lymph node metastases. Fluorescent in situ hybridization analysis revealed that his tumor had an EML4-ALK rearrangement. The administration of crizotinib (500 mg/day) was initiated. A partial response was achieved and maintained for 10 months (fig. ); however, regrowth of the mediastinal lymph nodes was confirmed (fig. ). Crizotinib was continued for 1 month, and the size of the lymph nodes increased slightly (fig. ). At that time, crizotinib was discontinued and he participated in a randomized double-blinded phase III study of erlotinib ± Met inhibitor. Chest CT before the start of the experimental therapy (2 weeks after discontinuation of crizotinib) showed evident increase of the mediastinal lymph nodes but he did not complain of any symptoms (fig. ). However, 1 week after the start of the experimental therapy (3 weeks after discontinuation of crizotinib), he started to complain of dyspnea and dysphagia, and chest CT revealed a marked increase of the mediastinal lymph nodes accompanying marked stenosis of the bronchus and esophagus (5 weeks after discontinuation of crizotinib) (fig. ). The diagnosis of disease flare was made and readministration of crizotinib was started immediately. However, his disease progressed rapidly, and he died 2 days after starting crizotinib retreatment.
|
[[50.0, 'year']]
|
M
|
{'21775534': 1, '31681574': 2, '22954507': 1, '27053502': 1, '31151303': 1, '29607190': 1, '31807489': 1, '26021741': 1, '27239236': 1, '22797152': 1, '30193240': 1, '23552377': 1, '17785570': 1, '22114572': 1, '31014142': 1, '32857178': 1, '30250648': 2, '24019783': 2}
|
{'6803543-1': 1, '6152477-1': 1}
|
163,104 |
3764957-1
| 24,019,765 |
noncomm/PMC003xxxxxx/PMC3764957.xml
|
Multiple Liver Lesions in an Immunosuppressed Patient: Is Infection Always the Answer?
|
A 17-year-old female with long-standing fibrostenotic CD necessitating ileocecostomy presented with a 3-week history of worsening abdominal pain and increased stool frequency. Additionally, she reported increased fatigue and recent initiation of 17.5 mg of methotrexate weekly for enteropathic arthritis. Physical examination was remarkable for mild abdominal tenderness to palpation. Medications at the time included 9 mg of budesonide per day and adalimumab 40 mg weekly in addition to methotrexate. Computed tomography (CT) enterography revealed active inflammation of the ileum as well as multiple small branching low-density areas in the inferior aspect of the right lobe of the liver and near the porta hepatis, suggestive of small fluid collections versus thrombosed peripheral veins (fig. ). Due to concern for hepatic abscesses and CD exacerbation, she was subsequently admitted to the hospital for broad-spectrum intravenous antibiotic therapy. Laboratory workup revealed: hemoglobin 10.8 g/dl, leukocyte count 6.3 × 109/l, platelets 459 × 109/l, aspartate aminotransferase 18 U/l (normal 8–43), alanine aminotransferase 8 U/l (normal 7–45), alkaline phosphatase 102 U/l (normal 52–144), and total bilirubin 0.2 mg/dl (normal 0.1–1.0). C-reactive protein was elevated up to 13.7 mg/l and sedimentation rate was 24 mm/h. A coagulation panel was notable for an elevated D-dimer of 820 mg/ml and elevated fibrinogen of 472 mg/dl. Further history and physical examination revealed no recent fever, right upper quadrant pain, tenderness or hepatomegaly. Review of the CT scan revealed patent portal, mesenteric and splenic veins.\nTo confirm our working diagnosis, a liver ultrasound with Doppler was performed and demonstrated several small, ill-defined, echogenic areas near the porta hepatis and in the inferior aspect of the right lobe of the liver, corresponding to the low attenuation area on the CT enterography, with sonographic appearance most consistent with focal fatty infiltration (fig. ), and a patent portal vein. Magnetic resonance imaging of the abdomen with fat saturation confirmed that the hepatic lesions represented focal areas of fatty deposition. The patient's blood cultures did not grow any organisms, intravenous antibiotics were discontinued, methotrexate was optimized at 25 mg per week, and the patient was discharged home on a taper of budesonide.
|
[[17.0, 'year']]
|
F
|
{'11641164': 1, '8589130': 1, '10086679': 1, '9487637': 1, '12702985': 1, '3080643': 1, '22265856': 1, '17565671': 2, '8956191': 1, '24019765': 2}
|
{'1904453-1': 1}
|
163,105 |
3764958-1
| 24,019,789 |
noncomm/PMC003xxxxxx/PMC3764958.xml
|
A Case of Expansion of Traumatic Choroidal Rupture with Delayed-Developed Outer Retinal Changes
|
A 15-year-old girl presented with blurred vision after being hit by an elbow on her left eye. Her best-corrected visual acuity (BCVA) was 16/20. On fundus examination, both a choroidal rupture that formed a crescent shape concentric to the optic disc and a subretinal hemorrhage were detected (fig. ). Optical coherence tomography (OCT) showed that the juxtafoveal retinal pigment epithelial layer with Bruch's membrane was disrupted, and the inner segment/outer segment (IS/OS) of the photoreceptor junction and the external limiting membrane (ELM) layer were distorted with suspected pinpoint disruption (fig. ).\nAfter 3 weeks, her visual acuity reduced to counting fingers. Fundus examination revealed that the subretinal hemorrhage had absorbed and the choroidal rupture had expanded. The crescent-shaped window defect including the fovea was observed on fluorescein angiography (FAG) (fig. ). Wider disrupted layers of the RPE, the IS/OS junction, and the ELM at the corresponding area were detected in OCT. When compared with the first medical examination after the injury, the IS/OS junction and the RPE adjacent to the ruptured site were hardly distinguishable, although they were originally clearly observed (fig. ).\nSteroid pulse therapy (methylprednisolone 500 mg intravenous for 3 days and prednisolone 30 mg oral, tapering for 11 days) was started in another hospital, and 3 months after the injury, visual acuity increased to 20/125. Five months later, OCT revealed that the size of the expanded choroidal rupture had reduced, and the adjacent retina had improved sufficiently to distinguish the IS/OS junction and the RPE. However, FAG disclosed a choroidal neovascular membrane originating from the nasal edge of the choroidal rupture (fig. , fig. ). An intravitreal bevacizumab (Avastin, 1.25 mg/0.05 ml; Genentech, Inc., San Francisco, Calif., USA) injection was administered, and 1 month later, the patient's BCVA of the left eye had improved to 20/32, and the CNV had shrunk (fig. , fig. ). Also the IS/OS junction and the RPE had improved sufficiently and were able to be distinguished (fig. ).
|
[[15.0, 'year']]
|
F
|
{'1565867': 1, '15660279': 1, '27186081': 2, '21240036': 1, '2466317': 1, '6531524': 1, '24707277': 2, '14700108': 1, '16925718': 1, '20288592': 1, '7356931': 1, '15808180': 1, '21665504': 1, '9502283': 1, '27437148': 1, '19079144': 1, '21366179': 1, '32971624': 2, '32999667': 2, '12131585': 1, '24019789': 2}
|
{'7728025-1': 1, '7728025-2': 1, '7728025-3': 1, '7728025-4': 1, '7506200-1': 1, '4847605-1': 1, '3975199-1': 1}
|
163,106 |
3764959-1
| 24,019,781 |
noncomm/PMC003xxxxxx/PMC3764959.xml
|
Skull Base Clear Cell Carcinoma, Metastasis of Renal Primary Tumor: A Case Report and Literature Review
|
We report on a 62-year-old male who presented to the Ophthalmology Service with VI cranial nerve bilateral paresis, absence of pharyngeal reflex, dysarthria, right tongue deviation, and paralysis to the right side of the face. CT and MRI were performed, with CT showing a large expansive process at the cranial base with clivus and right petrous apex osteolysis (fig. ). Poor enhancement was seen following intravenous contrast injection associated with rhinopharyngeal involvement (fig. ).\nAn MRI T1 sequence showed a solid isointense expansive process with bilateral internal carotid artery involvement (fig. ). An MRI T2 sequence revealed small hyperintense areas indicative of being cystic in nature or suggestive of central necrosis (fig. ). Ipsilateral side secretions coming from the Eustachian tube indicated the mastoid region had been compromised. An additional MRI T1 sequence following administration of gadolinium contrast material showed moderate enhancement with clear involvement of bilateral internal carotid arteries (fig. ) and the cavernous sinus, posterior ethmoidal sinus, clivus and both petrous apex infiltration. In addition, nasal and posterior superior rhinopharyngeal wall involvement was observed (fig. ).\nAfter imaging analysis, the patient was referred to the ENT service and a biopsy was performed. The diagnosis was clear cell adenocarcinoma and suspicion of renal tumor metastases. The Head and Neck Cancer Committee recommended ultrasonography, which subsequently revealed a heterogeneous echogenic multilobular mass on the right kidney, with irregular contours (fig. , fig. , fig. ).\nPelvic and abdominal CT was performed, revealing a large mass on the right kidney with irregular contours and poor definition. Further investigations performed following contrast injection revealed a heterogeneous density with a hypodense central area and some calcifications in thickness (hyperdense deposits in the body of the primary tumor: right kidney) (fig. ). Radiotherapy was recommended, but due to the advanced stage of the disease the patient was enrolled in a palliative care and pain control program.
|
[[62.0, 'year']]
|
M
|
{'22135565': 1, '19536555': 1, '21371782': 1, '21940088': 1, '19186459': 1, '22454642': 2, '12404280': 1, '26623243': 1, '18823541': 2, '21195689': 1, '21185638': 1, '17766217': 1, '15877835': 1, '28801336': 1, '30211212': 2, '24842354': 1, '28761635': 1, '22265168': 1, '24019781': 2}
|
{'3295564-1': 1, '2566576-1': 1, '6134277-1': 1}
|
163,107 |
3764960-1
| 24,019,769 |
noncomm/PMC003xxxxxx/PMC3764960.xml
|
Tumor-Like Growth of Giant Inflammatory Polyposis in a Patient with Ulcerative Colitis
|
A 25-year-old Japanese man with an UC history of 2 years and 6 months was successfully treated with prednisolone. The disease was in remission and his symptoms had been relieved. However, the disease flared up and the patient was admitted to our hospital because of severe abdominal pain and bloody diarrhea. Physical examination revealed direct soreness and masses in the upper and left lower abdominal sites. Blood examination revealed anemia (hemoglobin level 5.5 g/dl [normal 11.5–15.0]), hypoproteinemia (protein level 4.6 g/dl [normal 6.7–8.3]) and hypoalbuminemia (albumin level 1.9 g/dl [normal 3.8–5.3]).\nComputed tomography (CT) imaging showed bowel wall thickening of the transverse and descending colon, which raised suspicion of wall thickening of several segments of the small bowel. The CT scan also demonstrated localized high-density areas in the lumen of the transverse and descending colon (fig. ). Barium enema examination showed irregular mucosal contours with polyposis in these areas (fig. ). A colonoscopy revealed a large mass with numerous white-pale reddish polyps of complex shape in the descending colon. The endoscope could not be inserted beyond this point. Endoscopy indicated that the colon distal to the mass and the rectum were normal. Based on this examination, colon carcinoma was strongly suspected, and several biopsies were performed. Histology of the examined sections indicated uncharacteristic inflammatory changes in the mucosa, but no cellular dysplasia. Subsequently, the patient underwent a total colectomy for removal of the obstruction. His postoperative recovery was complete, and he remains in good health.\nMacroscopic examination of the excised colon indicated remarkable dilation. On excision, we observed one tumor measuring 23 × 18 cm in the transverse colon and another measuring 14 × 13 cm in the descending colon. There were no obvious areas of ulceration, although each tumor had a coral-reef-like surface with numerous soft, finger-like polyps (up to 5 cm in diameter) projecting into the lumen. These aggregating polyps occurred in the segment with the thickened wall. The cross-section of the tumors showed that narrow strings of tissue were interconnected, forming multiple, variably sized spaces inside the tumors (fig. ). The surrounding fat tissue was unaffected, and no suspicious lymph nodes were detected.\nMicroscopic examination revealed that the tumors comprised strings of fibrotic connective tissue, lined by inflamed colonic mucosa, and the surrounding spaces were filled with fecal and mucoid materials. A fibrovascular core and inflammatory polyposis were evident from the submucosa to the proper muscular layer and the submucosa had partially disappeared in both the elevated and the depressed lesions. The polyps contained regenerative and hyperplastic muscularis mucosa with an arborized and thickened configuration (fig. ). In most areas, the crypt architecture was normal, and no epithelial atypia of the polyps was noted. The mucosal inflammation consisted of lymphocytes, plasma cells, eosinophils and lymphoid follicles. Neutrophil infiltration, cryptitis, crypt abscess, which is characteristic of active UC, and Paneth cell metaplasia were found in the transverse colon (fig. ). Sections through the bowel wall near the mass showed colonic mucosa with regenerative features, including architecturally mildly distorted glands, but without active inflammatory changes (fig. ). There were no granulomas or parasites. Finally, histopathological examination of the resected colon led to the diagnosis of giant inflammatory (filiform) polyposis associated with UC.
|
[[25.0, 'year']]
|
M
|
{'33189004': 1, '7389523': 1, '30984431': 2, '11851832': 1, '12471554': 1, '25540051': 2, '12024154': 1, '14564633': 1, '29687785': 2, '19230051': 1, '15942721': 1, '14564641': 1, '830229': 1, '8652927': 1, '2341571': 1, '12031089': 1, '3717497': 1, '1392419': 1, '32595204': 1, '11089270': 1, '29984012': 2, '24019769': 2}
|
{'6015717-1': 1, '6015717-2': 1, '6431470-1': 1, '4364679-1': 1, '6158465-1': 1}
|
163,108 |
3764961-1
| 24,019,779 |
noncomm/PMC003xxxxxx/PMC3764961.xml
|
Posttraumatic Glioma: Report of a Case
|
A 37-year-old man was admitted in October 2002 with a several months history of medically refractory seizures and a more recent onset of headache and confusion. His past clinical history was relevant for a major brain trauma with left temporal hemorrhage, which occurred in 1977 and which was demonstrated by CT scanning as indicated by the clinical charts of another hospital. At admission, he showed mild confusion, short-term memory deficit but no speech impairment. MRI demonstrated a T1 hypointense and T2 hyperintense lesion in the left insular region, which did not enhance with gadolinum (fig. ). The lesion was exposed via a pterional approach and wide splitting of the Sylvian fissure and generously removed; however, it was intentionally not radically removed. No clear limit with the surrounding normal parenchyma could be seen at surgery. Histological examination revealed a moderately increased cellularity (fig. ) compatible with diffuse astrocytoma (grade II according to the WHO classification). In addition, pseudo-cystic areas containing hemosiderin pigment and CD68-positive macrophages, interstitial hemosiderin-loaded macrophages and inflammatory cells were also detected (fig. ). These findings would indicate the presence of a pre-existing hemorrhage. After surgery, the patient's confusion definitely improved, as did the focal epilepsy. This latter was well controlled with a low medication dosage until 2004, when, due to recrudescence of the seizures, he underwent a MRI that again documented an abnormal area in the deep left temporal region (fig. ). The lesion was removed via a transulcal left temporal approach and again removal was not radical. Histological examination in this occasion gave evidence of only local degenerative posttraumatic changes. Again, focal epilepsy improved. He was readmitted in December 2006 because an MRI follow-up study (fig. ), performed again because of worsening of the seizures, had demonstrated an area of contrast enhancement in the context of the previously abnormal area. The patient was submitted for surgery via the same previous temporal craniotomy, and the lesion was apparently totally removed. Histological examination now revealed (fig. ) an anaplastic astrocytoma (grade III according to the WHO classification). The postoperative course was uncomplicated. The patient underwent postoperative radiation treatment and chemotherapy. At the last follow-up, 5 years after surgery, the patient was well and had no signs of recurrence.
|
[[37.0, 'year']]
|
M
|
{'10884891': 1, '3591036': 1, '15510986': 1, '22320191': 1, '6700730': 1, '12057095': 1, '31847406': 1, '4278808': 1, '26893630': 1, '11562113': 1, '9758110': 1, '21500545': 1, '20714434': 1, '24019779': 2}
|
{}
|
163,109 |
3764962-1
| 24,019,782 |
noncomm/PMC003xxxxxx/PMC3764962.xml
|
Total Reconstruction of the Afferent Loop for Treatment of Radiation-Induced Afferent Loop Obstruction with Segmental Involvement after Pancreaticoduodenectomy with Roux-en-Y Reconstruction
|
A 65-year-old man was referred to our hospital due to recurrent episodes of crampy periumbilical pain and associated episodes of emesis over the previous 2 months. The patient had undergone PD 2 years earlier in our surgical department. The initial operation comprised PD along with distal gastrectomy, complete omentectomy, extended lymphadenectomy and Roux-en-Y reconstruction for a moderate differentiated, pT2pN1(2/39)MO, ly(+), v(+), R0 pancreatic ductal adenocarcinoma of the head. After the operation, the patient received concomitant flat infusional 5-FU chemotherapy (300 mg/m2/day, 5 days/week) during the entire course of external beam irradiation (50.4 Gy in 33 fractions over 7 weeks). No recurrence was found at the follow-up visits (assessment of CA19.9 levels every 3 months and abdominal CT scan every 6 months).\nAbdominal examination was remarkable for tenderness in the right upper quadrant. The laboratory workup revealed a normal white blood cell count, transaminases and slight elevation of bilirubin, alkaline phosphatase, γ-glutamyl transpeptidase and amylase. Plain abdominal X-rays were normal. Multidetector CT (MDCT) revealed: (a) segmental afferent loop wall thickening and lumen narrowing; (b) absence of lymphadenopathy, and (c) dilatation of the hepatic duct (9 mm) and the pancreatic duct (2.9 mm). Ductal pathology was further assessed though magnetic resonance cholangiopancreatography (MRCP) examination which revealed a fixed filling defect at the HJ and PJ with associated postobstructive hepatic and pancreatic duct dilation.\nThe diagnosis of chronic ALO along with HJ and PJ stricture was established; radiation enteritis of the afferent loop and/or the overlap of radiation enteritis and local recurrence in the length of involvement were presumed to be the causes of the obstruction. Elective laparotomy was performed via an extended upper midline incision. Once adhesions from the previous surgery were taken down and the free peritoneal cavity was entered, the liver, hepatoduodenal ligament, stomach, efferent loop, jejunojejunostomy and afferent loop were recognized (fig. ). The gastric remnant, efferent loop and afferent loop were released from adhesions and fully mobilized. Copious dissection in a field of dense adhesions and scar tissue on either side of the afferent loop enabled recognition of the HJ, PJ and pancreatic body. Peripherally, the afferent loop was transected distal to the involved segment (fig. ). Proximally, mobilization of the afferent loop exposed the surgical bed of the previous PD; no macroscopic evidence of local recurrence in the pancreatic bed, the liver or the peritoneal surface was observed (fig. ). The HJ was disconnected and a new end-to-side HJ was performed. Moreover, the PJ was taken down and examined. A short segment (1.5 cm) of the remnant pancreas was resected until the dilated pancreatic duct was revealed and a revised duct-to-mucosa PJ was performed using an anastomotic stent (fig. ). The distal remnant of the afferent loop, which was pulled toward the pancreas through the transverse mesocolon, had a sufficient redundancy to provide construction of the anastomoses without tension. A closed suction drain was placed at the subhepatic space near the anastomoses, and the abdomen was closed with a running No. 1 looped nonabsorbable suture and staples. Histology of the surgical specimen revealed microscopic findings of radiation enteritis without evidence of malignancy. The postoperative course was uneventful, and the patient was discharged home on postoperative day 9. At a follow-up time of 11 months, the patient was alive and asymptomatic; MRCP revealed no evidence of stenosis or diminished flow across the revised anastomoses.
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[[65.0, 'year']]
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M
|
{'20590889': 1, '26425267': 1, '16814147': 1, '21689816': 1, '18705336': 1, '23110908': 1, '1350387': 1, '20815857': 1, '23008765': 1, '11312162': 1, '24019782': 2}
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{}
|
163,110 |
3764963-1
| 24,019,786 |
noncomm/PMC003xxxxxx/PMC3764963.xml
|
Reversible Isolated Accessory Nerve Palsy due to a Large Thrombosed Vertebral Aneurysm
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A 70-year-old woman complaining of transient numbness in the upper right and lower limbs was referred to our hospital. Physical and neurological examinations revealed no definite abnormalities. However, MRI indicated a large mass lesion in the posterior fossa. The maximal diameter was 22 mm. The mass severely compressed the medulla oblongata and caused a high signal intensity lesion, suggesting a vasogenic edema. Both T1- and T2-weighted MRI showed a flow void signal and mixed signal intensity area inside the mass, suggesting a partially thrombosed vertebral aneurysm (fig. ). MRA disclosed a thrombosed large aneurysm of the right vertebral artery (VA) (fig. ).\nThe proximal VA was exposed through right suboccipital craniotomy and was clipped with one titanium aneurysm clip in order to reduce the pressure inside the aneurysm. The postoperative course was uneventful. No neurological deterioration occurred. Postoperative MRA showed the disappearance of the flow void signal inside the aneurysm. One month later, however, cerebral angiography revealed a partial recanalization of the right VA, probably because one titanium aneurysm clip was not enough to obliterate the sclerotic VA. She then underwent coil embolization of the right VA just proximal to the aneurysm clip. Subsequently, the right VA was completely obliterated. She was discharged without any neurological deficit. However, a couple of weeks later she complained of mild hoarseness and right shoulder pain. Physical and neurological examinations showed the atrophy of the right trapezius and sternocleidomastoid muscle, leading to the deepening of the right supraclavicular fossa (fig. ). No other cranial nerve deficits were observed. The symptoms were considered to result from right isolated accessory nerve palsy. Radiological examinations showed no newly developed lesion such as cerebral infarction in the brain stem. There was no significant change in size of the VA aneurysm. As a result, the isolated accessory nerve palsy was considered to be a delayed complication due to aneurysmal compression on the intracranial portion of the accessory nerve.\nFollow-up MRI showed that the VA aneurysm gradually decreased in size over a period of several months. The deformity of the medulla oblongata markedly improved and its high signal intensity lesion completely disappeared (fig. ). At the same time, the patient's hoarseness completely resolved. The deepening of the right supraclavicular fossa also disappeared completely (fig. ).
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[[70.0, 'year']]
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F
|
{'20647524': 1, '31359190': 1, '17661123': 1, '9814939': 1, '8875506': 1, '18295637': 1, '24019786': 2}
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{}
|
163,111 |
3764964-1
| 24,019,792 |
noncomm/PMC003xxxxxx/PMC3764964.xml
|
Retinal Arterial Occlusive Disease in a Young Patient with Cat Scratch Disease
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A 23-year-old woman was referred to our clinic with a 2-day history of scotoma in the left upper visual field of her left eye. The patient's past medical and ocular histories were unremarkable. At presentation, her Snellen best-corrected visual acuity was 10/10 in both eyes. Examination of the anterior segment did not reveal any abnormal findings, while a mild vitritis was noted in both eyes. Fundoscopy revealed an occlusion of the inferior temporal branch of the left retinal artery (fig. ) and multiple foci of retinitis in the posterior pole of both eyes, more prominently in the left. Fluorescein angiography was subsequently performed, which confirmed the diagnosis of arterial occlusion and the presence of vasculitis (fig. ). Leakage of the inferonasal part of the left optic disc was also noted. Laboratory investigations were undertaken for all possible causes of anterior and posterior uveitis. The patient had not received any treatment before the laboratory tests were performed.\nTwo weeks after presentation her clinical symptoms started to improve, while fundoscopy and fluorescein angiography showed resolution of the retinal arterial occlusion. Indocyanine angiography did not reveal choroidal involvement. Laboratory analysis showed a positive IgG titer for B.\nhenselae (IgG = 512, positive >128, indirect immunofluorescence) that continued to rise during the second month of the disease (IgG = 1,024) and declined afterwards. The IgM titers were notably negative throughout the course of the disease. Based on the elevated serum IgG titers, the diagnosis of cat scratch disease was established. Clinical examination did not reveal lymphadenopathy or skin lesions. The patient could not remember any incidents of being scratched or bitten by a cat despite the presence of 2 kittens in a nearby premise. The patient was advised to take oral doxycycline 100 mg BD for 4 weeks, but discontinued the treatment 3 weeks later. At follow-up, 2 months after the initiation of treatment, there was complete resolution of both the arterial occlusion and retinitis. By that time, some hard exudates had started to appear in the left macular region, without forming the typical ring of a macular star (fig. ).
|
[[23.0, 'year']]
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F
|
{'20148999': 1, '8862061': 1, '30852734': 1, '7575258': 1, '10168891': 1, '18454406': 1, '11020414': 1, '9627652': 1, '28182175': 1, '20973657': 1, '18645403': 1, '24019792': 2}
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{}
|
163,112 |
3764965-1
| 24,019,785 |
noncomm/PMC003xxxxxx/PMC3764965.xml
|
Prolonged Clinical Benefit of Everolimus Therapy in the Management of High-Grade Pancreatic Neuroendocrine Carcinoma
|
In June 2008, a 34-year-old woman presented with a 2-month history of epigastric and periumbilical pain, fatigue, anorexia, nausea, and emesis. Physical assessment showed mild abdominal distention with painful hepatomegaly extending to the left hypochondrium, no adenopathy, and normal findings on echocardiogram (left ventricular ejection fraction, 72%). Computed tomography (CT) revealed hepatomegaly with multiple lesions (the largest lesion measured approximately 11.5 cm in diameter), a 5 × 7-cm mass in the tail of the pancreas, and a collection of subcapsular hepatic, perihepatic, and perivascular fluid. An analysis of tumoral tissue obtained by liver biopsy showed electron-dense granules containing synaptophysin and chromogranin A (CgA), high mitotic count (30/10 high-power fields), and high expression of Ki-67 (found in 30–40% of tumor cells) (fig. ). Octreotide scintigraphy confirmed somatostatin receptor expression in the pancreatic tumor and in liver and peritoneal metastases. At the time of diagnosis, the patient's Karnofsky performance status (KPS) was 70%.\nChemotherapy was initiated with streptozocin and 5-fluorouracil in July 2008; the patient received 3 cycles of this first-line chemotherapy. In September 2008, clinical and biomarker evaluation demonstrated progressive disease, and treatment was switched to second-line cisplatin and etoposide for 4 cycles. After disease progression, the patient began treatment with streptozocin and doxorubicin. After the completion of 3 cycles, however, the disease continued to progress rapidly, as assessed by radiologic imaging and changes in biomarker levels (CgA value, 4,381 ng/ml) (table ).\nAfter 9 months of chemotherapy and 3 lines of therapy, the patient had a KPS of 60%, peritoneal metastases, and palpable hepatomegaly. She required high-dose opioids to achieve analgesia. Fourth-line treatment with temozolomide (150 mg/m2 on days 9–14) and capecitabine (1,000 mg/m2 for 14 days every 3 weeks) was subsequently initiated and led to the achievement of partial radiologic response at 12 weeks (4 cycles); however, the patient experienced disease progression after 6 cycles of therapy.\nIn September 2009, after receiving 1 dose of fifth-line weekly paclitaxel, the patient was hospitalized because of toxicity and general deterioration in health. She had uncontrolled pain, esophagitis, and small bowel partial obstruction caused by peritoneal disease progression that prevented her from eating without severe nausea. CgA concentration increased to 4,600 ng/ml, KPS decreased to 50%, and CT demonstrated massive hepatic and peritoneal tumor infiltration (fig. ). Therefore, the patient was given intravenous fluids, morphine, scopolamine butyl bromide, dexamethasone, and subcutaneous octreotide as palliative and conservative therapy. After 1 week, she was able to tolerate oral fluids and drugs and experienced some improvement in general state. Taking into account initial data findings from the recent RADIANT-2 study [], the patient's age, and her request to receive further lines of treatment, everolimus 10 mg/day plus octreotide LAR 30 mg every 4 weeks were initiated upon patient informed consent and compassionate use guidelines. Octreotide LAR had not previously been administered because of the patient's high baseline Ki-67 index (30–40%).\nFifteen days after the initiation of sixth-line therapy with everolimus plus octreotide LAR, the CgA concentration decreased to 1,388 ng/ml. The patient achieved partial radiologic response (>50% decrease in tumor size) after 2 months of treatment (fig. ). By January 2010, her general health status had markedly improved, corresponding to a KPS of 90%, with pain and oral restrictions alleviated. Clinically important partial response (decrease in tumor size >80%) was confirmed by CT (as per RECIST v1.0; fig. ) and by reduced CgA levels after 8 months of therapy with everolimus (fig. ). The lowest CgA value, 137 ng/ml, was achieved in August 2010 after approximately 1 year of treatment.\nThroughout the course of everolimus plus octreotide LAR treatment, the patient experienced grade 1 hyperglycemia and grade 2 anemia, which were treated with an antidiabetic diet and erythropoietin plus intravenous iron therapy, respectively. Grade 1 stomatitis was also documented but did not require pharmacologic intervention. After 1 year of treatment, the patient reported sporadic grade 1 emesis, grade 1 diarrhea, and grade 1 hand-foot syndrome.\nIn December 2010, after 15 months of everolimus and octreotide LAR as sixth-line therapy, the patient continued to be asymptomatic and had a KPS of 90%. Assessment by CT demonstrated an increase in the size of a peritoneal node (from 17 mm in early scans to 25 mm). To prevent disease progression, everolimus was administered at a higher dose (15 mg/day), and 1 month later the node had decreased in size (to 21 mm).\nAfter more than 1 year of treatment benefit with everolimus, during CT evaluation in March 2011, the patient's liver metastases were shown to have progressed. A diagnostic biopsy was repeated. However, it was possible only to confirm the high Ki-67 index and electron-dense granules containing synaptophysin and CgA. Most of the cells were necrotic, and it was not possible to check for tissue expression of potential everolimus response predictors such as mTOR and 4EB1. One week later clinical progression was reported, and 2 weeks later the patient was hospitalized with liver failure, fever, jaundice, painful hepatomegaly, extrinsic compression of the stomach, anorexia, and asthenia. After progressive deterioration in her general health, the patient died on April 4, 2011, 33 months after the initial diagnosis and 19 months after the initiation of treatment with everolimus plus octreotide LAR.
|
[[34.0, 'year']]
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F
|
{'29757017': 1, '31428952': 1, '18565894': 1, '19704057': 1, '20824724': 1, '17896148': 1, '20555086': 1, '19657638': 1, '26851029': 1, '19713713': 1, '21672194': 1, '18779618': 1, '31143376': 2, '29242283': 1, '21468754': 1, '21306238': 1, '22119496': 1, '25142799': 1, '15570077': 1, '20664477': 1, '14962717': 1, '27788498': 1, '26138480': 1, '28735458': 1, '24019785': 2}
|
{'6524935-1': 1}
|
163,113 |
3764967-1
| 24,019,767 |
noncomm/PMC003xxxxxx/PMC3764967.xml
|
A Case of Adult Type 1 Gaucher Disease Complicated by Temporal Intestinal Hemorrhage
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A 21-year-old male patient suffering from sudden rectal hemorrhage was admitted to a general hospital in July 2009. Emergent colonoscopy was performed with the findings of (1) a large amount of blood in the rectum and sigmoid colon and (2) oozing from eroded rectal mucosa. Laboratory investigation revealed thrombocytopenia (platelets 10.3 × 104/\nμl). Although the hemorrhage stopped spontaneously and did not occur again, the patient was referred to our hospital for further examinations. He had had no previous significant rectal bleeding. His past medical history was unremarkable except for occasional nasal bleeding during childhood.\nOn physical examination, the abdomen was soft and flat; a non-tender liver edge descended to 8.5 cm below the right costal margin, and the splenic tip was palpable 11.5 cm below the left costal margin. Neurologic examination revealed no evidence of abnormalities. The laboratory data are summarized in table . There were thrombocytopenia and slight leukocytopenia (platelets 6.7 × 104/μl, white blood cells 3,180/μl). Other laboratory findings disclosed: total bilirubin 1.4 mg/dl (reference range 0.2–1.3), direct bilirubin 0.5 mg/dl (reference range 0–0.3), and prothrombin time activity 77.0% (reference range 90–130). To find out the cause of thrombocytopenia and leukocytopenia, we performed serology tests for infection with hepatitis B virus, hepatitis C virus, Epstein-Barr virus and Helicobacter pylori; however, there were no remarkable findings. Anti-DNA antibody test showed a titer of 1:40 (reference range <1:40). His platelet-associated immunoglobulin G (PAIgG) level was elevated to 166 ng/107 cells (reference range 9.0–25.0), however anti-platelet antibody (anti-platelet-binding IgG) was negative.\nEnhanced computed tomography (CT) showed the extremely enlarged liver and spleen. The splenic and the superior mesenteric vein were dilated and tortuous, whereas no apparent cirrhotic change of the liver was observed (fig. ). For further examination, especially for the differential diagnosis of idiopathic portal hypertension, we performed a liver biopsy. The liver biopsy specimen showed that numerous large cells with striated cytoplasm assembled in Glisson's capsule (fig. ). The cells had abundant eosinophilic cytoplasm with a striated or fibrillar appearance like that of crumpled tissue paper, which is typical of Gaucher cells []. There was fibrous expansion of most portal tract areas, but bridging fibrosis was not seen. Additional blood investigations revealed high values of acid phosphatase and angiotensin-converting enzyme (ACE) concentrations (table ), which is compatible with Gaucher disease []. The enzymatic activity of leukocyte β-glucosidase, the measurement of which is necessary for the definitive diagnosis of Gaucher disease, had decreased to 11.67 nmol/h/mg (reference range 56.76–74.85) [, ]. We analyzed the seven common mutations (N370S, 84GG, F213I, IVS2+1, L444P, R463C and D409H) in the GBA gene as previously reported [, , ] with the informed consent of the patient and found the compound heterozygous mutations L444P/D409H. Based on these results, we diagnosed the patient with Gaucher disease type 1.\nWe started enzyme replacement therapy (ERT). 60 U/kg body weight imiglucerase, a macrophage-targeted recombinant human glucocerebrosidase, was injected every 2 weeks []. Figure shows the CT scan 5 months after ERT started. The liver and the spleen were sized down (liver: from 23.3 × 15.4 × 20.3 cm to 22.1 × 15.3 × 17.9 cm; spleen: from 12.8 × 10.5 × 21.1 cm to 11.8 × 9.4 × 17.3 cm). Platelet counts number and ACE concentration, a biomarker of the progress of Gaucher disease [], were also improved from 7.4 to 11.3 × 104/μl and from 42.5 to 24.7 IU/μl, respectively (fig. ).
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[[21.0, 'year']]
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M
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{'21670466': 1, '11025794': 1, '30285649': 1, '6540988': 1, '15149877': 1, '7985893': 1, '8698334': 1, '21209725': 1, '8257989': 1, '14253443': 1, '12826642': 1, '1852673': 1, '1589760': 1, '8132832': 1, '16967369': 1, '19094956': 1, '24019767': 2}
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{}
|
163,114 |
3764968-1
| 24,019,787 |
noncomm/PMC003xxxxxx/PMC3764968.xml
|
Levodopa-Responsive Benign Tremulous Parkinsonism
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A right-handed 56-year-old woman presented at our hospital with a 2-year history of right-hand tremor and complaints of fumbling with buttons. The patient had neither tremor nor family members with PD in her family history, and her past medical history was unremarkable. Physical examination showed blood pressure of 138/90 mm Hg and her cognitive function was normal. The neurological examination revealed pill rolling typical rest tremor (4–6 Hz) and slow finger tapping with decreased amplitude on her right hand; however, we did not observe posture tremor, rigidity, bradykinesia, or posture disability. Laboratory tests were all within normal limits, including thyroid function. T2-weighted magnetic resonance imaging did not show high-intensity spots in deep white matter, allowing us to rule out vascular parkinsonism (fig. ). Decreased cardiac uptake of 123I-metaiodobenzylguanidine (MIBG) during myocardial scintigraphy was observed [H/M ratio (early: 1.88, delayed: 1.78)]. Her Unified Parkinson's Disease Rating Scale III motor score was 4/108 points. She was diagnosed as having PD (Hoehn and Yahr stage 1) and received levodopa/carbidopa 200 mg/day, which effectively treated the rest tremor. When she was 61 years old, the right-hand rest tremor reoccurred and she was treated with levodopa/carbidopa (a total of 300 mg/day) and selegiline (2.5 mg/day). Slow finger tapping with decreased amplitude continued; however, her rest tremor improved. Approximately 11 years have passed since the patient's onset of symptoms and her parkinsonism is slowly progressive; however, she does not show disability apart from continuing to fumble with buttons.
|
[[56.0, 'year']]
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F
|
{'19373934': 1, '18795596': 1, '18098275': 1, '16533962': 1, '17030676': 1, '25221586': 1, '14531042': 1, '9827589': 1, '18307261': 1, '23239469': 1, '1641153': 1, '22323748': 1, '24019787': 2}
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{}
|
163,115 |
3764969-1
| 24,019,784 |
noncomm/PMC003xxxxxx/PMC3764969.xml
|
Bevacizumab is Effective for Recurrent Papillary Tumor of the Pineal Region: First Report
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A 31-year-old right-handed man was referred for treatment of recurrent PTPR in the posterior fossa with symptoms including headache, inability to open his eyes, confusion, and obstructive hydrocephalus. He originally presented at 24 years of age with obstructive hydrocephalus and a 1.5-cm enhancing pineal mass. Following placement of a ventriculoperitoneal shunt and a nondiagnostic biopsy, he underwent craniotomy and resection. The pathology report showed a papillary neoplasm negative for GFAP, synaptophysin, PLAF, and MEC, and positive for CAM 5.2 and cytokeratin 3. The MIB-1 index was 15%. The pathology was reviewed at Johns Hopkins University and has subsequently been reviewed by us; the diagnosis has been confirmed to be PTPR (fig. ). Because of residual tumor, he received 5,940 cGy of radiotherapy in 33 fractions.\nSeven months later, he developed a new 1-cm enhancing mass in the left lateral ventricle that increased in size over 3 months. New lesions also developed in the posterior fossa, and he was treated with Gamma Knife to 5 locations. Eighteen months later, he had Gamma Knife to 4 additional posterior fossa lesions, resulting in shrinkage of the lesions on MRI and decreased steroid requirement. Over the next 2 years, he had waxing and waning enhancement over the right inferior temporal lobe that was treated as radiation necrosis with pentoxifylline and vitamins, with subsequent resolution of the enhancement.\nBy the age of 28, he had increased edema and mass effect in the left cerebellum and underwent a posterior fossa craniotomy. The specimen was about 70% necrosis and gliosis and 30% viable PTPR. Because of residual enhancement, dose-dense temozolomide (75 mg/m2 for 21 days of a 28-day cycle) was given for 11 cycles. He then developed increased enhancement and worsening balance while on the temozolomide and was treated with 2 cycles of PCV and 2 cycles of carboplatin and etoposide.\nHis MRI then showed stable 1-cm lesions in the occipital lobe but an enlarging 4.6 × 3.2 × 2.8-cm mass in the midline posterior cerebellum and a 1.7 × 1 × 2.8-cm mass abutting the fourth ventricle, both with surrounding edema and mass effect, and he was referred to the University of Utah (fig. ). An extraventricular drain was placed, followed by a ventriculoperitoneal shunt. Reirradiation was recommended, but the patient declined due to prior toxicity.\nTwelve days later, at the age of 31, he began bevacizumab 10 mg/kg every 2 weeks. The enhancing midline cerebellar mass decreased in size to 2 × 1.4 × 2.8 cm (80% decrease in the cross-sectional area) and the periventricular mass decreased to 1.7 × 0.8 × 0.9 cm in 1 month (20% decrease in the cross-sectional area), and both remained stable for 13 months. The FLAIR signal remained decreased as well (fig. ). His dexamethasone dose remained at 2 mg daily for 6 months and then was tapered off.\nAfter 13 months, both masses increased in size to 3.1 × 1.9 cm (120%) and 2.2 × 1.1 cm (84%) in cross-sectional area, respectively (fig. ). Oral etoposide 50 mg/m2 for 21 out of 28 days was added, and his mass remained stable on MRI at 2, 5 (fig. : white arrow indicates tumor; black arrow indicates shunt), and 7 months. After 7 months of bevacizumab and etoposide, he had increased dysarthria and ataxia, and MRI demonstrated growth of the masses by 220% in cross-sectional area to 5.6 × 3.5 cm and by 100% to 3.1 × 1.7 cm. He again declined radiation and has continued on bevacizumab and etoposide. His dexamethasone dose has varied between 1 and 2 mg per day.
|
[[31.0, 'year']]
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M
|
{'17460510': 1, '18159143': 1, '22537279': 1, '18069972': 1, '21743183': 1, '17618441': 1, '23314823': 1, '34268174': 2, '20942871': 1, '12657936': 1, '19856218': 1, '22086239': 1, '21839968': 1, '17960392': 1, '21844577': 1, '22588068': 1, '17021405': 1, '16866300': 1, '17891572': 1, '19917990': 1, '19517065': 1, '21529195': 1, '21658955': 1, '20644284': 1, '24019784': 2}
|
{'8244718-1': 1}
|
163,116 |
3764970-1
| 24,019,791 |
noncomm/PMC003xxxxxx/PMC3764970.xml
|
Rare and Unusual Choroidal Abnormalities in a Patient with Systemic Lupus Erythematosus
|
A 42-year-old woman complaining of transient blindness in her left eye was referred to our hospital. The patient had a history of SLE and central retinal artery occlusion in her right eye that occurred at the age of 33 years. On initial examination, she had a best-corrected visual acuity of 1.2 in the left eye and no light perception in the right eye. Ocular pressures and anterior segments were normal (fig. ). Fundus examination showed no specific retinochoroidal abnormalities with the exception of optic disc atrophy due to central retinal artery occlusion in her right eye (fig. ) and a peripapillary small hemorrhage in her left eye (fig. ). Fluorescein angiography revealed no dye leakage and pooling (fig. ). However, NIR (Heidelberg Retina Angiograph 2, Heidelberg Engineering, Heidelberg, Germany) showed multiple bright patchy lesions in the choroid of the posterior pole and the mid-periphery of the fundus in both eyes (fig. ). OCT (RS-3000, NIDEK, Gamagori, Japan) images of these lesions revealed irregular, hyperreflective choroidal foci (fig. ).\nAdministration of oral steroids was continued and her laboratory values were as follows: hemoglobin 9.1 g/dl, hematocrit 29.3%, WBC count 6,900/mm3 and platelet count 223,000/mm3. No atypical cells were found during a peripheral blood smear. C-reactive protein was 0.97 mg/dl (normal <0.06 mg/dl). Hepatic and renal function tests and electrolytes were within normal limits. Urinalysis was normal. C3 and C4 complement fractions were 64 and 11 mg/dl, respectively (normal values are 86–160 and 17–45 mg/dl, respectively). Anti-double-stranded DNA antibody was 125.1 IU/ml (normal <12.0 IU/ml). Cranial magnetic resonance imaging findings were unremarkable.
|
[[42.0, 'year']]
|
F
|
{'11041400': 1, '21963267': 1, '11858825': 1, '8414628': 1, '14677041': 1, '9207339': 1, '12393709': 1, '18700931': 1, '6404285': 1, '803299': 1, '812832': 1, '21511760': 1, '8417346': 1, '22888215': 1, '32581507': 1, '10620616': 1, '2114220': 1, '15891894': 1, '2134734': 1, '24019791': 2}
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{}
|
163,117 |
3764971-1
| 24,019,780 |
noncomm/PMC003xxxxxx/PMC3764971.xml
|
Aspergillosis in a Patient Receiving Temozolomide for the Treatment of Glioblastoma
|
A 78-year-old woman was diagnosed 4 months before admission with a right frontal GBM with extension to the basal ganglia and temporal lobe. The patient underwent a frontal craniotomy and partial resection of the lesion, followed by hypofractionated radiation therapy (16 fractions of 250 cGy) with concomitant daily TMZ (75 mg/m2). During the concurrent phase, she developed grade 1 lymphopenia and grade 2 nausea, but the treatment was otherwise well tolerated. Two days after completing chemoradiation, the patient was admitted for dyspnea and asymmetrical lower extremity edema. At admission, she denied cough, sputum, hemoptysis or thoracic pain. She reported no fever, chills, sweats or weight loss. Neurologic symptoms were stable since her last assessment. She had a history of hypertension and controlled type 2 diabetes. Medications included omeprazole, amlodipine, metformin, gliclazide, sitagliptin and prophylactic sulfamethoxazole-trimethoprim. She was also taking dexamethasone 4 mg/day on a tapering scale.\nUpon physical examination, she had normal vital signs, with a respiratory rate of 18 breaths/min and oxygen saturation of 95% on room air. She had asymmetric edema of the lower limbs and, on auscultation, fine respiratory crackles bilaterally. Electrolytes, liver enzymes and renal function were normal. Blood counts were: hemoglobin 11.9 g/dl, platelets 67,000/mm3 and leukocytes 7,030/mm3, with an absolute lymphocyte count of 800/mm3. A venous duplex-scan of the lower extremities showed an extensive deep vein thrombosis involving the left common femoral vein. An angiotomography of the thorax diagnosed an acute pulmonary embolism and also revealed scattered lobulated nodules with areas of cavitation, measuring up to 2.7 cm, located predominately in the upper lobes, some with a surrounding ground-glass halo. There was no pleural effusion. Areas of peribronchial infiltrates and centrilobular nodules were also present (fig. ). Serum galactomannan levels, determined using an enzyme-linked immunosorbent assay, were elevated (optical density index = 6.7, optical density index ≥0.5 is considered a positive result). Blood samples obtained for culture and Cryptococcus neoformans and Histoplasma antigen assays were negative.\nA CT-guided pulmonary biopsy was then performed. Histochemical analysis (Gomori's silver stain) showed septate hyphal elements with acute-angle branching (fig. ), and culture of the pulmonary tissue was positive for Aspergillus fumigatus. The patient was promptly started on antifungal therapy with voriconazole and was discharged to complete the treatment as an outpatient. Chemotherapy with TMZ was resumed after 4 weeks of antifungal therapy. A control CT scan done approximately 30 days after admission revealed a reduction of the nodular lesions and ground-glass component previously identified (fig. ).\nWritten informed consent for publication of the clinical details and/or clinical images was obtained from the guardian/relative of the patient.
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[[78.0, 'year']]
|
F
|
{'21193785': 1, '25358508': 1, '16619154': 1, '17276936': 1, '19201195': 1, '11912174': 1, '19269895': 1, '14726505': 1, '20455691': 1, '21737504': 1, '17964019': 1, '11870182': 1, '15758009': 1, '31154345': 1, '19403905': 1, '17612935': 1, '16203762': 1, '24019780': 2}
|
{}
|
163,118 |
3764972-1
| 24,019,777 |
noncomm/PMC003xxxxxx/PMC3764972.xml
|
Herpes Simplex Virus Type-I and Pyogenic Granuloma: A Vascular Endothelial Growth Factor-Mediated Association?
|
A 52-year-old woman was diagnosed with hairy-cell leukemia in 1999 and treated with cladribine [2-chlorodeoxyadenosine (2CDA)], which led to complete remission. Two recurrences occurred in 2005, both successfully treated with 2CDA and lenograstim, a recombinant granulocyte colony-stimulating factor. In 2006, another recurrence was treated with lenograstim without obtaining complete remission. In 2007, due to persisting grade-2 pancytopenia and medullar infiltration, interferon alpha-2a was initiated. In 2008, remission was obtained with the chimeric anti-CD20 monoclonal antibody rituximab (8 cures), but leuconeutropenia persisted. Since June 2011, no further treatments have been administered, although the patient still presents moderate leuconeutropenia (without any infectious complications, however).\nThree months previously, a slow-growing vascular lesion appeared on the lower lip following an episode of labial herpes. Clinical examination revealed a large, unilateral, annular, ulcerated, painful, indurated and easily bleeding lesion on her left cheek (fig. ). No locoregional lymphadenopathies were evidenced. The treatment consisted of aldactazine once daily, elthyrone 100 gamma/day, lutenyl once daily and bisoprolol 2 × 2.5 mg. The laboratory counts were as follows: red blood cells 3.26 × 106/mm3 (3.90–4.90); platelets 146,000/mm3 (150,000–353,000); white blood cells 2.33 × 103/mm3 (4.60–10); neutrophils 31.1% (42.2–71.0); lymphocytes 67.2% (17.5–43.5); sedimentation rate 57 mm/h (<21); C-reactive protein 21.6 mg/l (0.0–6.0), and IgM <0.17 g/l (0.40–2.48). The T-cell population did not reveal any aberrant phenotype, and the CD4/CD8 ratio was 0.91. Immunophenotyping revealed the virtual absence of B cells, and the tricholeucocyte phenotype CD103 percentage was 0.2%. The serological status for HSV was IgM– and IgG+. The renal and hepatic functions were unremarkable. Various treatments, including topical antifungals, antibiotics, antiseptics and corticosteroids, were unsuccessful. Systemic antibiotics and antifungals were also inefficacious. After 3 months, a dermatologic advice was requested. Histology confirmed PG, revealing a vascular neoplasm characterized by small vessel ectasia with thin walls, normal endothelial cells and a dense lymphocytic and neutrophilic inflammatory infiltrate. The conjunctive stroma was severely edematous (fig. ). On serial sections, some isolated epithelial cell islands were intermingled in the PG. These epithelial cells sometimes showed signs of cytopathic effects (CPE), including intranuclear inclusions and giant syncytial cell formation, suggesting an alpha-herpesviridae infection (fig. ). Immunohistochemistry (IHC) was performed according to an earlier published protocol [] with the antibody panel shown in table . A strong nuclear and cytoplasmic signal for HSV-I was evidenced in some epithelial cells (fig. ), whereas the HSV-II and varicella zoster virus stainings remained negative. Some of the HSV-I-positive cells presented CPE, whereas others did not (fig. ). No immunohistochemical signal for HSV-I was evidenced in the endothelial cells or vessel walls of the PG. IHC using the Ulex europaeus lectin revealed a strong signal on the cell membranes of the HSV-I-infected epithelial cells as well as on the endothelial cells of the PG (fig. , red signal). Mac 387 immunostaining was positive for HSV-I-infected epithelial cell membranes. The vascular endothelial growth factor (VEGF) immunostaining provided a positive signal in the HSV-infected keratinocytes as well as in endothelial cells (fig. , red signal). The epidermal growth factor receptor (EGFR) immunostaining revealed intense membranous expression on HSV-I-infected epithelial cells (fig. , brown signal). The Ki67 marker revealed a strong signal in the nuclei of some epithelial and endothelial cells (fig. , red signal). IHC with antibodies against CD45 evidencing the leucocyte common antigen and CD3 T-cells provided an intense staining of the inflammatory infiltrate of the PG, but no signal surrounding the HSV-1-infected epithelial cells was observed. In contrast, IHC with CD45R0 demonstrating activated T cells revealed a very dense infiltrate among the epithelial cells. The CD45R B cell marker was negative. The markers CD68 and Mac 387 were positive in the inflammatory infiltrate surrounding the epithelial cells and the PG. Using the identical antibody panel for a post-traumatic labial PG of a patient without recurrent herpes labialis, the staining patterns were similar, except for the absence of signals for HSV-I, EGFR and CD45R0. A viral culture remained negative.\nFollowing the discovery of the HSV-I antigens in the PG, oral treatment with valaciclovir (1,000 mg, thrice daily for 15 days) was initiated, and the lesion promptly resolved after 15 days (fig. ). No search for viral thymidine kinase (TK) resistance was performed. After 1 month, a slightly erythematous postinflammatory pigmentation persisted (fig. ). Until now, the patient has remained recurrence free.
|
[[52.0, 'year']]
|
F
|
{'28658902': 1, '31105949': 2, '15655777': 1, '19722843': 1, '19115032': 1, '23125933': 1, '22659469': 1, '8547009': 1, '22955520': 1, '28197698': 1, '10872949': 1, '10598753': 1, '20227572': 1, '7864296': 1, '22434943': 1, '16536821': 1, '9669126': 1, '28197699': 1, '21056516': 1, '24019777': 2}
|
{'6501470-1': 1}
|
163,119 |
3764974-1
| 24,019,788 |
noncomm/PMC003xxxxxx/PMC3764974.xml
|
Intravitreal Injection of Dexamethasone Implant in Serous Macular Detachment Associated with Waldenström's Disease
|
A female patient, aged 52 years, affected by WM since December 2010, came to our Department in November 2012 complaining of a decrease in visual acuity and floating vision in both eyes, which was more severe in the left eye, for the duration of about 1 month. The patient had been treated with systemic corticosteroid and was currently undergoing chemotherapy with Rituxan® (rituximab) and Velcade® (bortezomib). At the time of the visit, the best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/30 in the left eye. At the slit lamp examination, the anterior segment was normal in both eyes, with no opacity of the lens and/or any signs of ocular inflammation. The intraocular pressure at Goldmann tonometry was 14 mm Hg in both eyes. A bilateral CRVO was diagnosed and confirmed by fluorescein angiography (FAG) and spectral domain optical coherence tomography (SD-OCT). FAG showed a bilateral CRVO with macular edema, complicated by serous macular detachment (SMD) in the left eye. SD-OCT (Cross Line, MM5, 3D Macular, RTVue® SD-OCT) showed a foveal thickness of 349 µm in the right eye and 858 µm in the left eye (fig. ).\nThe left eye was treated with an intravitreal injection of dexamethasone (Ozurdex®; Allergan, Inc., Irvine, Calif., USA) 3 days after the diagnosis. Ozurdex is a biodegradable copolymer of lactic acid and glycolic acid containing micronized dexamethasone, which forms a matrix structure able to gradually release the total dose over time after the injection []. The most common local side effect can be an increase of intraocular pressure and cataract [].\nOne month after the injection, the SD-OCT of the left eye showed a slight reduction of foveal thickness (686 µm) that was not related to any improvement of visual function (fig. ).\nAt 2 and 6 months after the injection, the SD-OCT showed a further mild reduction of foveal thickness that was 680 and 547 µm, respectively (fig. ).\nThis proves that there was a partial response to the injection of Ozurdex, although a complete reduction of foveal thickness is never achieved, unlike the usual response in non-WM-related CRVO [].\nAt the time of the follow-ups, 1, 2, and 6 months after the injection, BCVA remained stable at 20/30, intraocular pressure was 14 mm Hg, and the patient did not show any sign of opacity of the lens or ocular inflammation.\nIt was not possible to repeat the FAG because the patient's general health condition deteriorated over time.\nWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the consent is available for review.
|
[[52.0, 'year']]
|
F
|
{'29118506': 2, '33490879': 1, '25383828': 1, '2513133': 1, '21764136': 1, '2507620': 1, '32722556': 1, '30671569': 2, '18551947': 1, '23006995': 1, '17102008': 1, '18326744': 1, '23154502': 1, '26167478': 1, '25707055': 1, '23480270': 1, '18600248': 1, '19362987': 1, '33344607': 2, '21494891': 1, '12720118': 1, '12100172': 1, '24019788': 2}
|
{'5657173-1': 1, '7723702-1': 1, '6329023-1': 1}
|
163,120 |
3766327-1
| 24,032,076 |
noncomm/PMC003xxxxxx/PMC3766327.xml
|
Sonographic localization of a nonpalpable shunt: Ultrasound-assisted ventricular shunt tap
|
A 53-year-old male with a past medical history significant for hypertension, noninsulin-dependent diabetes mellitus, alcohol abuse, seizures, and traumatic brain injury secondary to a fall, necessitating several decompressive craniectomies, bilateral cranioplasties and a left occipital ventriculoperitoneal (VP) shunt (Rickham reservoir), initially presented to an outside institution obtunded and in acute status epilepticus. Seizures were initially generalized tonic-clonic, and then later right-sided convulsions with eye deviation. His seizures were aborted with intravenous lorazepam and fosphenytoin. A head CT was obtained at that time that was suggestive of hydrocephalus, which prompted transfer to our facility.\nUpon arrival to our ED the patient was noted to have residual focal right arm and facial twitching, for which he was reloaded with antiepileptic agents. The patient was new to our institution, and no prior imaging was available to aid in determining if he had acute hydrocephalus. A shunt series obtained in the ED showed no signs of discontinuity throughout the shunt system. Therefore, we attempted to perform a VP shunt tap to assess intracranial pressure and determine if he had either proximal or distal shunt failure. Initially, on examination his shunt reservoir was not palpable. This was likely secondary to the large thickness of his scalp and the location of his Rickham reservoir near a burr hole cover and along a raised ridge from his left cranioplasty site [].\nWe utilized the ED's portable ultrasound machine (Edge ® model; SonoSite, Incorporated), typically used in the ED for other procedures, to quickly assist us with imaging through the scalp. Using a 6 cm, 13-6 MHz linear transducer, visualization in both the short-axis and long-axis views allowed for a thorough examination and confirmation of the exact placement of the Rickham reservoir []. The patient was then prepped in the standard fashion, with the Rickham site marked and outlined allowing for the easy placement of our 23-guage butterfly needle into the reservoir site []. Once in place, there was no spontaneous flow. Utilizing a 5-cc syringe, we were only able to obtain a few drops of residual fluid initially from the proximal catheter with 2-3 mL of negative back pressure, and then no CSF return at all. The result of our ventricular shunt tap suggested proximal shunt failure. The patient was then emergently taken to the operating room (OR) for a shunt revision. In the OR, the left occipital proximal shunt catheter was found to be obstructed, demonstrating shunt failure, which correlated with our shunt tap. In this setting, the decision was made to place a left frontal VP shunt in the standard fashion. Briefly, an incision was made over Kocher's point and a burr hole was placed using a perforator drill. The left frontal catheter was then passed to the appropriate depth and clear CSF return was visualized under high pressure. The distal catheter was then tunneled from the frontal scalp incision to the back part of the previous trauma craniotomy incision, then down towards the neck. The sites were joined with a straight connector along with a medium-low pressure valve. Prior to the connection, distal runoff was checked and found to be appropriate. Postoperatively, the patient did well and was eventually transferred back to his nursing facility.
|
[[53.0, 'year']]
|
M
|
{'22766597': 1, '18518693': 1, '18431216': 1, '15617596': 1, '8891363': 1, '9339462': 1, '8688350': 1, '10616079': 1, '17446770': 1, '9606231': 1, '15344902': 1, '3200373': 1, '16636615': 1, '10940768': 1, '29737381': 1, '16418609': 1, '24032076': 2}
|
{}
|
163,121 |
3766328-1
| 24,032,077 |
noncomm/PMC003xxxxxx/PMC3766328.xml
|
Is “en-bloc” excision, an option for select large vascular meningiomas?
|
A 25-year-old male presented to our hospital in drowsy state with history of headache for 3 years progressively worsening for 6 months. His Glasgow Coma Scale was 13/15, magnetic resonance imaging (MRI) brain revealed giant left lateral sphenoid wing meningioma measuring 8 × 7 × 5 cm3 with no encasement of major blood vessels []. Preoperative embolization was not feasible. Hence left external carotid artery (ECA) was exposed in the neck and kept occluded. Large fronto-temporal scalp flap was raised after adequate infiltration of local anesthetic with adrenaline, and use of Raney's clips. Large fronto-temporal free bone flap was raised with craniotome and temporal bone rongeured flush with middle cranial fossa. Profuse bleeding of bone edges was controlled with bone wax. Bipolar coagulation of middle meningeal artery and other vessels over the dura was carried out. Dura was opened just around the tumor, and reflected as a flap detaching it from the underlying tumor. The tumor surface was studded with blood vessels. Bipolar coagulation was performed all around the exposed tumor surface thereby devascularizing and shrinking the tumor. Gradually the tumor started to separate from the arachnoid plane and started to bulge in a pulsatile manner []. Progressively deeper circumferential dissection carried out with placement of patties protecting the adjacent arachnoid layer. It appeared as if the brain pulsations were gently pushing the tumor out of the dural defect. No retractor or tumor manipulation was used throughout the procedure and finally, the whole tumor was delivered en bloc []. The blood loss was around 500 ml, most of which occurred during craniotomy. Patch duraplasty was carried out using pericranium, and layered closure performed. Postoperatively the patient had improved remarkably, contrast enhanced computed tomography (CECT) showing no residual tumor, and was discharged in good functional status on fourth day []. This ‘en bloc’ technique, as elaborated below, has been utilized in a series of seven more large meningiomas (>5 cm) safely with less blood loss.\nPatients with meningioma were positioned intraoperatively so that tumor was more superficial than brain. Sufficiently large basal craniotomy was carried out. Meningiomas with suspected encasement of neurovascular structures and significant interposition of brain around the tumor attachment were considered for internal decompression before dissection of tumor capsule. However, meningiomas with no contraindication as above were taken up for surgery with the rule of 4 D's: Devascularization, Diminutive dural opening, Detachment, and either Debulking followed by dissection or Dissection without debulking. After extensive coagulation of dural surface vessels, dural opening was made just at the tumor margin, so that surrounding brain was not exposed. The decision on performing internal decompression was made following early severance of dural attachment. Whenever arachnoid plane appeared favorable, dissection was carried out without debulking, and nearly always the tumor was pushed gradually by the underlying brain pulsations and edema so that the tumor gets delivered en bloc. The main advantages of ‘en bloc’ removal appear to be lesser bleeding and shorter operative time. The limited dural opening cannot be overemphasized to avoid herniation of the edematous brain being pushed out by the tumor. Also if tumor cannot be freed of its attachment in the initial phase of surgery internal debulking becomes unavoidable.\nOf the total 35 large meningiomas (>5 cm) operated by us in 2 years, 8 patients had en bloc removal while the rest had initial debulking. The mean blood loss in en bloc removal was around 400 ml, with no patient having new neurological deficit, new onset seizures, or postoperative hematomas.
|
[[25.0, 'year']]
|
M
|
{'13272053': 1, '26543669': 1, '25101204': 1, '26430585': 1, '26862451': 2, '30090133': 1, '18800638': 1, '21748714': 1, '34268156': 1, '27114854': 1, '675479': 1, '28588365': 1, '20672892': 1, '14522782': 1, '24032077': 2}
|
{'4722513-1': 1}
|
163,122 |
3766334-1
| 24,049,367 |
noncomm/PMC003xxxxxx/PMC3766334.xml
|
Case Report of Aspergillus Osteomyelitis of the Ribs in an Immunocompetent Patient
|
A 45-year-old lady presented with a history of right upper abdominal pain for six months. The pain worsened on deep inspiration and on applying pressure over the chest wall. It had been progressively worsening in severity. She gave a history of loss of appetite and loss of weight of approximately five kilograms during this period. There was no history of cough, fever or trauma. She gave a history of diabetes mellitus for five years, which was adequately controlled with oral hypoglycemic agents.\nOn examination, she had tenderness over her right upper abdomen. She had no underlying organomegaly, bony tenderness or lung findings. Investigations were normal, except an elevated ESR and CRP. Imaging studies, including chest radiograph, abdomen ultrasound and a bone scan were inconclusive. She was asked to follow-up after two months.\nShe presented again after six months with increased pain over the right upper quadrant. On examination, she was found to have a tender swelling on the right ninth and tenth ribs, measuring 3 × 2 cm each. With a tender swelling, and elevated inflammatory markers, a diagnosis of Osteomyelitis involving the ribs was made, and she underwent a computed tomography (CT) scan to confirm the same.\nCT of the chest and abdomen revealed a swelling over the lower end of the ninth and tenth ribs, associated with thickening of the underlying pleura, and necrosis of adjoining ribs and costochondral junctions. A screening ultrasound showed an 8cc collection with surrounding necrosis, which was aspirated under guidance. The histopathology report showed areas of necrosis on histology, with a lymphohistiocytic inflammatory infiltrate []. The aspirates were also sent for cultures, which grew Aspergillus fumigatus after two weeks of incubation []. This report was unexpected, as the patient did not have any traditional risk factors for Aspergillosis. She had diabetes mellitus, which was well controlled, without evidence of any complications.\nShe underwent surgical debridement, and was initiated on Voriconazole. She showed clinical improvement after the same
|
[[45.0, 'year']]
|
F
|
{'11486286': 1, '20718613': 1, '20512571': 1, '29181357': 2, '19403905': 1, '11315785': 1, '21045528': 1, '14749170': 1, '24049367': 2}
|
{'5702709-1': 1, '5702709-2': 1}
|
163,123 |
3766342-1
| 24,032,079 |
noncomm/PMC003xxxxxx/PMC3766342.xml
|
Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas
|
The patient was a 79-year-old male who had been receiving chemotherapy since he was diagnosed with peritoneal mesothelioma. He visited a neighborhood hospital when he experienced a fall and received a hard blow to the back of the head. One month later, his follow-up head computed tomography (CT) showed a thin right-sided CSDH, and he was prescribed oral administration of ibudilast and was followed up. Because hematoma enlargement was observed 4 months later [], right-sided burr hole irrigation was performed []. However, mild left hemiparesis occurred 3 months later. Head CT performed subsequently showed recurrence. Burr hole irrigation was repeated, resulting in the resolution of the left hemiparesis. Because of further recurrence in the following month [], a third burr hole irrigation was performed []. Subsequently, embolization of the MMA was scheduled.\nEmbolization\nEmbolization of the MMA was performed 6 days after the third burr hole irrigation of the hematoma.\nA 6F guiding catheter was inserted from the left femoral artery and placed in the right external carotid artery. A microcatheter was advanced into the parietal branch of the right MMA. Subsequently, angiography was performed, which showed cotton wool-like staining []. Sixteen per cent NBCA was injected after confirmation of the negative result of a provocative test with 1% lidocaine injection. The frontal branch was also embolized with 16% NBCA in a similar procedure.\nPostoperative course\nThe right subdural space was observed to gradually decrease in size. There was no sign of recurrence during the first month after embolization []. Although some traces were seen on head CT images taken 3 months later, the hematoma had almost disappeared [].\nNo recurrence has been observed since then.
|
[[79.0, 'year']]
|
M
|
{'26015518': 1, '11218765': 1, '28652561': 1, '21206540': 1, '31018739': 1, '11993178': 1, '32903661': 2, '33192990': 1, '21125409': 1, '28664018': 1, '33541902': 1, '8361567': 1, '9384397': 1, '34211887': 2, '6737050': 1, '33506148': 1, '34214657': 1, '31592397': 1, '34777190': 1, '10363254': 1, '29720020': 1, '33562252': 1, '34640453': 1, '34430157': 2, '20566092': 1, '34221563': 1, '7221864': 1, '9736085': 1, '34147057': 2, '11014549': 1, '27766029': 1, '34754700': 1, '24032079': 2}
|
{'3766342-2': 2, '8379556-1': 1, '8202376-1': 1, '7438730-1': 1, '7438730-2': 1, '7438730-3': 1, '8256020-1': 1}
|
163,124 |
3766342-2
| 24,032,079 |
noncomm/PMC003xxxxxx/PMC3766342.xml
|
Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas
|
The patient was a 68-year-old female who had been treated for cerebral infarction and pulmonary embolism with oral warfarin. She had no history of head bruises. She visited our hospital with a chief complaint of disorientation. Head CT showed left-sided CSDH [], and left-sided burr hole irrigation of the hematoma was performed []. Because of the high risks associated with discontinuation of warfarin, she was followed up with continuation of the oral administration. Although CT performed 1 month later showed only slight changes of density [], head CT performed 2 months later showed a slight enlargement of the hematoma and increased density []. These findings were considered as signs of recurrence, and embolization of the middle MMA was performed.\nEmbolization\nA 6F guiding catheter was inserted from the right femoral artery and placed in the left external carotid artery. A microcatheter was advanced into the left MMA. Subsequently, angiography was performed, which showed cotton wool-like staining []. The microcatheter was further advanced to the frontal branch. Twenty per cent NBCA was injected after confirmation of the negative result of a provocative test with 1% lidocaine injection. The parietal branch was also embolized with 20% NBCA in a similar procedure.\nPostoperative course\nThe hematoma started to decrease in size 1 week after embolization [] and disappeared in 4 months [].\nNo recurrence has been observed since then.
|
[[68.0, 'year']]
|
F
|
{'26015518': 1, '11218765': 1, '28652561': 1, '21206540': 1, '31018739': 1, '11993178': 1, '32903661': 2, '33192990': 1, '21125409': 1, '28664018': 1, '33541902': 1, '8361567': 1, '9384397': 1, '34211887': 2, '6737050': 1, '33506148': 1, '34214657': 1, '31592397': 1, '34777190': 1, '10363254': 1, '29720020': 1, '33562252': 1, '34640453': 1, '34430157': 2, '20566092': 1, '34221563': 1, '7221864': 1, '9736085': 1, '34147057': 2, '11014549': 1, '27766029': 1, '34754700': 1, '24032079': 2}
|
{'3766342-1': 2, '8379556-1': 1, '8202376-1': 1, '7438730-1': 1, '7438730-2': 1, '7438730-3': 1, '8256020-1': 1}
|
163,125 |
3766753-1
| 24,023,555 |
noncomm/PMC003xxxxxx/PMC3766753.xml
|
Eosinophilia, Pleural Effusion, Hepatitis, and Jaundice Occurring Early in Clozapine Treatment
|
Ms. A, a 47-year old woman with a 15-year history of schizophrenia, was hospitalized after noncompliance with antipsychotic medications, which resulted in decompensation characterized by aggressive behavior, auditory hallucinations and delusions. All laboratory tests performed on admission, including complete blood cell count (CBC), serum electrolytes, urinalysis, and liver function tests (LFTs), were within normal limits. Hepatitis serology revealed that the hepatitis B surface (HBs) antibody was positive and that the HBs antigen was negative. Ms. A was a non-smoker and non-drinker with no history of substance misuse and no significant medical history.\nDue to poor responses to previous antipsychotic treatments, the patient was started on clozapine with the dose titrated from 12.5 mg/day to 300 mg/day during a 4-week period. During this period the patient had no other medications.\nThe weekly checks of the CBC showed gradual increases in the eosinophil count following the beginning of clozapine treatment. The eosinophil count was 0.9% (57/mm3) before clozapine use, 1.7% (142/mm3) at day 8, 2.8% (248/mm3) at day 15, and 5.0% (416/mm3) at day 22. On day 29, the total leukocyte count increased to 10,910/mm3, and the eosinophilia reached 23.6% (2,575/mm3). Ms. A did not have any symptoms.\nOn day 35, the patient complained of general myalgia and 37.5℃ fever. Both leukocytosis (16,500/mm3) and eosinophilia (28.9%, 4,769/mm3) were aggravated. A chest X-ray revealed some amount of right side pleural effusion. The pleural effusion was considered to be the cause of the fever and leukocytosis, and conservative management of oral antibiotics was provided. Because clozapine was effective in managing the psychotic symptoms, it was maintained at the reduced dosage of 100 mg/day. On day 42, the total leukocyte count was normalized, at 9,230/mm3 but the eosinophil count had increased to 54.2% (5,003/mm3). She showed an intermittent 37.7℃ fever, but general myalgia had disappeared. On day 44, a repeat chest X-ray revealed that the pleural effusion had nearly disappeared, and the fever had subsided. The total leukocyte and eosinophil count decreased to 8,350/mm3 and 40.1% (3,348/mm3), respectively.\nOn day 48, the patient suddenly became jaundiced, and she was transferred to the department of internal medicine at a general hospital. The total leukocyte count was 3,600/mm3 with 12.9% (464/mm3) eosinophil. The LFTs were notable for the following abnormalities: alanine transaminase (ALT) 254 IU/L (range, 4-43), aspartate transaminase (AST) 277 IU/L (range, 7-38), r-glutamyl-transferase (GGT) 573 U/L (range, 8-48), total bilirubin 6.0 mg/dl (range, 0.2-1.2), and direct bilirubin 3.5 mg/dl (range, 0.1-0.4). Abdominal computed tomography showed hepatopathy by acute hepatitis. The urinalysis showed urobilinogen 2+ (range, trace). The patient retrospectively reported that her urine color had changed to red during the previous 2 weeks.\nAfter 5 days without clozapine, the LFTs improved, showing an ALT level of 22 IU/L, an AST level of 37 IU/L, a GGT level of 46 U/L, a total bilirubin of 0.6 mg/dl, and a direct bilirubin of 0.2 mg/dl. The total leukocyte count was 4,200/mm3 with 10.5% (441/mm3) eosinophil. Ms. A was readmitted to our hospital after 1 week without clozapine for treatment of psychotic symptoms. The total leukocyte count was 4,400/mm3 with 3.4% (150/mm3) eosinophil on the day of readmission. There were no recurrences of LFT or CBC abnormalities during following treatment with olanzapine and haloperidol.
|
[[47.0, 'year']]
|
F
|
{'19910731': 1, '8494085': 1, '10333168': 1, '9241012': 1, '21165382': 1, '1852790': 1, '9136851': 1, '9669191': 1, '29991947': 2, '27449495': 1, '29259655': 2, '25210451': 2, '19440569': 1, '24023555': 2}
|
{'4155895-1': 1, '5731207-1': 1, '6016221-1': 1}
|
163,126 |
3766781-1
| 24,023,998 |
noncomm/PMC003xxxxxx/PMC3766781.xml
|
Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-
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A 52-year-old male (weight, 63 kg; height, 167 cm, American Society of Anesthesiologists physical status classification I) was scheduled for laparoscopic low anterior resection for rectal cancer. He had no significant past medical history and no previous experience of general anesthesia. His family history included his mother's asthma.\nThe patient arrived at the operating room with no premedication. Cefotetan 1,000 mg IV was administered 20 minutes before arrival with no apparent adverse effects. His blood pressure, heart rate, and SpO2 were 140/80 mmHg, 60 beats/min, and 100%, respectively. After standard monitors were applied, midazolam 2 mg and lidocaine 20 mg were administered. Induction was started with a target effect-site concentration-controlled infusion (TCI; Asan Pump, version 2.0, Bionet Co., Ltd., Seoul, Korea) of propofol 2 µg/ml and remifentanil 3 ng/ml, followed by a bolus administration of cisatracurium 12 mg. Within a minute, mask-valve ventilation became difficult with pulse oximetry decreasing to 90%. His trachea was intubated immediately and ventilated with 100% oxygen. At this point, the peak airway pressure exceeded 30 cmH2O with a tidal volume of 550 ml and a respiratory rate of 12 breaths/min. The breathing sound in both lungs was decreased and wheezing was apparent on auscultation. Signs of cardiovascular collapse were also present: the blood pressure was 60/40 mmHg and there was a slight increase in the heart rate from 65 to 80 beats/min. Cutaneous reactions such as rash or urticaria were absent. A clinical diagnosis of anaphylactic shock was made. The patient was promptly treated with a 500 ml fluid bolus of lactated Ringer's solution and repeated doses of epinephrine10 µg up to a total dose of 50 µg. Arterial and 16 G venous catheters were placed and 500 ml of colloid was loaded. A continuous infusion of epinephrine was started (0.05 µg/kg/min). The blood pressure increased to 125/75 mmHg. Treatment for the bronchospasm was initiated by administering inhaled salbutamol through the endotracheal tube and hydrocortisone 100 mg IV. An hour after the event, the epinephrine infusion was slowly discontinued as the hemodynamics stabilized. The blood pressure and heart rate after epinephrine infusion discontinuation were 135/90 mmHg and 90 beats/min, respectively. The peak airway pressure decreased to 26 cmHg with the same ventilator setting. Wheezing was no longer present on auscultation. The surgery was cancelled and the patient was transported to the surgical intensive care unit with his trachea remaining intubated. One hour after arrival, the patient was awake and extubated without incident. His postoperative chest X-ray was normal.\nThree days later, the patient underwent allergy testing with the skin prick test for common allergens (latex included), an intradermal test for all perioperatively used drugs, and the metacholine bronchial provocation test. Other NMBAs such as succinylcholine, vecuronium, and rocuronium were included in the intradermal test drug panel. Skin testing revealed a positive reaction to cisatracurium at a 1 : 100 dilution (). All other medicines were negative. The patient also reacted positively in the metacholine bronchial provocation test.\nA week after the event, the patient was pretreated with methylprednisolone and fluticasone/salmeterol inhaler and returned for the scheduled surgery. Vecuronium was used instead of cisatracurium. The operation was uneventful.
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[[52.0, 'year']]
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M
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{'3766781-2': 2, '4280479-1': 1}
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163,127 |
3766781-2
| 24,023,998 |
noncomm/PMC003xxxxxx/PMC3766781.xml
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Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-
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A 70-year-old male (weight, 53.2 kg; height, 155 cm; American Society of Anesthesiologists physical status classification I) was anesthetized for total gastrectomy. The patient had a previous experience with general anesthesia in 1978 for an operation for gastric perforation but information about the anesthetic technique was not available. His past medical history and family history were insignificant.\nHe received no premedication other than cefotetan 1,000 mg IV, which was administered 20 minutes before his arrival without apparent adverse effects. Full monitoring was established and midazolam 2 mg and lidocaine 40 mg were administered. General anesthesia was induced with TCI (Asan Pump, version 2.0, Bionet Co., Ltd., Seoul, Republic of Korea) of microemulsion propofol 1.2 µg/ml (Aquafol™, Daewon Pharmaceutical Co., Ltd., Seoul, Korea) and remifentanil 3 ng/ml, followed by cisatracurium 12 mg. Approximately 1-2 minutes after induction, the non-invasive blood pressure was unmeasurable and mask-valve ventilation of his lungs was difficult with a SaO2 decrease from 99 to 85%. The patient was intubated immediately and assumed the head-down position. At this point, the measured non-invasive blood pressure was 45/20 mmHg and the heart rate was 70 beats/min. The patient was ventilated with 100% oxygen with a tidal volume of 450 ml and a respiratory rate of 14 breaths/min; the peak airway pressure was 30 cmH2O. On auscultation, wheezing was apparent in both lungs. Repeated doses of epinephrine 20 µg up to a total dose of 40 µg were administered and a continuous infusion of epinephrine was started at 0.1 µg /kg/min. A 16 G catheter was inserted and colloid 500 ml was loaded. An arterial catheter was placed in the right radial artery. The arterial blood pressure increased to 146/90 mmHg and the treatment for bronchospasm with a salbutamol inhaler and hydrocortisone 100 mg IV was started promptly. The hemodynamics stabilized and the peak airway pressure dropped from 30 to 20 cmH2O. The epinephrine infusion was tapered off and eventually discontinued. After monitoring the patient closely for an hour in the operating room, the neuromuscular blockade was reversed with glycopyrrorate 0.4 mg and pyridostigmine 15 mg. The patient was awake and extubated without incident. A follow-up chest X-ray was normal. The patient was transferred to the post anesthesia care unit and had an uneventful recovery.\nAbout 3 weeks later, the patient underwent allergy skin testing, including the skin prick test and the intradermal test for all perioperatively used medicines and other NMBAs. The patient reacted to cisatracurium at a 1 : 100 dilution and showed an equivocal reaction to rocuronium at a 1 : 100 dilution (). The patient returned for surgery a month after the event and underwent uneventful anesthesia with vecuronium.
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[[70.0, 'year']]
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M
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{'3766781-1': 2, '4280479-1': 1}
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163,128 |
3766782-1
| 24,023,999 |
noncomm/PMC003xxxxxx/PMC3766782.xml
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Anesthetic management including extracorporeal membrane oxygenation therapy of liver transplant recipient with life-threatening hypoxemia -a case report-
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A 49 year-old woman (160.0 cm, 94.6 kg) suffering from hepatocellular carcinoma with end-stage hepatitis B liver cirrhosis (model for end stage liver disease [MELD] score 14, Child-Pugh class B) presented for living donor LT. She had hypertension that was well controlled with medications. Her blood type was A, Rh+. The ABO compatible donor was her 25-year-old son (174.5 cm, 86.2 kg).\nAnesthesia was induced with fentanyl (100 µg), thiopental sodium (250 mg), and vecuronium (8 mg), and was maintained with oxygen, air, and desflurane. Neuromuscular block was maintained with atracurium. Hemodynamic monitoring included the right radial and femoral arterial, central and right femoral venous, pulmonary arterial, and capillary wedge pressures, and cardiac output measurements (Vigilance™ monitoring, Edwards Lifesciences, Irvine, CA, USA) through the right internal jugular vein.\nThe surgery proceeded by the piggyback technique, with preservation of caval flow. After the reperfusion of graft liver, right posterior sectionectomy was performed to improve the decreased right hepatic venous flow, a result of a relatively large size of graft liver (recipient original liver weight = 1,049 g, graft volume = 1,500 ml, graft weight = 1,228 g, graft-recipient weight ratio = 1.3%, respectively) and morbid obesity (body mass index: 37.0 kg/m2) of recipient. However, the graft blood flow did not improve, and intractable bleeding occurred at the resection site. Despite rapid volume resuscitation, hypovolemia was aggravated and then cardiac arrest occurred suddenly. Chest compression was started immediately by surgeon, and boluses of epinephrine 1 mg were injected 4 times. Aggressive volume resuscitation was continued using a fluid management system (FMS 2000, Belmont Instrument Corporation, Billerica, MA, USA).\nAfter 8 minutes of the cardiopulmonary resuscitation (CPR), spontaneous circulation was recovered with normal sinus rhythm. Arterial blood gas analysis (ABGA) and coagulation profiles at pre- and post-CPR are shown in and . During CPR, serum potassium level was elevated 4.5 mmol/L to 5.1 mmol/L and serum calcium level decreased 0.62 mmol/L to 0.45 mmol/L. Hematocrit level decreased 16 to 14%. However, significant oozing continued despite surgical hemostasis, and the operator decided to stop surgery for intensive medical treatment and planned a second operation. Thus, after finishing the operation with gauze packing, the patient was transferred to surgical intensive care unit (ICU). During 1,270 minute operation, 33,255 ml of crystalloid, 1,300 ml of 5% albumin, 2,000 ml of colloid, 14 units of leukocyte depleted red blood cell, 6 units of leukocyte depleted platelet concentrate, 984 ml of cell saver blood, 8 units of fresh frozen plasma, and 3 units of cryoprecipitate were infused. Urine output was 1,520 ml, and estimated blood loss was about 10,000 ml.\nAfter the operation, the patient's condition deteriorated, with metabolic acidosis with pH < 7.2 and azotemia with creatinine level over 2.0 mg/dl due to ongoing graft failure and intractable bleeding despite aggressive management. Severe hypoxemia persisted despite a fraction of inspired oxygen (FiO2) = 1.0 with mechanical ventilation set as 6 ml/kg of tidal volume (for ideal body weight), 30 breaths/minute, and increasing positive end-expiratory pressure (PEEP) of up to 10 cmH2O ().\nChest radiography revealed pulmonary congestion () and echocardiography was performed to rule out cardiogenic pulmonary edema, but cardiac physiology, function, and structure were in normal without any abnormalities. As anuria developed 7 hours after the end of the operation, continuous renal replacement therapy (CRRT) was started via the right femoral vein following a continuous VV hemodiafiltration protocol. Brain tomography was obtained before CRRT, but there was no definite abnormal finding.\nBecause of the failure of conventional ventilatory support, and in the hope of liver retransplantation, the decision was made to initiate VV ECMO as a rescue device. Although she suffered hypovolemic arrest during first LT, post-operative echocardiography revealed normal heart function, physiology and structures. Therefore, the cardiologist in our ECMO team suggested that there was no need of cardiac support with ECMO. The existing central cannula and Swan-Ganz catheter was removed. A 28 French (Fr) drainage cannula (DLP®, Medtronic Inc., Minneapolis, MN, USA) was placed in the right femoral vein, and a 21 Fr Medtronic return cannula was placed in the right internal jugular vein. A CAPIOX emergent bypass system and circuit (EBS®, Terumo Inc., Tokyo, Japan) was primed with 470 ml of normal saline. The CAPIOX EBS oxygenator kit contains 1.8 m2 of membrane lung surface. CRRT was continued through ECMO circuit (). VV ECMO circulation was maintained at 4.0-5.0 L/min (2.0-2.5 L/min/m2) with 5-6 L/min sweep gas flow at 100% oxygen. Heparin was not used because the patient had a severe bleeding tendency, and 500 IU of antithrombin was injected intravenously every 6 hour (Post-LT care protocol of our center). Activated clotting time (ACT) was measured every 5 min for the initial 15 min then 240 min thereafter. The ACT was maintained between 120-180 s throughout. After ECMO treatment, the patient's condition improved to 95% SpO2 with a FiO2 of 0.3-0.4 at the ventilator and 1.0 at ECMO ().\nAbout 24 hours after ECMO application, the patient was transferred to the operating room to receive deceased donor LT. The warm ischemic time of the donated liver was 41 minutes, and the cold ischemic time was 446 minutes.\nPerioperative ABGA profiles and coagulation profiles are shown in and , respectively. The preoperative chest radiograph showed a sustained pulmonary congestion and bilateral pleural effusions. Her MELD score at secondary LT was 30 with ECMO and CRRT support. Considering her condition with a high risk of massive bleeding along with the planned ECMO application during the operation, we decided to discontinue CRRT during the operation and restart after the operation depending on her condition.\nWhen the patient arrived at operating room, she was already intubated. The patient was monitored as during the previous operation except for femoral arterial blood pressure, pulmonary arterial pressure, and cardiac output monitoring, because there were no suitable cannulation site for these devices due to ECMO cannula and generalized edema. To maintain body temperature during anesthesia, core temperature was continuously monitored via mid-esophageal temperature probe. Administered fluid was heated by FMS 2000, and every peripheral vascular access was removed to prevent infusion of cold fluid. A warm blanket was spread on the operating table, and a humidifier (Hygroster, Covidien, Mansfield, MA, USA) was applied at the ventilatory circuit. The patient's limbs were covered with cotton roll and vinyl wrap and room temperature was maintained within 24.0 to 28.0℃. Anesthetic management followed our hospital's LT protocol.\nHer SpO2 was stable ranged from 97 to 100% with a FiO2 of 0.5 at the ventilator (pressure controlled ventilation; tidal volume of 3 to 4 ml/kg (about 5 to 6 ml/kg for ideal body weight), respiratory rate of 8 to 12 breaths/min, and PEEP of 5 to 10 cmH2O) and 1.0 at ECMO (Circuit flow of 4 to 5 L/min and gas sweep of 5 to 6 L/min). Her body temperature was maintained within the range of 35.8 to 36.1℃.\nCompartment syndrome was a concern during abdominal closure, so surgery was finished without suturing the abdominal wall. Total administered volume included crystalloid 7,400 ml, colloid 2,530 ml, 5% dextrose water 450 ml, cell saver autotransfusion 792 ml, leukocyte-depleted red blood cell 11 units, fresh frozen plasma 8 units, plateletpheresis 2 units, cryoprecipitate 8 units for 350 minutes. There was no severe oozing or acute massive bleeding on operation field. Hematocrit level was maintained over 24% during operation without rapid volume resuscitation. No hypotensive episode occurred below mean arterial pressure of 70 mmHg. Urine was not excreted during the entire operation.\nAfter the surgery, sedation was maintained with continuous infusion of midazolam and fentanyl. CRRT was restarted and ECMO was continued. Her body temperature was maintained within the range of 35.3 to 37.0℃ with forced-air warmer (Bair Hugger®, Augustine Medical, Eden Prairie, MN, USA), heated humidifier and circuit (MR850, Fisher and Paykel Healthcare, Auckland, New Zealand), and pre-warmed fluid. To check the return of consciousness, Glasgow coma scale was tested every 4 hours. Pupil size, light reflex, limb movement, and orientation were also checked to judge neurologic abnormalities. Pupil dilatation did not occur and light reflex was normal, but the other exams were meaningless during ECMO support because continuous sedation and muscular relaxation therapy with cisatracurium were sustained for the opened laparotomy wound.\nAfter 64 hours following ECMO support, and 32 hours after secondary LT, arterial oxygen saturation () and chest roentgenogram () were improved significantly. Based on sonography and improved coagulopathy (), the graft appeared functional. Hemodynamic stability was also achieved without high dose inotropic support (0.7 mcg/kg/min of norepinephrine was infused continuously before secondary LT, and tapered to 0.05 mcg/kg/min at before ECMO weaning). Recovery from hepatic failure was the most important factor to decide weaning, because our patient's respiratory failure was closely related to hepatic failure. To initiate weaning, in the first stage, we reduced bypass flow from 4.0-5.0 L/min to 3.0 L/min. And in the second stage, for 7 hours of close monitoring and ABGA at every 2 hours after start weaning, we reduced oxygen flow to ECMO to zero gradually, and FiO2 for ventilator was increased from 0.4 to 0.6 over an hour. Two hours after the second stage, ABGAs performed twice per hour showed appropriate oxygenation, then ECMO was removed from the patient. shows ABGA profiles for both during and after ECMO weaning. Comparing just before and after the ECMO support, PaO2/FiO2 ratio improved from 56.9 to 117.2. The PaCO2 level was similar to before ECMO support, but ventilatory demand was significantly decreased. Subsequently, PaO2/FiO2 stabilized at SpO2 over 90% with FiO2 0.6. The laparotomy wound closure was done 5 days after the surgery.\nHowever, liver congestion was noted one day after the wound closure and hepatic drainage failed. Surgical decompression was performed, but stenosis at intrahepatic IVC developed. Although stenting for the stenosis was performed 5 days after the surgical decompression, graft failure was not improved. In addition, long-term use of high dose vasopressor led to both leg necrosis and further sepsis. After stopping fentanyl and cisatracurium infusion, the patient showed continuous eye opening for a half-day and low grade motor responses, but no further improvement of consciousness. The patient expired 24 days after the second LT due to multi-organ failure caused by combined graft failure and uncontrolled sepsis.
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[[49.0, 'year']]
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{}
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163,129 |
3766783-1
| 24,024,000 |
noncomm/PMC003xxxxxx/PMC3766783.xml
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Application of cerebral oximetry for a parturient with Takayasu's arteritis undergoing cesarean section -a case report-
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A 53 kg, 157 cm, 35-year-old primigravida at the 38th week of pregnancy was admitted for a cesarean section due to breech presentation. She had been diagnosed with TA 7 years prior to this presentation. However she refused medications and further evaluation until delivery. Computed tomographic angiography performed 3 years prior had revealed that the left common carotid artery and left subclavian artery were totally occluded along with a thrombotic aneurysm 5.8 × 5.2 × 9.6 cm in size (). She also had a localized dissection in the low abdominal aorta and focal stenosis in the descending aorta as well as a large left coronary aneurysm and about 50% stenosis of the right coronary artery. Plain chest radiographs revealed a huge superior mediastinal mass which was suspected of an aneurysm with thrombus in the left subclavian artery (). Cardiac single photon emission computed tomography and echocardiography were performed preoperatively to follow up on her coronary artery statuses. These examinations showed an old myocardial infarct, a persistent perfusion defect in the basal inferior wall and a reduction in wall motion.\nThe patient had been diagnosed with Type III TA as determined by the involvement of the aortic arch and coronary artery as well as the descending thoracic and abdominal aortas. She developed dyspnea on exertion with New York Heart Association Functional Class III. On physical examination, peripheral pulsations were weak in all limbs except the right arm. Heart rate was 120 beats/min, and non-invasive blood pressure (NIBP) was 96/78 mmHg in the right upper limb and 95/69 mmHg in the left upper limb. NIBP in the lower limbs measured 148/99 mmHg on the right and 156/95 mmHg on the left. She was cooperative and neurological examinations indicated normal results. A slowly titrated epidural anesthesia was selected to maintain hemodynamic stability. Regional anesthesia functioned as a simple and reliable monitor of cerebral perfusion through the patient's level of consciousness. For these reasons, we planned and executed an elective caesarean section under epidural anesthesia.\nOn arrival at the operating room, we began intraoperative monitoring by electrocardiography, pulse oximetry and NIBP measurement. Electrocardiography was unremarkable with a heart rate of 126 beats/min and the pulse oximeter on her right index finger displayed a normal waveform with a saturation of 95-96% in room air. She was alert and oriented, and her initial NIBP was 113/77 mmHg in the right upper limb. Her left radial, brachial and axillary arteries pulsed feebly, whereas her brachial and axillary arterial pulsations were stronger on the right than on the left. An artery cannula was placed in the right radial artery under local anesthesia connected to a FloTrac™ sensor and Vigileo™ monitor system (Edward Lifesciences, Irvine, CA, USA) device for continuous cardiac output assessments to monitor continuous blood flow. The initial cardiac index was 1.5 L/min/m2. A cerebral oximeter probe (Invos™, Cerebral/Somatic Oximeter 5100C, Somanetics Corporation, Troy, MI, USA) was attached to the forehead. The initial regional cerebral oxygen saturation (rSO2) levels were 64% on the right and 51% on the left.\nAfter placing the patient in the left lateral recumbent position, the median approach was performed with loss of resistance technique using an 18 G Tuohy needle between the L4 and L5 lumbar spines. The catheter was inserted and fixed. Her position was then changed to the supine position with a wedge under her right hip. The height of the block was increased gradually to T5 by using 11 ml of 2% lidocaine injected through an epidural catheter. Oxygen was administered via a VentiR mask, and a capnometer was installed below her nose to monitor respiration. The value of rSO2 was stable. Ten minutes after skin incision, a 3,180 gram girl was delivered and her Apgar score was 8 at 1 minute and 9 at 5 minutes.\nThree minutes after delivery, the placenta was removed and 20 IU of oxytocin diluted in 1,000 ml of 0.9% saline continued to be intravenously infused. The rSO2 levels dropped from 64 to 61% on the right and from 51 to 39% in the left at 6 minutes after delivery. At that time, we were able to obtain NIBP measurements. Arterial blood pressure was 56/48 mmHg without changes in cardiac index. She complained of dysarthria, tinnitus, and stiffness of the posterior neck (). An intravenous infusion of phenylephrine (100 mcg) and rapid administration of colloid (300 ml over 10 minutes) improved dysarthria, tinnitus and stiffness of the posterior neck as rSO2 increased from 61 to 78% on the right and from 39 to 56% on the left. There was no corresponding change in arterial blood pressure and cardiac index with the increase of the NIBP to 81/71 mmHg. However, she still complained of numbness of the face and blurred vision. Her laboratorial test results were as follows: hemoglobin, 9.0 mg/dl; hematocrit, 26%; Na+, 135 mg/dl; K+, 3.03 mg/dl; and Ca2+, 0.85 mmol/L.\nThe patient's facial numbness and blurred vision were resolved 20 minutes after the neurologic symptoms developed. Over time, her arterial compliance was reduced and invasive arterial blood pressure waveform damped along with a progressive decline in pulse pressure (). She lost about 1,000 ml of blood and received, in total, 500 ml of colloid solution, 2,500 ml of crystalloid, and 1 unit of blood were infused.\nThe patient was transferred to the intensive care unit for special attention to neurologic symptoms with continuous arterial blood pressure monitoring. Even though no focal neurologic deficits, postoperative brain magnetic resonance imaging and a magnetic resonance angiographic study were performed to rule out acute cerebral infarction. Magnetic resonance imaging showed multiple old infarcts in the right frontal and left frontotemporoparietal areas and a suspicious acute left cerebellar small infarct. In addition, there were complete occlusions of the left subclavian, left common carotid, internal carotid and middle cerebral arteries. There were near-complete occlusions of the bilateral proximal vertebral arteries. The left distal vertebral artery was reconstituted by the left thyrocervical trunk (). She refused further treatments, including surgery. She was discharged on the sixth postoperative day.
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[[35.0, 'year']]
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F
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{}
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163,130 |
3766784-1
| 24,024,001 |
noncomm/PMC003xxxxxx/PMC3766784.xml
|
Fluid extravasation caused by bladder perforation during bipolar transurethral resection using saline solution -a case report-
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An 84-year-old male patient, 165 cm in height and 84 kg in weight, visited the hospital to have TURP for hyperplasia of prostate with obstruction. The patient had no specific medical history. The preoperative chest X-ray and electrocardiogram (ECG) were within normal range. The hemoglobin level (Hb) was 14.2 g/dl, and the hematocrit level was 41.1%, which were within normal limits.\nAfter arriving in the operating room, noninvasive blood pressure (NIBP), ECG, and pulse oximetry were attached. After a few minutes of rest, blood pressure was 150/95 mmHg, heart rate was 85 beats/min, respiratory rate was 15 breaths/min, and oxygen saturation (SaO2) was 94.0%. The patient's position was maintained at the right lateral decubitus position. After identifying the L4-5 intervertebral space, a 25 G Quincke spinal needle was inserted into the space. After the stylet was removed and cerebrospinal fluid was confirmed to be draining well, 11 mg of 0.5% bupivacaine (Marcaine®, AstraZeneca AB, Södertälje, Sweden) with 100 ug of epinephrine was injected. Ten minutes after he was placed in the supine position, the height of sensory block was increased to the T12 and checked by pin-prick test. The patient was placed in a lithotomy position. When bipolar TURP began, the irrigation fluid with 0.9% saline solution was injected from a height of about 150 cm without pressure. The patient had a severely enlarged right lobe of the prostate. At 120 minutes after anesthesia, 4 mg of ondansetron was injected because the patient vomited. At that time vital signs were stable (HR: 71 beats/min, NIBP: 150/85 mmHg). At 135 minutes after anesthesia, the patient complained of pain on operative site, considered to be caused by a low level of anesthesia. Therefore, with the consent of the patient, spinal anesthesia was switched to general anesthesia. Pre-oxygenation with 100% oxygen was conducted. After intravenous injection of 250 mg of thiopental and 40 mg of rocuronium, endotracheal intubation with a tube of internal diameter 7.5 mm was performed. Anesthesia was maintained with 2 L/min of oxygen, 2 L/min of air, and 2 vol% of sevoflurane. Tidal volume was 500 ml and respiratory rate was 10 breaths/min, so mechanical ventilation was initiated, when PIP was 24 cmH2O.\nForty minutes after switching to general anesthesia, the surgeon inserted a Foley catheter and finished the surgery. Glycopyrrolate 0.4 mg and neostigmine 1.5 mg were injected for reversal of muscle relaxation, the patient's spontaneous respiration and muscular strength recovered, and the endotracheal tube was removed. His blood pressure was well maintained at 140-100/100-70 mmHg throughout surgery, and the body temperature was around 36.2℃. However during emergence 10 mg of labetalol was injected twice due to high blood pressure (180/110 mmHg). The total anesthetic time was 3 hours and 15 minutes, and the total surgical time was 2 hours and 30 minutes. Seven hundred fifty ml of Ringer's lactate were injected, and 5 L of 0.9% saline solution was used as an irrigation fluid. When the patient was transferred to the PACU, SaO2 was measured as 80%. Although 10 L of O2 was provided with nonrebreathing reservoir facial mask, the SaO2 was not maintained at more than 90.0% (HR 77 beats/min, NIBP 190/110 mmHg). Arterial blood gas analysis showed a pH 7.159, PaCO2 53.5 mmHg, PaO2 58.9 mmHg, HCO3- 15.9 mmol/L, base excess -9.0 mmol/L, Na+ 139 mmol/L, K+ 3.5 mmol/L, Hb 14.2 g/dl and SaO2 81.8%. The patient complained of severe respiratory difficulties and abdominal pain. On physical examination, abdominal distension was founded. The surgeon suggested conducting an abdominal CT scan, but oxygen saturation was not maintained at more than 90% despite an Ambu-bagging with 10 L of 100% O2. The anesthesiologist decided to perform the endotracheal intubation again. Two hundred fifty mg of thiopental and 50 mg of rocuronium were injected, and endotracheal intubation with a tube of ID 7.5 mm was performed. A chest X-ray was taken and an intravenous injection of 10 mg of furosemide was conducted. In PACU NIBP was 180-140/110-85 mmHg and HR was 80-70 beats/min.\nA chest X-ray was normal. After the abdominal CT scan, the patient was transferred to the intensive care unit (ICU). Findings of the abdominal CT scan are seen . In the ICU, pressure support 11 cmH2O, FIO2 0.45, and PEEP 6 cmH2O were maintained as a PSV mode. Arterial blood gas analysis showed a pH 7.380, PaCO2 26.1 mmHg, PaO2 73.9 mmHg, HCO3- 15.6 mmol/L, base excess -7.3 mmol/L, and SaO2 94.7%. After the test, intravenous injections of 10 mg of furosemide were injected twice. The total volume of urine on the day of the surgery was 1100 cc.\nOn the first day after surgery the endotracheal tube was removed and checked ABGA. Three hours later ultrasonography was conducted and showed that a great volume of fluid had accumulated around the liver. A percutaneous catheter drainage (PCD) was done into the right upper abdomen, and about 650 cc of clear yellowish fluid was drawn. The patient was transferred to a general ward on that day. The PCD catheter was removed on the fourth day after the surgery. The patient was discharged from the hospital on the tenth day after the surgery.
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[[84.0, 'year']]
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M
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{'2698207-1': 1, '4600862-1': 1}
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163,131 |
3766785-1
| 24,024,002 |
noncomm/PMC003xxxxxx/PMC3766785.xml
|
Treatment of digit ulcers in a patient with Buerger's disease by using cervical spinal cord stimulation -a case report-
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The 62-year-old male patient in this case report had a smoking history of more than 30 pack-years and a medical history of hypertension and diabetes. He had had a percutaneous coronary intervention 6 years previously due to angina and had noticed a cold and numbing sensation in the extremities of both hands for the previous 3 years. Two years previously, the patient's fourth finger on the left hand had experienced blue discoloration, with extreme pain of greater than 90/100 mm on the visual analogue scale (VAS), followed by ulceration. After a few tests at the orthopedic clinic, the patient had been diagnosed with Buerger's disease. He had been referred to the pain clinic for conservative treatment one year previously. On the patient's upper extremity angiography, greater than 80% stenosis was observed in the first and third finger artery in the area of radial artery and palmer arch, and greater than 90% stenosis was also observed in distal ulnar artery.\nAt the time of referral, the patient had been taking oxycodone 40 mg twice a day, as well as limaprost 5 µg and gabapentin 300 mg 3 times day. Even with an increase in opiate dose and several chest sympathetic block and stellate ganglion blocks, the analgesic effect was temporal. The pain and ulcers on the fingers worsened, and a finger amputation was planned as arterial bypass surgery was not a valid method for this patient. Although a number of treatments were tried, the patient complained about extreme pain, 90/100 mm on VAS, and there were severe gangrenous ulcers progressing on the fourth finger of the left hand and the index finger of the right hand. The patient was very much against the amputation even though he was under extreme pain and had been referred to the pain clinic several times. Hence, the decision was made to attempt spinal cord stimulation prior to amputation.\nThe blood pressure, heart rate, oxygen saturation, and electrocardiography were monitored, and, with the patient in the prone position, local anesthesia was performed at T2-3 intervertebral space. A 15-gauge Tuohy needle was used for the paramedian approach with a C-arm fluoroscopic image. After ensuring the needle was positioned in the epidural space, the guidewire was inserted for easy insertion of the electrode, and the electrode was positioned in the posterior epidural space using the C-arm fluoroscopic image. The guidewire was removed, and the octrode electrode lead (Advanced Neuromodulation System Inc, Plano, Texas, USA) was placed 2 mm left of the radiological center. The distal electrode was placed at the bottom of the cervical spine ().\nThe electrode was connected to the test stimulator, and the stimulation was profound in the areas with pain. After the test stimulation, the pain was reduced by 50%. During 1 week of test stimulation, the patient's pain was maintained to within 20-30/100 mm on VAS, and the use of opiate analgesics was decreased by 50%. Hence, the permanent spinal cord stimulation insertion procedure was carried out. The Genesis IPG (Advanced Neuromodulation System Inc, Plano, Texas, USA) was buried under the lower left-side clavicle, and stimulation was well controlled with 3-4+ electrode combination, 4.0 V amplitude, 240 msec pulse width, and 34 Hz frequency.\nAfter the spinal cord stimulation insertion, the ulcers on both hands began gradual recovery and were completely recovered after 6 months. The pain was maintained within 30/100 mm on VAS, and the use of opioid analgesics was decreased more than 50% compared with the pre-procedure stage ().
|
[[62.0, 'year']]
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M
|
{'25844138': 1, '15886668': 1, '6830339': 1, '9610341': 1, '7531360': 1, '12238855': 1, '9055297': 1, '10231644': 1, '8076031': 1, '1062688': 1, '11599450': 1, '24023989': 1, '15026864': 1, '1621428': 1, '9013359': 1, '7696871': 1, '24024002': 2}
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{}
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163,132 |
3766788-1
| 24,024,005 |
noncomm/PMC003xxxxxx/PMC3766788.xml
|
Green discoloration of urine after propofol infusion
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A 49-year-old female patient with a history of epilepsy and alcohol abuse was admitted to the emergency room (ER) for loss of consciousness after suffering a seizure. Central pontine myelinolysis was suspected. On admission to the ICU, the following laboratory results were found: albumin, 3.8 g/dl; total bilirubin, 3.2 mg/dl; aspartate aminotransferase (AST), 209 U/L; alanine transaminase (ALT), 50 U/L; blood urea nitrogen (BUN), 9.2 mg/dl; and creatinine, 0.8 mg/dl. Mechanical ventilation was instigated under sedation with midazolam. As frequent neurological examinations were required, midazolam was replaced with propofol. After titration, adequate depth of sedation was achieved at a rate of 4 mg/kg/h. Green urine was found 64 hours after continuous infusion of propofol (). Blood examination revealed a serum albumin level of 2.5 g/dl, total bilirubin 0.7 mg/dl, and direct bilirubin 0.4 mg/dl. Urinalysis revealed the following: pH, 6.0; urine specific gravity (SG), 1.020; bilirubin content, negative; and urobilinogen level, 8.0 EU/dl. Urine cultures were negative. We suspected propofol to be the cause of the green urine. Urine color recovered 6 hours after discontinuation of propofol. A repeat urinalysis showed: pH, 7.0; urine SG, 1.015; bilirubin content, negative; and urobilinogen level, 8.0 EU/dl. During 3 months of admission, this was the only instance of urine discoloration.
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[[49.0, 'year']]
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F
|
{'3261062': 1, '30626986': 1, '29992157': 1, '18794836': 1, '10999506': 1, '7900408': 1, '24024005': 2}
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{'3766788-2': 2, '3766788-3': 2}
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163,133 |
3766788-2
| 24,024,005 |
noncomm/PMC003xxxxxx/PMC3766788.xml
|
Green discoloration of urine after propofol infusion
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A 19-year-old male patient with a history of epilepsy was admitted to the ER for generalized convulsive status epilepticus. The patient was admitted to the ICU and we instigated mechanical ventilation under deep sedation with propofol. On admission to the ICU, the following laboratory results were found: albumin, 3.2 g/dl; total bilirubin, 1.1 mg/dl; AST, 44 U/L; ALT, 38 U/L; BUN, 14.7 mg/dl; and creatinine, 1.1 mg/dl. After titration, adequate depth of sedation was acquired at a rate of 3.5 mg/kg/h. The patient's urine changed to a green color 6 hours after the continuous infusion of propofol (). Blood examination revealed a serum albumin level of 3.0 g/dl, total bilirubin level of 1.1 mg/dl, and direct bilirubin 0.5 mg/dl. Urinalysis revealed the following: pH, 6.0; urine SG, 1.015; bilirubin content, negative; and urobilinogen level, 0.2 EU/dl. Even before the urine culture results were available, we suspected propofol to be the cause of the green urine. The urine color returned to normal 3 hours after discontinuation of propofol. A repeat urinalysis showed: pH, 7.0; urine SG, 1.020; bilirubin content, negative; and urobilinogen level, 8.0 EU/dl. After 2 days, we confirmed the cessation of seizure activity and transferred the patient to the general ward.
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[[19.0, 'year']]
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M
|
{'3261062': 1, '30626986': 1, '29992157': 1, '18794836': 1, '10999506': 1, '7900408': 1, '24024005': 2}
|
{'3766788-1': 2, '3766788-3': 2}
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163,134 |
3766788-3
| 24,024,005 |
noncomm/PMC003xxxxxx/PMC3766788.xml
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Green discoloration of urine after propofol infusion
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A 32-year-old female patient had an emergency splenectomy after a traffic accident. Because of bilateral multiple rib fractures and accompanying bilateral hemothorax and pneumothorax, we decided to maintain prolonged mechanical ventilation after the surgery. A controlled mechanical ventilation mode was selected because of possible respiratory muscle fatigue and ventilator fighting. Appropriate sedation was achieved via continuous infusion of propofol at a rate of 3 mg/kg/h, with remifentanil at 2 mcg/kg/h. The patient's urine became yellowish green 19 hours after continuous propofol infusion (). Urinalysis revealed the following: pH, 6.0; urine SG, 1.015; bilirubin content, 1+; and urobilinogen level, 8.0 EU/dl. Urine culture was negative. As there were no signs of infection and no other known medication that could have discolored the urine, we suspected propofol as the cause. The urine color returned to normal 6 hours after discontinuation of propofol. The patient fully recovered after 2 weeks and was discharged from the ICU without further complications.\nThe main metabolic pathway of propofol is oxidation, reduction, and hydrolysis by cytochrome P450 and glucuronate conjugation in liver microsomes. Propofol exhibits a rapid distribution from the blood into tissue and a slow return from deep peripheral compartments back into the blood. Propofol is excreted in the urine after glucuroconjugation of the parent drug (to form the propofol-glucuronide) and sulfo- and glucuroconjugation of the hydroxylated metabolite to form 4-(2,6-diisopropyl-1,4-quinol)-sulphate, 1-, or 4-(2,6-diisopropyl-1,4)-glucuronide, respectively [,]. These quinol derivatives may be the cause of discoloration []. These derivatives do not reflect or alter renal function [].\nUrobilinogen, which is known to indicate liver parenchymal damage, was elevated in all 3 cases, as seen in previous reports [,]. This suggests that in a situation of dysfunction or functional decline of the liver, an extrahepatic pathway of propofol metabolism is augmented, resulting in the green coloration of the urine. As seen in case 1, changes in the pharmacokinetics may interfere with hepatic metabolism and may augment extrahepatic metabolism of propofol.\nThe total amount of infused propofol does not seem to be related to the induction of green urine (approximately 23500 mg in case 1, 4720 mg in case 2, and 2720 mg in case 3). Tan et al. [] reported that even injection with 100 mg of propofol, could cause green discoloration of the urine. The length of the administration period does not seem to be related either. While, Blakey and Hixson-Wallace [] reported that discoloration developed after 3 days of infusion, Tan et al. [] reported that the urine showed discoloration in 1 hour of propofol administration. In the present cases, green urine was shown after 6-64 hours of continuous infusion.\nIn conclusion, the green discoloration of urine was related to the circumstances facilitating extrahepatic metabolism, rather than the amount of propofol administered or the duration of administration. Although green urine associated with propofol is benign and rare, prompt recognition of such side effects is important in limiting medical expenditures, inordinate drug exposure, and distress among patients and clinicians [].
|
[[32.0, 'year']]
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F
|
{'3261062': 1, '30626986': 1, '29992157': 1, '18794836': 1, '10999506': 1, '7900408': 1, '24024005': 2}
|
{'3766788-1': 2, '3766788-2': 2}
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163,135 |
3766798-1
| 24,024,076 |
noncomm/PMC003xxxxxx/PMC3766798.xml
|
Onyx Embolization of Dural Arteriovenous Fistula, using Scepter C Balloon Catheter: a Case Report
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A 77-year-old man presented with gait disturbance that had persisted for 1 month. He had a history of dementia and depression for which he had received medication. Brain magnetic resonance imaging (MRI) revealed atrophy and venous congestion. Computed tomography (CT) angiography revealed DAVF of the superior sagittal sinus (SSS) (). Transfemoral cerebral angiography (TFCA) showed that the SSS DAVF was supplied via multiple branches of the external carotid artery (ECA), the right anterior cerebral arteries, and the meningeal branches of the internal carotid artery (ICA) and vertebral artery (). Anterograde drainage was not observed through the SSS, while drainage through the vein of Labbe and sphenoparietal sinus was main. TFCA revealed venous hypertension and galenic venous drainage. Furthermore, TFCA showed CVR (). The DAVF was large and complex. According to Borden classification, the DAVF was type 2.\nEmbolization of DAVF was performed under general anesthesia using a biplanar fluoroscopic unit. Right femoral artery and left femoral vein were punctured with an angiography needle (18 gauge). A 6Fr Envoy guiding catheter (Codman, Miami Lakes, Florida, USA) was then introduced to the right ECA. Another Envoy catheter was introduced to the right internal jugular vein through the venous root. Heparin was administered in order to achieve a targeted activated coagulation time of 250-300s throughout the procedure. Using a transvenous approach, a microcatheter (Echelon 10) was placed at the fistulous sac of the SSS (). Eleven coils (GDC 360 Standard 24 mm × 40 cm (×7), 22 mm × 40 cm (×3), 20 mm × 33 cm (×1)) were inserted through the microcatheter (Echelon 10). Another microcatheter (Prowler Select 18) was subsequently used to insert non-detachable coils; this was placed using Synchro 14 microwire. Other coils (Interlock Coil 14 mm × 30 cm (×2), 14 mm × 20 cm (×1), 12 mm × 30 cm (×1), 12mm × 20 cm (×1), Nester Coil 10 mm × 14 cm (×2), 6 mm × 14 cm (×3), 4 mm × 14 cm (×3)) were inserted through this microcatheter. Following intravenous coil embolization using various coils, DAVF was occluded partially. Angiography revealed that retrograde drainage through the fistula remained (). A Scepter C balloon catheter (4×15 mm) was placed at the most distal segment of the middle meningeal artery (MMA). The tip of the balloon microcatheter was positioned at the DAVF. After that, balloon inflation and deflation was successfully carried out. () In order to occlude any residual fistula, Onyx18 was then injected through the dual lumen balloon catheter positioned in the MMA. Over a period of 22 minutes, a total of 4.5 cc of Onyx18 was injected, after which the DAVF was almost completely occluded (). Following embolization, angiography revealed no arteriovenous shunting or CVR (). The balloon was deflated by syringe suction without difficulty. The catheter was then immediately removed without any noticeable adherence to the Onyx cast. Procedure related complications were not observed. The patient symptoms were unchanged during hospitalization.
|
[[77.0, 'year']]
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M
|
{'33164616': 1, '28352807': 1, '28818827': 1, '22248630': 1, '30588182': 1, '11988596': 1, '21990779': 1, '25358810': 1, '20849795': 1, '33004343': 1, '2140125': 1, '17989374': 1, '19284242': 1, '28801711': 1, '27313969': 1, '34667906': 2, '21990466': 1, '11846934': 1, '27094527': 1, '21631202': 1, '24024076': 2}
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{'8459695-1': 1}
|
163,136 |
3766799-1
| 24,024,077 |
noncomm/PMC003xxxxxx/PMC3766799.xml
|
Safe Implementation of Mechanical Thrombectomy in Acute Stroke Patients with Major Arterial Occlusion and Concomitant Subdural Hematoma
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Case 1. A 67-year-old right-handed man was admitted to our hospital complaining of left extremity weakness after 70 minutes from stroke onset. The initial neurological examination revealed drowsiness, global aphasia, left homonymous hemianopia, and left hemiparesis including facial palsy with an NIH Stroke Scale (NIHSS) score of 19. He also showed a laceration to the right forehead with perilesional swelling.
|
[[67.0, 'year']]
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M
|
{'23008406': 1, '23130938': 1, '11387500': 1, '23370205': 1, '21087940': 1, '16377950': 1, '17272772': 1, '22932714': 1, '24024077': 2}
|
{'3766799-2': 2, '3766799-3': 2}
|
163,137 |
3766799-2
| 24,024,077 |
noncomm/PMC003xxxxxx/PMC3766799.xml
|
Safe Implementation of Mechanical Thrombectomy in Acute Stroke Patients with Major Arterial Occlusion and Concomitant Subdural Hematoma
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Case 2. A 72-year-old right-handed man was admitted to our hospital within 3 hours after experiencing acute left-side weakness and dysarthria. The neurological examination showed moderate dysarthria, left hemiparesis including facial palsy, and neglect syndrome with an NIHSS score of 10.
|
[[72.0, 'year']]
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M
|
{'23008406': 1, '23130938': 1, '11387500': 1, '23370205': 1, '21087940': 1, '16377950': 1, '17272772': 1, '22932714': 1, '24024077': 2}
|
{'3766799-1': 2, '3766799-3': 2}
|
163,138 |
3766799-3
| 24,024,077 |
noncomm/PMC003xxxxxx/PMC3766799.xml
|
Safe Implementation of Mechanical Thrombectomy in Acute Stroke Patients with Major Arterial Occlusion and Concomitant Subdural Hematoma
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Case 3. A 76-year-old right-handed man was transferred to our hospital following CT revealing an acute SDH 6 hours after symptom onset. The neurological examination revealed stupor, quadriparesis, and decreased brainstem reflex with an NIHSS score of 27. Also, he presented with a laceration to the right forehead with perilesional swelling.
|
[[76.0, 'year']]
|
M
|
{'23008406': 1, '23130938': 1, '11387500': 1, '23370205': 1, '21087940': 1, '16377950': 1, '17272772': 1, '22932714': 1, '24024077': 2}
|
{'3766799-1': 2, '3766799-2': 2}
|
163,139 |
3766800-1
| 24,024,078 |
noncomm/PMC003xxxxxx/PMC3766800.xml
|
Multimodal Imaging Follow-up of a Thrombosed Developmental Venous Anomaly: CT, CT Angiography and Digital Subtraction Angiography
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A 31-year-old male presented with loss of consciousness of abrupt onset after several days of headache. Initial pre-contrast CT showed swollen hypodense area, ICHs and linear hyperdensity in the left frontal lobe (). CT angiography with 3-dimensional post processing revealed dilated medullary veins with caput medusa appearance, but no venous drainage from the left frontal DVA) (). Multiplanar source images of CT angiography demonstrated the filling defect in the anterior superior sagittal venous sinus and suggested the thrombosis in the draining vein (). On follow-up CT angiograms ten days (not shown in this report) and two months later (), thrombosed draining vein was progressively recanalized and detected were findings of venous infarction with multifocal parenchymal hemorrhages in the left frontal lobe. Repeated digital subtraction angiography two years after the initial clinical presentation () clearly showed the presence of resolving venous thrombosis at a month ().\nNo underlying cause such as connective tissue disease, coagulopathy, history of steroid administration, dehydration and so on was identified for the spontaneous thrombosis in the venous drainage from DVA.\nThe patient was treated conservatively, became conscious five days later and eventually recovered without localized neurological deficit. He developed generalized seizure, but had been under control with anti-epileptic medications.
|
[[31.0, 'year']]
|
M
|
{'17652917': 1, '30659007': 1, '8693990': 1, '26543692': 2, '17072663': 1, '9493181': 1, '20697060': 1, '8697463': 1, '3795187': 1, '18787814': 1, '15481728': 1, '10094347': 1, '19798638': 1, '15315533': 1, '20569563': 1, '10773651': 1, '19035729': 1, '9737164': 1, '18813722': 1, '2483861': 1, '29443146': 1, '22247645': 2, '18518718': 1, '24024078': 2}
|
{'3253395-1': 1, '4627833-1': 1}
|
163,140 |
3766811-1
| 24,023,559 |
noncomm/PMC003xxxxxx/PMC3766811.xml
|
Minute Pulmonary Meningothelial-Like Nodules Simulating Hematogenous Lung Metastasis: A Case Report
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A 52-year-old man was referred to our clinic for an 11.3 mm nodule in the left lower lobe discovered on a chest CT scan. We found eleven small nodules of various sizes in both lungs, but there was no definite lymph node enlargement in the mediastinum or either hilum (). The patient had complained of a persistent cough and mild dyspnea for several months. He had a history of secondary erythrocytosis, and was a current smoker with a history of 30 pack-years. He had no family history of cancer. His secondary erythrocytosis was mild, and he did not take any medication for it. His hemoglobin level was 18.2 g/dL, and the rest of the laboratory data revealed no abnormal results.\nInitially, we decided to perform a biopsy, and consulted with the chest radiologist to perform a transthoracic needle aspiration using CT scan guidance. The pathologic report showed a few clusters of atypical cells that were suspicious for malignancy. However, cells acquired during needle aspiration were scant, so we could not make a definite diagnosis. For further evaluation, we carried out a positron emission tomography (PET) scan, esophagogastricduodenoscopy (EGD), and colonoscopy. There was no evidence of malignancy on the EGD or colonoscopy. The PET images showed multiple lung nodules scattered in both lungs. The largest one was 11.3 mm in the left lower lobe and did not have any discernible fludeoxyglucose uptake (). We could not rule out the possibility of hematogenous lung metastasis from an unknown primary lesion.\nFor pathologic confirmation, video-assisted thoracoscopic surgery (VATS) was performed while excising a lung parenchyma sample of 3.5×1×0.6 cm. Analysis revealed a relatively well-circumscribed gray-white solid mass, measuring 1.1 cm in diameter. Microscopically, the surgical lung biopsy specimen showed an interstitial proliferation of cytologically bland oval to blunted spindle cells. The cells enveloped the small blood vessels, and seemed to form whorls with dispersed nuclear chromatin (). Immunohistochemical analysis was performed, and the sample was positive for epithelial membrane antigen (EMA), vimentin, CD56, and progesterone. Cytokeratin, thyroid transcription factor-1, and CD34 were negative. Finally, the diagnosis of MPMNs was established, and there was no evidence of malignancy. On the second postoperative day, the patient was discharged without any complications. Currently, he is being followed-up with at our hospital and is doing well.
|
[[52.0, 'year']]
|
M
|
{'17414111': 1, '19047895': 1, '30964241': 1, '23109985': 2, '10540672': 1, '15043310': 1, '31327818': 1, '13753180': 1, '177176': 1, '10208464': 1, '4293645': 1, '19144385': 1, '2830799': 1, '24023559': 2}
|
{'3479696-1': 1}
|
163,141 |
3766812-1
| 24,023,560 |
noncomm/PMC003xxxxxx/PMC3766812.xml
|
A Case of Giant, Benign Schwannoma Associated with Total Lung Collapse by Bloody Effusion
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A 36-year-old female presented with dyspnea with onset one week prior. Chest X-ray showed total opacity in the right lung (). Chest computed tomography revealed massive pleural fluid collection with total passive atelectasis of right lung. In addition, an inhomogeneous mass was found at the posterior portion of fluid collection (). The mass was well-circumscribed and showed minimal enhancement by radio-contrast dye (). A closed thoracentesis was performed and the aspirated pleural fluid was grossly bloody. Pleural fluid analysis was as follows: total protein 5.0 g/dL, lactate dehydrogenase 97 IU/L, glucose 96 mg/dL, pH 7.22, red blood cell 95,000/mm3, white blood cell 18/mm3 (differential count was impossible due to the small number of leukocytes), adenosine deaminase 21.9 IU/L. Cytologic exam was negative for malignant cell and a culture of pleural fluid did not grow any significant respiratory pathogens. Video-assisted thoracic surgery (VATS) revealed that right pleural cavity was filled with bloody fluid and a dumbbell-shaped tumor was found in the posterior thorax wall (). Because the mass was tightly fixated to the thoracic wall, VATS was converted into an open thoracotomy for the complete resection of the tumor. Upon removal, the mass was revealed to be a whitish soft tumor measuring 10.0×12.0×3.0 cm with a yellow cut-surface (). Upon microscopic exam, the tumor was composed of spindle cells with elongated nuclei, forming interlacing bundle with focal nuclear palisading. Mitotic figures were rare (). Immunohistochemical studies showed a strongly positive reaction with S-100 protein (data not shown). All of these findings are consistent with benign schwannoma. In the afternoon of the operation day, the patient complained of dyspnea and chest X-ray showed total haziness in the right lung (), which must have developed by re-expansion pulmonary edema after removal of massive pleural effusion. The patient was closely monitored in the intensive care unit with restriction of fluid administration. Several days later, the pulmonary edema was resolved and the patient was discharged on the 10th day after operation. Chest X-ray taken a month after the surgery showed full expansion of right lung ().
|
[[36.0, 'year']]
|
F
|
{'12775259': 1, '19491123': 1, '10597059': 1, '33768981': 1, '21320327': 2, '11517542': 1, '29021929': 2, '31814948': 2, '1630201': 1, '27797803': 1, '10355655': 1, '21781292': 2, '34909333': 2, '21682055': 1, '24023560': 2}
|
{'8660959-1': 1, '5634514-1': 1, '3050829-1': 1, '3154864-1': 1, '6856921-1': 1}
|
163,142 |
3766813-1
| 24,023,561 |
noncomm/PMC003xxxxxx/PMC3766813.xml
|
Community-Acquired Necrotizing Pneumonia Caused by ST72-SCCmec Type IV-Methicillin-Resistant Staphylococcus aureus in Korea
|
A 66-year-old man was referred to the Samsung Medical Center, Seoul, Korea, following a diagnosis of CAP with cytopenia which was made at another hospital. Three weeks prior to admission, he had ingested water of boiled wild mushroom. While he developed nausea and headache, which spontaneously resolved without medication, he did not experience any respiratory symptoms. Two week later, he developed dyspnea on exertion. He visited his regional hospital presenting with fever and dyspnea and was diagnosed with CAP. However, he was referred to our hospital for leukopenia (leukocyte count, 300/µL; absolute neutrophil count, 0/µL) and thrombocytopenia (platelet count, 3,000/µL) found on initial laboratory tests at the regional hospital. On admission to our hospital, his condition deteriorated rapidly and he was placed on mechanical ventilation for severe hypoxemia. Chest computed tomography (CT) showed consolidation and ground-glass opacity with cavitation in the left lower lobe which was compatible with necrotizing pneumonia (). The patient was diagnosed with severe necrotizing pneumonia in a neutropenic patient and was administered vancomycin, piperacillin-tazobactam and levofloxacin. Aplastic anemia associated with wild mushroom toxin was diagnosed with bone marrow biopsy which showed hypocellular marrow with suppressed trilineage hematopoiesis. While the Gram stain of respiratory specimens showed gram-positive cocci in pairs, chains and clusters, the urinary antigen test for Streptococcus pneumoniae was negative. The culture from sputum grew MRSA and while the strain was susceptible to gentamicin, rifampicin, ciprofloxacin and trimethoprim/sulfamethoxazole, it was resistant to erythromycin and clindamycin. The patient recovered completely following a 2 week treatment course with vancomycin. In order to genotype the bacterial isolate, multilocus sequence typing (MLST) was performed using polymerase chain reaction (PCR) amplification and sequencing of seven housekeeping genes (arcC, aroE, glpF, gmk, pta, tpi, and yqiL) as previously described. SCCmec type was determined by the multiplex PCR method. The isolate was screened for the genes (lukF-PV and lukS-PV) encoding the components of the PVL toxin by PCR amplification. Typing of the MRSA isolate from the patient revealed that the isolate belonged to MLST ST72, carried SCCmec type IV and was negative for PVL.
|
[[66.0, 'year']]
|
M
|
{'19467478': 1, '15614698': 1, '17884831': 1, '11888586': 1, '32713876': 1, '10524952': 1, '15814879': 1, '10698988': 1, '17599308': 1, '22652522': 1, '19405550': 1, '16236949': 1, '29968985': 1, '18462093': 1, '16707043': 1, '16914702': 1, '21382130': 1, '24023561': 2}
|
{'3766813-2': 2}
|
163,143 |
3766813-2
| 24,023,561 |
noncomm/PMC003xxxxxx/PMC3766813.xml
|
Community-Acquired Necrotizing Pneumonia Caused by ST72-SCCmec Type IV-Methicillin-Resistant Staphylococcus aureus in Korea
|
A 57-year-old woman who had previously been healthy except for a history of pulmonary tuberculosis thirty years ago and who was on current medication for hypertension and depressive episodes, was admitted to our hospital with high fever, cough and sputum for 3 days. On admission, dyspnea and chest pain developed. Chest CT showed multiple patchy consolidations in both lower lobes and the right middle lobe of the lung (). Laboratory tests revealed a leukocyte count of 1,820/µL, hemoglobin at 9.9 g/dL, and a platelet count of 192,000/µL. After 2 days, she rapidly deteriorated and was admitted to the intensive care unit (ICU) following intubation for severe hypoxemia. She was diagnosed with severe CAP and ceftriaxone and azithromycin were administrated empirically. While Gram stain of respiratory specimens revealed gram-positive cocci, the urinary antigen test for S. pneumoniae was negative. MRSA grew from sputum culture and the strain was susceptible to gentamicin, rifampicin, ciprofloxacin, trimethoprim/sulfamethoxazole, erythromycin and clindamycin. Vancomycin was added to the empiric treatment on hospital day 5. Due to the persistent fever following administration of vancomycin for 7 days, vancomycin was replaced with linezolid. Bilateral infiltration in the lungs with respiratory failure resulted in acute respiratory distress syndrome which was treated with adjunctive corticosteroid treatment. Ultimately, the patient recovered following linezolid treatment for 7 days in addition to vancomycin treatment for 7 days and corticosteroid treatment for 4 weeks. Typing of the MRSA isolate from the patient revealed that the isolate belonged to MLST ST72, carried SCCmec type IV and was negative for PVL.
|
[[57.0, 'year']]
|
F
|
{'19467478': 1, '15614698': 1, '17884831': 1, '11888586': 1, '32713876': 1, '10524952': 1, '15814879': 1, '10698988': 1, '17599308': 1, '22652522': 1, '19405550': 1, '16236949': 1, '29968985': 1, '18462093': 1, '16707043': 1, '16914702': 1, '21382130': 1, '24023561': 2}
|
{'3766813-1': 2}
|
163,144 |
3766814-1
| 24,023,562 |
noncomm/PMC003xxxxxx/PMC3766814.xml
|
Tracheal Stenosis after Tracheostomy Treated Successfully with Papillotome Electrocautery
|
A 39-year-old woman was admitted to our Department of Cardiothoracic Surgery because of dyspnea. Twenty years previously, she underwent surgery for a diagnosed brain lesion. Since then she had taken anticonvulsant medication. The seizure attack developed after she stopped taking the anticonvulsant drug due to pregnancy. A tracheostomy was performed. Since then, dyspnea had persisted. She had no relevant family history. Physical examination revealed stridor and a wheezing sound on both lung fields. Laboratory tests were within normal range, except for decreased hemoglobin level (9.9 g/dL). Pulmonary function test indicate fixed obstructed pattern (). Flexible bronchoscopy was performed, which revealed the two-third narrowing of the upper trachea due to web-like fibrotic stenosis (). A chest computed tomography (CT) revealed diffuse stenosis and focal web at the cervical trachea (). We tried to treat the stenosis with papillotome electrocautery. The patient was discharged and followed-up in the outpatient department. After 2 weeks, we performed bronchoscopy and pulmonary function tests for follow-up. Follow-up bronchoscopy revealed persistence of mild web type stenosis. Follow-up pulmonary function test still indicated fixed obstructed pattern. So, the stenosis was again treated with the needle knife approach ().\nAfter 2 months, a flow volume curve showed a normal pattern (). Bronchoscopy revealed ulcerative lesion, but improved stenosis (). CT showed the long stenosis of the cervical trachea was decreased (). The patient has been followed-up regularly on an outpatient basis.
|
[[39.0, 'year']]
|
F
|
{'11236779': 1, '8899924': 1, '10531180': 1, '20078894': 1, '15906845': 1, '10936149': 1, '10362058': 1, '12740291': 1, '7056101': 1, '7197061': 1, '16432969': 1, '1405685': 1, '23101015': 1, '12755310': 1, '10740659': 1, '24023562': 2}
|
{}
|
163,145 |
3767060-1
| 24,040,491 |
noncomm/PMC003xxxxxx/PMC3767060.xml
|
Rapid diagnosis of combined multifocal gastrointestinal stromal tumours and coeliac disease in a patient with type 1 neurofibromatosis
|
A 65-year-old man with type 1 neurofibromatosis (NF) was referred to the gastroenterology out patient department with recurrent iron deficiency anaemia and a week long history of melaena. His past medical history included ischaemic heart disease, hypertension and asthma. Medications included aspirin and prasugrel. The only positive findings on physical examination were cutaneous neurofibromata.\nA serological, haematological screen and tumour markers were all within normal limits. Initial investigations included a gastroscopy, duodenoscopy and colonoscopy; none revealed a source for his anaemia. A small bowel capsule endoscopy (SBCE) revealed an atypical polypoid submucosal lesion in the proximal small bowel with surface ulceration (). An anterograde double balloon enteroscopy (DBE) confirmed the lesion; however, it was not amenable to tunnelled biopsy due to extensive surface ulceration. The location was marked with ink to help with subsequent laparoscopic localization. Incidentally, on DBE, there were features suggestive of coeliac disease, which was confirmed by jejunal biopsies (Marsh IIIa).\nA magnetic resonance enteroclysis (MRE) was requested prior to laparoscopy which detected a 3.8 × 3.3 cm suspicious soft tissue mass in the right upper quadrant arising from the small bowel (). He proceeded to a laparoscopic-assisted small bowel resection. A large lesion in the jejunum close to the ileum was resected, and multiple additional nodules along the surface of the jejunum were biopsied.\nHistologically, the largest tumour was 4.5 cm and a confirmed gastrointestinal stromal tumor (GIST). The expression of c-kit/CD117 and DOG-1 was demonstrated. The mitotic count was <1 per 50 high power fields. The proliferative rate as manifest by MIB-1 expression was <1%. No nodal metastases were noted. Biopsies of the separate nodules (1 cm and 7 mm) also showed GIST with low/absent mitoses.\nFollowing multidisciplinary team (MDT) review, the additional lesions were felt to represent multifocal disease rather than metastases. In accordance with international guidelines, Imatinib treatment was not commenced and regular surveillance was employed. A gluten-free diet (GFD) was commenced. Unfortunately, a follow-up surveillance computed tomography (CT), seven months after surgical resection, showed a 3.5 cm jejunal GIST, representing local disease progression.
|
[[65.0, 'year']]
|
M
|
{'1916682': 1, '22831984': 1, '22493760': 1, '18628470': 1, '20670070': 1, '6129425': 1, '16418817': 1, '17349035': 1, '21479127': 1, '24040491': 2}
|
{}
|
163,146 |
3767063-1
| 24,040,494 |
noncomm/PMC003xxxxxx/PMC3767063.xml
|
Hypertriglyceridemic pancreatitis in pregnancy: case reports and review of the literature
|
A 32-year-old Bangladeshi woman was seen urgently in outpatient clinic with an unplanned pregnancy of approximately six weeks’ gestation.\nShe had a past history of polycystic ovarian syndrome, non-alcoholic fatty liver disease, obesity and developed type 2 diabetes six years previously. She had been noted at diagnosis of diabetes to have mild hypertriglyceridemia (), which was thought to be due to uncontrolled diabetes. Over the preceding four years, she had suffered three bouts of acute pancreatitis. On the first admission, she was noted to have marked hypertriglyceridemia. Despite high doses of insulin, statin, fibrate, omega-3 fish oils, metformin and sitagliptin, her glycaemic control remained poor (glycated haemoglobin ranging from 9.4% [79 mmol/mol] to 11.8% [105 mmol/mol]) as did her lipid control, despite input from diabetes nurses, dietitian and an inpatient admission for stabilization of glucose levels. She admitted her dietary concordance was poor. She had two previous uneventful pregnancies prior to her diagnosis of diabetes, neither of which was complicated by gestational diabetes.\nShe was counselled about the high risk of pancreatitis in pregnancy, but remained keen to continue the pregnancy. Fibrate, insulin, metformin and fish oil therapy was continued as the risk of hypertriglyceridemia-induced pancreatitis was deemed significant. She was seen by a dietitian and booked into the diabetic pregnancy service for weekly review. Glycaemic control and lipid control remained suboptimal despite rapid titration in insulin doses.\nAt 12 weeks’ gestation, she was admitted with acute abdominal pain and vomiting. Abdominal examination showed peritonism. She was dehydrated, blood pressure 110/80 mmHg and pulse 120 regular. Serum amylase was elevated at 1464 (normal range <90 U/L). Arterial blood gases were normal. She was admitted to the High Dependency Unit and received supportive therapy with intravenous fluids, starvation and antibiotics, and made a rapid recovery within five days. Careful counselling of her risk of recurrent pancreatitis was discussed. The option to have frequent plasma exchange during pregnancy was offered, but after discussion with her family she opted for a medical termination of pregnancy, which she underwent at 14 weeks’ gestation. Contraceptive advice was given to eliminate the risk of unplanned pregnancy in the future.
|
[[32.0, 'year']]
|
F
|
{'30254776': 2, '34095491': 1, '19770656': 1, '217273': 1, '18978108': 1, '19524405': 1, '16142021': 1, '15345258': 1, '9791843': 1, '25628906': 2, '19160449': 1, '21252809': 1, '21735079': 1, '24040494': 2}
|
{'3767063-2': 2, '4299559-1': 1, '6145316-1': 1}
|
163,147 |
3767063-2
| 24,040,494 |
noncomm/PMC003xxxxxx/PMC3767063.xml
|
Hypertriglyceridemic pancreatitis in pregnancy: case reports and review of the literature
|
A 24-year-old woman was admitted with acute abdominal pain. She had been diagnosed with hypertriglyceridemia during an admission with pancreatitis two years previously (), and treated with a statin and fibrate, achieving reasonable control of her hypertriglyceridemia. On examination, she had signs of peritonism, blood pressure 88/42 mmHg and pulse 130 regular. Serum amylase was 8962 (normal range <90 U/L). Pregnancy test was positive, and ultrasound confirmed a gravid uterus of approximately eight weeks’ gestation, and oedema of the pancreatic head. She was admitted to intensive care, treated with antibiotics, intravenous fluids and starvation. Her condition deteriorated, developing adult respiratory distress syndrome, requiring respiratory and inotropic support. She suffered foetal loss at day 4, but slowly recovered, without the need for laparotomy. Computerized tomography of the abdomen showed necrotizing pancreatitis, but no fluid collection or pseudocyst formation. She was discharged at day 17, back on her lipid lowering medication. She was given advice to avoid pregnancy in the near future.
|
[[24.0, 'year']]
|
F
|
{'30254776': 2, '34095491': 1, '19770656': 1, '217273': 1, '18978108': 1, '19524405': 1, '16142021': 1, '15345258': 1, '9791843': 1, '25628906': 2, '19160449': 1, '21252809': 1, '21735079': 1, '24040494': 2}
|
{'3767063-1': 2, '4299559-1': 1, '6145316-1': 1}
|
163,148 |
3767065-1
| 24,040,496 |
noncomm/PMC003xxxxxx/PMC3767065.xml
|
Neglected patellar tendon rupture. Reconstruction using semitendinosus-gracilis tendon grafts and FiberWire augmentation
|
A fit and well, non-smoker, 23-year-old male motorbike courier was referred to the senior author (DC) for the management of a neglected patellar tendon rupture, 10 weeks following a low-speed road traffic collision.\nPre-operatively, lateral radiographs of both knees were performed in order to estimate the Insall–Salvati ratio and use the measurement from the uninjured side as a guide during the reconstruction. The Insall–Salvati ratio measured 1.0. The patient was consented for a patellar tendon reconstruction using hamstring graft and possible Z lengthening of the quadriceps tendon.\nThe patient was placed under general anaesthesia in a supine position on the operating table and intravenous antibiotic prophylaxis was administered. Tourniquet ischemia was not applied as this may have caused tethering of the quadriceps, preventing adequate assessment of patellar height. During the examination under anaesthetic no restrictions of patellar mobility were identified and it was possible to bring the patella distally to its appropriate position. An anterior midline skin incision was made, with adequate exposure to allow for the anatomy to be fully defined. The ruptured patella tendon was identified and it was apparent that the tendon had ruptured off the distal pole of the patella. The scar tissue at the level of the rupture was excised to expose healthy tendon edges. An assessment of the ability to recreate the Insall–Salvati ratio was confirmed at this stage and the patella was mobilized distally without significant tension from the quadriceps. The pes anserinus was identified and the semitendinosus and gracilis tendons were harvested with an open tendon stripper, achieving maximum length of the tendon grafts and leaving the tendons attached distally at their tibial insertion. The free tendon edges were cleaned of remaining muscle and soft tissue and prepared with whipstitch sutures. Two transosseous tunnels were subsequently drilled following the general principles as described by Ecker et al.\n; first, a 5.5 mm transverse tunnel through the patella, just distal to the mid-patellar level and then a 4.5 mm oblique tunnel behind the tibial tubercle, beginning proximally on the lateral aspect and extending distally to the medial aspect (). With the knee in full extension, a FiberWire suture (Arthrex, Florida, USA) was passed through the tibial and patellar tunnels and tensioned to bring the patella distally. The suture was used to set the height of the patella, using the previously calculated Insall–Salvati ratio of the uninjured knee. This was confirmed using C-arm image intensifier with the knee at 30° of flexion (). The free end of the semitendinosus tendon was passed medio-laterally through the oblique tunnel behind the tibial tubercle using the whipstitch and a suture passer. It was then passed latero-medially through the transverse patellar tunnel, again using a suture passer. The free end of the gracilis tendon was then passed medio-laterally through the transverse tunnel in the patella. The remaining tendons were then overlapped and sutured to each other. The tendon edges at the site of the original tendon rupture were also sutured (Ethibond suture, Ethicon, Gargrave, UK). After the repair was completed, the knee could be flexed to 90° passively without any gapping at the rupture site and the final patellar height was assessed at 60° of knee flexion and found to be symmetrical to the uninjured side. The wound was closed in layers (Vicryl and Monocryl sutures, Ethicon, Livingston, UK), after repair and reefing of the injured extensor retinaculum.\nPostoperatively, the knee was immobilized in a plaster cast at 20° of flexion. The patient was discharged the second postoperative day, not weight bearing. At the two-week follow-up, the cast and sutures were removed and the knee was placed in a hinged brace allowing flexion from 0 to 20°. Quadriceps isometric exercises were initiated at this stage. Further follow-up appointments were arranged at two weekly intervals with a 20° increase of the knee flexion on every occasion, ultimately achieving 120° of flexion in 12 weeks. At the three-month follow-up, initiation of weight bearing was permitted along with closed chain knee exercises under the supervision of a physiotherapist. At the six-month follow-up, the patient was able to walk unaided and without a limp. He had full active knee extension and 130° of flexion, achieving pre-injury functional levels, including return to sport. His Lysholm knee score was 87 points.
|
[[23.0, 'year']]
|
M
|
{'20591676': 1, '3416533': 1, '18500064': 1, '33381404': 1, '12787993': 1, '11476386': 1, '8542694': 1, '5111961': 1, '26713328': 1, '479234': 1, '33624467': 1, '33312974': 1, '6985557': 1, '21835626': 1, '17579835': 1, '24040496': 2}
|
{}
|
163,149 |
3767070-1
| 24,040,501 |
noncomm/PMC003xxxxxx/PMC3767070.xml
|
An important diagnosis to consider in recurrent meningitis
|
A 49-year-old Greek Cypriot male was referred to us with a history of four episodes of meningitis over the past 15 years (1998, 1999, 2002 and 2009). The first three episodes had been treated elsewhere, each time presenting with headache, fever, photophobia but no rash. Though no bacterial diagnosis was ever made and no organism isolated, his episodes were associated with high cerebrospinal fluid (CSF) protein and CSF neutrophil infiltrate. He responded well to intravenous antibiotic treatment on each occasion with no neurological deficit. Computerized tomography (CT) and magnetic resonance imaging (MRI) head imaging had not detected the cause of his recurrent meningitis.\nHe had had two Staphylococcus aureus infections of his umbilicus in 2002 and 2009 but otherwise his medical history was unremarkable. There was no history of head trauma nor of recurrent ear or sinus infections. He did report some non-specific upper respiratory tract symptoms but none suggestive of CSF rhinorrhoea.\nDetailed investigation of his immune system revealed low mannose-binding lectin (MBL) levels (0.06 mg/L, normal range 1.0–4.0 mg/L). The rest of his humoral and cellular immune tests were normal. A coronal CT sinus scan done to investigate his non-specific upper respiratory tract symptoms showed a 4 × 3 mm defect in the cribriform plate adjacent to the vertical attachment of the middle turbinate, a relatively common site for ‘congenital’ defects (). A small rim enhancing CSF intensity sac was shown on MRI just beneath the cribriform plate defect, consistent with a meningocoele. This was confirmed at surgery. The defect was surgically repaired with temporalis fascia and inferior turbinate mucosa by an endonasal endoscopic route.
|
[[49.0, 'year']]
|
M
|
{'8416268': 1, '20502772': 1, '2677957': 1, '10199352': 1, '11177378': 1, '19434484': 1, '18625686': 1, '17682979': 1, '10402116': 1, '29138935': 1, '1396929': 1, '21043378': 1, '10509505': 1, '26865899': 2, '33751028': 1, '14978146': 1, '19015295': 1, '28439602': 1, '24040501': 2}
|
{'3767070-2': 2, '4729723-1': 1}
|
163,150 |
3767070-2
| 24,040,501 |
noncomm/PMC003xxxxxx/PMC3767070.xml
|
An important diagnosis to consider in recurrent meningitis
|
A 21-year-old Caucasian male was reviewed in our clinic with a history of Streptococcus pneumoniae meningitis and bacteraemia complicated by pneumonia requiring intensive care unit admission. He recovered well following treatment with intravenous ceftriaxone. Assessment of his immune system revealed an isolated borderline low IgG level (6.3 g/L, normal range 7–16 g/L), borderline low C4 level (15 mg/dL, normal range 16–54 mg/dL) and low pneumococcal antibody titres (16 mg/L, protective range >50). At the time of his first episode, his IgG level was also noted to be low (5.1 g/L, normal range 7–16 g/L). Viral testing was negative. He was vaccinated with 23-valent pneumococcal polysacharide vaccination and made an appropriate antibody response.\nHe continued to report tiredness and general malaise and just over a year later, at age 23, developed a second episode of pneumococcal meningitis. This again responded well to intravenous antibiotics. Serotype-specific pneumococcal antibodies were measured after the second episode and low titres to 7 of the 13 measured pneumococcal serotypes were found. There was no history of head trauma with either episode nor of CSF rhinorrhoea.\nThe past medical history included autoimmune hepatitis and Crohn’s disease, requiring low-dose maintenance oral steroids. Other medication intermittently used included mesalazine, mercatopurine and methotrexate. He had had recurrent tonsillitis as a child and had a tonsillectomy at the age of 20.\nInitial routine CT head was reported as normal. However, detailed sinus CT showed an anomalous, prominent right agger nasi ethmoid air cell extending up to the skull base with sclerotic thickened bony walls and opacification within (). This was diagnosed as a mucocoele of this anomalous air cell. It was surgically decompressed.\nLong-term pneumococcal antibiotic prophylaxis and pneumococcal vaccination were given as preventative measures. Currently, his IgG and complement levels are within normal range.
|
[[21.0, 'year']]
|
M
|
{'8416268': 1, '20502772': 1, '2677957': 1, '10199352': 1, '11177378': 1, '19434484': 1, '18625686': 1, '17682979': 1, '10402116': 1, '29138935': 1, '1396929': 1, '21043378': 1, '10509505': 1, '26865899': 2, '33751028': 1, '14978146': 1, '19015295': 1, '28439602': 1, '24040501': 2}
|
{'3767070-1': 2, '4729723-1': 1}
|
163,151 |
3767071-1
| 24,040,502 |
noncomm/PMC003xxxxxx/PMC3767071.xml
|
Sustained bilateral middle ear effusions post orthognathic surgery successfully treated with grommet insertion
|
A 22-year-old woman underwent a Le Fort I maxillary osteotomy to correct a class III malocclusion with maxillary hypoplasia after prior orthodontic treatment. The maxillary movements during the osteotomy consisted of a 4 mm advancement and 2 mm posterior impaction. The surgery was uneventful. Post-operatively, the patient gained an excellent aesthetic and functional result.\nFour months post orthognathic surgery, the patient commented on reduced hearing in both ears since her operation. There were no symptoms of otalgia, otorrhoea, tinnitus or vertigo. The patient had no history of prior otological problems and had no medical co-morbidities.\nAfter a two-year period, when the patient was seen in her local otolaryngology department and recommended various treatments (which she declined), she requested a second opinion and was seen in the otolaryngology department of the hospital where her original surgery had been performed.\nThe patient’s auditory symptoms persisted during this time and it was noted that she also suffered from bilateral nasal congestion with hyposmia. On examination, both external auditory canals were healthy. Both tympanic membranes appeared congested suggestive of middle ear effusions. Anterior rhinoscopy revealed a mildly deviated nasal septum to the left but with good airflow bilaterally. Nasendoscopy revealed rhinitic nasal mucosa without middle meatal pathology and a healthy post nasal space.\nPure tone audiometry (PTA) revealed mild bilateral conductive hearing loss (). Tympanometry revealed bilateral flattened (type B) traces confirming bilateral middle ear effusions. It was decided to proceed with bilateral grommet insertion to improve her middle ear ventilation and hearing. The patient was also commenced on a trial of topical nasal steroids to treat her rhinitis as well as possibly improving her Eustachian tube function.\nThe patient underwent bilateral grommet insertion under general anaesthetic approximately 30 months after the onset of her auditory symptoms. An antero-inferior myringotomy was performed on both tympanic membranes and thick glue-like fluid was suctioned from both middle ear cavities. Shah grommets were then inserted bilaterally. Examination of the post nasal space was unremarkable. The patient was well postoperatively and was discharged with a one-week course of antibiotic/steroid ear drops.\nThe patient was reviewed back in the otolaryngology clinic six weeks after grommet insertion. Her hearing had improved and this was confirmed on PTA (). On examination, both grommets were noted to be in situ and patent. Her nasal congestion was also noted to be improved.
|
[[22.0, 'year']]
|
F
|
{'12472515': 1, '15806058': 1, '6938647': 1, '19586753': 1, '3589572': 1, '28566723': 1, '33768357': 1, '2231145': 1, '3162241': 1, '8676227': 1, '24040502': 2}
|
{}
|
163,152 |
3767867-1
| 24,032,118 |
noncomm/PMC003xxxxxx/PMC3767867.xml
|
Colon Cancer After Acute Diverticulitis Treatment
|
A 63-year-old female with no specific history visited the emergency room with complaints of dyspepsia and right lower quadrant pain that had begun 5 days prior. Her vital signs were a blood pressure of 111/75 mmHg, a pulse rate of 100 beats/min, a breathing rate of 24 breaths/min, and a body temperature of 36.3℃. The patient showed acute illness, and physical findings indicated right lower abdominal tenderness, but there was no rebound tenderness. The peripheral blood examination showed leucocytes had increased to 10,800/mm3 and C-reactive protein (CRP) to 10.7 mg/dL; liver function tests and electrolytes showed no abnormalities. No specific findings were observed on the plain abdominal X-ray. The abdominal CT findings showed a diverticulum of ~2 cm on the outside above the colonic wall of the ileocecal valve and ascending colon, which was accompanied by focal wall thickening, fat infiltration and inflammation of >5 cm (). Based on these findings, the patient was diagnosed with acute diverticulitis and was treated with intravenous antibiotics (ceftriaxone, metronidazole) for 10 days. She was discharged with improved symptoms. One month after discharge, the follow-up CT showed a cystic lesion of ~2.5 cm remaining in the area of diverticulitis; therefore, an abdominal CT was performed at the follow-up 3 months later to detect abscess formation. The size of the cystic lesion had increased to ~4 cm, and the focal wall thickening remained (). A biopsy was performed during colonoscopy for differentiation of a chronic abscess, a mucinous cyst and colon cancer. The ulcer lesion was covered with dirty exudates, and bleeding upon easy touch was evident in the proximal ascending colon and ileocecal valve (). The biopsy results confirmed an adenocarcinoma, moderately differentiated, with a carcinoembryonic antigen (CEA) level of 1.4 ng/mL. A right hemicolectomy was performed, and, based on the surgical specimen, the patient was finally diagnosed with a mucinous adenocarcinoma, moderately differentiated, at the T3N0M0 stage. The patient has been followed up without chemotherapy for 90 months; the cancer has not recurred to date.
|
[[63.0, 'year']]
|
F
|
{'22347935': 1, '14987890': 1, '10715340': 1, '21713756': 1, '6985709': 1, '8491397': 1, '15889263': 1, '16741596': 1, '24906548': 1, '29942212': 1, '18594842': 1, '12780614': 1, '7390117': 1, '15513359': 1, '10535492': 1, '16945170': 1, '24032118': 2}
|
{'3767867-2': 2, '3767867-3': 2}
|
163,153 |
3767867-2
| 24,032,118 |
noncomm/PMC003xxxxxx/PMC3767867.xml
|
Colon Cancer After Acute Diverticulitis Treatment
|
A 46-year-old male visited the hospital with the complaint of right lower quadrant pain that had started approximately 1 week prior. At the time of the visit, the patient still had right lower abdominal tenderness and rebound tenderness. The peripheral blood examination showed that the leucocyte level had increased to 12,300/mm3 and the CRP to 2.42 mg/dL, and a plain abdominal X-ray showed no abnormalities. The abdominal CT revealed a diverticulum in the proximal ascending colon and a focal wall thickening of ~6 cm in the surrounding area, accompanied by peripheral fat infiltration and inflammation, although the appendix was normal. However, lymph nodes around the ileum were enlarged, so colon cancer could not be excluded (). Clinically, the patient was diagnosed with acute diverticulitis, and the symptoms improved after 5 days of antibiotics (ciprofloxacin) and conservative treatment. One month after discharge, a follow-up colonoscopy was performed for colon cancer differentiation. The colonoscopy showed irregular boundaries surrounding most of the lumen in the proximal ascending colon and an ulceroinfiltrative mass accompanied by changes in the mucosal layer (). The biopsy results confirmed an adenocarcinoma, poorly differentiated, with signet ring cells and a CEA level of 14.4 ng/mL. The patient underwent a laparotomy, but peritoneal seeding was found in all intraperitoneal areas and was strongly adhered in the ileum. Furthermore, because there was an obstruction in the lesion, only simple bypass surgery (ileum-transverse colon) was performed. Subsequently, the patient received palliative chemotherapy, but died 253 days from the date of surgery.
|
[[46.0, 'year']]
|
M
|
{'22347935': 1, '14987890': 1, '10715340': 1, '21713756': 1, '6985709': 1, '8491397': 1, '15889263': 1, '16741596': 1, '24906548': 1, '29942212': 1, '18594842': 1, '12780614': 1, '7390117': 1, '15513359': 1, '10535492': 1, '16945170': 1, '24032118': 2}
|
{'3767867-1': 2, '3767867-3': 2}
|
163,154 |
3767867-3
| 24,032,118 |
noncomm/PMC003xxxxxx/PMC3767867.xml
|
Colon Cancer After Acute Diverticulitis Treatment
|
A 47-year-old male visited the hospital with the complaint of right lower quadrant pain that had started 3 days prior. He had a family history of his mother dying of colon cancer, but no other medical history. At the time of the visit, the physical examination results showed right lower abdominal tenderness, but no rebound tenderness. The peripheral blood examination showed that leucocytes had increased to 11,900/mm3 and the CRP to 12.31 mg/dL; no specific findings were observed on plain abdominal X-ray. The abdominal CT findings suggested 4 cm × 1 cm fluid retention in the proximal ascending colon and abscess formation due to diverticulitis perforation towards the outer wall of the ascending colon. In addition, the centripetal focal wall thickening was concurrent; therefore, colon cancer could not be excluded (). Ultrasound-guided percutaneous abscess drainage was performed, and conservative treatment with intravenous antibiotics (ciprofloxacin, metronidazole) was initiated. Three days later, tubography was performed, and because no residual abscess was found, the patient was discharged seven days after admission. After removal of the drainage catheter in the outpatient clinic, a colonoscopy was recommended due to the possibility of colon cancer. However, the patient did not revisit. Approximately two years later, the patient was readmitted with the main complaint of right lower quadrant pain that had started 1 month prior. The abdominal CT suggested diverticulitis-induced bowel perforation in the middle of the ascending colon, accompanied by a thickening of the wall of the ascending colon of ~7 to 8 cm in length (). A colonoscopy was performed to verify the lesion; the results showed an inflammatory mass surrounding the lumen in the proximal ascending colon accompanied by edema ().\nThe CEA level was 2.8 ng/mL, and the biopsy result was high-grade dysplasia; however, the abdominal CT and colonoscopy findings suggested colon cancer. Therefore, a right hemicolectomy was performed. Based on the surgical specimen, the patient was finally diagnosed with an adenocarcinoma, moderately differentiated, at the T3N2M0 stage. The patient is receiving palliative chemotherapy and has been followed up for 19 months to date.
|
[[47.0, 'year']]
|
M
|
{'22347935': 1, '14987890': 1, '10715340': 1, '21713756': 1, '6985709': 1, '8491397': 1, '15889263': 1, '16741596': 1, '24906548': 1, '29942212': 1, '18594842': 1, '12780614': 1, '7390117': 1, '15513359': 1, '10535492': 1, '16945170': 1, '24032118': 2}
|
{'3767867-1': 2, '3767867-2': 2}
|
163,155 |
3767868-1
| 24,032,119 |
noncomm/PMC003xxxxxx/PMC3767868.xml
|
Chronic Pelvic Abscedation After Completion Proctectomy in a Rectal Stump Insufficiency; Treatment With Gracilis Muscle Flap Following Vacuum Assisted Closure Therapy
|
A 58-year-old man underwent Hartmann procedure for obstructed lower rectal cancer at another hospital in September 2011. Pathological findings at that time indicated a stage IIIB tumor that had infiltrated beyond the muscularis propria into pericolorectal tissues with three lymph nodes showing metastases (pT3N1M0). The patient underwent chemoradiotherapy; weekly, 5-fluorouracyl (500 mg/m2) and folinic acid (500 mg/m2) were administered over 6 weeks as one cycle. After two cycles of chemotherapy, chemoradiotherapy was administered using the intensity-modulated radiation therapy technique to a dose of 50.4 Gy radiation after the surgery. The patient was referred to our division for reversal of the Hartmann procedure on January 2012. However, he had complained of intermittent periods of fever and perineal pain since his surgery and lately had suffered from purulent secretion through the anus. The top of the rectal stump was palpated about 4 to 5 cm from the anal verge, but it had irregular borders and was hardened. Also, a hole was palpated at the tip of the rectal stump. During the digital examination, about 80 mL of pus and mucus evacuated through the anus, and a decreased anal sphincter tonus was found. Endoscopy revealed a short rectal stump just 2 cm above the dentate line, as well as a disruption and a draining hole centered on the top of the stump. The opening was wide enough to allow the introduction of the scope into the abscess cavity, which measured 6 cm × 3 cm and was filled with necrotic material (). Magnetic resonance imaging showed a large presacral collection of 7 cm and some osteonecrotic changes of the sacrum.\nThe adjuvant radiotherapy, the short rectal stump and the poor anal sphincter tonus increased the risk of bad functional outcome; therefore, we decided to perform a complete proctectomy with VAC. The rectal resection was performed, and the perineal cavity was left open, but was packed with four rolls of gauze in order to ensure perineal hemostasis prior to putting the VAC system in place. The pack was removed one day later, and the VAC system was set in place (the wound measured 10 cm × 15 cm, ) under general anesthesia and set at a 125-mmHg depression (Type of foam: VAC GranuFoam Medium Dressing Kit, Kinetic Concept Inc.). Owing to the considerable pain and the position of the wounds, the VAC system had to be reapplied in theater 3-times a week initially, which was later reduced to twice weekly. Sequential wound assessment demonstrated marked improvements with visible granulation tissue following the application of the VAC system set at a 125-mmHg continuous topical negative pressure (). The amount of fluid was 200 mL every day during the first five days and decreased to 10 mL during the last two days. Three weeks later, a significant reduction in the wound size (5 cm × 6 cm, ) was evident, and on day 28, VAC therapy was stopped because the size of the cavity was no longer decreasing. However, the remnant of the cavity was still large, and fibrosis prevented apposition of the remaining soft tissue structures. Thus, we decided to filled the cavity with a gracilis muscle flap. The muscle flap were obtained from the left thighs' gracilis muscle and was then positioned within the bulk of the pelvic dead space, and the perineum was reconstructed. First, the muscle flap was taken from the detached gracilis muscle containing the medial circumflex femoral artery, vein, and nerve to promote better blood supply to the flap. The flap was then rotated in the direction of the sacrum and sutured (). A suction drain was placed on the left thigh, and the perineum was closed with primary sutures. Although a postoperative sinus developed in the perineal wound, a good blood supply prevented graft failure, and the sinus closed spontaneously in a short period. Two months after the gracilis muscle flap transposition, the perianal wound was completely healed.
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[[58.0, 'year']]
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M
|
{'16447032': 1, '18197452': 1, '9188970': 1, '25528032': 1, '18095024': 1, '18189215': 1, '19508536': 1, '9188971': 1, '20011400': 1, '7127036': 1, '34036143': 2, '20857528': 1, '19341404': 1, '19037698': 1, '1444149': 1, '24032119': 2}
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{'8138672-1': 1, '8138672-2': 1}
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163,156 |
3767902-1
| 24,032,105 |
noncomm/PMC003xxxxxx/PMC3767902.xml
|
Osteonecrosis of the Knee after Arthroscopic Partial Meniscectomy
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A 50-year-old male visited our clinic with a major complaint of pain in the right knee that had started five days earlier. He had no history of trauma and complained of a pulling sensation behind the right knee and giving way symptoms when walking down stairs. The patient had been working as a medical technician carrying gurneys for 21 years and had no significant medical history or history of trauma, alcohol abuse, and intra-articular steroid injections. Physical examination revealed tenderness over the medial femoral condyle but no edema. The range of motion and lower limb alignment were normal. McMurray's test was negative, joint instability was not present, and early radiography was normal (), Magnetic resonance imaging (MRI) showed evidence of posterior meniscal tear without any chondral or bone marrow damage (). Surgical treatment of the posterior tear of the medial meniscus was performed. A complex tear of the posterior horn of the medial meniscus and an International Cartilage Repair Society grade II cartilage lesion (lesions involving <50% of the total cartilage thickness) in the medial femoral condyle were observed with arthroscopy (). Surgery was performed under spinal anesthesia while maintaining 70 mmHg of pressure with an arthroscopy pump, and a tourniquet was not used. Partial meniscectomy was performed with a basket forceps and a shaver without using a razor or radiofrequency device and the cartilage damage was treated with debridement. The total surgical time was approximately 20 minutes.\nThe patient complained of pain at the second postoperative week, which was managed with medication. At the sixth postoperative week, the patient felt severer pain and had the greatest difficulty in walking with straight legs, for which an increased dose of anti-inflammatory analgesics was administered. At the 12th postoperative week, an MRI scan was performed because the pain increased except for temporary relief.\nThe MRI scan revealed cartilage delamination of the medial femoral condyle that exhibited a low intensity signal on the T1-weighted image and a high intensity signal on the T2-weighted image (). Since the symptoms deteriorated during three months of medication therapy, another MRI examination was performed six months postoperatively, which showed more extensive cartilage delamination and cyst formation. An MRI scan taken nine months postoperatively showed an enlarged cyst, increased swelling around the bone, and severe cartilage delamination, all of which were the symptoms of osteonecrosis (). Thus, unicompartmental knee arthroplasty was performed (). Currently, at six months after surgery, the patient has been pain-free and returned to work.
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[[50.0, 'year']]
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M
|
{'32855667': 1, '9704320': 1, '10750005': 1, '5700639': 1, '1994431': 1, '6643563': 1, '17483642': 1, '7794437': 1, '30871297': 1, '18310754': 1, '3279040': 1, '17418337': 1, '33093717': 1, '24032105': 2}
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{}
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163,157 |
3768168-1
| 24,032,086 |
noncomm/PMC003xxxxxx/PMC3768168.xml
|
Multiple brain metastases in a patient with uterine papillary serous adenocarcinoma: Treatment options for this rarely seen metastatic brain tumor
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A 71-year-old female underwent abdominal hysterectomy with bilateral salpingo-oopherectomy 2 years and 3 months ago. Histopathological examination of the biopsy specimen showed UPSAC. Adjuvant chemotherapy was given after the abdominal hysterectomy. The patient's Glasgow Coma Scale score was 12/15 at the time of admission to our hospital. She presented with a 20-day history of headache and left hemiparesis, and she could not walk or use her left arm and left hand. Cranial magnetic resonance iaging (MRI) showed three lesions; two were located in the parenchyma of the cerebellum and had perilesional edema. but had no shift effect or obstruction on the fourth ventricle and the third lesion was located in the right frontobasal frontal lobe, and caused a large hemispheric edema and subfalcine herniation []. All the three lesions exhibited contrast enhancement following gadolinium injection. The lesions’ characteristics are shown in Figures -.\nThe patient underwent frontal craniotomy with gross total extirpation of the tumor located in the right frontal lobe on September 12, 2012. There were no surgical complications, such as bleeding or adhesiveness adjacent to the brain tissue during the removal of the tumor. The other two lesions located in the posterior fossa were left untouched because they had no mass effect. Histopathological examination of the biopsy specimen was consistent with metastatic UPSAC [].\nThe patient was able to walk with the assistance of a walker, and underwent follow-up cranial computed tomography (CT) 2 days postsurgery [], which showed that there was no residual tumor in the frontal lobe, the midline shift and subfalcine herniation improved, and less edema than presurgery. The patient was followed-up for 9 months postsurgery and via telephone (last contact on May 14, 2013) reported that she was able to walk independently, and use her left arm and left hand without any difficulty, and that she had undergone 10 days whole cranial radiotherapy and chemotherapy at another hospital. The contrast enhanced cranial MRI was performed following these therapies on February 18, 2013. It showed no residual or recurrent lesion at the operation site, and no lesion at the cerebellum, which had had two lesions in previous MRI. In addition, the edema was remarkably lessened at the right cerebral hemisphere regarding preoperative and early postoperative period.
|
[[71.0, 'year']]
|
F
|
{'14110359': 1, '11330963': 1, '7102898': 1, '27117594': 1, '29479514': 1, '9648591': 1, '8626115': 1, '8823767': 1, '8431882': 1, '1473741': 1, '6284595': 1, '18780313': 1, '23303801': 1, '8898164': 1, '26076093': 1, '33572880': 1, '33850993': 1, '12164685': 1, '9571001': 1, '8522253': 1, '24032086': 2}
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{}
|
163,158 |
3768190-1
| 24,049,340 |
noncomm/PMC003xxxxxx/PMC3768190.xml
|
Papillon-Lefevre syndrome: A case report of 2 affected siblings
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A 16-year-old boy had permanent dentition with severe gingival inflammation, abscess formation, and deep periodontal pockets. Severe mobility affecting most of the teeth, with heavy deposits of plaque and calculus and halitosis were also present [].\nThe patient was found to be completely edentulous in the mandibular right quadrant. In the other quadrants, the permanent teeth that were missing were the right maxillary first molar, the right maxillary first premolar and second premolar, the lateral incisors, the central incisors, the left maxillary second premolar [Figures and ]. All the permanent teeth that were present exhibited marked mobility. The gingiva adjacent to the teeth appeared red, inflamed and edematous. There was bleeding on probing with deep periodontal pockets. Gingival recession was present in all the teeth. The mucosa of the edentulous area appeared normal.\nThe radiographic examination using panoramic film showed extensive bone loss and areas suggestive of vertical defects [].
|
[[16.0, 'year']]
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M
|
{'17658183': 1, '18714933': 1, '1452914': 1, '10662808': 1, '15491306': 1, '11338309': 1, '12509601': 1, '11453246': 1, '3156059': 1, '8707975': 1, '10593994': 1, '8466848': 1, '9673173': 1, '25057233': 1, '23397598': 1, '34603725': 2, '15585850': 1, '8811566': 1, '10581013': 1, '10662805': 1, '10662807': 1, '10581027': 1, '2935561': 1, '19008627': 1, '10847540': 1, '30156642': 1, '2967778': 1, '11922261': 1, '11207971': 1, '27658951': 2, '24049340': 2}
|
{'3768190-2': 2, '5034476-1': 1, '5034476-2': 1, '5034476-3': 1, '5034476-4': 1, '5034476-5': 1, '8473953-1': 1}
|
163,159 |
3768190-2
| 24,049,340 |
noncomm/PMC003xxxxxx/PMC3768190.xml
|
Papillon-Lefevre syndrome: A case report of 2 affected siblings
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An 11-year-old girl, younger sibling, had mixed dentition with severe gingival inflammation, abscess formation, and deep periodontal pockets []. Severe mobility affecting most of the teeth with halitosis were present. The radiographic examination using panoramic and periapical films showed severe alveolar bone loss up to the apical third region of the roots of the permanent teeth that were present, giving them the characteristic “floating-teeth” appearance [Figures and ].\nOn lateral cephalogram, there was no evidence of intracranial calcification in both patients. Laboratory investigation was carried out, which included hematological and biochemical assessment.\nRoutine blood investigations and liver function tests were found to be within the normative range of values.
|
[[11.0, 'year']]
|
F
|
{'17658183': 1, '18714933': 1, '1452914': 1, '10662808': 1, '15491306': 1, '11338309': 1, '12509601': 1, '11453246': 1, '3156059': 1, '8707975': 1, '10593994': 1, '8466848': 1, '9673173': 1, '25057233': 1, '23397598': 1, '34603725': 2, '15585850': 1, '8811566': 1, '10581013': 1, '10662805': 1, '10662807': 1, '10581027': 1, '2935561': 1, '19008627': 1, '10847540': 1, '30156642': 1, '2967778': 1, '11922261': 1, '11207971': 1, '27658951': 2, '24049340': 2}
|
{'3768190-1': 2, '5034476-1': 1, '5034476-2': 1, '5034476-3': 1, '5034476-4': 1, '5034476-5': 1, '8473953-1': 1}
|
163,160 |
3768191-1
| 24,049,341 |
noncomm/PMC003xxxxxx/PMC3768191.xml
|
Orthodontic-periodontic intervention of pathological migration of maxillary anterior teeth in advanced periodontal disease
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A 32-year-old Indian female patient came to the Department of Periodontology, Government Dental College and Hospital, Ahmedabad, Gujarat, India, with a chief complaint of loose and palatally drifted upper left central incisor, which led to malalignment of upper anterior teeth. Patient wanted to correct those teeth for restoring the esthetics [].\nA comprehensive periodontal examination was completed including extraoral, intraoral and radiographic evaluations.\nThorough clinical examination revealed, the maxillary left central incisor was drifted palatally with Grade II mobility, with a 9 mm deep periodontal pocket. Radiographic evaluation revealed angular bony defect extending until middle-third of the root of maxillary left central incisor []. Intraoral clinical status assessment was made and the treatment was planned sequentially.\nInitial periodontal treatment consisting of scaling and root planning was performed and patient was given oral hygiene instructions. An ideal diagnostic upper working cast was made. On that cast, “Z” spring with labial bow was fabricated []. The “Z” spring was made of 0.5 mm hard round stainless steel wire. The spring consisted of two coils of very small internal diameter. The spring was made perpendicular to the palatal surface of the tooth. It had a retentive arm of 10-12 mm length that was embedded in the acrylic. The “Z” spring was activated by opening both the helices by about 2-3 mm at a time. This removable appliance was modified to form a fitted labial bow, which was used as a retaining device during the treatment. Patient was advised to wear it for a period of at least 6 weeks [].\nPost-orthodontic treatment, when maxillary left central incisor was realigned in the arch [], it was splinted with the adjacent teeth to improve the stability and masticatory comfort [Figures and ]. Later, surgical intervention of left maxillary incisors was recommended to eradicate the deep infrabony pocket.\nAfter the full thickness, mucoperiosteal flap was reflected labially and palatally under local anesthesia, angular bony defect was found in relation to maxillary left central incisor []. The surgical site was grafted with decalcified freezed dried bone allograft []. The flaps were reapproximated and sutured. The sutures were removed after a week. Healing was uneventful. Patient was placed on a 3 month periodontal maintenance recall program [Figures and ].\nOn post-treatment evaluation (after 8 years), realigned maxillary left central incisor was observed; thus, achieving an acceptable occlusion. Furthermore, there was a normal gingiva showing no evidence of bleeding on probing. Radiographic examination revealed significant fill of the infrabony defect [Figures and ].\nFinally, the ortho-perio interdisciplinary approach resulted in the restoration of esthetics and function, thus improving self-confidence of the patient.
|
[[32.0, 'year']]
|
F
|
{'18661066': 1, '4532114': 1, '11504894': 1, '20922083': 1, '2801640': 1, '28299350': 1, '2773869': 1, '10534072': 1, '10783559': 1, '21691554': 2, '4586682': 1, '4522455': 1, '1507046': 1, '19146051': 1, '17073360': 1, '12212683': 1, '283054': 1, '17823683': 1, '24049341': 2}
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{'3110470-1': 1}
|
163,161 |
3768194-1
| 24,049,344 |
noncomm/PMC003xxxxxx/PMC3768194.xml
|
Multiple myeloma presenting as gingival hyperplasia
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A 58-year-old male patient was referred to our department because of the generalized enlargement of gingiva. The enlargement was first noted by the patient 6 months prior to the referral, and progressed steadily since then. Patient also complained of weakness, fatigue and anorexia. The intraoral examination revealed soft, granular, friable, non-tender, and red/magenta enlargement that bled spontaneously. The growth was painless in nature. Purulent discharge from some areas of the enlargement was also noted. The enlargements were present on both buccal and lingual/palatal sides []. On physical examination, Grade III mobility was observed in 16, 17, 18, 36, 37. General examination showed signs of pallor and poor nourishment. The medical history of the patient included epilepsy for which he took prescribed medication with no occurrence of seizure for last 10 years. Based on clinical presentation, a provisional diagnosis of inflammatory gingival enlargement, plasma cell gingivitis or Wegener's granulomatosis was made. Routine blood investigations were done along with HIV and Hepatitis B and sputum examination to rule out any leukemic infiltration and enlargement associated with tuberculosis. Orthopantomography was advised, which revealed severe bone loss in 16, 17, 18 and 36, 37 regions. Oral hygiene status of the patient was good. After Phase I therapy and consultation with the physician, gingivectomy was performed in anterior mandibular region and excised tissue was sent for histopathological examination. Periodontal dressing was given after performing gingivectomy. The patient was followed up every week [] but after 1 month the clinical examination revealed recurrence of enlargement in the anterior mandibular region []. The histopathology report revealed a lining of stratified squamous epithelium with foci of ulceration. The subepithelial zone showed infiltration by sheets of plasma cells mainly mature with few being less differentiated []. Binucleate and multinucleate plasma cells were also noted []. Presence of rounded cytoplasmic inclusion bodies was identified in many of these cells. Based on these findings, serum protein electrophoresis and urine analysis for Bence-Jones proteins was carried out. Serum protein electrophoresis revealed monoclonal increase in immunoglobulin G levels. No Bence-Jones proteins were detected in urine. Subsequently, patient was advised to undergo cranial and pelvic radiography [Figures and ]. The radiographs revealed small punched out osteolytic lesions in the cranium and pelvic region. The patient was referred to an oncologist for systemic screening. Bone marrow aspiration was done, which showed a marginal prominence of plasma cells. The biochemistry revealed high values of alkaline phosphatase and lowered albumin/globulin ratio. Bone marrow biopsy also revealed a patchy prominence of plasma cells. The patient was diagnosed as a case of multiple myeloma and chemotherapy was started with thalidomide. The patient reported for follow-up after 1 month. The gingiva appeared normal after the start of chemotherapy [].
|
[[58.0, 'year']]
|
M
|
{'31582338': 1, '5259043': 1, '32134898': 1, '29519372': 1, '17698264': 1, '5254197': 1, '31222625': 1, '26380825': 1, '8843457': 1, '1582977': 1, '13063932': 1, '5224608': 1, '3163784': 1, '6369219': 1, '24049344': 2}
|
{}
|
163,162 |
3768297-1
| 24,032,082 |
noncomm/PMC003xxxxxx/PMC3768297.xml
|
Intraorbital arteriovenous fistula with thrombosed varix: Diagnosis and treatment without catheter angiography in a developing country
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A 50-year-old woman, presented with 18-month history of painless progressive proptosis of right eye in association with upper lid swelling and conjunctival chemosis. Initially the proptosis was more marked during episodes of straining or prone/stooping positioning. Only in the last 1-month, she reported acute onset of retro-orbital pain, fixed proptosis, decreased vision, and mucopurulent discharge. There was no history of orbital trauma or family history of vascular disorders. Ophthalmologic examination of the right eye disclosed marked dilatation of conjunctival vessels, chemosis, and exophthalmos [] with gross reduction of visual acuity (Perception of light). Ocular movements were almost normal. Intraocular pressure was 22 mmHg in the right eye and 10 mmHg in the left eye.\nComputed tomography (CT) of the head and orbits demonstrated a nonenhancing, serpiginous soft tissue mass within right retrobulbar space, extending from the superior ophthalmic fissure to the anterolateral wall of the orbit [] with no change in the size of the lesion on valsalva maneuvre. Contrast enhancement was evident within the neighboring artery. It was clearly separated from the optic nerve and extraocular muscles. CT angiogram with 3D reconstruction revealed intraconal serpiginous vascular lesion arising from right ICA and ending at the level of SOV, which is grossly dilated and tortuous (2 cm) and filled with nonenhancing thrombous []. The SOV drained anteriorly into several small tributaries with slow outflow. No nidus and no communication into the cavernous sinus were observed []. These findings were consistent with the diagnosis of thrombosed varicose SOV in association with pure intraorbital AVF, which was further confirmed by high frequency (5-7.5 MHz) B-scan ultrasound with color doppler.\nAs the lesion was symptomatic due to dilated thrombosed SOV posing significant mass effect, open surgical excision was planned in our center On opening the orbital roof through fronto-orbital craniotomy, a thickened serpiginous thrombosed SOV was found, which was resected [] completely as far back toward the orbital apex as possible after ligation of the proximal feeding artery. Postoperative course was uneventful with good clinical outcome. CT scan obtained at the time of discharge demonstrated complete decompression of the orbit []. At 6 month follow, she was doing well with no recurrence.
|
[[50.0, 'year']]
|
F
|
{'12789591': 1, '30803333': 1, '11780909': 1, '15302655': 1, '24667945': 1, '21785379': 1, '28424011': 1, '6696010': 1, '9055307': 1, '3966228': 1, '10372894': 1, '31807372': 1, '2183119': 1, '24032082': 2}
|
{}
|
163,163 |
3768339-1
| 24,032,087 |
noncomm/PMC003xxxxxx/PMC3768339.xml
|
Crystal storing histiocytosis presenting as a temporal lobe mass lesion
|
A 20-year-old female was evaluated at an ambulatory care center for headaches that had become progressively worse over the prior 2 weeks. She had been treated for mycoplasma infection by a primary care physician. At presentation, the headaches were reportedly severe. The patient had no history of fevers but reported a sore throat 3-4 days prior without a cough or other discomfort. Her past medical history had no notable illnesses. Regarding her social history, she lived on a farm with a friend who had been treated for fungal meningitis in the past. No tobacco, alcohol, or intravenous drug use was admitted. She denied exposure or prior treatment for sexually transmitted diseases. She had no significant past medical history. On examination she was afebrile with a blood pressure of 110/70 mmHg. She was alert and oriented with no adenopathy. A complete blood count revealed a white blood cell (WBC) of 12.4 (4.2-9.1 thousand/microliter), 87% neutrophils with no bands. Serology was negative for mycoplasma and HIV-1. Her neurological exam was normal. Magnetic resonance imaging revealed a 3.5 × 1.3 × 1.9 cm contrast enhancing lesion of the left temporal lobe with a mild midline shift []. Evaluation by multiple specialists suggested a differential diagnosis of a noninfectious process (favored) neoplastic process or infection. She was treated with vancomycin 1.25 g IV per 12 h and meropenem 2 g IV q 8 h and decadron.\nThe mass was resected and aerobic, anaerobic, mycobacterial, and fungal cultures were taken. Anaerobic and aerobic cultures as well as gram, modified acid fast bacillus, and fungal stains were negative. Brain tissue polymerase chain reaction analysis at the state Department of Public Health laboratory public was negative for infectious agents. Due to initial uncertainty about the diagnosis and anticipation of the need for multiple studies in the laboratories, she was postoperatively treated with vancomycin IV for 10 days. Postoperative scans revealed gross total resection. On postoperative day 1 and 30 she was neurologically intact.\nThe sections revealed a fibrotic lesion with an extensive chronic inflammatory infiltrate of CD138-immunoreactive plasma cells, CD68-immunoreactive macrophages and monocytes and S100-immunoreactive histiocytes []. Plasma cells showed IgG, IgM, predominantly lambda but also some kappa immunoreactivity. There were numerous periodic acid-Schiff (PAS) staining rhomboid crystals and granular material that was predominantly intracellular but also extracellular []. No polarizable material was found. Special stains for bacteria including Nocardia and Mycobacteria were negative. The Grocott's Methenamine Silver GMS stains revealed no fungal organisms. The Masson stain demonstrated extensive dense collagen deposition but no encysted amoeba. There was no Congo red staining apple green birefringent polarizable material. There were no giant cells, viral inclusions, Herpes Simple ×1 or 2, cytomegalovirus, Epstein–Barr virus, or Toxoplasma immunoreactivity. There was no Alk-1 but scattered spindle cells and blood vessels show SMA immunoreactivity. To evaluate whether immunoglobulin expression was predominantly one type, additional immunoflourescence and in situ hybridization were performed. These demonstrated overwhelmingly lambda light chain restriction []. Electron microscopy revealed numerous intracellular but also extracellular rhomboid and diamond-shaped crystals []. Collectively the findings of histiocytes with intracellular rhomboid and diamond-shaped crystals showing light chain and exclusion of other neoplastic and infectious processes were considered consistent with CSH, light chain subtype.
|
[[20.0, 'year']]
|
F
|
{'18711355': 1, '20110371': 1, '25518913': 1, '22430767': 1, '33922555': 2, '30066398': 1, '12176905': 1, '24032087': 2}
|
{'8122927-1': 1}
|
163,164 |
3768425-1
| 24,031,251 |
noncomm/PMC003xxxxxx/PMC3768425.xml
|
In vitro isolation and molecular characterization of an Ehrlichia canis strain from São Paulo, Brazil
|
A 7-year old male Labrador retriever was admitted to the São Paulo University Veterinary Hospital with recurrent history of anorexia, apathy, bloody diarrhea and tick infestation. Based on a previous clinical diagnosis of CME, the dog had been treated with doxycycline (10mg/Kg daily for 3 weeks) and imidorcarb dipropionate (5 mg/Kg,two doses with 15 days interval) 20 days before the appearance of clinical symptoms. The dog was normal upon physical examination. Hematological abnormalities were anemia [hematocrit: 33% (reference values: 37 - 55%); low erythrocytes: 4.7 x 106/mm3 (reference values: 5.5 - 8.5 x 106/mm3)], leucopenia [leukocytes: 4,700/mm3 (reference values: 5,000 - 10,000/mm3)], and thrombocytopenia [platelet: 19,000/mm3 (reference values: 200,000 - 500,000/mm3)]. Blood was collected in EDTA for PCR, and in heparin for cell culture isolation.
|
[[7.0, 'year']]
|
M
|
{'26414283': 1, '17294930': 1, '1374076': 1, '10225842': 1, '14637030': 1, '9316896': 1, '31694172': 1, '11760958': 1, '12910747': 1, '16647817': 1, '16996215': 1, '24136211': 2, '20595502': 1, '16621285': 1, '30637653': 1, '16237220': 1, '15099511': 1, '16181750': 1, '11953415': 1, '7929751': 1, '33669023': 1, '26565771': 1, '9705408': 1, '12756637': 1, '15482892': 1, '24031251': 2}
|
{'4087226-1': 1}
|
163,165 |
3768502-1
| 24,031,340 |
noncomm/PMC003xxxxxx/PMC3768502.xml
|
Invasive aspergillosis associated with systemic lupus erythematosus and cardiac postoperative complication
|
A 34-year-old woman was diagnosed with systemic lupus erythematosus and treated with glucocorticoids over a period of two years. Following improvement in clinical and laboratorial tests, she was discharged. Four months later, the patient presented intense abdominal pain, high fever and renal failure. She was submitted to continuous peritoneal dialysis and developed a suggestive fungal peritonitis.\nDirect examination of fresh abdominal fluid (peritoneal effluent) revealed broad septate dichotomously branched hyphae. Cultures on routine media such as Sabouraud dextrose agar with 50 mg chloranphenicol/L were incubated at room temperature and at 37ºC, exhibiting after 48h growth suggestive of Aspergillus. Macroscopically the culture produced a flat, white colony that quickly became gray-green with the conidia production. The texture varied from strictly velvety to deep felt, floccose. The reverse was colorless. Conidia mass of the conidial heads were columnar and compact. They ranged in size from 200 to 400 μ by 50 μ. Microscopically, conidiophores were short, smooth, and up to 300 μ in length and 5 to 8 μ in diameter (). Identification of A. fumigatus was performed according to the criteria developed by Hoog et al. () and Rapper and Fennel ().\nAs soon as the diagnosis of fungal peritonitis was confirmed, amphotericin B (1 mg/kg/day) was given intravenously in increasing doses up to a total dose of 1.13g. The peritoneal catheter was removed and the patient was successfully treated.\nAspergillus peritonitis had occurred as a complication of chronic ambulatory peritoneal dialysis (,,) and the removal of the dialysis catheter was essential for eradicating the infection (). According to the literature, antifungal therapy involving both intraperitoneal and systemic amphotericin B, as well as itraconazole should be used (,,).
|
[[34.0, 'year']]
|
F
|
{'12418448': 1, '7893833': 1, '7867312': 1, '453081': 1, '9564455': 1, '2245766': 1, '15618189': 1, '10770732': 1, '2117314': 1, '11709457': 1, '16195909': 1, '7478133': 1, '10052546': 1, '646828': 1, '12765308': 1, '16325257': 1, '7611273': 1, '12421277': 1, '7017583': 1, '2381245': 1, '14732749': 1, '23569520': 1, '24371751': 1, '12742319': 1, '8759494': 1, '6479974': 1, '12652395': 1, '27417327': 1, '15456363': 1, '11447699': 1, '11096043': 1, '24031340': 2}
|
{'3768502-2': 2}
|
163,166 |
3768502-2
| 24,031,340 |
noncomm/PMC003xxxxxx/PMC3768502.xml
|
Invasive aspergillosis associated with systemic lupus erythematosus and cardiac postoperative complication
|
A 45-year-old hypertensive male with a prior history of cardiac insufficiency was admitted with symptoms of acute onset of pain in both legs of two weeks duration and with pain in the right leg increasing gradually for the past one week. Investigations revealed normal scores of hemoglobin, 11.5 g%; urea, 25 mg dl-1; creatinine, 0.7 mg dl-1 and glucose, 95 mg dl-1. An aortogram undergone on the first day after admission revealed total occlusion of right common iliac artery and left common femoral arteries, following which he underwent a bilateral femoral embolectomy on the second post admission day.\nThe clot from the femoral artery was sent to the microbiology laboratory for culture, which grew A. fumigatus on solid media after 48h of incubation (,). On the first postoperative day (POD) he was started on amphotericin B at 0.25 mg kg-1 day-1 gradually increasing to 1 mg kg-1 body weight as an intravenous infusion. However, this had to be withheld from the second POD due to elevated renal parameters and nephrotoxicity.\nA transesophageal echocardiography revealed fungal growth on the aortic valve which was mildly thickened. An embolectomy specimen and portions of the native aortic valve were also sent to the Medical Mycology Laboratory (Federal University of Pernambuco) for direct examination and culture. A 20% KOH preparation revealed broad septate dichotomously branched hyphae. Small portions of the specimens were inoculated on routine media such as Sabouraud dextrose agar with 50mg chloranphenicol/L. Cultures were incubated at room temperature and at 37ºC. After 48h of incubation the specimens cultured exhibited fungal growth typical of Aspergillus spp. Identification through macroscopic and microscopic characteristics was conducted according to Hoog et al. () and Rapper and Fennel ().\nThe patient suddenly developed ventricular tachycardia and ventricular fibrillation and had a sudden cardiac arrest and was immediately intubated and put on ventilatory support. The patient rapidly went to fatal outcome, showing signs of fungal sepsis, including massive increase in leukocyte count, acute phase parameters and abnormal liver function tests.
|
[[45.0, 'year']]
|
M
|
{'12418448': 1, '7893833': 1, '7867312': 1, '453081': 1, '9564455': 1, '2245766': 1, '15618189': 1, '10770732': 1, '2117314': 1, '11709457': 1, '16195909': 1, '7478133': 1, '10052546': 1, '646828': 1, '12765308': 1, '16325257': 1, '7611273': 1, '12421277': 1, '7017583': 1, '2381245': 1, '14732749': 1, '23569520': 1, '24371751': 1, '12742319': 1, '8759494': 1, '6479974': 1, '12652395': 1, '27417327': 1, '15456363': 1, '11447699': 1, '11096043': 1, '24031340': 2}
|
{'3768502-1': 2}
|
163,167 |
3769198-1
| 24,039,428 |
noncomm/PMC003xxxxxx/PMC3769198.xml
|
Clozapine reinitiation following a “red result” secondary to chemotherapy
|
In the next part of this document, we discuss the case of CE, a 58-year-old male with chronic paranoid schizophrenia. Institutional Research Ethics Board approval (PSIY-380-12) and patient consent were obtained for the presentation of the current case. CE had been placed on clozapine after several trials of other antipsychotics in 1998, following a prolonged admission at a chronic care facility. He had been stable from that time onwards with clozapine at 500 mg in divided doses, and was residing at a group home under the care of the local assertive community team (ACT). ACTs are multidisciplinary mental health teams that manage individuals with severe mental illness in the community. They originated in North America in the 1980s as part of the planning to deinstitutionalize the chronic inpatient population and transition them in the community. It is an intense form of support in the community in most places in North America to manage severely mentally ill patients with multiple needs who would otherwise be unable to stay outside tertiary care hospitals. This community mental health team offers support in various domains, like medication compliance, maintenance of accommodation, employment, adhering to probation if required, managing addictions, and offering interventions to improve physical health. At some point, the team was considering discharging him to a step-down service in the community. He developed a swelling in the jaw (4 cm mass in the right preauricular region extending down into the submandibular region) and a right axillary mass (6 cm), which was on examination a lymph-node swelling as noted by the family physician. In addition to this, there were bilateral posterior sternocleidomastoid nodes (measuring 1–2 cm). This prompted a referral to an ear, nose, and throat specialist, who diagnosed him with a large B-cell lymphoma. An emergency referral to the hematologist was set in motion. The lymphoma was graded at clinical stage 3A.\nThis being a treatable form of lymphoma, the hematologist started the CHOP therapy with additional rituximab, now popularly known as the R-CHOP therapy, used for B-cell lymphomas. The plan was set in place for a 21-day cycle with six treatments. The first chemotherapy cycle was well tolerated by the patient, and showed a good response in shrinking of the mass. However, his white cell and neutrophil count went quite low (1.1 and 0.8, respectively) on the 13th day of the cycle, though this was as predicted. The white cell count climbed to 7.0 on the 19th day of the cycle. The local lab alerted the community psychiatrist when CE went for his monitoring blood work. As a consequence of being in the “red zone,” the Clozapine Monitoring Network was promptly informed and a discontinuation protocol initiated.\nThis had an adverse effect on his mental state: he became extremely agitated and restless, and was unable to sleep for days. He was placed on quetiapine in order to manage his psychiatric symptoms. This proved to be inadequate, and he relapsed; his usual relapse signature symptoms of religious delusions exacerbated, and he seemed to be clearly responding to auditory hallucinations. Unfortunately, this meant the hematology team could not give him his second treatment of the R-CHOP cycle. This led to various issues between the ACT service, the hematology team, and the family, who were extremely unhappy with the situation.\nHe ended up in the acute psychiatric unit in view of his psychotic relapse. In an attempt to stabilize him, he was initiated on olanzapine 20 mg in divided doses. Later on, aripiprazole was added to the regimen, which was titrated to 15 mg once daily. He was much calmer and able to sleep, though still tormented by his active psychotic symptoms (ie, religious delusions and auditory hallucinations). The chemotherapy was resumed with the cover of filgrastim (granulocyte colony-stimulating factor) by the heme oncology team.\nAs his psychotic symptoms persisted a decision was made to reinitiate him on clozapine, and the Clozapine Support Network was contacted. The directive given by them was as follows:\nPatient is deemed to be capable of consenting and signs the consent form.\nLetter to be submitted by the prescribing physician outlining the details of the treatment with chemotherapy regimen.\nMonitoring criteria to be set by the prescribing physician in consensus with the hematologist.\nThe consultant hematologist would review the submissions and if in agreement, the patient would be registered with the Novartis Special Program on a compassionate basis.\nThe monitoring service would be informed of the start and end dates of the chemotherapy.\nIf the chemotherapy had ended the regular monitoring protocols would be put in place upon informing the monitoring service.\nThese requirements were fulfilled and the patient was allowed to be reregistered on clozapine. He continued to stay as an inpatient, and received all six cycles of the R-CHOP therapy with filgrastim cover. His white blood cell counts remained within the range of 3.5–11.6, with his neutrophils in the vicinity of 3–5. His lymphoma went onto clinical remission; there was one remaining 2.5 cm right axillary node that was attributed to fibrotic tissue.\nThe patient’s mental state gradually improved with upward titration of clozapine to achieve a suitable therapeutic response at 375 mg daily in divided doses. The achievement of adequate efficacy at a lower dose than previously was attributable to his substantial reduction in smoking while an inpatient. His religious delusions went into the background and the auditory hallucinations lessened in intensity and frequency to a great extent. He was finally discharged to the care of the ACT after being an inpatient for approximately 4 months. The monitoring service was subsequently informed a few months later after review by the cancer (heme oncology) specialists that his treatment for the malignant lymphoma had been completed.
|
[[58.0, 'year']]
|
M
|
{'23059755': 1, '12590620': 1, '27222142': 1, '21969051': 1, '22113154': 1, '8837913': 1, '10479946': 1, '29944418': 1, '10372612': 1, '11266078': 1, '2682726': 1, '2772119': 1, '15052517': 1, '18593787': 1, '1503678': 1, '18477732': 1, '8925346': 1, '32373066': 1, '25489479': 1, '28197007': 2, '15538122': 1, '10401441': 1, '8515788': 1, '23694688': 1, '21972272': 1, '16507968': 1, '26755992': 1, '20428308': 1, '9345668': 1, '24039428': 2}
|
{'5270275-1': 1}
|
163,168 |
3770251-1
| 24,027,576 |
noncomm/PMC003xxxxxx/PMC3770251.xml
|
A Case of Podocytic Infolding Glomerulopathy with Focal Segmental Glomerulosclerosis
|
A 14-year-old girl was referred to our institution as an inpatient because of proteinuria. When she was 9 years old, she had urinary protein (UP) detected during a school physical examination and she was followed in the Pediatrics Department of our hospital. Her UP gradually increased to a level of 1.9 g/day, and at 14 years, she was referred to our division. Laboratory tests showed a UP level of 2.35 g/day, negative results for urinary sedimentation, and creatinine clearance of 111.9 ml/min/1.73 m2. No cytopenia, hypocomplementemia, or elevated liver enzymes were found (table ). Her physical findings were normal. Light microscopy of her first renal biopsy specimens showed a total of 14 glomeruli, 1 of which had global sclerosis; the others were MGAs. However, under light microscopy at a higher magnification under periodic acid methenamine silver (PAM) staining, the glomeruli had a bubbling appearance of diffuse glomerular loops (fig. ). Immunofluorescent staining was negative for immunoglobulin, complement, and fibrinogen. Electron microscopy revealed microspheres in the GBM, which were sparse but global (fig. ). The microstructures took various forms, and almost all of them were encircled with a unit membrane. There was no direct consecutive podocytic infolding in the GBM, nor any mesangial interposition. The endothelial cells were not swollen. Foot process effacement was scattered and there was no thickening of the GBM. This finding suggested the possibility of PIG. The patient was started on telmisartan 10 mg/day. However, her UP level gradually increased to the nephrotic range by 16 years, and at 17 years of age, she underwent a second renal biopsy. Laboratory tests showed a UP level of 3.06 g/day, negative results for urinary sedimentation, and creatinine clearance of 156.5 ml/min/1.73 m2. Antinuclear antibodies had changed to positive and the double-stranded deoxyribonucleic acid (dsDNA) level was elevated at 14 IU/ml. Serum total protein level was 5.5 g/dl and serum albumin level was 3.4 g/dl. No cytopenia, hypocomplementemia, or physical findings indicative of collagen disease were found (table ). Light microscopy of the second renal biopsy specimens revealed 31 glomeruli, of which 4 had global sclerosis, 2 had segmental sclerosis with cellular variant, while the remainder were MGA. The bubbling appearance of glomerular loops was detected at higher magnification on PAM staining, as in the first biopsy, although their number had markedly decreased. Immunofluorescent staining was positive for IgM, C3, and C1q in the segmental sclerosis lesions, whereas all were negative in the other lesions. Electron microscopy revealed endothelial cell swelling and endocapillary cell proliferation in the segmental sclerotic lesions. Foot process effacement was global. The microspheres observed in the GBM were sparser than in the first biopsy (fig. ). We diagnosed PIG complicated by FSGS. Prednisolone 40 mg/day (0.7 mg/kg) was prescribed, and the UP level gradually decreased. After 9 months, the UP was less than 0.5 g/day.
|
[[14.0, 'year']]
|
F
|
{'1949609': 1, '18974926': 1, '32393263': 2, '19012047': 1, '18839060': 1, '19012046': 1, '30879204': 1, '31438874': 2, '18979062': 1, '7199568': 1, '1595195': 1, '3537447': 1, '19002748': 1, '34659774': 1, '24027576': 2}
|
{'7216528-1': 1, '6704495-1': 1}
|
163,169 |
3770715-1
| 24,039,390 |
noncomm/PMC003xxxxxx/PMC3770715.xml
|
Two siblings with late-onset cone–rod dystrophy and no visible macular degeneration
|
Case 1 was an 82-year-old man who first noticed a decrease in his vision and color vision in both eyes in his early seventies. His decimal best-corrected visual acuity (BCVA) at our initial examination was 0.3 oculus dexter (OD) with +3.25 diopters (D) and 0.2 oculus sinister (OS) with +3.25 D. His pupillary light reflexes and intraocular pressures were normal in both eyes. There was no history of the use of retinotoxic drugs. His cataracts were removed in both eyes at age 75; however, his vision was not improved.\nOphthalmoscopy showed that the fundus was normal in both eyes, and FA showed small hyperfluorescent spots at the parafoveal region of the left eye (). Goldmann kinetic perimetry showed a central scotoma in both eyes (), and Farnsworth D-15 test showed a tritan axis error. Goldmann–Weekers dark adaptometry revealed a slight elevation of the threshold in both eyes (). The full-field scotopic ERGs elicited by both low- and high-intensity stimuli were slightly reduced. The scotopic b-wave elicited by a high-intensity stimulus was smaller than the a-wave, resulting in a negative-type ERG (). On the other hand, photopic single-flash and 30 Hz flicker ERGs were severely attenuated in both eyes (). The mfERGs were nonrecordable in the central area, but small responses were recorded in the midperiphery (). The photoreceptor inner segment/outer segment junction line was indistinct in the OCT images (). The thickness of the outer nuclear layer was 76 μm OD and 65 μm OS (normal mean 172 ± 17 μm) at the fovea, 65 μm OD and 43 μm OS (normal mean 128 ± 19 μm) at 0.5 mm superior to the fovea, and 65 μm OD and 54 μm OS (normal mean 135 ± 23 μm) at 0.5 mm inferior to the fovea. At 2 mm superior to the fovea, the thickness of the outer nuclear layer was 65 μm OD and 43 μm OS (normal mean 97 ± 13 μm), and at 2 mm inferior to the fovea it was 43 μm OD and 54 μm OS (normal mean 88 ± 18 μm). Thus, the outer nuclear layer was thin, especially in the parafoveal region in both eyes (). The thickness of the middle and inner layers of the retina were within normal limits.
|
[[82.0, 'year']]
|
M
|
{'18487367': 1, '9792858': 1, '1622952': 1, '4573331': 1, '2043573': 1, '9425234': 1, '19845558': 1, '16909397': 1, '4547582': 1, '22466457': 1, '18653602': 1, '9466990': 1, '11857109': 1, '9804150': 1, '25603773': 1, '13372680': 1, '9537410': 1, '20826268': 1, '15051206': 1, '18400204': 1, '9618177': 1, '2774037': 1, '11053295': 1, '1821435': 1, '15161866': 1, '3684214': 1, '9390563': 1, '8909203': 1, '22264887': 1, '19952985': 1, '18235024': 1, '2087294': 1, '6601944': 1, '21552474': 1, '854266': 1, '14060101': 1, '17041576': 1, '16505158': 1, '23456543': 1, '9427255': 1, '15531334': 1, '10916183': 1, '8540854': 1, '19278489': 1, '5660021': 1, '24039390': 2}
|
{'3770715-2': 2}
|
163,170 |
3770715-2
| 24,039,390 |
noncomm/PMC003xxxxxx/PMC3770715.xml
|
Two siblings with late-onset cone–rod dystrophy and no visible macular degeneration
|
Case 2 was the younger sister of case 1. She was 80 years old and had first noticed a decrease in her vision and photophobia in both eyes in her early seventies. Her cataract was removed in both eyes at age 76; however, her vision was not improved.\nOur examination showed that her decimal BCVA was 0.4 OD with +0.25 D and 0.2 OS with +0.5 D. Her pupillary light reflexes and intraocular pressures were normal in both eyes. There was no history of retinotoxic drug use.\nHer fundus was normal except for a slight mottling of the retinal pigment epithelium in the midperiphery. No macular degeneration was seen in either eye (). FA was not performed because of her allergy to fluorescein sodium. Goldmann kinetic perimetry revealed a central scotoma in the left eye and a mild constriction of the visual fields in both eyes (). Farnsworth D-15 test showed tritan axis errors in both eyes. Goldmann–Weekers dark adaptometry showed a slight elevation of the light threshold in both eyes (). The full-field scotopic ERGs elicited by low-intensity stimuli were slightly reduced, and the scotopic high-intensity ERGs were normal, except the oscillatory potentials were reduced. The photopic single-flash and 30 Hz flicker ERGs were nonrecordable in both eyes (). The mfERGs were nonrecordable in the right eye and reduced in the central and midperipheral areas of the left eye (). OCT showed similar findings to her elder brother in the macular area (). The photoreceptor inner segment/outer segment junction line was indistinct. The thickness of the outer nuclear layer was 130 μm OD and 129 μm OS (normal mean 172 ± 17 μm) at the fovea, 43 μm OD and 65 μm OS (normal mean 128 ± 19 μm) at 0.5 mm superior to the fovea, and 32 μm OD and 22 μm OS (normal mean 135 ± 23 μm) at 0.5 mm inferior to the fovea. At 2 mm superior to the fovea, the thickness of the outer nuclear layer was 65 μm OD and 76 μm OS (normal mean 97 ± 13 μm), and at 2 mm inferior to the fovea it was 65 μm OD and 43 μm OS (normal mean 88 ± 18 μm). Thus, the outer nuclear layer was thin, especially in the parafoveal region of both eyes ().
|
[[80.0, 'year']]
|
F
|
{'18487367': 1, '9792858': 1, '1622952': 1, '4573331': 1, '2043573': 1, '9425234': 1, '19845558': 1, '16909397': 1, '4547582': 1, '22466457': 1, '18653602': 1, '9466990': 1, '11857109': 1, '9804150': 1, '25603773': 1, '13372680': 1, '9537410': 1, '20826268': 1, '15051206': 1, '18400204': 1, '9618177': 1, '2774037': 1, '11053295': 1, '1821435': 1, '15161866': 1, '3684214': 1, '9390563': 1, '8909203': 1, '22264887': 1, '19952985': 1, '18235024': 1, '2087294': 1, '6601944': 1, '21552474': 1, '854266': 1, '14060101': 1, '17041576': 1, '16505158': 1, '23456543': 1, '9427255': 1, '15531334': 1, '10916183': 1, '8540854': 1, '19278489': 1, '5660021': 1, '24039390': 2}
|
{'3770715-1': 2}
|
163,171 |
3770854-1
| 24,044,114 |
noncomm/PMC003xxxxxx/PMC3770854.xml
|
Ectopic Prostate Tissue at the Bladder Dome Presenting as a Bladder Tumor
|
A 72-year-old man presented to our urology department with a history of gross painless hematuria and dysuria. Initial laboratory signs were within normal levels, except hematuria in routine urine analysis. Abdominal computed tomography revealed a sessile bladder mass (dimensions, 1.0 cm×1.5 cm) at the bladder dome, but no perivesical infiltration or regional lymphadenopathy was observed. Cystoscopy results also showed a smooth sessile mass (dimensions, 1.0 cm×1.5 cm) at the bladder dome (). The patient underwent transurethral resection for treatment of the bladder mass. Histological analysis of the tissue submitted showed several fragments of bladder mucosa and subepithelial tissue. Microscopic examination showed several benign prostate glands with 2 distinct cell layers (the basal cell and luminal epithelial cell layers) embedded in the subepithelial stroma (). Some of the glands were cystically dilated (), and some contained corpora amylacea. There was no direct continuation with the bladder mucosa, and although some of the bladder mucosa was denuded, no severe inflammation was evident in the surrounding tissue. Immunohistochemical analysis results showed that most prostatic glands were strongly positive for prostate-specific antigen (PSA). The postoperative course was uneventful. The postoperative 6-month follow-up indicated that the patient was well and had not experienced a recurrence.
|
[[72.0, 'year']]
|
M
|
{'2437337': 1, '2024385': 1, '9000392': 1, '20807045': 1, '16409614': 1, '12792918': 1, '21438904': 1, '11688585': 1, '30819008': 2, '29207717': 1, '24044114': 2}
|
{'6460601-1': 1}
|
163,172 |
3770855-1
| 24,044,115 |
noncomm/PMC003xxxxxx/PMC3770855.xml
|
Intrascrotal and Extratesticular Multiple Schwannoma
|
A 67-year-old man presented with a 2-year history of multiple slowly growing painless lumps in the scrotum. He did not have any history of trauma or infection. His medical history was unremarkable. Physical examination revealed () multiple non-tender, hard lumps measuring about 1×1×1.5 cm at the extrascrotal mass and about 3.5×2.5×1.8 cm at the intrascrotal mass. Some lumps had invaded the penile root without penile deviation and without pain on erection. There were no enlarged inguinal nodes. The laboratory results, including complete blood counts, serum electrolytes, testicular tumor markers, and urinalysis, were within the normal range. Scrotal ultrasonography revealed intrascrotal and extratesticular masses in the mid-scrotal region (). Complete excision of the scrotal masses was performed. After surgery, there was no testicular invasion. The mass was firm and appeared to be grossly homogeneous. Immunohistochemically, the tumor cells were positive to S-100 and negative to SMA (). The pathologic diagnosis was schwannoma of the scrotum. There was no evidence of recurrence during 6 years of follow-up.
|
[[67.0, 'year']]
|
M
|
{'17244372': 2, '4294037': 1, '9644798': 1, '29992916': 1, '19476995': 1, '15955931': 1, '3603916': 1, '11969043': 1, '4035850': 1, '27169021': 1, '24776090': 2, '1459159': 1, '24044115': 2}
|
{'1783662-1': 1, '4030735-1': 1}
|
163,173 |
3770881-1
| 24,039,293 |
noncomm/PMC003xxxxxx/PMC3770881.xml
|
A Case of Budd-Chiari Syndrome Associated with Alveolar Echinococcosis
|
A 62-year-old female patient admitted to our clinic because of recent fatigue, shortness of breath, abdominal distention, and pain in the right upper quadrant. In her history, she had a liver wedge resection 3 years ago with AE found in the biopsy material. On physical examination, the liver was 5 cm palpable under the right rib, the spleen was non-palpable, and Traube's space was clear. Tension ascites and collateral veins in an upward flow direction were noted on the abdomen. Respiratory sounds were decreased at the bases of both lungs and dullness was found with percussion.\nHemoglobin was 8.3 g/dl in the whole blood count. Except for low albumin levels (2.1 g/dl), all other biochemical tests were normal. There was no flow viewed in the left hepatic vein and inferior vena cava on abdominal portal Doppler ultrasound. The portal vein was 16 mm, and the splenic vein was 15 mm in diameter and hepatofugal flow was noted. On contrasted abdominal CT, there was a 54×70×45 mm-sized cystic lesion in left lobe of the liver extending towards the posterior mediastinum with irregular calcifications that invaded the diaphragm, esophagus, and pericardium. It was occluding the inferior vena cava and left hepatic vein at the level where the hepatic veins poured into the inferior vena cava. Secondary to inferior vena cava occlusion, the azygos vein and the hemiazygos vein appeared to be dilated. There was bilateral pleural effusion (). A grade 1 esophageal varix was observed on upper endoscopy. The inferior vena cava was found to be occluded at the L1 level with venography. It was determined that the venous return was provided by the azygos, hemiazygos system, and the collaterals (). In the performed echocardiography, the entrance of the inferior vena cava into the right atrium was normal.\nWith paracenthesis, the intraperitoneal fluid was turbid and total leucocyte number was 410/mm3 (10% neutrophils, 90% lymphomonocytes). The intraperitoneal fluid was exudate in character (serum acid albumin gradient was 0.2 g/dl) and protein was 5.1 g/dl. There was no other pathology found in the Gram staining and culture of the intraperitoneal fluid.\nAccording to these findings, the patient was diagnosed with secondary Budd-Chiari Syndrome (BCS) development due to AE. The patient was given 15 mg/kg albendazole (800 mg/day) for treatment.
|
[[62.0, 'year']]
|
F
|
{'29049181': 1, '17874275': 1, '32848335': 1, '17925775': 1, '14726458': 1, '18485517': 1, '21354448': 1, '15647637': 1, '17075481': 1, '31856063': 1, '21398158': 1, '14768004': 1, '25945006': 1, '24678390': 1, '28761473': 2, '30121887': 1, '24039293': 2}
|
{'5522693-1': 1}
|
163,174 |
3770888-1
| 24,039,395 |
noncomm/PMC003xxxxxx/PMC3770888.xml
|
Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature
|
A 36 year old man presented with decreased vision, pain, epiphora, and photophobia in the left eye (OS) after being hit in the eye by a blackberry bush. An external ophthalmologist treated him with oral and topical corticosteroids and cyclopentolate before referring him 2 weeks later. His left eye had hand motions visual acuity (VA) and an intraocular pressure (IOP) of 14. Slit lamp examination revealed a small subconjunctival elevation inferotemporal to the limbus, 4+ pigmented anterior chamber (AC) cell, a fibrin clot, and dense vitritis precluding clear fundus visualization. B-scan ultrasonography identified a hyper-reflective area that is concerning for a foreign body (). Examination of the right eye (OD) was unremarkable. It was decided to proceed with surgical intervention to address the presumed endophthalmitis and possible IOFB. The patient underwent vitrectomy, endolaser, and scleral buckle for a limited retinal detachment discovered intraoperatively in the area of the external injury. A small thorn which extended from the sclera, through the retina, and into the vitreous was discovered in this same area of the retinal detachment and was removed ( and ). He received intraoperative intravitreal injections of vancomycin, voriconazole, and ceftazidime. He was also treated postoperatively with topical atropine, polymyxin/trimethoprim, and prednisolone acetate along with oral moxifloxacin 400 mg daily and voriconazole 200 mg twice daily. Vitreous polymerase chain reaction (PCR) and cultures both revealed Staphylococcus epidermidis. Seven months following the initial surgery and 4 months following cataract removal and lens placement, the patient was pain-free with best corrected VA of 20/25+1.
|
[[36.0, 'year']]
|
M
|
{'11519565': 1, '11733280': 1, '32926709': 2, '10599667': 1, '10360297': 1, '9951481': 1, '3287937': 1, '9267599': 1, '3105296': 1, '21607931': 1, '2710485': 1, '10380023': 1, '22619702': 1, '8518700': 1, '3333767': 1, '6493718': 1, '24039395': 2}
|
{'3770888-2': 2, '3770888-3': 2, '7434245-1': 1}
|
163,175 |
3770888-2
| 24,039,395 |
noncomm/PMC003xxxxxx/PMC3770888.xml
|
Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature
|
A 10 year old boy presented with 2 weeks of pain, pressure sensation, photophobia, and redness without discharge in the left eye and a VA of 20/150. He was initially treated with topical and systemic corticosteroids. Despite treatment, his symptoms progressed and after one week his VA had worsened. He was then referred to a tertiary care center. Despite extensive questioning of both parents and patient, the patient denied any history of trauma, and the patient had no systemic symptoms. Examination of his right eye was unremarkable. His left eye had a VA of 20/300 and an IOP of 5. Examination of his left eye revealed conjunctival injection, 4+ AC cell, and 0.1 mm hypopyon. Fundus detail was obscured by vitreous haze. B-scan ultrasound was remarkable for mild vitritis but did not demonstrate a foreign body. The patient underwent an investigation for infectious and inflammatory causes including Herpes simplex virus, Varicella zoster virus, Cytomegalovirus, cat-scratch disease, Lyme disease, toxoplasmosis, toxocariasis, juvenile idiopathic arthritis, tubulointerstitial nephritis-uveitis, syphilis, and sarcoidosis, and each test was negative. He was initially treated with systemic azithromycin and valacyclovir but did not improve. As a result, he then underwent surgical exploration and vitrectomy with intravitreal injections of vancomycin, voriconazole, ceftazidime, and foscarnet. Although no signs of trauma or other injury were found during surgery, a hairlike intravitreal IOFB discovered during surgery was removed and sent to pathology. This IOFB was confirmed by pathology to be an eyelash. Vitreous cultures and PCR revealed methicillin sensitive Staphylococcus aureus. The patient was treated postoperatively with systemic dicloxacillin 500 mg four times daily, prednisone 20 mg daily with a rapid taper along with topical 1% atropine daily, and difluprednate 0.05% four times daily. Three weeks following surgery, the patient was pain-free, and his ocular inflammation was reduced to only 1+ cell in the AC. He later developed a total tractional retinal detachment that required surgical repair. Over the following 2 years the patient remained pain-free, and the eye remained quiet with hand motions VA in his left eye.
|
[[10.0, 'year']]
|
M
|
{'11519565': 1, '11733280': 1, '32926709': 2, '10599667': 1, '10360297': 1, '9951481': 1, '3287937': 1, '9267599': 1, '3105296': 1, '21607931': 1, '2710485': 1, '10380023': 1, '22619702': 1, '8518700': 1, '3333767': 1, '6493718': 1, '24039395': 2}
|
{'3770888-1': 2, '3770888-3': 2, '7434245-1': 1}
|
163,176 |
3770888-3
| 24,039,395 |
noncomm/PMC003xxxxxx/PMC3770888.xml
|
Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature
|
A 13 year old boy initially presented to an external provider with 3 weeks of redness, pain, photophobia, floaters in his left eye, and with a VA of 20/60. Despite topical and systemic corticosteroids, the patient’s VA worsened. As a result, he was referred for further evaluation and management to a tertiary care center. Despite extensive questioning of both parents and patient, the patient denied any history of trauma, and the patient had no systemic symptoms. Initially he was treated with cycloplegics and topical steroids. Later, 40 mg/day of oral prednisone and double strength Bactrim were added to cover possible toxoplasmosis due to a history of exposure to cats. Despite treatment, his vision and symptoms worsened. Examination revealed a normal OD. His left eye had hand motions VA with a nasal visual field deficit, pressure of 9, conjunctival injection, 4+ AC cell, 0.5 mm hypopyon, pupillary membranes, and no view to the posterior pole. B-scan ultrasound revealed a diffusely thickened choroid, vitreous debris, subretinal fluid, posterior vitreous detachment, and areas of minor traction but no apparent foreign body. Laboratory work up was negative for sarcoidosis, Lyme disease, HLA B27, toxoplasmosis, and Bartonella. Further treatment consisted of 80 mg of oral prednisone daily, difluprednate 0.05% four times daily, and atropine 1% twice daily. The patient failed to improve, so he underwent pars plana vitrectomy, lensectomy, vitreous biopsy, intravitreal injection of antibiotics (vancomycin and amikacin), endolaser, and silicone oil injection. A foreign body (histologically consistent with hair) was discovered in the vitreous and removed. Gram stain and cultures were negative. His postoperative course was complicated by a total retinal detachment requiring a second surgery which was unsuccessful. On follow-up, the patient denied pain, his VA remained at the hand motions level, and there was no evidence of ongoing inflammation on exam.
|
[[13.0, 'year']]
|
M
|
{'11519565': 1, '11733280': 1, '32926709': 2, '10599667': 1, '10360297': 1, '9951481': 1, '3287937': 1, '9267599': 1, '3105296': 1, '21607931': 1, '2710485': 1, '10380023': 1, '22619702': 1, '8518700': 1, '3333767': 1, '6493718': 1, '24039395': 2}
|
{'3770888-1': 2, '3770888-2': 2, '7434245-1': 1}
|
163,177 |
3771237-1
| 24,039,641 |
noncomm/PMC003xxxxxx/PMC3771237.xml
|
A Case of Erosive Polyarthritis in a Patient Diagnosed With a Suspicion of Atypical Mycobacteria
|
A 55- year old Saudi female patient newly diagnosed as a case of osteoporosis and polymyalgia rheumatic was presented to the outpatient rheumatology clinic in December 2011 at King Faisal Specialist Hospital and Research Center, in Jeddah, with a month-long history of bilateral hand joints pain and morning stiffness lasting for 1 hour. She had no other joints involvement or any systemic symptoms.\nHand examination revealed tenderness over the metacarpophalangeal (MCPs), proximal interphalangeal (PIPs) and wrists joints but there was no swelling. Laboratory studies showed that WBCs= 12.8 × l (4.00-11.0 x 109/L) erythrocyte sedimentation rate (ESR) =15 mm/hr (<30 mm/hr), C-reactive protein (CRP) = 0.459 mg/dl (0-5mg/dl). Antinuclear antibodies, rheumatoid factor & anti-citrullinated protein peptide antibody (ACPA) were negative. Ultrasound exam of hands showed erosions in the right second MCP and effusion in both second MCPs and wrists joints. At that time she was diagnosed as inflammatory arthritis. Methotrexate 12.5 mg/week, folic acid 5mg/week and 10 mg prednisolone once daily were initiated.\nIn April 2012, she was still complaining of hand joints pain and morning stiffness. Arthritis remained active despite the treatment with methotrexate. A biological treatment was considered. The PPD skin test showed 15 mm reaction and CXR showed left lower lobe nodule. She denied any symptoms suggestive of tuberculosis (TB). Patient was referred to the Infectious Diseases (ID) and Isoniazid (INH) with pyridoxine were initiated. Two weeks later she developed a productive cough, an intermittent fever and a night sweat. A sputum culture and Computed tomography (CT) scans of the chest were arranged.\nIn her follow up in June 2012 with ID service, only one culture showed acid-fast bacilli of atypical mycobacterium further identification grew M. abscessus. Polymerase chain reaction (PCR) for mycobacterium was negative. The patient did not meet the American Thoracic Society (ATS) criteria for NTM []. The sputum culture was repeated. She was maintained on INH. Meanwhile, it was considered that probably she had transient infectious process. In July 2012, a biological treatment was initiated, Etanercept; which is a TNF blocker (Enbrel) administered at a dose of 50 mg subcutaneous every one week.\nOn her follow up in September 2012, she demonstrated improvement in her arthritis but still had nonspecific symptoms with vague history of productive cough, intermittent undocumented fever, weight loss (4 kg) and the new development of chest pain. The decision was made to continue on Enbrel while she was being worked up for the presence of NTM.\nBy the end of September 2012 the repeated culture grew Mycobacterium Avium Complex (MAC) isolation. CT-chest showed left pleural-based granuloma. The ID service evaluation considered M. abscessus as the likely atypical mycobacterium causing the symptoms and MAC was considered as a contamination. Azithromax, ciprofloxacin and doxycycline were initiated as a treatment for M. abscessus. The biological therapy was discontinued.\nIn November 2012, she had the same non-specific complaints of productive cough and intermittent undocumented fever with no improvement on the antibiotic regimen that was given. Ethmbutol was added to add further coverage to include MAC but it was discontinued after one month. The subsequent culture was negative.\nIn December 2012, she newly developed aziothromax allergic reaction in form of gastrointestinal upset. The first culture and sensitivity showed intermediate resistant to Aziothromax. Therefore, linezolid was initiated and Aziothromax was discontinued.\nIn January 2013 with her follow up in rheumatology clinic, her symptoms improved. She gained 2Kg and her appetite was back to normal. She demonstrated significant improvement in her joint symptoms. The ultrasound exam of hands showed mild effusion in her joints. She remained off Enbrel and we decided to continue on the same treatment with follow up.
|
[[55.0, 'year']]
|
F
|
{'17277290': 1, '28348502': 1, '21963746': 1, '22588446': 1, '22878281': 1, '21819731': 1, '20674803': 1, '22855345': 1, '21163172': 1, '19078465': 1, '21630616': 1, '9228150': 1, '21211956': 1, '16490683': 1, '19861045': 1, '2337113': 1, '16912945': 1, '10728753': 1, '16127595': 1, '18591855': 1, '12794787': 1, '24383837': 1, '24039641': 2}
|
{}
|
163,178 |
3772249-1
| 24,043,963 |
noncomm/PMC003xxxxxx/PMC3772249.xml
|
Isolated Post-Transplantation Lymphoproliferative Disease Involving the Breast and Axilla as Peripheral T-cell Lymphoma
|
A 22-year-old woman, who had received allo-PBSCT due to acute myeloblastic leukemia, came to the oncology department for a regular check-up. Except for a recently developed cough, the patient had no B symptoms (i.e., fever, weight loss, night sweats). She had undergone computed tomography examinations of the chest and abdomen, in which exhibited no abnormal findings suggestive of relapse. In addition, the patient complained of a vaguely palpable mass in her right breast, and therefore, she had undergone whole breast ultrasonography (US) examination to evaluate the lesion.\nUltrasonography examination revealed 2 suspicious hypoechoic masses showing ill-defined margins, and mixed echo pattern with hyperechoic boundaries, and an area of focal parenchymal bulging in the right breast (). Mammography performed thereafter revealed 3, ill-defined, isodense masses in the right breast, which corresponded to the lesions detected on breast US (). US-guided core biopsy was performed targeting at the suspicious breast mass, and histologic examinations showed diffuse infiltration of large lymphoid cells with pleomorphic, irregular and prominent nuclei, and frequent mitoses that include some atypia (). Immunohistochemistry staining demonstrated that the tumor cells were positive for CD3, CD45, bcl-2, and focal positivity for CD5, but were negative for CD21, CD30, CD56 (). Epstein Barr Virus (EBV) in situ hybridization using Epstein-Barr-encoded RNA showed a negative reaction among the tumor cells. Final pathologic diagnosis of the breast mass was monomorphic peripheral T-cell, post-transplantation lymphoma. For further staging and evaluation of the presence of PTLD involvement of other organs, Fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET-CT) was performed. Multiple hypermetabolic uptake (maximum SUV: 2.4-4.3) was observed in the right breast axilla, but no other abnormal uptake was seen on whole body PET scans ().\nSubsequent bone marrow biopsy specimen showed diffuse, interstitial infiltration of the marrow space by a monotonous population of blastoid immature cells, and the patient was diagnosed finally as having PTLD of the right breast with comorbid AML relapse, 39 months after allo-PBSCT.\nIn spite of the 6 months of chemotherapy after diagnosis, the patient died of disseminated fungal infection and multi-organ failure.
|
[[22.0, 'year']]
|
F
|
{'11571518': 1, '10637249': 1, '15842046': 1, '8208929': 1, '17911538': 1, '12663726': 1, '16330097': 1, '17293073': 1, '20834235': 1, '9489654': 1, '11157030': 1, '28073814': 2, '19605652': 1, '15798050': 1, '20418462': 1, '16473741': 1, '24043963': 2}
|
{'5256493-1': 1}
|
163,179 |
3772250-1
| 24,043,964 |
noncomm/PMC003xxxxxx/PMC3772250.xml
|
Primary Breast Amyloidosis Presenting as Microcalcifications Only
|
A 72-year-old woman was referred to our hospital for further evaluations of calcifications detected on a screening mammography taken at another hospital. The patient had a 5-year history of diabetes mellitus. No other abnormality was evident from basic laboratory examinations. No breast symptoms were evident such as pains, palpable masses, or nipple discharges. Mammography demonstrated multiple, irregular calcifications in the subareolar area of the left breast; they were regionally distributed, generally smooth-branched, linear, and rod-like, and varied in sizes and shapes (). These calcifications were classified as category "4A": low suspicious findings at final assessment according to the Breast Imaging Reporting and Data System (). Thus, a biopsy was recommended and the patient underwent surgical excisional biopsy with mammoguided needle localization. Specimen mammography revealed several irregular-shaped calcifications (). There were no discrete mass evidences on the gross pathology. Histopathology examination revealed dystrophic calcifications in ectatic mammary ducts, amorphous eosinophilic material deposition; the infiltration of periductal lymphocytes and multinucleated giant cells were revealed upon hematoxylin-eosin staining (). The calcifications were stained with Congo-red and exhibited apple-green birefringence under polarizing microscopy () which were consistent with amyloidosis. No malignancies were pathologically identified. Immunohistochemistry confirmed the AL type amyloidosis. Our patient refused further investigations, and there was no clinical evidence suggesting generalized amyloidosis in her physical or laboratory results. There was no interval change in calcifications of the left breast on follow-up mammography for five years. During the follow-up period of five years, no clinical or laboratory evidence of systemic amyloidosis has been demonstrated.
|
[[72.0, 'year']]
|
F
|
{'11566701': 1, '30816362': 1, '33088378': 1, '14689800': 1, '27624800': 2, '17166682': 1, '11090381': 1, '9237186': 1, '22976248': 1, '11566702': 1, '18796554': 1, '30783867': 2, '12021928': 1, '24043964': 2}
|
{'6381191-1': 1, '5022187-1': 1}
|
163,180 |
3772251-1
| 24,043,965 |
noncomm/PMC003xxxxxx/PMC3772251.xml
|
Diagnosis of Acute Global Myocarditis Using Cardiac MRI with Quantitative T1 and T2 Mapping: Case Report and Literature Review
|
A 28-year-old male was presented to the emergency department complaining of dyspnea, dizziness, and chest tightness over the preceding 24 hours. He had no significant past medical history. His body temperature was 37.2℃, blood pressure was 104/72 mm Hg, heart rate was 95 beats per minute (bpm), and his physical examination was gernally normal. Laboratory studies showed a WBC count of 16.2 × 103/µL (reference range, 4.0-10.8 × 103/µL) and platelets of 219 × 103/µL (reference range, 150-400 × 103/µL). Additionally, troponin T was found to be 0.958 mcg/L (reference range, 0-0.014 mcg/L), and C-reactive protein (CRP) was 14.7 mg/L (reference range, 0.1-6.0 mg/L). Chest X-ray showed mild pulmonary congestion and cardiomegaly. ECG on admission revealed normal sinus rhythm at a rate of 79 bpm with T-wave abnormalities. Transthoracic echocardiography showed reduced global left ventricular systolic function with an ejection fraction (EF) of 34%, diffusely increased myocardial echogenicity, and a small pericardial effusion. Based on these results, acute myocarditis was suggested as a clinical diagnosis.\nA cardiac MRI was performed on the third day of admission using a 1.5-T MR scanner (Magnetom Avanto; Siemens Medical Solutions, Erlangen, Germany). After scout images were taken, the cine MRI was performed with balanced steady-state free precession (b-SSFP) to obtain horizontal long-axis, vertical long-axis, 3-chamber view, and contiguous short-axis images. T2-weighted images were obtained by using a triple inversion recovery black-blood turbo spin-echo sequence along the contiguous short-axis planes from the apex to the base of the left ventricle (LV). Quantitative T2 mapping with a T2-prepared SSFP pulse sequence and pre-T1 mapping with a modified Look and Locker technique were performed during the mid-diastolic phase along the same short-axis planes as the T2-weighted images. The acquisition parameters for T2 mapping were: T2 preparation times = 0 ms, 24 ms, and 55 ms; repetition time (TR) = 3 × R-R ms; echo time (TE) = 0 ms, 24 ms, and 55 ms; acquisition matrix = 126 × 192; acquisition time = 7 × R-R; single-shot acquisition; flip angle = 70°; and bandwidth = 916 Hz/pixel. The acquisition parameters for T1 mapping were: TR = 740 msec, TE = 1.06 msec, flip angle = 35°, acquisition matrix = 192 × 124, field of view = 320 × 400 mm, slice number = 10 slices. Late gadolinium enhancement-MRI (LGE-MRI) was performed using a magnitude and phase-sensitive inversion recovery (PSIR) prepared by fast gradient echo sequence with the inversion time adjusted to null the normal myocardium. LGE-MR images were obtained along the same axis plane and with the same slice thickness as in the cine-MRI, 10 minutes after the administration of 0.2 mmol/kg of a gadoterate meglumine (Dotarem®; Guerbet, France). The acquisition parameters were: TR = 600 ms, TE = 3.4 ms, flip angle = 25°, acquisition matrix = 156 × 256, field of view = 320 × 400 mm, slice number = 10 slices, cardiac phase = middiastole. After obtaining the LGE-MR images, the post-T1 mapping was performed 15 minutes after the contrast media injection, using the same slice axis and parameters as pre-T1 mapping. T2-pixel maps and pre-post T1-pixel maps were generated after motion corrections using commercially available software on the scanner's workstation (Syngo; Siemens Medical Solutions, Erlangen, Germany).\nOn cine images, global systolic dysfunction resulted in an EF of 30%. Bilateral pleural effusions and a pericardial effusion were also noted (). On T2WI, there was not a patchy region of increased signal intensity (SI) in the LV myocardium, but global edema was presented with a ratio of myocardium to skeletal muscle of > 2.0 (). On the TI scout images, it was difficult to determine the optimal nulling time for the LV. We ultimately selected 270 ms as the nulling time (). On LGE images with a magnitude and PSIR (), global hyper SI throughout the LV myocardium was suggested, though it was uncertain whether the increased SI was due to incomplete myocardial nulling or diffuse myocardial delayed enhancements. The T2 and T1 values were measured according to AHA myocardial segmentation with the exception of the apex () (). On quantitative T2 map images, myocardial T2 values remarkably increased to about 91.4 ± 6.1 milliseconds (ms) (reference value, 55.5 ± 2.3) () (). The precontrast T1 value of the myocardium also increased to 1276.6 ± 32.4 ms (reference value, 1034.1 ± 53.1) () (). On post-T1 mapping images, the mean myocardial T1 value was 625 ± 12.4 ms, which was similar to the T1 value of the LV cavity (623 ms) (). The myocardial extracellular volume (ECV) fraction was calculated as follows: ECV fraction = (ΔR1 of myocardium / ΔR1 of LV blood pool) × (1 - hematocrit), R1 = 1 / T1, ΔR1 = Post-contrast R1 - Pre-contrast R1 (). The pre-T1 value of the LV cavity was approximately 1520 ms. The patient's hematocrit was 43.6%. The calculated mean ECV fraction for the LV myocardium was 45.9 ± 1.9% (range: 43-49.7%). Thus, it was concluded that diffusely high myocardial SI on the LGE-MR images was not caused by incomplete nulling of the myocardium, but rather by ECV expansion of the myocardium.\nThe patient's final diagnosis was myocarditis based on clinical symptoms, ECG results, biomarkers, echocardiogram results, and cardiac MR findings. Follow-up echocardiography was performed one week after initiating conservative care, revealing improved global LV systolic function with an EF of 67%. CRP peaked on the fourth day of admission at 156.1 mg/L, but decreased thereafter and normalized to 1.1 mg/L on the fourteenth day of admission.
|
[[28.0, 'year']]
|
M
|
{'32080118': 2, '28624986': 1, '12135124': 1, '29728953': 1, '28656464': 1, '21954119': 1, '26700020': 1, '25034917': 1, '25673126': 1, '20042111': 1, '34789163': 1, '20109598': 1, '12426265': 1, '29076052': 1, '22698528': 1, '33658040': 1, '15630027': 1, '11070105': 1, '18180335': 1, '19389557': 1, '21414575': 1, '22279111': 1, '24043965': 2}
|
{'7034667-1': 1}
|
163,181 |
3772255-1
| 24,043,969 |
noncomm/PMC003xxxxxx/PMC3772255.xml
|
Primary Malt Lymphoma of the Common Bile Duct
|
A 79-year-old male presented with a four-week history of vague, generalized abdominal discomfort and progressive jaundice. He complained of pruritus and dark urine, although he showed no weight loss, febrile sensation or chills. He had no history of biliary stone disease or prior abdominal surgery. Physical examination revealed jaundice with icteric sclera. Laboratory studies showed cholestasis with a total bilirubin of 2.2 mg/dL (normal, < 1.0 mg/dL), direct bilirubin of 1.5 mg/dL (normal, < 0.3 mg/dL), aspirate amino transferase of 141 IU/L (normal, < 40 IU/L), alanine transferase of 190 IU/L (normal, < 56 IU/L), and alkaline phosphatase of 284 IU/L (normal, < 147 IU/L). Serum tumor markers, including CEA and CA 19-9, were not elevated.\nComputed tomography (CT) examination was performed on a 16-multidetector CT system (LightSpeed 16; GE Healthcare, Milwaukee, WI, USA) with triphasic dynamic imaging. The arterial-, portal-, and delayed-phase images were obtained using a 25-s, 72-s, and 180-s delay, respectively, after intravenous injection of 2.5 mL/kg of iopromide (Ultravist 370; Bayer Schering Pharma, Berlin, Germany) at a rate of 3 mL/s. The CT parameters were beam collimation of 16 × 1.25 mm, beam pitch of 0.938, 120 kV, 200 mAs, and slice thickness of 3 mm. CT revealed diffuse, irregular wall thickening of the CBD, including the intrapancreatic portion of the CBD, with minimal dilatation of the common hepatic duct (CHD) and the intrahepatic duct (IHD) (). The thickened ductal wall showed relatively homogeneous enhancement with isoattenuation compared to the liver parenchyma on the arterial, portal, and delayed phases. A small lymph node with a short-axis diameter of 8 mm was observed within the hepatoduodenal ligament. Magnetic resonance imaging (MRI) with MR cholangiography using a 1.5 T scanner (Magnetom Avanto; Medical Solutions, Erlangen, Germany) depicted ductal wall thickening with slight hypointensity relative to the liver parenchyma on T1-weighted images (TR/TE, 164/4.5; flip angle, 70°; FOV, 350 × 250; slice thickness, 6 mm) and slight hyperintensity on T2-weighted images (TR/TE, 1900/88; echo train length, 13; flip angle, 150°; FOV, 350 × 250; slice thickness, 6 mm). Diffusion-weighted images with a b-value of 800 showed heterogeneous hyperintensity in the CBD (). Although the distal CBD lumen was relatively maintained, the entire CBD exhibited irregular luminal narrowing on MR cholangiography using single-shot rapid acquisition with relaxation enhancement sequence (TR/TE, infinite/1000; echo train length, 256; FOV, 250 × 250; slice thickness, 40 mm) (). The CHD and IHD showed mild dilatation, which was in agreement with the CT findings.\nIn order to relieve the patient's obstructive jaundice, we performed endoscopic retrograde cholangiopancreatography (ERCP) with plastic biliary drainage catheter placement. ERCP revealed diffuse, irregular luminal narrowing of the entire CBD, including the intrapancreatic portion, with diffuse, mild dilatation of the upstream biliary tree (). ERCP also showed an out-pouching, diverticulum-like lesion in the proximal CBD.\nA preoperative diagnosis of cholangiocarcinoma involving the CBD was made, and the patient underwent pyloruspreserving pancreaticoduodenectomy. Grossly, the CBD was found to be diffusely thickened (). No significantly enlarged regional lymph nodes were found, although routine lymph node dissection was performed. Histologic examination under light microscopy revealed dense and diffuse infiltration of atypical lymphoid cells and the formation of lymphoid follicles within the CBD walls (). On immunohistochemical staining, the tumor exhibited CD20 positivity and CD3 negativity. Ki-67 was almost negative with less than 1% positivity. Lambda, kappa, IgG, and IgG4 were all noncontributory. A final pathology diagnosis of low-grade B-cell lymphoma of the MALT type arising from the CBD was made. Of the 15 dissected lymph nodes, no foci of lymphoma involvement were discovered.
|
[[79.0, 'year']]
|
M
|
{'20679881': 1, '11555119': 1, '20651169': 1, '16494193': 1, '19844157': 1, '7127262': 1, '15293142': 1, '6193858': 1, '7619750': 1, '15150028': 1, '18619375': 1, '19794999': 2, '20572800': 1, '19408087': 1, '6412283': 1, '1906678': 1, '15333766': 1, '11722987': 1, '24043969': 2}
|
{'2752784-1': 1}
|
163,182 |
3772256-1
| 24,043,970 |
noncomm/PMC003xxxxxx/PMC3772256.xml
|
Diffusion-Weighted MRI in Intrahepatic Bile Duct Adenoma Arising from the Cirrhotic Liver
|
A 64-year-old male patient with alcoholic liver cirrhosis, who was under surveillance for hepatocellular carcinoma (HCC), showed a mass-like lesion on a computed tomography (CT) scan. The CT scan performed 22 months earlier had revealed no abnormal lesion in the liver. Liver function tests on admission showed elevated serum aminotransferases, with a glutamic-oxaloacetic transaminase level of 121 IU/L (normal = 15-41 IU/L) and a glutamic-pyruvic transaminase level of 69 IU/L (normal = 17-59 IU/L). The serological workups for the hepatitis B virus antigen and hepatitis C virus antibody were negative, and the serum alpha-fetoprotein level was normal.\nDynamic CT scan was performed with a multi-detector row scanner (Somatom Definition Flash, Siemens Healthcare, Forchheim, Germany) before and after the intravenous injection of 2 mL/kg of non-ionic, iodinated contrast material (Xenetix 300, iobitridol; Guerbet, Sulzbach, Germany). Unenhanced images showed a newly developed 1.4-cm low-density subcapsular mass in the left lateral segment of the liver (). On dynamic contrast-enhanced images, the mass demonstrated homogeneous enhancement in the arterial phase (18 seconds after the injection of contrast material) and persistent enhancement in the portal venous phase (60 seconds) but appeared to be isoattenuated relative to the liver parenchyma in the delayed phase (180 seconds) (). The CT parameters were as follows: detector collimation, 0.63 mm; reconstruction interval, 3 mm; tube voltage, 120 kVp; and the product of the tube current and exposure time, 50-240 mAs in conjunction with dose modulation techniques.\nLiver dynamic MRI was performed one week later to rule out the possibility of small HCC with a 3-T whole-body MRI system (Intera Achieva 3.0T, Philips Medical System, Best, the Netherlands). On T2-weighted images, the mass showed high signal intensity. On T1-weighted images, it showed low signal intensity. On dynamic MRI using Gd-EOB-DTPA (Primovist, Bayer Schering Pharma, Berlin-Wedding, Germany; 0.025 mmol/kg), the mass showed strong enhancement in the arterial and portal venous phases (30 and 70 seconds after the injection of Gd-EOB-DTPA, respectively) but was isointense to the liver parenchyma in the late dynamic phase (180 seconds) (). In hepatobiliary phase images, which were obtained 20 minutes after the injection, the mass was distinctly hypointense (). Respiratory-triggered DWI sequences were performed with single-shot echo planar imaging with b values of 0, 50, 400, and 800 s/mm2. The apparent diffusion coefficient (ADC) was automatically calculated by the MR system and displayed as the corresponding ADC map. The mass showed high signal intensity on DWI even at high b-values and exhibited high signal intensity on the ADC map. The ADC value (2.21 × 10-3 mm2/s) of the tumor was more than twofold that of the surrounding liver parenchyma (1.01 × 10-3 mm2/s), which indicates that the hyperintensity seen on high b-value DWI was due to a very high signal intensity on T2-weighted images rather than diffusion restriction ().\nInitially, our first impression was that the patient had a benign enhancing nodule, such as focal nodular hyperplasia (FNH), FNH-like lesion, small hemangioma or dysplastic nodule. However, the possibility of HCC could not be ruled out. When all the possible diagnoses were explained to the patient, he chose to have the mass resected and underwent left lateral segmentectomy at our institution.\nA gross inspection of the specimen showed an ill-defined yellowish nodule located about 0.5 cm from the hepatic capsule, measuring about 1.2 × 1 cm. Microscopically, a proliferation of well-formed bile ductules on a background of fibrous stroma was noted without cellular atypia or mitotic activity (). The result from immunohistochemical stain was negative for carcino-embryonic antigen and p53, but positive for cytokeratin-19. The absence of p53 helps differentiate bile duct adenoma from metastatic adenocarcinoma. The presence of cytokeratin-19 shows that the nodule is of bile duct origin (). The histologic diagnosis was intrahepatic bile duct adenoma on a background of alcoholic liver cirrhosis.
|
[[64.0, 'year']]
|
M
|
{'18777553': 1, '32377756': 1, '26157758': 2, '20461183': 1, '20489091': 1, '26191317': 1, '20032142': 1, '8388005': 1, '10524847': 1, '16958429': 1, '26770929': 2, '24843248': 1, '30788586': 1, '15725808': 1, '22021534': 1, '17994317': 1, '30211677': 1, '19770331': 1, '8669534': 1, '22574289': 1, '20657216': 1, '32229432': 1, '3046396': 1, '26550237': 1, '21852900': 1, '19856432': 1, '20808701': 2, '18069697': 1, '20729445': 1, '17663420': 1, '24043970': 2}
|
{'4712168-1': 1, '2930166-1': 1, '4493364-1': 1, '4493364-2': 1, '4493364-3': 1}
|
163,183 |
3772257-1
| 24,043,971 |
noncomm/PMC003xxxxxx/PMC3772257.xml
|
An Immunoglobulin G4-Related Sclerosing Disease of the Small Bowel: CT and Small Bowel Series Findings
|
A 43-year-old man was admitted to our hospital with a one-year history of intermittent abdominal pains. He had a past medical history of acute myocardial infarction 10 years ago and a six-month history of benign prostatic hyperplasia. The physical examination revealed tenderness in the lower right quadrant of the abdomen.\nThe laboratory tests at presentation showed mild leukocytosis (10470/uL) with an elevated neutrophil percentage (79.6%) and an elevated C-reactive protein value (50.6 mg/L). The serum eosinophil count was in normal range (1.8%). The serum IgG4 level was not available in this case. A plain abdominal radiograph demonstrated no remarkable findings (not shown).\nContrast-enhanced abdominal CT with a 64-row MDCT (Sensation 64, Siemens Medical Solutions, Malvern, PA, USA) showed irregular wall thickening, losses of mural stratification and aneurysmal dilatation of the distal ileum (). Furthermore, adhesion and aggregation of distal ileal loops were also seen (). There were multiple enlarged lymph nodes (maximal diameter: 1.5 cm) around the distal ileum ().\nSmall bowel series showed similar findings to those from the CT. Aneurysmal dilatation and multifocal narrowing of the distal ileum were also seen. Adhesion of the bowel loops with traction and abrupt angulation were also revealed (). There were no significant abnormal findings in the other GI tracts. Clinically and radiologically, there were no significant abnormal findings in other organs.\nThe clinical and radiologic findings were somewhat confusing and non-specific because their sum can suggest both malignancy and benign inflammatory diseases, and are not specified to one category. The patient underwent exploratory laparoscopy. At surgery, the distal ileum showed segmental wall thickening and edematous wall with interloop adhesions. A segment of the distal ileum was resected. Regional lymph nodes dissection and appendectomy were also performed.\nPathological study confirmed the diagnosis of IgG4-related sclerosing disease, which showed intramural chronic inflammation with prominent IgG4 rich-lymphoplasmacytic infiltrates [IgG4 positive cells > 50/high power field (HPF)], fibrosis, and obliterative phlebitis ().\nThe patient's post-operative course was uneventful. The patient was discharged on day 9 in good condition with regular follow-ups in the surgical outpatient clinic.
|
[[43.0, 'year']]
|
M
|
{'29222587': 1, '17287899': 1, '22316447': 1, '14614606': 1, '18609677': 1, '29417330': 1, '32552502': 1, '16932997': 1, '26798227': 2, '14500215': 1, '23118580': 2, '20733352': 1, '12184534': 1, '15517359': 1, '34945093': 1, '26798216': 2, '19718789': 1, '23089913': 1, '21107087': 1, '26101684': 2, '22367294': 1, '7628283': 1, '21297584': 1, '24043971': 2}
|
{'4460202-1': 1, '4720812-1': 1, '4720802-1': 1, '3484302-1': 1}
|
163,184 |
3772258-1
| 24,043,972 |
noncomm/PMC003xxxxxx/PMC3772258.xml
|
Unusual Features in an Adult Pancreatic Hemangioma: CT and MRI Demonstration
|
In a 23-year-old woman with no symptoms, a 5.4 × 5.0 × 3.1 cm mass with internal heterogeneous hyperechogenicity in the pancreas head was found during an annual ultrasound health examination. Blood test findings were within normal range, including the complete blood count, liver function tests and tumor markers. The physical examination revealed no significant abnormality.\nCT was performed on a GE Lightspeed VCT scanner and included a plain scan and dual-phase enhanced scans respectively. CT parameters included 64 × 0.625 mm detector collimation, 120 kVp, 180 mAs, 1.0 pitch, 5 mm slice thickness. An enhanced scan using Iohexol (GE Healthcare, Shanghai, China) contrast agent during the arterial phase and portal venous phases (at 32 and 70 seconds, respectively, dose 1.5 mL/kg, injection flow rate 3.0 mL/s) were also performed. A plain CT scan of the abdomen showed a heterogeneous, well-defined mass at the pancreatic head. A contrast-enhanced CT scan revealed a heterogeneous, nonenhancing, multilocular cyst with fluid-fluid levels at the pancreatic head. The lesion grew outward and extended into the lesser sac ().\nMR imaging was performed with a SIEMENS 1.5-T superconducting system with a body coil. Sequences included T2-weighted fast spin echo with fat suppression (repetition time/echo time, 3250/110 msec; section thickness, 5 mm; gap, 1 mm) and T1-weighted breath-hold gradient echo (repetition time/echo time, 160/4.9 msec; section thickness, 5 mm; gap, 1 mm). A T1-weighted gradient-echo with fat suppression was performed during the hepatic arterial and portal venous phases (at 20 and 50 seconds, respectively) after manual administration of 0.1 mmol/kg Gadodiamide (GE Healthcare, Dublin, Ireland). The MR findings were similar to the CT findings. On MR, the superior fluid layer showed hyper signal intensity (SI) on T1WI and T2WI. The inferior fluid layer was slightly hyper SI to the pancreas on T1WI and hypo SI relative to the superior fluid layer on T2WI ().\nSubtotal pancreatectomy was done. At laparotomy, a soft, blood-red tumor was found arising from the head of the pancreas. There was no invasion of the surrounding vascular structures and the duodenum. The mass was resected from the pancreas. Gross pathologic examination revealed a reddish tumor composed of multiloculated cysts containing intracystic hemorrhaged blood. Microscopically, the tumor showed multiple vascular cysts of variable size lined by a single layer of uniformly flattened cells. The vascular cysts were separated by fibrous tissue (. Histologic examination was consistent with pancreatic hemangioma. The patient was healthy without any sign of recurrence oneyear after surgery.
|
[[23.0, 'year']]
|
F
|
{'26361427': 1, '26290651': 1, '32493358': 2, '30297496': 1, '20932519': 1, '21910381': 1, '8191292': 1, '9516506': 1, '2183300': 1, '10955029': 1, '20609542': 1, '22043156': 1, '12657961': 1, '31771513': 2, '33224837': 1, '19421421': 2, '26171000': 1, '1936772': 1, '19143058': 1, '24043972': 2}
|
{'2676326-1': 1, '6880481-1': 1, '7268514-1': 1}
|
163,185 |
3772259-1
| 24,043,973 |
noncomm/PMC003xxxxxx/PMC3772259.xml
|
MDCT Findings of Right Circumaortic Renal Vein with Ectopic Kidney
|
A 42-year-old man underwent abdominopelvic MDCT due to the evaluation for traumatic splenic rupture. CT examination was performed using a 128-detector-row CT scanner (definition AS+, Siemens Medical Solutions, Forchheim, Germany). Helical scan data was acquired using 32 × 1.2 mm collimation, a rotation speed of 0.5 sec, pitch of 0.6, and 120 kVp. Attenuation-based tube current modulation was used with a reference tube current-time product set at 210 mAs per rotation. Volume rendering images were obtained by using Aquarius iNtuition viewer (Terarecon, SanMateo, CA, USA). A right ectopic kidney was found incidentally. The left kidney was in an orthotropic position with normally coursing the renal vein. The right ectopic kidney was located between the level of the 3rd lumbar vertebral body superiorly and 5th lumbar vertebral body inferiorly. The right ectopic kidney was incompletely rotated while the hilum and renal pelvis were facing anterior to the parenchyma. The anterior portion of the right renal vein which was emerging from the anterior part of the ectopic kidney crossed to the left side of the aorta with a ventral course to the inferior vena cava (IVC) and aorta (). Then, it turned around and coursed dorsally to the aorta and finally drained into the IVC (). The right renal artery arose from the abdominal aorta as the upper polar artery (). The traumatic splenic lacerations and hemoperitoneum are also noted (). The patient showed American Association for the Surgery of Trauma splenic injury grade 2 and stable vital signs, so conservative treatment was performed.
|
[[42.0, 'year']]
|
M
|
{'10835118': 1, '21620097': 1, '25567101': 1, '30002780': 1, '20556387': 1, '10223477': 1, '11236347': 1, '10370998': 1, '24043973': 2}
|
{}
|
163,186 |
3772262-1
| 24,043,976 |
noncomm/PMC003xxxxxx/PMC3772262.xml
|
Use of Amplatzer Vascular Plug to Treat a Biliary Cutaneous Fistula
|
A 69-year-old female patient with painless obstructive jaundice was referred to the interventional radiology for decompression of biliary obstruction. The cause of obstruction was an intrahepatic tumor, a cholangiocarcinoma. A percutaneous puncture of a peripheral right hepatic duct branch was performed using a 22 G needle for cholangiography. Multisegmental bile duct obstruction was demonstrated, most likely due to the intrahepatic tumor.\nSubsequently, a 18 G Ring Needle (DPLN-40-25-RING Drainage Access Catheter Needle Set, William Cook, Bjaeverskov, Denmark) was used for the puncture of the adequate right bile duct. With this access, the stricture was negotiated with a biliary manipulation catheter (William Cook) and an angled hydrophilic guidewire (Glidewire; Terumo, Tokyo, Japan); an internal-external drainage was deployed. After about one week, indices of biliary stasis were not improved in relation with the multisegmental bile duct obstruction; therefore another drainage was positioned. The cholangiography performed through the first drainage was used for the correct deployment of the second internal-external drainage. The drainage was maintained for 10 days during which the jaundice resolved and bilirubin levels normalized. The patient was submitted to a laparoscopic view that confirmed the impossibility of surgical removal of the tumor. Therefore, a biliary permanent stent was deployed [10 × 80 mm, (Gore-Viabil Endoprosthesis, USA)]. In that same procedure, a biliary cutaneous fistula (BCF) consequent to the first internal-external drainage removal was observed. Moreover, a biliary leak was observed. A conservative approach was used as first line treatment. An external drainage was maintained for the time necessary to ensure that the stent functioned and for the diversion of bile flow away from the BCF and biliary leak. Subsequent cholangiograms revealed the persistence of BCF and of the biliary leakage and the correct functioning of the stent. The biliary leakage was successfully embolized using coils ().\nUsing the percutaneous approach, a fistulography was performed using a 7 Fr sheath (). Through the same approach, a 7 mm AVP IV (AVP-AGA Medical Corp., Plymouth, MN, USA)was deployed. Immediate fistulography and cholangiogram revealed the complete exclusion of the fistula (). External drainage was maintained for a few days to ensure the definitive embolization of the BCF.\nFollowing the procedures, the patient remained well, with resolution of her jaundice and of the leakage and BCF.
|
[[69.0, 'year']]
|
F
|
{'31183324': 1, '21111367': 1, '19484289': 1, '18953602': 1, '15947055': 1, '20808706': 2, '16415134': 1, '15389241': 1, '22526108': 1, '19713129': 1, '18612682': 1, '25489252': 1, '18341965': 1, '22623810': 2, '23482415': 2, '23118586': 2, '21600781': 1, '24043976': 2}
|
{'3590341-1': 1, '3484308-1': 1, '2930171-1': 1, '3354350-1': 1}
|
163,187 |
3772263-1
| 24,043,977 |
noncomm/PMC003xxxxxx/PMC3772263.xml
|
Combination Therapy of Temporary Tracheal Stenting and Radiofrequency Ablation for Multinodular Thyroid Goiter with Airway Compression
|
An 80-year-old man was presented with acute onset of dyspnea associated with cough and sputum. He had suffered from a thyroid goiter for 50 years, although it was non-toxic and growing very slowly. Intermittent dyspnea had begun 10 years earlier and had worsened during the previous week. The patient complained of dyspnea while resting when he was seen in our Emergency Department. He had not undergone previous treatments for his thyroid goiter (). CT scans () obtained on his first admission showed remarkable narrowing of the tracheal lumen caused by enlarged bilateral thyroid glands. The narrowest diameter of the stenosis was 5.8 mm.\nTo relieve his severe dyspnea, a self-expandable stent was placed in the stenotic trachea (). The normal diameter of the adjacent trachea was 18 mm and the stricture length was 6 cm; therefore, we chose a stent with diameter of 18 mm and length of 8 cm. According to our specifications, the stent was designed to be retrievable, self-expandable, and silicone-covered with barbed metallic (S&G Biotech, Seongnam, Korea). The metal used for the stent was nitinol. The stent had a retrievable design for elective removals when it was no longer necessary or if there were stent-related complications.\nTwo RF ablation sessions were then performed one and six weeks following stent placement and for which we used an 18-gauge, 1-cm, active-tip, internally cooled electrode (VIVA, STARmed, Goyang, Korea). On the basis of our previous clinical experiences (, ), an ultrasound-guided, trans isthmic approach was used to insert an electrode along the short axis of the nodule, and all nodules were then managed by using the moving shot technique. With the moving shot technique, multiple, small, conceptual ablation units are ablated unit-by-unit by moving the electrode (-). We began ablations with 30 W of RF power. If a transient hyperechoic zone did not form at the electrode tip within 5-10 seconds, the RF power was increased in 10-W increments up to 80 W. The procedure was accepted by our patient, and ablation was terminated when the planned imaginary units were changed to transient hyperechoic zones.\nWe decided to remove the stent four weeks after the second RF ablation session because the thyroid volume had progressively reduced externally according to follow-up on CT scans (); there was also a concern regarding possible complications, such as stent migration or granulation tissue formation around the stent, resulting from a long-dwelling stent. The last follow-up CT scans () obtained five weeks following stent removal showed stable maintenance of the reduced thyroid volume and an apparent narrow tracheal lumen which was, however, relatively wider than that seen on the initial CT scans. The narrowest diameter measured 6.4 mm on the last follow-up CT scans. This report is recorded four months after the stent removel and the patient was able to breathe normally.
|
[[80.0, 'year']]
|
M
|
{'14769757': 1, '11383812': 1, '21119260': 1, '19542381': 1, '14654487': 1, '7974300': 1, '15655205': 1, '19265492': 1, '18286289': 1, '15640412': 1, '17377041': 1, '21927553': 1, '20707660': 1, '20308523': 1, '21841482': 1, '25814656': 1, '20929405': 1, '22438678': 1, '24043977': 2}
|
{}
|
163,188 |
3772265-1
| 24,043,979 |
noncomm/PMC003xxxxxx/PMC3772265.xml
|
Desmoid Type Fibromatosis in the Facet Joint of Lumbar Spine: Case Report and Review of Literature
|
A 31-year-old man was presented with back pain and mild numbness from the left buttock to the ankle, which developed after the previous motor vehicle accident, 1 year and 5 months ago. Physical examination did not reveal any abnormality in motor or neurological examination. The symptoms were partially improved with epidural and left L5 nerve root block.\nConventional radiographs of the lumbar spine demonstrated a bony erosive lesion with a sclerotic rim at the left L3-4 facet joint (). CT revealed an isodense soft tissue mass to the muscle at the posterior portion of the left L3-4 facet joint, which eroded both L3 inferior and L4 superior articular processes, but the articular surfaces of the both eroded facets were well preserved (). MR images demonstrated about 1.6 × 1.0 × 1.0 cm sized soft tissue tumor on the facet joint, which infiltrated beyond the posterior joint capsule. The tumor was isointense to the muscle on T1-weighted image (repetition time [TR]/echo time [TE] 700/10.8 msec) (), and intermediate to low signal intensity of the tumor between the muscle and cerebrospinal fluid (CSF) on T2-weighted image (TR/TE 4000/97 msec) (). The lesion was well enhanced by the gadolinium without evidence of the internal necrosis (). Tc99m-MDP bone scan did not demonstrate an abnormal radiotracer uptake.\nThe patient underwent bone biopsy, and pathologically, the tumor was diagnosed as a desmoid tumor. After 2 months, the tumor was completely removed with partial facetectomy.\nMicroscopically, the tumor was composed of cellular proliferation of the elongated, slender, spindle-shaped cells arranged in interlacing bundles of fibroblasts with abundant collagenous stroma (). The cellularity varied from area to area with scanty mitotic activity, and the cells infiltrated into the adjacent bone. Further, the tumor cells were found in the facet joint capsule with extracapsular infiltration. Immunohistochemical stain showed positive reactions to the smooth muscle actin (), focal positive reactions to S100 protein, and negative reaction to CD34, vimentin and desmin. The tumor was diagnosed as the desmoid tumor.\nAfter surgical treatment, the patient was relieved from pain in the lower back and buttock.
|
[[31.0, 'year']]
|
M
|
{'16357411': 1, '18708919': 1, '1738999': 1, '31897201': 1, '19503798': 2, '6849031': 1, '17566795': 1, '3311517': 1, '16434899': 1, '12065994': 1, '2255948': 1, '3034013': 1, '19926768': 1, '10791589': 1, '3490146': 1, '21603874': 1, '479262': 1, '9265665': 1, '10478622': 1, '8016675': 1, '6844935': 1, '11735163': 1, '24043979': 2}
|
{'2688648-1': 1}
|
163,189 |
3772266-1
| 24,043,980 |
noncomm/PMC003xxxxxx/PMC3772266.xml
|
Image-Guided Percutaneous Lipiodol-Pingyangmycin Suspension Injection Therapy for Sacral Chordoma
|
A 74-year-old man presented with a progressively worsening pain in sacrum in January, 2004. MRI showed a mass lesion in the sacrum. In May, 2004, sacral pain was intolerable and accompanied with uroclepsia. Routine laboratory tests including blood routine, liver function and renal function all showed within normal limits. MRI showed the lesion increased in size and compressed the urinary bladder. The contrast-enhanced CT showed a 5-cm mass without enhancements (). An additional puncture biopsy was confirmed for the histologic diagnosis of chordoma. The patient refused to undergo surgical resections of the tumor. Percutaneous intratumoral injection with LPS was therefore suggested as an alternative treatment. In China, the usage of LPS for the treatment of solid tumors had to be approved by Institutional Review Boards. The patient thus gave his written informed consent.\nAccording to the CT images, the entry point of the skin was located on the left side of the 1st sacral vertebra with an 8-cm distance from the spine, and the direction of needle inserted into the tumor was a horizontal angle of 30°. The procedure was performed using a 15-cm-long, 21-gauge needle with a closed conical tip and three terminal side holes (Hakko, Tokyo, Japan) and under C-arm fluoroscopy (Axiom-Artis-dTA Angiographic System, Siemens Medical Systems, Germany) guidance.\nThe patient was put in prone position. Local anesthesia with 2% lidocaine was administered after local disinfections of the skin. The needle was inserted into the tumor under C-arm fluoroscopy, and the position of the needle tip was confirmed by anteroposterior and lateral fluoroscopy. Then, a 3 mL kermesinus liquid was aspirated from the tumor followed by injecting 3 mL of contrast medium (Iopamilon 300; Schering, Berlin, Germany) directly into the tumor. CT scan was immediately tested and showed that the contrast medium was accumulated within the tumor.\nThe procedure of intra-tumoral injection with LPS was performed afterwards. LPS was made as follows: pingyangmycin (PYM, Northern China Pharmaceutical Factory, Shijiazhuang, Hebei, China) 16 mg was dissolved in 5 mL of contrast medium and then mixed into a suspension with 5 mL lipiodol (LP, Laboratoire Guerbet, Roissy, France), and total LPS was about 10 mL in volume. Sequentially, LPS was manually injected slowly under simultaneous fluoroscopy until the vein drainage appeared. Then the needle was retracted 1-2 cm or adjusted to the direction of needling route. After the tip of needle within the lesion was confirmed by C-arm anteroposterior and lateral fluoroscopy, the additional injections were continued so that the LPS could be distributed throughout the entire tumor (). Three days after the procedure, an X-ray radiography was taken and showed that the LPS deposited well within the sacrum tumor ().\nFollow-up CT scan showed that LP deposited well within the tumor 2 months after the first procedure. Surveillances of CT/MRI scans were required every 6 months thereafter. However, as a lack of compliance, the patient obtained follow-up CT scans again 28 months after the first procedure because of severe sacroiliac pains. It showed that the lesion obviously increased in size measuring 8.7 × 5.4 × 8.1 cm and LP thinly retained in the tumor (). From September to October in 2006, the intratumoral injection with LPS was repeated in the same method 3 times under fluoroscopy guidance within the interval of one week, and the volume of LPS was respectively as follows: 20 mL (16 mg PYM, 10 mL LP, and 10 mL contrast medium), 10 mL (12 mg PYM, 5 mL LP, and 5 mL contrast medium), and 10 mL (12 mg PYM, 5 mL LP, and 5 mL contrast medium). LPS were distributed throughout the upper lesion after the first and second injections and the lower one after the third injection.\nIn April 2009, the patient was readmitted to our hospital, because he had experienced symptoms for more than one month, including severe sacroiliac pains, frequency and urgency of micturition, and weakness in lower limbs with greater severity on the right side. CT scan revealed that the sacrum tumor increased significantly and LP was deposited poorly in some regions. Intratumoral injection with LPS was repeated twice under CT guidance aimed to the region with only a little LP deposition in the interval of one week, with 20 ml of LPS (24 mg PYM, 10 mL LP, and 10 mL contrast medium) each time. In order to uniform the LPS distributions in the entire tumor mass, the third injection are required two weeks after being released from the hospital.\nRoutine laboratory tests were rechecked 3-7 days after the procedures, including blood routines, liver functions, and renal functions.\nThere were three sessions of treatments for the patient, and the intratumoral injection with LPS was repeated altogether 6 times with a total of 90 mL of LPS (PYM: 104 mg and LP: 45 mL) under fluoroscopy guidance (n = 4) and CT guidance (n = 2). The operation time ranged from 5 to 10 minutes (mean, 6.5 minutes) under fluoroscopy guidance, and it was 22 minutes and 31 minutes under CT guidance, respectively.\nAfter the first procedure, the pain in sacrum gradually diminished. The patient demonstrated significant improvements in quality of life. CT scan showed that the tumor lesion decreased from 5 cm to 3 cm in diameter and the residual LP deposited well within the tumor 2 months after this procedure (). Three days after the second procedure, CT scan showed that the tumor was filled fully with LPS (). Symptoms were relieved and then vanished 3 weeks after the third procedure.\nThe patient did not experience adverse reactions after each procedure, such as fever, nausea, and vomiting. Nevertheless, 3-7 days after the procedure, his routine laboratory tests including blood routine, liver function and renal function showed within normal limits. There were only some LP depositions in gluteus after the second procedure without any discomfort (). In the third procedure, disappointedly, the patient was not readmitted to the hospital to receive the third injection. No complications were observed during the follow-up period, such as skin necrosis, pelvic visceral injury, and neurological deficits.\nIn July, 2010, the patient presented with a severe pain in sacrum again. CT scan obtained in the local hospital revealed that the sacrum tumor increased significantly again, and lung metastasis appeared. The patient rejected further treatments and was unavailable for follow-ups. During a 6-year follow-up period, the patient demonstrated significant improvement in quality of life with a Karnofsky Performance Score above 80 points.
|
[[74.0, 'year']]
|
M
|
{'18356443': 1, '10813725': 1, '21940344': 1, '28746230': 1, '18584264': 1, '20642897': 1, '16496365': 1, '12919911': 1, '20084025': 1, '10091765': 1, '19752710': 1, '22840806': 1, '19100921': 1, '16391875': 1, '21427182': 1, '10472097': 1, '16613311': 1, '20635173': 1, '15383851': 1, '9894966': 1, '15502143': 1, '17202828': 1, '24043980': 2}
|
{}
|
163,190 |
3772267-1
| 24,043,981 |
noncomm/PMC003xxxxxx/PMC3772267.xml
|
Arachnoid Cyst in Oculomotor Cistern
|
A 29-year-old woman with progressive blurred vision and diplopia for 7 years was admitted for further evaluation. Ophthalmological examination revealed right oculomotor nerve palsy as ptosis and downward deviations in the right eye. In room light, pupils measured 6 mm in the right eye and 3 mm in the left eye.\nOrbit MRI was performed using 3.0T system (Magnetom Verio; Siemens Medical Solutions, Erlangen, Germany). T2-weighted axial MR images with heavily T2-weighted 3D turbo spin-echo sequence revealed a hyperintense lesion with an internal hypointense linear structure in the right orbital apex (). No enhancement was noted on gadolinium enhanced T1 weighted axial image (). The internal structure revealed right oculomotor nerve within the cystic lesion, which continued into oculomotor cistern on oblique sagittal images with heavily T2-weighted 3D turbo spin-echo sequence ().\nThe patient underwent right sub-frontal craniotomy and the cystic lesion on prior MR images was shown after unroofing the optic canal. The cystic wall was fenestrated and high pressure cerebrospinal fluid -like fluid was drained. Microscopically, the cystic wall was lined by normal arachnoid membrane, representing arachnoid cyst (). After the operation, she felt immediate regression of symptoms on the third nerve palsy.
|
[[29.0, 'year']]
|
F
|
{'17210311': 1, '16582644': 1, '15523194': 1, '11756120': 1, '18417604': 1, '17881939': 1, '21800781': 1, '12439687': 1, '30555949': 1, '9297723': 1, '18769282': 1, '20036550': 1, '19668771': 1, '24043981': 2}
|
{}
|
163,191 |
3772268-1
| 24,043,982 |
noncomm/PMC003xxxxxx/PMC3772268.xml
|
Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms
|
A 72-year-old man was being admitted with a Hunt & Hess grade 3 SAH. An angiography revealed a small, wide-necked aneurysm at the Acom. Under general anesthesia, a shuttle 6 Fr-guiding catheter was placed in the cervical ICA. First, a 0.014-inch microguidewire was positioned on the left anterior cerebral artery (ACA) A1 portion and the Scepter-C balloon 4/10 catheter was advanced over the microguidewire to the ACA A1 portion (). The microguidewire was positioned further to the right A2 portion and the balloon catheter was placed, thus, spanning the entire aneurysm neck, and then, the balloon-assisted coil embolization was performed (). Near the end of the coil embolization, a coil tail protruded the Acom after balloon deflation (). The balloon catheter was re-positioned to the left A2 using a reintroduced microguidewire. Inflation of the balloon pushed the protruded coil tail into the aneurysm sac (). A final control angiogram showed complete occlusions of the aneurysm sac ().
|
[[72.0, 'year']]
|
M
|
{'22033717': 1, '19749218': 1, '30799582': 1, '16961133': 1, '33362706': 1, '30652144': 1, '23136237': 1, '32026126': 2, '12775880': 1, '22268079': 1, '26998029': 1, '21349960': 1, '22958766': 1, '33164616': 1, '27621946': 1, '26381558': 1, '20559093': 1, '22778576': 2, '29628946': 1, '21131582': 1, '22125751': 1, '19959540': 1, '24043982': 2}
|
{'3772268-2': 2, '3772268-3': 2, '6966389-1': 1, '6966389-2': 1, '3384836-1': 1}
|
163,192 |
3772268-2
| 24,043,982 |
noncomm/PMC003xxxxxx/PMC3772268.xml
|
Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms
|
A 66-year-old woman was being admitted with a Hunt & Hess grade 3 SAH. An angiography showed a large aneurysm at the left MCA bifurcation. A three-dimensional reconstruction of the angiogram revealed that a superior branch was incorporated into the sac (). After placement of the Scepter-C balloon catheter from the M1 to MCA inferior division, a gradual over-inflation of the balloon indicated that a substantial portion of the balloon was herniated into the sac (), which made it possible to save the incorporated superior branch and, in turn, to perform the coil embolization of the aneurysm. At the end of the procedure, an angiography revealed a thrombus formation at the aneurysm neck close to the origin of the superior branch (). After administering an intra-arterial Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1 mg) infusion, a follow-up angiography 30 minutes later showed a resolution of the thrombus and a complete occlusion of the aneurysm sac (). The patient showed no neurological deficit post-treatment.
|
[[66.0, 'year']]
|
F
|
{'22033717': 1, '19749218': 1, '30799582': 1, '16961133': 1, '33362706': 1, '30652144': 1, '23136237': 1, '32026126': 2, '12775880': 1, '22268079': 1, '26998029': 1, '21349960': 1, '22958766': 1, '33164616': 1, '27621946': 1, '26381558': 1, '20559093': 1, '22778576': 2, '29628946': 1, '21131582': 1, '22125751': 1, '19959540': 1, '24043982': 2}
|
{'3772268-1': 2, '3772268-3': 2, '6966389-1': 1, '6966389-2': 1, '3384836-1': 1}
|
163,193 |
3772268-3
| 24,043,982 |
noncomm/PMC003xxxxxx/PMC3772268.xml
|
Initial Experience with the New Double-lumen Scepter Balloon Catheter for Treatment of Wide-necked Aneurysms
|
An 80-year-old woman was being admitted with a Hunt & Hess grade 2 SAH. A three-dimensional reconstruction of the angiogram showed a large aneurysm on the left MCA bifurcation and another very small aneurysm close to the bifurcation aneurysm neck at the superior branch (). After placement of the Scepter C balloon catheter from M1 to the inferior M2 division (), a balloon-assisted coil embolization of the large aneurysm was successfully completed. After repositioning the balloon catheter, a very small aneurysm at the superior division was also embolized. The final control angiogram revealed a complete occlusion of both aneurysms and well-preserved MCA superior and inferior divisions ().
|
[[80.0, 'year']]
|
F
|
{'22033717': 1, '19749218': 1, '30799582': 1, '16961133': 1, '33362706': 1, '30652144': 1, '23136237': 1, '32026126': 2, '12775880': 1, '22268079': 1, '26998029': 1, '21349960': 1, '22958766': 1, '33164616': 1, '27621946': 1, '26381558': 1, '20559093': 1, '22778576': 2, '29628946': 1, '21131582': 1, '22125751': 1, '19959540': 1, '24043982': 2}
|
{'3772268-1': 2, '3772268-2': 2, '6966389-1': 1, '6966389-2': 1, '3384836-1': 1}
|
163,194 |
3772270-1
| 24,043,984 |
noncomm/PMC003xxxxxx/PMC3772270.xml
|
Multi-Detector Row Computed Tomographic Evaluation of a Rare Type of Complete Vascular Ring: Double Aortic Arch with Atretic Left Arch Distal to the Origin of Left Subclavian Artery
|
The first patient was a 16-year-old girl who presented difficulty swallowing, which had persisted for 3 years. Barium esophagography () revealed posterior indentation of the middle esophagus so MDCT was arranged to delineate the anatomical details of the aortic arch.\nThe scan was done with a 40-detector-row CT scanner (Brilliance 40; Philips, Best, the Netherlands) according to a protocol published in the literature (). The scan was interpreted on a dedicated MDCT workstation (Extended Brilliance Workspace; Philips, Best, the Netherlands).\nMulti-detector row computed tomography imaging study disclosed apparent right aortic arch with ascending aorta giving origin to a left innominate artery as first branch, which was followed by right common carotid artery and right subclavian artery (RSCA), and a blind-end diverticulum arising from descending aorta (D-aorta) with tip toward the left side (). A small protruding pouch was also noted over proximal left pulmonary artery. Proximity of the small pouch over pulmonary artery, descending aortic diverticulum, and posterioinferiorly distorted LSCA on CT suggested presence of fibrous tissue connecting these three structures.\nFibrous cord between LSCA and descending aortic diverticulum was confirmed during the surgery, and thus, the double aortic arch with left arch atresia distal to the origin of LSCA (distal left arch atresia) was the final diagnosis rather than the right aortic arch with mirror branching. In addition, left ligamentum arteriosum arising from the small pouch to the fibrous cord was also noted. The surgeons transected both the fibrous cord and ligamentum arteriosum to separate the proximity. After the operation, no specific complications occurred and the patient reported that food swallowing was improved. The follow-up MDCT one year later revealed upward migration of the LSCA without inferior tethering to descending aortic diverticulum, which meant that the ring comprising the "double aortic arch" was no longer present, thereby releasing the trachea and esophagus ().
|
[[16.0, 'year']]
|
F
|
{'14521025': 1, '33446185': 1, '16565909': 1, '18877614': 1, '15855130': 1, '17377058': 1, '34680355': 1, '19270864': 1, '33046002': 1, '20354848': 1, '24043984': 2}
|
{'3772270-2': 2}
|
163,195 |
3772270-2
| 24,043,984 |
noncomm/PMC003xxxxxx/PMC3772270.xml
|
Multi-Detector Row Computed Tomographic Evaluation of a Rare Type of Complete Vascular Ring: Double Aortic Arch with Atretic Left Arch Distal to the Origin of Left Subclavian Artery
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The second patient was a 3-year-old girl who suffered from failure to thrive and had recurrent respiratory infections. Results of barium esophagography suggested evidence of vascular ring.\nMulti-detector row computed tomography was conducted with similar settings to those used with the first patient (), and the same vascular anomaly was revealed with a more significant anatomic continuity among the LSCA, descending aortic diverticulum, and pouch over pulmonary artery. Furthermore, compressed trachea and esophagus were also revealed after post-processing with volume rendering (). Double aortic arch with distal left arch atresia was diagnosed, and the small pouch over pulmonary artery suggested a ductal diverticulum.
|
[[3.0, 'year']]
|
F
|
{'14521025': 1, '33446185': 1, '16565909': 1, '18877614': 1, '15855130': 1, '17377058': 1, '34680355': 1, '19270864': 1, '33046002': 1, '20354848': 1, '24043984': 2}
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{'3772270-1': 2}
|
163,196 |
3772271-1
| 24,043,985 |
noncomm/PMC003xxxxxx/PMC3772271.xml
|
Severe Posterior Reversible Encephalopathy in Pheochromocytoma: Importance of Susceptibility-Weighted MRI
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A 13-year-old girl was presented with flushing and swelling on her hands and feet, sweating and critical headache for one year. On her medical history; she had previously been admitted for similar complaints and underwent surgery. Right adrenalectomy was made seven years ago and pathology result was pheochromocytoma. She had been discharged with a cure and a recommendation of interval follow-ups. But, the patient did not attend any follow-up visits nor receive any treatments over the last seven years. She started to complain of similar symptoms again since last year. On physical examination; she had cyanosis and edema on both hands and feet. The patient's blood pressure was 215/165 mm Hg, and her pulse rate was 137 beats per minute. Biochemical and radiological examinations were performed to determine recurrent pheochromocytoma. Urinary and plasma catecholamine levels were high. Urinary normetanephrine level was 30084 µg/24 h (reference values are 63-402 µg/24 h), urinary metanephrine level was 1452 µg/24 h (reference values are 32-167 µg/24 h), plasma noradrenalin level was 17540 pg/mL (reference values are 0-400 pg/mL). Contrast enhanced abdominal MRI was performed with a large mass within the left adrenal gland, measuring 65 × 50 mm in size. It was hypointense on T1-weighted and heterogeneous hyperintense on T2-weighted image with intense enhancement on post-contrast images (), suggesting residue or recurrence of the adrenal pheochromocytoma. Cranial MRI was performed because of serious headaches. T2-weighted and fluid attenuated inversion recovery (FLAIR) images showed abnormal hyperintense signals on bilateral caudate, lentiform nuclei, dentate nuclei and periventricular and deep white matter (). Furthermore, there were two hematomas; a chronic hematoma with peripheral hemosiderin rim on the right external capsule measuring 3 × 1 cm in size and a subacute hematoma on the right globus pallidus measuring 1 cm in diameter (). There was increased diffusion in the lesions consistent with the vasogenic edema. These findings were consistent with severe PRES for the involvement of periventricular and deep white matter and deep gray matter as well as parenchymal hematomas.\nOn the tenth day of anti-hypertensive therapy, we obtained follow-up cranial MRI with additional SWI sequence. There was remarkable regression of vasogenic edema with near completed resolution of T2 high signal intensities on periventricular and deep white matter, and complete loss of edema on caudate, lentiform, and dentate nuclei (). On SWI, many millimetric foci of hypointensity suggesting micro hemorrhages were observed on bilateral basal ganglia, periventricular white matter and brain stem (). These microhemorrhagic foci were not detectable on conventional MRI. Reversible high signal intensities supported that this condition was PRES secondary to hypertension. SWI sequence revealed many micro and macro hemorrhagic foci of hypertensive encephalopathy as a complication of untreated chronic hypertension.
|
[[13.0, 'year']]
|
F
|
{'9409033': 1, '9010526': 1, '23482893': 2, '25276129': 1, '15608506': 1, '15366751': 1, '10954269': 1, '32820130': 1, '23292521': 1, '29594605': 1, '22572502': 1, '17885064': 1, '23118581': 2, '33281266': 1, '22241378': 1, '567764': 1, '24043985': 2}
|
{'3590348-1': 1, '3484303-1': 1}
|
163,197 |
3772272-1
| 24,043,986 |
noncomm/PMC003xxxxxx/PMC3772272.xml
|
Visualization of Peripheral Pulmonary Artery Red Thrombi Utilizing Optical Coherence Tomography
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A 42-year-old man was transferred to our institution for emergency treatment. He had experienced acute occlusion of the left and right pulmonary arteries caused by a rupture of a massive right atrial thrombus as confirmed by MDCTA (). He received thrombolytic therapy with intravenous administration of 100 mg recombinant tissue plasminogen activator, followed by anticoagulation with subcutaneous lower-molecular-weight heparin. Anticoagulation treatment with oral warfarin was consistently administered. After being discharged one month later, he had shortness of breath under moderate-intensity exertion and was readmitted. MDCTA was performed and the result revealed a complete resolution of the thrombi in both main pulmonary arteries as well as an inconclusive filling defect sign in the peripheral pulmonary artery of the right lower lobe (). To explore pulmonary arteries, pulmonary angiography and selective pulmonary angiography were performed via the right femoral approach, using a 6 Fr sheath, pig tail and multipurpose catheters, respectively. The results revealed several filling defects in the subsegmental pulmonary arteries of both the lower and right upper lobes (). Then, OCT was performed to evaluate these intravascular lesions. An OCT system (Model M2 Cardiology Imaging System, LightLab Imaging, Inc., Westford, MA, USA) with a motorized pull-back system was used. A 0.016-inch OCT image wire (ImageWire, LightLab Imaging, Inc.) was advanced to the distal end of the lesions through a 3 Fr occlusion balloon catheter. In order to remove the blood as well as to obtain clear images, the occlusion balloon was inflated with an inflated device, with the inflating pressure ranging from 0.4 to 1.0 atm (1 atm = 101.3 kPa) at the proximal site of the vessel. Lactate Ringer's solution was infused into the artery from the distal tip of the occlusion balloon catheter at 1.0 to 2.0 mL·s-1. Motorized pullback OCT imaging was performed at a rate of 1.0 mm·s-1 for a length of 30 mm. Images were acquired at 15 frames·s-1 and were digitally archived. The OCT images revealed mostly total occlusive mural protrusions (). After OCT imaging, a multipurpose catheter was advanced to the opening of the pulmonary artery and the proximal connected syringe and was slowly retracted. These retrieved materials were dark red strip-like tissue (), which were fixed in formalin and processed for staining with hematoxylin and eosin. The result of the histological examination was red thrombi (). An immediate check-up angiography showed the disappearance of the filling defects (). OCT was performed again and demonstrated no mural protrusion (). After a half-year of anticoagulation treatment with warfarin, his symptoms were resolved.
|
[[42.0, 'year']]
|
M
|
{'17765119': 1, '14752178': 1, '22932201': 1, '8131558': 1, '20484114': 1, '15321058': 1, '16845250': 1, '4138834': 1, '19892716': 1, '16765119': 1, '24043986': 2}
|
{}
|
163,198 |
3772273-1
| 24,043,987 |
noncomm/PMC003xxxxxx/PMC3772273.xml
|
Sandstorm Appearance of Pulmonary Alveolar Microlithiasis Incidentally Detected in a Young, Asymptomatic Male
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A 24-year-old Malay male patient was referred to the respiratory clinic because of an abnormal pre-employment chest radiograph. He had been smoking about 10 cigarettes a day since he was 21 years of age. He stopped smoking 10 months ago after he noticed he had being having reduced effort tolerance for the past three years. He was an office worker and did not have a history of exposure to organic or inorganic dusts. His two siblings were asymptomatic.\nOn examination, the patient was not tachypnoeic. There were no signs of finger clubbing or pulmonary hypertension. His oxygen saturation on room air at rest was 94% and dropped to 92% after climbing up four flights of stairs. Spirometry testing revealed a restrictive pattern of lung disease with a forced expiratory volume in 1 second (FEV1) and a forced vital capacity (FVC) of 2.7 L (69% of predicted) and 3.2 L (68% of predicted), respectively. The FEV1/FVC ratio was 85%.\nHis haemoglobin (168 g/L), serum parathyroid hormone (2.9 pmol/L [normal, 1.1-7.3]) and calcium (2.34 mmol/L) levels were normal. 24-hour urine calcium was also normal 6.9 mmol with a 24-hour urine volume of 2.8 L.\nHis chest radiograph () revealed dense micronodular opacities distributed symmetrically and predominantly in the middle to lower zones of both lungs giving the classical "sandstorm" appearance. The cardiac borders were obscured by the sand-like opacities.\nA high-resolution computed tomography (HRCT) scan of the lungs () showed widespread tiny microcalcifications throughout the lungs with a preponderance of microliths in the lower lobes. There were associated areas of interlobular septal thickening and ground-glass changes. Subpleural cystic changes were also seen in both lower lobes giving rise to the 'black pleura sign' () (). No pneumothorax or pleural effusion was present. Both the bronchial system (including the small bronchioles) and the size of the pulmonary vessels were normal.\nAs this was diffuse parenchymal lung disease, videoassisted thoracic surgical (VATS) lung biopsy was planned but the procedure was converted into a mini-thoracotomy because there was difficulty in manoeuvering the endostapler. There was a moderate pneumothorax postmini-thoracotomy from which the patient fully recovered after 5 days in the ward. The lung biopsy specimen revealed features consistent with PAM, with numerous calcospherites within the alveolar spaces (). The intervening alveolar septae were congested and showed mild fibrosis with infiltrates of mainly lymphoplasmacytic cells.
|
[[24.0, 'year']]
|
M
|
{'4095678': 1, '16960801': 1, '9530388': 1, '16129256': 1, '21415198': 1, '12097548': 1, '18026653': 1, '16035566': 1, '8776269': 1, '15554073': 1, '19617834': 1, '33884208': 2, '24043987': 2}
|
{'8041554-1': 1}
|
163,199 |
3772286-1
| 24,044,080 |
noncomm/PMC003xxxxxx/PMC3772286.xml
|
Evaluation of Probability of Survival Using Trauma and Injury Severity Score Method in Severe Neurotrauma Patients
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A 67-year-old man was brought directly to our trauma center after a cultivator accident. Upon arrival at the emergency medicine department, the patient was found to have a systolic blood pressure of 150 mm Hg and a respiratory rate of 24 breaths/min and GCS of 3 (eye=1, verbal=1, motor=1). His pupils were 4/4 mm in size and did not respond to light. Also, his corneal reflex disappeared. Brain computed tomography (CT) represented a large amount of subdural hemorrhage and midline shifting from right to left (). His blood pressure (RTS coded value=4), respiratory rate (RTS coded value=4), and GCS (RTS coded value= 0) gave him an RTS of 4.09 (RTS=0.9368×0+0.7326×4+0.2908×4=4.09). His head and neck injuries, acute subdural hemorrhage (AIS=5) and his ISS was 25 (ISS=1st AIS2=52=25). Therefore, his calculated probability of survival by the TRISS methodology was 60.18%. During his hospital course, Brain swelling progressed and compressed the brain stem. He eventually died and was considered an unexpected nonsurvivor. If his AIS of the head and neck was given 6, his calculated probability of survival by the TRISS methodology would have decreased to 2.76%.
|
[[67.0, 'year']]
|
M
|
{'2231804': 1, '23025964': 1, '16759417': 1, '3123707': 1, '8576997': 1, '6623052': 1, '11003333': 1, '15179251': 1, '7745667': 1, '16766966': 1, '2020032': 1, '26393173': 1, '32201699': 1, '21274684': 1, '16508487': 1, '18646254': 1, '20220424': 1, '16688062': 1, '14759963': 1, '26816061': 1, '15454791': 1, '20386271': 1, '34834496': 1, '24044080': 2}
|
{'3772286-2': 2}
|
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