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164,500 | 3843902-1 | 24,348,402 | noncomm/PMC003xxxxxx/PMC3843902.xml | Recurrent Annular Peripheral Choroidal Detachment after Trabeculectomy | A 54-year-old African-American male with a remote history of prednisone treated polymyositis developed bilateral open angle glaucoma. His past ocular history included trabeculectomy in the right eye, bilateral cataract surgery and the maintenance of topical steroid drops to manage his rebound iritis. On the day of surgery, he reported some mild cold symptoms, but he insisted on having the surgery done. He had an uneventful trabeculectomy with mitomycin C performed on his left eye and did well during the first postoperative week with deep anterior chamber and an IOP in the 7–9 mm Hg range. He was on Vigamox 0.5% (Alcon, Fort Worth, Tex., USA) and prednisolone acetate 1% 4 times a day. He returned for a follow-up on postoperative day 11 with a complaint of persistent left eye pain for the last 3 days. On examination, his visual acuity was 20/80, pin holed (PH) to 20/30, and IOP was 10 mm Hg. His anterior chamber was flat with a complete iris-cornea touch except a 1/5 cornea thickness space between the cornea and the intraocular lens (IOL). The superior fornix-based bleb was slightly elevated without leakage and the peripheral iridectomy was patent. There were severe fibrin exudates in the anterior chamber with a 360° posterior synechiae of the pupil. The retina was flat on fundus exam without scleral depression. The initial differential diagnosis included: overfiltration, pupillary block, aqueous misdirection, choroidal effusion or choroidal hemorrhage. Inflammation was considered to play a role because of his history of steroid dependency, eye pain and copious fibrin in the anterior chamber. He was given oral prednisone 60 mg daily, topical Atropine 1% (Falcon Pharmaceuticals, Ltd., Fort Worth, Tex., USA) and phenylephrine 2.5% (Akorn, Inc., Lake Forest, Ill., USA) to dilate the pupil. Prednisolone was discontinued and Durezol (Difluprednate Ophthalmic Emulsion 0.05%; Alcon) was given one drop every hour []. In addition, he was given a 2-mg dexamethasone subconjunctival injection. Following the application of dilating drops in the clinic, the anterior chamber began reforming and posterior synechiae began to break down. He was sent home with Atropine 1% and phenylephrine 2.5% 4 times a day as well as Durezol every hour. The next morning, his visual acuity was 20/200 (PH 20/60), IOP was 7 mm Hg, and his anterior chamber was flat with cornea-IOL touch. His fundus exam revealed no choroidal detachment or hemorrhage. Healon (Abbott Medical Optics Inc., Santa Ana, Calif., USA) was injected to reform the anterior chamber []. His oral prednisone and topical drops were continued.\nDespite this treatment, the patient returned to the clinic 2 days later. He had a totally flat anterior chamber with a normal fundus and an IOP of 10 mm Hg. Aqueous misdirection was suspected, but peripheral choroidal effusion could not be ruled out. Transverse B-scan using a temporal approach identified a shallow annular anterior choroidal effusion (fig. ). He was taken to the operating room the same day and the suprachoroidal effusion was drained from infero-nasal and infero-temporal sclerotomies []. A moderate amount of light yellow clear fluid was retrieved. The anterior chamber was reformed with Healon (Abbott Medical Optics Inc.) at the end of the surgery aiming at a high IOP to prevent choroidal effusion from recurring. He was continued on oral prednisone 60 mg daily and Durezol every 2 h and dilating drops 4 times a day.\nHis anterior chamber remained deep for 2 days with IOP in the mid-teens. However, on the third day after drainage of the choroidal effusion, the anterior chamber was flat with an IOP of 10 mm Hg. Aqueous misdirection was suspected, but repeat transverse B-scans showed recurrent peripheral choroidal effusion. The patient was taken to the operating room. One sclerotomy wound was reopened and a smaller amount of suprachoroidal fluid aspirated. The conjunctival incision for trabeculectomy was opened and additional 10–0 nylon sutures were placed on the sclera flap. Also, a half-thickness 3 × 3 mm donor scleral patch was placed to reinforce a thin area on the scleral flap. Postoperatively, his anterior chamber was deep with an IOP in the 40's. The IOP was lowered to the 30's over the next 2 days with paracentesis and ocular massage. Suture lysis was performed on the third postoperative day and his IOP decreased to the mid 20's. The patient developed a large corneal epithelial defect postoperatively. The oral prednisone was decreased by 20 mg every 2 days from the initial 60 mg/day, and topical Durezol was decreased from one drop every 2 h to 4 times a day to promote corneal healing.\nThe patient presented 7 days later with counting fingers vision due to diffuse corneal stromal edema and Descemet's membrane folds. The epithelial defect was completely healed and the IOP was 18 mm Hg with a deep anterior chamber. The corneal edema was thought to be due to the rapid steroid tapering. Oral prednisone 60 mg/day was resumed. The first dose of prednisone was given in the clinic and topical Durezol was increased to one drop every 2 h. The patient's corneal edema and Descemet's membrane folds cleared with vision improving to 20/50 the next morning. Oral prednisone was slowly tapered by 10 mg/week, while topical Durezol was continued at one drop every 2 h for 5 weeks, followed by a very slow taper. At this point, his anterior chamber depth stabilized and cornea remained clear. Suture lysis was performed cautiously and as needed. Visual acuity in the eye returned to 20/20 and IOP was 15 mm Hg, 8 months after the initial surgery, without glaucoma drops. | [[54.0, 'year']] | M | {'32596553': 1, '11865955': 1, '8008343': 1, '19142129': 1, '12671473': 1, '7493243': 1, '9082270': 1, '3412765': 1, '3317956': 1, '28118610': 1, '9400754': 1, '33814824': 2, '20809807': 1, '11735786': 1, '15939389': 1, '6480299': 1, '22244522': 1, '24348402': 2} | {'7993050-1': 1} |
164,501 | 3843903-1 | 24,348,320 | noncomm/PMC003xxxxxx/PMC3843903.xml | Systemic Reactive Amyloidosis Associated with Castleman's Disease | A 51-year-old African-American man who had been born and raised in the United States first presented to the medical clinic with complaints of generalized weakness, fatigue, unintended weight loss, anorexia and progressively worsening abdominal distension of 3 months duration. His medical comorbidities included essential hypertension and gout. Physical examination at the time was significant for a firm, indurated right-sided submandibular mass, hepatomegaly and mild epigastric tenderness.\nAn initial set of laboratory studies showed abnormal liver enzymes (alanine transaminase of 61 IU/l, aspartate transaminase of 83 IU/l, markedly elevated alkaline phosphatase of 1,003 IU/l and gamma-glutamyl transferase of 1,879 IU/l with normal bilirubin levels). Additional work-up done for evaluation of abnormal liver enzymes including viral hepatitis panels (hepatitis A, B and C), anti-nuclear antibody, anti-smooth muscle antibody, anti-liver kidney microsomal antibodies and anti-mitochondrial antibody were negative. A computed tomography scan of the abdomen showed hepatomegaly (18 cm).\nThe patient underwent biopsy of the submandibular mass that revealed features of Castleman's disease (fig. ). A subsequent liver biopsy revealed perisinusoidal deposition of eosinophilic, amorphous material within the extracellular matrix with hepatocyte atrophy, consistent with hepatic amyloidosis (fig. ). Bone marrow biopsy revealed diffuse extracellular eosinophilic, amorphous material consistent with amyloidosis with increased kappa light chain-restricted plasma cell count (6% of hematopoietic bone marrow cells) (fig. ). The patient underwent a colonoscopy that revealed no gross mucosal lesions; biopsies were unremarkable. A definitive diagnosis of secondary (AA) reactive amyloidosis with hepatic involvement was made.\nThe patient had subsequent hospitalized with new-onset, rapidly progressing tense ascites. He underwent large-volume paracentesis. Ascitic fluid analysis revealed an elevated serum-ascites albumin gradient of 1.7 and very low protein of 0.9 g/dl. Cell count analysis was consistent with spontaneous bacterial peritonitis. He was treated with intravenous antibiotics. A computed tomography scan of the abdomen done at the time revealed dilated loops of small bowel consistent with small bowel obstruction, which resolved with conservative management. He was not considered for chemotherapy in view of active infection and was not a liver transplant candidate because of his poor physical condition. The patient was discharged to be readmitted only 2 weeks later with recurrent ascites from decompensated liver disease. He was found to have worsening jaundice. His clinical condition rapidly deteriorated with superimposed severe metabolic acidosis resulting from acute renal dysfunction. He ultimately expired from multiorgan failure. | [[51.0, 'year']] | M | {'33967527': 2, '31563665': 1, '7959246': 1, '8213634': 1, '26528023': 1, '14530778': 1, '7727877': 1, '30946344': 2, '19583148': 1, '12942463': 1, '15367866': 1, '28403848': 2, '4872136': 1, '20883547': 1, '32028407': 2, '5473607': 1, '8097803': 1, '3151378': 1, '17554117': 1, '4031967': 1, '1152671': 1, '32432144': 1, '17062386': 1, '17915620': 1, '1916751': 1, '21997995': 1, '4551306': 1, '16867906': 1, '3115870': 1, '6437933': 1, '28352636': 2, '24348320': 2} | {'5352960-1': 1, '8083446-1': 1, '7015640-1': 1, '5389156-1': 1, '6456117-1': 1} |
164,502 | 3843904-1 | 24,348,394 | noncomm/PMC003xxxxxx/PMC3843904.xml | Presacral Ganglioneuroma: Diagnostic Considerations and Therapeutic Strategy | A 35-year-old man presented to our hospital due to mild lower left abdominal pain lasting for 2 weeks. He reported one episode of uncomplicated diverticulitis 5 years ago, and his past medical history was unremarkable. He did not suffer from back pain or other neurologic symptoms and was physically active. Changes in bowel habits were not present. Routine blood tests, serum tumor markers (carcinoembryonic antigen, cancer antigen 19-9, and cancer antigen 125), α-fetoprotein and plasma and urine catecholamines were within normal range.\nAbdominal ultrasonography incidentally revealed a huge solid pelvic mass, with well-defined borders. Abdominal computed tomography (CT) confirmed the presence of a well-circumscribed solid tumor in the presacral region, measuring 10 × 8.5 cm in size and presenting smooth edges and no calcifications (fig. ). Pelvic magnetic resonance imaging (MRI) confirmed the extension of the lesion from the S2 level to the coccyx (fig. ). The mass had low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images with no intraspinal or rectal extension. In addition, we were able to demonstrate by T2-weighted images that it was a compartmentalized solid tumor with cystic components (fig. ). Colonoscopy examination revealed the presence of diverticulum in the sigmoid colon without inflammation and tumor involvement of the rectum.\nThe patient was submitted to surgical laparotomy without a preoperative fine-needle biopsy (FNA). An abdominal approach was used with the patient in the modified Lloyd-Davies position. The lesion was approached transperitoneally with presacral mobilization of the rectum, and complete tumor resection with free surgical margins was achieved. The specimen included a tumor of 10 × 8.5 × 4 cm in size, surrounded by a thin fibrous capsule, with elastic consistency, a compact form, and a grayish and partially brownish color.\nAfter microscopic examination and immunohistochemical study, the diagnosis of mature GN was established. The neoplasm contained mature ganglion cells and Schwann cells together with collagen (fig. ). Ganglion cells were distributed diffusely throughout the tumor or arranged in small clusters. There was no neuroblastomatous component. Mitoses were very rare. The immunophenotype of the neoplasm was as follows: synaptophysin (+), neuron-specific enolase (+), S-100 (+), neurofilaments (+), vasoactive intestinal polypeptide (+), protein 27 (+), myeline basic protein (–), and epithelial membrane antigen (–). The index of cellular proliferation ki-67 was <1%.\nThe patient had an uneventful recovery and was discharged on the 12th postoperative day. Repeat MRI at 12 and 24 months after surgery and neurologic examination were unremarkable. | [[35.0, 'year']] | M | {'1544674': 1, '5825608': 1, '28490166': 2, '12110723': 1, '22339762': 1, '11346873': 1, '17465461': 1, '15796364': 1, '30460019': 1, '8213687': 1, '15981068': 1, '2752635': 1, '11178704': 1, '3591208': 1, '2766597': 1, '12045531': 1, '16909248': 1, '16047206': 1, '16315071': 1, '8618605': 1, '2917322': 1, '20698154': 1, '10421273': 1, '3704795': 1, '12131432': 1, '17933000': 1, '17764452': 1, '24348394': 2} | {'5426442-1': 1} |
164,503 | 3843905-1 | 24,348,410 | noncomm/PMC003xxxxxx/PMC3843905.xml | Floating Vitreous Cyst: Two Clinical Cases | A 39-year-old, highly myopic man with a 2-day history of a dark object floating in his right eye was examined in our clinic. The patient had no history of ocular trauma or intraocular inflammation. Best-corrected visual acuity was 0.4 in the right eye and 0.9 in the left eye. The anterior segments were normal in both eyes. Dilated fundus examination revealed slightly tilted optic discs with peripapillary atrophy due to high myopia and small flame-shaped hemorrhage on the temporal side of the right optic disc (fig. ). Posterior vitreous detachment (PVD) and an oval, opaque, and pedunculated cyst was seen in the vitreous cavity of the right eye (fig. ). The free-floating cyst was located in the inferior vitreous when the eye was in primary position and obscured the underlying retina. Fundus images were taken with a fundus camera and a spectral-domain optical coherence tomography (SD-OCT) (Heidelberg Engineering, Heidelberg, Germany) was performed (fig. ). B-scan ultrasound of the right eye demonstrated intravitreal opacities and confirmed the presence of a hyperechogenic cyst with no internal reflectivity (fig. ). The diameter of the cyst was 3.1 mm. Blood serology tests were negative for Toxoplasma gondii, Toxocara canis, cysticercosis and Echinococcus. Observation of the cyst was advised. | [[39.0, 'year']] | M | {'19960034': 1, '24962488': 1, '4088623': 1, '7862424': 1, '4808776': 1, '8789866': 1, '19911021': 1, '26314744': 1, '5849862': 1, '11466258': 1, '2622126': 1, '25884156': 2, '484997': 1, '3982808': 1, '21485975': 1, '2220982': 1, '9593381': 1, '28974214': 2, '22374162': 1, '24348410': 2} | {'3843905-2': 2, '4355964-1': 1, '5627412-1': 1} |
164,504 | 3843905-2 | 24,348,410 | noncomm/PMC003xxxxxx/PMC3843905.xml | Floating Vitreous Cyst: Two Clinical Cases | A 78-year-old man was referred to the Eye Hospital because of vitreomacular traction in the left eye. He reported a slow visual deterioration in his left eye over the last 2 years, but had no problems with the right eye. Only when specifically asked, he reported transient blurring of vision in his right eye when changing head position. His medical history was unremarkable. The patient's best-corrected visual acuity was 0.5 in the right eye and 0.3 in the left eye. Slit-lamp examination showed nuclear cataract in both eyes, anterior segments were otherwise normal. Fundus examination of the right eye showed a big, round, semitranslucent, and partially pigmented vitreous cyst just below the inferior temporal vascular arcades (fig. ). The cyst appeared empty. During eye movements, the cyst was freely floating in the vitreous cavity. Inferior temporal retinoschisis was also noted in this eye, but there were no other changes of the fundus. Fundus examination of the left eye revealed significant vitreomacular traction. B-scan ultrasonography of the right eye showed partial PVD and a cystic, well-demarcated formation not fixed to any other ocular structures, with a diameter of 6 mm (fig. ). The cyst was evaluated also by SD-OCT. Images confirmed a thin, well-defined cyst wall with a hyporeflective lumen. Inside the cyst, small hyperreflective spots were present (fig. ). Blood serology tests were negative for Toxoplasma gondii, Toxocara canis, cysticercosis and Echinococcus. Observation was recommended as in the first case. | [[78.0, 'year']] | M | {'19960034': 1, '24962488': 1, '4088623': 1, '7862424': 1, '4808776': 1, '8789866': 1, '19911021': 1, '26314744': 1, '5849862': 1, '11466258': 1, '2622126': 1, '25884156': 2, '484997': 1, '3982808': 1, '21485975': 1, '2220982': 1, '9593381': 1, '28974214': 2, '22374162': 1, '24348410': 2} | {'3843905-1': 2, '4355964-1': 1, '5627412-1': 1} |
164,505 | 3843906-1 | 24,348,405 | noncomm/PMC003xxxxxx/PMC3843906.xml | Successful Corticosteroid-Sparing Effect of Rituximab in the Treatment of Refractory Idiopathic Orbital Inflammatory Disease | A 61-year-old woman presented with symptoms of left-sided headache, peri-orbital pain and left-sided ocular protrusion. Examination revealed a decrease in her visual acuity from 6/6 to 6/24, which was associated with a left-sided relative afferent pupillary defect. Her left eye was proptotic by 3 mm on exophthalmometry, with associated ocular pain and conjunctival injection (fig. ). Extraocular movements were normal and intraocular examination proved unremarkable.\nBlood investigations including thyroid function tests, fasting blood glucose, liver and renal function tests, erythrocyte sedimentation rate and serum ACE were all normal, as was an immune screen including rheumatoid factor, antinuclear antibody and antineutrophil cytoplasm antibody.\nA provisional diagnosis of left IOID was made based on the clinical findings and negative blood investigations, and oral prednisolone was started at a dose of 60 mg/day. Her symptoms resolved rapidly and her vision and proptosis improved within days, supporting the diagnosis. However, she suffered a disease relapse when her prednisolone was tapered to 20 mg/day. Subsequent attempts at steroid sparing with mycophenolate mofetil 1 g b.i.d. and methotrexate 20 mg p.o. weekly proved ineffective over a period of 8 months. The patient started again at 60 mg/day prednisolone together with each second-line agent, but she was unable to get below 20 mg prednisolone without renewed disease activity. Measurement of IgG subclasses at this point demonstrated normal IgG4 levels, although this result may have been confounded by her concurrent treatment with corticosteroids and other immunosuppressive medication.\nShe then received 2 infusions of rituximab 1 g i.v. separated by an interval of 2 weeks. This effected disease remission within 4 weeks and enabled her prednisolone to be tapered to 7.5 mg o.d. without relapse over a period of 2 months. Nine months on, she remains in remission on 7.5 mg prednisolone only and maintains a visual acuity of 6/6 with no relative afferent pupillary defect, and no abnormalities on repeat MR scanning (fig. ). | [[61.0, 'year']] | F | {'19015801': 1, '34448063': 1, '22302065': 1, '19404964': 1, '32215344': 1, '12441835': 1, '19321476': 1, '22018678': 1, '21907416': 1, '24348405': 2} | {} |
164,506 | 3843907-1 | 24,348,399 | noncomm/PMC003xxxxxx/PMC3843907.xml | Multiple Vascular Accidents Including Rupture of a Sinus of Valsalva Aneurysm, a Minor Ischemic Stroke and Intracranial Arterial Anomaly in a Patient with Systemic Congenital Abnormalities: A Case Report | A 39-year-old man was admitted to our hospital because of a sudden onset of hemiparesis on his left side with dysarthria. He had a history of a SVA rupture that was surgically treated at the age of 24 (fig. ). During the surgery, there were no specific findings of cystic medial necrosis or crystalline lens subluxation due to the Marfan syndrome. In his infancy, there were no developmental abnormalities. In his school records, the subject had poor grades during childhood and adolescence. His family history over 3 generations was unremarkable in terms of neurological, psychological, and cardiac diseases. During the patient's examination, his body temperature was 37.0°C, blood pressure was 184/104 mm Hg, pulse was 83 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 97% (while he was breathing ambient air). At the time of hospitalization, the patient presented with an acute stroke and the symptoms included left-sided weakness and dysarthria; these neurological symptoms lasted for a week after admission. We assessed the risk of juvenile ischemic stroke in a laboratory study, but high-risk factors that are linked to juvenile cerebral ischemia, such as collagen diseases and vasculitides, were not found. An electrocardiogram revealed a sinus rhythm within the normal range. Although we performed magnetic resonance imaging (MRI) with a 1.5-tesla unit on the first day and with a 3-tesla unit 2 weeks later, acute cerebral infarction was not detected (fig. ). Routine sonographic evaluation of the carotid arteries demonstrated a diffuse narrowing of the left ICA and a low-lying carotid bifurcation. Thereby, cerebral angiography was conducted, and it showed hypoplasty of the left ICA and a low-lying carotid bifurcation at the level of the C6 vertebra (fig. ). The A1 segment of the bilateral anterior cerebral arteries (ACAs) was united and formed an azygos type (fig. ). The common ACA duct and left posterior cerebral artery were mainly supplied by the right ICA. Aortography and 4 vessel studies (bilateral common carotid arteries and vertebral arteries) were conducted, and there was no embolic source, such as ulceration of the arterial surface or arterial dissection, or significant partial arterial stenosis. No right-to-left shunt was found in transesophageal echocardiography.123 I iofetamine single-photon emission computed tomography brain imaging was performed, and no regional reductions or abnormal accumulations of tracer uptake into the brain were observed. The patient's intelligence quotient was evaluated with the Wechsler Adult Intelligence Scale-III []; his mental faculties were found to be at a significantly low level of functioning (table ). Facial manifestations were unremarkable, but he showed symptoms of nasal speech and nasal air emission while talking. In the otorhinolaryngological examinations, velopharyngeal insufficiency was revealed by laryngoscopy. The patient was discharged after 3 weeks; MRI could not detect any significant abnormal findings such as infarction, hemorrhage, or malformation. We decided that the patient should continue with an antithrombotic therapy after assessing normal treatment for cerebral ischemia. The patient is now taking warfarin; the target range for the prothrombin time/international normalized ratio is 2.0–3.0. | [[39.0, 'year']] | M | {'15282498': 1, '19096567': 1, '9592798': 1, '15122191': 1, '18848693': 1, '11784530': 1, '22885127': 1, '10798425': 1, '16638563': 1, '3813939': 1, '24348399': 2} | {} |
164,507 | 3843908-1 | 24,348,378 | noncomm/PMC003xxxxxx/PMC3843908.xml | Verrucous Spitz Nevus in a Japanese Female | A 23-year-old Japanese female presented with a pigmented skin lesion on the left lower leg. It had been noted for 5 months. She had no specific symptoms. Physical examination revealed a reddish-brown dome-shaped hyperkeratotic nodule of 11 × 10 mm with a sharply demarcated, symmetrical border (fig. ). Dermoscopic examination demonstrated prominent whitish scaly areas of ring-like appearance, pinkish-white structureless areas, a few milia-like cysts, dotted and glomerular vessels, light brown globules, and dotted hemorrhages (fig. ). The lesion was completely excised under the diagnosis of verruca vulgaris or dermatofibroma.\nHistopathologic study revealed a well-circumscribed symmetric lesion with no lateral extension of individual melanocytic proliferation. Hyperkeratosis, acanthosis, and pseudohorn cysts were observed (fig. ). There were confluent nests with peripheral clefts composed of spindle-shaped and epithelioid melanocytes with large cytoplasm at the dermal-epidermal junction and in the papillary dermis (fig. ). There was stromal fibrosis surrounding the nests (fig. ). Mitotic figures and Kamino bodies were absent. Moderate proliferation of capillaries in the papillary dermis was observed (fig. ). There were perivascular cell infiltration and maturation of nevus cells at the bottom of the lesion. Immunohistochemical staining with melan-A or S-100 was positive for tumor cells, but the staining with HMB-45 was negative. Melan-A was weaker in the deeply situated cells than in the superficial ones (fig. ), and nests ascending up to the stratum corneum appeared as transepidermal elimination (fig. ). We eventually made a diagnosis of verrucous Spitz nevus based on these findings. | [[23.0, 'year']] | F | {'15611426': 1, '19836657': 1, '28977136': 1, '22082838': 1, '31334082': 1, '23062610': 1, '24348378': 2} | {} |
164,508 | 3843912-1 | 24,348,382 | noncomm/PMC003xxxxxx/PMC3843912.xml | Paradoxical Reaction to Golimumab: Tumor Necrosis Factor α Inhibitor Inducing Psoriasis Pustulosa | A female, 50-year-old, black patient with rheumatoid arthritis, followed-up by the Rheumatology Sector, was forwarded to the Dermatology Ambulatory as an emergency case due to complaints of sudden onset of pustular lesions in the palms and soles (fig. , fig. ), and erythematous-desquamating plaques with pustules in the limbs, chest and dorsum (fig. ). During anamnesis, we found that the patient had recently begun the use of golimumab, a TNF-α inhibitor, and that she was on her fourth monthly dose of the medication. The clinical picture began soon after administration of this last dose and she was also using methotrexate concurrently. The patient had no previous personal or familial history of psoriasis. A skin biopsy was carried out with clinical suspicion of pustular psoriasis by paradoxical effect, since there are literature reports of similar adverse events with other TNF-α inhibitors. We decided to suspend the medication, given the extension of the cutaneous picture. Histopathology showed abundant neutrophilic infiltrate (Munro's abscess), acanthosis, presence of Kogoj's spongiform pustule, and dilation of papillary dermal capillaries (fig. , fig. ). The clinical-histopathologic correlation confirmed the diagnosis of pustular psoriasis. We continued treatment with methotrexate 15 mg for a week, in an attempt to treat the cutaneous-articular manifestations. The patient is undergoing ambulatory follow-up, but, after over 12 months of suspension of the drug, she still has skin lesions, with periods of exacerbation and appearance of new lesions, providing evidence of triggering a new disease caused by the use of the medication. | [[50.0, 'year']] | F | {'16702050': 1, '17310002': 1, '18155297': 1, '17492843': 1, '18576309': 1, '15998792': 1, '24348382': 2} | {} |
164,509 | 3843913-1 | 24,348,391 | noncomm/PMC003xxxxxx/PMC3843913.xml | Growing Teratoma Syndrome of the Ovary Showing Three Patterns of Metastasis: A Case Report | A 14-year-old girl presented to a local hospital in June 2006 with abdominal fullness. Physical examination was normal except for abdominal discomfort. Computed tomography (CT) scans revealed a 15-cm mass and a small amount of ascites, but no sign of lymph node enlargement (fig. ). Serum tumor markers were slightly elevated: CA19-9 = 113.8 U/ml, CA125 = 60 U/ml, SCC = 2.5 ng/ml, and α-fetoprotein (AFP) = 297.4 IU/ml. Serum human chorionic gonadotropin (HCG) was negative. Liver and renal function tests, electrolytes, and a complete blood count were all normal. The initial laparotomy revealed that the left ovary was larger than the size of a child's head and had already ruptured with slightly bloody fluid in the pelvic cavity. Left salpingo-oophorectomy and omentectomy were performed. The cytologic examination of ascites detected malignant cells. Histological examination revealed the tumor to be a mixed germ cell tumor which included a grade 3 immature teratoma (75%), mature teratoma (10%), embryonal carcinoma (10%), and yolk sac tumor (5%) (fig. ). The patient was therefore diagnosed with a left ovarian mixed germ cell tumor, clinical stage 1c [pT1c(2) NxMx].\nShe underwent 6 cycles of chemotherapy postoperatively with cisplatin, etoposide, and bleomycin (BEP). The tumor markers normalized 1 month after the operation. Five years after the completion of chemotherapy, routine CT scans revealed dissemination in the pelvic region, para-aortic lymph node metastasis, and lung metastasis (fig. ). However, the interval since the last examination had been 18 months based on the patient's wishes. No tumor marker was elevated.\nThe patient was admitted to Nagoya University Hospital for resection of the three types of metastatic mass. Secondary laparotomy showed a 3-cm dissemination on the mesentery of the sigmoid colon and two 1-cm disseminations on the posterior uterus. We removed the three disseminated lesions. Next, we removed an 8-cm metastatic tumor in the para-aortic lymph node. One month after the secondary laparotomy, video-assisted thoracoscopic surgery was performed for a right lung metastasis. Pathologic analysis of the resected specimens revealed that all metastatic tumors were mature teratomas (fig. ). The patient is now undergoing regular follow-up and remains disease free 11 months after the second surgery. | [[14.0, 'year']] | F | {'10899652': 1, '6478436': 1, '6288220': 1, '32957389': 2, '18043048': 1, '14751185': 1, '28656118': 2, '29279691': 2, '21450035': 1, '18307026': 1, '9205463': 1, '26886604': 2, '65751': 1, '16946208': 1, '25593702': 2, '1634130': 1, '20068327': 1, '24348391': 2} | {'5731097-1': 1, '4286866-1': 1, '5471592-1': 1, '4998604-1': 1, '7505337-1': 1} |
164,510 | 3843915-1 | 24,348,389 | noncomm/PMC003xxxxxx/PMC3843915.xml | Early Relapse of Unresectable Gallbladder Cancer after Discontinuation of Gemcitabine Monotherapy Administered for 5 Years in a Patient Who Had Complete Response to the Treatment | A 77-year-old man with a 2-month history of right shoulder and upper abdominal pain visited his physician at another hospital. A gallbladder tumor, about 3 cm in diameter, was detected by ultrasonography, and the patient was then referred to our hospital for further diagnosis and treatment. His laboratory findings at presentation were nearly normal, including the serum levels of tumor makers. Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen showed the mass to be located at the cervix of the gallbladder and to involve the common and right hepatic arteries, with enlargement of the No. 12 lymph node (fig. ). A percutaneous biopsy of the tumor revealed an adenocarcinoma, and immunohistochemical analysis of the tumor showed positive staining for carcinoembryonic antigen (CEA) and cytokeratin 7, and negative staining for cytokeratin 20. Thus, the tumor was diagnosed as an unresectable gallbladder cancer.\nThe patient was initiated on treatment with gemcitabine at a dose of 1,000 mg/m2 administered on days 1, 8, and 15 of each 4-weekly cycle. After 13 cycles of treatment, a marked decrease of the tumor size on CT was noted (fig. ), and the treatment response was rated as partial response according to the Response Evaluation Criteria in Solid Tumors (RECIST) criteria, version 1.0. After 15 cycles of treatment, the tumor disappeared altogether, and CR was confirmed by CT after 20 cycles of gemcitabine monotherapy (fig. ). After CR had been achieved, the tumor was reevaluated for possible surgical resection by our surgeon. However, the patient was judged to be an unsuitable candidate for surgery, because he had severe bronchial asthma. Therefore, gemcitabine monotherapy was continued. After 27 cycles of treatment, corresponding to a further 12 months of treatment after CR had been confirmed, we held a discussion with the patient and his family about whether or not they would like the gemcitabine therapy to be continued. They made the decision for the gemcitabine therapy to be continued, for fear that the tumor might relapse. At this time, because of thrombocytopenia, the administration schedule of gemcitabine was changed to 3-weekly cycles, with the drug administered at the same dose as previously, but on days 1 and 8, followed by 1 week's rest. From the 40th cycle onward, the administration schedule was changed again to biweekly cycles, with no reduction of the drug dose, because of grade 1 malaise.\nAfter the completion of 5 years of treatment with gemcitabine, we again held discussions with the patient and his family and decided to discontinue the gemcitabine therapy, because the patient had remained relapse free for 45 months. Gemcitabine had been administered a total of 160 times, over 60 cycles, for 5 years, while the drug toxicities had remained rather mild in nature throughout the course of treatment, consisting only of grade 2 leukopenia and thrombocytopenia and grade 1 malaise.\nHowever, 11 months after treatment discontinuation, the patient presented with signs of obstructive jaundice. Brushing cytology of the bile duct by endoscopic retrograde cholangiopancreatography revealed an adenocarcinoma. MRI showed relapse of the tumor at the porta hepatis (fig. ). The metastases to the lymph nodes invaded the celiac artery and common hepatic artery. Thus, the patient was diagnosed as having unresectable relapse of gallbladder cancer, and gemcitabine therapy was restarted. Six months later, the tumors showed an increase in size and multiple liver metastases appeared. The second term of gemcitabine therapy was less effective against the disease as compared to the first, although the best response was stable disease. At the time this case report was written, the patient was receiving S-1 therapy and has remained alive for 79 months after the commencement of the first gemcitabine therapy. Serial changes of the serum levels of carbohydrate antigen 19-9 and CEA during the entire treatment are shown in fig. . | [[77.0, 'year']] | M | {'20628385': 1, '1718594': 1, '12714891': 1, '15083178': 1, '20375404': 1, '19575200': 1, '17179730': 1, '18214482': 1, '16142487': 1, '26397134': 1, '9477094': 1, '10202270': 1, '21063134': 1, '17325704': 1, '24348389': 2} | {} |
164,511 | 3843917-1 | 24,348,387 | noncomm/PMC003xxxxxx/PMC3843917.xml | Incidental Discovery of Testicular Microlithiasis: What Is the Importance of Ultrasound Surveillance? Two Case Reports | A 39-year-old man with a 6-month history of lumbar pain came to our hospital to perform an MRI examination in order to rule out a lumbosacral hernia. The MRI images showed no slipped disks, but we unfortunately detected a voluminous retroperitoneal solid mass. Therefore, we decided to perform a total body CT to better characterize the mass and its relationship to adjacent structures. CT images showed a large heterogeneous retroperitoneal mass with curvilinear calcifications and a marked inhomogeneous enhancement after intravenous contrast medium injection due to the presence of necrotic-colliquative areas. This lesion displaced the left renal vein cranially, the abdominal aorta anteriorly and towards the right, and infiltrated the inferior vena cava, the left renal vein, and the left psoas muscle (fig. ).\nThe patient's α-fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin levels were 2.680 IU/l (normal, 90–180 IU/l), 279 ng/ml (normal, 0–7.5 ng/ml), and 4 mIU/ml (normal, <5 mIU/ml). We performed a scrotal ultrasonography (US) to rule out that this mass was a retroperitoneal metastasis of a primary testicular tumor: US showed bilateral classic TM (defined as more than 5 calcifications scattered throughout the testicle), without a focal lesion (fig. ). Comparing the current ultrasound images with previous US testicular images (the patient underwent a scrotal US when he was 25 years old because of a testicular trauma), we noticed that microcalcification patterns were very similar.\nThe patient underwent a CT-guided biopsy and at histology, an immature teratoma was diagnosed. | [[39.0, 'year']] | M | {'11863093': 1, '20858789': 1, '17199868': 1, '21098858': 1, '21768233': 1, '22710430': 1, '18304228': 1, '21461280': 1, '8648846': 1, '24348387': 2} | {'3843917-2': 2} |
164,512 | 3843917-2 | 24,348,387 | noncomm/PMC003xxxxxx/PMC3843917.xml | Incidental Discovery of Testicular Microlithiasis: What Is the Importance of Ultrasound Surveillance? Two Case Reports | A 33-year-old man came to our emergency department complaining of abdominal pain, vomiting, weight loss and mild jaundice. Ultrasound examination detected a large, ill-defined heterogeneous abdominal mass.\nThe patient's serum α-fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin levels were 2.470 IU/l (normal, 90–180 IU/l), 232 ng/ml (normal, 0–7.5 ng/ml) and 3 mIU/ml (normal, <5 mIU/ml). Besides, the serum markers of cholestasis were high: conjugated bilirubin was 2 mg/100 ml (normal, <0.2 mg/100 ml), γ-glutamyl transpeptidase 70 IU/l (normal, 1–30 IU/l) and alkaline phosphates 300 IU/l (normal, <170 IU/l).\nCT and MRI examinations showed a giant retroperitoneal mass made up by multiple necrotic-colliquative fluid areas with a multilocular aspect, which dislocated the inferior vena cava anteriorly and with possible infiltrating signs; it also compressed the portal vein and the common bile duct with moderate dilatation of the intrahepatic ducts (fig. ).\nThe patient was sent to do an US to rule out the presence of a primary testicular tumor, which revealed bilateral TM without a focal hypoechoic lesion; the microcalcification pattern was quite similar to that of a past ultrasound exam that was performed when the patient was 22 years old because of a suspected varicocele.\nThe patient underwent a CT-guided biopsy and at histology, a yolk sac tumor was diagnosed. | [[33.0, 'year']] | M | {'11863093': 1, '20858789': 1, '17199868': 1, '21098858': 1, '21768233': 1, '22710430': 1, '18304228': 1, '21461280': 1, '8648846': 1, '24348387': 2} | {'3843917-1': 2} |
164,513 | 3843920-1 | 24,348,319 | noncomm/PMC003xxxxxx/PMC3843920.xml | Life-Threatening Gastrointestinal Mucosal Necrosis during Methotrexate Treatment for Rheumatoid Arthritis | An 82-year-old woman was referred to our hospital for constipation and lower abdominal pain 3 days after she had taken her last dose of MTX. She had been diagnosed with RA at the age of 74 and was being treated with nonsteroidal anti-inflammatory drugs (NSAIDs; 180 mg/day loxoprofen sodium hydrate), prednisolone (4–6 mg/day) and low-dose MTX (8 mg/week). At the first visit to our hospital, physical examination showed fullness and slight tenderness of the lower abdomen. Blood tests showed that she had anemia (hemoglobin [Hb] 10.0 g/dl) and mild inflammation (white blood cell [WBC] count and C-reactive protein [CRP] levels were 18,600/μl and 0.95 mg/dl, respectively). Her platelet count was 388,000/μl, and biochemical examination showed no significant abnormality. Computed tomography of the abdomen showed slight thickening of the descending colonic wall and no organic lesions resembling neoplasms. Lower gastrointestinal endoscopy showed mucosal petechiae in the descending colon, and the patient was believed to have colitis caused by fecal impaction (fig. ). Her symptoms were immediately relieved once she defecated after receiving laxative treatment. Antibiotics were not administered. To provide bowel rest, ingestion of enteral nutrients and parenteral nutrition were started.\nNine days after the first visit, the patient again complained of nausea, epigastralgia and abdominal fullness. The next day, she developed a fever (38.6°C) and ulcerative oral mucositis. Laboratory examination showed a WBC count of 900/μl, a Hb level of 7.6 g/dl, a platelet count of 120,000/μl and a CRP level of 14.45 mg/dl. Upper gastrointestinal endoscopy showed severe mucosal necrosis covering a large area (almost the entire circumference) of the lower esophagus, linear erosive gastritis and multiple duodenal ulcers. Lower gastrointestinal endoscopy was performed again, and mucosal necrosis with sloughing was observed along the entire circumference of the descending colon (fig. ). Contrast-enhanced computed tomography showed wall thickening along the entire circumference of the lower esophagus and descending colon, with mild pleural effusion. Microscopic examination of biopsy specimens from the esophagus and descending colon also revealed necrotic mucosa. On fecal culture analysis conducted at the same time, methicillin-resistant Staphylococcus aureus (MRSA) was detected, but Clostridium difficile or Candida albicans was not. Therapy with granulocyte colony-stimulating factor and empiric antibiotics was initiated. Eleven days after the first visit, the patient developed pancytopenia; her WBC count was 400/μl, Hb was 6.1 g/dl and platelet count was 59,000/μl. Severe inflammation and renal injury were observed (CRP 27.99 mg/dl; blood urea nitrogen 84 mg/dl; creatinine level 1.18 mg/dl). Blood transfusion and intravenous administration of meropenem, vancomycin, gamma-globulin, recombinant human soluble thrombomodulin and a proton pump inhibitor were started for the pancytopenia and infection. Leucovorin rescue was also initiated with a 3-mg intravenous bolus every 8 h, since the involvement of MTX was suspected. However, since the patient's general condition did not improve immediately, continuous hemodiafiltration with polymyxin B-immobilized fibers was performed. After 2 days of this blood purification therapy, the patient's general condition improved gradually.\nThe DLST was performed for MTX, NSAIDs and prednisolone. MTX showed a strong positive reaction, with a stimulation index of 443% compared to drug-free normal controls. The patient resumed oral intake 30 days after her first visit but had developed cicatricial stricture of the esophagus and colon (fig. ). Therefore she required balloon dilatation, twice for the esophagus and once for the descending colon. She was discharged from our hospital 15 weeks after admission (fig. ). | [[82.0, 'year']] | F | {'11254248': 1, '27333839': 1, '26443090': 1, '32344632': 1, '9189054': 1, '22110423': 1, '20967860': 1, '21963744': 1, '34041953': 2, '9146556': 1, '1412121': 1, '3052323': 1, '7538828': 1, '33505476': 1, '24884884': 1, '21893583': 1, '27041864': 1, '12695153': 1, '24348319': 2} | {'8165836-1': 1} |
164,514 | 3843924-1 | 24,348,408 | noncomm/PMC003xxxxxx/PMC3843924.xml | Macroaneurysm on the Optic Disc in a Patient with Aortic Dissection | A 60-year-old female who experienced deteriorated vision in her right eye the previous week visited our hospital. Best-corrected visual acuity in her right eye was limited to hand motion, her intraocular pressure was 15 mm Hg, the lens showed mild cataract, and the fundus was invisible due to vitreous hemorrhage. B-mode echography showed no retinal detachment, but there was mass refraction on the optic disc (fig. ). Vitrectomy combined with lens extraction by phacoemulsification and artificial intraocular lens implantation was performed. After removing the vitreous hemorrhage, a large macroaneurysm appeared on the optic disc (fig. ). The macroaneurysm was beating and oozing blood, but no other abnormal finding was observed. The aneurysm was not treated, and the oozing of blood from the macroaneurysm continued after surgery. Three weeks after surgery, however, the vitreous hemorrhage disappeared, and the patient's best-corrected visual acuity in the right eye increased to 1.0. The macroaneurysm gradually shrunk, and the oozing of blood and beating disappeared. The fundus photograph made 3 months after surgery is shown below (fig. ).\nOur patient started medication for hypertension at the age of 41 and kept her hypertension under control. She did not have hyperlipidemia, but she developed acute Stanford type A aortic dissection at the age of 51 (fig. ) and underwent synthetic graft replacement surgery. Marfan-like phenotype was not found. A contrast-enhanced computed tomography scan of the head showed no intracranial aneurysm (data not shown). Currently, the patient still has false lumen, but it did not progress after surgery.\nAt the age of 57, she started glaucoma eye drops (latanoprost) in both eyes at an ophthalmic clinic. | [[60.0, 'year']] | F | {'4062155': 1, '15004587': 1, '21427799': 1, '18853104': 1, '2285682': 1, '29282401': 2, '21173794': 1, '2039629': 1, '24348408': 2} | {'5731140-1': 1} |
164,515 | 3843925-1 | 24,348,380 | noncomm/PMC003xxxxxx/PMC3843925.xml | A Case Report of Atypical Scrotal Leiomyoma | A 32-year-old man presented with a lump on the right side of his scrotum without any predisposing factors. The lump had been progressively growing in size over the last 3 years. Early on, there were 4–5 soybean-shaped, gray and black, flat wart bands with clustered distribution without exudation and desquamation; however, there was paroxysmal itching or the sensation of ants crawling on the skin. The patient often felt his skin was burning and tingling when the itching was very severe. He self-medicated with Compound Dexa-methasone Acetate cream, Xuanshi solution, and other medications for external use. After such treatment, the itching eased but the rashes slowly expanded. After drinking or using hot water to clean the areas, the urticant ache became worse each time. He had used some medicine containing hydrochloric acid 1 year previously. Then, the topical skin developed ulcers. After the patient took cephalosporin antibiotics, the wound healed and the warts became flat, but the primary sense still remained. To confirm the diagnosis, he visited the hospital. There was no similar history or genetic diseases in his family.\nA physical examination revealed no special abnormalities. A more in-depth examination revealed an approximately 3 × 5-cm2, pink, ill-defined, hyperplastic plaque with an uneven surface, basal infiltration, sheet depigmentation in the center (fig. ), and nearly superficial lymph nodes without palpable enlargement.\nThe skin biopsy showed dermal spindle cells in nodular hyperplasia. The nucleus was round at both ends, a perinuclear halo could be seen, and staining was positive for actin and negative for S100. The combination of HE morphology, immunohistochemistry, and pathology was in line with a diagnosis of scrotal leiomyoma (fig. , fig. , fig. ). | [[32.0, 'year']] | M | {'27529047': 2, '29904485': 1, '945360': 1, '26351492': 1, '16285627': 1, '18782437': 2, '8874523': 1, '18001420': 1, '18417864': 1, '15175778': 1, '24348380': 2} | {'2542396-1': 1, '4978837-1': 1} |
164,516 | 3843926-1 | 24,348,406 | noncomm/PMC003xxxxxx/PMC3843926.xml | Toric Intraocular Lens Implantation for Correction of Astigmatism in Cataract Patients with Corneal Ectasia | A 57-year-old woman presented to our ophthalmology outpatient clinic with a gradually decreased visual acuity in both eyes because of posterior subcapsular cataract. On presentation, best spectacle-corrected visual acuity (BCVA) was 2/10 in the right eye and 4/10 in the left eye, with −3.75 −3.50 × 165° and −1.00 −3.50 × 6° subjective refraction in the right and left eye, respectively. Automated refractometry showed −4.75 −4.25 × 164° with K1 44.00 at 180° and K2 46.5 at 90° in the right eye and −10.75 −5.00 × 5° with K1 46.00 at 179° and K2 49.75 at 89° in the left eye. Corneal topography was performed using Orbscan (Bausch and Lomb Inc., Rochester, N.Y., USA) and revealed a central corneal thickness of 533 mm and an inferior temporal displacement of the thinnest point (512 mm), indicative of KC in both eyes (fig. ). Keratometry (K) values for the steep and flat axis were 47.25 D at 86° and 44.00 D at 176°, respectively, in the right eye, and 49.8 D at 84° and 45.6 D at 174°, respectively, in the left eye. It is important to mention that KC was stable in this patient for the last 2 years, which had been confirmed by previous corneal topographies. Biometry was performed with the IOL Master (Carl Zeiss Meditec, Jena, Germany) to calculate the IOL power for emmetropia using the Sanders-Retzlaff-Kraff theoretical (SRK/T) formula. A web-based toric IOL calculator program was used to determine the optimal cylinder power and alignment axis of the IOL (available at ) (fig. ). A standard phacoemulsification with toric IOL implantation (AcrySof SN60T7 Alcon, Ltd., Fort Worth, Tex., USA), with a spherical power of 19.5 D and a cylinder power of 4.50 D at the IOL plane aligned at 84°, was performed in the right eye. In the left eye, a toric IOL (AcrySof SN60T8) with a spherical power of 16.0 D and a cylinder power of 5.25 D at the IOL plane, being aligned at 89°, was used. Postoperatively, the BCVA was 9/10 with −0.50 sph in the right eye and 8/10 with −1.50 sph in the left eye, which remained stable at the 18-month and 24-month follow-up for the right and left eye, respectively. Corneal topography remained almost stable, with K values for the steep and flat axis of 47.5 D at 90° and 43.7 D at 180°, respectively, in the right eye, and 50.0 D at 94° and 46.0 D at 4°, respectively, in the left eye. The toric IOL alignment axis, as determined by slit-lamp biomicroscopy, remained at the same degrees at the end of the follow-up for both eyes (fig. ). | [[57.0, 'year']] | F | {'21562460': 1, '32411427': 1, '17681291': 1, '24825942': 2, '19772260': 1, '18721707': 1, '21667880': 1, '8278190': 1, '33163043': 1, '19878840': 1, '21782086': 1, '22316653': 1, '33367183': 2, '17873627': 1, '18460196': 1, '20953620': 1, '20610106': 1, '17640609': 1, '12699184': 1, '20846724': 1, '14707968': 1, '9493273': 1, '22261324': 1, '31317089': 1, '17251799': 1, '28086913': 1, '12948318': 1, '24348406': 2} | {'3843926-2': 2, '3843926-3': 2, '4008038-1': 1, '7739021-1': 1} |
164,517 | 3843926-2 | 24,348,406 | noncomm/PMC003xxxxxx/PMC3843926.xml | Toric Intraocular Lens Implantation for Correction of Astigmatism in Cataract Patients with Corneal Ectasia | A 72-year-old woman presented to our outpatient clinic with decreased visual acuity in both eyes. Slit-lamp examination showed bilateral nuclear cataract. The BCVA was 4/10 in both eyes with +1.00 −4.25 × 90° and +1.00 −5.00 × 91° in the right and left eye, respectively. Automated refractometry showed +1.50 −5.25 × 106° with K1 40.25 at 92° and K2 54.75 at 2° in the right eye and −8.0 × 98° with K1 41.75 at 106° and K2 49.50 at 16° in the left eye. Orbscan confirmed PMD in both eyes (fig. ), which had been known and stable for the last 3 years. K values for the steep and flat axis were 39.28 D at 93° and 54.7 D at 3°, respectively, in the right eye, and 39.7 D at 106° and 48.3 D at 16°, respectively, in the left eye. Lens power calculation was performed as described for case 1. A standard phacoemulsification with toric IOL was performed in both eyes. In the right eye, a toric IOL (AcrySof SN60T9) with a spherical power of 9.5 D and a cylinder power of 6.00 D at the IOL plane was implanted at an axis of 3°. In the left eye, a toric IOL (AcrySof SN60T9) with a spherical power of 16.5 D and a cylinder power of 6.0 D at the IOL plane was implanted at 14°. Postoperatively, the BCVA was 7/10 with −2.50 × 80° in the right eye and 8/10 with −1.50 × 100° in the left eye, which remained stable at the 24- and 28-month follow-up for the right and left eye, respectively. Corneal topography remained almost stable, with K values for the steep and flat axis of 53.3 D at 180° and 38.5 D at 90°, respectively, in the right eye, and 48.6 D at 15° and 39.9 D at 105°, respectively, in the left eye. The toric IOL alignment axis, as determined by slit-lamp biomicroscopy, was at 5° in the right eye and at 15° in the left eye (fig. ). The patient was satisfied with the postoperative visual outcomes at the end of the follow-up. | [[72.0, 'year']] | F | {'21562460': 1, '32411427': 1, '17681291': 1, '24825942': 2, '19772260': 1, '18721707': 1, '21667880': 1, '8278190': 1, '33163043': 1, '19878840': 1, '21782086': 1, '22316653': 1, '33367183': 2, '17873627': 1, '18460196': 1, '20953620': 1, '20610106': 1, '17640609': 1, '12699184': 1, '20846724': 1, '14707968': 1, '9493273': 1, '22261324': 1, '31317089': 1, '17251799': 1, '28086913': 1, '12948318': 1, '24348406': 2} | {'3843926-1': 2, '3843926-3': 2, '4008038-1': 1, '7739021-1': 1} |
164,518 | 3843926-3 | 24,348,406 | noncomm/PMC003xxxxxx/PMC3843926.xml | Toric Intraocular Lens Implantation for Correction of Astigmatism in Cataract Patients with Corneal Ectasia | A 72-year-old man presented to our outpatient clinic with decreased visual acuity in the right eye due to cataract. The BCVA was 3/10 with −2.00 −2.00 × 60°. Automated refractometry showed −8.00 −3.25 × 58° with K1 42.25 at 62° and K2 45.5 at 152° in the right eye. Orbscan showed changes consistent with PMD (fig. ), which had been stable for the last 2 years. K values for the steep and flat axis were 47.3 D at 155° and 42.9 D at 65°, respectively. Lens power calculation was performed as described for case 1. A standard phacoemulsification was performed and a toric IOL (AcrySof SN60T5) with a spherical power of 15.5 D and a cylinder power of 3.00 D at the IOL plane was implanted. Postoperatively, the BCVA was 9/10 with −0.50 −0.50 × 73° in the right eye which remained stable in the 1-year follow-up. Corneal topography remained almost stable, with K values for the steep and flat axis of 47.1 D at 155° and 42.8 D at 65°, respectively. The patient was satisfied with the postoperative visual outcomes at the 18-month follow-up.\nAltogether, in all cases, there was a significant improvement in BCVA, as well as in refraction, which remained stable over time, as illustrated in table . Specifically, in subjective refraction, all patients achieved BCVA from 7/10 to 9/10 with up to −2.50 cyl. Corneal topography also remained stable. No IOL misalignment or other complications occurred and all patients were satisfied by the postoperative outcome.\nWritten informed consent was obtained from all patients. | [[72.0, 'year']] | M | {'21562460': 1, '32411427': 1, '17681291': 1, '24825942': 2, '19772260': 1, '18721707': 1, '21667880': 1, '8278190': 1, '33163043': 1, '19878840': 1, '21782086': 1, '22316653': 1, '33367183': 2, '17873627': 1, '18460196': 1, '20953620': 1, '20610106': 1, '17640609': 1, '12699184': 1, '20846724': 1, '14707968': 1, '9493273': 1, '22261324': 1, '31317089': 1, '17251799': 1, '28086913': 1, '12948318': 1, '24348406': 2} | {'3843926-1': 2, '3843926-2': 2, '4008038-1': 1, '7739021-1': 1} |
164,519 | 3843927-1 | 24,348,390 | noncomm/PMC003xxxxxx/PMC3843927.xml | A Husband and a Wife with Simultaneous Presentation of Glioblastoma Multiforme: A Case Report | The husband was a 76-year-old man who presented with headache, vague balance difficulties, left hemisensory and hemiparetic deficits in February 2012. He was admitted to another institution before he came to our institution, from which he was discharged with a clinical and neuroimaging diagnosis of hemorrhagic stroke (fig. ). Over the next 2 months, the patient did not complain about any discomfort except for mild-to-moderate left hemidysesthesia. In April 2012, a brain MRI showed resorption of the bleeding and clear evidence of a large, right parietal, extra-axial mass (fig. ). Platelet counts, prothrombin time and activated partial thromboplastin time were within normal ranges. The patient had no history of diabetes, hypertension or coagulation disorders and no history of trauma. He was a retired goldsmith living in a small town. His family history was negative for tumors and his two children were healthy. He pointed to his use of cell phones, which had started only a few years earlier, however, and occurred with moderate frequency. The patient underwent a subtotal resection of the intracranial mass through a right temporoparietal approach. Pathologic evaluation showed a GBM tumor cell proliferation index – as evaluated by anti-ki-67 MIB1 antibody (rabbit monoclonal antibody, diluted 1:100; NeoMarkers, Inc., Fremont, Calif., USA) – of about 55–65%, an EGFR of about 65% and p53 was negative. The final pathologic diagnosis was grade IV GBM according to the WHO 2007 grading system. In May 2012, a brain MRI confirmed the lesion mass with a further bleeding. Considering the patient's clinical conditions and neuroimaging findings, we opted for supportive care and therapy with corticosteroids. No irradiation was performed. The patient continued supportive care waiting for the clinical conditions to allow treatment, but unfortunately, he died of his primary brain tumor in July 2012. | [[76.0, 'year']] | M | {'11150363': 1, '3018184': 1, '15685439': 1, '34123356': 1, '21845765': 1, '22163205': 1, '32676458': 1, '1922234': 1, '19656635': 1, '3967180': 1, '15977639': 1, '12559880': 1, '22016439': 1, '11937180': 1, '19119195': 1, '22403263': 1, '24348390': 2} | {'3843927-2': 2} |
164,520 | 3843927-2 | 24,348,390 | noncomm/PMC003xxxxxx/PMC3843927.xml | A Husband and a Wife with Simultaneous Presentation of Glioblastoma Multiforme: A Case Report | The wife was a 72-year-old woman who presented in March 2012 with ingravescent, vague balance difficulties. A brain MRI (fig. ) showed a large, inhomogeneous, irregularly gadolinium-enhancing, right, paratrigonal, intra-axial mass. Additional findings included a macroadenoma and a small left frontal meningioma. The patient grew up in the same small town as her spouse, had always worked as a nurse and was retired at the time of diagnosis. She had been married for 46 years, with no evidence of possible consanguinity with her husband. Her family history was negative for tumors. She reported that use of cell phones had occurred only within the last 10 years, with a very moderate frequency and only upon need. The patient underwent subtotal resection of the intracranial mass. Pathologic evaluation showed a GBM tumor cell proliferation index – as evaluated by anti-ki-67 MIB1 antibody (rabbit monoclonal antibody, diluted 1:100; NeoMarkers, Inc., Fremont, Calif., USA) – of about 45–55%; EGFR and p53 were negative. A diagnosis of grade IV GBM according to the WHO 2007 grading system was rendered. A follow-up brain MRI 1 month after surgery showed a volumetric increase of the right temporoparietal intra-axial mass with a mass effect on the ventricular system and midbrain, causing subfalcine herniation and a midline shift. Therefore, a second palliative surgery was performed. In May 2012, the patient started treatment with temozolomide (TMZ) in combination with adjuvant radiation therapy and corticosteroids. After she had finished radiotherapy, she was started on a 6-month TMZ treatment. However, after only two cycles of TMZ, our patient went into a coma and died in July 2012. | [[72.0, 'year']] | F | {'11150363': 1, '3018184': 1, '15685439': 1, '34123356': 1, '21845765': 1, '22163205': 1, '32676458': 1, '1922234': 1, '19656635': 1, '3967180': 1, '15977639': 1, '12559880': 1, '22016439': 1, '11937180': 1, '19119195': 1, '22403263': 1, '24348390': 2} | {'3843927-1': 2} |
164,521 | 3843928-1 | 24,348,388 | noncomm/PMC003xxxxxx/PMC3843928.xml | Successful Chemotherapy with Carboplatin and S-1 for Thymic Carcinoma: A Case Report | A 74-year-old female was diagnosed with thymic carcinoma in October 2012. Magnetic resonance imaging (MRI) of the chest revealed a large anterior mediastinal mass, pleural dissemination, and pericardial effusion (fig. ). Immediate pericardiocentesis improved her cardiopulmonary distress. A CT-guided percutaneous biopsy of the anterior mediastinal mass was done and small tissue fragments were obtained. Histologically, the tumor was composed of epithelioid cells with high cellularity, which had nuclear atypia and eosinophilic cytoplasm in fibrotic stroma (fig. ). Lymphoid cell infiltration was not evident in the tumor. Immunohistochemically, tumor cells were positive for epithelial markers such as AE1/3 and CK5/6. In addition, CD5 (fig. ) and CD117 (fig. ) were also detected in tumor cells. Neuroendocrine markers including chromogranin A and synaptophysin were negative. The tumor cells showed a high MIB-1 labeling index (approximately 30%). These findings were consistent with thymic carcinoma. According to the Masaoka classification, the patient had unresectable, locally advanced disease (IVa). In consideration of the complication of the pericardial effusion and the fact that the patient had adequate organ function, we initially treated her with carboplatin plus paclitaxel. However, an allergic reaction to paclitaxel occurred. In November 2012, the patient provided written informed consent before treatment and she was started on carboplatin (AUC, 5) plus oral S-1 (40 mg/m2 twice per day) on days 1–14 as second-line chemotherapy in cycles which were repeated every 3 or 4 weeks. After 2 cycles of this regimen, MRI of the chest revealed a 32% decrease in the diameter of the anterior mediastinal tumor and a reduction of the pericardial effusion, indicating a partial response based on the RECIST criteria (fig. ). The partial response was confirmed after 4 cycles of this regimen (fig. ). Hematologic toxicity consisted of grade 3 neutropenia and grade 1 thrombocytopenia, and nonhematologic toxicity consisted of grade 2 nausea, grade 2 anorexia, and grade 1 fatigue. No dose reduction was necessary. Since the completion of treatment with carboplatin plus oral S-1, the patient has remained well, and no disease progression has been observed up until the time of writing this case report (September 2013). | [[74.0, 'year']] | F | {'18758317': 1, '18317069': 1, '1991250': 1, '19409644': 1, '21079147': 1, '602973': 1, '21273614': 1, '8653704': 1, '23277482': 1, '21502559': 1, '19632949': 1, '20951466': 1, '24348388': 2} | {} |
164,522 | 3843929-1 | 24,348,409 | noncomm/PMC003xxxxxx/PMC3843929.xml | A Simple and Easy Method Using Rigid Endoscope to Detect Iridocorneal and Keratolenticular Adhesions in Peters’ Anomaly | A 20-day-old neonatal female was referred to our department because of corneal opacity. The patient was born maturely following an unremarkable pregnancy. Although her right eye (OD) was normal, her left eye (OS) showed a central corneal opacity (fig. ). In both eyes, intraocular pressure was within normal ranges. The anterior chamber structures of the OS could be partially visualized through the clear area. Fundus examination showed a normal appearance of the OD and OS except for the superior periphery, which was difficult to observe because of the corneal opacity. Thus, to examine the anterior chamber in detail, we performed TEI with a previously reported method [, ]. Briefly, the authors used a rigid endoscope with an otoscope 6.0 cm in length and an outer diameter of 4 mm (1215AA; Karl Storz, Tuttlingen, Germany) with a crescent-shaped illuminating tip. A xenon lamp (Xenon Nova 175; Karl Storz) was used as the light source. The endoscope was connected to a digital camera utilizing a 400,000-pixel charge-coupled device image sensor unit, which was connected to a monitor in turn. The patient was placed on a bed in the supine position, and topical anesthetic was instilled into the OS. A spatula was placed between the eyelids, and hydroxyethyl cellulose solution was applied on the corneal surface to protect it and to create an interface that would improve the quality of the image. The endoscope was placed in proximate contact with the cornea and directed such that the angle could be observed. As shown in figure , the iris stroma was adhered toward the back of the opacified area of the cornea, which confirmed the diagnosis. | [[20.0, 'day']] | F | {'474688': 1, '22785602': 1, '4813314': 1, '25135697': 1, '11734512': 1, '1287176': 1, '1180307': 1, '15256994': 1, '11801506': 1, '4938989': 1, '24348409': 2} | {'3843929-2': 2} |
164,523 | 3843929-2 | 24,348,409 | noncomm/PMC003xxxxxx/PMC3843929.xml | A Simple and Easy Method Using Rigid Endoscope to Detect Iridocorneal and Keratolenticular Adhesions in Peters’ Anomaly | A 4-month-old male was referred to our department because of a bilateral corneal opacity. The patient was born maturely following an unremarkable pregnancy. Our examination demonstrated the presence of a bilateral central corneal opacity and extremely shallow anterior chambers, which made it impossible to observe the fundus in both eyes (fig. ). The intraocular pressure measured was 8 mm Hg in the OD and 9 mm Hg in the OS. Ultrasonographic investigations showed the presence of short axial lengths (OD: 16.0 mm; OS: 16.2 mm) and funnel-shaped retinal detachment. No systemic anomalies were detected during this pediatric examination. When TEI was performed via the clear peripheral cornea, both a keratolenticular adhesion and a surrounding iridocorneal adhesion were observed behind the area of corneal opacity (fig. ). The patient was diagnosed as having Peters’ anomaly and persistent fetal vasculature. | [[4.0, 'month']] | M | {'474688': 1, '22785602': 1, '4813314': 1, '25135697': 1, '11734512': 1, '1287176': 1, '1180307': 1, '15256994': 1, '11801506': 1, '4938989': 1, '24348409': 2} | {'3843929-1': 2} |
164,524 | 3843930-1 | 24,348,404 | noncomm/PMC003xxxxxx/PMC3843930.xml | Traumatic Partial Aniridia and Cataract after Iris-Fixated Foldable Phakic Intraocular Lens Implantation | A 27-year-old woman presented with a sudden loss of vision and ocular pain in her left eye after blunt trauma with a hand during a quarrel. The patient had a history of bilateral implantation of an Artiflex pIOL 1 month previously to correct −6.5 diopters (D) of myopia. On initial examination of the left eye, visual acuity was hand motion and the eye had a 6-mm corneoscleral laceration extending from the previous superior clear corneal incision. The iris was dialyzed from 7 to 1 o'clock, and half had prolapsed along with the medial haptic side grasping the iris through the wound; the haptic-optic junction was stuck in the wound (fig. ). The optic and another haptic enclavated on the iris stroma of the pIOL were left in the anterior chamber, and partial hyphema was also present. The absence of retinal detachment and vitreous hemorrhage was confirmed by B-scan ultrasonography.\nAfter removing the firmly enclavated pIOL, the prolapsed iris was repositioned with partial resection of the severely damaged iris. The corneoscleral laceration was repaired with 10-0 nylon with interrupted suture (fig. ). Hyphema and inflammation subsequently subsided, and then a traumatic cataract and a peripapillary subretinal hemorrhage 1 disc diameter in size were found (fig. ).\nThree weeks after surgery, the corneoscleral sutures were removed. The best-corrected visual acuity was 20/40 with −3.75 −4.0 × 130, and the intraocular pressure was normal. Corneal topography showed 4.0 D astigmatism at 40 degrees, and the corneal endothelial cell count was 1,967 cells/mm2. The peripapillary subretinal hemorrhage resolved spontaneously (fig. ).\nSix weeks after primary repair, the traumatic cataract had become denser, and partial aniridia with iridodialysis remained (fig. ). Partial zonular dialysis from 8 to 10 o'clock was noticed. No further change in corneal astigmatism was confirmed by 3 consecutive topographies conducted at 1-month intervals.\nFive months after presentation, the traumatic cataract was removed, and a toric intraocular lens (Acrysof Toric IOL, model SN60T5; Alcon Laboratories, Inc., Fort Worth, Tex., USA; models T6–T9 were not available in Korea) was implanted to correct the large amount of astigmatism. A clear corneal incision was made on the steepest axis of the cornea, and a capsular tension ring was used for partial zonular dialysis. The iridodialysis was repaired with mattress sutures with 10-0 polypropylene (fig. ).\nSix months after the second surgery, the uncorrected visual acuity of the left eye was 20/32 and the best-corrected visual acuity was 20/20 with plano −1.0 × 140. Corneal endothelial cells had decreased to 1,634 cells/mm2 but remained stable by serial examination, and the intraocular pressure was normal. Although partial aniridia remained, the patient experienced no discomfort during daily activities (fig. ). | [[27.0, 'year']] | F | {'11777727': 1, '16243399': 1, '17049332': 1, '17586400': 1, '11318293': 1, '19344820': 1, '24348404': 2} | {} |
164,525 | 3843932-1 | 24,348,393 | noncomm/PMC003xxxxxx/PMC3843932.xml | Gastric and Endobronchial Metastases in a Case of Lobular Breast Cancer | A 51-year-old female patient underwent quadrantectomy with right axillary dissection on May 31, 1999. Pathological examination showed a 1-cm ILC, histological grade I, and no lymph node involvement. The immunohistochemical analysis showed high expression of ER (100%) and progesterone (PR, 100%) receptors.\nThe adjuvant chemotherapy AC regimen [Adriamycin 60 mg/m2 and cyclophosphamide 600 mg/m2, both on day (D) 1, every 21 days] was given for 4 cycles, followed by adjuvant radiotherapy and hormone therapy with tamoxifen 20 mg/day for 5 years until March 2005.\nIn May 2005, due to a recent onset of dyspeptic symptoms, the patient underwent an upper endoscopy, which showed an infiltrative lesion involving the bottom half of the proximal gastric body. The biopsy revealed adenocarcinoma, but an immunohistochemical analysis was not performed. The staging examinations showed no evidence of metastatic disease, and based on the hypothesis of a primary neoplasm of the stomach, the patient underwent a total gastrectomy. The immunohistochemical analysis performed later on the gastrectomy specimen showed ER and PR expression and a lack of HER2 expression, favoring the diagnosis of breast cancer recurrence in the gastric mucosa.\nAfter resection, based on the hypothesis of a second primary, there was no evidence of disease, and treatment was continued with adjuvant chemotherapy with 8 cycles of docetaxel 75 mg/m2. Afterward, the patient received hormone therapy with anastrozole, maintained until March 2009, when disease progression was detected in the bones. A new biopsy showed persistence of the previous immunohistochemical findings.\nAt that time, bone pain and dyspnea were noted upon moderate physical exercise. Chest tomography did not show lung parenchyma involvement, but there was a tapering distal to the right main bronchus suggestive of secondary involvement of the bronchial mucosa, which was confirmed by pathological examination (fig. ).\nThe patient underwent brachytherapy with a high dose of radiation (fig. , fig. ) for bronchial lesion treatment. In April 2009, first-line palliative chemotherapy with paclitaxel 80 mg/m2 on D1, D8 and D15, every 28 days, was started, in combination with Avastin 10 mg/kg on D1 and D15. Treatment was discontinued only in July 2010 due to bone disease progression detected by PET-CT.\nFrom July 2010 to November 2010, the patient received second-line hormone therapy with Faslodex, presenting symptomatic progression of bone disease after 5 months of treatment. In October 2010, third-line chemotherapy with capecitabine 1,750 mg/m2 from D1 to D14, every 21 days, was started. The patient maintained stable disease until October 2011, when she developed disease progression and was treated with everolimus plus an aromatase inhibitor. In March 2012, the patient presented with bone disease progression and was treated with radiotherapy. She developed an ocular metastasis when radiotherapy followed by chemotherapy (vinorelbine plus gemcitabine) was indicated. After new bone disease progression in July 2012, treatment was changed to liposomal doxorubicin 35 mg/m2 until October 2012, when a peritoneal metastasis was detected; carboplatin plus paclitaxel was initiated. The patient developed meningeal metastasis and died in January 2013. | [[51.0, 'year']] | F | {'11243955': 1, '15068323': 1, '33828068': 1, '26266010': 2, '26114067': 1, '1421863': 1, '30918733': 2, '9692131': 1, '8934538': 1, '28943914': 1, '11879552': 1, '25902937': 2, '6331484': 1, '1653879': 1, '9496256': 1, '15693887': 1, '1138668': 1, '14746850': 1, '24348393': 2} | {'6408989-1': 1, '4508641-1': 1, '4414004-1': 1} |
164,526 | 3843933-1 | 24,348,398 | noncomm/PMC003xxxxxx/PMC3843933.xml | Psychiatric Presentation of Frontotemporal Dementia Associated with Inclusion Body Myopathy due to the VCP Mutation (R155H) in a French Family | The proband was a 54-year-old French male patient with a personal history of dyslipidaemia and tuberculosis in childhood. From the age of 41 years, he slowly developed progressive weakness and atrophy of proximal upper-limb muscles and later (at 46 years of age) involvement of the lower limbs, associated with axial weakness. At that time, the walking test was unlimited, whereas at 50 years of age, he was only able to walk 50 m using a cane for support.\nThen, the proband developed acute behavioural changes including irritability, severe anxiety and major depression, which led to him being hospitalised in a psychiatric hospital at 53 years of age. He developed gradual cognitive decline characterised by impairment of executive functions. The deterioration of upper- and lower-limb weakness and cognitive functions accelerated. The patient was eventually unable to walk and was confined to a wheelchair. His cognitive dysfunctions consisted of impaired frontal lobe functions, dominated by major behavioural changes (such as changes in affects, decline in social interpersonal conduct and perseveration) and aphasia (phonemic and semantic paraphasia). His score on the Frontotemporal Behavioural Scale was abnormal (3 items out of 4 were pathological). However, his memory was not impaired: the Mini-Mental State Examination (MMSE) was normal (29 out of 30 points).\nAn electromyography (EMG) (fig. ) showed fibrillation potentials and positive sharp waves at rest, and myopathic or neurogenic features according to the muscles examined: polyphasic small-amplitude short-duration motor unit potentials and polyphasic long-duration with slow-frequency motor unit potentials were found together in the EMG study. These results suggested inclusion body myopathy, which was confirmed by a muscle biopsy revealing histopathological changes consisting of rimmed vacuoles. Plasma creatine kinase levels were mildly increased (262 IU/l, normal values 20–220 IU/l). Nerve conduction studies were normal.\nCerebral magnetic resonance imaging (MRI) was performed at 54 years of age and revealed frontal and internal temporal atrophy (fig. ). Fluorodeoxyglucose (FDG) positron emission tomography (PET) scan showed severe bilateral hypometabolism, involving especially the frontal and temporal lobes (fig. ). The occipital lobe, basal ganglia and cerebellar metabolism were normal. Behavioural-type frontotemporal dementia was therefore diagnosed based on the clinical frontal lobe dysfunction and the results of the cerebral MRI and PET scan.\nMoreover, the mother and the grandfather of the index patient had died with an unknown myopathy (confined to a wheelchair at the end of their lives). His mother also suffered from dementia. The index patient has an asymptomatic 25-year-old son.\nThe diagnosis of IBMPFD due to a mutation in the VCP gene was suggested given the personal and familial history of the patient. This diagnosis was confirmed by the genetic study of the VCP gene which revealed the VCP R155H mutation (exon 5, domain CDC48, 464 G>A). The genetic study was not performed in the mother and the grandfather of the index patient.\nThe absence of bone pain, hearing problems or spontaneous fractures, the normality of the serum concentration of alkaline phosphatase and the normality of a 99mTC total-body bone scan ruled out Paget's disease of the bone. The cardiac exam was normal. | [[54.0, 'year']] | M | {'19364651': 1, '21839829': 1, '28692196': 1, '19208399': 1, '26388768': 1, '18796596': 1, '18341608': 1, '29344342': 1, '18063588': 1, '25852467': 1, '17889967': 1, '16247064': 1, '17763460': 1, '16790606': 1, '29127544': 1, '15732117': 1, '19380227': 1, '25582679': 1, '18845250': 1, '20335036': 1, '15034582': 1, '24348398': 2} | {} |
164,527 | 3843934-1 | 24,348,379 | noncomm/PMC003xxxxxx/PMC3843934.xml | Scleromyxedema with Subcutaneous Nodules: Successful Treatment with Thalidomide and Intravenous Immunoglobulin | A 42-year-old male had been well until December 2008, when he noted progressive swelling of the face, hands and forearms, accompanied by pruritus, increased hair loss, arthralgia, myalgia and fatigue. In the following weeks, skin induration of the hands and forearms, papular eruption on the neck and upper trunk, and nodular lesions on the face and fingers developed. The patient was admitted to the local hospital, where systemic fibrosing disorder was suspected and systemic glucocorticoid treatment (methylprednisolone 1 mg/kg body weight) was introduced. Since only partial regression of the facial and hand edemas was observed, he was referred to the University Medical Centre Ljubljana, initially to the Department of Rheumatology and later to the Department of Dermatovenereology.\nAt admission in February 2009, dense papular lesions were present on the neck, retroauricular areas, scalp and upper trunk, partly in a linear arrangement. Sclerodactyly with impaired finger motility was present. Tender nodules of a hard consistency could be palpated bilaterally on the upper and lower eyelids, on the forehead, lateral parts of the nose, behind the ears and on the fingers (fig. ). Sclerodermoid induration of the skin with irregular loss of hair was present on the forearms. The patient still complained of general symptoms and dysphagia.\nComplete blood cell count, serum levels of inflammatory parameters, electrolytes, glucose, calcium, creatinine kinase, myoglobin, aldolase as well as tumor markers were within normal range. Renal function tests and urinalysis were normal. Testing for antitopoisomerase and anticentromeric antibodies, antiphospholipid antibodies and cryoglobulins was negative. Thyroid function was normal. Serum protein electrophoresis showed polyclonal hypergammaglobulinemia without paraproteinemia. In addition, immunofixation electrophoresis of serum and urine did not show monoclonal paraproteinemia.\nChest radiograph was normal, as were the results of lung function tests, abdominal ultrasound, echocardiography, nailfold capillaroscopy, radiographs of the hands and feet and bone marrow examination. Since electromyography detected signs consistent with myopathy, neurological examination and muscle biopsy were performed. The former revealed no pathology but the biopsy demonstrated mild myopathy with atrophy involving selectively type 2 fibers without inflammation. Photoplethysmography did not confirm Raynaud's phenomenon. Computer tomography of the periorbital region excluded involvement of extracutaneous tissue with nodules.\nBiopsies of the nodules on the hand and periorbital region and of papular lesions on the trunk were performed. Histopathological examination was characteristic of scleromyxedema in all three specimens. There was abundant proliferation of large stellate fibroblasts in the reticular dermis and subcutis, with prominent deposits of a myxoid substance between thick collagen bundles. Mucin deposition was demonstrated with Alcian blue staining (fig. ).\nAccording to the clinical picture and histopathology, a diagnosis of scleromyxedema was established. Treatment with thalidomide was introduced (initial dosage 100 mg/day) and the previously prescribed glucocorticoid gradually tapered off and discontinued. After 3 months of thalidomide treatment, only a partial regression of the skin lesions was achieved. Myalgia and arthralgia persisted. Therefore, additional treatment with high-dose IVIg was introduced (0.4 g/kg body weight/day for 5 consecutive days every month for the duration of 6 months). After only two cycles of IVIg, a marked regression of the nodular lesions on the face and hands and improvement of the papular and sclerodermoid mucinosis was observed. The general clinical condition of the patient improved significantly. Thereafter, he received four additional cycles of IVIg at the same dosage at 8-week intervals. Treatment with thalidomide was continued with a lower daily dose (50 mg/day) and finally discontinued in July 2011 due to complete disease remission (fig. ).\nDuring the 2-year follow-up, the patient sustained a complete drug-free remission. Results for paraproteinemia were negative. During thalidomide treatment, the patient reported numbness in his feet; however, electromyographic investigation did not confirm a peripheral sensory neuropathy. | [[42.0, 'year']] | M | {'11174386': 1, '8621831': 1, '27990110': 2, '18204366': 1, '17191049': 1, '3336281': 1, '15243538': 1, '22607617': 1, '31115676': 1, '15023770': 1, '22278389': 1, '16902294': 1, '21831425': 1, '15987294': 1, '2033150': 1, '30775299': 2, '10435560': 1, '23874293': 2, '813582': 1, '20232589': 1, '7601944': 1, '30962839': 1, '3389450': 1, '14674909': 1, '18221985': 1, '21390475': 1, '8115146': 1, '22806700': 1, '23453242': 1, '1247293': 1, '24348379': 2} | {'3712821-1': 1, '5156886-1': 1, '6362738-1': 1} |
164,528 | 3843935-1 | 24,348,392 | noncomm/PMC003xxxxxx/PMC3843935.xml | Use of an Amplatzer Device for Endoscopic Closure of a Large Bronchopleural Fistula following Lobectomy for a Stage I Squamous Cell Carcinoma | We report on a 68-year-old woman with a history of a diffuse, large, B-cell, non-Hodgkin lymphoma of the thyroid and stomach (stage IV B). She underwent surgery (resection of a thyroidal mass) and was treated with chemotherapy after which complete remission was achieved. At that time, she also underwent tracheal stenting because of recurring aspiration related to a fistula (postoperative) between the oesophagus and the trachea.\nFive years later, she was diagnosed with a squamous lung carcinoma in the right lower lobe – stage IA. She smoked one package of cigarettes a day. A lobectomy was performed and the initial postoperative course was favourable. However, 5 days later, she started suffering from marked dyspnoea. During clinical examination, we noted a subcutaneous emphysema. Developing respiratory insufficiency with extensive bilateral infiltrates visible on chest X-ray prompted intubation and mechanical ventilation. Bronchoscopy revealed a large (approximately 10 mm in diameter) bronchopleural fistula in the middle of the right bronchial stump.\nInitial treatment with antibiotics, chest tube drainage and parenteral feeding failed. Since the patient had a high oxygen need, she was considered inoperable. Due to the size and central location of the fistula, conventional endoscopic treatment did not seem an option either. The tracheal stent was removed and tracheotomy was performed. Unfortunately, the patient remained septic and repeated bronchoscopy was needed to remove extensive, sticky, endobronchial secretions.\nSince no other therapeutic option was available, a 10-mm Amplatzer septal occluder device was eventually placed through the fistula. This device, originally developed for the endovascular closure of cardiac septal defects, consists of two expandable disks, made of nitinol wire mesh, connected by a central waist. The device can be compressed inside a catheter. By placing the catheter inside the defect and then releasing the device from the delivering sheath, the disks can anchor the device on either side of the defect.\nIn our case, a guide wire was introduced through the fistula under direct bronchoscopic visualization. Subsequently, a delivery sheath was pushed over the guide wire beyond the defect. The Amplatzer device was then placed by pulling the delivering sheath back gradually. The distal disk was first extruded and pulled back against the distal side of the defect. The central waist filled the actual defect. Then, the second disk was placed on the proximal side of the defect. Once positioned correctly, the device was released by unscrewing the attached cable.\nThe procedure was successful with almost complete closure of the fistula, but because of a small persistent air leak, BioGlue surgical adhesive was applied after a couple of days to obtain a complete seal of the bronchopleural fistula (fig. ). Within the next week, the patient could be weaned from ventilation. Bronchoscopic reassessment showed granulation tissue developing progressively around the device which caused further closure of the fistula. The patient was eventually discharged from the hospital to a rehabilitation facility several weeks after the insertion of the device. Follow-up 6 months after the insertion of the Amplatzer device was reassuring. There were no remaining symptoms and CT thorax showed a good position of the device and full expansion of the lung tissue without any remaining pleural cavity (fig. ). | [[68.0, 'year']] | F | {'31331927': 1, '16354867': 1, '11888471': 1, '21362655': 1, '11053810': 1, '18574292': 1, '11309718': 1, '21600781': 1, '24348392': 2} | {} |
164,529 | 3843936-1 | 24,348,407 | noncomm/PMC003xxxxxx/PMC3843936.xml | Möbius Syndrome: Surgical Treatment for Eyelid Dysfunction | We present the case of a 44-year-old woman with Möbius syndrome and congenital craniofacial cleft. During her childhood, she had undergone multiple surgeries in the Departments of Traumatology, Plastic Surgery and Maxillofacial Surgery.\nThe patient was being monitored due to her eye problems derived from the facial paralysis. Four years ago, she had undergone a permanent partial bilateral tarsorrhaphy that improved her eyelid closure problems. However, at the last checkups, the lower eyelids had retracted again, and she presented recurrent lower keratitis caused by a scleral exposure of 1–2 mm in both eyes, in spite of a good Bell's phenomenon and an intensive treatment with lubricants (fig. ).\nWe decided to introduce a graft for the lower eyelid in order to alleviate the retraction and reduce the scleral exposure. In view of the fact that the patient had undergone surgery of the palatal area on several occasions due to her craniofacial malformations (fig. ), we used an auricular cartilage instead of a hard palate.\nWe performed an incision at the end of the lower conjunctival sac, we separated the retractor muscles from the tarsal plate, and we disinserted the capsulopalpebral ligament, so that the tarsal plate was left free and completely exposed. A 6 × 20 mm section of auricular cartilage was extracted and its upper border was sewn into the lower edge of the lower tarsal plate with 7-0 vicryl. The lower edge of the graft was sutured to the retractors, and the incision in the conjunctival sac was also sutured with 7-0 vicryl. | [[44.0, 'year']] | F | {'16143684': 1, '12063657': 1, '17318102': 1, '22186530': 1, '25258883': 1, '18470830': 1, '15988243': 1, '15747768': 1, '24348407': 2} | {} |
164,530 | 3843937-1 | 24,348,403 | noncomm/PMC003xxxxxx/PMC3843937.xml | Forme Fruste Keratoconus Imaging and Validation via Novel Multi-Spot Reflection Topography | We present the case of a 45-year-old male subject diagnosed with topographic and topometric asymmetrically manifested FFKC [, ] between his two eyes. The patient, a resident of Sweden, father of a 17-year-old adolescent who had developed keratoconus, attended treatment with the Athens Protocol procedure of his son in our institution []. Due to the known hereditary nature of the disease [], our keratoconus protocol involves examination of next-of-kin whenever possible.\nThree imaging modalities were studied in this work. Scheimpflug imaging was provided by the WaveLight Oculyzer II (Alcon Surgical, Fort Worth, Tex., USA), a Pentacam HR (high-resolution) camera providing corneal pachymetry and tomography imaging (covering a 9-mm diameter area). The system, running on Examination Software version 1.17r47, additionally provides keratometry, topographic keratoconus classification and computes irregularity keratoconus indices, namely the Index of Surface Variance (ISV) and the Index of Height Decentration (IHD) [, ]. Placido imaging was provided by the WaveLight Allegro Topolyzer (Alcon Surgical). The Topolyzer is a wide cone Placido system covering an approximately 8.5 mm-diameter area with 22 concentric rings for the detection of up to 22,000 elevation points. Both systems are incorporated in our keratoconus screening protocol and are employed in the topography-guided treatment in conjunction with accelerated cross-linking [].\nThe Cassini (running on software version 1.1.1) was employed to provide anterior surface imaging. The system produces anterior elevation, tangential and axial curvature, and refractive power three-dimensional maps covering approximately a 7.5-mm diameter area. The report provides keratometry data (steep and flat K, simulated astigmatism), and computes topographic and keratoconus indices, namely the Surface Asymmetry Index (SAI) and the Surface Regularity Index (SRI) []. In addition, an aberrations report is provided, according to the Zernike nomenclature. Four consecutive scans in each case were obtained by all systems.\nThe right eye (OD), the more symptomatic to the patient, had uncorrected distance visual acuity of 20/25 and manifest refraction of plano +0.50 × 45°. Corrected distance visual acuity with this prescription was 20/20. In addition to the complete ocular examination, the FFKC diagnosis was further confirmed by Scheimpflug topometry and Placido topography. Data supporting this diagnosis include thinnest local corneal thickness of 492 μm, and an asymmetric posterior surface elevation, indicating a minimum depression of −31 μm located superiorly and a maximum protrusion of +25 μm located inferiorly. However, this eye (as well as the less affected OS) was classified as nonkeratoconic according to the Scheimpflug imaging-provided topographic keratoconus classification. []\nThe left eye (OS), the less affected, had uncorrected distance visual acuity of 20/20 and manifest refraction of plano. The rather symmetric posterior elevation, as obtained by the Pentacam, indicated a minimum superior depression of −25 μm, minimum inferior depression of −17 μm, and a maximum local inferior protrusion (within the center 2-mm area) of +13 μm. The thinnest local corneal thickness was 496 μm.\nRepeatability results for flat and steep keratometry, astigmatism and meridian axis as measured by all three modalities, were assessed by the standard deviation of data from the four consecutive acquisitions. Descriptive statistics for the above parameters are reported in table . Results from the Cassini keratoconus indices (SAI and SRI) and Scheimplug-derived keratoconus indices (ISV and IHD) [] are reported in table . Results from anterior elevation data as measured by the Cassini and the Pentacam are reported in table .\nComparative examples of anterior elevation maps from both modalities employed in the study for the more affected OD and the less affected OS eye are provided in fig. , b, respectively. In addition, comparative examples of anterior surface curvature maps for the evidently asymmetric OD and the less affected OS are provided in fig. , respectively. Fig. presents the results of the Placido topography system imaging for the right (top) and left (bottom) eye.\nThis study adhered to the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of our Institution. Informed consent was obtained from the subject at the time of the first clinical visit. | [[45.0, 'year']] | M | {'31027491': 1, '25408671': 2, '17164684': 1, '23935360': 1, '27574391': 1, '28317679': 1, '19553507': 1, '20940828': 1, '25709385': 1, '32943840': 1, '31482276': 1, '13861052': 1, '26904709': 1, '34441401': 1, '9403889': 1, '23795306': 1, '9344352': 1, '29339918': 1, '20554609': 1, '34429579': 1, '26057324': 1, '23901251': 1, '17873765': 1, '23861576': 1, '31917136': 1, '24763473': 1, '23746611': 1, '24348403': 2} | {'4224253-1': 1} |
164,531 | 3845543-1 | 23,544,449 | noncomm/PMC003xxxxxx/PMC3845543.xml | A modified radiofrequency ablation approach for treating distant lymph node metastasis in two patients with late-stage cancer | A 58-year-old man was admitted in August 2011 with a 2-month history of progressive pain of the right lower limb. One year prior, he was diagnosed with stage T3N1M0 nasopharyngeal carcinoma (NPC) according to the Union for International Cancer Control (UICC, 2009) classification and treated with radical radiotherapy (70 Gy in 35 fractions, 5 fractions per week) combined with 3 courses of concurrent cisplatin chemotherapy. During physical examination, a tender, unfixed lymph node measuring 1.0 cm × 1.0 cm × 0.9 cm could be palpated in level III of the right cervicum, and this finding was confirmed by ultrasonography (). The skin of the cervical region was normal in appearance, and no lesions were found in the oral cavity. No facial nerve palsy was present. During the course of the disease, there were no reports of headache, diplopia, abnormal deglutition, nasal occlusion, or blood-stained nasal discharge. Emission computed tomography (ECT) and magnetic resonance imaging (MRI) scans revealed metastasis from NPC to the lumbar vertebra 2/3 and a single lymph node in level III of the right cervical region. Laboratory studies, which included full blood cell count, electrolytes, urinalysis, and liver function tests, showed results within normal limits.\nAccording to the presentation, physical examination, and laboratory examination, this patient was diagnosed, after radio-therapy, with NPC with metastasis to the lumbar vertebra and a single lymph node in level III of the right cervical region. The patient was unwilling to undergo radiotherapy again and instead was treated with palliative radiotherapy for metastasis in the lumbar vertebra and radiofrequency ablation for lymph node metastasis in the right cervical region. This patient did not undergo radiotherapy for the right cervical lymph node because of local radiation-induced injury from the treatment of primary NPC. Thus, this patient underwent a radiofrequency ablation treatment to destruct the right cervical lymph node.\nThe patient achieved clinical complete response after 1 month of treatment. The follow-up protocol included clinical and laboratory examinations every 3 months in the first year after therapy and every 6 months thereafter. The patient was in good condition at the last follow-up in February 2012 and was living a normal life. | [[58.0, 'year']] | M | {'11856701': 1, '20149473': 1, '7931493': 1, '16237146': 1, '12391519': 1, '21212413': 1, '7008932': 1, '10658699': 1, '29434784': 1, '33756082': 1, '17032920': 1, '21296516': 1, '11742325': 1, '19041020': 1, '23544449': 2} | {'3845543-2': 2} |
164,532 | 3845543-2 | 23,544,449 | noncomm/PMC003xxxxxx/PMC3845543.xml | A modified radiofrequency ablation approach for treating distant lymph node metastasis in two patients with late-stage cancer | A 57-year-old woman presented with metastasis of esophageal carcinoma after chemoradiotherapy. She was previously diagnosed with stage T3N1M0 esophageal carcinoma (UICC 2009) in 2010 and underwent radical radiotherapy (60 Gy in 30 fractions, 5 fractions per week) with 4 courses of synchronous chemotherapy (5-fluorouracil plus cisplatin). Positron emission tomography/computed tomography (PET/CT) scan showed signs of primary local advance and solitary metastasis in the right supraclavicular lymph node in April 2011. Ultrasound revealed the lymph node was 2.6 cm × 1.4 cm × 1.2 cm ().\nThe patient refused to undergo radiotherapy for the right supraclavicular lymph node because of the severe adverse effects of previous radiotherapy. Subsequently, the patient underwent systemic chemotherapy (5-fluorouracil plus cisplatin) for local esophageal carcinoma and radiofrequency ablation for the right supraclavicular lymph node. This patient underwent a radiofrequency ablation treatment to destruct the right supraclavicular lymph node. The follow-up protocol was the same as that for case 1. After 1 month of radiofrequency, the right supraclavicular lymph node was not enhanced on contrast-enhanced CT scans, but the local lesion had advanced. Hence, gemcitabine was added to control the local progressive primary disease. At the last follow-up in February 2012, the patient was in good condition, and there was no evidence that distant lymph node metastasis had recurred. | [[57.0, 'year']] | F | {'11856701': 1, '20149473': 1, '7931493': 1, '16237146': 1, '12391519': 1, '21212413': 1, '7008932': 1, '10658699': 1, '29434784': 1, '33756082': 1, '17032920': 1, '21296516': 1, '11742325': 1, '19041020': 1, '23544449': 2} | {'3845543-1': 2} |
164,533 | 3845547-1 | 23,668,927 | noncomm/PMC003xxxxxx/PMC3845547.xml | Urinary bladder malignant paraganglioma with vertebral metastasis: a case report with literature review | In September 2005, a 53-year-old woman complaining of odynuria over a week was admitted to the Department of Urinary Surgery at the Affiliated Zhongshan Hospital of Dalian University. The pain began as an odd sensation described as a pricking pain in the lower abdomen without radiating pain. This pricking pain happened suddenly, without any motivation or signs. There was no history of hematouria, pyuria, or low-back pain, and there was no precipitating trauma nor aggravating or alleviating factors.\nThe patient appeared healthy and had a blood pressure of 21.3/12.0 kPa (160/90 mmHg). In the following physical examination, there was no tenderness to palpation over the whole abdomen, nor were any other positive physical signs found. Abdominal sonography revealed a heteroplastic, hyperechoic mass in the right anterior wall of the urinary bladder, which was confirmed on subsequent computed tomography (CT) scan. The CT documented the presence of a hypervascularized mass approximately 4.7 cm in diameter with a homogeneous aspect.\nThe patient underwent partial cystectomy for bladder tumor. During surgery, the tumor appeared as an intensely vascularized mass (6 cm × 5 cm × 4 cm) located in the right anterior wall of the urinary bladder. No apparent margin invasion and local metastasis were found, and these findings were confirmed by subsequent pathologic examination. The biopsy in the remaining proximal part of the urinary bladder revealed that there was no tumor tissue left. The tumor histology revealed an alveolar pattern with nests of neoplastic cells surrounded by vascularized connective tissue septa, and no vascular or capsular invasion was found. The tumor was composed of three cell types: epithelioid cells, surrounding spindle-shaped sustentacular cells, and scattered ganglion cells. The epithelioid cells were arranged in nests. Immunohistochemical staining was positive for chromogranin A, neuron-specific enolase, and synaptophysin () and negative for cytokeratin. No signs of necrosis were found. Based on the pathologic findings, the definite diagnosis was paraganglioma. The patient's postoperative course was uncomplicated, and she was discharged on the eighth day after surgery. No further therapy was thought to be indicated.\nFollow-up at 1 year showed complete resolution of preoperative symptoms, and abdominal sonography revealed no evidence of local recurrence. However, at 19 months of follow-up, the patient came back to the hospital and reported a month-long history of increasing back pain radiating along the intercostal space. She got abrupt paralyzing numbness in both lower limbs as well. The patient reported that the pain was usually aggravated at night. She also reported a month-long history of night sweat and hectic fever. In the physical examination, there was apparent tenderness on palpation of the spinous process and the nearby area of the sixth and seventh thoracic vertebra. The measurement of muscle strength revealed grade 3/5 flexion at the hips and extension at the knees, and grade 4/5 dorsiflexion and plantar flexion at the ankles. Hypesthesia was present under the fourth lumbar nerve level in both lower limbs as well as in the saddle area.\nA thoracic CT scan showed bone damage with low density in the sixth thoracic vertebra, where there was a soft tissue mass protruding into the vertebral canal and compressing the spinal cord (). Total body Tc-99m bone scan revealed a well-circumscribed area of intense uptake in the same region ().\nBecause of the vertebral tumor, the patient underwent tumor excision together with allograft bone transplantation and spinal fusion. The surgery confirmed the tumor in the sixth thoracic vertebra. Pathologic examination confirmed the diagnosis of vertebral metastasis of the malignant paraganglioma, which had the same histologic pattern and immunohistochemical findings as the paragangioma in her urinary bladder 19 months before. The patient's postoperative course was uncomplicated, and she was discharged on the 14th day after surgery. Follow-up at 1 year and 1.5 years showed complete resolution of preoperative symptoms and no local recurrence or metastasis according to CT scan and total body metaiodobenzylguanidine (MIBG) scintigraphy. | [[53.0, 'year']] | F | {'19554653': 1, '26171023': 1, '34803407': 1, '31574816': 1, '14668728': 1, '33900943': 1, '33256692': 2, '15630855': 1, '31966391': 1, '10226821': 1, '15167935': 1, '15220821': 1, '18684026': 1, '11979086': 1, '10679654': 1, '15294882': 1, '18692411': 1, '11903030': 1, '18224469': 1, '15240407': 1, '17243882': 1, '23668927': 2} | {'7708907-1': 1} |
164,534 | 3845561-1 | 23,544,448 | noncomm/PMC003xxxxxx/PMC3845561.xml | A Chinese patient with relapsed and refractory Hodgkin lymphoma treated with brentuximab vedotin | A 17-year-old girl presented with painless swelling of the right neck and supraclavicular lymph nodes accompanied with fever and fatigue in February 2007. The pathology report after lymph node biopsy indicated that the normal lymph node structure had disappeared and scattered distributions of Reed-Sternberg (RS) cells and Hodgkin disease (HD) cells occurred. Immunohistochemical staining showed that these cells were positive for CD30 (), paired box protein 5 (PAX5) (), and Epstein-Barr virus (EBV), and negative for CD15 and anaplastic lymphoma kinase (ALK). The patient was diagnosed with stage IIa HL, mixed cellularity subtype. Treatment with 4 cycles of ABVD was conducted as induction chemotherapy followed by bilateral neck and supraclavicular radiation therapy (36 Gy). The patient achieved complete remission (CR) but, after about 1 year, relapsed with inguinal and mediastinal lymph node involvement, as detected by positron emission tomography (PET)/computed tomography (CT) scan. Afterwards, 8 cycles of salvage chemotherapy with cyclophosphamide, vindesine, epirubicin, and prednisone (CHOP) were performed, and the patient achieved CR again.\nA PET/CT scan in April 2010 indicated relapse, with mediastinal, left axillary, retroperitoneal, pelvic cavity, and inguinal lymph node involvement and multiple nodules at the thoracolumbar vertebrae, right iliac crest, and right ischium. The patient was diagnosed with HL of nodular sclerosis subtype after a left inguinal lymph node biopsy. She then underwent 2 cycles of salvage chemotherapy with rituximab, cyclophosphamide, vindesine, epirubicin, prednisone, and etoposide (R-CHOPE) and underwent ASCT in December 2010. A PET/CT scan in June 2011 subsequently demonstrated relapse once more, with nodules in the liver, spleen, and lung (). The patient gradually developed pancytopenia during the treatment progress. Consequently, 2 cycles of salvage chemotherapy with gemcitabine, dexamethasone and nedaplatin (GDP) were given, but the disease persisted at the end of therapy. On October 20th, 2011, results of CT scan showed that the number and size of nodules in the lung significantly increased (). The patient exhibited persistent fever and systemic failure, and showed an Eastern Cancer Oncology Group (ECOG) score of 3.\nIn October 2011, the patient began brentuximab monotherapy, with a dose of 1.8 mg/kg, once every 3 weeks. Following the first course of brentuximab, the patient's body temperature dropped gradually after 4 days of treatment and returned to normal 1 week later. Because of bone marrow involvement, white blood cell, hemoglobin, and platelet counts decreased markedly before treatment. However, the patient continued with brentuximab therapy without interruption under the support of granulocyte colony-stimulating factor (G-CSF), thrombopoietin (TPO), and interleukin-11 (IL-11). Following the first course of brentuximab, CT scan showed that the lung nodules were significantly reduced in size and number (). After the second treatment, the patient began to recover from pancytopenia and regain physical strength, and her condition improved significantly. After the third course of treatment, the patient was capable of self-care, indicating an ECOG score of 2. PET/CT scan suggested partial remission (PR). After the fourth course of treatment, anemia began to improve, with hemoglobin increasing from 60 to 100 g/L. After physical activity palpitations disappeared, the patient's heart rate fell from 110–130 to 70–80 beats/min. Shrinkage was noted in multiple nodular shadows in double lung fields (). After the sixth course of treatment, hemoglobin count had nearly returned to normal, and lesions in the lungs, liver, spleen, bones, mediastinum, and abdomen significantly decreased. A PET/CT scan showed that the lung nodules had disappeared, and the maximum standard uptake values (SUVmax) of thoracolumbar vertebral nodules and liver and spleen nodules had decreased to normal (). The patient achieved CR, and the ECOG score was 1. The patient encountered reversible adverse reactions during treatment, including peripheral neuropathy, elevated aminotransferases, hair loss, and dry cough, and these adverse effects were controlled with symptomatic treatments. At the time this paper was submitted, the patient had never suffered from infection. | [[17.0, 'year']] | F | {'16314615': 1, '21047225': 1, '18223284': 1, '22454421': 1, '22424602': 1, '28486951': 1, '18086796': 1, '22547611': 1, '23544448': 2} | {} |
164,535 | 3845595-1 | 22,958,743 | noncomm/PMC003xxxxxx/PMC3845595.xml | Retroperitoneal schwannoma mimicking metastatic seminoma: case report and literature review | A 29-year-old man presented with the right testis enlarged for 1 month without causing any discomfort. Physical examination revealed that the right testis measured up to 6 cm × 5 cm × 4 cm, which was much bigger than the left testis. This patient's medical history was not unusual. Notably, his brother was diagnosed with seminoma 10 years ago but was still alive and in good health. CT of the chest and abdomen revealed a single abdominal mass (29 mm × 31 mm) located below the renal hilum along the para-aorta. The serum concentration of α-fetoprotein, human chorionic gonado-tropin, and lactate dehydrogenase were normal. Right radical orchiectomy was performed. The section of the right testis contained a light white uncapsulated mass, measuring 5 cm × 4 cm. Microscope examination revealed seminoma limited to the testis and epididymis without vascular/lymphatic invasion, making the clinical stage NB. The patient refused radiotherapy but underwent 3 cycles of cisplatin, etoposide, and bleomycin (PEB). Post-chemotherapy CT revealed persistence of the retroperitoneal mass, with no change in tumor size or characteristics ().\nRetroperitoneal lymph node dissection was performed, and the harvested tissue contained negative lymph nodes but a single mass in the attached fat. The mass was diagnosed pathologically as retroperitoneal schwannoma and confirmed as such with immunohistochemistry (positive for S-100 and CD56, negative for CD34 and CD117). Cell proliferation was evaluated with Ki-67 staining, and a low proliferation rate (Ki-67 < 5%) was reported, supporting the benign nature of the lesion. Six months after the initial surgery, the patient was alive and in good health without any evidence of relapse. Complications such as retrograde ejaculation, ascites, and intestinal obstruction were not observed. | [[29.0, 'year']] | M | {'21876639': 1, '4855872': 1, '11052882': 1, '2069106': 1, '27472709': 2, '34421273': 2, '14665342': 1, '9607888': 1, '20643666': 1, '511121': 1, '22958743': 2} | {'5265846-1': 1, '8343282-1': 1} |
164,536 | 3845606-1 | 23,470,145 | noncomm/PMC003xxxxxx/PMC3845606.xml | Malignant meningioma of the cerebellopontine angle in a 2-year-old girl: a case report and literature review | A 2-year-old girl with no significant medical history presented at our department in July 2006, describing a 4-month clinical history of droop of the right corner of the mouth and an inability to close the right eye normally and a 2-month history of aggravated headache. A physical examination at admission was abnormal: the right side of her face presented a distorted commissure and hypophasis. Computed tomography (CT) scan of the brain revealed an inordinate globate and defined slightly high-density lesion in the right cerebellopontine angle (). Magnetic resonance imaging (MRI) showed that the lesion had a slightly short T1 signal () and a long T2 signal (). Contrast-enhanced MRI revealed that the lesion had a conspicuous heterogeneous enhancement, with patchy un-enrichment in the lesion. The dural tail sign was visible and measured approximately 38.7 mm × 31.2 mm × 34.7 mm (). A meningioma was diagnosed before the histopathologic examination.\nResection with a right suboccipital retrosigmoid approach was performed. During the operation, the lesion was observed to arise from the meninges of the right cerebellopontine angle and have obscure boundaries. The lesion was grayish-red and tenacious, with copious blood supply. The tumor was completely removed and subjected to pathologic examination immediately.\nThe tumor tissue was processed and stained with hematoxylin & eosin (HE). The histopathologic examination demonstrated that the tumor was composed of cells with nuclear pleomorphism, prominent nucleoli, a high mitotic index, and a high nucleus/cytoplasm ratio. The mitoses occurred at a rate of approximately 15-20/10 hpf (highest possible frequency) (). Immunohistochemically, the tumor cells were positive for vimentin (), epithelial membrane antigen (EMA) (), and S-100 () and negative for Syn () and glial fibrillary acidic protein (GFAP), leading to a final diagnosis of malignant meningioma (WHO grade III).\nThe patient had no complications after the operation. After surgery, the patient was sent to the neurosurgery intensive care unit (NICU) for vital sign surveillance and neurologic observation. Head CT was performed and showed no residual lesion. Routine follow-up was performed and was scheduled at 1, 6, and 12 months and annually thereafter. The clinical and radiological findings were normal during a 6-year follow-up. No radiotherapy or chemotherapy was administered after surgery. | [[2.0, 'year']] | F | {'19027587': 1, '19641924': 1, '18214497': 1, '21719288': 1, '16383246': 1, '11358066': 1, '16755189': 1, '21507650': 1, '7940095': 1, '8470588': 1, '18230924': 1, '25685652': 1, '18831662': 1, '11734983': 1, '23470145': 2} | {} |
164,537 | 3845622-1 | 23,237,217 | noncomm/PMC003xxxxxx/PMC3845622.xml | Pituitary metastasis from a renal cell carcinoma progressed after sorafenib treatment | A 51-year-old man originally presented with an asymptomatic tumor in his left kidney revealed by a routine abdomen ultrasonography in October 2005. His medical history was unremarkable except for 11 years of hypertension, which was controlled well with calcium antagonist. Radical nephrectomy was then undertaken and pathologic examination showed clear-cell RCC (), staged T3N0M0. He underwent cytokine therapy with interleukin-2 for 3 months after surgery and felt well. However, in subsequent routine examinations, a computed tomographic (CT) scan suggested metastases to bilateral adrenal glands (), retroperitoneal lymph nodes, and multiple bones. Brain magnetic resonance imaging (MRI) was then performed and showed diffuse enlargement of the pituitary gland (), which was considered pituitary nonfunctional adenoma or pituitary hyperplasia. In June 2006, the patient began treatment with sorafenib, taking 400 mg orally twice daily. Treatment was interrupted in the third week and then between the 12th and 16th week because of grade 3 hand-foot reaction syndrome and aggravated hypertension accompanied by grade 2 alopecia and arthralgia according to Common Terminology Criteria for Adverse Events (CTCAE) v3.0. After the interruption, the dose of sorafenib was reduced to 400 mg orally once daily. After 8 weeks of sorafenib treatment, CT scan of the abdomen showed tumor shrinkage and partial response (), which was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST). This partial response status was verified 4 weeks later. In the 20th week, the patient felt rapid deterioration with blurry vision. Physical examination revealed left-sided temporal hemianopia, ptosis of the left upper lid, left sixth nerve palsy, and diplopia. Hormonal evaluation suggested adrenocorticotropic hormone (ACTH) deficiency and hyperprolactinemia (). Additional brain CT scan showed a Sellar mass with suprasellar extension compressing the optic chiasm and eroding the Sellar base (). In November 2006, transsphenoidal surgery revealed a vascular tumor that invaded the Sellar base and the normal pituitary gland. Only biopsy was performed, and pathologic examination showed clear-cell carcinoma consistent with pituitary metastasis of RCC (). Treatment with sorafenib was stopped when disease progression was detected. The patient underwent conformal radiotherapy to the pituitary tumor bed at a dose of 3,000 cGy in 10 fractions and then 600 cGy in 3 fractions. After radiotherapy, his visual acuity and visual field recovered partially. One month later, multiple bilateral lung nodules were suggested by chest CT scan. In September 2007, the patient died due to dyspnea. Survival time was 23 months from nephrectomy, 16 months from initial diagnosis of metastases and use of sorafenib, and 9 months from diagnosis of symptomatic pituitary metastasis. | [[51.0, 'year']] | M | {'14764764': 1, '18671240': 1, '2789715': 1, '30139817': 1, '30176934': 2, '21972190': 1, '18165649': 1, '17541748': 1, '34869016': 1, '24626183': 1, '32908722': 2, '30461658': 1, '4355105': 1, '20862748': 1, '23237217': 2} | {'6122676-1': 1, '7450332-1': 1} |
164,538 | 3845692-1 | 24,302,940 | noncomm/PMC003xxxxxx/PMC3845692.xml | A rare anomalous origin of left subclavian artery from the circle of Willis in combination with right sided aortic arch: A case report | A 10-year-old boy referred to the pediatric cardiology clinic of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran on 1-May-2012 with a chief complaint of recurrent chest pain from two weeks ago. He had an atypical chest pain in the 4th and 5th left intercostals areas without any radiation which lasted for several minutes. He had no other symptoms though.\nIn physical examination, the pulses of left upper limb and left carotid artery were not detected; however, the other pulses were normal. He had no cyanosis or clubbing in his extremities. In heart auscultation, the S1 and S2 sounds were normal and a grade I-II/VI systolic ejection-type murmur was heard on the left sternal border. The other examinations were normal.\nNo abnormal findings were revealed in electrocardiography.\nThe cardiothoracic ratio was in upper normal range and the pulmonary vascular markings were normal in chest X-ray (CXR). The right sided aortic arch was observed in .\nThe main abnormal findings in echocardiography included mild mitral valve prolapse (MVP) and tricuspid regurgitation (TR) with a pressure gradient of 25 mmHg. Besides, the right sided aortic arch was observed.\nIn CT angiogram, the left carotid artery was significantly narrower than the right one which seemed to be dilated for enough cerebral circulation. Moreover, as a rare anomalous finding, the left subclavian artery aroused from this narrow carotid artery and the left vertebral artery originated from this subclavian artery (.A and .B).\nThereafter, the patient underwent the left heart catheterization. The arterial catheter passed from the femoral artery into descending aorta (DAO), ascending aorta (AAO), and left ventricle (LV), respectively. It entered into the right and left coronary arteries (RCA and LCA) normally.\nSystemic sample was saturated. In addition, it entered into the right subclavian and right carotid arteries, but it could not enter into the left brachiocephalic artery.\nLV, coronary arteries and aortic root injections revealed no pathologic findings. The right sided aortic arch was observed again. Aortic arch injection in the right anterior oblique view showed normal right subclavian and right carotid arteries and also showed with no connection of the left subclavian artery to the aortic arch.\nSelective right carotid artery injection showed opacified left subclavian artery. The left subclavian and left vertebral arteries supplied from the circle of Willis (right vertebral artery). Selective right subclavian artery showed no anomaly (.A, .B, and .C).\nFollowing the whole procedures, the patient was discharged and was advised to refer periodically for clinical follow-up. | [[10.0, 'year']] | M | {'12857711': 1, '11123130': 1, '22070004': 1, '11959744': 1, '30167747': 1, '11455394': 1, '30787266': 1, '16177024': 1, '12376613': 1, '22238123': 1, '2658110': 1, '24302940': 2} | {} |
164,539 | 3845697-1 | 24,302,939 | noncomm/PMC003xxxxxx/PMC3845697.xml | Aortic valve streptococcus group B endocarditis post-extracorporeal shock \nwave lithotripsy | A 55 year old man referred with the chief complaint of frequency and dysuria, and urinary tract infection. Examination of the patient showed 4 to 6 mm renal stones in right kidney, 3 small stones in the left kidney, and also a cortical cyst with 5*6 mm width in the right kidney. Extracorporeal shock wave lithotripsy was done for him and fever progress was observed for 4 days. He was treated with ceftriaxone and his general condition improved slightly, but his fever persisted. Kidney sonography was repeated and showed small 3-4 mm stones in both kidneys without abscess and hydronephrosis. Because of continuing fever and hematuria, with urosepsis diagnosis the patient was admitted and started on antibiotics that contain gentamicin, ciprofloxacin and ceftriaxone, but he was referred to our center because he did not respond to treatment. On admission physical examination was normal except temperature = 39.7 ºC, HR = 90 min, RR = 26 min, Bp = 135/80 mmHg. Hemodynamic pattern and ECG were normal. Fever workup was done for him. Blood culture was positive for streptococci group B in first and third days after admission. Hematologic and serum chemical laboratory data are shown in .\nAlthough cardiac examination was normal, due to continuing fever and bacteremia echocardiography was done to find the source of infection of urinary system and bacteremia. Echocardiography showed normal ejection fraction (60%), mild AI, and vegetation on aortic valve (). Antibiotic therapy was started and continued for 4 weeks.\nAt the end of the course of medical therapy the patient was well and had shown a good response to antibiotic therapy, and thus did not need cardiac surgery. The patient was discharged when blood culture was negative and the level of ESR was decreased. In 2 years follow-up, he was well without any complications. | [[55.0, 'year']] | M | {'14627217': 1, '9163498': 1, '21274492': 1, '8746286': 1, '20856102': 1, '20417661': 1, '24302939': 2} | {} |
164,540 | 3846998-1 | 24,307,848 | noncomm/PMC003xxxxxx/PMC3846998.xml | Successful management of colonic perforation with a covered metal stent | An 82-year-old man was admitted to our institution for treatment of a colonic anastomotic stricture. He had undergone a laparoscopic left hemicolectomy for cancer of the descending colon. One week after surgery, anastomosis leakage developed, and loop ileostomy was performed. Three months after ileostomy, a colonoscopic exam was performed prior to ileostomy repair, which revealed a stricture at the site of the end to end anastomosis, 17 cm from the anal verge, measuring approximately 3 mm in diameter and 8 mm in length. The patient showed no symptoms.\nAfter bowel enema, the anastomotic stricture was dilated under endoscopic and fluoroscopic guidance, and a guide wire was inserted endoscopically through the stricture site. The controlled radial expansion balloon (5.6 cm in length; CRE Wireguided Balloon Dilator, Boston Scientific Co., Natick, MA, USA) traversed the stricture under fluoroscopic guidance, and the balloon was inflated to a diameter of 15 mm. Just after balloon dilatation, sigmoidoscopy revealed a perforation adjacent to the anastomotic site (). A simple abdominal X-ray showed free air below the diaphragm. A guide wire was inserted via the scope (TTS) method, and a fully covered, colonic, SEMS, 8 cm in length and 20 mm in diameter (Hanarostent, MI Tech Co., Seoul, Korea) was inserted across the stricture under fluoroscopic guidance to completely cover the perforation ( and ). After the procedure, the patient complained of abdominal pain with no evidence of peritonitis. The patient was managed conservatively with intravenous antibiotics. An endoscopic examination 2 days after the insertion of the stent showed satisfactory re-establishment of luminal continuity (). After 4 days of fasting after the procedure, the abdominal pain resolved and gas was gone. The patient was then put on a diet and remained symptom free. Eight days after the procedure, the patient was discharged.\nThe stent was successfully removed 3 weeks after placement, with no complications. Follow-up sigmoidoscopy showed that the perforation had healed completely (). Two months after the procedure, repair of the ileostomy was performed. The patient did not complain of any difficulty with defecation, and there was no evidence of recurrence of the anastomotic stricture. | [[82.0, 'year']] | M | {'31266269': 1, '28944333': 1, '27815744': 1, '32821766': 1, '25783831': 1, '12190673': 1, '12910226': 1, '17879415': 1, '16996368': 1, '17453289': 1, '25861277': 2, '24307848': 2} | {'4378701-1': 1} |
164,541 | 3846999-1 | 24,307,849 | noncomm/PMC003xxxxxx/PMC3846999.xml | Two dislodged and crushed coronary stents: treatment of two simultaneously dislodged stents using crushing techniques | A 58-year-old female patient was admitted to the cardiology department due to a 7-day history of chest pain. She had hypertension but electrocardiography was normal and cardiac enzymes were in the normal range. Left coronary angiography performed via the left radial artery showed irregular significant tubal stenosis of the mid LAD, tubular 50% narrowing of the LM, severe stenosis of the ostial LAD, and narrowing of the ostial left circumflex coronary artery (). Right coronary angiography showed no significant narrowing of the right coronary artery (). We recommended off-pump coronary artery bypass (OPCAB) for the LAD lesion and we planned to undergo PCI in the LCX lesion after OPCAB. Five days later, she underwent OPCAB, in which anastomoses were formed of the left internal mammary artery (LIMA) to the first diagonal branch (D1), and the right internal mammary artery (RIMA) to the distal LAD. Seven days postoperatively, follow-up coronary angiography revealed intact graft flow from the RIMA to the distal LAD, (), but completely occluded graft flow from the LIMA to the D1 (). Therefore, PCI was planned for the LM, the ostial and mid LAD, and the ostial LCX. A 7 Fr extraback-up (EBU) guiding catheter (Medtronics, Santa Rosa, CA, USA) was engaged at the ostium of the LM. Runthrough wires (Termo, Tokyo, Japan) were placed in the distal LAD and LCX. Initially, a 3.0 × 15 mm Xience stent (Abbott Vascular, Santa Clara, CA, USA) was implanted in the mid LAD (). Using a 2.5 × 15 mm Ryujin balloon (Termo), ostial segments of the LCX and LAD were alternatively dilated. Next, we used minicrush techniques. First, a 2.5 × 12 mm Xience stent was positioned in the proximal LCX more distally and was then pulled back to the point that the proximal marker of the LCX stent contacted the body of the main vessel stent. A 3.5 × 23 mm Xience stent was then introduced into the distal LM to the proximal LAD to overlap the mid LAD stent. However, it could not be delivered to the target lesion despite multiple attempts to advance the stent distally. We felt that further aggressive dilation was required. When we attempted to retrieve the stents into the guide catheter, both stents simultaneously detached from the stent balloons and two guide wires were placed in the center of the stents (). We initially planned to retrieve the dislodged stent in the LM to the proximal LAD using a 5 mm Gooseneck snare (St. Jude Medical, Sylmar, CA, USA). After the stent was successfully snared, we retracted the snare without removing the whole system, because the other stent had dislodged in the LM to the ostial LCX. When we retracted the snare, the stent was distorted and elongated into the guide catheter, preventing withdrawal using the guide catheter. At that time the patient was stable, so we decided to remove the two dislodged stents surgically. When the entire system including the guide catheter and wires were removed, the stent remained from the LM to the ascending thoracic aorta (). Later the patient developed severe chest pain, which was followed by cardiogenic shock. Immediately, another 7 Fr EBU guiding catheter was engaged at the ostium of the LM and coronary angiography showed nearly total occlusion at the distal portion of the LM with thrombolysis in myocardial infarction 1 flow due to an intracoronary thrombus (). The ostial segment of the LAD was dilated using a 2.5 × 15 mm Ryujin balloon to 8 atmosphere (atm) and a new 3.5 × 23 mm Xience stent was introduced into the mid LM to the proximal LAD across the LCX lesion and deployed (), restoring the blood pressure to 125/75 mmHg. After a new Pilot wire (Abbott Vascular) was placed in the distal LCX, the ostial LCX was additionally dilated using a 2.5 × 15 mm Ryujin balloon to 14 atm. Although the blood flow in the distal LCX was slightly decreased due to dissection by the guide wire, the final result on coronary angiography was good (). Subsequently, both stents, including the distorted and elongated stent, were crushed to the LM wall (). Five days postoperatively, the patient was discharged in stable condition on triple antiplatelet agents including cilostazol. Six months later, she presented with chest pain and mild dyspnea, so coronary angiography was repeated, which showed no evidence of restenosis or progressive disease (). | [[58.0, 'year']] | F | {'17285381': 1, '34317275': 1, '11285606': 1, '19937790': 1, '12822150': 1, '34322313': 1, '17605069': 1, '11373221': 1, '11108675': 1, '20124597': 1, '14962660': 1, '11285596': 1, '24307849': 2} | {} |
164,542 | 3847000-1 | 24,307,850 | noncomm/PMC003xxxxxx/PMC3847000.xml | Postinfectious Guillain-Barre syndrome in a patient with methimazole-induced agranulocytosis | A 57-year-old female presented with fever, abdominal pain, and diarrhea for 3 days. She had been diagnosed with Graves disease 25 years prior and was taking methimazole, the dose of which had been increased from 5 to 20 mg twice a day, as of 10 weeks prior. When the patient visited a primary care hospital, her laboratory findings revealed leukopenia and anemia with a white blood cell (WBC) count of 570/mL, absolute neutrophil count of 10/mL, hemoglobin of 9.4 g/dL, and platelet count of 161,000/mL. The physician diagnosed her with methimazole-induced agranulocytosis and stopped methimazole.\nDuring the neutropenic period, the patient developed fever and cough. The pathogen of infection was not confirmed, and she took empirical antibiotics for pneumonia. Clinical features were not improved, and the physician considered fungal pneumonia based on the findings of chest computed tomography. Ten days after onset of respiratory symptoms, she suddenly presented with symmetric weakness of the lower extremities, which progressed to the upper extremities. A nerve conduction study (NCS) showed axonal-type motor polyneuropathy. Intravenous immunoglobulin (IVIg) was started for probable GBS, and she was referred to our hospital for further management.\nWhen the patient first came to our emergency room, a neurologic examination showed quadriplegia, flaccid dysarthria, and aflexia, all of which were worse than 5 days before. The findings of spinal tap were 218.9 mg/dL protein and 10/mL WBC in the cerebral spinal fluid, known as albuminocytologic dissociation, which supported GBS. She was treated with IVIg (0.4 g/kg/day) for 5 days. The patient showed maximum weakness during the first 2 weeks after admission to the intensive care unit, but artificial ventilation was not needed. Neurologic examination and follow-up NCS improved a month after the onset of weakness ().\nAs methimazole treatment was discontinued, thyrotoxicosis was aggravated. The patient faced an impending thyrotoxic crisis with free thyroxine of 6.59 ng/dL (reference range, 0.89 to 1.8), thyroid-stimulating hormone (TSH) of 0.01 mIU/mL (reference range, 0.35 to 5.5), and TSH receptor antibody of 107 IU/L (reference range, 0.1 to 1.0). Lugol's solution and lithium were prescribed to reduce thyroid hormone production and secretion. A total thyroidectomy was performed three weeks later ().\nThe patient had been admitted for 40 days and received physical rehabilitation. With gradual neurologic improvement, she could ambulate using a wheelchair when discharged. After discharge, she maintained rehabilitation therapy for 6 months. The patient could walk without orthotics; however, she felt fatigue after a long distance walk. | [[57.0, 'year']] | F | {'34049504': 2, '1552913': 1, '18848313': 1, '14504313': 1, '15081257': 1, '16096809': 1, '33442145': 2, '19356935': 1, '18550875': 1, '15642902': 1, '11214662': 1, '24307850': 2} | {'7784229-1': 1, '8161606-1': 1} |
164,543 | 3847001-1 | 24,307,851 | noncomm/PMC003xxxxxx/PMC3847001.xml | A case of Tsutsugamushi disease presenting with nephrotic syndrome | A 72-year-old female was admitted with generalized edema. Her general medical condition had been stable for 2 weeks before presenting to the district clinic with a fever and myalgia. She had no history of renal disease. She denied taking any drug except acetaminophen for fever relief. The patient had a persistent fever and subsequently developed generalized edema. On physical examination, the patient was confused, acutely ill-looking, and showed grade 3 pitting edema of both lower extremities. An ecchymotic 3-cm plaque with a 1-cm black eschar was observed over the right lower abdomen (). At the time of admission, she had a blood pressure of 85/55 mmHg, a respiratory rate of 30 per minute, and a body temperature of 39.4℃. Laboratory studies revealed anemia (a hemoglobin level of 10.6 g/dL and a hematocrit of 33.0%) and leukocytosis (a white blood cell count of 17,420/mm3, neutrophils 78.4%, lymphocytes 12.3%, and monocytes 7.7%). Other relevant parameters included a total protein of 6.2 g/dL, a serum albumin of 2.5 g/dL, a blood urea nitrogen of 22.2 mg/dL, a serum creatinine of 1.57 mg/dL, and a total cholesterol of 250 mg/dL. Urinalysis revealed a 4+ proteinuria without significant casts and hematuria. The 24-hour urinary protein excretion was 5.4 g with a random urine protein to creatinine ratio of 9.14.\nThe anti-Tsutsugamushi antibody test was strongly positive (1:2,560), but was otherwise unremarkable (negative antinuclear antibody, negative anti-dsDNA antibody, negative antistreptolysin O, serum C3 82.6 mg/dL, and serum C4 20.7 mg/dL). Tsutsugamushi disease was diagnosed based on the clinical and laboratory findings. Renal ultrasound revealed normal-sized kidneys with increased echogenicity. Percutaneous renal biopsy was performed under ultrasonographic guidance to identify the cause of the nephrotic syndrome. Light microscopy of the renal biopsy specimen demonstrated diffusely and globally thickened glomerular basement membranes with subepithelial spikes and double contours (). Tubulointerstitial changes were unremarkable. Immunofluorescent staining revealed fine granular deposition of immunoglobulin G along the peripheral capillary wall (). Transmission electron microscopy showed that the glomerular basement membrane was diffusely thick with relatively evenly-spaced intramembranous electron dense deposits. The glomerular epithelial foot processes were diffusely effaced (). Based on these pathologic findings, the patient was diagnosed with membranous glomerulonephritis (MGN).\nThe patient was treated with doxycycline (200 mg/day). After 5 days of treatment with antibiotics, her clinical symptoms and signs, including fever, weakness, and hypotension, greatly improved. After 4 weeks of treatment, her urinary protein:creatinine ratio was 0.9, serum albumin levels rose to 3.7 g/dL, and the edema resolved. The patient was discharged 5 weeks after admission. | [[72.0, 'year']] | F | {'16932438': 1, '12803503': 1, '9571750': 1, '12746805': 1, '3147416': 1, '28298367': 1, '19289508': 1, '26943125': 1, '8593201': 1, '14717236': 2, '8104604': 1, '24307851': 2} | {'4531640-1': 1} |
164,544 | 3847257-1 | 24,347,775 | noncomm/PMC003xxxxxx/PMC3847257.xml | Levofloxacin and furazolidone induced toxic epidermal necrosis | A 69-year-old male patient with the complaints of fever of mild to moderate grade and loose motions, 4-6 times a day consulted a private practitioner and was prescribed tablet levofloxacin 500 mg twice daily, tablet furazolidone 100 mg thrice a day and tablet rabeprazole 20 mg once a day. After taking medications for 2 days, he complained of rashes all over his body associated with pain, which later developed into erosions and peeling of the skin. He also complained the difficulty in swallowing food due to oral ulcers.\nOn examination, the patient was alert and his pulse and blood pressure were within normal limits. He had no pallor, icterus, lymphadenopathy, clubbing and pedal edema. His respiratory, cardiovascular and central nervous systems were within normal limits. On examination, oral erosions, dusky red skin over the chest, abdomen, back, face, upper and lower limbs with epidermal peeling involving more than 40% of the total body surface area was observed. The Nikolsky's sign was positive. Ocular inflammation was also present [].\nOn the day of admission, his serum urea and serum creatinine was 78 mg/dl and 1.4 mg/dl, respectively. The red blood cell counter was 19.7 cell/μl (mcL) and peripheral blood smear showed neutrophils with toxic granules and band form. Nuclei and platelets were adequate. His erythrocyte sedimentation rate was 60 mm/h. The liver function tests were within the normal limit. Blood culture report done at the time of admission was negative after 24 h incubation. His Scorten Score was 2. Following the abnormal reports, levofloxacin and furazolidone were stopped and he was prescribed injection dexamethasone 8 mg intravenous (i.v.) 4 times a day for 5 days, later tapered for the next 4 days. Injection of combination of amoxicillin with clavulunic acid 1.2 g i.v. thrice a day for 15 days, calamine lotion locally twice a day, betadine gargles 4 times a day for oral ulcers and injection pantoprazole 40 mg i.v once a day were also prescribed. At 10 days later, the symptoms improved, he was able to take food orally and the epidermal peeling also subsided. Laboratory investigations were repeated after 10 days were normal. | [[69.0, 'year']] | M | {'19029983': 1, '8466217': 1, '19474709': 1, '17075281': 1, '11549784': 1, '19492670': 1, '7249508': 1, '21195149': 1, '24347775': 2} | {} |
164,545 | 3847258-1 | 24,347,776 | noncomm/PMC003xxxxxx/PMC3847258.xml | Allopurinol induced erythroderma | A 45-years-old male patient was admitted with complains of fever, redness and scaling all over the body for last 20 days. His recent drug history revealed that he was on oral allopurinol 200 mg daily for last 1½ month. He told that allopurinol was given by his general practitioner for increased uric acid level only. However when serum uric acid were repeated at our hospital the levels were normal. On further probing, he gave a history of generalized erythematous maculopapular rash along with a fever after 3 weeks of starting allopurinol, but he continued the medication. Later, there was the development of extensive erythema along with the scaling over the whole body within 4 days.\nOn examination, diffuse erythema with fine scaling was observed all over the body. Erythema and scaling were more pronounced over the trunk []. No significant lymphadenopathy or hepatosplenomegaly was observed. A skin biopsy done from back showed epidermal hyperplasia, foci of parakeratosis, spongiosis and a few necrotic keratinocytes. Dermis showed sparse superficial perivascular infiltrates consisting of lymphocytes and a few eosinophils. Laboratory investigations revealed raised liver enzymes (aspartate aminotransferase-114, alanine aminotransferase-112), but bilirubin was normal. Total blood counts including eosinophil count, renal function tests and serum electrolytes were within the normal limits. The causality was assessed using the Naranjo's adverse drug reaction probability scale. The association was “probable” as per the Naranjo's scale; hence, a diagnosis of allopurinol induced erythroderma was made. Allopurinol was stopped. Oral antihistamines and oral prednisolone 40 mg/day were started along with a supportive therapy. Patient improved over a period of 2 weeks [ showing improvement after 1week of treatment] and steroids were tapered and eventually stopped. | [[45.0, 'year']] | M | {'17896799': 1, '21572797': 2, '8299230': 1, '10583616': 1, '16339094': 1, '2527769': 1, '8453174': 1, '11981327': 1, '24347776': 2} | {'3088941-1': 1, '3088941-2': 1, '3088941-3': 1, '3088941-4': 1} |
164,546 | 3847259-1 | 24,347,777 | noncomm/PMC003xxxxxx/PMC3847259.xml | Sodium Valproate induced priapism in an adult with bipolar affective disorder | A 48-year-old married male was brought by his family in the emergency department with an acute onset of elation, grandiosity, distractibility, pressured speech and hallucinatory behavior for the past 2 months. Patient had a history suggestive of two manic episodes of moderate severity, with complete inter-episodic recovery in last 4 years. There was no past history of any depressive episode or medical comorbidity. There was no family history of medical or psychiatric morbidity or substance use. A diagnosis of bipolar affective disorder was made. The current episode was diagnosed as manic with psychotic features.\nA detailed treatment history and perusal of medical records revealed that 3 years ago, he had experienced persistent painful penile erection when he had been on sodium valproate (1500 mg/day) and risperidone (6 mg/day). This was unrelated to sexual arousal or stimulation and lasted for around 20-24 hours. He had five to six such episodes over a span of 7-10 days. Despite significant distress, he did not report the problem to the clinician. This was the only adverse effect experienced by the patient. He discontinued taking the medication and got relief from the priapism after 3-4 days of the last dose, but had another manic episode 2 years ago.\nIn light of existing medical literature, priapism was attributed largely to risperidone in this instance. However, it was difficult to attribute an adverse effect due to drug combination solely to a single agent. In view of history of priapism possibly due to risperidone and valproate, lithium carbonate was started as the mood stabilizer and olanzapine as anti-psychotic during the second episode. Over the next 6 months, olanzapine was gradually tapered-off. Around 8 months ago (nearly 1½ year after initiation) lithium carbonate was stopped after lithium induced hypothyroidism was detected. Thereafter, he was prescribed sodium valproate again; suspecting that earlier episode of priapism was attributable to risperidone, as sodium valproate has not been reported to cause priapism. Sodium valproate was started and doses were increased upto 1500 mg/day, with corresponding serum levels of 100 mg/l. This time patient adhered to treatment with sodium valproate at doses of 1500 mg/day continuously for a period of 5 months, until he developed priapism. This happened around 3 months ago and attributing this condition to medication, patient discontinued treatment and got relieved of this adverse effect. | [[48.0, 'year']] | M | {'11411819': 1, '11473107': 1, '20075651': 1, '2211542': 1, '17052448': 1, '7249508': 1, '24347777': 2} | {} |
164,547 | 3847260-1 | 24,347,778 | noncomm/PMC003xxxxxx/PMC3847260.xml | Pott's disease and hypercalcemia in a patient with rheumatoid arthritis receiving methotrexate monotherapy | In July 2012, a 74-year-old female patient with a 15-year history of well-controlled RA under MTX monotherapy (10 mg/week) was admitted with a 4-week history of gradually increasing generalized muscle weakness, fatigue, lumbar pain and ulcers on her lips and inguinal region. Her family physician prescribed an analgesic and muscle relaxant for pain relief (phenyramidol hydrochloride 2 × 100 mg/day). At the same time, she was taking treatment for hypertension (telmisartan 80 mg/day) and levothyroxine (100 mg/day) for Hashimoto thyroiditis.\nPatient was referred to medicine department because of the worsening of her complaints and onset of fever. Physical examination of the patient revealed fever (temperature 38.5°C), erosions in the oral mucosa, hemorrhagic crusts on the lower lip and well-demarcated ulcers in the genital region and left medial thigh. Lumbar tenderness, 3/5 muscle weakness and reduced tendon reflexes in both lower extremities were also noted. Laboratory examination revealed pancytopenia along with elevated levels of C-reactive protein (CRP): 15.53 mg/dl (normal: 0-5 mg/dl), aspartate aminotransferase: 120 IU/L (normal: 7-38), alanine aminotransferase: 84 IU/L (normal: 7-35), serum creatinine: 2.01 mg/dl (normal: 0.6-1.2) and blood urea nitrogen (BUN): 53 mg/dl (normal: 8-23). Patient's calcium level was measured as 11.6 mg/dl (normal 8.8-10.2) []. Patient's blood, urine, throat and stool cultures were taken: Owing to the absence, any additional medication or use of contrast substance, pancytopenia and elevated levels of CRP, transferases, BUN and creatinine were attributed to MTX therapy, which was withheld. Serum MTX level was measured higher than the normal therapeutic range. Folic acid treatment was initiated to overcome the toxic effects of MTX. Meropenem (3 g × 1 g intravenous) was started as an empirical initial treatment. Skin biopsy were performed by a Dermatologist revealed papillomatosis in the epidermis and dense eosinophilic infiltration consistent with drug reaction.\nAfter treatment, resolution in the skin and oral lesions was observed. Because of an accompanying hematological disease, bone marrow aspiration and biopsy of the patient were performed and sent for pathological and microbiological evaluation. A normocellular bone marrow with granulomatous foci suggesting megakaryocytosis was reported []. Gram- and acid-resistant staining of the aspirated specimen revealed no bacteria. Due to the patients's lumbar pain, a bone scintigraphy was performed which revealed a pathological involvement in the L4. Further examination with positron emission tomography (PET) (F-18 fluorodeoxyglucose) showed a pathological involvement consistent with inflammation []. A lumbar magnetic resonance imaging (MRI) revealed a psoas abscess causing spinal stenosis consistent with tuberculous spondylodiscitis. A computed tomography (CT)-guided biopsy of the vertebral lesion was performed but no malignancy was reported. Gram- and acid-resistant staining of the vertebral biopsy specimen revealed no bacteria; a culture of this specimen was also obtained. A performed QuantiFERON test was positive. Because all gathered information about the patient was consistent with tuberculosis, tuberculosis treatment was initiated without waiting for the results of the culture specimens. No other additional pathology was found to explain hypercalcemia other than granulomatous foci in the bone marrow and vertebral lesions. Mycobacterium tuberculosis was isolated in cultures of the specimens from the patient's bone marrow and lumbar region. The patient was diagnosed with pancytopenia, renal failure, tuberculous spondylodiscitis and hypercalcemia due to the use of MTX. Anti-tuberculosis therapy yielded an improvement in the patient's clinical status and as well as her hematological and biochemical parameters []. | [[74.0, 'year']] | F | {'17337408': 1, '11285384': 1, '3202473': 1, '16332954': 1, '15901903': 1, '24347778': 2} | {} |
164,548 | 3847261-1 | 24,347,779 | noncomm/PMC003xxxxxx/PMC3847261.xml | A rare case of imatinib-induced erythroderma | A 52-year-old male presented to the medical outpatient department with complaints of low grade fever and lump on the left side of abdomen since one month duration. Investigations revealed total leukocyte count of 1.2 lakhs/mm3. Bone marrow examination revealed 2% blast cells, serum lactate dehydrogenase was 1134 IU/L, and an ultrasound of the abdomen revealed splenomegaly with span of 19 cm. Chromosomal studies revealed a bcr– abl gene rearrangement. The case was diagnosed as CML in chronic phase and patient was prescribed imatinib mesylate 400 mg once daily.\nTen days later, he developed redness and scaling involving dorsum of both hands which increased to involve his entire body over a period of 20 days. The lesions were associated with severe itching. There was no history of any other drug intake, or history of fever, jaundice, chest pain, palpitation and dyspnoea on exertion. Imatinib was continued and the rash worsened.\nWhen the patient was referred to us, he had generalized skin rash of 40 days duration. General physical examination was unremarkable while systemic examination revealed splenomegaly, 3 cm below costal margin. Dermatological examination revealed generalized involvement of the body in form of dusky, blanchable erythema, and diffuse fine scaling. Lichenification was noted in flexures viz groin, axillae and neck [Figures and ]. Angular cheilitis was present. Ophthalmological examination revealed periorbital edema with conjunctival congestion and loss of eyelashes. Nails showed transverse hyperpigmented bands at the same level in all nails. Investigations revealed hemoglobin of 14.5 gm%, total leukocyte count 11,500/mm3, and differential count was polymorphs- 50, lymphocytes- 8, monocytes- 2, and eosinophils 40. Urine examination, blood sugar, renal, and liver function tests were within normal limits.\nImatinib was immediately stopped and patient was prescribed on tablet prednisolone 40 mg/day, which was maintained at full dose for two weeks, tapered by 10 mg every week, and stopped after a total of five weeks. Supportive measures including high protein diet, appropriate temperature control, fluid, and electrolyte balance were provided. Improvement was noted with decreased erythema on fifth day and significant reduction in scaling by day 11. The rash disappeared completely within three weeks. The patient was changed to an alternative anti-CML medication (Cyclophosphamide based) and rechallenge or desensitization was not resorted to, as erythroderma is considered a severe form of drug reaction. | [[52.0, 'year']] | M | {'17951138': 1, '16573254': 1, '14571082': 1, '11287972': 1, '12668652': 1, '17680975': 1, '16394445': 1, '24347779': 2} | {} |
164,549 | 3847262-1 | 24,347,780 | noncomm/PMC003xxxxxx/PMC3847262.xml | Phenytoin-induced cerebellar atrophy in an epileptic boy | A 16-year-old boy was admitted to the hospital with fever and weakness. His systemic examination was normal. His past history included history of seizure for the last 10 years. He was on oral PHT, 5 mg/kg daily once daily. After initiating therapy with PHT 10 years back, he was seizure free for 2 years. Then he started getting seizures that required adjustment in his medication. Patient was also occasionally prescribed clobazam, 5 mg, oral, as and when required. The episodes used to last for a brief period of over 6-7 days. He would then be seizure free for the next 3-4 months. Seizures used to occur at every 3-4 months interval. The boy had history of birth asphyxia and delay in developmental milestones. His previous MRI scans of brain revealed no abnormality. There was no family history of seizure. The boy was managed conservatively for viral fever. After the patient recovered, he was evaluated again due to complaint of difficulty in walking. CNS examination revealed normal mentation with cerebellar signs including gaze-evoked nystagamus, truncal, and appendicular ataxia. MRI scan of the brain was advised and it showed cerebellar atrophy as shown in . The patient had no other neurological and other systemic problems other than epilepsy. Serum phenytoin level was high (30 mcg/ml) and PHT was withdrawn immediately. Patient was started on valproic acid and followed up. The causality assessment was done using the Naranjo scale.[] The causal analysis showed a probable association of the ADR with phenytoin. | [[16.0, 'year']] | M | {'7362207': 1, '821007': 1, '9141798': 1, '11435657': 1, '22144787': 2, '9118858': 1, '24347780': 2} | {'3229798-1': 1} |
164,550 | 3847263-1 | 24,347,781 | noncomm/PMC003xxxxxx/PMC3847263.xml | Pregabalin-induced self-harm behavior | A 21-year-old male patient weighing 52 kg who was diagnosed with chronic low back pain was prescribed capsule pregabalin 75 mg, o.d., at bed time for 2 weeks and local treatment in the form of diclofenac gel and hot fermentation with back strengthening exercises. The patient had no history of smoking, alcohol consumption, or any substance abuse. There was no other associated pathology or history of any concurrent drug intake. He had no personal history or family history of any previous mental/psychiatric disorders. The patient was referred to the adverse drug reaction monitoring (ADRM) centre after 2 months of treatment with complaint of recent change in behavior manifesting as compulsion to take pregabalin at night in spite of the presence or absence of pain and an attempt of self-harm in the form of self-inflicted multiple cuts on the forearm []. Recent disinterest in work, family, friends, clothing, and food was also reported by the family. There was no history of weight change, anxiety, or insomniaor any conflict with family, friends or at work place. Clinical examination revealed that there was no rheumatological or neurological problem. Physiatrist evaluation revealed that Hamilton Rating Scale for Depression (HAM-D) score was 15 suggesting mild depression at the time of examination.\nLaboratory investigations such as complete blood count, hemoglobin, complete blood count, routine urine and stool examination, blood sugar, liver function test, renal function test, lipid profile and electrocardiogram, and X-ray lumber sacral spine were normal.\nThe patient was advised to stop the drug, when the cause of the recent behavioral change could not be ascertained, on suspicion that pregabalin was the causal drug. De-challenge of drug did not cause any withdrawal symptoms. Depressive symptoms disappeared on the eighth day after de-challenge. However, after being advise by psychiatrist, the patient was started olanzapine (2.5 mg, o.d.) in view of potential serious consequences of the ADR. Further re-challenge was not done in the interest of the patient fearing reappearance of ADR and due toethical constraints. The appearance of self-harm behavior in a patient taking pregabalin could not be explained by a concurrent disease, drug, or chemicals. A dechallenge followed by treatment with an antidepressant improved the symptoms.\nThe ADR was ‘Probable’ as assessed by the causality scale with Naranjo (score of six) and the WHO Uppsala Monitoring Centre (UMC) scale. The case was reported to ADRM Centre, Government Medical College, Jammu. | [[21.0, 'year']] | M | {'12777346': 1, '17177755': 1, '28223849': 1, '20563568': 1, '25657479': 1, '7249508': 1, '23277244': 1, '20660863': 1, '11072960': 1, '17253878': 1, '20388896': 1, '24347781': 2} | {} |
164,551 | 3848514-1 | 24,396,635 | noncomm/PMC003xxxxxx/PMC3848514.xml | Emphysematous Pyelonephritis Caused by Citrobacter freundii in a Patient with Type 2 Diabetes and Neurogenic Bladder | A 57-year-old woman presented at the emergency department with confused mentality, fever, myalgia, and general weakness. The patient had a medical history of type 2 diabetes, hypertension, neurogenic bladder, and bilateral renal abscesses with sepsis caused by extended spectrum beta-lactamase (ESBL) producing E. coli, 1 year ago. Meropenem (1 g/day) was administered for approximately 4 weeks with an indwelling urinary catheter for approximately 2 weeks at that time.\nInitial systemic examination revealed that the patient had a body temperature of 38.0℃, blood pressure of 138/64 mmHg, heart rate of 124 beats/min, respiratory rate of 34 breaths/min, tenderness in the left costovertebral angle, and peripheral pitting edema.\nFurther tests revealed that the patient had hypochromic normocytic anemia with hemoglobin levels of 9.3 g/dL, a white blood cell count of 13,700/mm3 (59% neutrophils and 26% band forms), and a platelet count of 194,000/mm3. Kidney function test revealed blood urea nitrogen (BUN) of 39.8 mg/dL and creatinine (Cr) of 3.9 mg/dL. Similar tests performed 1 year ago had revealed the BUN and Cr to be 31.9 mg/dL and 1.3 mg/dL, respectively. Furthermore, urinalysis revealed pyuria, glycosuria, and proteinuria without ketone bodies or nitrites. Arterial blood gas tests indicated that the pH of the patients' blood was 7.31, pCO2 were 35 mmHg, pO2 were 72 mmHg, SaO2 were 93%, and HCO3- were 17.6 mEq/L. Concentrations of C-reactive protein, sodium, potassium, and chloride were 11.12 mg/dL, 135 mEq/L, 6.7 mEq/L, and 102 mEq/L, respectively; tests for serum ketone body was negative. The initial blood glucose concentration was 411 mg/dL and glycosylated hemoglobin level was 9.8%. Concentrations of fibrin degradation product, fibrinogen, D-dimer, and anti-thrombin III were 26.8 µg/mL, 819 mg/dL, 1.5 µg/mL, and 82%, respectively. A chest radiograph showed bilateral pulmonary congestions.\nThe patient further displayed clinical features of sepsis with renal failure in the form of fever, tachycardia, tachypnea, leukocytosis, azotemia with hyperkalemia, and pulmonary congestion. Initially, a broad-spectrum intravenous antibiotic (meropenem, 1 g/d) was administered based on prior admission history. Contrast-enhanced abdominal computed tomography (CT) images of the kidneys showed hydroureteronephrosis and a collection of gas bubbles with heterogenous enhancement in the enlarged left kidney (12.5 × 6 cm). Further, perinephric infiltration with fluid collection and wall thickening of the calyces, renal pelvis, and ureter were also observed (). Prompt percutaneous nephrostomy (PCN) with a pig-tail tube was performed in the left kidney, resulting in 50 mL of pus being drained with air. Microbiological examination of both blood and pus obtained from the PCN revealed the presence of C. freundii. As a result, the antibiotic regimen was switched to a third generation cephalosporin based on the results of culture and sensitivity tests. The patient responded to the treatment and became afebrile and clinically stable. PCN was maintained for 2 weeks and the antibiotic was continued for 6 weeks. After treatment, an abdominal CT showed improved lesions of left kidney with no gas bubbles detected in the renal parenchyma, pelvis, and calyces. Despite the improvements in patient's condition following treatment, the patient developed permanent kidney failure, which required hemodialysis. | [[57.0, 'year']] | F | {'12634070': 1, '4595716': 1, '22513034': 1, '17469032': 1, '20121956': 1, '19404766': 1, '21673472': 1, '18682995': 1, '8766145': 1, '21525582': 1, '20840327': 1, '16123565': 1, '10737279': 1, '16815552': 1, '9378933': 1, '24396635': 2} | {} |
164,552 | 3848517-1 | 24,396,637 | noncomm/PMC003xxxxxx/PMC3848517.xml | Catheter-Associated Rhodotorula mucilaginosa Fungemia in an Immunocompetent Host | A 77-year-old man with a history of diabetes, hypertension, and Parkinson's disease developed new-onset fever 10 days after admission at the intensive care unit of our hospital. He was initially diagnosed with community-acquired pneumonia at right lower lung, and received ceftriaxone and azithromycin as empirical intravenous antibiotics. Because he was in a hypoxic state, he was transferred to the intensive care unit and started on mechanical ventilation. We inserted a central venous catheter for monitoring the central venous pressure and total parenteral nutrition. Six days after admission, a chest radiograph showed diffuse, peripherally located reticulonodular infiltrates in both lung fields. Pseudomonas aeruginosa was isolated in the sputum. We diagnosed the patient with ventilator-associated pneumonia and switched the antibiotic regimen to piperacillin-tazobactam. Following the modified treatment, the patient's fever decreased and other laboratory parameters stabilized. Ten days after admission, new-onset fever developed. The patient's vital signs were as follows: temperature was 38.4℃, pulse rate was 90 beats/min, respiratory rate was 24 breaths/min, and blood pressure was 130/80 mmHg. Further laboratory evaluation demonstrated the following results: white blood cell count 6,090/mm3 (neutrophils 86.4%), hemoglobin was 8.6 g/dL, platelet count was 119,000/mm3, blood urea nitrogen was 30 mg/dL, creatinine was 1.8 mg/dL, aspartate aminotransferase was 18I U/L and alanine aminotransferase was 81 IU/L. Two sets of blood culture were drawn, from peripheral venipuncture and the central venous catheter. After 72 hours, both blood culture sets had confirmed fungal growth with a yeast form. Blood cultures drawn from the central venous catheter demonstrated positive results 3 hours earlier than the peripheral cultures. We diagnosed the patient with central venous catheter-associated blood-stream infection and started intravenous fluconazole (400 mg/day) and removed the catheter. The yeast was subsequently subcultured on Sabouraud dextrose agar, producing multiple colonies. They were moist, glistering, smooth to mucoid and salmon pink to coral red color. Gram staining revealed budding yeast cells, which were short, ovoid, 2-6 µm in diameter and arranged in short chains and clusters. The organism was urease-positive and did not ferment conventional sugars. The isolate was identified as R. mucilaginosa on the basis of these characteristics and by an API 20C AUX system. (bioMerieux, Marcy l'Etoile, France). In addition, we identified the isolate using sequences of the D1/D2 domain of the large subunit (LSU) rRNA. Portions of the LSU rRNA gene were amplified using the primer sets LSU-F (5'-GCA TAT CAA TAA GCG GAG GAA AAG-3') and LSU-R (5'-GGT CCG TGT TTC AAG ACG-3') []. Unambiguously determined sequences (559 bp) were compared with the GenBank public database, using the BLASTn program (). The LSU rRNA gene sequence of the isolate showed 100% similarity with R. mucilaginosa ATCC32736T followed by 96.7% with Rhodosporidium sphaerocarpum SJ105 (AY953966). Thus, we could confirm that the isolate was R. mucilaginosa.\nAfter 5 days, we changed fluconazole to amphotericin B deoxycholate. New sets of blood culture drawn 48 hours later were also positive for yeast, confirmed as R. mucilaginosa. After 3 days of amphotericin B treatment, we switched the patient to liposomal amphotericin B because he developed azotemia. The patients responded to this treatment; fever resolved and blood culture result converted to negative. Liposomal amphotericin was continued for 10 days and followed by fluconazole for an additional 14 days. After 34 days of additional hospitalization, he was discharged to a long-term care facility. | [[77.0, 'year']] | M | {'1576278': 1, '17921663': 1, '22131080': 1, '14616717': 1, '14605170': 1, '18974495': 1, '29152230': 1, '23114761': 1, '33936656': 2, '26369644': 1, '32987845': 1, '18785780': 1, '13763698': 1, '17654271': 1, '22576941': 1, '32829588': 1, '34672698': 1, '25858834': 1, '11957131': 1, '12748053': 1, '10843082': 1, '16912936': 1, '10685444': 1, '11863261': 1, '31080710': 1, '24396637': 2} | {'8077285-1': 1} |
164,553 | 3848520-1 | 24,396,636 | noncomm/PMC003xxxxxx/PMC3848520.xml | Brain Abscess Caused by Enterococcus avium: A Case Report and Review of the Literature | A 48-year-old man with a 13-day history of headache and right otalgia was admitted to our tertiary medical center. He was diagnosed with type 2 diabetes mellitus 3 years earlier and was thereafter treated with oral hypoglycemic agents up until the current presentation. The patient had chronic suppurative otitis media for several years. Physical examination showed that his verbal output was reduced and his neurologic status was 11 on the Glasgow Coma Scale. The patient's temperature was 36.8℃, blood pressure was 140/100 mmHg, and pulse was 80 beats/min. Otoscopic evaluation revealed the exudation of fresh pus from the right ear. Laboratory studies revealed an elevated leukocyte count of 18,500/mm3 and an elevated C-reactive protein level of 18.9 mg/dL. Serological tests were negative for human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. Brain magnetic resonance imaging (MRI) showed the presence of a 3.5-cm, rim-like enhancing lesion in the right temporoparietal lobe with perilesional edema (). Obliteration of the right mastoid air cells with sclerotic changes was noted, and its communication to the right mastoid was suspected. The patient underwent stereotactic aspiration of the brain abscess and treated with parenteral antibiotics, including ceftriaxone (2 g every 12 hours) and metronidazole (500 mg every 6 hours). Elective surgery was scheduled, but a follow-up computed tomography (CT) scan showed significant decreases in the extent of brain abscess due to abscess drainage through the communication site of the right ear. Therefore, the scheduled surgery was cancelled.\nOn day 6 of hospitalization, E. avium was isolate from ear discharge and aspirates of brain abscess culture. Species identification and antimicrobial susceptibilities of E. avium were determined using the MicroScan Pos Breakpoint Combo Panel Type 28 (Siemens, CA, USA). Ampicillin (2 g every 4 hours) was subsequently administered to the patient. Antibiotic susceptibility testing of the isolates showed that the pathogen was susceptible to penicillin, ampicillin, imipenem, glycopeptides, fluoroquinolones, and high level of aminoglycosides. Parenteral antibiotic therapy consisting of ceftriaxone, metronidazole, and ampicillin was continued for 4 weeks. After parenteral antibiotic therapy, the patient's neurologic deficits improved, and he was discharged in a stable condition with oral antibiotics. Oral antibiotic therapy comprising amoxicillin (500 mg every 8 hour) and levofloxacin (750 mg every 24 hours) was continued for 8 weeks. Compared the images of the initial MRI and the follow-up CT performed 1 month later, the abscess seemed to be completely resolved. Three months after diagnosis, the patient was full recovered without any residual neurologic deficits. | [[48.0, 'year']] | M | {'21667269': 1, '23427029': 1, '26167038': 1, '12893401': 1, '12467694': 1, '11864347': 1, '16679664': 1, '15767825': 1, '17675790': 1, '7834601': 1, '16436297': 1, '15774018': 1, '17180609': 1, '22473142': 1, '15764177': 1, '11023953': 1, '15040934': 1, '8110922': 1, '16183134': 1, '24396636': 2} | {} |
164,554 | 3848538-1 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 10-year-old boy was referred to our pediatric gastroenterology unit with rectal bleeding. He had had episodes of diarrhea, sometimes bloody, during 10 years. Diarrhea had worsened (bloody and increased in frequency) over the 3 months before admission. His physical examination was unremarkable except for rectal prolapse. He had normal growth and had any evidence of bleeding diathesis, significant anemia, bacterial or parasitic infection, or any other systemic diseases. The laboratory examinations including complete blood count, stool examination for parasites and ova, Clostridium difficile toxin and coagulation profile were normal.\nColonoscopy showed an ulcer 2×2.5 cm in diameter located at 6 o'clock in the rectum. Histopathological examination revealed fibromuscular hyperplasia of the lamina propria. The treatment with mesalazin (5-aminosalicylate [5-ASA]) enema was initiated. The treatment was continued with oral sucralfate for 1 year. He is currently being followed with no treatment and further complaints. | [[10.0, 'year']] | M | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-2': 2, '3848538-3': 2, '3848538-4': 2, '3848538-5': 2, '3848538-6': 2} |
164,555 | 3848538-2 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 12-year-old boy with hypogammaglobulinemia was referred to our clinic for evaluation of a 1-year history of rectal bleeding. His physical examination was unremarkable except for pallor. He had anemia (hemoglobin [Hb], 10 g/L). Colonoscopy revealed solitary lesion 1×1 cm in diameter located between 6 and 9 o'clock in the rectum. Combined oral and enema treatment with mesalazin was initiated. No improvement was observed in his symptoms and follow-up colonoscopy showed no change in the lesion. In addition to ongoing therapy, steroid enema and treatment for constipation was initiated. He used rectal mesalazin and steroid during 1 year. His symptoms had completely resolved and he is currently being followed with no treatment. | [[12.0, 'year']] | M | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-1': 2, '3848538-3': 2, '3848538-4': 2, '3848538-5': 2, '3848538-6': 2} |
164,556 | 3848538-3 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 12-year-old boy was referred to our pediatric gastroenterology unit for evaluation of a 6-year history of constipation and bloody stool. His physical and laboratory examinations were normal. Colonoscopy revealed solitary lesion 1×5 cm in diameter located at 5 to 10 cm from the anal verge with circumferential distribution. Combined oral and enema treatment with mesalazin was initiated. Because of the failure to achieve clinical improvement in 6 months, second colonoscopy was performed and revealed no significant endoscopic improvement. Therefore, steroid enema (Entocort enema, Prednol-L ampoule, Mustafa Nevzat, Turkey) was used additionally (once a day for 6 months). He responded well to the treatment and his symptoms completely resolved. He is currently being followed with oral mesalazin (during last 1 year). | [[12.0, 'year']] | M | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-1': 2, '3848538-2': 2, '3848538-4': 2, '3848538-5': 2, '3848538-6': 2} |
164,557 | 3848538-4 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 14-year-old boy admitted with massive rectal bleeding. He had had abdominal pain and bloody diarrhea (10 to 12 episodes daily) during the last 3 months. His physical examination was normal except for pallor. Initial laboratory examinations revealed only anemia (Hb, 10 g/L). Colonoscopy was performed and revealed a lesion located circumferentially at a mean distance of 5 cm from the anal verge. Histopathological examination, including hyperplasia of lamina propria, mild crypt distortion confirmed the diagnosis of SRUS (). Combined oral and enema treatment with mesalazin (Salofalk, twice daily dosing) was initiated. Rectal steroid and rectal sucralfate (3×5 cc/day) was added. He responded well to the treatment and rectal steroid discontinued after 1 month. The rectal bleeding ceased (once every other day). Stool became soft and frequency decreased to two to three times a day. He is currently being followed with ongoing therapy (rectal sucralfate 2×5 cc/day) for SRUS. | [[14.0, 'year']] | M | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-1': 2, '3848538-2': 2, '3848538-3': 2, '3848538-5': 2, '3848538-6': 2} |
164,558 | 3848538-5 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 14-year-old girl was admitted with massive rectal bleeding. She had had constipation and recurrent rectal bleeding during the last 1 year. Despite receiving regular treatment for constipation, the bleeding had not resolved and massive rectal bleeding had occured over the last day before admission. Her physical examination was unremarkable except for pallor. Laboratory examinations revealed only anemia (Hb, 9.7 g/L). Colonoscopy revealed a solitary ulcer 1×2 cm in diameter located between 6 and 9 o'clock in the rectum. Treatment with rectal sucralfate and mesalazin was started. The bleeding ceased. She is currently being followed with ongoing therapy rectal sucralfate (2×5 cc/day). | [[14.0, 'year']] | F | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-1': 2, '3848538-2': 2, '3848538-3': 2, '3848538-4': 2, '3848538-6': 2} |
164,559 | 3848538-6 | 24,312,719 | noncomm/PMC003xxxxxx/PMC3848538.xml | Solitary Rectal Ulcer Syndrome in Children: A Report of Six Cases | A 16-year-old boy was admitted with rectal bleeding. He had had constipation for 4 years. Colonoscopy revealed multiple, ulcerated polipoid lesions located at 3 to 4 cm from the anal verge (). He responded well to the treatment with mesalazin, sucralfate (3×5 cc) and steroid enema. He is currently being followed with sucralfate enema (2×5 cc) during the last 1 month. The demographic and clinical characteristics of the cases are summarized in . | [[16.0, 'year']] | M | {'31898642': 1, '4045639': 1, '12456946': 1, '19115614': 1, '22266488': 1, '1740066': 1, '32766189': 1, '18188027': 1, '20453265': 1, '23236227': 1, '28848799': 1, '10731872': 1, '22094902': 1, '17139403': 1, '21160895': 1, '1183059': 1, '17080282': 1, '19636181': 1, '27610352': 1, '2651639': 1, '27086003': 1, '3536217': 1, '11153436': 1, '15999319': 1, '5358578': 1, '33936361': 1, '18188026': 1, '24312719': 2} | {'3848538-1': 2, '3848538-2': 2, '3848538-3': 2, '3848538-4': 2, '3848538-5': 2} |
164,560 | 3848546-1 | 24,312,718 | noncomm/PMC003xxxxxx/PMC3848546.xml | A Novel Germline Mutation in Exon 10 of the SMAD4 Gene in a Familial Juvenile Polyposis | A 21-year-old man presenting rectal bleeding visited our hospital. Based on initial laboratory results, his hemoglobin was mildly decreased of 12.7 g/dL, but no additional abnormalities were found. A colonoscopy indicated multiple colon polyps with hyperemic features (). Histological examination revealed hamartomatous polyps with cystically dilated glands, which were surrounded by stroma and showed prominent inflammatory cell infiltration (). Upper endoscopy identified the presence of other lesions and revealed numerous reddish polypoid lesions in the whole stomach (). To confirm small bowel involvement, capsule endoscopy was conducted and it showed numerous polypoid lesions in the jejunum and the ileum (). Endoscopic removal of gastric and colonic polyps was done. We planned the surveillance with upper endoscopy and colonoscopy every 1 to 2 years, and also planned the evaluation of small bowel every 2 to 3 years.\nThe patient's 47-year-old mother had a history of subtotal gastrectomy due to gastric polyposis with anemia 15 years earlier. She had also undergone a right hemicolectomy because of ascending colon cancer 2 years previously. A colonoscopy performed during that time indicated a pedunculated polyp, which is similar to the type of polyp found in her son (). The histological analysis of the polyps showed hamartomatous features that were consistent with juvenile polyposis () Upper endoscopy revealed multiple erythematous polyps in the stomach including cardia which are similar to her son ().\nGiven the clinicopathological findings and the family history, the diagnosis was FJP. Subsequently, written informed consent was obtained from both patients to perform genetic testing, and screening was performed to determine the presence of a germline mutation in the SMAD4, PTEN, and ENG genes in both patients. All coding exons and the flanking intronic regions of the SMAD4, PTEN, and ENG genes were amplified by polymerase chain reaction on a thermal cycler (Applied Biosystems, Foster City, CA, USA) using primer pairs designed by the authors. Direct sequencing was performed using the same primers on the ABI Prism 3130 Genetic Analyzer using the BigDye Terminator Cycle Sequencing Reaction Kit (Applied Biosystems). The sequences were analyzed using the Sequencher program (Gene Codes Corp., Ann Arbor, MI, USA) and compared with the reference sequence. The direct sequencing analysis revealed a novel nonsense mutation in the SMAD4 gene in both the mother and the son. The mutation, a C to G transition at position 1239 in exon 10, resulted in premature stop codon at tyrosine 413 (p.Tyr413*) (). To our knowledge, this mutation has not been described previously. The mutation was not detected in the PTEN and ENG genes. | [[21.0, 'year']] | M | {'17303595': 1, '25401122': 1, '11920286': 1, '10398437': 1, '11381269': 1, '16246179': 1, '26569228': 1, '34419139': 1, '22115830': 1, '18178612': 1, '17873119': 1, '19816839': 1, '34189096': 1, '22171123': 1, '22965402': 1, '12821112': 1, '12417513': 1, '28428902': 2, '1656892': 1, '20427401': 1, '9582123': 1, '10455879': 1, '7582207': 1, '2853131': 1, '9869523': 1, '24312718': 2} | {'5385889-1': 1} |
164,561 | 3848677-1 | 24,364,010 | noncomm/PMC003xxxxxx/PMC3848677.xml | Cesarean section in a patient with non-compaction cardiomyopathy managed with ECMO | The 39-year old, 68 kg and 165 cm patient, mother of a 20 year old son, was referred to our institution during the 33rd week of pregnancy. One year before, she had experienced multiple transitory ischemic attacks, she was in NYHA (New York Heart Association) class IV and IVNC was diagnosed based on echocardiography. Besides warfarin, which during pregnancy was switched to low molecular weight heparin, pharmacological therapy with an angiotensin converting enzyme inhibitor had been established. Although severe ventricular arrhythmias had been diagnosed, the patient refused implantation of an internal defibrillator. The transthoracic echocardiography (TTE) at admission showed the typical picture of IVNC: a massively dilated left ventricle (end-diastolic diameter of 80 mm - normal value <50mm), a mitral valve regurgitation grade I, a severely impaired left ventricular ejection fraction (LVEF) of 25% (normal value>55%) and a semi-systemic systolic pulmonary artery pressure (PAP) of approximately 60 mmHg. Due to the inherent risk of cardiac decompensation in the late pregnancy, the patient was admitted to our heart centre one week later and elective caesarean section scheduled for the 35th week of gestation. Due to the risk of sudden life-threatening decompensation during surgery, it was planned to perform the operation under general anaesthesia and “stand by” of veno-arterial extracorporeal membrane oxygenation (ECMO) for extracorporeal life support. On the day before surgery, TTE revealed further decrease of the LVEF to 20%, increase of the mitral valve regurgitation to grade II and increase of the systolic PAP to 2/3rds of the systemic value of approximately 80 mmHg.\nThe patient received 150 mg of ranitidine 12 and 2 hours before the operation. After having arrived in the anaesthesia induction room in nearly sitting position, 30 ml of sodium citrate (0.3 molar) was administered orally. Standard monitoring with electrocardiogram and pulsoxymetry was established. In addition, paddle leads for external defibrillation were placed. Thereafter, an arterial line was placed into the left radial artery; a 4 lumen central venous catheter and a 9 gauge introducer were placed into the right jugular internal vein in local anaesthesia. A pulmonary artery (PA) catheter with atrial and ventricular pacing option (Baxter International, Illinois, USA) was inserted into the introducer and placed into the PA.\nAt this time the heart rate was 110/min with multiple polytopic ventricular extra-systolic (VES) beats. In the nearly sitting position, the arterial blood pressure was 110/70/90 mmHg and the PAP 75/30/50 mmHg with a pulmonary capillary wedge pressure of 30 mmHg. Pharmacologic therapy with a continuous infusion of dobutamine 3 µg/kg/min and milrinone 0.25/kg/min was started. Additionally, two 6 French introducer catheters were placed under local anaesthesia into the right femoral artery and right femoral vein. These catheters were inserted to facilitate quick percutaneous access to the vessels for emergency installation of ECMO for extracorporeal life support in case of acute cardiac decompensation.\nAfter these preparations, the patient was transferred into the operating room and preparations for surgery were performed.\nAfter pre-oxygenation, anaesthesia was induced with 5 mg of rocoronium, 15 mg of etomidate, 35 mg of S ketamine and 100 mg of succinylcholine and a rapid sequence intubation was performed. Three minutes later, a healthy 2800 g child was delivered by classic longitudinal caesarean section (APGAR values of 9-10-10). Thereafter, anaesthesia was continued with a bolus of 30 mcg of sufentanil and 35 mg of rocoronium and a continuous infusion of remifentanil (2 µg/kg/min) and propofol (0.1 mg/kg/min) without using Target Controlled Infusion (TCI). Additionally, 1 g of paracetamol and 1 g of novamin-sulfate and 4 mg of ondansetron were infused. At the end of the procedure residual muscle relaxation was antagonized with 300 mg of sugammadex.\nDuring the entire period of anesthesia, hemodynamics remained completely stable, the PAP decreased to 1/3rd systemic values of 50/30/20 mmHg while, however, polytopic VES were still observed. The completely awake and orientated patient was extubated on the surgical room. The patient was transferred to the intensive care unit (ICU) and she remained here for 5 days. Therapy with milrinone and dobutamine was continued during ICU stay. The patient was discharged uneventfully from hospital 14 days after surgery. | [[39.0, 'year']] | F | {'16670098': 1, '32181020': 2, '24800200': 1, '15834351': 1, '21356004': 1, '17125992': 1, '19911495': 1, '31093376': 2, '21970146': 1, '15194627': 1, '24364010': 2} | {'6476149-1': 1, '7066400-1': 1} |
164,562 | 3848927-1 | 24,348,013 | noncomm/PMC003xxxxxx/PMC3848927.xml | First case of fungal keratitis caused by Pestalotiopsis clavispora | A 73-year-old male gardener presented to Kurume University Hospital in Japan in April 2012 complaining of a foreign body sensation in his right eye after sweeping up leaves and twigs on a windy day. He had a medical history of hypertension, paroxysmal atrial fibrillation, and angina. He had previously received anticoagulation therapy with warfarin. His ocular history in the right eye included cataract surgery (1990), five episodes of herpes simplex keratitis (2006, 2007, 2008 [two times], and 2010), three glaucoma surgeries (2007 [two times] and 2008), and bullous keratopathy (2011). He had been treated with corticosteroids for years ().\nAt initial presentation, his visual acuity was hand motion in the right eye and 20/250 in the left eye. Intraocular pressure (IOP) was not measured in the right eye, and was 6 mmHg in the left eye. Slit-lamp examination of the right eye revealed conjunctival injection and an oval infiltrate with feathery margins in the temporal half of the cornea (). Corneal opacity constrained visualization of the fundus in the right eye. Light microscopy of corneal scrapings taken from the right eye at initial presentation revealed uniformly thick septate hyphae (). The patient was diagnosed as having keratitis caused by a filamentous fungus, and was admitted to the hospital. A foreign body was found in the infiltrate when corneal debridement was performed (). The foreign body could not be identified.\nTopical corticosteroid treatment was discontinued, and topical treatment with voriconazole 1% hourly and pimaricin (natamycin) 1% ointment six times per day was initiated. One week after admission, the infiltrate decreased in size by about 1 mm. The patient was discharged at 1 month, after the infiltrate had resolved. At the time of discharge, visual acuity in his right eye was hand motion and IOP was 10 mmHg. Treatment with topical voriconazole four times per day, and pimaricin two times per day, was continued.\nA search for the causative organism was initiated at the Central Clinical Laboratory of Kurume University Hospital, but the organism was not identified. The isolate was then sent to the Laboratory for Clinical Investigation at Osaka University Hospital, where it was examined morphologically. The isolate was suspected to be Pestalotiopsis spp., based upon light microscopy with lactophenol cotton blue staining, which revealed conidia-bearing appendages ().\nA freshly isolated strain of Pestalotiopsis spp. from the clinical specimen was subcultured on potato dextrose agar (PDA) at 25°C for 7 days. An inoculum suspension was prepared in Roswell Park Memorial Institute (RPMI) 1640 medium and adjusted to a final inoculum of 10,000 conidia. The minimum inhibitory concentrations (MICs) for micafungin, amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole, miconazole, and pimaricin were determined by the method of microdilution in RPMI 1640 broth, according to the protocol approved by the Clinical and Laboratory Standards Institute. The final concentrations of the drugs were 0.015–16 μg/mL for micafungin, 0.03–16 μg/mL for amphotericin B, miconazole, and pimaricin, 0.12–64 μg/mL for flucytosine and fluconazole, and 0.12–8 μg/mL for itraconazole and voriconazole. Frozen microplates were obtained from Eiken Chemical Co., Ltd. (Tokyo, Japan). For the assay, 100 μL of adjusted inoculum were added, and the plates were incubated at 25°C, without shaking. All MICs were read at 48 hours.\nThe isolate was sent to Teikyo University Institute of Medical Mycology for further morphological and molecular identification. A colony incubated on PDA at 27°C in the dark for one month revealed that the conidia were narrowly fusoid to fusoid-clavate, straight or somewhat curved, five-celled, with the upper cell conical to cylindrical, hyaline, fairly thin-walled, without visible cellular contents, and bearing two to four rather stout central apical appendages, 10–20 μm long and up to 1 μm wide (). Based on these morphological characteristics, the isolate was identified as Pestalotiopsis spp.\nFungal DNA was extracted from the isolate according to the rapid method described by Makimura et al, and the internal transcribed spacer (ITS) region of the rRNA gene was sequenced directly from the polymerase chain reaction products with the ITS1–ITS4 universal primer pair.\nA Basic Local Alignment Search Tool (BLAST) search revealed the sequences had 100% similarity only to P. clavispora (EF119336), registered in the DDBJ/EMBL/GenBank database, and less than 100% similarity to other species of Pestalotiopsis.\nAlthough the isolate demonstrated relatively high resistance to voriconazole (MIC: 2.0 μg/mL) and pimaricin (MIC: 2.0 μg/mL) through antifungal susceptibility testing (), topical voriconazole and pimaricin continued to be used because the infiltrate decreased in size. Treatment was discontinued 7 months after discharge, based upon the absence of conjunctival injection and corneal infiltrate. Four days later, the keratitis had relapsed (). Although fungus was not isolated from corneal scrapings at this time, treatment with topical micafungin (MIC: 0.03 μg/mL) 0.1% half-hourly, intravenous micafungin 50 mg daily, and corneal debridement weekly was commenced, based on the results of antifungal susceptibility testing. Liver function and prothrombin time/international normalized ratio (PT-INR) were monitored periodically during systemic micafungin administration. The corneal infiltrate resolved 1 month after the relapse. Intravenous micafungin was discontinued, and topical micafungin was tapered over 7 months, after resolution from half-hourly to three times per day. During this period, the conjunctival injection and the corneal infiltrate were not seen. Visual acuity in his right eye was hand motion at the final visit, 7 months after resolution. No side effects related to topical voriconazole and micafungin were noted during the 15-month follow-up. Topical micafungin will be discontinued 1 year after resolution. | [[73.0, 'year']] | M | {'10074502': 1, '33628978': 1, '30574929': 2, '22249927': 1, '17172908': 1, '31817121': 1, '25809973': 1, '18490971': 1, '23689706': 1, '25492988': 1, '32977587': 1, '20168220': 1, '24348013': 2} | {'6324099-1': 1} |
164,563 | 3848928-1 | 24,348,012 | noncomm/PMC003xxxxxx/PMC3848928.xml | Diabetic papillopathy with macular edema treated with intravitreal ranibizumab | A 51-year-old male with a 10-year history of poorly controlled type 2 DM presented with acute painless visual loss in his right eye. His best-corrected visual acuity was 20/320 in the right eye and 20/50 in the left eye. Intraocular pressure was 12 mmHg in both eyes. An anterior-segment examination showed moderate nuclear sclerosis of both lenses. There was no afferent pupillary defect. Fundus examination of the right eye showed nonproliferative diabetic retinopathy with serous retinal detachment and a swollen optic disk with telangiectatic vessels (). Fluorescein angiography of the right eye showed optic disk leakage with the presence of microaneurysm (). Optical coherent tomography imaging of the right eye revealed serous macular detachment and a significant increase in retinal nerve fiber-layer thickness ( and ). Visual field examination showed diffuse depression on the right eye. Pattern visual evoked potential showed normal findings. The patient underwent clinical neurologic examination (including brain magnetic resonance imaging), blood pressure measurement, and complete blood count and electrolyte testing, all of which were within normal limits. Glycosylated hemoglobin was 10.9%. A diagnosis of DP and diabetic macular edema in the right eye was made. DP is a diagnosis of exclusion, made after other causes of disk swelling have been ruled out. Through full explanation of the expected effects and possible complications of intravitreal ranibizumab injection, informed consent was obtained from the patient before injection, and intravitreal ranibizumab (0.5 mg/0.05 mL) injection was performed using the standard technique.\nTwo weeks following injection, there was marked regression of disk swelling and improvement of macular edema, with visual acuity improving to 20/100 ( and ). Three months following injection, there was complete resolution of optic disk swelling, and visual acuity was 20/50 in his right eye ( and ). No further treatment was required. | [[51.0, 'year']] | M | {'2237759': 1, '28356776': 2, '22268957': 1, '11217941': 1, '15094720': 1, '15183815': 1, '12476102': 1, '20557939': 1, '18502511': 1, '34674724': 2, '25685281': 1, '32490284': 1, '7605280': 1, '22279402': 2, '21887082': 2, '24348012': 2} | {'3263167-1': 1, '5367760-1': 1, '8532332-1': 1, '8532332-2': 1, '3162739-1': 1} |
164,564 | 3849142-1 | 24,348,041 | noncomm/PMC003xxxxxx/PMC3849142.xml | Influence of cerebellar stereotactic stimulation on left–right electrodermal information transference in a patient with cerebral palsy | A 13-year-old boy suffering from cerebral palsy developed spastic quadriparesis with a pronounced startle reaction that seriously disabled his voluntary activity (patient in wheelchair). The patient had two deep brain stimulation electrodes (Medtronic model 3389; Minneapolis, MN, USA) stereotactically implanted (September 6, 2011) in the anterior lobe of the cerebellum (culmen and central lobule–superior cerebellar peduncle) from lateral suboccipital regions ( and ). The electrodes were temporarily connected to a transcutaneous extension to allow further clinical tests and neurophysiological examination, and effects of the stimulation were assessed and verified.\nAfter verification of the effectiveness of stimulation, an internal pulse generator (Medtronic Activa PC) was implanted (September 12, 2011) and stimulation programs were set for therapeutic stimulation (frequency, 250 Hz; pulse width, 0.180 milliseconds; amplitude: right electrode, 1.1 V, and left electrode, 2.7 V; and cycling mode of stimulation, on for 15 minutes, off for 3 hours). Using these parameters of stimulation, the patient was relaxed and spasticity decreased. During a test at a slightly higher amplitude (plus 0.2–0.4 V), the patient experienced an immediate feeling of pleasure. However, an even higher stimulation voltage (3–4 V) evoked bilateral aggravation of the pathological posture of the patient and was accompanied with an intense feeling of fear. For therapeutic stimulation, the amplitude was adjusted to the level at which relaxation and decreased spasticity were achieved.\nDuring experimental EDA measurement, the application of monopolar stimulation was performed in the interval from 1 to 1.5 V with an increase of 0.1 V in each step. The stimulation lasted 120 seconds. Because of stimulation spasticity and pathological startle, reactions were remarkably reduced and there was improved fluency in speech, mood, and cooperation of the patient during physical therapy. The study was approved by the Slovak Medical University ethical committee (Banska Bystrica, Slovakia), and all participants gave written informed consent. | [[13.0, 'year']] | M | {'12680998': 1, '17157435': 1, '11954558': 1, '17691310': 1, '11276236': 1, '300098': 1, '11036180': 1, '10789694': 1, '6977103': 1, '18572305': 1, '16963240': 1, '22079130': 1, '14745217': 1, '8799763': 1, '21541318': 1, '7639067': 1, '8170568': 1, '20956067': 1, '11255071': 1, '308193': 1, '22132204': 1, '11964575': 1, '1084966': 1, '24348041': 2} | {} |
164,565 | 3849310-1 | 24,311,932 | noncomm/PMC003xxxxxx/PMC3849310.xml | A Case of Korean Patient with Macular Corneal Dystrophy Associated with Novel Mutation in the CHST6 Gene | A 59 year-old female with a family history of MCD presented to our clinic with progressive loss of vision over a 40-year period. Her visual acuity was finger count/50 cm OU. Slit lamp examination revealed diffusely hazy corneas with bilateral opacities. There were multiple irregular grayish-white, dense, poorly delineated spots in the stroma. Because her parents died at an early age, her family history was unclear. Of note, her only son complained of foggy vision and was 37 years old. His slit lamp examination revealed a similar, but less severe appearing corneal exam compared to that of his mother ().\nPenetrating keratoplasty was performed on the right eye. A 7.75 mm donor button was sutured into a 7.5 mm host bed. Histopathologic examinations were conducted on the excised corneal buttons obtained from the procedure. Genomic DNA was extracted from the leukocytes of her peripheral blood via standard procedures. One year post-operatively, that patient had a best-corrected visual acuity of 20 / 100 OD and a clear cornea graft.\nInformed consent for both the clinical examinations and DNA analyses was obtained from the patient and her son in accordance with the Declaration of Helsinki. The study was approved by the institutional review board at the Catholic University of Korea, St. Mary's Hospital.\nHematoxylin and eosin (HE), alcian blue, periodic acid-Schiff (PAS), colloidal iron, and Masson's trichrome stains were performed on the specimen using standard techniques. For transmission electron microscopy, the corneal specimen was immersed immediately in a fixative solution containing 3% glutaraldehyde with 0.2 M sodium cacodylate at a pH of 7.4. After overnight fixation, the fixative solution was removed and replaced with a phosphate buffer, followed by 1% osmium tetroxide buffered with sodium cacodylate. After one hour, the osmium was replaced with increasing concentrations of ethanol through propylene oxide, and the tissue was embedded in the epoxy. The embedded tissue was then sectioned with an ultra-microtome into 1 µm-thick sections, and stained with toluidine blue. The area to be observed was placed under a light microscope, ultra-sectioned from 60 to 100 nm in thickness, double stained with uranyl acetate and lead citrate, and examined via transmission electron microscope (JEM 1010; JEOL, Tokyo, Japan).\nThe unique exon involving the coding region, exon 3, was amplified via polymerase chain reaction (PCR) with the previously described primers []. Thermal cycling was conducted via the following protocol. The cycling program began with an initial denaturing step of 5 minutes at 95℃ followed by 33 cycles of 94℃ for 30 seconds, 53℃ to 57℃ for 30 seconds, and 72℃ for 45 seconds with a final extension step at 72℃ for 10 minutes. The PCR products were purified and sequenced directly on both strands using an automatic DNA sequencer (ABIPrism 377XL; Applied Biosystems, Foster City, CA, USA). The nucleotide sequences were compared with the published cDNA sequence of CHST6 (NM_021615) [].\nLight microscopy showed a normal epithelium and Bowman's membrane. HE staining revealed faintly basophilic deposits between the stromal lamellae, and within keratocytes and endothelial cells. These deposits were positive to alcian blue, PAS, and colloidal iron stain, but negative to Masson's trichrome stain (). Electron microscopy revealed keratocytes distended by membrane-bound intracytoplasmic vacuoles containing electron-dense fibrillogranular material. These vacuoles harbored dense osmophilic whorls. Similar vacuoles were also present in the interstromal lamellae and endothelial cells ().\nAnalysis of the entire CHST6 coding region revealed distinct genetic defects. One missense mutation was identified in a homozygous state (p.Arg205Trp [c.613C>T]), which had not been previously reported. Samples from the patient's son also showed the same missense mutation (p.Arg205Trp [c.613C>T]) (). | [[59.0, 'year']] | F | {'4265065': 1, '4170533': 1, '11818380': 1, '27439461': 1, '19365571': 1, '16549065': 1, '15013869': 1, '14609920': 1, '11017086': 1, '6447876': 1, '14217673': 1, '7724173': 1, '11139648': 1, '3484610': 1, '26604660': 1, '19337156': 1, '24311932': 2} | {} |
164,566 | 3849311-1 | 24,311,933 | noncomm/PMC003xxxxxx/PMC3849311.xml | Self-inflicted Chronic Bacterial Keratoconjunctivitis Using Self Semen | A 20-year-old male soldier was referred to our clinic for the evaluation of refractory chronic bacterial conjunctivitis. Over the previous 4 months, he had been treated for copious mucous discharge, conjunctival injection, and superficial punctate keratitis on both eyes at an army hospital and a local eye clinic. The transfer note stated that Citrobacter koseri was cultured from a conjunctival swab, but targeted topical and systemic antibiotic treatment based on antimicrobial susceptibility testing had not been effective.\nIn our clinic, he also complained of ocular redness, pain, and severe discharge in both eyes. Best-corrected visual acuity was 20 / 20 in both eyes. Slit lamp examination showed multiple punctate erosions on the inferior cornea and severe conjunctival injection on both bulbar and palpebral conjunctiva (). Mucous discharge was observed in both eyes (). Other ophthalmic examinations were within normal limits.\nPrior to topical antibiotic treatment, conjunctival swabs were collected for smear and culture. Moxifloxacin 0.5% ophthalmic solution (Vigamox; Alcon Laboratories, Fort Worth, TX, USA) was prescribed for use every 2 hours. The conjunctival swabs revealed a mixed infection of Acinetobacter baumannii and Staphylococcus xylosus. As S. xylosus was reported to be resistant to moxifloxacin, topical vancomycin eye drops were added; however, despite 4 weeks of topical antibiotic treatment, the patient showed no improvement. On the repeated conjunctival swabs, microorganisms continued to be cultured, but different bacterial strains were observed, including A. baumannii and Chryseobacterium indologenes. The patient's complete blood count was normal, and serologic tests such as human immundeficiency virus antibody were negative.\nDuring the repeated smear and culture of conjunctival swabs, surprisingly, a few sperm were detected on Gram staining (), revealing that the condition was a self-inflicted bacterial keratoconjunctivitis involving the patient's own semen. We informed the patient and his father of the smear results and recommended a psychiatric consultation. | [[20.0, 'year']] | M | {'12689904': 1, '12640421': 1, '7171528': 1, '8081352': 1, '740856': 1, '28265427': 1, '18170109': 1, '15002007': 1, '1847025': 1, '2393650': 1, '7148943': 1, '24311933': 2} | {} |
164,567 | 3849312-1 | 24,311,934 | noncomm/PMC003xxxxxx/PMC3849312.xml | Free-floating Vitreous Cyst in an Adult Male | In December 2010, a 50 year-old male was referred to our clinic due to a floating mass in his right eye. The patient complained about floaters in the right eye which he had experienced since childhood. The patient`s uncorrected visual acuity was 10 / 10 in both eyes and he did not have any systemic disorder or history of trauma. His ophthalmological examination revealed an unremarkable anterior segment with no signs of inflammation. The intraocular pressure was 16 mmHg and 15 mmHg in the right and left eyes, respectively.\nIndirect opthalmoscopy and posterior segment biomicroscopy performed with a 90D lens were unremarkable in the left eye, but a single, oval 6×5 mm diameter cyst was identified in the right eye, floating freely in the vitreous. The cyst was partially masking the underlying retinal vasculature (). Optical coherence tomography was normal in both eyes. A B-scan ultrasound revealed an echo-free, round-shaped cyst that was free from surrounding vitreous strands and retina, and was located in the posterior vitreous (). Fluorescein angiography (FA) ruled out the presence of intra- and overlying vascularization of the cyst. Indeed, FA showed a clear-edged hypofluorescence due to a pre-retinal masking effect ().\nThe indirect hemagglutinin tests of the patient for ecinococcus and cysticercosis were negative. Eosinophilia was not detected in the preripheral blood smear. Ultrasonography of the liver, spleen and kidney revealed no pathology. Based on these findings the patient was diagnosed with a primary vitreous cyst. | [[50.0, 'year']] | M | {'9547797': 1, '26314744': 1, '15134115': 1, '9593381': 1, '10551312': 1, '24311934': 2} | {} |
164,568 | 3849313-1 | 24,311,935 | noncomm/PMC003xxxxxx/PMC3849313.xml | Frosted Branch Angiitis as Ocular Manifestation of Behçet's Disease: Unusual Case Report and Literature Review | A 39-year-old male presented with decreased vision in his left eye for two days. Visual acuity was 20 / 20 in the right eye and hand movement in the left eye. On slit lamp examination of the left eye, severe inflammation was seen in the anterior chamber (cells +4) and the vitreous (cells +4). Fundus examination of the left eye demonstrated thick, white, confluent sheathing surrounding the retinal veins and arteries from the posterior pole to the periphery with extensive retinal hemorrhages, optic disc swelling, and macular edema (). The right eye was normal. B-scan ultrasonography and spectral-domain optical coherence tomography of the left eye showed a severely edematous and detached retina in posterior pole (). Fluorescein angiography demonstrated a prolonged arteriovenous transit time, blockage of fluorescein corresponding to extensive retinal hemorrhage, widespread area of capillary non-perfusion, and extensive staining of sheathing veessels (). A diagnosis of occlusive retinal vasculitis resembling acute FBA was made and systemic evaluation for retinal vasculitis was performed. The patient had a history of recurrent genital and oral ulcers over two years, but no other systemic manifestations of Behçet's disease on presentation. The results of laboratory examinations, including serology for herpes virus, varicella zoster virus, and human immunodeficiency virus were normal or negative. Other examinations, including brain magnetic resonance imaging and polymerase chain reaction assay for varicella zoster virus and cytomegalovirus in the aqueous humor, were negative or normal. Human leukocyte antigen typing resulted in a positive HLA-B51.\nThe patient was started on intravenous methylprednisolone. Vitreous opacity progressed and angle hypopyon appeared until 24-hour after treatment initiation (). However, during two weeks after treatment, the vascular sheathing and vitreous opacity gradually disappeared. Systemic steroids were slowly tapered during the next two months and cyclosporine 150 mg/day was added. Two months later, follow-up angiographic findings revealed a widespread area of non-perfusion in three retinal quadrants with neovascularization of the disc (). Although panretinal photocoagulation for non-perfusion areas was performed, neovascularization progressed by four months (). However, iris rubeosis and neovascular glaucoma had not developed by 10 months. Six months after his presentation, he developed two ulcers on oral mucosa and pseudofolliculitis on his face, along the hairline. A diagnosis of Behçet's disease was made using the international criteria following a rheumatology consultation. Eight months later, follow-up optical coherence tomography imaging revealed atrophy and disruption of the photoreceptor layer in the macular area (). The final visual acuity was hand movement in the left eye. He is currently on maintenance cyclosporine therapy. | [[39.0, 'year']] | M | {'10528040': 1, '21501319': 1, '16422220': 1, '33980269': 2, '26055592': 1, '27287993': 2, '19616344': 1, '9355182': 1, '21034306': 1, '27065852': 2, '28410605': 2, '32613135': 1, '26612759': 1, '15131687': 1, '21586851': 2, '1970380': 1, '21677886': 1, '24311935': 2} | {'3120249-1': 1, '4901211-1': 1, '4821144-1': 1, '8114011-1': 1, '5392234-1': 1} |
164,569 | 3849314-1 | 24,311,936 | noncomm/PMC003xxxxxx/PMC3849314.xml | Ophthalmic Artery Aneurysm: Potential Culprit of Central Retinal Artery Occlusion | A 59-year-old woman presented to the emergency room with sudden visual loss in the right eye, which had started 15 hours prior. She denied past systemic or ophthalmic history. Her best corrected visual acuities were light perception OD and 20 / 22 OS. Her intraocular pressures were 13 mmHg OD and 12 mmHg OS by Goldmann applanation tonometry. Anterior segment examination was normal, and fundus examination demonstrated a pale retina with typical "cherry red spot" in the right eye. Her blood pressure, glucose, lipid, and coagulation profiles, as well as her erythrocyte sedimentation rate and C-reactive protein were within normal limits. Under the diagnosis of acute non-arteritic CRAO, she was urgently transferred to the neuro-intervention team for intra-arterial thrombolysis. Although there is some debate regarding the efficacy of intra-arterial thrombolysis for treatment of CRAO, her acute onset of symptoms within 15 hours without any systemic risk factors, and her insistence for further intervention encouraged consideration for thrombolysis therapy.\nTransfemoral cerebral angiography demonstrated normal choroidal blush with a patent right ophthalmic artery which was stemming from a 3.7 × 4.5 × 5.2 mm sized aneurysm located at the origin of the ophthalmic artery (). External cerebral artery angiography revealed visualization of distal parts of the ophthalmic artery via the middle meningeal artery. Due to the fear of aneurysm rupture, and as the middle meningeal artery collateral communication was confirmed, the right middle meningeal artery was selected for target vessel instead of ophthalmic artery and 200,000 units of urokinase and 100 grams of tirofiban were hand injected. Procedures were finished without any clinical or angiographic complications. The next day, her visual acuity improved to finger count and the right fundus showed macular edema with improved vascularity. Fluorescein angiography showed normal arteriovenous transit time and full peripheral perfusion (). Spectral-domain optical coherence tomography (SD-OCT; Spectralis OCT, Heidelberg Engineering, Germany) showed increased thickness and reflectivity of the inner retina (). Goldmann visual field test demonstrated typical temporal islands, and electroretinography revealed decreased amplitude of the b-wave in the affected eye. To evaluate other possible systemic causes of the CRAO, ancillary studies including brain magnetic resonance imaging, transcranial Doppler, Holter monitoring, carotid Doppler, and echocardiography were performed and no further abnormalities were found aside from an asymptomatic patent foramen ovale. Definite treatment of the ophthalmic artery aneurysm was not recommended considering the risk of the procedure. After four months, her visual acuities were stationary (hand motion), but SD-OCT showed atrophy of the inner retina (). | [[59.0, 'year']] | F | {'10612510': 1, '30918825': 1, '11476698': 1, '10690717': 1, '19577305': 1, '20949300': 1, '11056108': 1, '31853171': 1, '24311936': 2} | {} |
164,570 | 3849315-1 | 24,311,937 | noncomm/PMC003xxxxxx/PMC3849315.xml | Horner's Syndrome and Contralateral Abducens Nerve Palsy Associated with Zoster Meningitis | A 55-year-old woman presented with diplopia that had developed 12 days prior. The diplopia was preceded five days earlier by malaise and two days earlier by tingling sensation and pain in the right shoulder. The paresthesia spread along the whole right arm, and then arm weakness developed. Three days after the occurrence of paresthesia, the patient developed multiple painful vesicular eruptions on the right shoulder. After three more days, the tingling sensation involved the right lower leg.\nOn presentation, she was found to have 35 prism diopters of esotropia, which worsened on left gaze at distance and near in the primary position. There was an abduction limitation in the left eye (). The pupils were isocoric and reactive in both eyes. Visual acuity, the margin-reflex distance, levator function of the eyelid, anterior segments and fundi were normal in both eyes. The ocular and medical histories were unremarkable.\nOn neurological examination, right upper extremity strength was decreased to Medical Research Council grade II. Electromyography revealed a right C4 and C5 radiculopathy. Sensation was also decreased in the right C3 to C5 dermatomes. Although mental status was intact and brain magnetic resonance imaging (MRI) was normal, an analysis of cerebrospinal fluid (CSF) showed pleocytosis of 26 cells/mm3 and immunoglobulin (Ig) G varicella zoster virus (VZV) antibody. IgG and IgM VZV antibodies were detected in the serum as well. The patient was diagnosed as having zoster meningitis and was admitted for antiviral treatment. Acyclovir was administered intravenously and analgesics by mouth. With treatment, the skin lesions and shoulder weakness improved within one week.\nOn the 14th day after admission, she newly developed right blepharoptosis. The marginal reflex distance 1 was 1.5 mm in the right eye and 3.5 mm in the left eye. The levator function was 12 mm in both eyes. The patient complained of hemifacial anhidrosis on the right side. Pupils were reactive in both eyes, however were anisocoric with the pupil size of 3 mm in the right eye and 4 mm in the left eye in light. Anisocoria increased in the darkness to 3 mm in the right eye and to 4.5 mm in the left eye (). She was diagnosed as having Horner's syndrome in the right eye. There was no change in the abduction limitation of the left eye. By the 22nd day, the motor and sensory functions recovered considerably and the patient was discharged.\nWhen she returned to clinic one month after discharge, she demonstrated improvement of the abduction limitation in the left eye (), but anisocoria and blepharoptosis were still persistent.\nSix months after discharge, the abduction limitation and diplopia were completely restored. Anisocoria, blepharoptosis, and hemifacial anhidrosis resolved. The only remaining symptom was a mild paresthesia of the right arm. | [[55.0, 'year']] | F | {'7280987': 1, '14615640': 1, '338027': 1, '3763136': 1, '28298208': 1, '16908941': 1, '33835758': 1, '33012914': 1, '19952907': 1, '15232597': 1, '21275600': 1, '5504713': 1, '11051293': 1, '22131787': 2, '17361269': 1, '8113436': 1, '24311937': 2} | {'3223717-1': 1} |
164,571 | 3849750-1 | 24,339,843 | noncomm/PMC003xxxxxx/PMC3849750.xml | Staged Subtalar Fusion for Severe Calcaneus Fractures with Bone Loss | A 19-year-old woman was transferred to our trauma center from another facility for treatment of injuries she sustained as the unrestrained driver in a motor vehicle accident. She was found to have an open right calcaneus fracture, in which a 2 cm x 3 cm bone fragment from the posterior calcaneal facet had been extruded out the medial-sided 6 cm skin laceration. A CT scan was obtained, which demonstrated a comminuted intra-articular calcaneus fracture.\nThe patient was taken to the operating room that night for irrigation and debridement, where it was determined that the extruded bony fragment contained approximately two-thirds of the posterior facet of the calcaneus. It reportedly had a thread of attached viable soft tissue, and thus it was reduced back to its anatomic position. The patient was taken back to the operating room for repeat irrigation and debridement. At this time, it was felt that the bony fragment was no longer viable, and it was therefore excised. Three Steinmann pins were used for fixation of the remaining fragments, and the void left behind from excision of the posterior facet fragment was filled with a strand of antibiotic beads consisting of polymethyl methacrylate (PMMA) mixed with tobramycin and strung on a wire. The skin was closed without tension.\nThe medial wound healed over the course of two months and the skin recovered. The patient was taken to the operating room at 12 weeks after her initial injury for hardware removal, removal of the beads, and subtalar bone block fusion using iliac crest bone graft and resorbable beads mixed with tobramycin. She was allowed to bear full weight on her right lower extremity seven weeks postoperatively. Radiographic evidence of solid fusion was noted 15 weeks postoperatively.\nThe patient was able to wear a regular shoe and return to full time employment as a factory worker. | [[19.0, 'year']] | F | {'10406705': 1, '11722137': 1, '19013401': 1, '22443992': 1, '6471139': 1, '18670282': 1, '23386767': 1, '23460669': 1, '20182249': 1, '3066724': 1, '11465132': 1, '8403672': 1, '14668494': 1, '23787531': 1, '773941': 1, '23478886': 1, '14676549': 1, '23467872': 1, '22857958': 1, '24339843': 2} | {} |
164,572 | 3852629-1 | 24,968,390 | noncomm/PMC003xxxxxx/PMC3852629.xml | Congenital trans-mesenteric herniation: a rare cause of small intestine strangulation in adults | A 21-year-old woman who was otherwise healthy before presented with severe abdominal pain. The pain was generalized, severe, acute onset and continuous. She was also found to have multiple episodes of vomiting for a period of 24 h. Otherwise, she had no fever, no history of previous abdominal surgery, no other co-morbids and no trauma.\nOn examination she was drowsy, tachycardic with a pulse rate of 120 beats/min, BP 130/78 mmHg, temperature 37.0°C, dehydrated and respiratory rate of 24 breaths/min. An abdominal examination revealed distended abdomen, generalized abdominal tenderness and guarding. Bowel sounds were absent.\nLaboratory investigations results were normal, except for an elevated white blood cell count of 16 000/mm3.\nIn view of generalized peritonitis, the abdomen was explored through an emergency midline laparotomy after initial resuscitation.\nUpon entering the peritoneal cavity, 2 l of hemorrhagic fluid was drained. A loop of ileum had herniated through a small mesenteric defect. A total of 180 cm ileum noted to be gangrenous with loss of peristalsis and absent pulsations (Fig. ). Terminal ileum and the ileocecal junction were also nonviable. Pulsations of mesenteric vessels were intact. The mesenteric defect measuring 3 × 3 cm located about 4 cm from the mesenteric edge of mid-jejunum. There was no evidence of malrotation. A limited right hemicolectomy with extensive gangrenous small bowel resection was performed and a stapled side-to-side functional anastomosis created. The mesenteric defect mentioned earlier was closed with interrupted sutures. The patient recovered well from the surgery. She was allowed orally on day 3 post surgery (Figs –). | [[21.0, 'year']] | F | {'6729672': 1, '24880799': 1, '26612129': 2, '14121782': 1, '11152781': 1, '16612930': 1, '3752377': 1, '967490': 1, '14523875': 1, '12866012': 1, '17458600': 1, '24968390': 2} | {'4955433-1': 1, '4955433-2': 1} |
164,573 | 3852630-1 | 24,964,321 | noncomm/PMC003xxxxxx/PMC3852630.xml | The irreducible floating hip: a unique presentation of a rare injury | A 35-year-old male was involved in a high-speed urban dirt biking accident. The patient was stable with a GCS of 15 and was neurovascularly intact. His left knee exhibited a 10 × 20 cm medial traumatic arthrotomy and his thigh compartments were soft and compressible. Imaging revealed a left hip postero-superior dislocation, posterior wall acetabular fracture, ipsilateral transverse femoral diaphyseal fracture and an engaging hill-sachs-type lesion of the femoral head with the postero-superior acetabulum (Figs –). Cefazolin, gentamicin and tetanus prophylaxis were administered along with a bedside washout of the traumatic arthrotomy. The patient was medically cleared for operative intervention as all blood work and further imaging were normal.\nOperative management focused on closed reduction of the dislocated left hip. Two 5.0 mm Schanz pins with a carbon fiber bar (Zimmer, Warsaw, Indiana, USA) were placed in the proximal femur fragment. This was used to aid with the closed reduction maneuver of knee flexion, hip traction, adduction and internal rotation. Confirmed by intra-operative fluoroscopy, the femoral head was irreducible due to the engaging femoral head lesion on the acetabulum. A conversion to open reduction via a Kocher–Langenbeck approach in the lateral position ensued. The femoral head and posterior wall were reduced under direct visualization with two 3.5 mm pelvic reconstruction plates (Zimmer). The patient was moved to the supine position and underwent definitive femoral fixation with a retrograde, reamed femoral nail (Zimmer). Thigh compartments at the conclusion of the femoral fixation were tense and non-compressible, requiring a thigh compartment fasciotomy. Negative pressure therapy was placed over the incision and the knee laceration was primarily closed. After multiple washouts of his lateral fasciotomy incision, he was primarily closed 1 week after initial presentation. He was discharged non-weight bearing on his left lower extremity on post-operative day 22. Eleven months post-injury, he remains full weight bearing without assistance. He reports intermittent pain with ambulation and radiographs show early arthritic changes and heterotopic ossification of his left hip (Fig. ). | [[35.0, 'year']] | M | {'10392514': 1, '20512766': 1, '8437199': 1, '6026515': 1, '34709174': 1, '7085052': 1, '12213424': 1, '18301213': 1, '18921642': 1, '27830101': 2, '24964321': 2} | {'5086512-1': 1} |
164,574 | 3852632-1 | 24,964,323 | noncomm/PMC003xxxxxx/PMC3852632.xml | Laparoscopic repair of left paraduodenal hernia | A 35-year-old male presented to accident and emergency with left upper abdominal pain, nausea and loss of appetite for 3 days. On retrospective questioning, he admitted to a propensity to vomit occasionally after large meals dating back to his childhood. On examination his abdomen was mildly distended with tenderness and a mass in his left upper quadrant. Chest and abdominal X-ray were normal. CT scan of the abdomen and pelvis with oral and i.v. contrast showed a left paraduodenal hernia (Fig. ). Within 24 h his symptoms had resolved spontaneously and he was able to eat freely without pain and was discharged. He had mild left upper quadrant pain on a few occasions over the next 2 weeks and the option of surgical repair was discussed. As 50% or more paraduodenal hernias develop partial or complete small intestinal obstruction, surgical treatment was recommended. The patient decided to proceed to surgical treatment and a minimal access approach was planned.\nHasson's insufflations technique was used for an initial infra-umbilical port insertion. Two further operating ports were place in the right lower quadrant under direct vision. Laparoscopy confirmed the radiological findings; the majority of the small intestine was found to lie inside the paraduodenal hernial sac. The sac lay behind the mesentery of the descending colon extending cranially behind the transverse colon and splenic flexure and lesser sac in front of the structures of the left retro-peritoneum. The neck of the hernia neck was formed anteriorly by free edge of descending colonic mesentery containing inferior mesenteric vein and posteriorly by retro-peritoneum. The neck lay to the left and caudal to the duodeno-jejunal junction with the ligament of Treitz fusing with the superior boarder. The proximal Jejunum directly distal to the DJ flexure entered the sac, the terminal ileum was identified within the abdomen, the caecum lay in the right iliac fossa, the remainder of the small intestine was within the hernia (Fig. 1 and 2). There were peritoneal adhesions at the neck of the hernia to the viscera entering the sac which prevented spontaneous reduction. Operative reduction of the hernia commenced with sharp dissection of these adhesions, followed by sharp and blunt dissection, the neck of the sac was cleared and mobilized. Once this procedure was complete the small intestine was easily reduced to the abdominal cavity, occasional adhesions to the hernial sac were divided to complete this process (Fig. 3 and 4). The hernial neck was closed with a continuous suture opposing the peritoneum of the free boarder of the descending colonic mesentery to the peritoneum below the D-J flexure to the left of the aorta. Post-operative recovery was uncomplicated and discharge was within 23 h. The patient made good recovery and to date has had no recurrence of symptoms over 3 years of follow-up. | [[35.0, 'year']] | M | {'31006063': 1, '9419303': 1, '20635458': 2, '5664096': 1, '29848337': 2, '28739567': 1, '25437660': 1, '26826933': 1, '24964323': 2} | {'5977483-1': 1, '5977483-2': 1, '5977483-3': 1, '5977483-4': 1, '5977483-5': 1, '2908883-1': 1} |
164,575 | 3852797-1 | 24,964,319 | noncomm/PMC003xxxxxx/PMC3852797.xml | Spontaneous evisceration of bowel through an umbilical hernia in a patient with refractory ascites | A 50-year-old Caucasian male with a long-standing history of cirrhosis, secondary to chronic alcohol abuse and hepatitis C infection, presented to the Emergency Department with evisceration of his small bowel through an existing umbilical hernia (Fig. ). The patient had a complicated course of liver disease marked by recurrent ascites and hepatic encephalopathy. Two years prior, the patient had his umbilical hernia primarily repaired; however, he developed a recurrence of the umbilical hernia secondary to recurrent and refractory ascites. The patient stated that he suddenly noticed protrusion of bowel through his umbilical skin after a sudden coughing bout several hours prior to presentation. The patient also reported copious drainage of ascitic fluid through the hernia site following the evisceration. He presented to the emergency room dehydrated and with signs of peritonitis. The patient was promptly resuscitated and taken to the operating room. He underwent segmental small bowel resection and biologic mesh repair of the umbilical hernia. Following his surgery, the patient spent 7 days in the ICU after which he was transferred to a medical–surgical floor and subsequently discharged with normal bowel function and in stable condition. He has remained recurrence free several months after. | [[50.0, 'year']] | M | {'21621237': 1, '34336523': 2, '17976794': 1, '24964319': 2} | {'8321416-1': 1} |
164,576 | 3852857-1 | 24,968,428 | noncomm/PMC003xxxxxx/PMC3852857.xml | Massive prolapsed haemorrhoids managed by ablation and correction in a poor resourced area | A 75-year-old man was admitted electively to the hospital for assessment and management of persistent prolapsed haemorrhoids (Fig. ), despite recurrent surgery, thrice in the past 3 years. This was associated with constipation and straining at stool. There was fresh rectal bleeding not mixed with stool during defaecation. He had no loss of appetite nor weight loss. On examination, he was pale and tired-looking. Chest, cardiovascular and abdominal examinations were unremarkable. A rectal examination revealed massive, irreducible, prolapsed, circumferential haemorrhoids that were ulcerating, bleeding and occluding the anal orifice. The external components showed squamous hyperplasia with keratinization and a frond-like, friable appearance. Proctoscopy revealed solid palpable internal haemorhoidal components with a similar pigmentation (acanthosis) as the external components at their classic anatomical positions—the left lateral, right posterior and right anterior positions—but no definite rectal mucosal lesion was seen. Rigid sigmoidoscopy was normal. He was found to be anaemic with a haemoglobin level of 7 gm/dl. The differential diagnosis included an extensive locally advanced anal carcinoma, an extensive fungating perianal condylomata acuminata (Buschke-Lowenstein's disease), chronically prolapsed (fourth degree) haemorrhoids with external components or a chronic rectal prolapse. A biopsy revealed haematoma consistent with a haemorrhoid. His iron-deficiency anaemia was corrected by blood transfusion prior to an examination under anaesthesia.\nIn the lithotomy position, an extensive Milligan–Morgan haemorrhoidectomy with mucocutaneus skin bridges and high ligation was performed (Fig. ). The external component of the haemorrhoidal tissue disintegrated into black clots on dissection (Fig. ). An intussucepting rectal prolapse with a sulcus between the prolapse and the edge of the anal canal became evident. A modified Delorme's procedure was done by excising the redundant mucosal sleeve, reducing the prolapse and plicating the prolapsed muscle wall to the proximal rectal mucosa cuff (Fig. ). However, as most of the anal canal skin at the level of the dentate line was incorporated in the extensive internal and external haemorrhoidal engorgement and thus been excised en-bloc, the distal component of the plication was sutured but to the fascia (epimysium) overlying the internal anal sphincter. Pouting of the rectal mucosa at the anal orifice causing a mucoid leak was prevented by not stitching to the perianal skin. The wide perianal skin defects were approximated to facilitate healing and reduce pain (Fig. ). The estimated intra-operative blood loss was <300 ml. The anal sphincteric tone was satisfactory. His postoperative haemoglobin level was 9 g/l, for which he received a further unit of blood. A laxative (lactulose) was prescribed and the patient mobilized. He made good recovery with no passive or active (urge) incontinence. He was discharged on the eighth postoperative day on iron supplements and advised a high-fibre diet and regular follow-up. | [[75.0, 'year']] | M | {'12525915': 1, '14569447': 1, '17054255': 1, '12006945': 1, '8181407': 1, '12790985': 1, '12034384': 1, '12470995': 1, '24968428': 2} | {} |
164,577 | 3853028-1 | 24,968,426 | noncomm/PMC003xxxxxx/PMC3853028.xml | Disseminated enteroinvasive aspergillosis in a critically ill patient without severe immunocompromise | A 47-year-old man with a history of hepatitis C, hemophilia A managed on home Factor VIII and, recently, diagnosed ulcerative colitis on prednisone 40 mg for 10 days was transferred to our facility for concern for toxic megacolon and admitted to the medical intensive care unit (MICU). Admission vital signs were temperature 34.4°C, heart rate 96 bpm, blood pressure 107/51, respiratory rate 14 breaths per minute and oxygen saturation 97% on 3 l/min by nasal cannula. On physical examination, the patient was cachectic and his abdomen was distended and diffusely tender but without rebound tenderness or guarding. The rectal examination was positive for gross blood. A non-contrast abdomen and pelvis computed tomography (CT) scan was significant for pancolitis and the patient was started on antibiotics.\nEmergency general surgery was consulted, and the patient was transferred to the surgical intensive care unit (SICU). The patient developed hypotension requiring vasopressors and respiratory failure requiring mechanical ventilation. Over the next 2 days, leukocytosis and lactic acidosis normalized, and the patient was weaned off vasopressors and extubated. Clostridium difficile antigen was negative and antibiotics were narrowed.\nOn hospital day 6, the patient complained of sudden onset sharp abdominal pain and developed peritoneal signs on abdominal examination. Non-contrast abdominal CT scan demonstrated pneumoperitoneum, colitis and ascites. In the context of the patient's co-morbidities, the patient was deemed too high a surgical risk for exploratory laparotomy. The patient was taken to the operating room for a loop ileostomy rescue procedure. Intraoperatively, the small bowel appeared normal, and ascites appeared clear. The patient was extubated postoperatively and initially improved.\nOn postoperative day 3, he developed supraventricular tachycardia, respiratory failure requiring mechanical ventilation, hypotension requiring vasopressors and large-volume serosanguinous ascites drainage from the intra-abdominal drain. Concurrently, intraoperative ascites cultures grew Candida, Methicillin-resistant Staphylococcus aureus, and E. coli and appropriate antibiotic therapy was initiated. Sputum cultures grew 1+ Aspergillus fumigatus. A repeat endotracheal (ET) aspirate culture was negative for fungus, and a non-contrast chest CT scan demonstrated no evidence of a fungal pneumonia. For the next week, the patient remained intubated but was successfully weaned off vasopressors, and his abdominal examination improved.\nOn postoperative day 14, peritoneal signs and acute hypotension requiring vasopressors recurred. The patient developed black ileostomy output, bleeding from the intra-abdominal drain and bright red blood per rectum. The patient underwent an emergent exploratory laparotomy. Intraoperatively, the small bowel was necrotic from the distal jejunum to the distal ileum. Seventy-three centimeters of small bowel were resected, and a primary anastomosis was performed.\nPostoperatively, the patient had profuse, uncontrollable intra-abdominal bleeding and remained hemodynamically unstable. Despite massive transfusion and aggressive attempts to correct coagulopathy, the patient continued to deteriorate. Goals of care were changed to comfort measures, and the patient died the next morning. Concomitantly, a third ET aspirate culture was positive for 2+ A. fumigatus. The family refused autopsy.\nPathologic evaluation of the resected bowel revealed hemorrhagic, gangrenous bowel (Fig. ) and granular friable, ulcerated mucosa (Fig. ). Microscopically, there were areas of transmural bowel necrosis (Fig. ) and fungi within the bowel wall, artery wall and lumen (Fig. ). Gomori Methenamine Silver stain was characteristic of Aspergillus species (Fig. ). | [[47.0, 'year']] | M | {'23231712': 1, '15987390': 1, '29357049': 1, '29296188': 1, '18177225': 1, '22517788': 1, '28839844': 1, '17180588': 1, '16387806': 1, '6350492': 1, '11886192': 1, '15229094': 1, '24968426': 2} | {} |
164,578 | 3853105-1 | 24,968,427 | noncomm/PMC003xxxxxx/PMC3853105.xml | A rare opportunity for conservative treatment in a case of blunt trauma to the supradiaphragmatic inferior vena cava | A 20-year-old female was the restrained driver of a vehicle traveling ∼45 miles per hour when her vehicle crashed into a city bus. She was extricated on scene by emergency responders and brought to the trauma bay alert, oriented and in stable condition complaining of pain on deep inspiration as well as left leg pain. She denied any abdominal pain or light-headedness. Vital signs on arrival were heart rate of 115 bpm, respiratory rate of 20 breaths per minute and blood pressure of 101/76 mmHg; her Glasgow coma scale was 15. The initial chest radiograph showed a small, right-sided pneumothorax and pulmonary contusions. Two radiographic views of the left leg revealed comminuted, mildly displaced tibia and fibula fractures. Computed tomography (CT) scans of the brain and neck were unremarkable. A contrast-enhanced chest CT scan demonstrated non-displaced right lateral second and third rib fractures, right upper lobe pulmonary contusions with laceration and a small pneumothorax, partially visualized grade 5 liver laceration with active contrast extravasation, and an acute, traumatic supradiaphragmatic IVC injury with an associated moderate hematoma and contrast extravasation that appeared to be contained, as seen in Figs and . In view of incompletely imaged critical findings of the upper abdomen and continued hemodynamic stability of the patient, a dedicated abdomen and pelvis CT scan, seen in Figs –, was performed 20 min later, which showed a stable 1.3 cm pseudoaneurysm of the supradiaphragmatic IVC without extension into the pericardium, stable moderate pericaval hematoma surrounding the injury, stable grade 5 liver laceration and a trace amount of fluid in the peritoneal cavity. A liver transplant surgeon and a cardiovascular surgeon were consulted due to the presence of acute traumatic suprahepatic IVC pseudoaneurysm.\nThe patient remained in stable hemodynamic condition over the subsequent 3 h, and the decision was made to obtain an IVC venogram, depicted in Fig. , which showed a small focal contour irregularity of the suprahepatic IVC and slight irregularity of the right middle vein consistent with a pseudoaneurysm and no active contrast extravasation. Conservative management of the hepatic laceration and IVC injury was continued in the intensive care unit with strict bed rest. On post trauma day 3, her tibia and fibula fractures were repaired without complications. The patient was discharged on post trauma day 7. | [[20.0, 'year']] | F | {'16508504': 1, '32181075': 1, '20972205': 1, '10823550': 1, '22437064': 1, '11264087': 1, '10515547': 1, '9012433': 1, '17099508': 1, '23438570': 1, '19215898': 1, '24968427': 2} | {} |
164,579 | 3853234-1 | 24,964,329 | noncomm/PMC003xxxxxx/PMC3853234.xml | Primary spinal epidural Hodgkin's lymphoma | A 30-year-old male patient was admitted to our clinic with back pain. Pain was provoked by movements. The severity of pain was associated with the inability to perform the activities of daily living. The patient did not have any lymphoma-related B-type symptoms, including body weight loss, fever and sweat at night. He did not have a past and family history. There was no neurological deficit. Routine laboratory test results were normal. A magnetic resonance imaging (MRI) scan of the thoracic spine demonstrated an epidural tumor at the T9–11 level (Figs –). The patient underwent spinal cord decompression via total laminectomy of T9–11 levels. Subtotal resection of the tumor was performed. Histological examination revealed the polymorphous cellular infiltration by histiocytes, large mononuclear cells and lacunar Reed–Sternberg cells with folded multi-lobed nuclei and small nucleoli (Fig. ). Immunohistochemical staining was positive for CD15 and CD30 and negative for CD3, CD20, CD79a or CD45Ro. These features were most frequently observed in the mixed cellularity type of Hodgkin's lymphoma. Histological examination of the vertrebral body revealed no abnormality. The results of all other examinations (F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET/CT), bone marrow biopsy and computed tomography (CT) of the chest, abdomen and pelvis) were negative for an occult disease. The patient was referred to the hematology department to undergo staged treatment. Six courses of chemotheraphy containing ABVD regimen (adriamycin, bleomycin, vinblastine and dacarbazine) were given to the patient. Postoperative MRI scan did not reveal any evidence of Hodgkin's disease (Fig. ), F-18 FDG PET/CT, CT of the chest, abdomen and pelvis were obtained in 24 months and did not reveal any evidence of Hodgkin's disease. | [[30.0, 'year']] | M | {'17445629': 1, '32990023': 1, '11504124': 1, '7102395': 1, '1383821': 1, '12913100': 1, '16412837': 1, '19433288': 1, '7871955': 1, '24964329': 2} | {} |
164,580 | 3853346-1 | 24,964,320 | noncomm/PMC003xxxxxx/PMC3853346.xml | Unusual presentation of popliteal soft tissue sarcoma: not every swelling in the knee is a Baker's cyst | An 80-year-old female presented to the general practitioner with 3-month-old history of gradual onset swelling in the back of her right knee, painful right leg and swelling in her right ankle. There was no history of trauma, constitutional symptoms, weight loss or loss of appetite. She lived alone and was independently mobile.\nShe suffered from gout, hypertension and asthma but otherwise quite fit for her age.\nOn examination, she had a nontender 5 × 5 cm fluctuant and nonpulsatile lump in popliteal fossa with no overlying skin changes.\nAn ultrasound scan (Fig. ) revealed a large mass lesion with heterogeneous appearances in the popliteal fossa extending between the two heads of the gastronemii and large blood vessels in the central region of the mass. It measured ∼13 × 5.5 × 4.5 cm in dimension and a magnetic resonance imaging (MRI) scan was suggested to rule out mass arising from the popliteal vessels being enveloped by the mass.\nThe MRI scan of the right knee (Figs and ) with gadolinium-enhancement showed a large mass lesion in the posterior aspect of the right knee extending into the popliteal fossa and into the upper third of the right leg having appearance of bursal pathology. Post gadolinium images showed evidence of circumferential rim enhancement but no internal enhancement indicating the presence of a fluid filled lesion. The mass (Figs and ) measured ∼8.39 × 6.14 × 12.72 cm and was seen between semimembranosus and biceps femoris muscles. There was no evidence of any infiltration of either the sciatic nerve or the popliteal vessels. A likely diagnosis of complicated synovial cyst with a differential diagnosis of haematoma was reported and a provisional diagnosis of Baker's cyst was established.\nShe was admitted a month later in the medical ward with right leg swelling to rule out deep vein thrombosis. On admission, she had calf tenderness, right lower leg pitting oedema, mild erythema around the foot and ankle and faint peripheral pulses. Venogram ruled out deep vein thrombosis and X-ray of the knee revealed extensive ill-defined calcification within the soft tissue mass in the popliteal fossa extending posteriorly to the proximal tibia but no other bony abnormality was found.\nTwo months later she was admitted under vascular surgeons with critical ischaemia of the right leg. Doppler examination revealed swollen calf, reduced sensation in the foot and absent pulses in posterior tibial and dorsalis pedis arteries.\nAn urgent incisional biopsy of the popliteal mass was performed, which revealed soft tissue sarcoma (STS). A CT scan confirmed soft tissue mass consistent with STS in the popliteal fossa with metatstasis to the lungs and stomach.\nPatient was offered above-knee amputation which she declined and subsequently developed gangrene of her foot. This patient had a rapid worsening of her symptoms over a few months but unfortunately her diagnosis was delayed till she developed neurovascular compromise and already had secondary lesions implying a very poor prognosis and she chose not to have any intervention. | [[80.0, 'year']] | F | {'5057099': 1, '7134987': 1, '16957647': 1, '1336692': 1, '17174515': 1, '24964320': 2} | {} |
164,581 | 3853399-1 | 24,347,911 | noncomm/PMC003xxxxxx/PMC3853399.xml | Palliative Radiation in Primary Squamous Cell Carcinoma of Thyroid: A Rare Case Report | A 70-year-old male patient noticed a rapidly increasing painless mass at the anterior aspect of the left side of neck for 1 month. It was also associated with dysphagia and stridor for 2 weeks. He was a heavy smoker who used to smoke 1 pack of cigarettes/day. There was no history of any previous radiation exposure in the neck. On physical examination, an 11 cm × 7 cm firm lobulated mass was found in the left side of the anterior aspect of the neck. His routine blood investigations and chest X-ray were within the normal limit.\nContrast enhanced computed tomography scan showed evidence of well-defined large, lobulated heterogeneously enhancing solid cystic lesion measuring 11 cm × 8.6 cm × 7.4 cm in relation to the left lobe of thyroid gland. The lesion showed multiple thin intervening septae along with few specks of calcification within it. Posteriorly lesion was extending up to the vertebral column and inferiorly retrosternally up to the brachiocephalic trunk. Mass effect of the lesion was seen in the form of compression and displacement of the trachea toward right and there was also compression and displacement of the left subclavian and carotid vessels, left internal jugular vein and left sternocleidomastoid []. His endoscopy findings were within the normal limit. On positron emission tomography scan, a large multi lobulated heterogeneously enhancing solid-cystic mass (7.8 cm × 7.7 cm × 5.8 cm) was seen in the left side of the neck arising from the left lobe of the thyroid gland with intense fluorodeoxyglucose (FDG) avidity (standardized uptake value max 17.7) in the solid component and along the peripheral margin of the cystic component. The mass was extending into the anterior mediastinum until the level of D4 vertebra and posteriorly until the prevertebral fascia. It was seen to displace the trachea to the right and compressing it []. No FDG avid focus was found in any other part of the body.\nFine-needle aspiration cytology (FNAC) revealed scattered malignant epithelial cells which showed moderate pleomorphism, high nuclear cytoplasmic ratio, hyperchromatic nuclei and mild to moderate cytoplasm. Large areas of necrosis were also seen. The overall features were those of SCC [ and ].\nAggressive treatment in the form of radical surgery was not possible in this particular patient because of its unresectability due to encasement of major vessels. Hence, we delivered palliative radiotherapy 30 Gy in 10 fractions over 2 week's period. Though there was not much regression of the disease, but his pain and shortness of breath was improved reasonably and patient is leading a good quality-of-life for last 1 year. | [[70.0, 'year']] | M | {'11869012': 1, '10912933': 1, '27872538': 1, '3394892': 1, '3184953': 1, '7427886': 1, '28100571': 1, '28633125': 1, '7507159': 1, '10556008': 1, '10432891': 1, '30719559': 1, '16487020': 1, '2193180': 1, '24347911': 2} | {} |
164,582 | 3853457-1 | 24,212,310 | noncomm/PMC003xxxxxx/PMC3853457.xml | Pigmented paravenous chorioretinal atrophy with Coat's like response | A 64-year-old man of Asian origin presented to us with complains of slowly progressive defective vision left eye (OS) for five years. There was no history of suggestive of previous inflammation, trauma or nyctalopia, or family history of retinal disorder. He was a known hypertensive on regular treatment.\nHis best corrected visual acuity (BCVA) was 20/20 right eye (OD) and 20/32 OS. Anterior segment was unremarkable both eyes (OU). Central fields were normal. Fundus evaluation showed pigment clumps along the retinal veins with variable chorioretinal atrophy extending from the disc up to equator OU [Fig. and ] and intraretinal and subretinal exudation with telangiectasia along the superotemporal vein OU w(more evident clinically in OS). A clinical diagnosis of PPCRA with CLR, OU was made.\nElectroretinography (ERG) was normal OU. Fluorescein angiography showed areas of hyperfluorescence in atrophic areas in the peripapillary area and hypofluorescence corresponding to the pigment clumps along the retinal veins along with its branches with telangiectasia and exudation along superotemporal vein OU and multiple macro aneurysms with capillary nonperfusion areas OS akin to Coat's disease (CD) [Fig. -]. | [[64.0, 'year']] | M | {'2751980': 1, '3676145': 1, '646699': 1, '18169492': 1, '1180304': 1, '2457260': 1, '434087': 1, '30127171': 2, '28559726': 1, '6676982': 1, '24212310': 2} | {'6113825-1': 1} |
164,583 | 3853458-1 | 24,212,311 | noncomm/PMC003xxxxxx/PMC3853458.xml | Infestation of the lacrimal sac by Rhinosporidium seeberi: A clinicopathological case report | A 25-year-old North-Indian male presented to our center with history of recurrent painful swelling below the right lower lid for the past 1 year with associated watering. He also gave history of chronic sinusitis for the past 10 years. There was no history of purulent or serosanguineous discharge. He was diagnosed elsewhere as a case of chronic dacryocystitis of the right lacrimal sac and treated with systemic antibiotics with no resolution in symptoms. A computerized tomography (CT) scan was done 1 year back which reported a small oval swelling in the right medial canthal region with deviated nasal septum, bilateral small maxillary sinus polyps, and concha bullosa.\nOn examination, vision was 6/6 N6 in both eyes. Anterior and posterior segment examinations of both eyes revealed normal findings. There was fullness of the right lower lid with erythema, induration, and tenderness. Regurgitation on pressure on the lacrimal sac (ROPLAS) was negative and syringing showed the lacrimal drainage system to be bilaterally patent. A clinical diagnosis of right partial nasolacrimal duct obstruction with preseptal cellulitis was made. An otolaryngology opinion was sought. Nasal endoscopic evaluation revealed a deviated nasal septum to the left with giant concha bullosa with tenderness and congestion over the lacrimal sac area. The patient was started on systemic antibiotic and nonsteroidal anti-inflammatory agents. However, there was no clinical improvement even after 1 month. Since his clinical features were suggestive of idiopathic orbital inflammatory disease (IOID), a trial of systemic steroids was given. The patient reported symptomatic relief after 2 days.\nMeanwhile, the patient underwent right conchoplasty under general anesthesia by the otolaryngologist based on the history of recurrent episodes of pain and diagnostic nasal endoscopic findings. During surgery, area around the lacrimal sac was found to be inflamed and a tissue biopsy was taken. It revealed multiple sporangia and sporocysts of R. seeberi with chronic inflammation.\nIn view of the diagnosis, it was decided to excise the lacrimal sac after counseling the patient about postoperative epiphora. Right dacryocystectomy was performed under local anesthesia. There was brisk intraoperative bleeding. The sac was removed completely along with nasolacrimal duct with wide excision and generous electrocauterization of the surrounding margins. The wall of nasolacrimal duct was also cauterized. The lacrimal sac fossa was copiously irrigated with 5% povidone-iodine solution.\nOn histopathological examination, the lacrimal sac showed fibrocollagenous tissue with dense lymphocytic infiltration. Multiple vascular channels were seen with areas of hemorrhage. Numerous sporocysts in various stages of maturation were seen just underneath the stratified squamous epithelium of the lacrimal sac [].\nThe patient has been counseled about the chances of recurrence of infection and advised periodic checkup. | [[25.0, 'year']] | M | {'22224014': 1, '16687856': 1, '27003980': 2, '10827117': 1, '16552528': 1, '31703563': 1, '17657050': 1, '4465292': 1, '31686971': 1, '20578497': 1, '10449446': 1, '9715938': 1, '24212311': 2} | {'4780178-1': 1} |
164,584 | 3853461-1 | 24,212,314 | noncomm/PMC003xxxxxx/PMC3853461.xml | Optical coherence tomographic findings in optic nerve hypoplasia | A 67-year-old woman presented with blurring of the left eye. The patient presented with best-corrected visual acuity of count fingers at 2’ oculus dexter (OD) and 20/40 oculus sinister (OS). A relative afferent pupillary defect was observed in the right eye. There were nuclear sclerosis (Lens Opacities Classification System (LOCS) III grading = 1) in both eyes. A small optic disc and double ring sign were observed in the right eye and left was normal.\nIn order to evaluate the thickness of each layers of retina, OCT imaging was performed for both eyes. 5-line Raster scan, which makes five line scans with 6 mm width in horizontal and each separated by 250 μm, and optic disc cube scan were generated. We selected the results with minimum signal strength seven and the third row of the five line scans that passed the fovea to compare both eyes.\nTo compare and analyze each layers of the retina, 21-points of each Raster scans were selected using the caliper tool in the device. Each points were located at 250; 500; 750; 1,000; 1,250; 1,500; 1750; 2,000; 2,250; and 2500 μm apart from the fovea to nasal and to temporal side.\nOur OCT device did not provide thickness maps of each layers of retina, which was the main concern in this study. Therefore, for quantitative analysis of retinal layers, segmentations were done to three parts, which were RNFL, inner retinal layer (IRL), and ORL; on the basis of internal limiting membrane, posterior boundary of the RNFL, posterior boundary of the outer plexiform layer, and anterior boundary of the cone outer segment tip line.[] RNFL thickness (RNFLT), IRL thickness (IRLT), and ORL thickness (ORLT) were measured manually using the caliper tool in the device. The Wilcoxon's signed-rank test and t-test were used for the comparison of RNFLT, IRLT, and ORLT; between both eyes. Statistical analysis was performed using SPSS®, version 14.0 (SPSS Inc., Chicago, IL). The results were considered significant at P < 0.05.\nThe average of RNFLT of ONH was thinner than the opposite eye [] and the thickness analysis of each five line scans were represented by a graph and fundus photograph map, respectively []. RNFLT and IRLT of ONH were significantly thinner than the opposite eye, for all five lines (P < 0.05). However, ORLT did not show significant difference between both eyes for all five lines (P > 0.05). In addition, to compare the thickness of retinal layers of the nasal and temporal areas from the fovea, each 50 points from the fovea to the nasal and temporal sides were divided into two groups. The results were the same as above. RNFLT and IRLT of the right eye were significantly thinner than the left eye on the temporal and nasal side (P < 0.000), but ORLT did not show significant difference between both eyes (P = 0.879, 0.164). The differences of RNFLT and IRLT between both eyes are greater on the nasal side than the temporal side as shown in (difference of RNFLT between both eyes on the temporal and nasal side: 2.04 vs 9.02 μm, IRLT: 20.86 vs 45.02 μm). | [[67.0, 'year']] | F | {'25727589': 1, '21825201': 1, '2191713': 1, '3310293': 1, '1624045': 1, '21323261': 1, '28205530': 1, '25128595': 1, '17392858': 1, '25939636': 1, '24212314': 2} | {} |
164,585 | 3853464-1 | 24,212,317 | noncomm/PMC003xxxxxx/PMC3853464.xml | Clinical utility of 18 Fluorodeoxyglucose (FDG)-PET/CT scans in patients with suspect ocular tuberculosis | A 38-year-old female patient presented with a history of recurrent attacks of bilateral pain, redness, and visual loss since the past 2 years. Previous investigations included a complete blood count and a mantoux test, and had 1 month ago, been started on empirical antitubercular therapy (based on a “positive” result) along with topical corticosteroid therapy.\nHer best corrected visual acuity was counting fingers at 2 meters in the right eye and counting fingers close to her face in her left eye. Slit lamp examination of her right eye revealed fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber was shallow with 360 ° adherence of the iris to the capsule of a complicated cataract. There was significant forward bowing of the iris diaphragm with peripheral anterior synechiae. There was significant iris neovascularization seen. Similar findings were seen in the left eye but there was a more marked shallowing of the anterior chamber with extensive irido-corneal touch. There was no fundal view but an ultrasound showed an anatomically normal posterior segment. The intraocular pressure was 10 and 8 mmHg.\nA repeat mantoux test showed induration of 21×18 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme, and serological tests to detect HIV infection were normal.\nA 18 FDG-PET scan revealed a metabolically active, large 3×2.2 cm heterogenous right supraclavicular, partially necrotic, lymph node (SUV max 6.6) [Figure , ]. There were metabolically active lymph nodes in the chest (right paratracheal [1.0×1.5 cm; SUV max 5.5] and subcarinal [1.5 × 2.6 cm; SUV max 7.7]) but the lungs were clear. Minimally metabolically active nodes were seen in the axilla.\nShe underwent ultrasound guided fine needle aspiration cytology of the right cervical lymph node that was highlighted on the PET/CT scan. The microscopic examination revealed caseating granulomas suggestive of tuberculosis. A Transcription Mediated Amplification (TMA) polymerase chain reaction (PCR) for mycobacterium tuberculosis genome had a positive result.\nShe was started on a standard four drug antitubercular regimen along with topical and periocular steroid therapy. On last follow up one month later there was a marked reduction of clinical anterior chamber activity. | [[38.0, 'year']] | F | {'20935307': 1, '3975863': 1, '24212317': 2} | {'3853464-2': 2} |
164,586 | 3853464-2 | 24,212,317 | noncomm/PMC003xxxxxx/PMC3853464.xml | Clinical utility of 18 Fluorodeoxyglucose (FDG)-PET/CT scans in patients with suspect ocular tuberculosis | A 58-year-old female patient presented with a history of persistent pain, redness accompanied by bilateral visual loss since the past one and one half years. Previous significant medical history included surgery for pituitary macroadenoma 26 years ago. Previous investigations included a mantoux test that had been reported as “positive” but the patient had declined to start antitubercular therapy.\nHer best corrected visual acuity was counting fingers at 6/12 in the right eye and 6/36 in her left eye. Slit lamp examination of her right eye revealed multiple fresh nongranulomatous keratic precipitates with a severe anterior chamber reaction (cells 2+, flare 2+). The anterior chamber had a normal depth but there were extensive posterior synechiae with a complicated cataract. similar findings were seen in the left eye.\nThe disc and the retina were normal in either eye. The intraocular pressure was 10 and 12 mmHg.\nSystemic evaluation revealed palpable cervical and axillary lymph nodes. A repeat mantoux test showed an induration of 22× ×25 mm. Her total and differential blood counts, tests for serum creatinine, serum calcium, serum angiotensin converting enzyme and serological tests to detect human immunodeficiency virus (HIV) infection were normal.\nA 18 FDG-PET scan revealed several metabolically active, bilateral level 5 lymph nodes in the neck, the largest on the left side measuring 1.6 ×1.8 cm with SUV max 5.5 and the largest on the right measuring 1.4 cm with a SUV max 5.2. The lungs and mediastinum were clear. Several metabolically inactive nodes were seen bilaterally in the axilla.\nShe underwent an ultrasound guided biopsy of a right posterior cervical lymph node suggested by the PET/CT scan. The microscopic examination revealed several medium sized epithelioid granulomas with occasional central necrosis suggestive of tuberculosis.\nShe was started on standard four drug therapy along with topical and periocular corticosteroids. Two months later there was a marked reduction of clinical anterior chamber activity. | [[58.0, 'year']] | F | {'20935307': 1, '3975863': 1, '24212317': 2} | {'3853464-1': 2} |
164,587 | 3853465-1 | 24,088,642 | noncomm/PMC003xxxxxx/PMC3853465.xml | Association of extensive myelinated nerve fibers and high degree myopia: Case report | A 9-year-old girl was presented with strabismus. Best corrected visual acuity (BCVA) was 20/300 and 20/20 in the right and left eyes. Cycloplegic autorefractometric measures revealed refractive error of –16.00 (–2.25 α 175 °) dioptry (D) and +1.50 (–0.75 α 5 °) D in the right and left eyes. Biomicroscopic examination was normal, dilated fundus examination was unremarkable in the left eye. Extensive peripapillary myelinated retinal nerve fibers were present in the right eye []. Cover-uncover test revealed constant 40-prism dioptry (PD) right esotropia. A-scan ultrasound biometry showed an axial length of 24.84 mm and 21.03 mm in the right and left eyes. Contact lenses were prescribed, and occlusion therapy 4 hr/day was initiated. The visits were scheduled for 3rd, 6th, and 9th months for monitoring the visual acuity. During the 3 visits, no increase in right BCVA could be achieved []. | [[9.0, 'year']] | F | {'29403600': 1, '7224936': 1, '484678': 1, '1890569': 1, '9559744': 1, '12003622': 1, '3598829': 1, '31242454': 1, '2358833': 1, '17765436': 1, '24088642': 2} | {'3853465-2': 2, '3853465-3': 2, '3853465-4': 2} |
164,588 | 3853465-2 | 24,088,642 | noncomm/PMC003xxxxxx/PMC3853465.xml | Association of extensive myelinated nerve fibers and high degree myopia: Case report | A 5-year-old girl was referred to our clinic for strabismus and low vision. BCVA was 20/200 and 20/20 in the right and left eyes. Cycloplegic autorefractometric measures revealed refractive error of –18.00 (–1.25 α 165 °) D,−0.25 (–0.50 α 15 °) D in the right and left eyes. Cover-uncover test revealed 10 PD right esotropia. Anterior segment examination was normal. In fundus examination, extensive myelinated nerve fibers were detected in the right eye, left eye was normal. The patient was prescribed –15.50 (–1.00 α 165 °) D and –0.50 (–0.50 α 15 °) D spectacles, and 4 hr/day occlusion therapy was initiated. There was no increase in BCVA during the 3rd, 6th, and 9th months’ visits. | [[5.0, 'year']] | F | {'29403600': 1, '7224936': 1, '484678': 1, '1890569': 1, '9559744': 1, '12003622': 1, '3598829': 1, '31242454': 1, '2358833': 1, '17765436': 1, '24088642': 2} | {'3853465-1': 2, '3853465-3': 2, '3853465-4': 2} |
164,589 | 3853465-3 | 24,088,642 | noncomm/PMC003xxxxxx/PMC3853465.xml | Association of extensive myelinated nerve fibers and high degree myopia: Case report | A 4-year-old girl was brought to the clinic for preschool screening. BCVA was 20/160 and 20/25 in the right and left eyes. Sciascopic measures with cycloplegia were –4.00/–4.00 D and +2.00/+2.00 D in the right and left eyes. Biomicroscopic examination was normal. No manifest squint was detected. Extensive myelinated nerve fibers were detected in the right eye. Left eye was normal. The patient was prescribed with –3.00 D and vertical plane spectacles and 4 hr/day occlusion. During the 3rd, 6th, and 9th months follow-up, minimal increase in visual acuity was recorded. The BCVA was 20/125. She is still in follow-up. | [[4.0, 'year']] | F | {'29403600': 1, '7224936': 1, '484678': 1, '1890569': 1, '9559744': 1, '12003622': 1, '3598829': 1, '31242454': 1, '2358833': 1, '17765436': 1, '24088642': 2} | {'3853465-1': 2, '3853465-2': 2, '3853465-4': 2} |
164,590 | 3853465-4 | 24,088,642 | noncomm/PMC003xxxxxx/PMC3853465.xml | Association of extensive myelinated nerve fibers and high degree myopia: Case report | A 32-year-old woman referred to our clinic for low vision in the left eye. Her BCVA levels were 20/20 and 20/200 in the right and left eyes. Cycloplegic autorefractometric measures revealed refracter error of +1.00 (+0.25 α 105 °) D and −6.75 D in the right and left eyes. Biomicroscopic examination was normal. Extensive myelinated nerve fibers were detected in the left eye. Right eye was normal. A-scan ultrasound biometry showed an axial length of 22.92 mm and 25.83 mm in the right and left eyes. –6.00 D contact lens was prescribed for the left eye. No increase in BCVA was recorded in the 3rd, 6th, and 9th months visits. | [[32.0, 'year']] | F | {'29403600': 1, '7224936': 1, '484678': 1, '1890569': 1, '9559744': 1, '12003622': 1, '3598829': 1, '31242454': 1, '2358833': 1, '17765436': 1, '24088642': 2} | {'3853465-1': 2, '3853465-2': 2, '3853465-3': 2} |
164,591 | 3853481-1 | 24,964,327 | noncomm/PMC003xxxxxx/PMC3853481.xml | Submucosal lipoma acting as a leading point for colo-colic intussusception in an adult | A 49-year-old gentleman presented to our emergency department with a 10-day history of intermittent abdominal pain. The pain was exacerbated by eating and he reported a reduced appetite. His past medical history included a right-sided nephrectomy for a benign tumour and an appendicectomy.\nOn examination, he was apyrexial and vital signs were all within normal limits. Abdominal examination revealed a soft abdomen, with localized epigastric tenderness. There were no palpable masses and bowel sounds were normal. Laboratory blood tests were unremarkable, apart from a mild microcytic anaemia.\nAbdominal ultrasound demonstrated a bowel-related mass lesion in the epigastric region (Fig. ). Computed tomography (CT) scan of the abdomen and pelvis revealed a 3 × 6 cm fatty ovoid lesion within the transverse colon resulting in intussusception (Fig. ). Colonoscopy showed an abnormal dusky grey lesion occupying most of the lumen in the distal transverse colon. There were two ulcerated areas on the front of the lesion, most likely the leading point of the intussusception. A laparotomy was performed. Intussusception of the transverse colon was found, for which an extended right hemicolectomy was performed (Fig. ), with ileo-transverse colon anastomosis and defunctioning loop ileostomy. The patient had an uneventful postoperative recovery and returned later for reversal of his loop ileostomy. The histopathology report confirmed a 6 × 4.5 cm submucosal lipoma acting as a leading point for the intussusception. There was no evidence of malignancy. | [[49.0, 'year']] | M | {'17846839': 1, '19152443': 1, '25895980': 1, '16702451': 1, '7129044': 1, '5557762': 1, '33953464': 1, '12842756': 1, '9074370': 1, '4645612': 1, '13326008': 1, '2227312': 1, '24964327': 2} | {} |
164,592 | 3853595-1 | 24,349,836 | noncomm/PMC003xxxxxx/PMC3853595.xml | Endometrial Osseous Metaplasia: Case Report with Literature Review | A 28-year-old woman presented with history of menorrhagia. She was married for 4 years and she gave a history of one full-term vaginal delivery and a miscarriage subsequent to which she underwent dilatation and curettage at 13 weeks gestation 6 months ago. Menstrual history was normal before the event. Her general examination and bimanual exploration were normal. Her routine haematological parameters were normal and no abnormality was detected.\nHistopathological evaluation of endometrial curettage material was carried out. On gross examination, multiple irregular, tiny, hemorrhagic tissue bits altogether weighing 25 g. Microscopic examination of H and E, stained sections showed mature bony trabeculae with non-hematopoietic bone marrow [], []. The surrounding endometrial tissue revealed tubular endometrial glands with scanty stroma and the mild stroma infiltration by chronic inflammatory cells. There is no evidence of granulomas and the metaplastic nature of this condition is proved morphologically by its continuity with stromal cells.\nThe patient had no signs or laboratory findings suggesting a calcium metabolism disorder.\nA histopathological diagnosis of endometrial osseous metaplasia was given. | [[28.0, 'year']] | F | {'30515339': 1, '21209755': 2, '18559080': 2, '34804329': 1, '27803535': 1, '26023606': 1, '21772743': 1, '19185859': 1, '18973894': 1, '8981150': 1, '21126963': 1, '24349836': 2} | {'2970784-1': 1, '2441636-1': 1} |
164,593 | 3853596-1 | 24,349,837 | noncomm/PMC003xxxxxx/PMC3853596.xml | Twin Fetuses Papyraeci in a Spontaneous Triplet Pregnancy Presenting with Unexplained Preterm Contractions | A 39-year-old Nigerian grand multipara, was referred to University of Maiduguri Teaching Hospital at 27 weeks of gestation on account of persistent uterine contraction of 3 days prior to presentation. An accompanying ultrasound scan report revealed a live singleton fetus at 27 weeks 2 days gestation, presenting breech, with a fundally placed placenta. The history and general examination were unremarkable. The pulse rate was 86 beat per min and her blood pressure was 130/80 mmHg. The fundal height was 29 cm which was compatible with her date of 27 weeks. The fetal heart rate was 142 beats per min. There was one palpable uterine contraction, of moderate intensity and lasted 25 s. Vaginal examination was unremarkable. Results of initial investigations were: Packed cell volume (PCV) 28%, white blood cells 8 × 109/L, platelet normal, high vaginal swab (HVS) for microscopy, culture and sensitivity (MCS) – normal, urine MCS – normal, fetal kick count – normal, up until 31st March, 2010. A repeat ultrasound scan confirmed earlier report from the referring centre. She was placed on intravenous fluid, cefuroxime axetil 500 mg twice daily for 10 days, pentazocin 60 mg once in 8 h for 24 h and continued on tablets of ibuprofen. During the 9 weeks period of admission she had received steroids for fetal lung maturity, nifedipine, phenobarbitone, and hematinics. The contractions never abated completely but it waxed and waned despite the tocolytics. An ultrasound scan at 34 weeks put the estimated fetal weight at 2320 g. She complained of reduced fetal movement at 36 weeks, 2 days and a review of the fetal kick count showed 5 kicks in the preceding 14 h. Her PCV then was 32% and urinalysis was negative for protein and glucose. She was offered emergency caesarean section and the products were two macerated male fetuses with monochorionoc placenta, weighing 150 g and 130 g. The live female fetus weighed 2.3 kg with Apgar score of 7 and 10 in 1st and 5th min, respectively. The placenta of the surviving twin and that of the twin papyraceous weighed 500 g and 200 g, respectively. She was discharged on the third post-operative day with her baby. Both had no complaints at the 6th week post-natal visit. | [[39.0, 'year']] | F | {'19151989': 1, '6184068': 1, '8210773': 1, '1750494': 1, '1984228': 1, '2182133': 1, '506533': 1, '19394587': 1, '8474948': 1, '15024229': 1, '10471152': 1, '14669434': 1, '2198920': 1, '24349837': 2} | {} |
164,594 | 3853597-1 | 24,349,838 | noncomm/PMC003xxxxxx/PMC3853597.xml | A Case Report of Plasmodium Vivax, Plasmodium Falciparum and Dengue Co-Infection in a 6 Months Pregnancy | A 25-year-old 6 months pregnant lady from a rural background was admitted to a private tertiary care hospital in north India with complaints of fever with chills since 4 days. The patient had a BP = 100/60 mm of Hg, pulse = 112 bpm, RR = 22/min, temperature = 101°F, and was maintaining a saturation of 96% with oxygen support at 2 l/min. The patient was dyspneic, had a blanching erythematous rash, pallor (+++) and the fetal heart sounds could be heard. The cardiovascular and neurological examination was, however, normal. A complete blood count with peripheral smear, ELISA for immunoglobulin G (IgG) and immunoglobulin M (IgM) for dengue, were sent along with the routine blood examinations. The patient was managed symptomatically and was given supportive treatment.\nThe patient had Hb = 4.1 gm/dl, TLC = 5000/mm3, DLC = P68%, L32%, E0, B0, Platelets = 50,000/mm3, blood urea = 58.8 mg/dl, Sr.creatinine = 1.8 mg/dl, Sr.Na+ = 145 meq/L, Sr.K+ = 4.3 meq/L, total bilirubin = 0.8 mg/dl with a direct bilirubin = 0.7 mg/dl and an indirect bilirubin = 0.1 mg/dl, total serum protein = 3.9 g/dl, Sr.albumin = 2.2 g/dl, Sr.globulin = 1.7 g/dl, Aspartate Amino transferase (AST) = 60 U/L, Alanine Aminotransferase (ALT) =13 U/L, Sr.Alkaline Phosphatase = 113 U/L. Dengue duo Nonprotein Surface (NS1) antigen combo kit manufactured by standardia using one step rapid immunochromatograpic test for detection of NS1 Antigen and IgG and IgM were employed for the detection of dengue infection. Peripheral smear examination revealed presence of gametocytes of P. vivax and P. falciparum. The histidine rich protein-2 card test was also positive for P. vivax and P. falciparum. A general blood picture was that of markedly reduced red cell mass, red blood cells were microcytic and hypochromic along with anisopoikilocytosis in the form of tear drop cells, target cells and helmet cells. The treatment was accordingly modified and anti-malarials were started in the form of artisunate based combination therapy. Paracetamol in divided doses was given to control the fever and proper care was taken for fetal well-being by fetal sonography. During fetal sonography the amount of amniotic fluid, blood flow through the Doppler study, fetal activity, placenta and cervix were examined to ensure that there was no fetal compromise. The patient was given four units of packed red blood cell transfusion and was discharged after 7 days of in-patient treatment with a live fetus and is on a regular follow-up. | [[25.0, 'year']] | F | {'16032797': 1, '16785712': 1, '27128316': 1, '17568646': 1, '6038994': 1, '29879935': 1, '9886130': 1, '12416761': 1, '24349838': 2} | {} |
164,595 | 3853598-1 | 24,349,839 | noncomm/PMC003xxxxxx/PMC3853598.xml | Rectal Lipoma Associated with Genital Prolapse | A 58-year-old post-menopausal woman presented with six months history of hematochezia, tenesmus, constipation, loss of appetite, and vaginal mass prolapsed. On general examination, patient was thin and pale. Abdominal examination was unremarkable. Rectal examination revealed a soft swelling in the anterior wall of rectum measuring approximately 3 × 3 cm and 6 cm above the anal verge. Speculum examination showed second-degree utero-vaginal prolapse, cystocele, and rectocele. In vaginal examination, uterus appeared to be atrophic and retroverted. There were no signs of tumor infiltration into fornices. Recto-vaginal examination showed mass in rectum/recto-vaginal septum with atrophic perineal body. Findings were confirmed by colonoscopy and contrast-enhanced CT scan [] of the abdomen, showing a sub-mucosal rectal mass. She underwent vaginal hysterectomy with pelvic floor repair. This was followed by transrectal excision of the rectal mass []. The macroscopic appearance of excised mass was suggestive of lipoma. Histopathological examination confirmed the diagnosis of lipoma and revealed ulceration of the overlying rectal mucosa []. | [[58.0, 'year']] | F | {'1675882': 1, '3319030': 1, '2670056': 1, '8956963': 1, '12399859': 1, '11419863': 1, '4026070': 1, '16937511': 1, '24349839': 2} | {} |
164,596 | 3853599-1 | 24,349,840 | noncomm/PMC003xxxxxx/PMC3853599.xml | Sternal Tuberculosis | A 26-year-old male presented with a primary complaint of swelling and discharge in the upper part of sternum since last 6 months []. There was history of development of discharging sinus and fistula following pus aspiration from swelling. He also complained of intermittent fever, anorexia and weight loss of nearly 7 kg during last 6 months. There was no past history of Koch's. On examination, there was a discharging sinus in upper part of the sternum. Rest general physical and systemic examination was within normal limits. Routine blood investigations-complete blood count, kidney function test, liver function test, random blood sugar and serum electrolytes were within normal limits; hemoglobin was 11 g/dl; erythrocyte sedimentation rate-64 mm/h; Mantoux-15 mm × 15 mm; chest radiograph was normal; patient was non-reactive to HIV test; ultrasound chest revealed two hypoechoic linear tracts communicating with skin; pus aspirate was positive for acid fast bacilli on Ziehl-Neelsen staining; Contrast enhanced computed tomography (CECT) of the thorax [Figures and ] showed peripherally enhancing hypodense collection seen in the subcutaneous plane with underlying irregularity of body of sternum-caries of sternum with few calcified lymph node noticed in paratracheal region; underlying lung parenchyma appeared normal. Patient was counseled and started on anti-tubercular therapy under directly observed therapy short course (DOTS) of alternate day regime prescribed under Revised National Tuberculosis Control Program, i.e., isoniazid (600 mg), rifampicin (450 mg), pyrazinamide (1500 mg) and ethambutol (1200 mg). The patient is under follow up and has improved clinically with afibrile status, weight gain, resolution of pus and healing of sinuses. It is planned to administer intermittent therapy under DOTS for 9 months. | [[26.0, 'year']] | M | {'11852218': 1, '21119799': 1, '20209722': 1, '10525881': 1, '16131781': 1, '11026712': 1, '28217237': 1, '18364662': 1, '11195244': 1, '22703726': 1, '34457101': 1, '27168857': 1, '15520485': 1, '29507030': 1, '24349840': 2} | {} |
164,597 | 3853600-1 | 24,349,841 | noncomm/PMC003xxxxxx/PMC3853600.xml | Superior Mesenteric Artery Syndrome: An Uncommon Cause of Abdominal Pain Mimicking Gastric Outlet Obstruction | A 42-year-old female patient presented with abdominal pain and vomiting after every meal since 3 months. The pain was colicky in nature relieved on lying down on left lateral position. Patient had history of weight loss of about ten kilogram in the last 3 months; she weighed 30 kg and looked cachexic. She had past history for appendicular perforation 3 years back for which she was operated.\nLaboratory investigations revealed PCV - 46%, Hb - 11.1 g/dl, MCV - 71.63 cu.mm (80-90) - microcytic, total leucocytes count of 11,400 cu.mm with Neutrophils - 62%. Upper gastrointestinal endoscopy was attempted however probe could not be negotiated through third part of duodenum. Barium meal follow through showed dilated proximal duodenum with linear vertical filling defect across proximal third part of duodenum was suggestive of SMA syndrome [Figures -]. A provisional diagnosis of SMA syndrome was made. For further investigation patient was advised computed tomography (CT) scan, however patient could not afford it.\nA nasogastric tube was inserted and the patient was started on parenteral nutrition. Conservative measures failed, and 1 week later the patient was subjected to laparotomy, where dilatation of the duodenum proximally to the superior mesenteric vessels was observed. The third part of the duodenum was exposed and mobilized and a loop duodenojejunostomy was performed, approximately 10 cm distally to the ligament of Treitz. Her post-operative course was uneventful. | [[42.0, 'year']] | F | {'19468230': 1, '15957095': 1, '30081961': 2, '17476104': 1, '18810558': 1, '18595543': 1, '19342937': 1, '17198067': 1, '10881780': 1, '17575776': 1, '18186572': 1, '20601910': 1, '24349841': 2} | {'6091179-1': 1} |
164,598 | 3853601-1 | 24,349,842 | noncomm/PMC003xxxxxx/PMC3853601.xml | Pediatric Stroke: Neurological Sequelae in Uncorrected Tetralogy of Fallot | A 3-year-old male child was brought to the hospital with complaints of weakness of the left upper and lower limbs and one episode of generalized tonic-clonic seizures associated with up rolling of eyeballs and frothing from the mouth. Child was a diagnosed case of Tetralogy of Fallot following history of recurrent chest infections in infancy. He had two episodes of vomiting and five to six episodes of loose motions per day since 2 days. There was no history of surgical intervention (Informant – Mother). Lab investigations revealed PCV-46%, Hb-14.1 gm/dL, mean cell volume-61.33 cumm (80-90)-microcytic, TLC-13,400 cumm, and neutrophils – 74%.\nCT scan was performed on emergency basis [Figures -]. For further evaluation, MRI with magnetic resonance (MR) venography was also performed the next day [Figures -]. | [[3.0, 'year']] | M | {'17917783': 1, '12616682': 1, '981659': 1, '10972417': 1, '7490597': 1, '11129914': 1, '17183984': 1, '12223385': 1, '1764134': 1, '24349842': 2} | {} |
164,599 | 3853602-1 | 24,349,843 | noncomm/PMC003xxxxxx/PMC3853602.xml | Familial Dermal Eccrine Cylindromatosis with Emphasis on Histology and Genetic Mapping | A 32-year-old woman presented to us with multiple asymptomatic swellings over the scalp, face, neck, legs, and chest for the past 12 years with a progressive increase in size and number over the years. There was a history of similar lesions in her family including her mother, aunt, cousins, grandfather, and her elder child [].\nOn examination, multiple, rounded, smooth surfaced, firm, non-tender, skin colored to reddish papules and nodules of varying sizes were seen on scalp and face []. Lesion was also extending to nose, arms, and legs []. Examination of mucosa, nails, and hair showed no abnormalities.\nAll the laboratory investigations were within the normal range. Computed tomography brain showed multiple lobulated masses over scalp and face, which could represent neoplastic or inflammatory pathology []. Biopsy was suggested for further evaluation. Gene mapping was done. The susceptibility locus has been mapped to chromosome 16q12-q13.\nFine needle aspiration was performed and smears were stained with May-Grünwald stain (MGG). The most distinctive feature in the aspirated material was the homogenous hyaline globules stained purple with MGG. These globules were surrounded by cohesive benign epithelial cells with dark uniform nuclei. The background was clean and no mitosis was noticed.\nSurgical excision along with the skin grafting was performed to improve the facial appearance of the patient. Specimen was submitted in the histopathology section. On gross examination, the lesion was nodular with irregular surface []. Cut surface was solid and homogenously grey white.\nHistopathologically, the lesion consisted of well-circumscribed islands of epithelial cells surrounded by a dense membrane material, and focally containing hyaline globules. Islands of epithelial cells fit together like pieces of “jig-saw” puzzle. Two distinct cell populations were seen; smaller peripheral basaloid cells in palisade arrangement and larger central cells with vesicular chromatin []. | [[32.0, 'year']] | F | {'18986490': 1, '20895749': 1, '22398229': 1, '19397670': 1, '22628987': 2, '16272260': 1, '19171990': 1, '16484982': 1, '24349843': 2} | {'3358935-1': 1} |
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