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164,800 | 3866319-1 | 24,363,755 | noncomm/PMC003xxxxxx/PMC3866319.xml | A Case of Progressive Ductal Constriction in a Fetus | A 22-year-old woman, gravid 2, para 1-0-0-1, was referred to our institution for fetal echocardiography at 23 weeks of gestation because of abnormally looking great arterial arches. The pregnancy had not been complicated. The mother had not had any diseases or taken any drugs or herbal medications. There was no family history of congenital heart disease. Obstetric evaluation showed normal fetal growth, normal amount of amniotic fluid and normal placenta. The fetal echocardiography revealed the normal four chamber view, where two atria and two ventricles were normal in size and thickness (). The two atrioventricular valves moved normally. Two great arteries arose normally from the appropriate ventricles. The pulmonary and aortic valves looked normal and the size of the main pulmonary artery and aortic root was within normal limits. The aortic arch was normal in size and in location, but the ductal arch was not visualized in any views. The main pulmonary artery bifurcated into two branch pulmonary arteries but was not continuous with the DA (). However color Doppler examination showed a tortuous 'S' shaped ductus cuddled inside the aortic arch (). The DA joined the descending aorta with an obtuse angle and showed a flow signal from the main pulmonary artery to the descending aorta (). Color aliasing occurred along the course of the ductus but pulsed Doppler measurement of velocity was not attempted because of the poor angle of insonation. Flow velocity and waveforms of the two great arteries were within normal limits and no TR was found. A diagnosis of S-shaped DA with mild narrowing was made and follow up examination was arranged.\nA repeat examination was performed at 27 weeks of gestation and showed nearly the same findings as before. The RV was normal in size and thickness and no TR was noted. Because the DA was S-shaped, it was very difficult to assess size along the whole range of the DA. However, the color Doppler examination showed tortuous turbulent flow in the ductus and suggested mild obstruction. The sagittal section of the aortic arch showed a ductal junction through which low velocity forward flow from the DA to the descending aorta was noted. Obstetric evaluation showed that fetal growth was appropriate and the amniotic fluid index was adequate. No signs of hydrops were noted.\nThe third examination was performed at 33 weeks of gestation. The right atrium was big and the RV was hypertrophied and globular in shape. The intracavitary volume of the RV looked slightly smaller than normal because of the thick ventricular wall and hypertrophy of the trabeculations. The right ventricular endocardial lining and the chordae of the tricuspid valve were very bright (). Color Doppler examination showed moderate TR and its velocity was 4.5 m/sec (). Every attempt failed to demonstrate any flow through the ductus. In spite of the right ventricular overload, fetal growth was within normal range and there was no evidence of fetal hydrops.\nAfter a discussion, we decided to deliver the baby. A female infant weighing 2625 g was born at 34 weeks gestation by induced delivery. Apgar scores were 7 at 1 minute and 8 at 5 minutes. Symptoms and signs immediately after birth were tachypnea, chest retraction, grunting sound and low oxygen saturation. An echocardiography performed at 20 minutes after birth showed a small hypertrophied RV and increased echogenicity of the moderator band and chordae of tricuspid valve (). There was a moderate TR with a velocity of 3.7 m/sec (). The short axis view showed a hypertrophied RV (). The ductus was searched for but no ductus was found in 2-D and color images (). Shunt flow through the foramen ovale was mainly right to left (). She required respiratory support with a mechanical ventilator for the first 3 days. She was successfully weaned from the ventilator on her fourth day and discharged at 12 days old. Follow-up examination at the outpatient clinic showed that she did not have any cardiac symptoms or signs. Echocardiography taken at 2 months of age showed much improvement. The RV was nearly normal in size and thickness. Increased echogenicity of the RV was also nearly normalized. There remained TR with a velocity of 3.0 m/sec. At 7 months of age, all echocardiographic findings returned to normal with resolution of TR. | [[22.0, 'year']] | F | {'10846777': 1, '7614140': 1, '18779991': 1, '18422673': 1, '22837295': 1, '8633660': 1, '8309905': 1, '7719875': 1, '19389789': 1, '9383875': 1, '34096417': 2, '1856423': 1, '21269413': 1, '21426387': 1, '20845046': 1, '9516015': 1, '21087423': 1, '33410971': 1, '9259929': 1, '19641513': 1, '14666282': 1, '15133807': 1, '24363755': 2} | {'8189142-1': 1} |
164,801 | 3866342-1 | 24,363,849 | noncomm/PMC003xxxxxx/PMC3866342.xml | Pitfall of bispectral index during intraoperative seizure -a case report- | A 42-year-old male patient with chronic renal failure underwent emergency kidney transplantation. The patient had undergone kidney transplantation 15 years previously, but graft failure had occurred 7 years previously. Ever since then, the patient had been on hemodialysis. Preoperative laboratory findings showed serum sodium 126 mmol/L with uric acid 5.9 mg/dl. The patient had no medical history of epilepsy.\nAnesthesia was induced with propofol 100 mg, fentanyl 100 µg, and atracurium 25 mg. After tracheal intubation, ventilation was controlled to keep end-tidal CO2 (ETCO2) maintained around 35 mmHg. Monitors included invasive right radial arterial blood pressure, central venous pressure through right internal jugular vein, pulse oximetry, electrocardiography, peripheral nerve stimulation applying train-of-four stimulation, body temperature using esophageal temperature probe, and bispectral index (BisVISTA, Aspect Medical Systems, Newton, MA, USA). Anesthesia was maintained with desflurane 5-6% based on hemodynamic measurements and BIS values, O2 with Air (1 : 1, FiO2 60%), and muscle relaxation was achieved by using atracurium. Fluid replacement was done with 0.45% saline.\nThe BIS value dropped to 40 following the induction sequences and was stably maintained 40-50 afterward. About 4 hours after the beginning of surgery, when surgery was almost over and surgeons were closing fascia, generalized tremor occurred along with deviation of the eyeballs to the right upper side. At that time the BIS value increased from 40 to a peak value of 62, and then was maintained mainly in the 50s during the seizure. After the tremor, a sudden and brief fall of BIS values were noticed. The BIS value dropped from 50 to 0 within a minute, stayed at 0 for about 5 minutes, and then returned to 50 without significant hemodynamic change (). During these sudden changes, signal quality index stayed over 80 with no other error messages. Arterial blood gas analysis was done immediately, which showed serum sodium level of 122 mmol/L. In order to correct hyponatremia, 0.45% saline was replaced with 0.9% saline. Neuromuscular blockade was not sufficiently maintained, which was below 75%, since we were preparing for emergence concerning the time remaining in the surgery. When tremor occurred, an additional dose of atracurium 10 mg was injected to stop muscle contraction. Although the generalized tremor faded, such a brief fall of BIS occurred periodically for the next 30 minutes, after which the BIS value stabilized and stayed around 40 and the patient emerged without any problem. At emergence, the patient's mental status was clear enough to allow recall of his own name.\nThe patient was transferred to intensive care unit (ICU) right after emergence. Fifteen minutes from emergence, the patient had a generalized tonic-clonic seizure lasting 10 minutes, followed by three more episodes, each lasting 5 minutes, every 30 minutes. The patient's laboratory findings when having seizure were uric acid 13.1 mg/dl and serum sodium 124 mmol/L. The patient was immediately referred for consultation to staff neurologists. An electroencephalography (EEG) performed in postictal period showed brief and generalized 5-7 Hz theta slowing waves indicative of mild cortical dysfunction caused by metabolic disturbance, toxic state, interictal state or postictal state. Intravenous lorazepam 4 mg was used and O2 3 L/min was supplied by nasal cannula. The consulting neurologists diagnosed seizure by metabolic disturbance and prescribed intravenous fosphenytoin 150 mg every 8 hours and intravenous sodium valproate 300 mg every 12 hours. No further seizures occurred, but patient displayed a confused mental state for 10 days before normalizing. Serum sodium and uric acid normalized 2 days after surgery. Antiepileptic drugs were continued for 3 days. | [[42.0, 'year']] | M | {'15567546': 1, '16115989': 1, '11168988': 1, '18249346': 1, '22000655': 1, '20332745': 1, '15155337': 1, '28757846': 1, '15616071': 1, '10824078': 1, '20661203': 1, '15488073': 1, '21945334': 1, '16135205': 1, '32005870': 1, '15333411': 1, '30032325': 1, '17666727': 1, '24363849': 2} | {} |
164,802 | 3866343-1 | 24,363,850 | noncomm/PMC003xxxxxx/PMC3866343.xml | Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report- | A 63-year-old male, 159 cm in height and 70 kg in weight, was scheduled to undergo resection of cervical epidural mass. The patient had a medical history of well-controlled hypertension and old healed pulmonary tuberculosis. The patient had facial and neck purpuras and ecchymoses, whose cause could not be identified at a private dermatologic clinic. Blood test results concerning platelet count, prothrombin time and activated partial thrombosplastin time were normal.\nGeneral anesthesia was induced with propofol 100 mg and remifentanil 0.5 µg/kg/min. Rocuronium 50 mg was administrated to facilitate tracheal intubation. Anesthesia was maintained with 6 vol% desflurane with 50% O2 in air, remifentanil, and rocuromium. After a change from a supine to a prone position, bleeding from the lacerated facial purpuras was recognized while identifying head position on a Mayfield headrest. Swollen purpuras and eyeballs hyperemia were evident. The operation was canceled in order to evaluate the facial lesions and the patient was transported to the postanesthetic care unit when fully conscious.\nSkin biopsy from the facial lesions () and serum free light chain assay were performed during the stay at the general ward, and resulted in the diagnosis of systemic amyloidosis of monoclonal gammopathy with lambda type. Multiple myeloma, which usually accompanies systemic amyloidosis, was excluded after bone marrow biopsy and immunoprotein measurement of serum and urine.\nThe patient had complained of dyspnea since post-anesthesia day 16. Bilateral pleural effusion and interstitial pulmonary edema were identified by high resolution chest computed tomography. Pulmonary function test revealed moderate degree of chronic obstructive pulmonary disease. Cervical magnetic resonance imaging taken 48 days after the anesthesia showed spontaneous resolution of the epidural mass. Post-anesthetic echocardiograph showed thickened myocardium, which was not confirmatory of cardiac amyloidosis. According to abdominal ultrasound, there was no hepatomegaly or splenomegaly. Symptoms and signs suggesting the involvement of other organs, such as renal, neurologic, and hematologic abnormalities, were not observed. Treatment with chemotherapy and auto-peripheral blood stem cell transplantation was planned. | [[63.0, 'year']] | M | {'22100031': 1, '22489348': 1, '21483018': 1, '27330215': 1, '15470177': 1, '10470639': 1, '10417460': 1, '19626465': 1, '24363850': 2} | {} |
164,803 | 3866344-1 | 24,363,851 | noncomm/PMC003xxxxxx/PMC3866344.xml | Fluid balance in late preterm infants with prenatal gastrointestinal pathology -a report of two cases- | A 31-year-old pregnant woman (59 kg/170 cm, 34w+5, G4P2A1L2) was admitted for Caesarean section. The patient had no problems until fetal bowel obstruction was diagnosed by routine obstetrical ultrasonography taken 10 days earlier ().\nGeneral anesthesia was induced with 250 mg of thiopental sodium and 75 mg of succinylcholine. Ten minutes after skin incision, a 2.66 kg, 46 cm of male baby was born with an Apgar score of 7 at 1 min and 9 at 5 min. The newborn cried relatively well despite the moderately distended abdomen, so routine care was given, which included transfer to the neonatal intensive care unit (NICU).\nPeripheral oxygen saturation (SpO2) of the baby was maintained at 96-97% with 2 L/min of oxygen in the hood and first urine was passed at 4 h of age. However, abdominal distention was sustained and nothing was aspirated through the positioned oro-gastric tube. An infantogram, bowel sonography, and barium enema were performed. Distended small bowel loops up to 3 cm and microcolon were seen and no more contrast was passed proximal to terminal ileum, which suggested ileal atresia ().\nEmergency surgery was performed at 10 h of age. Under standard monitoring including electrocardiography (ECG), non-invasive blood pressure (NIBP), end-tidal CO2 (ETCO2), and SpO2 (dual monitor at right arm and left foot), the patient was intubated with a 3.5 Fr cuffed endotracheal tube. Two 24 gauge intravenous (IV) lines were started on the left arm and right leg, a 6 Fr feeding tube was inserted for gastric decompression, and a Foley catheter was inserted for hourly urine count. To minimize heat loss, the room temperature was increased, the patient was hatted, a warm air mattress and warmed IV fluids were used, and body temperature was monitored. The anesthesia was maintained with sevoflurane, FiO2 of 0.3-0.4 with air, pressure control mode of 18 mmHg, and a respiratory rate (RR) of 20 breaths/min. BP was maintained at 50-80/30-45 mmHg, heart rate (HR) at 140-160 beats/min, ETCO2 at 32-40 mmHg, and SpO2 98-100%. There were severe adhesions on the entire abdomen such that the anatomy was not easily distinguishable. After massive adhesiolysis, segmental resection of injured bowel and anastomosis were performed. Moderate amount of reactive fluid was seen and moderate bleeding was ongoing. At 90 min of the surgery, HR abruptly rose to 170 beats/min. Arterial blood gas analysis was taken, which showed pH 7.34, PaCO2 38 mmHg, PaO2 191 mmHg, HCO3 20.5 mM/L, Na 134 mEq/L, K 4.2 mEq/L, Hb 10.2 g/dl, and blood sugar 118 mg/dl. Packed red blood cells 30 ml were transfused and no other intraoperative symptoms were found. Total time taken for surgery was 2 h 45 min and for anesthesia, 3 h 20 min. Total fluid administered was SD 1 : 3 solution 20 ml, lactated Ringer's solution 50 ml, and normal saline 10 ml.\nAfter the surgery, the patient was extubated and SpO2 was maintained over 97% without supplemental oxygen. Urine output was 1 ml/h and 1.5 ml/h, respectively, during the first 2 h of surgery, however, no further urine was observed during last hour of surgery. However, 7 ml of urine was formed after 2 h of surgery without fluid loading and no further oliguria was seen. Hb after transfusion was 13.6 g/dl and hemodynamic parameters were stable thereafter. Breast feeding was started 5 days after the surgery and the baby was discharged at postoperative day 24. | [[31.0, 'year']] | F | {'21033013': 1, '19955503': 1, '13679934': 1, '16533639': 1, '9677209': 1, '6761036': 1, '18312509': 1, '16735810': 1, '24363851': 2} | {'3866344-2': 2} |
164,804 | 3866344-2 | 24,363,851 | noncomm/PMC003xxxxxx/PMC3866344.xml | Fluid balance in late preterm infants with prenatal gastrointestinal pathology -a report of two cases- | A 29-year-old, pregnant woman (70 kg/169 cm, 29w+5, G1P0A0L0) was transferred from outlying hospital for polyhydroamnios with fetal abdominal mass. On obstetrical ultrasonography and magnetic resonance image, a cystic mass about 8.5 × 7 cm in size was observed in the fetal peritoneal cavity ( and ). On the decision that the baby required more maturation, surgery was postponed until gestational age 35 weeks with steroid therapy and follow-up sonography. At 35 weeks, two operating theaters were prepared for surgery for both mother and the baby.\nGeneral anesthesia for Caesarean section was induced with 250 mg of thiopental sodium and 75 mg of succinylcholine. Ten minutes after skin incision, a profuse amount of meconium stained amniotic fluid was released and an approximately 2.5 kg male baby was delivered. Apgar scores were 5 at 1 min and 7 at 5 min. The baby's abdomen was markedly distended () and meconium stained secretion continuously flowed from the nose and mouth. After suction of the airway, intubation was tried with 3.5 Fr cuffed endotracheal tube. This failed, so a 3.0 Fr tube was inserted in the second attempt. A pulse oximeter was attached on the baby's right hand and left leg, which showed 97% with 100% oxygen after resuscitation. Two 24 gauge IV lines were started both on the right arm and right leg. A 6 Fr feeding tube was inserted for gastric decompression. We requested Foley catheter insertion. However, it was not performed. Anesthesia was maintained with sevoflurane and FiO2 of 0.3-0.4 with air under standard monitoring and temperature devices similar to setting of case 1. The ventilator was set by pressure control mode of 24 mmHg (TV near 25 ml) and RR of 30 breaths/min, however, SpO2 dropped and was maintained around 70%. Therefore, FiO2 was increased up to 1.0. However, SpO2 did not change so manual ventilation was applied with 100% oxygen for about 40 min until the abdomen opened and the cyst was evacuated. SpO2 was maintained at 90% during that period and, just after cyst evacuation, it abruptly increased to 98%, so the FiO2 was decreased to 0.3. The ventilator was set by a pressure control mode of 18 mmHg (TV near 30 ml), 25 breaths/min, and controlled according to the ETCO2 level. BP was maintained at 40-60/25-35 mmHg, HR at 130-160 beats/min, ETCO2 at 27-35 mmHg, and SpO2 at 97-100%.\nSurgery was complicated by lots of bowel manipulations. Severe adhesion to omentum, liver, and small bowel was seen and moderate ascites were found. After adhesiolysis, the cyst was removed and end-to-end anastomosis of the small bowel was performed. Total time taken for the surgery was 3 h 30 min and for anesthesia, 4 h 10 min. Total fluid administered was 5% dextrose in water (D5W) 35 ml and lactated Ringer's solution 130 ml. After 120 min of anesthetic induction, venous blood gas analysis was taken, which showed pH 7.29, PaCO2 44 mmHg, PvO2 34 mmHg, HCO3 21.2 mM/L, Na 133 mEq/L, K 3.7 mEq/L, Hb 18.7 g/dl, and blood sugar 121 mg/dl.\nJust after the surgery, we looked for evidence of urination on drape linen, but it was dry. The baby was sent to the NICU with a secured ET tube with manual assisted ventilation. Foley catheterization was done at the NICU and urine output was very poor after the surgery. Dopamin 5 µg/kg/min was infused with normal saline 60 ml, fresh frozen plasma (FFP) 40 ml, and 20% albumin 13 ml over 6 h. Furosemide 4 mg was IV injected two times during hydration period, however, only 4 ml of urine was formed. Generalized edema appeared with heart murmur, but urine starting to pass at 10-20 ml/h at the same time. The baby was extubated 20 h after the surgery and SpO2 was maintained over 95% without supplemental oxygen. Feeding was started 8 days after the surgery. | [[29.0, 'year']] | F | {'21033013': 1, '19955503': 1, '13679934': 1, '16533639': 1, '9677209': 1, '6761036': 1, '18312509': 1, '16735810': 1, '24363851': 2} | {'3866344-1': 2} |
164,805 | 3866345-1 | 24,363,852 | noncomm/PMC003xxxxxx/PMC3866345.xml | Epidural catheterization with a subcutaneous injection port for the long-term administration of opioids and local anesthetics to treat zoster-associated pain -a report of two cases- | 72-year-old man (height 163 cm, weight 72 kg) with a 10-year history of diabetes mellitus presented with intermittent intolerable sharp and lancinating pain over the left anterior chest wall and the back for 1 month. He received 300 mg/day of carbamazepine, 300 mg/day of gabapentin, and 1500 mg/day of valacyclovir orally for 7 days following diagnosis with acute herpes zoster at a local private clinic. He reported severe pain in the affected area (a score of 8 or 9 on a visual analog scale where 0 indicated "no pain" and 10 indicated "the strongest pain imaginable") despite a healed skin rash. A physical examination revealed allodynia and hyperalgesia over the left T2 and T3 dermatomes. The pain relief was maintained for only 3 days through the use of a thoracic epidural block with 10 ml of 0.1% bupivacaine and 10 mg of triamcinolone at the intervertebral space between the T1 and T2 (a visual analog scale pain score of 2 or 3). Simultaneously, the gabapentin and carbamazepine dosages were increased to 900 mg/day and 400 mg/day, respectively, and the antiviral therapy was completed. The patient received 6 subsequent blocks, but each block relieved the pain for only 3 days. He complained about the short-lasting effect of the blocks and the frequent follow up. After reviewing the benefit-risk ratio of the various available forms of therapy, the decision was made to implant a subcutaneous port connected to an epidural catheter for the continuous infusion of opioids and local anesthetics.\nOn arrival in the operating room, the arterial pressure, electrocardiogram, and peripheral oxygen saturation (SpO2) of the patient were monitored, and venous access was secured. The patient was positioned on an operating table in the lateral decubitus position with the patient's side for the port pocket nondependent. His arms were extended at the shoulders and secured in position away from the surgical field. The skin was prepared, and sterile drapes were applied. The radiographic C-arm was then positioned across the thoracic region to provide a cross-table anteroposterior view of the thoracic spine. Using fluoroscopy, the T7-8 interspace, which was thought to be the most appropriate interspace, was identified for the subcutaneous tunneling of an epidural catheter connected to an injection port placed in the right upper quadrant of the abdomen. An epidural catheter was then inserted through an 18-gauge Tuohy needle using a loss of resistance technique until the tip was at the intervertebral space between the T1 and T2 (). The needle was then withdrawn. An 8 cm transverse incision was made in the right upper quadrant of the abdomen, and a subcutaneous pocket was created caudad to the incision using a blunt dissection. A tunneling device was then extended within the subcutaneous tissue between the needle insertion site and the pocket. The catheter was then advanced through the tunnel and trimmed to a length that allowed a small loop of catheter to remain deep to the port (Celsite®, B. Braun, Boulogne-Billancourt, France). The port was connected to the epidural catheter and sutured to the abdominal fascia. Finally, the skin incision was closed. A port needle (Hubsite®, B. Braun, Ecouen, Germany) with a length appropriate for the thickness of the subcutaneous needle was used to deliver epidural medications: 25 mg of morphine, 200 mg of bupivacaine, and 185 ml of normal saline (a total volume of 250 ml) (). The background infusion rate was 2 ml/hr (no bolus).\nAfter the completion of the procedure, the patient was delivered to the general ward and was observed closely for morphine-induced respiratory depression using pulse oximetry. The other side effects related to the use of epidural morphine and bupivacaine (pruritus, nausea, vomiting, urinary retention, constipation, systemic toxicity, motor weakness, etc.) were also monitored. Oral bisacodyl (5 mg) and docusate (16.75 mg) were administered daily for constipation prophylaxis. Because no side effects or complications associated with the epidural catheterization, implanted injection port and epidural medications were reported during the 11 days of admission, the patient was discharged and followed up every 10 days to exchange the port needle and epidural infusion pump (Accufuser®, WooYoung Medical, Seoul, Korea). The epidural infusion and concurrent administration of 900 mg/day gabapentin and 10 mg/day amitriptyline were maintained for 66 days. During treatment, the patient's pain intensity was successfully reduced from 10 (using the visual analog scale) and maintained between 2 and 3. The patient was very satisfied with the treatment. He reported slight hypoesthesia over the left anterior chest and back in the early treatment period. There were no complications associated with the epidural catheters or the medications used. Sixty-six days after the procedure, the subcutaneous port and epidural catheter were removed due to the obstruction of the catheter. He did not complain of pain thereafter but reported a slight numb sensation that remained over the lesion site for 3 months, during which oral gabapentin and amitriptyline were tapered off uneventfully. The patient was thereafter lost to follow up. | [[72.0, 'year']] | M | {'8114860': 1, '10073152': 1, '28298208': 1, '2385333': 1, '8758156': 1, '8786499': 1, '1921486': 1, '27536071': 1, '9084539': 1, '8267188': 1, '30095665': 1, '15322436': 1, '2487670': 1, '3605702': 1, '27076712': 1, '9203886': 1, '18458560': 1, '7499805': 1, '24363852': 2} | {'3866345-2': 2} |
164,806 | 3866345-2 | 24,363,852 | noncomm/PMC003xxxxxx/PMC3866345.xml | Epidural catheterization with a subcutaneous injection port for the long-term administration of opioids and local anesthetics to treat zoster-associated pain -a report of two cases- | A 64-year-old man (height 160 cm, weight 62 kg) with a 10-year history of diabetes mellitus, who had undergone a left pneumonectomy due to squamous cell carcinoma in his left upper lobe, presented with pain along the incision site (corresponding to a T5-6 dermatomal distribution) for 20 days. The pain began 3 days before the appearance of vesicles, which appeared 20 days after the pneumonectomy, and a physical examination revealed allodynia and hyperalgesia at the incision site. Following the diagnosis of acute herpes zoster, he was treated with 1000 mg/day of acyclovir intravenously for 5 days and with 150 mg/day of pregabalin orally for 3 weeks. Three weeks after pain onset, he was referred to our department for treatment because the pain persisted after the skin lesions had healed. A thoracic epidural block at the T6-7 interspace with a single dose of 10 ml of 0.1% bupivacaine and 10 mg of triamcinolone resulted in complete pain relief and a bilateral sensory block of the T5-8 dermatomes as determined by the pinprick method. However, the pain relief lasted less than 3 days. At this point, he was scheduled to receive 4 cycles of adjuvant chemotherapy. Following the decision that no additional thoracic epidural blocks were possible during the chemotherapy, epidural catheter placement and the subcutaneous implantation of an injection port were recommended. The same procedure as that used in the previous case was performed at the T10-11 interspace with the catheter tip located at the T5 (). Immediately after the completion of the procedure, the epidural infusion device containing 20 mg of morphine, 20 ml of 0.5% bupivacaine and 210 ml of normal saline (a total volume of 250 ml) was programmed to deliver at a basal rate of 2 ml/hr and delivered through a port needle. The side effects and complications associated with the procedure and epidural medications were monitored closely in the general ward. Oral medications consisting of 150 mg/day of pregabalin and 10 mg/day of amitriptyline were maintained. A stool softener and a bowel stimulant were added to the routine medications to prevent opioidinduced constipation. The epidural infusion pump was changed, and the pain intensity was evaluated every 5 days. One week after the procedure was completed, 4 cycles of adjuvant chemotherapy consisting of the daily intravenous administration of paclitaxel (175 mg/m2 × 0.9) and cisplatin (75 mg/m2 × 0.9) began, with 3 weeks between each cycle.\nThe analgesic regimen decreased the visual analog scale pain score from 8 or 9 to 1 or 2. The lower pain scores were maintained until the removal of the subcutaneous port and the epidural catheter. Leukocytosis occurred during each chemotherapy cycle, but no epidural catheter infection-associated signs or symptoms presented. During the chemotherapy, no complications related to the subcutaneous port or the epidural catheter were noted. Due to the obstruction of the epidural catheter identified 120 days after the procedure, the catheter and subcutaneous port were removed. After removal, the patient reported a visual analog scale pain score of 1 or 2. Oral pregabalin and amitriptyline were tapered off uneventfully 1 month after the removal. Although the decreased visual analog pain scores of the zoster-associated pain were maintained during the 6-month follow-up period after the removal, opioid therapy (20 to 80 mg of oxycodone per day) was initiated after a new onset of cancer-related pain (left lower extremity pain). Until his death (16 months after the removal), no symptoms or signs of herpes zoster were reported. | [[64.0, 'year']] | M | {'8114860': 1, '10073152': 1, '28298208': 1, '2385333': 1, '8758156': 1, '8786499': 1, '1921486': 1, '27536071': 1, '9084539': 1, '8267188': 1, '30095665': 1, '15322436': 1, '2487670': 1, '3605702': 1, '27076712': 1, '9203886': 1, '18458560': 1, '7499805': 1, '24363852': 2} | {'3866345-1': 2} |
164,807 | 3866346-1 | 24,363,853 | noncomm/PMC003xxxxxx/PMC3866346.xml | Computed tomography-guided cervical selective transforaminal epidural block for a patient with bilateral anatomical variations of vertebral artery -a case report- | A 56-year-old female patient presented with neck and left shoulder pain radiating to the left upper extremity. However, no objective loss of sensory or motor function was observed. Her pain had been aggravated for 10 days. Her visual analogue scale (VAS) score was 7 of 10. Although conservative treatments, including as resting, traction, non-steroidal anti-inflammatory drug and muscle relaxant were properly done for two weeks, her pain was not improved. The neurosurgeon requested a selective left C6 nerve root block. A cervical spine plain film radiograph showed degenerative cervical spondylosis (). The radiologist reported that the cervical magnetic resonance image (MRI) revealed a left-sided foraminal stenosis at the C5-6 level. Before performing the procedure, the author re-examined the MRI meticulously. Although the radiologist did not mention the VA, the author detected a tortuous anatomical variation in the VA at the left C5-6 level on the MRI (). The author ordered a CT angiogram to show the anatomical variations in the VA more precisely. The CT angiogram clearly showed bilateral tortuous anatomical variations in the VA (). In particular, the 3D reconstruction image showed a unilateral atypical entrance into the foramen transversarium (FT) of the fifth cervical vertebra and a hypoplastic abnormality of the right VA (). The diameters of the left and right VA were 4.86 mm and 2.47 mm at the lower endplate level of C5, respectively. The diameter of the left VA was 2.39 mm greater than that of the right at the C5 lower endplate. The maximum diameters of the tortuous component of the left and right VA were 9.80 mm and 6.64 mm, respectively. The maximum diameter of the tortuous component of the left VA was 3.16 mm greater than that of the right. The left VA entered the FT of the sixth cervical vertebra, whereas right entered the fifth. To minimize adverse events, the procedure was performed with dexamethasone (non-particulated steroid) and under CT guidance. The patient was placed in the supine position on a CT table with her head tilted slightly to the right. Before scanning, a wire was placed on the lateral side of her neck to use as a marker. The patient was scanned to identify a suitable approach point for the 23 G spinal needle. A path that avoided contact with the periosteum and deep cervical plexus was chosen to minimize patient discomfort. The scanning level for the CT fluoroscopy (CTF) image was selected and the target lesion was scanned to a thickness of 1 mm from the middle of the C5 body to the middle of the C6 body. The skin entry point and target point for the spinal needle was determined on the CT scan view () and marked on the neck. Before the CSTE was performed, 2% lidocaine was aseptically infiltrated into the skin and subcutaneous tissue. The needle was then advanced toward the target point using intermittent CTF guidance. The needle was advanced slowly into the left C5-6 foraminal area while avoiding the large tortuous VA. It was confirmed that the 23 G spinal needle was located exactly within the left-sided C5-6 foraminal area using 0.3 ml of radio-contrast dye (). After confirmation of appropriate needle placement, the author injected a mixture of 0.5% lidocaine 2 ml and dexamethasone 5 mg. Pain was relieved immediately after completion of the procedure and two weeks later, VAS score was decreased to 1 or 0 of 10. The patient's symptoms were relieved almost completely and did not recur in the following 3 months. | [[56.0, 'year']] | F | {'16543102': 1, '17449763': 1, '20938397': 1, '15246308': 1, '22828692': 1, '25031813': 1, '16281916': 1, '16712623': 1, '15661697': 1, '28553170': 1, '19308072': 1, '19900752': 1, '14634474': 1, '25316168': 1, '15166582': 1, '8724095': 1, '20350674': 1, '24363853': 2} | {} |
164,808 | 3866668-1 | 24,379,533 | noncomm/PMC003xxxxxx/PMC3866668.xml | Bone scintigraphy in Ollier's disease: A rare case report | A 35-year-old male patient presented with 1 year history of intermittent headache and giddiness. This was sometimes associated with loss of consciousness and involuntary movements in hands. There was occasional loss of bowel and bladder control. In the past patient gave history of hard swellings in the right hand and lower legs from the age of 9 years. The swellings were biopsied and reported as enchondroma. On and off he sustained fractures in hand swellings after trivial trauma. They were managed conservatively with splints and analgesics. Patient had no other symptoms until 1 year back. There was no family history of similar illness. Systemic examination of the patient was unremarkable. Local examination revealed marked bony deformities with hard swellings in both the hands. Hard swellings were also palpable in the right fore arm and distal ends of both lower limbs. The laboratory profile revealed a normal hemogram, normal kidney function tests and normal serum electrolytes. The fasting blood sugar, serum uric acid, calcium and phosphorus were within the normal limits. Serial serum liver function tests revealed isolated elevation of bilirubin ranging from 2.51 mg/dL to 2.58 mg/dL. Total serum proteins were 6.50 g/dL with albumin fraction of 4.5 g/dL. The coagulogram parameters were within the normal limits. The electrocardiogram was normal. Abdominal ultra-sonogram revealed a Grade I prostatomegaly. X-ray examination showed lytic lesions with sclerosed margins in the metacarpals and phalanges of both hands []. Similar lesions were noted in both the tibia and fibula []. There were two exostosis (osteochondroma) one each at the medial aspects of upper ends of both the tibia []. X-ray skull was reported to be normal. In order to see the extent of skeletal involvement patient underwent a whole body technetium-99m methylene diphosphonate scan on a dual head gamma camera fitted with a low-energy all-purpose collimator. The bone scan revealed multiple foci of intense tracer uptake in sternum, right humerus, right radius, right ulna, right hand, right femur, right tibia, right fibula, left hand, left femur, left tibia, left foot []. The lesions predominantly involved the tubular limb bones sparing the axial skeleton. Bone scan revealed extra sites of involvement at right humerus, sternum and both femoral shafts. Bone scan appearance was reported to be consistent with multiple enchondroma seen in Ollier's disease. A non-contrast CT head showed a well-defined hypo-dense lesion with no evidence of perilesional edema in left insular cortex. MRI revealed a well-defined lesion with no perilesional edema in left insular area that was hypo-intense on T1-W image [] and hyper-intense on T2-W image and flair sequences []. Radiological features suggested a glioma in the region of left insular cortex. There was moderate enhancement on contrast imaging. At surgery a grayish mass was seen in the left insular area of brain, which on histo-pathological examination was reported as low grade astrocytoma. A final diagnosis of Ollier's disease associated with osteochondroma, Gilbert's syndrome and insular glioma of brain was made. | [[35.0, 'year']] | M | {'19795968': 1, '10392492': 1, '8052390': 1, '10398153': 1, '27036230': 1, '9921931': 1, '3171621': 1, '12584501': 1, '16995932': 1, '20661403': 1, '22623818': 2, '11850620': 1, '7565971': 1, '24379533': 2} | {'3354360-1': 1} |
164,809 | 3866669-1 | 24,379,534 | noncomm/PMC003xxxxxx/PMC3866669.xml | Technetium-99m methylene diphosphonate uptake in the brachialis muscle hematoma in a patient with prostate cancer and coagulation disorder mimicking bone metastasis evaluated by single-photon emission tomography-computed tomography/computed tomography | A 79-year-old man with prostate cancer and coagulation disorder was referred for a bone scan because of left shoulder pain. A bone scan was performed to assess for any skeletal involvement, especially in the shoulder. A total of 20 mCi (740 MBq) MDP was injected intravenously and imaging was performed 3 h later using a large field of view, dual headed gamma camera fitted with a low-energy, high-resolution collimator. Anterior whole-body images showed intense uptake in the left axilla []. SPECT CT of the chest [Figures and ] was performed to rule out whether the uptake is in the humerus, but it showed a hematoma in the left brachialis muscle, which he developed due to his coagulation disorder. A hematoma was confirmed on fine-needle aspiration and resolved spontaneously over the next 4-5 weeks. Follow-up bone scan carried out after 6 months showed resolution of uptake in the left axilla []. | [[79.0, 'year']] | M | {'3582396': 1, '10836701': 1, '1544261': 1, '16950146': 1, '26097427': 2, '2659230': 1, '15192477': 1, '3161737': 1, '8356264': 1, '24379534': 2} | {'4455172-1': 1} |
164,810 | 3866671-1 | 24,379,536 | noncomm/PMC003xxxxxx/PMC3866671.xml | A rare case of primary malignant melanoma of clivus with extensive skeletal metastasis demonstrated on 18F-FDG PET/CT | A 55-year-old woman, presented to the hospital with chief complaints of headache, decreased vision in the left eye, and occasional episodes of vomiting since 3 months. MRI brain revealed altered signal intensity lesion with solid, hemorrhagic, and few cystic components in basiocciput, basisphenoid, clivus, sella, and right petrous apex; displacing optic chiasma superiorly. There was associated soft tissue component extending into cavernous sinus with partial encasement of cavernous segment of right internal carotid artery. CEMR study revealed a large moderately enhancing mass lesion involving the clivus with sellar-suprasellar extension with encasement of bilateral internal carotid arteries suggestive of plasmacytoma/chordoma or metastasis []. She underwent endonasal transsphenoidal excision of clival tumor and the black colored, relatively avascular tumor was confirmed to be melanocytic melanoma of clivus on histopathological examination. The patient was thoroughly examined to rule out any lesion on the skin and mucosa with other investigations including chest X-ray. A week after the surgery, this patient was referred to our department for a whole body 18F-FDG PET/CT scan for restaging. Whole body PET-CT scan was performed after intravenous (IV) administration of 10 mCi of 18F-FDG. PET and contrast-enhanced CT images were acquired and reconstructed to obtain transaxial, coronal, and sagittal views. Fused PET-CT images were then generated. The study revealed residual hypermetabolic well-defined lobulated soft tissue lesion in the basisphenoid and sella turcica region extending into the extraaxial space of right middle cranial fossa causing destruction of the sella turcica, sphenoid sinus, dorsal sella, and clivus; suggestive of residual disease. Also multiple metabolically active skeletal lesions were noted suggestive of skeletal metastasis []. Thereafter, the patient was planned for palliative chemotherapy and brain irradiation. | [[55.0, 'year']] | F | {'1615371': 1, '25767575': 2, '19259614': 1, '28061499': 1, '21358999': 1, '17618441': 1, '10088024': 1, '24379536': 2} | {'4352627-1': 1} |
164,811 | 3866672-1 | 24,379,537 | noncomm/PMC003xxxxxx/PMC3866672.xml | Ovarian carcinoma producing parathyroid hormone-related protein causing hypercalcemia and metastatic calcification detected on 18F-FDG PET-CT | A 65-year-old female was diagnosed with carcinoma ovary 10 years ago. Laparoscopic cholecystectomy and ovarian cystectomy was performed in 2004. Histopathology revealed papillary serous cyst adenocarcinoma of ovary with metastatic deposits in serosa of the gallbladder. This was followed by ovarian laparotomy and peritoneal flush. Then, she was followed up with cancer antigen (CA)-125 level. A rising trend in CA-125 level from 250 mg/dl in February 2012 to 1194 mg/dl in November 2012 was noted. She was then referred to our department for 18F-FDG PET-CT study. 18F-FDG PET-CT scan revealed FDG-avid irregular soft tissue density mass lesion, measuring 5.1 × 7.7 cm, with calcification in left rectus abdominis (pelvic region). Another FDG-avid soft tissue density mass lesion in the subcutaneous region involving right rectus abdominis muscle, measuring 1.1 × 3.4 cm, in the region of epigastrium was also noted. FDG-avid enlarged lymph nodes with foci of calcification were noted in left inguinal, left external iliac, left obturator, and left common iliac regions []. In view of raised CA-125 levels, these lymph nodes were reported as metastatic lesions. The patient then underwent USG-guided aspiration from the left inguinal lymph node, which was positive for a metastatic lesion. Her serum calcium level was 16 mg/dl (normal 7.4-9.0 mg/dl). PTHrP level was estimated to look for a possible cause of hypercalcemia and was found to be markedly raised at 116 pmol/l (normal 17.6-61.2 pmol/l). | [[65.0, 'year']] | F | {'1759057': 1, '12893397': 1, '6987579': 1, '15673803': 1, '29236066': 2, '7943531': 1, '8198376': 1, '24379537': 2} | {'3866672-2': 2, '5745396-1': 1} |
164,812 | 3866672-2 | 24,379,537 | noncomm/PMC003xxxxxx/PMC3866672.xml | Ovarian carcinoma producing parathyroid hormone-related protein causing hypercalcemia and metastatic calcification detected on 18F-FDG PET-CT | A 47-year-old female presented with amenorrhea and pain in lower abdomen since 2 months. On pelvic ultrasound examination, lobulated soft tissue lesions showing mildly echogenic center and peripheral hypoechoic soft tissue rim with moderate internal vascularity were noted in the pouch of Douglas [31.7 × 31.9 × 34.0 mm (volume 18 cc)] and left adnexa [32.9 × 24.6 × 17.7 mm (volume 7.5 cc)]. On contrast-enhanced computed tomography (CECT) whole abdomen examination, there were extensive retroperitoneal, retrocrural, and pelvic lymphadenopathies. Majority of the nodes revealed tiny punctuate calcific foci. Both ovaries were bulky and cystic. Her CA-125 level was markedly elevated (4969 mg/dl). A CT-guided fine needle aspiration cytology (FNAC) from retroperitoneal lymph node revealed features of metastatic adenocarcinoma. The patient was advised a trucut biopsy, but biopsy could not be done as the treating gynecologist declined to perform trucut biopsy because of the risk of spread of disease. She was classified as stage IIIC (FIGO staging), as the retroperitoneal lymph nodes were involved with no distant metastasis. She was then referred to our department for 18F-FDG PET-CT study.18F-FDG PET-CT scan revealed serosal deposit in the sigmoid colon and pararectal mesentery, with mildly increased FDG uptake and foci of calcification. The scan also revealed multiple enlarged FDG-avid left external iliac, left internal iliac, left common iliac, retroperitoneal, and multiple mesenteric lymph nodes with foci of calcification []. So, a final impression of metastatic disease involving multiple lymph nodes, serosal and mesenteric deposits was reported. The patient later underwent CT-guided FNAC from retroperitoneal lymph node. FNAC smear was found to be cellular with small clusters and cell balls. The cells were found to be crowded with enlarged nuclei with prominent nucleoli in a background of blood, lymphocyte, few mesothelial cells, and adipose tissue fragments []. Her serum calcium level was 15 mg/dl (normal 7.4-9.0 mg/dl). PTHrP level was estimated to look for a possible cause of hypercalcemia and was found to be markedly raised at 108 pmol/l (normal 17.6-61.2 pmol/l). | [[47.0, 'year']] | F | {'1759057': 1, '12893397': 1, '6987579': 1, '15673803': 1, '29236066': 2, '7943531': 1, '8198376': 1, '24379537': 2} | {'3866672-1': 2, '5745396-1': 1} |
164,813 | 3866673-1 | 24,379,538 | noncomm/PMC003xxxxxx/PMC3866673.xml | Extraosseous uptake of technetium-99m methylene diphosphonate by an acute territorial cerebral infarct in a classical biodistribution pattern | A 77-year-old woman was referred for Tc-99m MDP whole body nuclear bone scan to rule out metastases. She underwent bilateral mastectomy 3 years ago for bilateral breast carcinoma and received chemotherapy also. She had multiple comorbidities including diabetes mellitus, hypertension and hypercholesterolemia and was bed-ridden, due to her chronic debilitated status.\nIn the anterior and posterior images of the whole body bone scan, a normal physiological pattern of tracer uptake was observed in the bones and degenerative changes were observed in bilateral shoulders, left knee and left ankle. No focus of intense uptake of tracer in bones suspicious of metastases was identified in axial and appendicular skeleton []. However, a heterogeneous and diffuse tracer uptake was noted in the right hemicranium and following which spot films of skull lateral views were obtained. The distribution of tracer uptake in the right lateral view of skull corresponded with the anterior circulation territory of the brain, sparing the posterior circulation territory of posterior fossa with a sharp demarcation []. Since the finding raised a strong suspicion of right anterior circulation territorial infarct of brain, patient was subjected to clinical examination, which revealed that the power of the left lower and upper limbs were reduced when compared to the right side.\nPatient was referred to the intensive care unit immediately for acute medical care. Later, patient was further investigated with magnetic resonance imaging (MRI), which confirmed the presence of an acute cerebral infarct confined to the right internal carotid arterial territory [Figure –]. Patient was discharged after conservative management. | [[77.0, 'year']] | F | {'18716525': 1, '27833325': 1, '16550022': 1, '17413590': 1, '2217976': 1, '27833318': 2, '14508283': 1, '12971637': 1, '3262477': 1, '6317260': 1, '8356264': 1, '24379538': 2} | {'5041421-1': 1} |
164,814 | 3866674-1 | 24,379,539 | noncomm/PMC003xxxxxx/PMC3866674.xml | Synchronous papillary carcinoma thyroid with malignant struma ovarii: A management dilemma | A 51-year-old multigravida with no comorbid illnesses was evaluated at an outside hospital for an abdominopelvic mass, wherein she was administered two cycles of chemotherapy with cisplatin and cyclophosphamide with a presumed clinical diagnosis of an ovarian malignancy. She subsequently defaulted for treatment, only to present to our center, 7 years later with vague complaints of abdominal pain and distension. Clinical evaluation revealed a 12 × 8 cm sized abdominopelvic mass, which could not be made out separately from the uterus on rectal and vaginal examination. General examination and examination of the other systems were normal. A computed tomography (CT) scan of the abdomen and pelvis revealed a 13 × 7.6 cm heterodense adnexal mass with solid and cystic components and punctate calcifications []. The levels of the tumor marker CA-125 was elevated at 85 U/ml. She underwent a staging laparotomy and an optimal cytoreduction (total abdominal hysterectomy, bilateral salpingo-oophorectomy with omentectomy, lymph nodes, and peritoneal sampling) after a frozen section diagnosis of an ovarian teratoma with SO from the right ovary. The final histopathology revealed the mass to be arising from the right ovary [] which on microscopy revealed a neoplasm composed of mixed elements arising from all germ layers with predominance of thyroid parenchyma composed of multiple nodules with colloid filled follicles. The nodules within the thyroid tissue measuring 0.5-0.8 mm showed closely packed follicles lined by columnar cells with cell crowding, loss of polarity and nuclear grooves, and features suggestive of FVPTC. The left ovary, uterus, fallopian tubes, omentum, nodes, and the peritoneal biopsies were within normal limits. The final diagnosis suggested an malignant SO []. A total thyroidectomy was subsequently performed, a preoperative ultrasound of the thyroid gland revealed a 4 mm nodule in the right lobe of the thyroid, which was indeterminate on an ultrasound-guided fine needle aspiration cytology (FNAC). The final histopathology of the thyroidectomy specimen revealed the nodule with histological features suggestive of FVPTC. The postoperative iodine-131 whole body scan was negative for metastasis. The patient is on follow-up after remnant ablation for the past 6 months on suppressive doses of eltroxin. | [[51.0, 'year']] | F | {'18214583': 1, '19696610': 1, '26430330': 1, '22883659': 1, '22181336': 1, '23645304': 1, '22369392': 1, '31007958': 2, '23391779': 1, '26137011': 1, '29264493': 1, '22288964': 1, '19471561': 1, '12798728': 1, '30039072': 2, '24379539': 2} | {'6441504-1': 1, '6032648-1': 1} |
164,815 | 3866675-1 | 24,379,540 | noncomm/PMC003xxxxxx/PMC3866675.xml | Incidentally detected diaphragmatic hernia mimicking angina pectoris with Tc-99m MIBI myocardial perfusion imaging | A 74-year-old male patient with a history of hypertension, hypercholesterolemia, a mild transient chest pain, palpitation and severe dyspnea was referred to our Nuclear Medicine Department for Myocardial Imaging. Consists of a detailed medical history from the patient, characteristics of the chest pain was astringent, nonproductive, localized in the central part of the chest and occur after eating, and also cough and nausea accompanied by angina. The patient experienced severe dyspnea which was worse in supine position. All the laboratory blood biochemistry findings, complete blood count, the blood cardiac enzymes levels (troponin, creatinine phosphokinase, myocardial isoenzyme) electrocardiogram, echocardiography were in normal range. But, the chest X-ray was not performed before myocardial perfusion scan.\nAfter written informed consent was obtained from the patient, he underwent same day stress and rest 99mTc MIBI myocardial imaging with SPECT and stress test was performed with treadmill exercise. Target heart rate was 147 beat/min, achieved heart rate was 139 beat/min (94%) with 9.7 METS in 06.00 minutes. Stress images were acquired 45 minutes after intravenous administration of 296 MBq (8 mCi) at the peak heart rate on treadmill exercise test. Subsequently, the rest images were acquired 60 minutes after the second intravenous administration of 925 MBq (25 mCi). The images, provided after motion correction but not attenuation correction, show a moderate to severely reduced perfusion in the mid and inferolateral segments. In gated SPECT process, wall motion and thickening was normal. The ejection fraction was 60%. A review of the unprocessed data of rest imaging revealed, an extracardiac activity localized in the left hemitorax, behind the myocardium like a mirror vision of the left ventricle myocardium in rest images. The raw data of the rest images revealed a doughnut activity in the left chest, behind of the left ventricle. On the contrary, only minimal minimal activity was seen in the raw data of the stress at this localization []. Localization of 99mTc MIBI within that area likely considered as a herniation, which was not mentioned in the patients’ history.\nThe patient subsequently underwent the CT scan of the thorax and upper abdomen for the determination of the nature of the mass. Subsequent computed tomography (CT) of the thorax demonstrated that a part of the bowel, stomach and mesenteric fat tissue were herniated in the left hemithorax and because of these herniated tissues, the lungs were compressed at this localization []. Computed tomography (CT) of the thorax confirmed that the activity in the raw data of the MPS images corresponded to the left diaphragmatic hernia (Bochdalek type). Within the CT results; as the myocardial perfusion scintigraphy was normal, the patient's symptom of dyspnea, angina and vomiting was correlated with the herniation. The patient was referred to thoracic surgery clinic for the surgery. | [[74.0, 'year']] | M | {'17314607': 1, '8708757': 1, '23668793': 2, '14668788': 1, '15899350': 1, '9122602': 1, '11805483': 1, '9554200': 1, '10656656': 1, '11150455': 1, '15657504': 1, '5032716': 1, '24379540': 2} | {'3668166-1': 1, '3668166-2': 1, '3668166-3': 1} |
164,816 | 3866704-1 | 24,358,070 | noncomm/PMC003xxxxxx/PMC3866704.xml | The Pathophysiology of Primary Hip Osteoarthritis may Originate from Bone Alterations | A 62-year-old woman, 155.5 cm tall and weighing 68.0 kg, with no past history visited our hospital. At her first visit, she complained of slight locking symptoms with accompanying right hip pain after a long walk during a trip and bilateral knee pain while walking and reclining in a lateral recumbent position. Plain radiographs of the bilateral knee joints showed advanced-stage OA, while the right hip joint did not show OA features (KL grading 0, Fig. ). Physical examination revealed restricted abduction range of motion (ROM) in her right hip. A month after the onset of pain, hip MRI showed broad and heterogeneous low intensity by T1W and high intensity by T2-STIR (Fig. , ). Two months after onset, her joint pain disappeared; however, a slight joint space narrowing in the femoral head was found on plain radiographs (KL grading I, Fig. ). Interestingly, her left hip joint, which was without pain, had already shown slight joint space narrowing, but no signal change on MRI (Figs. ). | [[62.0, 'year']] | F | {'19410032': 1, '25250098': 2, '14603577': 1, '24044031': 1, '25317214': 2, '22868925': 1, '23321609': 1, '3780104': 1, '6478691': 1, '3488657': 1, '9185156': 1, '15077302': 1, '20678201': 1, '25436838': 1, '22542276': 1, '20191005': 1, '24133552': 2, '22932918': 1, '26776564': 2, '25568659': 1, '9608330': 1, '17161286': 1, '3363134': 1, '24358070': 2} | {'3866704-2': 2, '3795405-1': 1, '3795405-2': 1, '3795405-3': 1, '4192849-1': 1, '4192849-2': 1, '4192849-3': 1, '4726085-1': 1, '4726085-2': 1, '4726085-3': 1, '4726085-4': 1, '4166791-1': 1} |
164,817 | 3866704-2 | 24,358,070 | noncomm/PMC003xxxxxx/PMC3866704.xml | The Pathophysiology of Primary Hip Osteoarthritis may Originate from Bone Alterations | A 67-year-old woman, 166 cm tall and weighing 57 kg, visited our hospital very recently. Her pain in the right hip joint started during gait without any episode. Plain radiographs showed a KL grading of 0 in the right hip (KL grading 0, Fig. ). ROM in the right hip joint was full. A week after the onset of pain, hip MRI revealed femoral-lateral local bone alterations in the right hip joint (Fig. , ). More joint space narrowing was seen in the right hip on a plain radiograph (KL grading I, Fig. ). Her right hip pain is currently much reduced. | [[67.0, 'year']] | F | {'19410032': 1, '25250098': 2, '14603577': 1, '24044031': 1, '25317214': 2, '22868925': 1, '23321609': 1, '3780104': 1, '6478691': 1, '3488657': 1, '9185156': 1, '15077302': 1, '20678201': 1, '25436838': 1, '22542276': 1, '20191005': 1, '24133552': 2, '22932918': 1, '26776564': 2, '25568659': 1, '9608330': 1, '17161286': 1, '3363134': 1, '24358070': 2} | {'3866704-1': 2, '3795405-1': 1, '3795405-2': 1, '3795405-3': 1, '4192849-1': 1, '4192849-2': 1, '4192849-3': 1, '4726085-1': 1, '4726085-2': 1, '4726085-3': 1, '4726085-4': 1, '4166791-1': 1} |
164,818 | 3867616-1 | 24,369,001 | noncomm/PMC003xxxxxx/PMC3867616.xml | Deformity Correction by Femoral Supracondylar Dome Osteotomy with Retrograde Intramedullary Nailing in Varus Deformity of the Distal Femur after Pathologic Fracture of Giant Cell Tumor | A 46-year-old female patient visited our clinic with a complaint of persistent pain in the left knee that had lasted for one year. She had no history of trauma or infection. Physical examination revealed mild tenderness along the medial joint line and restricted range of motion in the affected knee (0-120 i) compared to the intact knee (0-140 pa). Although varus deformity of the knee was visible to the naked eye, joint instability was not present. Plain radiographs showed a varus deformity caused by malunion in the left distal femur, medial femorotibial joint space narrowing, and subchondral sclerosis (). The umbilicus malleolar distance (UMD) was 84.8 cm on the intact side and 83.2 cm on the affected side. The spina malleolar distance was 80.2 cm on the intact side and 79.1 cm on the affected side. The patient did not complain of discomfort related to the leg length discrepancy. The femorotibial angle was measured as 21.5° of varus, the mechanical lateral distal femoral angle (M-LDFA) was 104.3° and the anatomical lateral distal femoral angle (A-LDFA) was 109.5° in the left knee (). Her medical history showed that she had been diagnosed with giant cell tumor of the distal femur ten years ago, which was treated with curettage and cryotherapy with liquid nitrogen and allograft (), and then the same treatment was performed 9 and 8 years ago, respectively, due to recurrence. Thereafter, she sustained a pathologic fracture in the same region after a slip and fall, which was treated conservatively ().\nDeformity correction was determined necessary considering the patient's young age and radiographic findings of severe varus deformity combined with arthritis in the medial compartment. Although the UMD on the affected knee was shorter than that on the intact knee (83.2 cm vs. 84.8 cm), there was no significant side-to-side difference in the total anatomical length of the femur and the tibia (68.3 cm in the intact knee and 67.9 cm in the affected knee) and the patient did not complain of any discomfort. Thus, leg-length equalization was considered unnecessary. The correction angle was determined as 30° with the aim of achieving 5°-10° varus of the feromotibial angle postoperatively. It was estimated that the 30 correction for the femur with a diameter of 4 cm would result in 2.3 cm of leg lengthening with use of a medial open technique whereas 2.3 cm of leg shortening with use of a lateral closed technique. Thus, we determined to perform a corrective dome osteotomy that would have no significant influence on the leg length.\nAdhesiolysis around the anterior joint capsule and quadriceps lengthening were considered necessary due to limited flexion. For the osteotomy, we determined to use an anteromedial approach as in the previous surgery. After making a 15 cm skin incision on the anteromedial aspect, adhesiolysis around the anterior joint capsule and quadriceps lengthening using Z-plasty were performed. After verifying the recovery of complete range of motion, the rectus femoris and patellar bone were retracted laterally to expose the distal femur. Evidence of arthritis was observed across the medial articular surface of the distal femur, but specific findings that suggest a giant cell tumor were not noted. The center of rotation angulation (CORA) was located under fluoroscopy. After determining the dome osteotomy site from the femoral supracondylar with an interval of 10.0 mm using a 2.0 mm drill bit, the osteotomy was performed using a parallel saw blade (Synthes GmbH, Solothurn, Switzerland) (). The varus deformity was corrected and the mechanical and anatomical axes were assessed under the guidance of fluoroscopy. Without an additional incision, retrograde intramedullary nailing was performed through the distal femur for fixation. PolyBone (Kyungwon Medical Co., Seoul, Korea) containing polyphosphonate and bone morphogenetic protein was additionally inserted (). For six postoperative weeks, long leg cast immobilization was applied, and active joint exercises and partial weight-bearing were allowed. Full weight-bearing was permitted from the 12th postoperative week. At 24 weeks postoperatively, bone union and normal range of motion were achieved. The femorotibial angle was 6.3° of varus, the M-LDFA was 78.6, and the anatomical A-LDFA was 76.3 at 24 weeks postoperatively (). | [[46.0, 'year']] | F | {'32489748': 1, '21561776': 1, '2684463': 1, '29632977': 1, '23459260': 1, '18512777': 1, '23624677': 1, '25142271': 1, '8028880': 1, '28300344': 1, '10484909': 1, '21210313': 1, '10426228': 1, '24369001': 2} | {} |
164,819 | 3867617-1 | 24,369,002 | noncomm/PMC003xxxxxx/PMC3867617.xml | Multiple Osteochondritis Dissecans of Knee Joint in a Patient with Wilson Disease, Focusing on Magnetic Resonance Findings | A 17-year-old man visited our orthopedic department with an acute attack of the left knee pain that had begun 2 days previously. The patient had experienced discomfort in both knees for the previous 7 months. A physical examination revealed diffuse swelling and tenderness of the left knee and motion limitation due to pain. Positive Wilson sign was evident and there seemed no other joint involvement but the both knees.\nThe patient had no record of previous medical history or family history of other diseases.\nPlain radiography was performed, which revealed symmetrical multiple OCD on femoral condyles of both knees (). Further evaluation was warranted for the unusual presentation of the disease. The patient was admitted and had a routine laboratory test prior to admission and it was his first time to take laboratory tests. His laboratory tests showed thrombocytopenia platelet count of 83×103/µL, prolonged prothrombin (PT)/activated partial prothrombin time (aPTT) of 14.7/45.3 sec. Further lab tests were carried out, and revealed deficit of coagulation factors V, XI, and XII (all 44%; normal range, 60% to 140%). Abdominal ultrasound revealed cirrhotic morphologic changes of the liver and splenomegaly. A suspicion of Wilson disease led to more additional laboratory tests for confirmation, which showed low ceruloplasmin (<4 mg/dL; normal range, 16.2 to 35.6 mg/dL), low serum copper (43 µg/dL; normal range, 70 to 145 µg/dL), and high urine copper (383 µg/dL: normal range, 15 to 60 µg/dL). Ophthalmologic examination showed Keyser-Fleischer rings in both corneas.\nHe was diagnosed with Wilson disease. Examinations of other commonly involved joints affected by Wilson disease, such as spine, hip, and wrists, were done and showed normal findings, and bone mineral density study also revealed normal values.\nAn MRI scan of the knee was performed to evaluate OCD lesions for its stage and treatment plans and to evaluate ligamentous or meniscal injury, if any. The MRI scan revealed characteristic bilateral symmetric OCD on both knees and symmetric detached OCD on the medial condyle of the bilateral femurs. Subchondral cysts were also seen on the medial femoral condyle of both knees and the trochlear dysplasia was observed in both femurs (-).\nArthroscopic debridement was performed for treatment of OCD.\nArthroscopic findings revealed OCD lesions on both medial and lateral femoral condyles, which were not apparently unstable at first under direct arthroscopic visualization. Using an arthroscopic probe, the medial femoral condyle lesion was found at the inferocentral portion of the medial femoral condyle; the lesion was unstable and already in a detached state (). The detached fragment too fragile to fixate was excised, and curettage and multiple drilling were performed subsequently (). The lesion on the lateral femoral condyle, also located at the inferocentral aspect, was stable and undetached, and was left untouched with the expectation of spontaneous healing ().\nMicroscopically, the section revealed articular cartilage with secondary calcification and synovial tissue (, ).\nAfter the arthroscopic treatment, the symptoms slowly diminished and at the 2-month postoperative follow-up, the patient was pain free with full range of motion of the knee. Ever since the diagnosis of the Wilson disease, the patient was on chelation therapy and had no recurrence of knee joint pain within the total 6 months of follow-up period. | [[17.0, 'year']] | M | {'3361541': 1, '857745': 1, '5410330': 1, '6817993': 1, '5031611': 1, '14439031': 1, '1117834': 1, '29998741': 1, '3975658': 1, '13521109': 1, '33575051': 2, '28642858': 2, '4751778': 1, '24369002': 2} | {'7864730-1': 1, '5472800-1': 1} |
164,820 | 3867618-1 | 24,369,003 | noncomm/PMC003xxxxxx/PMC3867618.xml | Femoral Nerve Palsy with Patella Fracture | A 25-year-old active young woman (weight 57 kg, height 1.64 m) suffered a left patella fracture due to a slip and fall. She had a medical history of right knee arthroscopy in 2001 due to a cruciate ligament injury. Complete blood count, electrolyte panel, coagulation screening, electrocardiography, and plain radiographic findings were all within normal limits. A physical examination revealed moderate tenderness and swelling in the left thigh and knee area. We could not check motor grade of the left knee due to severe pain. Open reduction and internal fixation with a tension band wiring was performed under spinal anesthesia three days after admission to the emergency room. A pneumatic tourniquet was inflated to 370 mmHg at the onset of the procedure and was deflated 80 minutes after surgery. Her leg was elevated to 30 degrees immediately after surgery, and an ice bag was applied to the operation site. Immediate full weight bearing and range of motion were allowed. There were no signs of infection. The patient was discharged with a crutch four days after the operation.\nThe patient returned the following week for consultation. She had marked pain in the left knee area, difficulty in extending the knee, and weakness of the quadriceps muscle. She was referred to a rehabilitation physician and a neurologist for electromyography-nerve conduction velocity (EMG-NCV) testing, but she refused the test.\nEight weeks after being discharged, she was readmitted because of persistent pain and neurologic symptoms. At that time, manual muscle testing of the left lower limb showed grade IV hip abduction, grade V adduction, grade III hip flexion, grade II knee extension, grade V ankle dorsiflexion, and grade V plantar flexion. Pinprick sensation of the femoral nerve and lateral cutaneous nerve in the thigh area was decreased to 8 points on a scale from 0 to 10 points. Reflexes at the left patella were not assessable. Knee pain was measured as 5 on a visual analogue scale. MRI of the knee showed no evidence of abnormalities of the anterior cruciate ligament, posterior cruciate ligament, lateral collateral ligament, medial collateral ligament, or meniscus abnormality, except for slight increase in the amount of joint effusion. However, evaluations of the patella, infrapatellar fat pad, quadriceps tendon, patellar tendon, and anterior horn of medial/lateral menisci were limited due to severe metallic artifacts. Diffuse T2 high signal intensity was observed in the anterior compartment of the left thigh, suggesting an acute denervation change related to left femoral neuropathy. Furthermore, the whole volume of the muscles of the left thigh was reduced, suggesting combined disuse atrophy (). MRI of the lumbar spine depicted a normal spinal cord, L4 nerve roots, and lumbar plexus, except for bulging discs with an annular tear at L3-4, L4-5, and L5-S1. In addition, mildly increased echogenicity was noted in the left anterior compartment muscle with decreased volume by joint ultrasonography, suggesting disuse atrophy or a denervation change.\nAn EMG study was performed on the left tibialis anterior, gastrocnemius medialis, vastus lateralis, vastus medialis, rectus femoris, adductor brevis, gluteus medius, and lumbar paraspinal (L3 and 4) muscles. Positive sharp waves and fibrillation potentials were observed in the vastus lateralis, vastus medialis, and rectus femoris muscles by needle electromyography. Furthermore, a sensory nerve conduction study (NCS) revealed reduced conduction for the left saphenous nerve. One week after the test, a follow-up EMG study was done by another neurologist, and the results were the same.\nAccordingly, the study established the presence of partial peripheral neuropathy of the left femoral nerve. The patient was referred for electrical stimulation therapy and steroid therapy but refused any further treatments. The internal fixation device was removed at two months after surgery due to severe pain, and subsequently, the knee pain scale improved to visual analogue scale 3 five days after the device removal. | [[25.0, 'year']] | F | {'21187558': 1, '2981881': 1, '15954069': 1, '8028880': 1, '11734499': 1, '20143990': 1, '16186707': 1, '12808548': 1, '24369003': 2} | {} |
164,821 | 3867619-1 | 24,369,004 | noncomm/PMC003xxxxxx/PMC3867619.xml | Adenomyoepithelioma Located Over the Tibial Tuberosity | A 41-year-old Russian female visited our clinic with a chief complaint of tenderness over a lump on the right tibial tuberosity. It had been present for 20 years without pain or changes in size and level of tenderness. In physical examination, an approximately 2×2 cm soft, round-shaped mobile mass was detected. Severe tenderness was noted, but neither abnormal sensation nor decreased mobility was evident. Plain radiography revealed increased soft tissue density immediately below the right tibial tuberosity (). Ultrasonography showed a hypoechoic multinodular lesion in the subcutaneous fat layer ().\nUnder local anesthesia, a 4-cm longitudinal incision was made below the tibial tuberosity, through which a salmon-colored mass measuring 2×2×1 cm was noted in the subcutaneous fat layer () without adhesion to the adjacent tissue or bursitis. The mass was excised, taking care to minimize adjacent soft tissue damage. Histologic examination revealed the mass was composed of glandular structures lined by epithelial cells and surrounded by multiple layers of myoepithelial cells (). On immunohistochemical analysis, the inner epithelial cells was strongly positive for cytokeratin 7 (CK7) and the myoepithelial cells positively reacted to p63.\nPostoperatively, neurological symptoms were not observed. The patient was satisfied with disappearance of tenderness after the excision of the tumor. At six months after surgery, there were no signs of complications and recurrence. | [[41.0, 'year']] | F | {'9363454': 1, '6438900': 1, '3301214': 1, '7611543': 1, '1384377': 1, '2824328': 1, '18318577': 1, '22964617': 1, '12753168': 1, '24369004': 2} | {} |
164,822 | 3868093-1 | 24,379,502 | noncomm/PMC003xxxxxx/PMC3868093.xml | Adolescent Male Peer Sexual Abuse: An Issue Often Neglected | M, a 13-year-old boy, presented with complaint of small water-filled lesions in the perianal region, which burst to form raw areas, associated with burning pain and bloody discharge. On examination, the lesions were grouped, multiple, superficial with central slough, and peripheral erythema []. Herpes progenitalis was diagnosed (later confirmed by Tzanck smear). Strongly suspecting it to be sexually transmitted, the dermatologist questioned about sexual exposure, which was initially denied by M as well as by his father. On a more tactful enquiry in the absence of his father, M did admit to have been sodomized. The revelation was shocking to his father as he was completely unaware about it. A psychiatric referral was made for psychological evaluation.\nHistory revealed that 10 days back, while roaming around alone in his native village, he was approached by a boy, who was a complete stranger to him. He tried to befriend M, telling him that he was 13 years old and stayed in the neighboring village. He then immediately proposed that he wished to “penetrate” M and promised that the experience would be immensely pleasurable. M gave in to his demand, though with an initial resistance. In an isolated place in the nearby fields, they indulged directly in unprotected peno-anal sex with M being the recipient. Soon after the act began, M felt intense pain and immediately asked to stop, but the boy continued to thrust forcibly. M managed to push him away. He returned home, but could not gather the courage to report it to his parents. He experienced perianal pain for a day, but was asymptomatic thereafter for about 10 days until the appearance of the skin lesion. His father reported that there were no observable emotional or behavioral changes during that period.\nMental status examination did not suggest an overt psychopathology, although it was noted that while narrating the incident, M avoided eye-to-eye contact indicating a sense of guilt and embarrassment attached to it. He also expressed anger toward the perpetrator. He denied having any prior sexual experience. His academic record was good and intelligence was clinically average. He tested negative on Venereal Disease Research Laboratory (VDRL) test, and serological tests for Australia antigen and HIV. He did not come back for follow-up. | [[13.0, 'year']] | M | {'9125368': 1, '15701094': 1, '16125232': 1, '11197037': 1, '19038448': 1, '22727072': 1, '9846781': 1, '24379502': 2} | {} |
164,823 | 3868094-1 | 24,379,503 | noncomm/PMC003xxxxxx/PMC3868094.xml | Tiapride for the Treatment of Auditory Hallucinations in Schizophrenia | A 37-year-old right handed female Christian graduate was brought to the out-patient department by family members with chief complains of hearing voices inaudible to others, suspiciousness toward others as though they are talking about her and plotting against her since the past 5 years. She would hear voices of known and unknown people saying sometimes good things and majority of times saying bad things to her. She would get commanding hallucinations telling her to tear her books, bible, certificates, etc., She also complained of occasional anger outbursts, decreased sleep, and stopped doing household activities. She was diagnosed as having Paranoid Schizophrenia as per Diagnostic and Statistical Manual for the Classification of Psychiatric Disorders – 4th edition text revised (DSM-IV TR) (DSM-IV TR) criteria and was started on olanzapine 10 mg/day, haloperidol 10 mg/day and trihexyphenidyl 4 mg/day all in oral formulations. Gradually, the doses were increased weekly to olanzapine 20 mg/day, haloperidol 20 mg/day, and trihexyphenidyl 6 mg/day. Her suspiciousness and other behavioral disturbances started decreasing. However, her auditory hallucinations persisted even after 6 months of regular treatment. Clozapine 25 mg at night was added, which was gradually increased to 100 mg at night. Her hallucinations persisted, but there was some improvement in that the number of people whose voices she used to get reduced. She continued having auditory hallucinations lasting whole day. The patient and relatives were not willing for electroconvulsive therapy (ECT) as a treatment option. Hence, tiapride 50 mg/day was added after 6 months of addition of clozapine 100 mg. Her hallucinations started reducing in frequency and duration. After 2 weeks of tiapride therapy, the dose was increased to 100 mg/day in divided doses. The patient was completely relieved of her hallucinations in 4 weeks of starting tiapride. Olanzapine was reduced as she complained of excessive sedation with it. Currently, the patient is on haloperidol 20 mg/day, olanzapine 10 mg/day, trihexyphenidyl 6 mg/day, clozapine 100 mg at night and tiapride 100 mg/day. She was assessed for hallucinations using the hallucinations subscale of the psychopathology rating scale (PSYRATS). Her score on the hallucination subscale improved from 28 to 11 after the addition of tiapride. | [[37.0, 'year']] | F | {'7960671': 1, '7521826': 1, '10755670': 1, '11697583': 1, '21694785': 1, '18801220': 1, '15176768': 1, '11520476': 1, '11520478': 1, '3493497': 1, '10721880': 1, '24379503': 2} | {'3868094-2': 2} |
164,824 | 3868094-2 | 24,379,503 | noncomm/PMC003xxxxxx/PMC3868094.xml | Tiapride for the Treatment of Auditory Hallucinations in Schizophrenia | A 32-year-old married 10th standard educated female was brought to the out-patient department by her sister with complaints of suspiciousness toward the neighbors that they are talking about her and that they would kill her and her family members since the past 6 months. She would feel that they are keeping a watch on her by cameras fitted in her house by them. She would also hear voices inaudible to others commenting on her actions and sometimes giving running commentary also. She also had decreased sleep and decreased working ability. She was diagnosed as having Paranoid Schizophrenia as per DSM-IV TR criteria and was started on risperidone 4 mg/day and trihexyphenidyl 4 mg/day. Gradually risperidone was increased to 8 mg/day in weekly increments and trihexyphenidyl to 6 mg/day. Her symptoms showed no improvements after 1 month and olanzapine 10 mg/day was added, which was increased gradually to 20 mg/day. Her suspiciousness reduced and her sleep improved. She started doing routine and household activities. However, her complains of auditory hallucinations were persistent even 6 months of treatment. She and her family members were not consenting for ECT and tiapride 50 mg/day in divided doses was added to her medication. She started feeling better, her voices began to reduce and the intensity and frequency of hallucinations decreased. Tiapride was gradually raised to 150 mg/day in divided doses. The patient claimed 80% improvement in auditory hallucinations after 2 months of addition of tiapride to her medication. Her total score on the PSYRATS-hallucination subscale improved from 41 to 25 after addition of tiapride. | [[32.0, 'year']] | F | {'7960671': 1, '7521826': 1, '10755670': 1, '11697583': 1, '21694785': 1, '18801220': 1, '15176768': 1, '11520476': 1, '11520478': 1, '3493497': 1, '10721880': 1, '24379503': 2} | {'3868094-1': 2} |
164,825 | 3868095-1 | 24,379,504 | noncomm/PMC003xxxxxx/PMC3868095.xml | Recurrent Dissociative Fugue | A 32-year-old, right handed, Hindi speaking male was brought by police during emergency hours to mental hospital to get him admitted. He was produced before the court by the police who had taken him in their custody because he was found wandering aimlessly and could not give proper history on being probed. He had no identity card, cell phone or diary at the time of admission.\nHe was of average built with “SHIVA” tattooed on his right forearm. He was conscious, cooperative, and communicative but appears dazed and had difficulty to maintain eye contact during examination. He spoke very little about himself and express his difficulty to recollect events, details of personal whereabouts, specifically of recent past. Other tests of cognition and judgment were normal. He denied history of hearing voices, fall, and unconsciousness. He also denied history of alcohol, ganja, and bhang consumption. Systemic examination was normal. All investigations including electroencephalogram and magnetic resonance imaging (MRI) brain scan was found to be normal.\nSuccessive mental status examination revealed improved orientation but failed to recollect his personal identity. Tablet Lorazepam 2 mg was started after complaining of difficulty in sleep.\nGradually he started socializing with other inmates, took interest in ward work and then started going to occupational department. He established good rapport with nursing staff and social worker.\nHe was by then diagnosed with dissociative fugue according to DSMIV TR Text revision and managed with supportive psychotherapy. After obtaining consent from the patient, Pentothal interview was done during which he had hazy memory of his children.\nHe remains unchanged until about 2 month when Pentothal interview was again repeated when he spoke about his wife who eloped with neighbor about 6 months back leaving behind two children.\nPatient identified himself as Rajesh (name changed) who earns livelihood by selling bangles, he expressed concern about his children as well his identity of being unfair father who cannot sustain his children because of poverty.\nSocial worker then informed his brother at his village near Chhattisgarh, who informed that it, was his 3rd episode of fugue state. In the last 5 years he similarly lost his way and found in Haridwar and Jaipur in same way. Patient's family members after a week took him home. | [[32.0, 'year']] | M | {'16585437': 1, '15093151': 1, '15054137': 1, '9653418': 1, '24379504': 2} | {} |
164,826 | 3868096-1 | 24,379,505 | noncomm/PMC003xxxxxx/PMC3868096.xml | Atypical Charles Bonnet Syndrome | A 72-years-old female was brought to psychiatry outpatient department, relatives reported that for last 1 month, she is complaining, she is not in her home as she often says that she should be taken to her own home. She was not able to move about freely due to her impaired vision, weight and diabetic neuropathy. She had to be helped for activities of daily living due to impaired vision. She would often say that there are people around her whom she does not know. She was also hearing voices of some persons crying and would ask her daughter-in-law about it. She said she could see a few children eating from her plate when she is eating her meals and she would ask them to be removed. She said there are 3-4 children of 6-8 years age who are eating from her plate. She could see monkeys in her room. At times she would say that she is being taken in an ox-cart, she could see the desert and ruins of a building. She would repeatedly say that she can see many persons around her and they should be removed from there, or she should be taken to her own home. She remained irritable due to the presence of unwanted persons around her. At times, she also said that someone has carried out black magic on her, though on examination, it was not a firmly held belief. On mental status examination her cognitive functions were intact. She had auditory and visual hallucinations. She was troubled by auditory and visual hallucinations and lacked insight.\nShe was a diagnosed case of diabetes and hypertension since 1999. She also had diabetic nephropathy and neuropathy. She was on injection Insulin twice a day 18 units and 12 units, morning and evening.\nIn March 2009, she had an ophthalmic examination. She had proliferative diabetic retinopathy and ocular hemorrhage. She had complete vision loss since March 2009 (2 months) and had to be helped for activities of daily living. She was taking tablet alprazolam occasionally for last 1 year. Her appetite was normal, but sleep was disturbed.\nShe was started on Tablet Aripiprazole 10 mg/day, later increased to 15 mg/day. However, there was no improvement after 2 months and in June 2009, tablet Risperidone was started initially 2 mg/day, increased to 4 mg/day. She was also given tablet lorazepam 2 mg/day. There was no improvement in any of her symptoms. A computed tomography scan was suggested but due to her difficulty in walking and obesity, relatives expressed inability to get it done.\nIn June 2010, she had her ophthalmic checkup. She had mature cataract in both eye, it was not possible to examine her retina. A decision was made to perform cataract surgery in both eyes simultaneously, as it was difficult to bring her to hospital repeatedly. After cataract surgery her psychotic symptoms resolved completely within 1 week. Her risperidone was stopped; she remained symptom free until her death in September 2011. | [[72.0, 'year']] | F | {'11430294': 1, '15793700': 1, '10438699': 1, '29744073': 2, '28615779': 2, '30405266': 2, '31238427': 1, '33425420': 2, '15633863': 1, '10196592': 1, '2647403': 1, '24379505': 2} | {'7775156-1': 1, '5930191-1': 1, '6201671-1': 1, '5461855-1': 1} |
164,827 | 3868098-1 | 24,379,507 | noncomm/PMC003xxxxxx/PMC3868098.xml | Early Onset Obsessive Compulsive Disorder with Obsessive Slowness: A Case Report and Demonstration of Management | Mr. M, a 15-year-old boy from middle socioeconomic status, Hindu, nuclear family, student of eighth class, without any past medical and psychiatric illness, with anankastic traits in parents as rigidity and stubbornness, and with slow to warm premorbid temperament; presented with 3 year history of insidious onset and progressively deteriorating course of symptoms characterized by repeated doubts (regarding locking and unlocking the door knobs, turning switches on and off), repeated fears (something bad would happen with him if somebody would touch him while performing almost all routine activities), magical thinking (roof falling on him if he would not stand properly from toilet seat), mental compulsion (counting) with progressive slowness in self-care behavior (brushing, bathing, changing clothes, walking, and eating), and avoidance of routine activities with academic decline. For 6 months prior to reporting to a tertiary level referral hospital in India, the patient started having anxious and low mood, loss of interest in all pleasurable activities, and stopped going to the school. He would remain confined to bed, would not speak and communicate mostly by gestures. He would spend 2-3 h in finishing his one meal, and similar time in bathing, changing clothes, etc., The mental status examination revealed obsessive slowness, obsessive doubts and fears, magical thinking, yielding, and mental compulsions. Yale-Brown Obsessive Compulsive Scale (YBOCS) score was 40 at the time of initial assessment. He was diagnosed as a case of OCD with slowness following International Classification of Diseases and Related Health Problems (ICD-10).[] It was planned to manage him as inpatient with combined pharmacological and behavioral treatment. His relevant and routine investigations were within normal limits. He was started on fluoxetine 20 mg/day. After detailed behavior analysis, it was found that he had slowness and repetition in all routine activities with score of 9-10 for distress on a scale of 1-10. He would remain in bed throughout the day and would do all routine activities only on being coaxed by parents. Prompting, pacing, and shaping of routine activities were carried out daily. Exposure and response prevention sessions were conducted on alternate days. Also, fluoxetine was slowly titrated to 60 mg/day and was well tolerated by him. Initially, it was difficult to get him involved in the treatment as he would take several minutes while coming to interview room, starting conversation, and following instructions. It was decided to make individual sessions longer because the slowness and resistance made it difficult to achieve the individual session goals. The duration of sessions was increased to 90-120 min instead of usual 45-50 min. Also, psychoeducation for the family members was started. Initially, the parents had difficulty in accepting the fact that their son's problems were because of a psychiatric illness as they believed that M's problems were due to maladaptive behavior and he did it on purpose to annoy them. However, later on with psychoeducation, his mother understood the nature of his illness. She agreed to be cotherapist and her increased involvement and dedication made the therapy more intense and helped the team to achieve more and more cooperation from the patient. The two major hurdles in managing the case were difficulty in establishing rapport with the patient and retaining him in the therapy. After beginning of the combined therapy, he started showing improvement in almost all the problem areas (as tabulated below) and after 3 months, YBOCS score reduced to 25 with improvement in the time spent in getting out of bed, brushing, going to toilet, answering to questions, changing clothes, and eating. Post discharge from the hospital, he came regularly for follow-ups and his mother continued to be a cotherapist and would practice therapy at home. He maintained the improvement post 3 months of discharge []. | [[15.0, 'year']] | M | {'4816233': 1, '18975671': 1, '12354323': 1, '30713890': 1, '21206819': 1, '8435690': 1, '24379507': 2} | {} |
164,828 | 3868099-1 | 24,379,508 | noncomm/PMC003xxxxxx/PMC3868099.xml | Transient Eating Problems in an Adolescent without Body Image Disturbances: A Diagnostic Quandary | A 12-year-old young lady belonging to lower socioeconomic rural background was seen by the psychiatry services when referred for problems of eating since past 2 months. The patient had a history of delayed development and achieved milestones slower than other siblings. She would mostly be shy and would interact with children younger than her age. She would answer briefly when spoken to by classmates and teachers. She would eat what was given to her by her mother, and ask for specific food items occasionally. Her school performance remained below average and had difficulties in making small purchases.\nAround 2 years back, the patient developed generalized tonic clonic seizures during sleep which were followed by myoclonic jerks. The electroencephalograpm (EEG) findings were consistent with a diagnosis of juvenile myoclonic epilepsy (JME). Sodium valproate was started, which was gradually increased to 600 mg per day. The episodes of generalized tonic clonic seizures were well controlled with valproate, but myoclonic jerks continued to recur. Due to the occurrence of jerks at school, other children would tease her. Hence she started to refuse going to school. She became irritable with her family members quite often, and would hit the siblings when provoked. She did not have depressive cognitions or change in sleep or appetite then. Due to behavioral problems of refusal to go to school and irritability, she was evaluated in psychiatry outpatient. Intelligence quotient (IQ) assessment was done and reported as 57 with a diagnosis of mild mental retardation.\nSince around 2 months prior, the patient started to refuse specific food stuffs. She would eat rice at the previous amounts, but would refuse to eat rotis, the staple diet of the family. If persuaded, she would get irritable and start crying and go to sleep without eating anything. She would also refuse to eat biscuits and bread at times. She would not give any specific reason for the refusal. At times she said that she was hungry and would ask for food, and would eat rice but refuse rotis. She did not have any associated loose stools, abdominal pain, vomiting, or regurgitation. She would not demand for specific food items like chocolates, etc.; would not appear sad, withdrawn or fearful, or have any disturbances in sleep. Over the period of 1 month, the weight reduced by about 1 kg. On further exploration, no preoccupation with body image, of previously fussiness of eating was reported by the family members. The child had a slow to warm up temperament and there was no history suggestive of eating inedible objects, delusions, hallucinations or repetitive behaviors, significant obstinacy, hyperactivity or inattentiveness. There was no family history of psychiatric illness. The general physical examination was within normal limits, the height and weight was over the 10th percentile and there were no signs of chronic malnutrition. Rapport could be established with difficulty and the child answered briefly only after urging from the mother and therapist. The patient was followed up with the suggestion of keeping a watch on weight. Mother was encouraged to observe the diet and no structured behavioral intervention was done. When patient returned in 2 weeks, there was no further decrement in weight and the patient started to eat all kinds of food stuffs again and to the previous amounts. Even on recovery, she did not elaborate the cause of decreased intake of certain foodstuffs and that of resumption. | [[12.0, 'year']] | F | {'8125571': 1, '24916133': 1, '12827010': 1, '9702643': 1, '1819572': 1, '24379508': 2} | {} |
164,829 | 3868100-1 | 24,379,509 | noncomm/PMC003xxxxxx/PMC3868100.xml | Linezolid-Induced Near-Fatal Serotonin Syndrome During Escitalopram Therapy: Case Report and Review of Literature | A 65-year-old elderly female, from urban and middle socioeconomic background, presented with history suggestive of depressed mood, middle and late insomnia, anorexia, lethargy, reduced interest in pleasurable activities since 1 year. She was diagnosed as depressive disorder as per ICD-10 diagnostic criteria.[] She had no prior medical history of hypertension, diabetes, or any drug intake. Escitalopram (5 mg/day) and clonazepam (0.25 mg/day) therapy showed partial improvement, fortnight later. Escitalopram was increased to 10 mg/day, while clonazepam was discontinued due to drowsiness, a month later. Patient had full remission of depressive symptoms with escitalopram (10 mg/day), 2 months later. Compliance with medications was ensured and supervised by her apprehensive spouse.\nPatient presented with acute onset high-grade fever, cough with greenish-yellow expectoration, breathlessness, and asthenia of a week's duration following recent travel. She had received antipyretics, mucolytics, expectorants, antibiotics (amoxicillin and clavulanate) for 5 days from medical practitioner but found no respite. Later, she was referred to physician and hospitalized. On admission, she had 101°F temperature, pulse rate of 126/min, and blood pressure (BP) of 136/88 mm Hg. Her general physical and systemic examination revealed no other abnormal findings, except for bilateral scattered fine crepitations and reduced bilateral air entry in lower respiratory areas. A complete blood count revealed leukocytosis (15640/cmm) and neutrophilia (80%). Her blood glucose (105 mg/dL), blood urea (25 mg/dL), and serum creatinine (1.0 mg/dL) were within normal limits. Electrocardiograph revealed no abnormalities. Her chest roentgenogram showed bilateral patchy consolidation suggestive of pneumonitis. Patient was treated with intravenous linezolid (600 mg twice daily), antipyretics, bronchodilators (etophylline), expectorants (guaiphenesin), mucolytics (ambroxol), and chest physiotherapy.\nWithin the first 24 hours of antibiotic treatment, the patient had a rapid clinical deterioration with restlessness, diaphoresis, tremor, shivering, myoclonus, diarrhoea, exaggerated deep tendon reflexes, hypoxia (SPO2-80% with 6-8 L of oxygen) and high fever (103°F), along with mental status changes such as disorientation, confusion, and hallucinatory behavior. However, in view of neurological symptoms, cranial computerized tomography and lumbar puncture for the exclusion of central nervous system (CNS) infection were performed but were unremarkable. The patient was intubated due to severe respiratory difficulties and transferred to the intensive care unit. Psychiatrist consultation was sought for delirium. Detailed history and sequence of emergence of events (including history of depression and escitalopram treatment from caregivers) were observed and SS was suspected. Linezolid and escitalopram were discontinued, and cyproheptadine (4 mg thrice daily) via the nasogastric tube was initiated. Pneumonitis was treated with intravenous cephalosporin (cefotaxime; 2 g twice daily) and aminoglycoside (amikacin; 500 mg twice daily) antibiotics. Patient showed the first signs of improvement few hours later. Withdrawal of sedation and ventilator weaning took place 48 hours later. Patient gradually regained consciousness and orientation to person, location, and time. At discharge, vital parameters were stable with pulse of 86 bpm and BP of 130/80 mm Hg. Patient was discharged with escitalopram 10 mg/day. | [[65.0, 'year']] | F | {'15213578': 1, '15784664': 1, '28197902': 1, '20513454': 1, '11816261': 1, '2035713': 1, '16779744': 1, '16466332': 1, '9696181': 1, '22452676': 1, '30381307': 1, '34158725': 2, '26541469': 2, '19828401': 1, '9031998': 1, '19226083': 1, '10925598': 1, '16280409': 1, '10727586': 1, '26491328': 2, '18757161': 1, '17381671': 1, '17267801': 1, '12925718': 1, '30886699': 2, '22537574': 1, '18455905': 1, '15827071': 1, '22037635': 1, '12032904': 1, '18624020': 1, '22563571': 1, '17110838': 1, '17189581': 1, '30410924': 1, '24379509': 2} | {'6413434-1': 1, '4675765-1': 1, '4599182-1': 1, '8188929-1': 1} |
164,830 | 3868102-1 | 24,379,511 | noncomm/PMC003xxxxxx/PMC3868102.xml | Is Semen Loss Syndrome a Psychological or Physical Illness? A Case for Conflict of Interest | A 24-year-old male, unmarried, agricultural worker by occupation and without any drug habits had come with complaint of erectile dysfunction and depressive symptoms secondary to that. These complaints started around 4 months back, when his father was looking for a bride. Prior to this, he reported never having had sexual ideas and his friends tried to give him advice on how to show sexual prowess to a woman on her first night. That night when he went to sleep he felt some shadow crawling over his body and he had spontaneous ejaculation. This was first time such thing had happened to him. His father reassured him that night. Next two nights also he had spontaneous ejaculation at night and this terrified the patient that all his semen may have drained out and consequently, his ability to impregnate a woman and his energy to carry out physical work had been depleted significantly. His friends had advised him to masturbate and told him to continue the technique to get semen out at least once a month. To his dismay, he found that he was unable to do as there was ‘no rigidity’ in the penis. When questioned about the nature and importance of semen, he said that semen is important for producing children and having a family but added that he had no idea where it came from. He consulted a Siddha practitioner for his problems and was told that if semen was not coming out through its proper channel, it would fill other body fluids and also come out in the saliva. That doctor took sample of saliva in small bottles and told the patient that after testing he had come to the conclusion that they are containing sperms. Along with this presumed ‘imbalance in bodily fluids’, he had developed depressive symptoms secondary to semen loss when he presented to us and had attempted suicide once during this period.\nAfter evaluation, he was admitted as a case of severe depressive disorder. During ward stay and with various treatments there was improvement in biological functions and consultations also revealed acute gastritis for which he was treated adequately. He continued to believe that semen is coming out through saliva. By its taste and smell he was able to confirm what the previous Siddha doctor had told him. Few weeks later, he observed that the size of his penis had shrunken and corroborated this observation by taking his measurements. He began to worry about how he was going to live without his own family and how he would become a laughing stock among people for losing his ‘maleness’ or ability to impregnate a woman. He also worried about earning his livelihood by farming due to accompanying weakness.\nDuring assessment we found that he has hypolibidinal state prior to onset of these problems. There were no local pathology and sex hormone study and thyroid function tests did not show any abnormalities. | [[24.0, 'year']] | M | {'18298609': 1, '28584609': 1, '19653589': 1, '20661389': 1, '26538854': 1, '24379511': 2} | {} |
164,831 | 3868146-1 | 24,379,470 | noncomm/PMC003xxxxxx/PMC3868146.xml | Transient long thoracic nerve injury during posterior spinal fusion for adolescent idiopathic scoliosis: A report of two cases | A 12.5-year-old girl with adolescent idiopathic double thoracic scoliosis (Lenke 2A-) underwent posterior arthrodesis T2-L4 []. Four days after surgery, she noted medial winging of her right scapula without shoulder dysfunction or pain. Patient made a good recovery and the LTN neuropraxia resolved spontaneously 8 months following spinal fusion. | [[12.5, 'year']] | F | {'10910833': 1, '511883': 1, '18866299': 1, '8814576': 1, '15866961': 1, '17343759': 1, '19468892': 1, '18523718': 1, '10613149': 1, '22959502': 1, '10790670': 1, '479228': 1, '22959503': 1, '24379470': 2} | {'3868146-2': 2} |
164,832 | 3868146-2 | 24,379,470 | noncomm/PMC003xxxxxx/PMC3868146.xml | Transient long thoracic nerve injury during posterior spinal fusion for adolescent idiopathic scoliosis: A report of two cases | A 17-year-old girl with adolescent idiopathic primary thoracolumbar compensatory thoracic scoliosis (Lenke 5CN) underwent posterior arthrodesis T9-L3 []. Six days after surgery, she was noted to develop medial winging of her right scapula with good shoulder function and no pain. Patient made a good recovery and the LTN neuropraxia resolved spontaneously 11 months following scoliosis correction. | [[17.0, 'year']] | F | {'10910833': 1, '511883': 1, '18866299': 1, '8814576': 1, '15866961': 1, '17343759': 1, '19468892': 1, '18523718': 1, '10613149': 1, '22959502': 1, '10790670': 1, '479228': 1, '22959503': 1, '24379470': 2} | {'3868146-1': 2} |
164,833 | 3868147-1 | 24,379,471 | noncomm/PMC003xxxxxx/PMC3868147.xml | Traumatic posterior atlantoaxial dislocation without related fractures of C1-C2 | A 32 year old man presented with pain and stiffness in the neck, difficulty in breathing associated with lacerations on face and deformity of mandible with inability to open the mouth following trauma. He was travelling in a car which was hit to a parked lorry from the side. There was no history of unconsciousness or signs of head injury. The neurological examination showed no apparent neural deficit. Emergency tracheostomy was performed.\nOn secondary survey, the patient was well oriented to time and space with no evidence of concomitant chest, abdominal or head injuries except laceration on his face with fracture of mandible. The flexion/extension and rotation of the neck, along with opening of mouth were restricted. The patient did not have any signs of generalized ligamentous laxity.\nRadiographs of the cervical spine demonstrated a posterior dislocation of the atlas with respect to the axis [] with no evidence of fracture. The C7 vertebra was not visualized due to overlap of the shoulders. Magnetic resonance imaging (MRI) [] of the cervical spine demonstrated no cord compression or intramedullary cord signal abnormality at the level of the atlantoaxial dislocation. The membrana tectoria/apical and transverse ligament at lateral attachment of dens was torn. Superior transverse ligament was found intact. Computed tomography (CT) of the spine showed anterior displacement of C2. The dens was situated anterolateral to the anterior arch of C1 with facet joint dislocation of C1-C2. There was diffuse prevertebral soft tissue shadow seen from C1 to C4 level. A tiny fracture fragment seen adjacent to odontoid process. Atalanto-occipital joint appeared normal. Body and posterior arch of C2 appeared normal. Occipital condyles and rest of visualized cervical spine appeared normal. Comminuted displaced fracture was seen involving the angle and ramus of mandible on the right side.\nClosed reduction on skeletal traction under anesthesia was attempted with help of image intensifier [] and neurological monitoring by Wong three-step method.[]\nTraction is applied in slight flexion to keep C1 ring apposed to posterior odontoid.\nThe C1 ring has slipped back over the odontoid but is displaced too far forward because of slightly excessive flexion angle of traction.\nTraction is changed to slight extension, allowing the C1 ring to come closer to anterior odontoid. Traction is then released over several hours.\nThe attempt of closed reduction failed. We had to proceed for open reduction with posterior stabilization and fusion []. | [[32.0, 'year']] | M | {'5781589': 1, '11057538': 1, '21207046': 1, '18259747': 1, '14239870': 1, '9853505': 1, '6835503': 1, '4436359': 1, '2053005': 1, '33344615': 2, '12546392': 1, '19714372': 1, '864499': 1, '511875': 1, '11224897': 1, '1118566': 1, '12851361': 1, '4822522': 1, '1983884': 1, '10078135': 1, '12195506': 1, '24379471': 2} | {'7723728-1': 1} |
164,834 | 3868148-1 | 24,379,472 | noncomm/PMC003xxxxxx/PMC3868148.xml | Treatment of habitual dislocation of patella in an adult arthritic knee | A 50-year-old woman presented with iatrogenic habitual dislocation of left patella from childhood and pain from past 3 years. She recalled a childhood surgery over middle third of left thigh (incision and drainage). Few years after the surgery, she started noticing the giving way of patella and lived for 38 years without much disability. She was carrying out her daily activities without much pain or symptoms, but she was never symptom free during this period.\nPhysical examination did not reveal general joint laxity or malalignment of the lower extremity. There was a healed surgical scar over middle and lower third lateral aspect of the left thigh. Although the patella was in the femoral trochlear groove in extension, it dislocated laterally with 25 degrees of knee flexion. She complained slight discomfort by an apprehension test, but was not very painful even when dislocated. The passive lateral patellar tilt test was negative since the soft tissue attachment to the lateral border of the patella was diffusely stiff and tight. Radiological examination revealed evidence of patella alta as defined by Insall and Salvati,[] and Q angle was 18 degrees. Clinically and radiologically (Grade III Kellgren and Lawrence classification[]) tricompartmental degenerative knee arthritis was appreciated []. Preoperative Kujala score[] was 49.\nWith patient in supine position under epidural anesthesia, an anterior midline knee incision was used with paramedian arthrotomy. The lateral retinaculum was thickened while the medial retinaculum was thinned. The lateral tether is released by dividing the fibrous adhesions, which extended along the lateral intermuscular septum. The lateral patellar retinaculum and the synovium were divided and vastus lateralis was detached from the quadriceps tendon, leaving a rim of tendon for suturing.\nDue to shortening of the extensor mechanism, the patella could not be reduced. Quadriceps tendon was lengthened using V Y plasty at aponeurotic junction. Tracking was augmented with MPFL reconstruction using semi-tendinosus tendon and patellar end was fixed with 2.8 mm FASTak titanium anchor on the medial border of patella and over near isometric point on medial epicondyle of femur, which was checked under fluoroscopy. Patellar maltracking was persistent and so, it was decided to proceed with medial and distal transfer of tibial tuberosity.\nA long-leg hinged knee brace was applied with the knee in 20° of flexion and partial weight bearing with crutches for four weeks was advised, during which the patient was encouraged to do vigorous static quadriceps strengthening exercises. Knee mobilization and full weight bearing was started after four weeks. Initially patient had extensor lag of 15 degrees as she was immobilized in flexion. But after vigorous quadriceps exercises, patient improved without any extensor lag.\nAt final followup two years postoperatively, the patient was pain-free. There was no evidence of patellar maltracking or instability on detailed physical examination. Radiographs showed well reduced patella in both lateral, anteroposterior view and skyline view []. The patient's kujala knee society score 89 [] and range of motion was 0° to 90° on the left side []. Quadriceps strength was rated 4 (MRC grade). | [[50.0, 'year']] | F | {'2312713': 1, '535247': 1, '11580134': 1, '8119024': 1, '12931813': 1, '25802785': 2, '17724090': 1, '12750927': 1, '3335088': 1, '9306873': 1, '8461073': 1, '5111961': 1, '7584171': 1, '3372563': 1, '16307194': 1, '22912521': 1, '22448067': 2, '24379472': 2} | {'3308670-1': 1, '4329834-1': 1} |
164,835 | 3868149-1 | 24,379,473 | noncomm/PMC003xxxxxx/PMC3868149.xml | Reconstruction of bilateral tendoachilles with fascia lata graft | A 19 year old male presented to outpatient department with slow and progressive enlargement of tendinous nodule on the posterior aspect of ankle for last 2 years. The disease had progressively worsened in last 3 months with difficulty in walking. The patient was mentally retarded (intelligence quotient 55). Clinical examination did not reveal nodule or mass anywhere else in the body. The patient's blood lipid profile showed hypercholesterolemia (serum cholesterol level 331.7 mg/dl) while serum uric acid level was normal. There was no history of prolonged medication or antecedent trauma. There was no similar history in any of his siblings. Karyotyping of the patient and his parents was normal.\nThe radiographs of the lower legs and ankles demonstrated bilateral soft tissue shadows on the posterior ankle region []. The masses on both sides extended from the ankle to the lower calf and were located along the expected course of the tendoachilles []. No associated calcification or osseous abnormalities were seen. Magnetic resonance imaging of the brain showed diffuse cerebral and cerebellar atrophy.\nFine needle aspiration cytology showed giant cell rich lesion both side. The patient was taken for bilateral wide local excision of tendoachilles and reconstruction of the tendon with fascia lata graft.\nThe curvilinear lazy S incisions were made on the posterior aspect of the lower calf till tendoachilles insertion in prone position. Tendoachilles exposed which revealed large grayish white rounded mass involving 3/4th of length on the right side and full length of tendoachilles on the left side []. Abnormal tendoachilles tendons were excised almost completely creating a large gap which was not possible to reconstruct by primary repair. The defect in each limb was almost from musculotendinous junction to insertion on calcaneum. The thigh was prepared for fascia harvesting. A 25 cm skin incision was made 6 cm proximal to the lateral femoral condyle at the lateral border of patella, extending towards the anterior border of the greater trochanter. The skin flaps were sharply elevated above the fascia lata and reflected apart. The sheath was outlined 3-4 cm anterior to the lateral intermuscular septum, that is, anterior to the iliotibial tract. The deep fascia of thigh was separated from the underlying muscle. A transverse incision was made through the fascia distally while two tissue forceps were used to hold and fasten the fascia. The fascial sheet of 30 cm × 10 cm was procured and divided into two halves of 30 cm × 5 cm each. Each sheet layered onto itself 4 times with width of one cm and secured by interrupted suture with 4-0 proline. One end of prepared deep fascia was sutured to the cut end of muscles with proline 3-0 then it was tunneled through a drill hole in the calcaneum. During the repair, the foot was kept in equinus to reduce the gap and produce repair under adequate tension []. Other end of fascia graft was sutured back to the muscle end of the gastrocnemius and soleus with proline 3-0. The closure was done in layers. Thompson's test was done prior to dressing to check the integrity of reconstruction. The procedure was repeated in other limb in the same sitting. The excised specimen was sent for histopathological examination.\nGross specimen showed large cylindrical grayish white soft tissue mass that involved the tendoachilles completely on the left side and almost 3/4th of tendon on the right side. Specimen was measuring 12 cm × 3 cm × 3 cm on the right and 13 cm × 4 cm × 4 cm on the left side in craniocaudal, transverse and anteroposterior dimension [].\nMicroscopic examination showed a large number of granuloma composed of giant cells with foamy cytoplasm and lymphocytes in subepithelial tissue. Giant cell were mostly langhans type []. Adjacent tissue was with a smaller number of granuloma.\nPostoperatively, the ankle was immobilized in nonweight bearing plaster at 15° of plantar flexion for first 6 weeks and then in plantigrade cast for another 4 weeks. Stitch removal was done at 3 weeks postop and showed no evidence of wound dehiscence, infection or discharging sinus.\nAfter removal of plaster cast the patient was allowed to begin active physiotherapy. Weight bearing was delayed as this was a bilateral case. After 3 months, patient was allowed to increase weight bearing progressively within the limits of comfort. At 5 months followup the patient was able to walk without crutches. At 1 year followup, range of motion in both ankle joints was 15° of plantar flexion and 10° of dorsiflexion. The patient was able to stand and walk on toes, which he was able to since 6 months postsurgery []. Despite low intelligence quotient, at 1 year followup, the patient was independently mobile without pain with good cosmetic outcome. The functional outcome was satisfactory in all aspect except moderate limitation of sagittal and hindfoot motion with an American Orthopedic Foot and Ankle Society ankle hind foot score of 93/100. | [[19.0, 'year']] | M | {'16715243': 1, '9429992': 1, '19037553': 1, '17512270': 1, '16949535': 1, '3017187': 1, '19567865': 1, '10353770': 1, '8221541': 1, '22146219': 1, '8141018': 1, '19083622': 1, '16757769': 1, '8537903': 1, '19038615': 1, '24379473': 2} | {} |
164,836 | 3868683-1 | 24,368,989 | noncomm/PMC003xxxxxx/PMC3868683.xml | Torsion of the gallbladder in pregnancy | A 36-year-old pregnant woman at 17 weeks of gestation presented to the Emergency Department with a one-day history of severe epigastric pain. The abdominal pain had started as epigastric discomfort that increased in intensity and then became more localized to the right upper quadrant. The pain was sharp and constant in nature. Physical examination revealed a thin woman (height, 165 cm; weight, 56 kg) with a blood pressure of 123/64 mmHg, a pulse of 80 beats/min, and a body temperature of 36.6℃. The abdomen was tender in the right upper quadrant. No guarding and rebound tenderness were noted. The laboratory data showed a white blood cell count of 9,700/mm3, a hemoglobin level of 11.8 g/dL, and the platelet count was 152,000/mm3. Other blood chemistry parameters including liver function test were unremarkable. Abdominal US demonstrated a distended gallbladder without stones but with mild wall thickening. Magnetic resonance imaging (MRI) demonstrated a slightly distended gallbladder with a markedly edematous and multilayered wall (). A diagnosis of acute cholecystitis was made, and antibiotics were administered; however, the patient's symptoms worsened. On the third hospital day, laparoscopic cholecystectomy using three-port was performed under the impression of an acalculous cholecystitis. The gallbladder was gangrenous and the body of the gallbladder had rotated 180° clockwise on the gallbladder mesentery (). The gallbladder was supported by the mesentery which was attached only to the proximal body of the gallbladder, thereby allowing the gallbladder to hang free. The gallbladder was untwisted and then removed without difficulty. Histopathological examination showed an acute gangrenous inflammation with extensive infarction. The postoperative course was uneventful and the patient was discharged on the 4th day after surgery. | [[36.0, 'year']] | F | {'7551289': 1, '10664294': 1, '9358785': 1, '14018964': 1, '30719303': 2, '32864259': 2, '10720123': 1, '11180895': 1, '3944403': 1, '10556460': 1, '34900611': 1, '27114247': 1, '8345558': 1, '7676376': 1, '32320550': 1, '24368989': 2} | {'7450884-1': 1, '6349984-1': 1} |
164,837 | 3868684-1 | 24,368,990 | noncomm/PMC003xxxxxx/PMC3868684.xml | Perineal accessory scrotum with a lipomatous hamartoma in an adult male | A 46-year-old male patient was admitted to Dongguk University Gyeongju Hospital because of a perineal mass. The patient was born with the mass but he didn't undergo any treatment. There was no history of rapid growth or other complications. Recently, he has felt discomfort from the mass, especially during defecation. He was a hepatitis B virus carrier and he had a 20-year history of rheumatoid arthritis. Physical examination revealed a round, pedunculated mass arising from the left lateral aspect of the anus. The mass was soft, nontender and movable, measuring 5 cm × 4 cm. There was a 3.5 cm × 1.5 cm sized elongated skin-tag-like protuberance on the left lateral portion of the main mass. The rugated skin of the protuberance was contiguous with the covering skin of the main mass. Anal sphincter was normal. There were no abnormalities in the anorectal and genitourinary system. Under the impression of a lipoma, we completely excised the mass. On section, the main mass was a lump of ill-defined yellow adipose tissue partly divided by whitish fibrous septa. The elongated small protuberance was composed of whitish soft tissue and had a rubbery texture (). At the junction of the two lesions, adipose tissue was intermingled with whitish soft tissue of the small nodule. Microscopically, the main mass consisted of predominant mature adipose tissue that was neither encapsulated nor well circumscribed from surrounding tissue (). Small bundles of bland smooth muscle fibers, mature neural tissue and blood vessels were scattered within the adipose tissue mass (). Atypical cells or malignant cells were absent. The main mass was diagnosed as a hamartoma with predominant adipose tissue (lipomatous hamartoma). The skin-tag-like protuberance was composed of numerous, irregularly oriented smooth muscle bundles, resembling the tunica dartos (). It was confirmed as an accessory scrotum. The perineal mass was diagnosed as perineal accessory scrotum with a lipomatous hamartoma. There was neither postoperative complications nor functional sequelae. | [[46.0, 'year']] | M | {'10738197': 1, '20660463': 1, '8958554': 1, '8283564': 1, '18705771': 1, '15902476': 1, '26793694': 2, '19083282': 1, '26412897': 1, '12941131': 1, '24368990': 2} | {'4717609-1': 1} |
164,838 | 3868695-1 | 24,368,974 | noncomm/PMC003xxxxxx/PMC3868695.xml | A Totally Thoracoscopic Ablation for Persistent Atrial Fibrillation | A 72-year-old female visited the emergency room because of a suddenly developed headache. The brain imaging studies revealed acute cerebral infarction. Further, the electrocardiography showed atrial fibrillation (AF). The echocardiography revealed that the mean left atrial dimension was 32.7 mm in the parasternal long axis view and 38.6 mm in the apical four-chamber view. The left ventricular ejection fraction was 86%. Transthoracic echocardiography revealed no intracardiac thrombus and normal valvular function. Amiodarone and coumadine were begun and maintained for the following five months. Just before the operation, the electrocardiogram still showed AF and the patient complained of palpitation and chest discomfort. We decided to perform thoracoscopic ablation. We performed transesophageal echocardiography after induction of anesthesia to rule out intracardiac thrombus. Before induction, defibrillator pads were placed appropriately. With the right lung deflated, the initial 10-mm port was placed in the sixth interspace at the anterior axillary line (). After thoracoscopic examination, two additional ports were inserted. Under thoracoscopic control, the pericardium was opened by electrocautery approximately 2 cm anterior to the right phrenic nerve. Pericardial traction was executed using an endoscopic suturing device (Endostitch; Covidien Inc., Norwalk, CT, USA). The oblique sinus was entered by gentle blunt dissection through the pericardial reflections under the inferior vena cava. A light dissector was used for encircling the pulmonary venous antrum. The antral area was ablated using a bipolar radiofrequency clamp (EMR; Atricure Inc., Cincinnati, OH, USA) (). The end point for pulmonary vein antral ablation was a complete exit block from the pulmonary veins. The autonomic ganglia plexuses (GPs) were ablated. High-frequency testing of the GPs was performed. Each of the testing sites was stimulated at a rate of 1,000 Hz and an amplitude of 18 V with at least a doubling of the R-R interval qualifying as a positive response. The right GP travels toward the right pulmonary veins and the interarterial groove. The left GP travels in the direction of the base of the left atrial appendage and the left upper pulmonary vein. Bipolar radiofrequency energy at 15 W was delivered through the bipolar pen (Isolator multifunctional pen; Atricure Inc.) to the GPs. After dissecting the transverse sinus, additional lines, which were a superior line through the transverse sinus and an inferior line through the oblique sinus, were made with the aid of a Cool Rail (Atricure Inc.). After the left lung was deflated, three trocars were inserted and were placed more posteriorly. Marshall's ligament was divided after left pericardiotomy. The previously performed line of ablation (superior line) across the transverse sinus was easily visualized and extended onto the left superior pulmonary vein, and the previously performed ablation line (inferior line) in the oblique sinus from the right chest was clearly identified. The linear probe created a line of ablation connecting the caudal margins of the two pulmonary isolation boxes (). The left atrial appendage exclusion was performed using a stapler (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) after the absence of flow was confirmed by intraoperative transesophageal echocardiography. Normal sinus rhythm was converted intraoperatively. A single chest tube was placed for draining each pleural space. The patient was extubated in the operating room. The operative time was 125 minutes. Postoperatively, coumadine and amiodarone were continued. The length of the hospital stay was 7 days. She resumed normal sinus rhythm two months after total thoracoscopic ablation, which was confirmed by 24-hour electrocardiogram monitoring. | [[72.0, 'year']] | F | {'14688693': 1, '22082673': 1, '9725923': 1, '7864703': 1, '15936622': 1, '16155107': 1, '16153931': 1, '24368974': 2} | {} |
164,839 | 3868696-1 | 24,368,975 | noncomm/PMC003xxxxxx/PMC3868696.xml | Floating Thrombus in Aortic Arch | A 56-year-old man was hospitalized because of pain and numbness in his left hand since he slipped a week earlier. He had no medical history of diabetes or hypertension. He had a thirty pack-year smoking history. In the physical examination, we found that the motor and sensory functions of his left hand were normal. However, his radial artery had no pulsation. His laboratory data, including anti nuclear antibody, anti-neutrophil cytoplasmic antibody, and rheumatoid arthritis factor, were within normal limits. However, the laboratory analysis showed decreased protein C and S concentrations (protein C antigen, 57%; protein S antigen, 19%). The diagnostic work-up to determine the degree of lesion included a computed tomography (CT) angiography, which showed an intraluminal lesion of the left upper extremities vessel. In the CT scan, the deep brachial and radial artery of the left hand was occluded (). Coincidently, we stumbled across a mass lesion on the aortic arch. For the evaluation of the incidental mass lesion, we performed a chest CT scan and transthoracic echocardiography. The ascending aorta and the aortic arch had intact intima and a normal size (). In transthoracic echocardiography, we found a floating mass in the lesser curvature of the aortic arch (). We decided to surgically remove this floating mass because of the risk of peripheral embolization, including thrombectomy for the brachial and radial artery occlusion of the left arm. We inserted arterial cannulation in the left femoral artery. A median sternotomy was performed, a venous cannula was inserted in the RA auricle, extracorporeal circulation was begun, and the central temperature was decreased to 25℃. The patient was then in total circulatory arrest. An incision was made in the aortic arch, and the 3.0-cm intraaortic mass was completely removed (). The mass had no definite stalk, and its attachment site in the aorta was relatively normal. A histopathologic examination revealed the mass to be a fibrin thrombus. We also removed the thrombus of the left upper extremities through the brachial artery. In the postoperative peripheral angiography, the brachial artery and the radial artery showed good blood flow (). One week later, the patient recovered without complications and was discharged on the regimen of warfarin. | [[56.0, 'year']] | M | {'18364189': 1, '29307933': 1, '28042559': 2, '33297988': 2, '22263129': 2, '15745299': 1, '1987243': 1, '11722078': 1, '24368975': 2} | {'3249278-1': 1, '5198766-1': 1, '7724786-1': 1} |
164,840 | 3868698-1 | 24,368,977 | noncomm/PMC003xxxxxx/PMC3868698.xml | Extrauterine Epithelioid Trophoblastic Tumor of Lung in a 35-year-old Woman | A 35-year-old multiparous woman was transferred to Asan Medical Center because of abnormal findings on lung imaging. She was admitted to the regional tertiary hospital because of abdominal pain, nausea, and vomiting 10 days prior to presentation to Asan Medical Center. During a work-up for evaluating the cause of her abdominal pain, a 2.7-cm pulmonary nodule was incidentally discovered in an abdominal computed tomography (CT) scan. Subsequently, a chest CT scan revealed that the nodule was located in the basal segment of the left lower lobe. The nodule had a well-defined lobule, whereas no other definite nodules or active lesions were found in the lungs (). For further evaluation, the patient was referred to Asan Medical Center. At the time of admission, the patient's vital signs were stable and her physical examination was unremarkable. The results of all laboratory tests were within normal limits.\nA lung needle biopsy was performed, the results of which indicated a few atypical cells that were positive for p63 and cytokeratin in a necrotic background. We believed that the characteristics of the nodule indicated squamous cell carcinoma. In 18-fluorodeoxyglucose positron emission tomography, the nodule showed a maximum standardized uptake value of 1.6 in the basal segment of the left lower lobe that indicated low metabolic activity. No other significant hypermetabolic lesions were found.\nThe follow-up chest CT performed after 1 month indicated that the mass had enlarged to 3.3×3.0 cm. No definite evidence of lymphadenopathy was seen in the hilar mediastinum. Because distant metastasis was not evident in brain magnetic resonance imaging or a bone scan, we performed video-assisted left lower lobectomy in addition to mediastinal lymph node dissection.\nOn gross examination, an ill-defined firm mass measuring 3.2×2.5×2 cm was observed. The mass was yellowish gray, firm, and granular with necrosis and an anthracotic pigment at the cut surface. Microscopic examination indicated that the mass was well-circumscribed and had replaced the normal pulmonary parenchyma. The tumor cells had a relatively uniform, mononuclear epithelioid appearance and were arranged in nests or cords. They had eosinophilic cytoplasm and irregular nuclei with prominent nucleoli. Hyaline-like materials were observed surrounding the tumor nest. Mitoses were occasionally observed (). Tumor cells had positive immunoreactivity for p63 (), beta-human chorionic gonadotropin (β-hCG) (), cytokeratin, inhibin (), sal-like protein 4, and placental alkaline phosphatase. Immunohistochemical staining for human placental lactogen, alpha-fetoprotein, and CD30 was negative.\nWe consulted the department of gynecology for pelvic examination ultrasonography, the findings of which were unremarkable. Endometrial curettage revealed normal menstrual-phase endometrium. The results of the postoperative serial serum β-hCG and carbohydrate antigen 19-9 tests were within normal limits at that time.\nOn postoperative day 3, the patient was discharged without complications. She received conservative treatment after that and underwent regular follow-ups in the outpatient clinic. After 15 months, a follow-up chest CT did not show any evidence of recurrence. | [[35.0, 'year']] | F | {'16258513': 1, '19773636': 1, '30702558': 2, '18078982': 1, '28217684': 2, '34563007': 2, '9808132': 1, '34258359': 2, '23307273': 1, '24368977': 2} | {'8482181-1': 1, '5313356-1': 1, '8258853-1': 1, '6380824-1': 1} |
164,841 | 3868699-1 | 24,368,978 | noncomm/PMC003xxxxxx/PMC3868699.xml | A Rare Case of Bilateral Pulmonary Sequestration Managed with Embolization and Surgical Resection in a Patient | A 22-year-old male was admitted because of discomfort due to repeated upper respiratory tract infection symptoms, chronic cough, and sputum for several years. There were no abnormal findings reported in the initial laboratory results and electrocardiogram. Chest X-ray and enhanced chest computed tomography (CT) scans were taken; these revealed bilateral cystic lesions on both the lower lobes. Like the chest X-ray, the chest CT also revealed bilateral cystic lesions. In particular, pneumonic consolidations were found on the lesions of the right lower lobe (RLL) (), and both the lesions were fed directly from the thoracic aorta and drained into the pulmonary vein (). On the basis of the CT image analysis of the chest, the patient was diagnosed as having bilateral intralobar pulmonary sequestration on the RLL and left lower lobe (LLL).\nThe patient wanted surgery for repeated chronic cough and sputum. We planned staged bilateral lobectomy for both lungs and prophylactic embolization of the feeding vessels for preventing unexpected hemorrhage during the operation. On hospital day (HD) 1, angiography was done for embolization of feeding vessels of the pulmonary sequestration. Each of them was occluded with embolic coils (). On HD 3, right lower lobectomy of lung with video-assisted thoracic surgery was done because of the pneumonic consolidations.\nThe patient was discharged on postoperative day 10 without surgery of the LLL because of personal schedules and recovery. In the serial outpatient department follow-up, the patient did not feel any respiratory discomfort and was satisfied with the result of angiographic embolization; he refused additional surgery of the LLL. | [[22.0, 'year']] | M | {'20940163': 1, '23217881': 1, '9754996': 1, '15222956': 1, '29745038': 2, '24368978': 2} | {'6026609-1': 1} |
164,842 | 3868701-1 | 24,368,980 | noncomm/PMC003xxxxxx/PMC3868701.xml | Solitary Plasmacytoma of the Sternum | A 62-year-old female patient was referred by a regional hospital to department of thoracic and cardiovascular surgery because of a mass in her sternum. At presentation, the patient had no disease other than hypertension. She had received calcium channel blocker therapy for her hypertension at a regional hospital for >3 years prior to this presentation, and her blood pressure was well controlled. She was a housewife by occupation and did not have any specific family history of cancer. Her blood pressure was 118/72 mmHg; pulse rate, 64 beats/min; respiratory rate, 16/min; and body temperature, 36.7℃. A physical examination revealed a bulging mass in the mid-sternum and mild tenderness around the mass. Laboratory tests revealed white blood cell, 7,800/µL and hemoglobin, 13.2 g/dL. However, other initial laboratory test results were noted to be within the normal range. Plain chest radiographs, including the sternum lateral view, revealed a sternal mass. Chest computed tomography (CT) revealed a sternal mass 4×4 cm in size containing an osteoclastic lesion in the body of the sternum. A further evaluation using whole body bone scintigraphy revealed a focus of mild increased uptake in the sternum with a bone-to-soft tissue ratio of 2.34:1, and no evidence of a hot uptake lesion was noted in the other bony areas. Positron emission tomography-CT (PET-CT) with 18-fluro-deoxyglucose showed a mildly hypermetabolic mass in the body of the sternum with a standard uptake value of 4.6 but did not detect any other lesions or distant metastasis other than a sternal lesion (). Under localized anesthesia, an incisional biopsy was performed, which showed atypical plasma cells having centrally or eccentrically located ovoid nuclei and eosinophilic cytoplasm. These histological findings indicated a plasma cell neoplasm suggestive of solitary plasmacytoma of the sternum (). Immunohistochemical studies of the specimen showed positive lambda chains and negative kappa chains, but the results were all negative for the clusters of differentiation 99, neuron specific enolase, S-100, cytokeratin, and desmin. Further studies were performed to differentiate solitary plasmacytoma of sternum from multiple myeloma (MM). Complete skeletal radiographs, including the humerus and femur, revealed negative results and no evidence of other osteolytic lesions. In addition, laboratory studies, including complete blood cell count, serum electrophoresis, 24-hour urine protein electrophoresis, alkaline phosphatase, lactic dehydrogenase, C-reacting protein, serum calcium, and phosphate showed normal values and no evidence of anemia, hypercalcemia, or renal involvement suggestive of systemic myeloma. Immunofixation of serum and concentrated urine exhibited no monoclonal proteins.\nMultidisplinary approaches for further management, including radiotherapy, surgical management with wide resection, and chemotherapy, were discussed, and radiation therapy was determined to be the best choice for the patient. The patient was transferred to the department of hemato-oncology and radiation oncology. | [[62.0, 'year']] | F | {'33234766': 2, '12780789': 1, '8417251': 1, '7819027': 1, '10979944': 1, '23197064': 1, '29662571': 1, '2688582': 1, '24368980': 2} | {'8548202-1': 1} |
164,843 | 3868702-1 | 24,368,981 | noncomm/PMC003xxxxxx/PMC3868702.xml | Operative Management in a Patient with Scapulothoracic Bursitis | A 58-year-old male patient presented with a rapidly growing mass at the right posterior chest wall for one month. Initially, the patient had found an egg-sized lump at his right posterior chest wall. The patient received acupuncture at an oriental medicine clinic 10 days before admission. The soft mass showed relative hardening and rapid growth after the acupuncture.\nIn the physical examination, an approximately 5-cm mass was palpable at the right posterior lateral chest wall around the inferior angle of the scapula. The mass was mild and tender, without heat or redness. The patient had no history of trauma and had played golf excessively for the last six months.\nChest radiograph showed no bony abnormality or lung infiltration. Chest computed tomography showed a heterogeneous cystic mass on the right chest wall. A magnetic resonance axial T1-weighted image showed a well-demarcated lenticular mass lesion located in the right subscapular region between the serratus anterior muscle and the thoracic rib cage ().\nWe first recommended sonographically guided aspiration; however, the patient refused to undergo this procedure because of the possibility of recurrence after aspiration and rapid growth of mass. Excision of the mass was performed under general anesthesia. The patient was placed in a left lateral decubitus position. The latissimus dorsi and serratus anterior muscle were dissected after an incision was made over the right subscapular area. A soft, movable scapulothoracic mass, which was loosely attached between the serratus anterior and the intercostal muscle, was observed.\nA well-encapsulated cystic mass measuring 8×5×5 cm in size was excised. A hemorrhage occurred, which was suspected to be a result of acupuncture in an oriental medicine clinic (). A histopathologic examination showed a pseudocyst with a thickened fibrotic wall, which was filled with blood clots. Many lymphocyte proliferations were observed in the cystic wall without neoplastic cells ().\nThis patient's history included playing golf, pathological features, and radiological images; therefore, this patient was diagnosed with scapulothoracic bursitis. The patient recovered well after surgery. No chest wall pain was observed, and no recurrent mass was found at the 10-month follow-up. The patient still enjoys playing golf. | [[58.0, 'year']] | M | {'20853053': 1, '15091127': 1, '29911140': 1, '16179630': 1, '30641437': 2, '34680339': 1, '9753753': 1, '23015932': 1, '24368981': 2} | {'6330383-1': 1} |
164,844 | 3869913-1 | 24,368,882 | noncomm/PMC003xxxxxx/PMC3869913.xml | A case of atypical progressive supranuclear palsy | The patient was a 72-year-old, right-handed male, with 17 years of education and no family history of a neurodegenerative disorder. He was a retired university office manager. The patient only suffered from high blood pressure and was in good health until approximately 2 years before presentation, when he was affected by a depression of mood state.\nA neuropsychological evaluation performed at that time, in 2009, highlighted only an impairment in episodic memory and reduced phonemic fluency and a pathological performance in the Frontal Assessment Battery.\nAt the first visit in our clinic, in January 2011, a general physical examination did not reveal any known pathology. A neurological examination detected hypomimic facies; impaired balance; ataxic-type gait; pyramidal-extrapyramidal hypertonia in all four limbs; reduced strength, especially on the right side; wide-base standing position; and supranuclear upgaze paresis.\nMagnetic resonance imaging (MRI) showed the ventricular–cisternal system in its normal axis, normal morphology and size, and no areas of altered signal in the brain parenchyma. Diffuse cortical atrophy was present.\nSingle photon emission computed tomography (SPECT) showed widespread hypoperfusion of the cerebral cortex, with thinning of cortical thickness. The hypoperfusion of both hemispheres appeared more pronounced in the posterior temporal cortex, with a prevalence in the left hemisphere. Perfusion of the basal ganglia and cerebellar hemispheres was preserved.\nThe patient was assessed by the same neuropsychologist for all follow-ups, using a wide battery of neuropsychological tests to investigate all cognitive functions. | [[72.0, 'year']] | M | {'4819905': 1, '20129321': 1, '30458509': 1, '7964817': 1, '3249773': 1, '2742547': 1, '11113214': 1, '20108378': 1, '8909427': 1, '8413479': 1, '11227131': 1, '22347799': 1, '17765337': 1, '8915764': 1, '14044222': 1, '19733862': 1, '16092096': 1, '5349366': 1, '10802782': 1, '3429213': 1, '3190499': 1, '6494408': 1, '12584413': 1, '19812461': 1, '20071178': 1, '1015380': 1, '8546857': 1, '24283522': 1, '3734316': 1, '10577638': 1, '1827513': 1, '18989114': 1, '1202204': 1, '2065260': 1, '9862549': 1, '16295955': 1, '16093229': 1, '12177369': 1, '474177': 1, '10945805': 1, '8710059': 1, '7991117': 1, '2878699': 1, '8954307': 1, '27414076': 1, '9561983': 1, '19520613': 1, '20798538': 1, '24368882': 2} | {} |
164,845 | 3869915-1 | 24,368,892 | noncomm/PMC003xxxxxx/PMC3869915.xml | Isolated granulocytic sarcoma of the nasopharynx: a case report and review of the literature | A 63-year-old Caucasian female sought evaluation in the Otolaryngology clinic (Virginia Mason Medical Center, Seattle, WA, USA) due to decreased hearing in her left ear and progressive nasal congestion. Prior to that visit, she had been treated empirically for several months with various antibiotics and decongestants and briefly with intranasal steroids. Her chronic medical problems were notable for nonallergic rhinitis, hypertension, hyperlipidemia, and morbid obesity. Her general and cranial nerve exam were unremarkable, but she was identified as having conductive hearing loss due to a left middle ear effusion. On sinonasal endoscopy, an excoriated mass was also identified, involving the posterior nasopharynx and nasal turbinates. A biopsy of the mass revealed intermediate-sized blastic cells that stained positive for MPO, CD68 (dim), CD99, and CD117 (dim), consistent with involvement by GS (). The results of the laboratory studies included a normal complete blood count (CBC) as well as unremarkable serum chemistry and liver enzyme levels. A flow cytometry study of the circulating white cells was also unremarkable, as were the polymerase chain reaction (PCR) studies of peripheral blood for the breakpoint cluster region (BCR)-Abelson (ABL) gene rearrangements and Janus kinase 2 (JAK-2) mutations. A bone marrow biopsy showed no evidence of AML or features of an MPN; normal trilineage hematopoiesis was present. A chromosome analyses showed an XX karyotype. An integrated whole body positron emission tomography–computed tomography (PET-CT) scan showed only modest inflammation in the nasopharynx (). Because of her age and comorbid medical conditions, we elected to treat her GS with involved-field radiation therapy to the nasopharynx, 30 Gy delivered in 15 daily fractions. She tolerated the radiation therapy well, with alopecia involving the vertex of her scalp and mild mucositis, fatigue, and dysgeusia. Subsequently, she was monitored closely, with exams of her nasopharynx coupled with blood studies every 2 to 3 months. Twelve months after her initial diagnosis of isolated GS, the patient presented to clinic with fever and cough of a week’s duration and complained of recrudescent fatigue and dyspnea on exertion. On exam, she appeared acutely ill, dehydrated, febrile, and diaphoretic, and with diminished breath sounds and crackles at the left lung base. A chest radiograph showed findings consistent with left lower lobe pneumonia. Her CBC consisted of a white blood count (WBC) of 11.8 × 109/L with 62% myeloid blasts, hematocrit of 23%, and platelets of 117 × 109/L. The flow cytometric analysis of peripheral blood revealed an abnormal population of blasts (CD45-dim) that expressed CD117 (moderate) and bright uniform CD33; this population comprised approximately 80% of the circulating WBCs. The tumor cells were negative for human leukocyte antigen (HLA)-DR, CD34, CD13, CD14, CD15, CD16, CD64, CD2, CD3, CD4, CD5, CD7, CD56, CD71, and CD38. The phenotype was similar to the phenotype of the myeloid blasts identified in her prior nasopharyngeal biopsy. Band karyotyping of the peripheral blood blasts showed normal (46, XX) cytogenetics. Induction chemotherapy was prescribed, consisting of cytarabine (100 mg/m2/day, days 1–7) and idarubicin (13 mg/m2/day, days 1–3). Her clinical course was notable for mild mucositis, fluctuating blood sugars, and culture-negative neutropenic fever. A bone marrow aspirate and biopsy obtained on day 14 was markedly hypocellular; a repeat bone marrow biopsy on day 28 was normocellular, with maturing trilineage hematopoiesis and no residual leukemia. She went on to receive an additional three cycles of consolidation therapy, with continuous infusion cytarabine and bolus idarubicin (5+2 regimen). She remains in remission, with a normal CBC at the 18-month follow-up visit. | [[63.0, 'year']] | F | {'15352981': 1, '14745436': 1, '18688157': 1, '11443644': 1, '21640961': 1, '17169797': 1, '3465429': 1, '18606981': 1, '11135470': 1, '11172221': 1, '23233559': 1, '3466674': 1, '31788245': 2, '20116851': 1, '2423654': 1, '26957189': 1, '21638303': 1, '8733701': 1, '9167610': 1, '8423716': 1, '27698857': 1, '3455867': 1, '16450777': 1, '23557893': 1, '12357718': 1, '17579173': 1, '11920536': 1, '12481238': 1, '32821125': 2, '6950808': 1, '16898967': 1, '7602369': 1, '4513297': 1, '4908654': 1, '7625623': 1, '383264': 1, '18089498': 1, '15481450': 1, '11342325': 1, '7023656': 1, '17170724': 1, '23017332': 1, '15567934': 1, '9244412': 1, '1730080': 1, '10862926': 1, '19887783': 1, '21685468': 1, '19565030': 1, '12764375': 1, '21747080': 1, '21795742': 1, '27123069': 1, '17443224': 1, '24368892': 2} | {'7423397-1': 1, '7423397-2': 1, '7423397-3': 1, '6878049-1': 1} |
164,846 | 3870217-1 | 24,371,396 | noncomm/PMC003xxxxxx/PMC3870217.xml | Kaposi Sarcoma in a Patient with Chronic Renal Failure Undergoing Dialysis | A 51-year-old Korean man visited a dermatology clinic because he developed hyperpigmented lesions on both soles. He had noticed the first lesion 1 year earlier, and it had grown gradually (). The patient's medical history included a 10-year history of diabetes mellitus and a 3-year history of diabetic nephropathy and hypertension. He had been on regular peritoneal dialysis to treat chronic renal failure for 2 years. In addition, there were swelling, crusts, and scars on both lower extremities that had been diagnosed as stasis dermatitis and treated with topical steroids for 2 years (). On physical examination, deep gray-colored, non-tender, non-fluctuant linear patches were noted along the arch of the sole, with no ulcerations or nodules. There were reddish-brown patches, edema, and crusts on the shin, and some hyperpigmented crusted plaques on the knee. The laboratory examination, including a complete blood cell count and differential, platelets, fibrinogen, serum electrolytes, chemical analyses, and liver function tests were within normal limits, except for increased blood urea nitrogen (33.1 mg/dl) and creatinine (6.4 mg/dl) levels. Human immunodeficiency virus antibody was negative. Examination for the immune status, such as the Th/Ts ratio in peripheral blood, C3, C4 and immunoglobulin quantization, and sensitization with allergens, was not done. The skin of the sole and shin was biopsied. The specimen from the sole showed numerous dilated, anastomosing slit-like vascular spaces throughout the entire dermis (). The vascular structures were lined by a single layer of endothelium and there was diffuse extravasation of erythrocytes. Immunohistochemical staining for HHV-8 was strongly positive in the spindle-shaped cells and vascular endothelial cells (). The specimen from the shin showed proliferating dilated capillaries and fibroblasts with diffuse dermal edema (). The vascular slits and atypical endothelial cells were absent in this lesion. The sole lesions were diagnosed as KS and the shin lesions as stasis dermatitis.\nThe sole lesions were treated with cryotherapy and the shin lesions with topical steroid. After one cycle of cryotherapy, the patient was lost to follow-up. | [[51.0, 'year']] | M | {'18638627': 1, '18701615': 1, '16053020': 1, '7997879': 1, '7494359': 1, '17337401': 1, '12207098': 1, '131369': 1, '14987280': 1, '9761528': 1, '11374413': 1, '11289393': 1, '17668582': 1, '1766501': 1, '24371396': 2} | {} |
164,847 | 3870218-1 | 24,371,397 | noncomm/PMC003xxxxxx/PMC3870218.xml | Extensive Psoriasis Induced by Pegylated Interferon Alfa-2a and Ribavirin in the Treatment of Chronic Hepatitis C | A 56-year-old male patient was referred to our clinic with generalized confluent erythematous scaly plaques of 6 months duration. He had no previous history of cutaneous disease such as psoriasis and presented with sharply circumscribed erythematous plaques with scales on his trunk, buttock, extremities, and scalp (). The skin eruptions were relatively symmetric in distribution and were asymptomatic. In addition, he presented prominent nail pitting, and onycholysis on his finger nails. A histopathological examination revealed marked acanthosis, epidermal hyperplasia, and Munro's microabscess compatible with psoriasis (). According to these clinical and histopathological findings, the patient was diagnosed as having psoriasis.\nWe then sought to identify the possible triggering factors and found that he had been treated for chronic hepatitis C for 11 months, with a treatment protocol consisting of pegylated interferon alfa-2a 180 µg injected subcutaneously once weekly and ribavirin 1,000 mg daily. While receiving treatment, his transaminase levels (aspartate aminotransferase [AST], alanine aminotransferase [ALT]) decreased to normal and hepatitis C virus RNA became undetectable. However, five months after beginning treatment, psoriatic lesions occurred and gradually worsened during the therapy. Nevertheless, he continued the interferon treatment due to a progressive reduction in transaminase levels and the absence of any uncomfortable symptoms associated with the skin lesions. However, the psoriatic lesions worsened and eventually involved more than 40% of his body surface area. At the time of diagnosis, the interferon treatment was only one month from completion, but considering the severity of the psoriasis, we stopped interferon and started narrow-band ultraviolet B (NB-UVB) phototherapy and topical calcipotriol/betamethasone dipropionate ointment. Subsequently, the psoriasis slowly improved without recurrence. | [[56.0, 'year']] | M | {'10971502': 1, '1751354': 1, '11583749': 1, '10824054': 1, '8213720': 1, '29458351': 1, '10190717': 1, '15886478': 1, '11053930': 1, '10599347': 1, '16297178': 1, '15757824': 1, '25574096': 1, '12591189': 1, '17875206': 2, '20089020': 1, '8274788': 1, '24371397': 2} | {'2075503-1': 1} |
164,848 | 3870220-1 | 24,371,399 | noncomm/PMC003xxxxxx/PMC3870220.xml | New Onset Guttate Psoriasis Following Pandemic H1N1 Influenza Vaccination | A 26-year-old Korean female was presented with guttate psoriasis-like lesions of multiple erythematous scaly macules scattered on her extremities and trunk (). She was injected with an inactivated split-virus influenza A/H1N1 vaccine without adjuvant (Greenflu-S®) on her left deltoid area ten days before the visit to our department. The first lesion appeared on the injection site three days after the vaccination, and its size slowly increased (). After a few days, multiple small scaly macules developed on the trunk and extremities. On the lesion on her back, an Auspitz sign was observed when silvery scales were removed. She suffered appendicitis four months before the vaccination and had no history of any other inflammatory disorders. There was no personal or family history of psoriasis. Routine laboratory investigation results were within the normal range of limits except for antistreptolysin-O (ASO) titer, which elevated to 773 IU/ml (normal: <200 IU/ml). However, there was no definite history of streptococcal infection, such as pharyngitis. Histopathological examination showed neutrophilic collections within the parakeratotic cornified layer, moderate acanthosis, diminished granular layer, elongation and edema of the dermal papillae, and dilated capillaries (). The lesions were successfully treated with topical steroids and ultraviolet B phototherapy within three weeks. And for the following fourteen months, there was no relapse. | [[26.0, 'year']] | F | {'8542217': 1, '33485646': 1, '20561127': 1, '34869811': 1, '1739285': 1, '4755912': 1, '14387477': 1, '20403114': 1, '15233196': 1, '33339348': 1, '19002352': 1, '34363647': 1, '20600483': 1, '21621174': 1, '33331024': 1, '26380315': 1, '17187052': 1, '18664162': 1, '31491865': 1, '28377495': 1, '20421727': 1, '24371399': 2} | {} |
164,849 | 3870221-1 | 24,371,400 | noncomm/PMC003xxxxxx/PMC3870221.xml | A Granulomatous Drug Eruption Induced by Entecavir | A 65-year-old woman was referred for consultation of a facial granulomatous facial eruption. The patient had a history of carrying the HBV for 35 years. Since her serum aspartate aminotransferase and alanine aminotransferase level were elevated for 3 months, she had been taking entecavir (Baraclude®) at a dose of 0.5 mg daily. Two months after initiating the antiviral therapy, she presented with multiple pruritic erythematous papules and telangiectasia on the forehead, both periorbital areas and the cheeks (). The patient did not show other accompanying systemic symptoms. She had not taken any other medication before starting the entecavir therapy, and there was no previous medical history. Routine laboratory examinations revealed increased serum aspartate transferase (83 IU/L), alanine transferase (99 IU/L), alkaline phosphatase (107 IU/L) and gamma-glutamyl transferase (49 IU/L). A skin biopsy was performed on her right cheek. Histopathologic findings showed granulomatous inflammatory reactions in the dermis and subcutaneous tissues (). The prominent perivascular lymphocytic infiltrate, endothelioid histiocytic infiltrate, and some telangiectasia of the vessels were seen (). Bacterial and fungal culture, and mycobacterial culture for Mycobacterium tuberculosis were all negative. She had no past history of granulomatous disease such as rosacea, and no history of taking medications before the entecavir therapy, and she had a relatively acute onset of the clinical manifestations. The most important point in favor of the eruption being diagnosed as an entecavir induced drug eruption was that her skin lesions had which developed after retreatment in this case. Entecavir therapy was discontinued immediately and thisen was followed by treatment with 0.75% topical metronidazole and oral minocycline therapy (100 mg/d for 14 days), as well as sunscreens. Because of abdominal discomfort after taking minocycline, she discontinued the oral minocycline therapy herself. Within approximately two months of the skin lesions appearing, they completely resolved. However, the same cutaneous eruption recurred in the same site of her face after she started entecavir therapy again three months later (). The entecavir was promptly discontinude and we check the photograph with patient's aggrement. The entecavir was promptly discontinued. A patch test was performed ten months after the drug eruption had disappeared completely. To the back area, entecavir (0.001%, 0.01%, 0.1%, 1%, 10%) in petrolatum was applied using an 8 mm Finn chamber (Smart Practice, Phoenix, AZ, USA) and Scanpor tape (Alpharma AS, Oslo, Norway). The patches were removed 48 hours later and a reading was done at 48 hours and 96 hours after the patch test, which was negative on both occasions according to the criteria of the International Contact Dermatitis Research Group. | [[65.0, 'year']] | F | {'12454840': 1, '12575862': 1, '1824746': 1, '11526545': 1, '15149527': 1, '9521495': 1, '30459136': 1, '16525137': 1, '11181644': 1, '18721215': 1, '16230074': 1, '19215336': 1, '32948126': 1, '24371400': 2} | {} |
164,850 | 3870852-1 | 23,816,555 | noncomm/PMC003xxxxxx/PMC3870852.xml | Lymphoma and cerebral vasculitis in association with X-linked lymphoproliferative disease | A 5-year-old boy who presented with a one-month history of headache and vomiting two years after being cured of Burkitt lymphoma was admitted to our cancer center on March 7, 2011. Prior to being admitted to our center, he was initially treated at a local hospital with mannitol-induced dehydration and dexamethasone for suspected relapse of lymphoma involving the brain. His symptoms were partially controlled with mannitol and dexamethasone but worsened with regular exacerbation of mental and movement retrogression. He manifested with abnormal gait and declined ability to play games without fever. During each exacerbation, his symptoms were controlled with dehydration. During one episode on the day after admission, he developed transient headache, vomiting, and obnubilation. He developed seizures involving both hands and legs. He was treated with mannitol and dexamethasone intravenously. Anti-infection therapy including meropenem, itraconazole, voriconazole, and aciclovir was initiated; he recovered consciousness and headache disappeared on the following day.\nAt the age of 3 years, the patient was diagnosed with stage IV Burkitt lymphoma in our cancer center. Fluorescence in situ hybridization (FISH) examination showed positive for MYC/IgH translocation. Epstein-Barr virus (EBV)-encoded early RNA (EBER) was negative. Treatment consisted of non-Hodgkin's lymphoma-Berlin-Frankfurt-Milan-90 (NHL-BFM-90) protocol and rituximab. The patient completed chemotherapy on July 14, 2009. He continued to have persistent complete remission and was well on follow-up. There was a family history of fulminant infectious mononucleosis (FIM); his older brother and maternal male cousin died of this condition at the age of 10 months and 2 years, respectively. The patient was diagnosed with confirmed mutation in SH2D1A, a C>T nonsense substitution mutation. There was no family history of other cerebral vascular accidents or cerebral tumors.\nMagnetic resonance imaging (MRI) revealed multiple non-homogeneous, hypodense masses along the bilateral cortex, diffusing edema of the cerebral white matter, and demyelination (). The bone marrow showed normal presentation. Cerebrospinal fluid (CSF) was grey yellow, and laboratory examinations showed a slight decrease in glu (1.13 mmol/L, normal 2.5–4.5 mmol/L) and Cl (110.4 mmol/L, normal 120–130 mmol/L). In the CSF, protein levels were elevated (1,950 mg/L, normal 80–430 mg/L), and cell concentration was 6 × 106/L. Pandy test was positive. CSF pressure was normal. Evidence of tumor cells was absent on repeated examinations. CSF culture showed gram-positive bacteria; there was no evidence of the pathogens cryptococcosis, mycete, or mycobacterium. EBV-DNA copy number was 0. C-reactive protein (CRP) and procalcitonin (PCT) were normal.\nLumbar puncture was carried out in two weeks again after anti-infection therapy. CSF remained grey yellow. CSF smears showed many mature lymphocytes. CSF culture was negative. Glu and Cl levels in CSF were lower than normal (0.79 mmol/L and 117.2 mmol/L, respectively), whereas protein levels were high (1,910 mg/L). The patient's worsening mental and motor conditions were not resolved by two-week anti-infection therapy. He could not speak clearly or recognize his parents. The patient remained seizure-free. MRI scans of his brain showed multiple non-homogeneous, hypodense masses along the bilateral cortex, diffuse abnormal signals in the bilateral cerebral cortex, and extensive edema in the bilateral white matter. These brain lesions were more severe than those revealed by prior MRI. His mental condition had not improved after 3 weeks of anti-infection therapy. Biopsy was performed on masses in the right cerebral front lobe to exclude Burkitt lymphoma relapse involving the central nervous system. Cerebral pathology revealed local pallium and white matter with a yellow appearance. Light microscopy revealed neurogliocyte and vessel hyperplasia accompanied by lymphocyte infiltration. Immunohistochemistry revealed moderate CD68, CD3, CD2, CD5, CD8, cytotoxic granule-associated RNA binding protein (TIA1), and glial fibrillary acidic protein (GFAP) staining and mild Ki-67 staining (1%). T-cell receptor (TCR) rearrangment, CD4, and EBER were negative (). Special staining for Ag, periodic acid-schiff (PAS), and anti-acid was negative. There was no tumor in the brain. The biopsy tissue was cultured and no pathogen was found. Pathologic presentation coincided with chronic inflammatory changes, and pathologic diagnosis was cerebral vasculitis in the brain. On follow-up, the patient remains in a vegetative state. | [[5.0, 'year']] | M | {'15761493': 1, '20926771': 1, '26433589': 1, '14726378': 1, '11169415': 1, '27492260': 1, '11034354': 1, '8559596': 1, '19621458': 1, '8892735': 1, '10898506': 1, '21219180': 1, '48119': 1, '10975798': 1, '32908732': 1, '15749842': 1, '11093147': 1, '15677558': 1, '11049992': 1, '21083659': 1, '15711562': 1, '23816555': 2} | {} |
164,851 | 3871033-1 | 24,396,701 | noncomm/PMC003xxxxxx/PMC3871033.xml | Co-Occurrence of Papillary Thyroid Carcinoma and Mucosa-Associated Lymphoid Tissue Lymphoma in a Patient with Long-Standing Hashimoto Thyroiditis | An 81-year-old female patient was admitted to a local hospital for weight loss, goiter, and hoarseness. The goiter and hoarseness had been present for about 10 years; the weight loss was 10 kg over the prior 6 months. However, there were no symptoms of fever or night sweats. She had a history of hypertension, but had no family history of cancer, and had no history of thyroid disease or radiation exposure. On physical examination, the thyroid was firm, fixed, and diffusely enlarged; however, there was no pain or tenderness. The thyroid gland measured approximately 10 cm in width and 12 cm in length. Other than the goiter, physical examination was unremarkable. Laboratory tests were as follows: white blood cell count, 6,760/µL; hemoglobin, 13.4 g/dL; platelet count, 207,000/µL; total protein, 9.5 g/dL; albumin, 3.7 g/dL; aspartate aminotransferase, 25 IU/L; alanine aminotransferase, 16 IU/L; lactate dehydrogenase, 257 IU/L (normal range, 135 to 214). Thyroid function tests: free T4, 0.79 ng/dL (normal range, 0.75 to 2.00); T3, 99.5 ng/dL (normal range, 79.8 to 200); thyroid stimulating hormone (TSH), 2.55 µU/mL (normal range, 0.3 to 5.0); and antithyroglobulin antibody level, 14.75 U/mL (normal range, 0 to 60) were within normal limits, but antithyroid peroxidase antibodies were elevated (165.22 U/mL; normal range, 1 to 60).\nInitial ultrasonography revealed diffuse enlargement of the thyroid gland, with heterogeneous background parenchyma. Transverse imaging revealed an ill-defined hypoechoic nodule measuring 3.7×3 cm in the right thyroid gland. The left thyroid gland and isthmus showed a diffuse goiter with ill-defined multiple patchy hypoechogenicities and heterogenecity (). Fine needle aspiration revealed the nodule to be suspicious for PTC. Thereafter, the patient was admitted to our hospital for surgery. Preoperative computed tomography (CT) of the neck revealed a diffusely enlarged thyroid gland with nodules in both lobes ().\nA total thyroidectomy and right and left central neck node dissection was performed. Gross and microscopic examination disclosed a 3.7×3.0 cm papillary carcinoma in the right thyroid gland (). There was minimal extrathyroidal extension, all surgical resection margins were negative and no metastatic lymph nodes were found (pathologic TNM staging, T3N0Mx, stage III). Background thyroid tissue showed diffuse lymphocyte infiltration, the presence of Hürthle cells, small follicles with scanty colloid, and germinal center formation, which are all characteristics of HT. The left thyroid gland weighed 116 g and was measured 9.6×6.9×2.9 cm; microscopic histopathology revealed a nodular proliferation of small B cells, with a lymphoepithelial lesion suggestive of MALT lymphoma in the left thyroid gland. Much of the normal thyroid architecture was replaced by dense, diffuse infiltrates of atypical small B lymphocytes, showing strong CD20- and lambda light chain-immunopositivity, and an absence of κ light chain (). IgH gene rearrangement assay confirmed the diagnosis of MALT lymphoma.\nBone marrow examination is necessary in order to set the stage of lymphoma. However, the patient refused invasive evaluation due to her age. Postoperative neck CT and 18F-fluorodeoxyglucose positron emission tomography of the neck performed within 1 month of surgery demonstrated no persistence or recurrence of either neoplasm. There was no evidence of lymph node enlargement in the neck, mediastinum, or abdomen. Although a bone marrow biopsy was not performed, MALT lymphoma was considered to be confined to the thyroid gland, corresponding to stage IE according to Ann Arbor classification.\nThe patient is currently taking levothyroxine as a sole postsurgical therapy. Based on age and health status, radioiodine treatment was not administered. Symptoms of hoarseness and weight loss improved after surgery. One year after surgery, a thyroid function test was performed and antithyroglobulin antibody levels and thyroglobulin levels were measured (free T4, 1.61 ng/dL; T3, 122.1 ng/dL; TSH, 0.00 µU/mL; antithyroglobulin antibody, 11.02 U/mL; thyroiglobulin, 0.227 ng/mL). Neither tumor has recurred during the 1-year follow-up period. | [[81.0, 'year']] | F | {'11788631': 1, '29686785': 2, '25411835': 1, '31938434': 1, '19225216': 1, '17235456': 1, '20625656': 1, '10800981': 1, '10989966': 1, '25309783': 1, '32071897': 1, '3838363': 1, '22568399': 1, '30089952': 2, '23238509': 1, '14615444': 1, '24396701': 2} | {'5901269-1': 1, '6060575-1': 1} |
164,852 | 3871035-1 | 24,396,700 | noncomm/PMC003xxxxxx/PMC3871035.xml | Papillary Thyroid Carcinoma: Four Cases Required Caution during Long-Term Follow-Up | A 74-year-old female patient visited the emergency center with respiratory distress, facial edema, and sore throat as her primary complaints. The patient had a surgical history of total thyroidectomy due to PTC accompanied by multiple lymph node metastases performed 18 years prior, and she had received postoperative high-dose radioactive iodine (RAI) ablation (150 mCi) at the time. Physical examination revealed a palpable mass on the patient's neck with pus discharge from a neck scar (). On neck sonography, a tumor thrombus was found in the right internal jugular vein (). On chest computed tomography (CT) and positron emission tomography (PET)-CT, a large tumor causing superior vena cava syndrome, a tumor in the right upper lobe of the lung and multiple perimediastinal lymph node enlargements were found (). The authors performed a CT-guided percutaneous fine needle biopsy of an enlarged lymph node and the tumor in the right upper lobe of the lung to establish a histological diagnosis (). The biopsy revealed metastatic PTC (). We considered immediate surgical treatment for each tumor, but deferred surgery due to the patient's disease progression. Instead, we started the high-dose RAI therapy on the basis of antithrombotic therapy. Nevertheless, the patient exhibited symptoms such as headache, dyspnea, and hemoptysis just a week after initiation of the antithrombotic therapy, and, when we performed additional examination, we observed brain metastasis (). Consequently, the patient discontinued antithrombotic therapy and continued conservative therapy. However, the patient expired after 2 weeks. | [[74.0, 'year']] | F | {'859443': 1, '15770642': 1, '20470207': 1, '19558727': 2, '19825162': 2, '20576407': 1, '25309783': 1, '19888854': 1, '16714903': 1, '19860577': 1, '24396700': 2} | {'3871035-2': 2, '3871035-3': 2, '3871035-4': 2, '2765443-1': 1, '2765443-2': 1, '2712461-1': 1} |
164,853 | 3871035-2 | 24,396,700 | noncomm/PMC003xxxxxx/PMC3871035.xml | Papillary Thyroid Carcinoma: Four Cases Required Caution during Long-Term Follow-Up | A 44-year-old female patient with a history of PTC was reoperated due to the PTC recurrence in a neck lymph node. The patient was diagnosed and treated 10 years prior with total thyroidectomy and high-dose RAI ablation (150 mCi). At that time, we performed the lymph node dissection in the neck as well as high-dose RAI ablation (200 mCi). During follow-up, we conducted neck sonography, measurement of thyroxin withdrawal thyroglobulin level, whole-body 131I scan, and PET-CT, but none of these tests revealed any findings of remnant PTC. However, after 1 year, follow-up chest X-ray indicated ~0.3 cm lung nodules in lung fields on both sides. The tentative diagnosis was that these were benign lesions according to the interpretation of the radiologist. Due to the patient's past history of thyroid cancer, however, we shortened the follow-up interval and took another chest CT 3 months later. The chest CT did not show any significant differences from the previous chest X-ray (). When compared with chest CT images taken 3 months later, we were able to observe slight increases in the size of the lesions. We performed a biopsy of the lung nodes by video-assisted thoracoscopic surgery, which resulted in a diagnosis of metastatic papillary thyroid cancer and bronchioloalveolar carcinoma (). | [[44.0, 'year']] | F | {'859443': 1, '15770642': 1, '20470207': 1, '19558727': 2, '19825162': 2, '20576407': 1, '25309783': 1, '19888854': 1, '16714903': 1, '19860577': 1, '24396700': 2} | {'3871035-1': 2, '3871035-3': 2, '3871035-4': 2, '2765443-1': 1, '2765443-2': 1, '2712461-1': 1} |
164,854 | 3871035-3 | 24,396,700 | noncomm/PMC003xxxxxx/PMC3871035.xml | Papillary Thyroid Carcinoma: Four Cases Required Caution during Long-Term Follow-Up | A 68-year-old female patient, who was diagnosed with PTC and underwent the total thyroidectomy 10 years prior, had a hypoechoic neck lymph node enlargement revealed on follow-up neck sonography (). We performed a fine needle aspiration biopsy of the enlarged lymph node, and the biopsy results showed recurrent metastatic PTC. We planned immediate surgical intervention, however, in the process of preparing for the surgery, the patient complained of a mild degree of dyspnea accompanied by chest pain on the right side. When chest X-rays were taken, we observed pleural thickening and pleural fluid on the right side. We performed a pleural biopsy, and biopsy findings indicated metastasis of PTC. Two days later, the patient's dyspnea was even more aggravated, and we noted compression of trachea caused by mediastinal lymph node enlargement and a rapid increase in the amount of pleural fluid on subsequent chest CT (). The patient died 3 weeks after the diagnosis of metastasis of PTC in spite of conservative palliative treatment. The cause of death was suggested to be the aggressive anaplastic change of PTC or aggressive malignancy of other organ including esophagus or lung. | [[68.0, 'year']] | F | {'859443': 1, '15770642': 1, '20470207': 1, '19558727': 2, '19825162': 2, '20576407': 1, '25309783': 1, '19888854': 1, '16714903': 1, '19860577': 1, '24396700': 2} | {'3871035-1': 2, '3871035-2': 2, '3871035-4': 2, '2765443-1': 1, '2765443-2': 1, '2712461-1': 1} |
164,855 | 3871035-4 | 24,396,700 | noncomm/PMC003xxxxxx/PMC3871035.xml | Papillary Thyroid Carcinoma: Four Cases Required Caution during Long-Term Follow-Up | A 67-year-old female patient received total thyroidectomy due to PTC. Metastases of the carcinoma in the neck lymph node were found, and the patient underwent lymph node dissection in the neck area as a secondary procedure (). After all procedures were completed, she received high-dose RAI therapy. While conducting a 2-year follow-up, lung nodules were found, and we conducted additional high-dose RAI therapy. A post-RAI follow-up chest CT was conducted, but revealed an increase in the number and size of nodules (). RAI ablation (200 mCi) was performed again due to refractory disease. The patient complained of pain in thoracic wall and dyspnea after 6 months, and chest CT findings showed a large amount of pleural fluid on the right side, as well as metastatic lymph nodes (). We performed a pleural biopsy in addition to pleural fluid drainage and pleurodesis (). Nevertheless, the amount of pleural fluid continued to increase and dyspnea was aggravated. Consequently, the condition of the patient deteriorated and the disease remained refractory to treatment, so we maintained only conservative treatment. The patient died 3 months after pleural fluid was first observed. | [[67.0, 'year']] | F | {'859443': 1, '15770642': 1, '20470207': 1, '19558727': 2, '19825162': 2, '20576407': 1, '25309783': 1, '19888854': 1, '16714903': 1, '19860577': 1, '24396700': 2} | {'3871035-1': 2, '3871035-2': 2, '3871035-3': 2, '2765443-1': 1, '2765443-2': 1, '2712461-1': 1} |
164,856 | 3871037-1 | 24,396,698 | noncomm/PMC003xxxxxx/PMC3871037.xml | Recurrent Insulin Autoimmune Syndrome Caused by α-Lipoic Acid in Type 2 Diabetes | A 67-year-old female visited the outpatient clinic of our institution complaining of numbness and coldness in both feet. She has been diagnosed with type 2 diabetes 5 years prior and was being treated with a sulfonylurea (gliclazide 30 mg). Based on the examination results, she was diagnosed with diabetic peripheral neuropathy, and thioctacid (600 mg) was prescribed. She experienced repeated occurrences of hunger, hand tremor, cold sweat, and dizziness 3 to 4 hours after a meal since having taken the drug, but symptoms consistently improved after eating snacks. Her past history was insignificant except an appendectomy 40 years prior. On physical examination, her height was 165 cm and body weight 60 kg. Blood pressure was 130/90 mm Hg. There was no thyroid goiter or skin pigmentation.\nBlood examination showed leukocyte count 4,700/mm3, hemoglobin 13.0 g/dL, platelet 202,000/mm3, blood urea nitrogen 17.0 mg/dL, Cr 0.7 mg/dL, total protein 7.1 g/dL, albumin 4.6 g/dL, aspartate aminotransferase 26 IU/L, alanine aminotransferase 36 IU/L, alkaline phosphatase 116 IU/L, total cholesterol 166 mg/dL, triglyceride 115 mg/dL, high density lipoprotein 39 mg/dL, calcium 8.8 mg/dL, phosphate 3.3 mg/dL, sodium 135 mEq/L, and potassium 4.2 mEq/L. Thyroid and adrenal cortical function tests were performed. Free T4 was 1.12 ng/dL (normal range, 0.93 to 1.7), thyroid stimulating hormone 2.25 µIU/L (normal range, 0.27 to 4.2), adrenocorticotropic hormone 16.5 pg/mL (normal range, 6 to 56.7), and cortisol 13.4 µg/dL.\nOn admission, hemoglobin A1c (HbA1c) was 6.6%, fasting blood glucose 208 mg/dL, and postprandial blood glucose 195 mg/dL. Serum insulin, when measured by radioimmunoassay (RIA, immunoradiometric assay, INSULIN-IRMA, Biosource Europe, Nivelles, Belgium) was normal at 15.33 and 19.41 µIU/mL on fasting and postmeal, respectively (normal range, 2 to 25). However, C-peptide (immunoradiometric assay, C-Peptide IRMA, IZOTOP, Budapest, Hungary) was increased to 13.96 ng/mL on fasting and 18.24 ng/mL after meals (normal range, 1.07 to 3.51).\nSulfonylurea administration was discontinued, but the hypoglycemic symptoms persisted. After eating carbohydrate snacks between meals, daytime frequency of hypoglycemia decreased, but hypoglycemia with a level less than 50 mg/dL persisted at dawn with prolonged fasting. A 72-hour fasting test was attempted but was ended after 6 hours because the patient complained of severe hypoglycemia with a blood sugar level of 44 mg/dL. During a 6-hour examination, the blood sugar levels were 90, 70, and 44 mg/dL at baseline, 4 and 6 hours, and the serum insulin values measured by RIA were within the normal range at 22.92, 22.16, and 27.47 µIU/mL, respectively. The C-peptide values were increased to 15.60, 20.31, and 15.65 ng/mL, respectively. The antinuclear antibody was negative, while the insulin autoantibody value (RIA, Cobra 5010, Biosource Europe) was very high at 53% (normal range, <7). The human leukocyte antigen (HLA) class II result was DRB1*0406/1454. Abdominal computed tomography revealed no abnormalities in the pancreas ().\nBecause the patient continued to suffer from fasting hypoglycemia after suspending sulfonylurea administration, and serum C-peptide and insulin autoantibody levels increased, she was diagnosed with IAS. As the sulfhydryl-containing thioctacid first administered 2 weeks before the occurrence of hypoglycemia, it was regarded as the causal factor and discontinued. The patient continued to eat complex carbohydrates between meals, but hypoglycemia persisted. Prednisolone (10 mg) administration reduced the frequency of hypoglycemia and was able to be discontinued after 2 months because recovery was observed. At 4 months after diagnosis, the insulin autoantibodies were still high at 80.4%, but no signs of hypoglycemia were evident. At the 2-year follow-up, insulin autoantibody titer was reduced to 50.9%, and hypoglycemia was no longer detected.\nThe patient visited the rehabilitation department of another hospital to treat diabetic peripheral neuropathy 2 years after the initial occurrence and was prescribed thioctacid. Hypoglycemia recurred 10 days later, for which she visited our hospital. At that time, the patient was treated with voglibose (0.6 mg). HbA1c was 5.7% and insulin autoantibody was 77.2%. We performed a 75 g oral glucose tolerance test. The fasting plasma glucose was 98 mg/dL and the 2-hour plasma glucose after glucose load was 135 mg/dL, but serum insulin levels measured by enzyme-linked immunosorbent assay (ELISA, Roche Elecsys insulin test, Roche Diagnostics, Mannheim, Germany) were increased to more than 1,000 µU/mL for both fasting and 2 hours posttest. Fasting and 2-hour posttest C-peptide values were 10.91 and 16.92 ng/mL, respectively. After taking prednisolone (10 mg), she recovered from hypoglycemia. The dose of prednisolone was tapered by 5 mg and was discontinued 2 months later. Before discharge, the patient was instructed to avoid thioctacid. Six months after discharge, most of the values were normalized, i.e., HbA1c 5.7%, serum insulin 267 µU/mL, and C-peptide 3.71 ng/mL, but insulin autoantibodies remained high at 78% without hypoglycemia.\nThe patient was again prescribed thioctacid 2 years after the second occurrence, for which she revisited our hospital due to the recurrence of hypoglycemia. At that time, she was taking voglibose (0.6 mg) as a hypoglycemic agent. Her serum insulin level based on ELISA was abnormal, measuring higher than 1,000 µU/mL, while C-peptide was 21.06 ng/mL and insulin autoantibodies were 96%. According to the test results, the patient was prescribed prednisolone (5 mg), and after 4 months, serum insulin (measured by ELISA) and C-peptide were reduced to 210 µU/mL and 2.81 ng/mL, respectively, but the insulin autoantibodies remained high (88.9%). However, there was no sign of hypoglycemia (). | [[67.0, 'year']] | F | {'17827827': 1, '30532998': 1, '31915554': 2, '19070385': 1, '9467587': 1, '30627435': 2, '1346661': 1, '25309783': 1, '17329919': 1, '31966997': 1, '34122657': 1, '30085133': 1, '21868770': 1, '24396698': 2} | {'6930746-1': 1, '6311546-1': 1} |
164,857 | 3871041-1 | 24,396,699 | noncomm/PMC003xxxxxx/PMC3871041.xml | Rhabdomyolysis and Acute Kidney Injury Associated with Hypothyroidism and Statin Therapy | A 63-year-old female patient presented to our hospital complaining of edema, fatigue, and numbness in the right femoral region. She had normal appetite, but her urine output had gradually decreased over the course of the 15 days prior to visiting the hospital. Oliguria began 8 to 9 days after making Kimchi in squat position. Her systemic edema had worsened over the three days prior to presentation, and she was experiencing asthenia and numbness of the right femoral region, which prompted her to visit the hospital through the emergency room. She did not complain of any respiratory distress or chest pain.\nShe had a medical history of hypertension and cerebral hemorrhage 7 years previously and her current medications were aspirin 100 mg, clinidipine 10 mg, valsartan 160 mg, thiazide 12.5 mg, and bisoprolol 5 mg. During the regular follow-up at the cardiology department of our hospital, hyperlipidemia (total cholesterol, 273 mg/dL; low density lipoprotein cholesterol [LDL-C], 167 mg/dL) was developed, and she was treated with rosuvastatin 20 mg starting 40 days before presentation. There were no specific findings in her family history.\nBlood pressure at the time of presentation was 120/90 mm Hg, pulse rate was 54 beats per minute, and body temperature was 35℃. Heart and breath sounds were normal. The skin tugor was decreased, the femoral region was tender to palpation, and she had systemic nonpitting edema especially on the face and periocular region. There was no sign of goiter. Muscle strength was slightly decreased in the bilateral lower extremities, but the remainder of the motor exam was unremarkable. There were no sensory abnormalities in the lower extremities, and the results of straight leg raise test, patellar subluxation test, tarsal test, and ankle clonus reflex test were normal. The pulse on both dorsalis pedis and popliteal arteries was palpated normally.\nBlood tests performed at presentation demonstrated white blood cell, hemoglobin, and platelets of 11,890/mm3, 15.5 g/dL, and 249,000/mm3, respectively. Blood urea nitrogen and serum creatinine were 89.1 and 9.8 mg/dL. Serum Na/K/Cl/total CO2, serum calcium/phosphate, plasma total cholesterol, triglycerides, and LDL-C were 131/4.1/91/17.5 mmol/L, 7.7/7.6 mg/dL, 111, 158, and 42 mg/dL. Aspartate aminotransferase/alanine aminotransferase, creatine kinase, and lactate dehydronase (LDH) were increased to 1,521/360, 72,850, and 1,974 IU/L, respectively. A whole-body bone scan showed diffuse isotope uptake in the muscle of right pelvis and both lower extremities, consistent with rhabdomyolysis (). Urinalysis revealed hematuria and 2+ proteinuria but urine myoglobin was negative.\nTo rule out hypothyroidism, as a possible risk factor for statin-induced muscle injury and as a cause of nonpitting edema and hypercholesterolemia, thyroid function test was performed. T3, free T4, and thyroid-stimulating hormone (TSH) were <25 ng/dL (normal range, 58 to 159), <0.4 ng/dL (normal range, 0.7 to 1.48), and 100 µIU/mL (normal range, 0.35 to 4.94), respectively. In addition, the patient had high titer of thyroid peroxidase autoantibody (1:6,400) and thyroglobulin autoantibodies (1:6,400). Based on all of the aforementioned findings, the patient was diagnosed as hypothyroidism associated with Hashimoto thyroiditis.\nDespite fluid resuscitation with normal saline and administration of a diuretic, the patient failed to maintain adequate urine output of ≥30 mL/hr. Instead, she developed symptoms of fluid overload. Accordingly, she was treated by continuous venovenous hemofiltration (CVVH; Prisma, Gambro, Lund, Sweden) with 2 L per hour of filtration volume via internal jugular venous catheter. Her hypothyroidism was also treated with levothyroxine 50 µg once daily starting from the second day of hospitalization immediately after she was diagnosed with hypothyroidism. After the second day of CVVH, urine output increased to ≥100 mL per hour and renal replacement therapy was stopped on the third day of hospitalization. The patient was discharged from the hospital on the 19th day with the following biochemical values: creatine kinase 507 IU/L, LDH 445 IU/L, blood urea nitrogen 24 mg/dL, and creatinine 2.3 mg/dL. Serum creatinine recovered to the normal range of 1.2 mg/dL 2 months after discharge. Due to the diagnosis of statin induced rhabdomyolysis, rosuvastatin was discontinued at discharge; however, plasma total cholesterol and LDL-C were again elevated to 232 and 151 mg/dL, respectively, 2 months after discharge. Therefore, we began treatment with another type of hydrophilic statin, pravastatin, at a dose of 20 mg per day. At 6 months after discharge, the patient's kidney function remained stable and T3, free T4, and TSH were 89.3 ng/mL, 1.19 ng/dL, and 6.181 µIU/mL, respectively. We continued levothyroxine 50 µg/day and slowly adjusted the dose depending on thyroid function tests. | [[63.0, 'year']] | F | {'17620856': 1, '33688591': 1, '29897980': 1, '19571284': 1, '12803243': 1, '11005703': 1, '25309783': 1, '12672737': 1, '15006590': 1, '2253372': 1, '5935360': 1, '17148561': 1, '24396699': 2} | {} |
164,858 | 3872090-1 | 24,379,687 | noncomm/PMC003xxxxxx/PMC3872090.xml | Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports | A 55-year-old Caucasian woman was initially treated in September 2011 with 33 units (U) of onabotulinumtoxinA (Vistabel®) in the upper third of the face. She received 6 U over three injection points in each orbicularis oculi, 5 U at one injection point in each corrugator muscle, 5 U at one injection point in the procerus, and a total of 6 U over three injection points in the frontalis muscle (one central and two lateral) ().\nThe patient experienced almost no response to the first treatment ( and ). At the second visit, in October 2011, she was switched to treatment with 80 Speywood U of abobotulinumtoxinA (Dysport®; Ipsen Ltd., Basking Ridge, NJ, USA/Azzalure®; Galderma, Paris, France) in the same injection points. A mild response was observed, which lasted 3 months. The patient’s serum was tested after the second treatment for the presence of neutralizing antibodies to botulinum toxin type A at a specialized laboratory (Toxogen GmbH, Hannover, Germany). The patient was positive for neutralizing antibodies, although the titers were not very high. | [[55.0, 'year']] | F | {'32095419': 1, '9294406': 1, '18546321': 1, '16714951': 1, '34515975': 1, '25559581': 1, '28388717': 1, '19278576': 1, '18180443': 1, '19352590': 1, '11385265': 1, '7675238': 1, '20370628': 1, '22162643': 1, '17278332': 1, '8196686': 1, '30013379': 1, '28388721': 1, '27119917': 1, '18452456': 1, '29089780': 1, '34566211': 1, '21134050': 1, '21209727': 1, '12682332': 1, '15027060': 1, '9854974': 1, '19620852': 1, '22123065': 1, '17617291': 1, '29344324': 1, '20737546': 1, '24379687': 2} | {'3872090-2': 2, '3872090-3': 2, '3872090-4': 2, '3872090-5': 2} |
164,859 | 3872090-2 | 24,379,687 | noncomm/PMC003xxxxxx/PMC3872090.xml | Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports | Case 2 concerns a 54-year-old Caucasian woman who had been receiving botulinum toxin type A preparations for 2 years. She was initially treated with abobotulinumtoxinA (Dysport®) in April 2009, when she received 50 Speywood U over five injection points in the glabella, 20 U over ten injection points in the frontalis muscle, 50 U (25 each side) over four injection points in the orbicularis oculi, and 50 U in the jawline, along and below the mandibular line (). Within the next 4 weeks, she received 50 U over ten injection points in the platysmal bands with two further top-ups in the platysmal bands over the following month (). Over the course of the year, the woman received three more treatments with abobotulinumtoxinA (Dysport®) in the glabella, frontalis, orbicularis oculi, and jawline as outlined in .\nIn May 2010, the woman received further injections with abobotulinumtoxinA (Dysport®) in the glabella, frontalis, orbicularis oculi, and platysmal bands (), but reported that the treatment was not working as well as it had been ( and ). At the next treatment, 6 months later, she was switched to onabotulinumtoxinA (BOTOX®) (), but the treatment had little effect. Three months later, the patient returned to treatment with abobotulinumtoxinA (Dysport®), but reported no effect after 4 weeks. A final treatment with incobotulinumtoxinA (Xeomin®/Bocouture®; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany) was tried 9 months later, but the duration of effect was only 2 weeks. The patient tested positive (++) for antibodies to botulinum toxin type A. At this time, no further therapy is planned. | [[54.0, 'year']] | F | {'32095419': 1, '9294406': 1, '18546321': 1, '16714951': 1, '34515975': 1, '25559581': 1, '28388717': 1, '19278576': 1, '18180443': 1, '19352590': 1, '11385265': 1, '7675238': 1, '20370628': 1, '22162643': 1, '17278332': 1, '8196686': 1, '30013379': 1, '28388721': 1, '27119917': 1, '18452456': 1, '29089780': 1, '34566211': 1, '21134050': 1, '21209727': 1, '12682332': 1, '15027060': 1, '9854974': 1, '19620852': 1, '22123065': 1, '17617291': 1, '29344324': 1, '20737546': 1, '24379687': 2} | {'3872090-1': 2, '3872090-3': 2, '3872090-4': 2, '3872090-5': 2} |
164,860 | 3872090-3 | 24,379,687 | noncomm/PMC003xxxxxx/PMC3872090.xml | Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports | A 41-year-old Caucasian woman was initially treated for hyperhidrosis in 2006 with 100 U of onabotulinumtoxinA (BOTOX®) (). The treatment effect lasted 5 months. In 2009, the woman received a further 100 U of onabotulinumtoxinA for hyperhidrosis and an additional 50 U over ten injection points in the frontalis muscle, four injection points in the corrugator muscles, one injection point in the procerus, and four injection points in each orbicularis oculi muscle. The treatment effect was 2–3 months. In 2010, she received a repeat treatment for hyperhidrosis with 150 U of onabotulinumtoxinA with clinical effect lasting 2–3 months. At her last treatment for hyperhidrosis, she received 500 U of abobotulinumtoxinA (Dysport®) with a duration of effect of only 1.5 months. The patient was considered a nonresponder, as the treatment effect was very weak and the sweating partially remained. The patient tested positive (++) for antibodies to botulinum toxin type A. | [[41.0, 'year']] | F | {'32095419': 1, '9294406': 1, '18546321': 1, '16714951': 1, '34515975': 1, '25559581': 1, '28388717': 1, '19278576': 1, '18180443': 1, '19352590': 1, '11385265': 1, '7675238': 1, '20370628': 1, '22162643': 1, '17278332': 1, '8196686': 1, '30013379': 1, '28388721': 1, '27119917': 1, '18452456': 1, '29089780': 1, '34566211': 1, '21134050': 1, '21209727': 1, '12682332': 1, '15027060': 1, '9854974': 1, '19620852': 1, '22123065': 1, '17617291': 1, '29344324': 1, '20737546': 1, '24379687': 2} | {'3872090-1': 2, '3872090-2': 2, '3872090-4': 2, '3872090-5': 2} |
164,861 | 3872090-4 | 24,379,687 | noncomm/PMC003xxxxxx/PMC3872090.xml | Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports | The patient in the fourth case study was a 43-year-old Caucasian woman who had received botulinum toxin type A for facial rejuvenation over a period of 8 years, starting in 2004. During this time she had received a total of 1,000 U of abobotulinumtoxinA (Dysport®) over eight injection sessions, with injection points in the frontalis, corrugator, procerus, orbicularis oculi, and platysmal bands (). For the first 3 years, the duration of effect lasted 6–8 months. However, after 2007, treatment effects could not be observed after 3 months. Results of antibody titers were high positive (++). | [[43.0, 'year']] | F | {'32095419': 1, '9294406': 1, '18546321': 1, '16714951': 1, '34515975': 1, '25559581': 1, '28388717': 1, '19278576': 1, '18180443': 1, '19352590': 1, '11385265': 1, '7675238': 1, '20370628': 1, '22162643': 1, '17278332': 1, '8196686': 1, '30013379': 1, '28388721': 1, '27119917': 1, '18452456': 1, '29089780': 1, '34566211': 1, '21134050': 1, '21209727': 1, '12682332': 1, '15027060': 1, '9854974': 1, '19620852': 1, '22123065': 1, '17617291': 1, '29344324': 1, '20737546': 1, '24379687': 2} | {'3872090-1': 2, '3872090-2': 2, '3872090-3': 2, '3872090-5': 2} |
164,862 | 3872090-5 | 24,379,687 | noncomm/PMC003xxxxxx/PMC3872090.xml | Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports | The final case study involved a 38-year-old European male. His treatment began in 2010 when he received 120 U of abobotulinumtoxinA (Dysport®) over three injection points each in the frontalis, corrugator, and procerus (). The initial duration of effect was 6 months. In 2011, he received 200 U in the same injection points with a duration of effect of only 2 months. His final treatment, in 2012, with 250 U of Dysport® produced no effect. Results of antibody titers were high positive (++). | [[38.0, 'year']] | M | {'32095419': 1, '9294406': 1, '18546321': 1, '16714951': 1, '34515975': 1, '25559581': 1, '28388717': 1, '19278576': 1, '18180443': 1, '19352590': 1, '11385265': 1, '7675238': 1, '20370628': 1, '22162643': 1, '17278332': 1, '8196686': 1, '30013379': 1, '28388721': 1, '27119917': 1, '18452456': 1, '29089780': 1, '34566211': 1, '21134050': 1, '21209727': 1, '12682332': 1, '15027060': 1, '9854974': 1, '19620852': 1, '22123065': 1, '17617291': 1, '29344324': 1, '20737546': 1, '24379687': 2} | {'3872090-1': 2, '3872090-2': 2, '3872090-3': 2, '3872090-4': 2} |
164,863 | 3872144-1 | 24,379,651 | noncomm/PMC003xxxxxx/PMC3872144.xml | Spontaneous resolution of foveal detachment in dome-shaped macula observed by spectral domain optical coherence tomography | A 28-year-old female Japanese patient with no previous history of ocular disease was referred to our hospital 14 days after complaining of blurred vision in both eyes. She reported that she had flu-like symptoms 7 days before the initial visit. Upon initial examination, her best corrected visual acuity (BCVA) was 1.2 with −8.0 sphere and 0.5 with −8.0 sphere in the right and left eyes, respectively. No significant findings were observed in the anterior segment or vitreous of either eye. Funduscopy showed a mild staphyloma with some pigmentary changes in the fovea in both eyes ( and ). Fluorescein angiography (HRA2; Heidelberg Engineering GmbH, Heidelberg, Germany) showed hyperfluorescence in the fovea in both eyes resulting from a retinal pigment epithelium defect, but there was no leakage point ( and ). Indocyanine green angiography (HRA2; Heidelberg Engineering) in both eyes revealed punctuate hyperfluorescence in the fovea with no vascular hyperpermeability ( and ). SD-OCT (CIRRUS HD-OCT; Carl Zeiss Meditec AG, Jena, Germany) in both eyes showed an anterior bulge of the macula with SFD in the horizontal scan ( and ). The diagnosis of DSM with SFD was made on the basis of characteristic findings from previous studies.– No treatment was initiated.\nThree months later, SFD seen at the initial visit disappeared on SD-OCT ( and ), and the patient’s BCVA was 1.2 and 1.0 in the right and left eyes, respectively. Her symptoms had also subjectively improved. One month later, there was an occurrence of SFD in the right eye ( and ), although subjective visual worsening was not reported. The left eye remained unaffected. One month later, the SFD had disappeared ( and ), and the patient’s BCVA was 0.9 in the right eye. | [[28.0, 'year']] | F | {'23972305': 1, '29572456': 1, '34084035': 2, '21616212': 1, '21129729': 1, '26265324': 1, '24899797': 2, '26942003': 1, '32448138': 1, '27994399': 2, '22087101': 1, '33909033': 1, '18342827': 1, '24379651': 2} | {'8095312-1': 1, '5141629-1': 1, '4038426-1': 1, '4038426-2': 1} |
164,864 | 3872574-1 | 24,379,559 | noncomm/PMC003xxxxxx/PMC3872574.xml | Successful outcome of adult-onset Coats’ disease following retinal laser photocoagulation | A 23-year-old male, with no previous medical history, presented to our eye clinic with increasing paracentral scotoma in the right eye of 2 months duration.\nOn examination, best corrected visual acuity (BCVA) was twenty out of twenty (20/20) in both eyes, with normal intraocular pressure. Fundal examination of the right eye showed extensive hard exudates in the superior retina extending close to the fovea []. No abnormalities were seen in the left eye. Fundal fluorescein angiogram (FFA) revealed early hyperfluorescence of telangiectatic, leaking vessels in the superior temporal and nasal regions and hypofluorescence consistent with the subretinal exudates in the right eye. Optical coherence tomography (OCT) showed increased macular thickness. A diagnosis of adult-onset Coats’ disease was considered.\nThe telangiectatic vessels in the superior temporal and nasal retina were treated with direct laser photocoagulation and scatter retinal photocoagulation was applied to the rest of the superior retina. Five months after presentation, the exudates had decreased and there was resolution of the angiomatous changes [Figure and ]. BCVA remained stable at 20/20. There was no recurrence of disease after 3 years of follow-up. | [[23.0, 'year']] | M | {'18784449': 2, '11336931': 1, '15590551': 1, '17020897': 1, '15882905': 1, '32443362': 2, '24379559': 2} | {'2629899-1': 1, '7254772-1': 1} |
164,865 | 3872575-1 | 24,379,560 | noncomm/PMC003xxxxxx/PMC3872575.xml | Spectral-domain optical coherence tomography findings in chronic solar retinopathy | A 66-year-old female was referred to our center with complaint of no improvement of visual acuity in the left-eye after cataract surgery, which was done 6 months back. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/40 in the left eye, respectively. The anterior segment examination was normal in both the eyes. Dilated fundus examination was performed, which showed dull foveal reflex with RPE changes in her left fovea. Fundus examination of the right eye was unremarkable. Fluorescein angiography showed a minimal leak at fovea during late phase in the left eye. SD-OCT scan of the left eye demonstrated central foveal thinning along with two hypo-reflective vertical band showing disruption in outer- and inner-segment junction along with photo receptor damage []. When SD-OCT was acquired in 3D mode and magnified for image analysis in detail, retinal pigment epithelium (RPE) disruption was seen at left vertical hypo-reflective band []. Vitreoretinal interface was found to be normal in both the eyes. After assessment of SD-OCT findings, patient revealed exposure to solar eclipse with naked eyes few years back. | [[66.0, 'year']] | F | {'6195575': 1, '15183809': 1, '30260904': 1, '8325420': 1, '16950247': 1, '3328915': 1, '24379560': 2} | {} |
164,866 | 3872593-1 | 24,381,627 | noncomm/PMC003xxxxxx/PMC3872593.xml | Prostate adenocarcinoma with negative immunohistochemical stain of prostate-specific antigen presenting with cervical mass: A case report | A 63-year-old male was referred to our hospital for a left supraclavicular mass. The patient complained of an asymptomatic swelling on the left side of his neck for approximately one month. He denied any other subjective complaints, including difficulty in swallowing or breathing. However, he had a family history of gastric cancer (two brothers died of gastric cancer). Physical examination of the patient's neck revealed a hard left-sided neck mass, approximately 4 cm in diameter. Subsequent computerized tomography (CT) scan of the head and neck showed a 5 cm, solid, left supraclavicular mass, with extension from the clavicles to the true vocal cords []. The abdominal CT scan showed multiple enlarged retroperitoneal lymph nodes []. Percutaneous fine needle aspiration (FNA) was performed and interpreted as poorly differentiated adenocarcinoma.\nLaryngoscopy, bronchoscopy, colonoscopy, and gastroscopy were performed on the patient, and no evidence of any tumor was found. Biopsy of the left supraclavicular mass showed metastatic adenocarcinoma and the immunohistochemistry tests showed up with a negative PSA stain [] and positive P504s stain []. A digital rectal examination revealed an enlarged prostate with an uneven surface. In the absence of other signs or symptoms, serum tumor markers were measured and the PSA level was found to be increased to 21.820 ng/mL. Although the PSA stain was negative, metastatic adenocarcinoma from the prostate was greatly suspected, considering the morphology, P504s stain, and PSA level. The patient underwent a transrectal ultrasound-guided biopsy and the histopathological diagnosis was poorly differentiated invasive acinar adenocarcinoma (Gleason score 8 = 4 + 4; cT2aNxM1) with a negative PSA stain [] and positive P504s stain []. Finally, a whole-body bone scan was performed with a normal result.\nThe patient started treatment for the neoplasm with an androgen blockade (oral flutamide and a GnRH agonist) in August 2011. Eight months later, the serum PSA level declined to 1.360 ng/ml and a cervical ultrasound examination showed a significant response in terms of the number and size of the nodal involvement. | [[63.0, 'year']] | M | {'15796261': 1, '4758761': 1, '14595895': 1, '34159017': 2, '11593193': 1, '2317763': 1, '15330799': 1, '17634715': 1, '15897914': 1, '28716144': 2, '2438955': 1, '27799225': 1, '15982318': 1, '22196474': 1, '1707989': 1, '6876294': 1, '16830117': 1, '11713729': 1, '19112959': 1, '1505932': 1, '12454820': 1, '24381627': 2} | {'8212848-1': 1, '5514504-1': 1} |
164,867 | 3872594-1 | 24,381,628 | noncomm/PMC003xxxxxx/PMC3872594.xml | Ulnar aplasia, dysplastic radius and preaxial oligodactyly: Rare longitudinal limb defect in a sporadic male child | The subject, a 12-year-old school-going boy, originates from a rural area of Southern Punjab, Pakistan. His parents were first cousins (inbreeding coefficient, F = 0.0625), and he had four normal siblings (3 brothers, 1 sister). The maternal and paternal ages were 28 and 33 years, respectively, at the time of his birth. The pregnancy had been uneventful and the birth was at home, in the presence of a traditional birth attendant. The study was approved by the institutional review committee and all the information was obtained according to the Helsinki II declaration. The initial ascertainment and detailed clinical examinations were carried out in several visits during 2009-2010.\nThe subject had normal developmental landmarks, dentition, and intelligence quotient (IQ). He was observed to have an isolated limb anomaly. Upon physical examination, he had a standing height of 146 cm, sitting height 71 cm, arm span 130 cm, head circumference 53 cm, neck circumference 29 cm, and chest 68 cm. There was no family history of any limb or other anomaly.\nClinical examination showed a short left arm []. The upper arm was thin and weak, and the middle and forearm were reduced in size. The elbow demonstrated limited flexion and extension [Figure ,]. The middle arm was flat and depicted restricted supination. The palm was narrow with a few flexion creases []. The ‘hand’ harbored only three functional fingers identified as third, fourth, and fifth, each comprising two flexion creases at the interphalangeal joints. The thumb and index finger were completely omitted. The posterior finger, that is, the fifth digit, was weak and showed volar inclination [Figure ,].\nIn the roentgenograms, the ulna was grossly degenerate and was only represented by a club-shaped decalcified bony island of ~2.5 cm at the distal zeugopod [Figure , ; ]. The radius appeared short, hypoplastic, and dysplastic. In the absence of the ulna, the radius demonstrated a compensatory curvature and maintained a varus concavity of ~20° []. Its proximal head was ill grown, misaligned, and posteriorly dislocated, and was losing its normal axis along the humeral trochanter. The distal head of the radius was broad, weak, and decalcified, depicting signs of immaturity, and was capped with dysplastic epiphysis []. In the upper arm, the humerus was short, thin, and decalcified [; ]. Its distal head was dysplastic with ill-developed epiphysis and hence, was unable to support the zeugopod.\nIn the autopod, four carpals were visible which were crowded and malformed []. Three metacarpals were present which though thin, maintained normal size []. At the anterior axis, the ‘third’ finger depicted volar inclination, whereas at the posterior axis, the ‘fifth’ digit showed clinodactyly []. There was minor cutaneous syndactyly between the fourth and fifth fingers which was not witnessed at the osseous level [] (see for detailed roentgenographic measurements).\nIn the right arm, roentgenograms were unremarkable except for crowding of the carpals. There was no involvement of any other organ system; there were no symptoms of oral, faciocranial, skeletal, or vital internal organs. His parents could not recall any drug exposure during the pregnancy. The subject has fully adapted this limb deficiency and can manage his daily life activities well. | [[12.0, 'year']] | M | {'9195458': 1, '3817811': 1, '5135223': 1, '20150392': 1, '4372353': 1, '24949004': 1, '12190225': 1, '22078357': 1, '29506338': 1, '3234954': 1, '818089': 1, '24381628': 2} | {} |
164,868 | 3872595-1 | 24,381,629 | noncomm/PMC003xxxxxx/PMC3872595.xml | Congenital chloride diarrhea misdiagnosed as pseudo-Bartter syndrome | A 15-month-old girl presented to our department (Al-zahra Hospital, Isfahan, Iran) for failure to thrive and poor feeding in 2011. She was born with polyhydramnios from healthy non-consanguineous parents at 32 weeks of gestation. She had a birth weight of 2050 g and body length of 42 cm, which were appropriate for her age. Following birth, she was admitted to the neonatal surgery department due to abdominal distention, lack of meconium and dilated bowel loops in abdominal X-rays and abdominal sonography (include figures), with suspection to intestinal obstruction and received conservative treatment. Hirschprung disease, hypertrophic stenosis of pylorus and intestinal obstructions were ruled out. She was discharged after 7 weeks with feeding tolerance and normal defecation. Serum levels of sodium (Na+), potassium (K+), blood urea nitrogen (BUN) and creatinine (Cr) at the time of discharge were 139 mEq/L (normal: 135-145), 3.7 mEq/L (normal: 3.5-5.5), 19 mg/dL (normal: 6-20) and 0.9 mg/dL (normal: 0.3-1.2), respectively. In the abdominal ultrasonography, both kidneys had normal parenchymal echotexture without any stone or hydronephrosis. Liver and spleen were normal in size and echotexture. Intestinal loops were dilated.\nAfter 2 months, she was admitted to a hospital because of moderate dehydration suspecting polyuria. Serum levels of Na+, K+, BUN and Cr were 110 mEq/L, 2.7 mEq/L, 40 mg/dL and 0.5 mg/dL, respectively. Urine analysis was normal with a pH of 6. After 5 days, she was discharged in a stable condition. However, she was presented to another hospital due to poor feeding and anuria after 10 days. Regarding her past medical history, she was referred again to our center for specific workup.\nAt the time of admission, physical examination showed severe dehydration, severe failure to thrive without organomegaly and low grade fever with mild diarrhea. Laboratory data revealed white blood cell count, hemoglobin, platelets, serum Na+, serum K+, BUN and Cr, 5800/mm3, 10.6 g/dL, 880 × 103/mm3, 133 mEq/L, 2.6 mEq/L, 130 mg/dL and 5.1 mg/dL, respectively. Blood gas analysis showed a normal anion gap acidosis with a pH of 6.9, carbon dioxide partial pressure (pCO2) of 10 mmHg and HCO3− of 4 mEq/L (normal: 22-26). The enzymes alanine aminotransferase and aspartate aminotransferase, as liver function indicators, were normal. Finally, she underwent peritoneal dialysis. After 4 days, Cr level decreased to 1.1. Shohl's solution (polycitra) was then prescribed for her. Distal renal tubular acidosis (type I) was considered as the main diagnosis and she was discharged home in a stable condition.\nWhile being treated with Shohl's solution, thiazide and zinc sulfate, the patient was followed-up for 6 months in the nephrology clinic. She did not gain weight within this period and returned with severe dehydration. She was resuscitated with 40 cc/kg normal saline. New laboratory findings showed a serum Na+ level of 134 mEq/L, K+ level of 2.1 mEq/L and chloride (Cl−) level of 82 mEq/L (normal: 98-108). Metabolic alkalosis (pH = 7.57, pCO2 = 32 mmHg and HCO3- = 34 mEq/L) and hyperreninemia (129 μIU/ml) and hyperaldosteronemia (317 pg/ml) was also observed. At this point, pseudo-Bartter syndrome was suspected and the treatment began promptly. She had a dramatic response to intravenous (IV) therapy and hypokalemia resolved quickly (despite what is normally seen in pseudo-Bartter syndrome), urine electrolytes on admission were: Na+ 67 mEq/L, K+ 28.3 mEq/L and Cl− 2 mEq/L. Consequently, all treatments were halted and a new diagnostic workup was planned to reach the definite diagnosis. A new history from the mother revealed that the patient has had loose defecation during the past months which has been considered as normal by the mother and she had never passed normal stools; watery content of diarrhea since infancy had been confused with that of urine.\nFollowing consultation with our gastroenterologist, measuring stool electrolytes showed Na+ of 64 mEq/L (normal: 20-30 mEq/L), K+ of 50 mEq/L (normal: 55-65 mEq/L) and Cl− of 120 mEq/L (normal: 5-20 mEq/L) were confirmed with repeated analyses. Stool pH was 5. Upper gastrointestinal endoscop, rectosigmoidoscopy, histopathology of duodenoum and rectosigmoid were normal. Stool microscopy and cultures were normal. Stool reductant material and fat were negative. Celiac serologic tests were negative. Cystic fibrosis was ruled out by normal sweat test. With these findings, CCD was established for her and treatment began by IV fluid replacement and total parentral nutrition, which resulted in a 1-kg weight gain after 1 month. Fortunately, the patient was discharged after 1 month with oral omeprazole, 3 mg/kg/day, potassium chloride (KCl 2 mEq/kg/day), sodium chloride (NaCl 3 mEq/kg/day), cholestyramine (150 mg/kg/day), multivitamin (as recommended daily allowance [RDA]) and mineral pills (as RDA). She was followed with gastroenterological, nutritional and nephrological services for 1 year. Her condition gradually improved and she does not have a major problem except mild to moderate delayed growth and development at the present time. Her food tolerance is also acceptable. | [[15.0, 'month']] | F | {'31976143': 1, '33173177': 1, '18852645': 1, '9886972': 1, '21805424': 1, '2651131': 1, '21127979': 1, '30760291': 1, '22362191': 1, '643381': 1, '30635044': 1, '11524734': 1, '25568271': 1, '7211368': 1, '29849040': 1, '34414498': 1, '16641574': 1, '24381629': 2} | {} |
164,869 | 3872615-1 | 24,379,852 | noncomm/PMC003xxxxxx/PMC3872615.xml | Indefinite antiviral therapy may be required after surgical resection for hepatocellular carcinoma complicating chronic hepatitis B | A 66-year-old male patient was admitted to First Affiliated Hospital, Zhejiang University School of Medicine, China in January 2006. The patient who had a 15-year history of HBV infection and treated with lamivudine (LAM) (100 mg once daily, take orally, GlaxoSmithKline, UK), was found LAM-resistant mutation in the YMDD motif of the polymerase gene (rtM204I) in 2006; thus an additional adefovir (ADV) (10 mg once daily, take orally, GlaxoSmithKline, UK) was given. Five months later, the patient was admitted to our hospital for a high alpha-fetoprotein (AFP) level (642.2 ng/ml). HCC was highly suspected by the computed tomography (CT) []. Therefore, a local tumor resection was performed and the pathology confirmed the mass nature of HCC with high-moderate differentiation []. Serum AFP level decreased sharply after the operation and viral load was stable with persistent undetectable HBV DNA. During the following long-term follow-up, the patient was in a satisfactory status [].\nIn March 2009, the patient was found hepatitis B envelope antigen (HBeAg) seroconversion. He discontinued antiviral treatment after a 13-month consolidation therapy. One month later, the patient suffered fatigue, nausea, jaundice, abdominal distension and then hepatic encephalopathy. The initial serology showed high serum levels of total bilirubin (TB) (203 umol/L) (normal range: 3.4-17.1 umol/L), aminoleucine transferase (ALT) (808 IU/L) (normal range: 0-40 U/L), aspartate aminotransferase (AST) (1020 U/L) (normal range: 4-40 U/L) and international normalized ratio (INR) (2.2) (normal range: 2.0-2.5). Viral markers showed HBV reactivation (HBsAg 421.91 ng/ml (normal range: 0-0.18 ng/ml), HBeAg 11.7 ng/ml, antibody to hepatitis B core antigen 120.63 ng/ml and HBV DNA 4.68 × 107 copies/ml (normal range: <103 copies/ml). Both the AFP level and radiological assessment of liver were negative for HCC recurrence. The patient was diagnosed as HBV-related acute-on-chronic liver failure (ACLF) and treated with combined nucleoside analogs (LAM [100 mg once daily, take orally, GlaxoSmithKline, UK] and ADV [10 mg once daily, take orally, GlaxoSmithKline, UK]) and foscarnet sodium injection (3 g once daily, Chia-tai Tianqing Pharmaceutical Co., Ltd., China) besides other conservative therapies. Two weeks later, the patient was noted an obviously improved liver function (ALT/AST 68/81 IU/L, TB 71 umol/L, INR 1.3) and a decreased viral load (HBV DNA 6.31 × 104 copies/ml). A gradually resolution of hepatic encephalopathy and ascites was also achieved. After a 2-month conservative treatment, the patient gained a sustained clinical remission of ACLF with normal liver function and undetectable HBV DNA.\nIn September 2010, the patient was found two occupancies located in the right lobe of cirrhotic liver [] with normal serum AFP level. HCC recurrence was highly suspected and curative hepatic segmentectomy was performed. Both tumors were confirmed by pathology as poorly differentiated HCC and the immunohistochemistry showed different results from the initial one's []. In addition, real-time polymerase chain reaction revealed positive results of covalently closed circular DNA (cccDNA) and HBV-x gene levels in the recurrent HCC and primary one, although serum HBV DNA levels were undetectable []. The patient was subsequently discharged after 2 weeks of operation. CT scan performed post-operatively showed no evidence of disease recurrence up to now. | [[66.0, 'year']] | M | {'17468919': 1, '21488914': 1, '20413301': 1, '20572309': 1, '20492323': 1, '27877054': 1, '26563120': 1, '25431264': 1, '19554391': 1, '20422305': 1, '16280177': 1, '30140982': 1, '17499584': 1, '17914972': 1, '25276281': 1, '19669255': 1, '30823932': 1, '19712848': 1, '16391218': 1, '19747749': 1, '19122351': 1, '27495026': 1, '24379852': 2} | {} |
164,870 | 3872620-1 | 24,379,857 | noncomm/PMC003xxxxxx/PMC3872620.xml | Genetic alterations in syndromes with oral manifestations | A male patient aged 10 years with mental retardation reported to our out-patient department with the chief complaint of decayed tooth. Extraoral examination revealed brachycephaly, oblique palpebral fissure, depressed nasal bridge, short neck, and gap between toes, short broad hands with simian crease and lip incompetence [Figure –].\nIntraoral examination revealed a high arched palate with crowding of teeth [], and macroglossia. These phenotypical features were analyzed and were found to have complete manifestations of Down's syndrome such as abnormal facial and skeletal features[] and mental retardation.[] | [[10.0, 'year']] | M | {'11175294': 1, '9341860': 1, '2180284': 1, '11404025': 1, '1542340': 1, '7773282': 1, '10640719': 1, '7493034': 1, '10100050': 1, '10678659': 1, '1613769': 1, '7874170': 1, '7352442': 1, '10233224': 1, '9192803': 1, '10835635': 1, '7920632': 1, '5279523': 1, '7589793': 1, '12952869': 1, '1856834': 1, '15517394': 1, '16620627': 1, '370588': 1, '2521249': 1, '11523056': 1, '12407090': 1, '9095215': 1, '9784380': 1, '1852208': 1, '7987400': 1, '8595418': 1, '15926293': 1, '7611299': 1, '10756346': 1, '10890722': 1, '15861007': 1, '8782809': 1, '8681379': 1, '7966195': 1, '3856492': 1, '8528259': 1, '10319867': 1, '8055322': 1, '8906787': 1, '12402346': 1, '3480489': 1, '8152817': 1, '10861295': 1, '9192811': 1, '14596856': 1, '15308259': 1, '9843040': 1, '8762878': 1, '10067756': 1, '11471165': 1, '15716609': 1, '24379857': 2} | {'3872620-2': 2, '3872620-3': 2, '3872620-4': 2, '3872620-5': 2} |
164,871 | 3872620-2 | 24,379,857 | noncomm/PMC003xxxxxx/PMC3872620.xml | Genetic alterations in syndromes with oral manifestations | A female patient aged 14 reported to our out-patient department for painful teeth. On extraoral examination, her physique was abnormal with tall stature [], dolichostenomelia (positive wrist sign) and dolichocephalic face [], arachnodactyly (spidery finger and long digits) [Figure and ]. Intraorally, high arched palate along with decayed tooth was identified.\nCardiac evaluation revealed aortic dilatation. These phenotypical features had partial manifestations of Marfan's syndrome (MFS). Appropriate genes were mapped by reviewing the literature. | [[14.0, 'year']] | F | {'11175294': 1, '9341860': 1, '2180284': 1, '11404025': 1, '1542340': 1, '7773282': 1, '10640719': 1, '7493034': 1, '10100050': 1, '10678659': 1, '1613769': 1, '7874170': 1, '7352442': 1, '10233224': 1, '9192803': 1, '10835635': 1, '7920632': 1, '5279523': 1, '7589793': 1, '12952869': 1, '1856834': 1, '15517394': 1, '16620627': 1, '370588': 1, '2521249': 1, '11523056': 1, '12407090': 1, '9095215': 1, '9784380': 1, '1852208': 1, '7987400': 1, '8595418': 1, '15926293': 1, '7611299': 1, '10756346': 1, '10890722': 1, '15861007': 1, '8782809': 1, '8681379': 1, '7966195': 1, '3856492': 1, '8528259': 1, '10319867': 1, '8055322': 1, '8906787': 1, '12402346': 1, '3480489': 1, '8152817': 1, '10861295': 1, '9192811': 1, '14596856': 1, '15308259': 1, '9843040': 1, '8762878': 1, '10067756': 1, '11471165': 1, '15716609': 1, '24379857': 2} | {'3872620-1': 2, '3872620-3': 2, '3872620-4': 2, '3872620-5': 2} |
164,872 | 3872620-3 | 24,379,857 | noncomm/PMC003xxxxxx/PMC3872620.xml | Genetic alterations in syndromes with oral manifestations | A male patient aged 23 years, reported to our college with the chief complaint of halitosis. On examination, he had striking clinical features such as exophthalmos, hypertelorism, strabismus [], depressed nasal bridge, hypoplastic maxilla, relative mandibular prognathism, short upper lip []. Intraorally, high arched palate was present []. These features showed complete manifestations of Crouzon syndrome. The phenotypic manifestation was correlated with the genotypes collected from the literature. The candidate gene mutation was fibroblast growth factor receptor 2 (FGFR2) with the loci of 10q26. | [[23.0, 'year']] | M | {'11175294': 1, '9341860': 1, '2180284': 1, '11404025': 1, '1542340': 1, '7773282': 1, '10640719': 1, '7493034': 1, '10100050': 1, '10678659': 1, '1613769': 1, '7874170': 1, '7352442': 1, '10233224': 1, '9192803': 1, '10835635': 1, '7920632': 1, '5279523': 1, '7589793': 1, '12952869': 1, '1856834': 1, '15517394': 1, '16620627': 1, '370588': 1, '2521249': 1, '11523056': 1, '12407090': 1, '9095215': 1, '9784380': 1, '1852208': 1, '7987400': 1, '8595418': 1, '15926293': 1, '7611299': 1, '10756346': 1, '10890722': 1, '15861007': 1, '8782809': 1, '8681379': 1, '7966195': 1, '3856492': 1, '8528259': 1, '10319867': 1, '8055322': 1, '8906787': 1, '12402346': 1, '3480489': 1, '8152817': 1, '10861295': 1, '9192811': 1, '14596856': 1, '15308259': 1, '9843040': 1, '8762878': 1, '10067756': 1, '11471165': 1, '15716609': 1, '24379857': 2} | {'3872620-1': 2, '3872620-2': 2, '3872620-4': 2, '3872620-5': 2} |
164,873 | 3872620-4 | 24,379,857 | noncomm/PMC003xxxxxx/PMC3872620.xml | Genetic alterations in syndromes with oral manifestations | A female patient aged 10 years, reported to our college with the complaint of halitosis and decayed tooth. Clinical examination revealed no obvious changes []. An orthopantomograph revealed unilocular radiolucencies with scalloped margins in all the four quadrants of maxilla and mandible []. Biopsy was carried out and histopathology showed a cystic lining comprised of parakeratinized epithelium with palisading basal layer along with connective tissue wall [], suggestive of odontogenic keratocyst (OKC).\nA diagnosis of multiple OKC was arrived at, based on these findings. However, she did not have any other manifestations relating to a Nevoid Basal cell Carcinoma Syndrome (NBCCS). Chest radiograph did not show any relevant features []. Gene mutation leading to sporadic OKC was mapped to the Patched (PTCH) gene, a tumor suppressor gene at 9q22.3. | [[10.0, 'year']] | F | {'11175294': 1, '9341860': 1, '2180284': 1, '11404025': 1, '1542340': 1, '7773282': 1, '10640719': 1, '7493034': 1, '10100050': 1, '10678659': 1, '1613769': 1, '7874170': 1, '7352442': 1, '10233224': 1, '9192803': 1, '10835635': 1, '7920632': 1, '5279523': 1, '7589793': 1, '12952869': 1, '1856834': 1, '15517394': 1, '16620627': 1, '370588': 1, '2521249': 1, '11523056': 1, '12407090': 1, '9095215': 1, '9784380': 1, '1852208': 1, '7987400': 1, '8595418': 1, '15926293': 1, '7611299': 1, '10756346': 1, '10890722': 1, '15861007': 1, '8782809': 1, '8681379': 1, '7966195': 1, '3856492': 1, '8528259': 1, '10319867': 1, '8055322': 1, '8906787': 1, '12402346': 1, '3480489': 1, '8152817': 1, '10861295': 1, '9192811': 1, '14596856': 1, '15308259': 1, '9843040': 1, '8762878': 1, '10067756': 1, '11471165': 1, '15716609': 1, '24379857': 2} | {'3872620-1': 2, '3872620-2': 2, '3872620-3': 2, '3872620-5': 2} |
164,874 | 3872620-5 | 24,379,857 | noncomm/PMC003xxxxxx/PMC3872620.xml | Genetic alterations in syndromes with oral manifestations | A male patient aged 21 years reported to our institute with the chief complaint of loss of many teeth. Clinical examination revealed features such as brachycephaly [], cataract, skeletal abnormality of the fingers and dermatosis []. Premature exfoliation of teeth and partial anodontia was present. Radiographs revealed taurodontism []. An analysis of this array of phenotypic features revealed that the patient had only partial manifestations not fitting into any particular syndrome. The phenotype was correlated with genotype from the literature and the possible mapping was arrived as the RecQ like-protein 4 (RECQL4) gene at 8q24.3. | [[21.0, 'year']] | M | {'11175294': 1, '9341860': 1, '2180284': 1, '11404025': 1, '1542340': 1, '7773282': 1, '10640719': 1, '7493034': 1, '10100050': 1, '10678659': 1, '1613769': 1, '7874170': 1, '7352442': 1, '10233224': 1, '9192803': 1, '10835635': 1, '7920632': 1, '5279523': 1, '7589793': 1, '12952869': 1, '1856834': 1, '15517394': 1, '16620627': 1, '370588': 1, '2521249': 1, '11523056': 1, '12407090': 1, '9095215': 1, '9784380': 1, '1852208': 1, '7987400': 1, '8595418': 1, '15926293': 1, '7611299': 1, '10756346': 1, '10890722': 1, '15861007': 1, '8782809': 1, '8681379': 1, '7966195': 1, '3856492': 1, '8528259': 1, '10319867': 1, '8055322': 1, '8906787': 1, '12402346': 1, '3480489': 1, '8152817': 1, '10861295': 1, '9192811': 1, '14596856': 1, '15308259': 1, '9843040': 1, '8762878': 1, '10067756': 1, '11471165': 1, '15716609': 1, '24379857': 2} | {'3872620-1': 2, '3872620-2': 2, '3872620-3': 2, '3872620-4': 2} |
164,875 | 3872635-1 | 24,379,872 | noncomm/PMC003xxxxxx/PMC3872635.xml | Large ameloblastic carcinoma: A rare case with management | A 44-year-old female patient presented to the Outpatient department with a chief complaint of swelling in the lower jaw since 6 months. There was difficulty in speech, mastication, and deglutition. There was no associated pain. She had no contributing medical history.\nOn extra oral examination a large well-defined swelling was noticed in the mandibular anterior region crossing the midline causing facial asymmetry [].\nThe swelling extended below the inferior border of the mandible and the skin over the swelling was stretched and smooth. She had difficulty in opening the mouth. No lymph nodes were palpable.\nIntraoral examination showed a large swelling, which extended completely into the floor of the mouth and completely obliterating the lingual and buccal vestibules mediolaterally [].\nThe lingual frenum was pushed back. Anteriorly, it extended from the labial sulcus to the ramus posteriorly. There was no surface discharge present, the mucosa over the swelling was normal and its color was same as that of the normal tissue. All the mandibular incisors were missing. Generalized extrinsic stains were present.\nOn palpation the inspectory findings were confirmed. The swelling was bony hard, non-tender, and immobile. None of the teeth present showed mobility.\nRoutine blood and urine examination was normal. Fasting and post-prandial sugar levels were also normal.\nComputed tomography showed a large multilocular osteolytic lesion extending from 37 to 47 region crossing the midline, destruction of both cortices and pathologic fracture was seen []. Soap bubble and honeycomb patterns were appreciable. A multi-centric growth pattern was seen showing a permeative type of destruction [].\nA chest radiograph was taken to rule out any primaries in the lung.\nA provisional diagnosis of ameloblastoma was established. A differential diagnosis of odontogenic keratocyst was made.\nAn incisional biopsy was performed under local anesthesia and microscopic examination revealed odontogenic islands infiltrating the connective tissue, the peripheral tall columnar cells showed proliferation and peripheral palisading of basal cells with reverse polarity of the nucleus. Stellate reticulum was scanty [].\nHigh power view showed cells with atypical features of pleomorphism, hyperchromatism, altered nuclear-cytoplasmic ratio, and mitotic figures [].\nA final diagnosis of ameloblastic carcinoma was established.\nA total mandibulectomy was carried out under general anesthesia []. An immediate reconstruction was done []. | [[44.0, 'year']] | F | {'280645': 1, '6957827': 1, '29937652': 1, '5354042': 1, '6928185': 1, '28469829': 2, '3313152': 1, '6366686': 1, '9702634': 1, '1527663': 1, '24379872': 2} | {'5410684-1': 1} |
164,876 | 3872636-1 | 24,379,873 | noncomm/PMC003xxxxxx/PMC3872636.xml | Occurrence of epidermolysis bullosa along with Amelogenesis imperfecta in female patient of India | An 18-year-old female patient reported to department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore with a complaint of discolored teeth since childhood. Her past dental history revealed similar type with early loss of tooth structure in deciduous dentition. Her medical history revealed presence of multiple dermal lesions, which started appearing immediately after birth, which was later diagnosed as EB. She is second child from a consangious marriage and her sister is also affected with similar dermal lesions since childhood. Her gait was abnormal owing to non-healing ulcer in feet. Blisters were seen on the lower part of feet with irregular borders and yellowish slough present at the base of the lesions []. Scarring of healed lesions on knee was also noticed [].\nOn examination, diffuse reddish pseudo membranous area is seen extending from external occipital protuberance and spreading bilaterally until ear and extends until scapula. Loss of hair is seen with respect to that area. There was presence of itching and burning sensation in the affected area. Surface was erythematous with yellowish slough []. On intra oral soft tissue examination, a vesicle was seen on the right rugae area on the hard palate []. However, there was no abnormal eruption pattern noticed. From a functional point of view, she had been avoiding hard food substances and carious lesion was noticed affecting enamel and dentin of teeth.\nOn detailed hard tissue examination, it was found that she had a normal complement of teeth. Height of teeth was reduced because of complete chipping of enamel and exposing dentin. Underlying dentin appears to be normal. The surfaces of the teeth were rough. The teeth, in general, exhibited a yellowish brown discoloration, with diffuse pitting present on the exposed tooth surfaces, more prominent on the labial and buccal aspects. The emergence pattern and timing of teeth seemed to be within the normal range. No occlusal disharmony is present [].\nPanoramic radiograph revealed a normal pulp chamber and root canal spaces. The enamel was completely lost, radiopaque dentin is clearly appreciated []. Based on history, clinical and radiographic features we arrived at diagnosis of hypoplastic, rough, autosomal recessive AI. Patient was advised to undergo biopsy and immunoflourense test, but owing to unwillingness of patient's parents regarding non-healing of wound, tests could not be carried out. Aesthetic restoration was carried out with the composite veneering in relation to maxillary central incisors and left lateral incisor and patient is undergoing restoration of other teeth []. The patient was also referred for dermatological treatment. | [[18.0, 'year']] | F | {'17098678': 1, '19036806': 1, '19089295': 2, '20878018': 1, '24379873': 2} | {'4327286-1': 1} |
164,877 | 3872637-1 | 24,379,874 | noncomm/PMC003xxxxxx/PMC3872637.xml | Metastatic follicular carcinoma of thyroid in maxilla | A 31-year-old female reported with swelling and mobile teeth in right upper posterior region of maxilla and she had noticed the swelling and mobile teeth 2 months back. The condition gradually increased in severity. After 1 month, she developed a dull pain in 16, radiating to tempero-mandibular joint, and back of head and neck region.\nExamination revealed a firm to bony hard swelling of 2 cm2 × 1 cm2 extending from 13 to 17 regions, bi-cortical expansion with more expansion of buccal aspect and mild tenderness on palpation. Teeth associated were mobile with grade-I mobility in 13, 17 and grade-II mobility in 14, 15 and grade-III mobility in 16 [].\nRadigraphic examination revealed a well-defined multilocular radiolucency with irregular borders extending from 13 to 17 with root resorption in 16 and root displacement in 15, 17 []. Computed tomography (CT) scan images revealed an expansile mass in the right maxilla causing enlargement and destruction of buccal, palatal cortices and floor of maxillary sinus [].\nClinical diagnosis of odontogenic tumor was made. Biopsy was taken and 16 was extracted.\nThe histopathologic examination revealed well-developed thyroid follicles with abundant periodic acid Schiff (PAS) positive staining colloid material resembling thyroid tissue [Figures and ]. A diagnosis of metastsatic follicular carcinoma of the thyroid was given.\nThe case was reviewed by the head and neck tumor board. A metastatic work-up was carried out. Ultrasonography of neck showed degeneration of the left lobe of thyroid gland, and neck examination revealed a multinodular goiter. Fine Needle Aspiration Cytology (FNAC) found to be follicular neoplasm of thyroid and was treated by total thyroidectomy. Excised tissue specimen was histopathologically confirmed as follicular carcinoma of the thyroid.\nI-131 whole body scan was done to assess metastatic lesions. Metastatic lesions were found in the right maxilla and the right leg and were treated by Iodine radioactive ablation. Patient with follow-up period of 7 years is healthy without any recurrence. | [[31.0, 'year']] | F | {'9617933': 1, '8746264': 1, '28351395': 2, '29682275': 1, '30967736': 2, '7815371': 1, '9028369': 1, '12730658': 1, '2312106': 1, '12576032': 1, '10217022': 1, '17138711': 1, '24379874': 2} | {'6421918-1': 1, '5370488-1': 1} |
164,878 | 3872644-1 | 24,381,801 | noncomm/PMC003xxxxxx/PMC3872644.xml | Cavernous sinus tuberculoma mimicking a neoplasm: Case report, literature review, and diagnostic and treatment suggestions for tuberculomas in rare locations | A 42-year-old immunocompetent female patient presented with a 6-month history of severe intermittent right hemicraneal headaches. Four months later she developed a right eye ptosis and ophtalmoplegy. She had benign medical and epidemiologic histories. A neurologic examination revealed gaze limitations in all directions, ptosis of the right eye and right hemifacial hypoesthesia, with no signs of meningeal irritation. The general examination, routine hematologic examination, and chest radiography were normal with no history of fever or respiratory tract infections. Orbital computed tomographic scans and magnetic resonance imaging (MRI) were normal. Brain MRI revealed a right CS tumor []. Erythrosedimentation, HIV serology, VDRL, C3, C4, ANA, ANCA, thyroid profile, and PCR for Epstein–Barr virus and TB all yielded negative results. Cerebrospinal fluid (CSF) testing was normal.\nThe patient was empirically treated with steroids suspecting a granulomatous disease with partial clinical improvement; however, she did not take the medications regularly and missed physician follow-up evaluations. Five months later she was readmitted with a clinical relapse and a new cerebral MRI revealed marked tumoral progression with adjacent right mesial temporal involvement [Figure –].\nWith no definitive diagnosis and tumoral progression, the patient was referred to our Neurosurgery Department and a surgical excisional procedure was recommended.\nWe considered it an inconclusive case and with the suspicion of a brain neoplasm, under general anesthesia, a right craneo-orbito-zygomatic with extended middle fossa approach was performed. The extradural anterior clinoidectomy and the CS and middle fossa peeling, allowed to identify both dural layers (dura propia and dura periostica). The inner layer of the lateral wall of the CS was not infiltrated by the tumor. The basal temporal and CS dura propia with an infiltrative tumoral mass, invading the mesial temporal lobe, was resected. The tumor had a firm, white appearance []. Subtotal tumor resection was achieved as the intraoperative pathologic impression was of an inflammatory disease. The CS was not opened. Dural closure was achieved with fascia lata.\nMicroscopy revealed a caseous necrotic centre surrounded by a granulomatous reaction that included Langhans giant cells, epithelioid cells, and lymphocytes. In addition, there was abundant fibrosis [Figure and ]. Immunological test were performed and definitive pathologic findings consisted of a tuberculoma, although Ziehl Neelsen and PAS stains did not demonstrate acid-fast bacilli and bacteriologic cultures were negative.\nAntituberculous treatment was immediately begun with a four drug (rifampin, isoniazid, ethambutol, and pyrazinamide) 2-month regimen followed by a two drug (rifampin and isoniazid) regimen for 10 months, and dexamethasone for the first 8 weeks.\nThe postoperative course was uneventful with no surgical morbidity and clinical improvement in the weeks thereafter. The 1-year postoperative follow-up MRI showed complete regression of the lesion [Figure and ] and complete resolution of the symptoms. | [[42.0, 'year']] | F | {'19643501': 1, '1617066': 1, '8465937': 1, '25410584': 1, '26839786': 1, '8307908': 1, '10817892': 1, '7632368': 1, '9442521': 1, '10514587': 1, '19126443': 1, '7888539': 1, '29386735': 1, '16190918': 1, '11760175': 1, '8553259': 1, '7610243': 1, '8362890': 1, '14735380': 1, '25977906': 2, '16308650': 1, '30460000': 1, '27000208': 1, '11483200': 1, '34108784': 1, '9304538': 1, '8516044': 1, '14519219': 1, '24381801': 2} | {'4426276-1': 1} |
164,879 | 3872646-1 | 24,381,796 | noncomm/PMC003xxxxxx/PMC3872646.xml | Dolichoectasia of the vertebral basilar and internal carotid arteries: A case report and literature review | A 67-year-old male with a known dolichoectasia of his vertebrobasilar artery, presented with a history of increasing falls over the past 3 months. A computed tomography (CT) scan of the head [] and magnetic resonance imaging (MRI) of the brain [] demonstrated a VBD with formation of a focal fusiform aneurysm in the proximal basilar artery. This caused mass effect on the left anterior aspect of the adjacent pons.\nA magnetic resonance (MR) angiogram [] revealed fusiform dilatation of the intradural distal right vertebral artery giving rise to the dysplastic dilated basilar artery, which had increased in size. The lumen was within a larger partially thrombosed vessel. This gave rise to a short segment of normal caliber basilar artery, which then again dilated just proximal to the basilar tip. There was also a new fusiform dilatation of the posterior cavernous left internal carotid artery consistent with a fusiform aneurysm. There was presence of ventriculomegaly of the lateral and 3rd ventricle, with the 4th ventricle being collapsed.\nHis past medical history included: Hypertension, dyslipidemia, long time smoker, chronic obstructive pulmonary disease, previous transient ischemic attack, depression, and prostate cancer treated with radiotherapy and NSTEMI treated with PCI (two bare metal stents).\nThe presence of new ventriculomegaly on imaging raised the possibility of symptomatic hydrocephalus. A radionuclide cerebrospinal fluid (CSF) flow study was undertaken. It revealed normal migration of the radio tracer from the subarachnoid lumbar space to the basal cisterns and sylvian fissures, with no activity within the lateral ventricles in the 24 and 48 hour images. However, the patient also underwent a trial of lumbar drainage, during which his gait was assessed by the medical allied health team documenting an objective improvement in his gait. Consequently, the patient had a ventriculoperitoneal (VP) shunt inserted with no complications. | [[67.0, 'year']] | M | {'16775273': 1, '4035557': 1, '13197110': 1, '21716844': 2, '21311374': 1, '10504850': 1, '14707300': 1, '20146694': 1, '12736544': 1, '7062068': 1, '19570679': 1, '31338131': 1, '30728879': 1, '9633713': 1, '15976311': 1, '14683536': 1, '2234385': 1, '29184707': 2, '8592220': 1, '1294002': 1, '15739178': 1, '21221115': 1, '29545249': 1, '7484654': 1, '24778908': 1, '11126452': 1, '3082145': 1, '15596743': 1, '4856351': 1, '1355889': 1, '5807284': 1, '9282873': 1, '1775825': 1, '15987592': 1, '34434302': 2, '3055165': 1, '18344271': 1, '7753308': 1, '18641883': 1, '8377917': 1, '1506885': 1, '13835959': 1, '14476671': 1, '15799799': 1, '6738853': 1, '9482190': 1, '12760391': 1, '15658099': 1, '9506608': 1, '14694039': 1, '20424441': 1, '1708460': 1, '15255255': 1, '15968519': 1, '16427428': 1, '9384409': 1, '471228': 1, '24381796': 2} | {'3123011-1': 1, '8383699-1': 1, '5680668-1': 1} |
164,880 | 3872647-1 | 24,381,794 | noncomm/PMC003xxxxxx/PMC3872647.xml | Analysis of a synchronous gliosarcoma and meningioma with long survival: A case report and review of the literature | A previously healthy 51-year-old woman, with no family history of cancer, was admitted in another institution in October 2003 with a history of dysarthria and left hemibody paresthesias followed by generalized tonic-clonic seizure. On physical examination the patient was full awake with mild dysarthria and a grade 4 left hemiparesis with brachiofacial predominance. She had no signs of intracranial hypertension. The Karnofsky performance status (KPS) was 70. A computed tomography (CT) scan was performed showing a right frontal cortico-subcortical hypodense area resembling a secondary lesion in nature. Primary neoplasm investigation was negative and the patient was referred to our institution (Hospital S. João, Porto; Portugal). A magnetic resonance imaging (MRI) was done and revealed a right frontal parasagittal and well-demarcated hyperintense lesion with homogeneous contrast-enhancement and a second lesion in the posterior right frontal lobe with poorly demarcated borders and heterogeneous contrast-enhancement. The patient underwent a right frontal craniotomy with gross total removal of the two lesions in December 2003. There was no complication and the patient was discharged with a grade 4 hemiparesis and a complete recovery of the dysarthria. The KPS at discharge was 80. The pathological examination revealed two distinct lesions being the anterior a meningioma and the posterior a gliosarcoma []. The patient received postoperative radiotherapy with a total dose of 60 Gy given in 30 fractions with margin of 1 cm in the area of the gliosarcoma. The patient remained asymptomatic until September 2005 when she developed dysarthria and worsening of the hemiparesis. The MRI showed a regrowth of the initial gliosarcoma and the patient was re-operated with macroscopically complete removal of the recurrent gliosarcoma []. The patient recovered again from the neurological deficits and started temozolomide treatment with 150 mg/m2 followed by 200 mg/m2. In November 2005, the patient showed progressive neurological deterioration with headaches, disorientation episodes, and paresis worsening with left arm plegia. The MRI showed an early new regrowth with no indication for surgical removal and the patient underwent palliation with dexamethasone. In June 2006 a new MRI showed a growth of the right frontal lesion with involvement of the basal ganglia and corpus callosum, crossing the midline and development of hydrocephalus. The patient died in October 2006 after a progressive neurological deterioration. The overall survival was 36 months. No postmortem examination was performed.\nHistological examination of the initial anterior lobular frontal and posterior lobular frontal lesions revealed two clear distinct tumors: A meningioma (M) depicting positivity for epithelial membrane antigen (EMA) staining and a gliosarcoma (GS) exhibiting typical features of intermingled GFAP and reticuline neoplastic regions. The analysis of recurrent lesion showed the presence of a gliosarcoma (GS-R) with a more prominent glial component.\nIn order, to determine the presence of mutations in the TP53 (exons 5-8) and BRAF (exon 11 and 15) genes, DNA was isolated from the formalin-fixed and paraffin-embedded tissues of all three lesions. The screening of mutations was carried out by polymerase chain reaction (PCR)-single-strand conformational polymorphism (PCR-SSCP), followed by direct DNA sequencing, as previously described.[] None of lesions showed TP53 or BRAF mutations [].\nWe further investigated for the presence of MGMT protein expression by immunohistochemistry, using the mouse anti-MGMT monoclonal antibody (dilution 1:400; clone MT3.1, Chemicon International) and correlated with MGMT gene promoter hypermethylation, assessed by methylation-specific PCR (MSP) as previously described.[] As illustrated in , MGMT methylation was found in both primary and recurrent gliosarcoma. The meningioma lesion was negative for MGMT methylation [ and ]. In concordance with methylation status, MGMT expression was only present in the meningioma and absent in both primary and recurrent gliosarcoma [ and ]. Next, we analyzed the presence of EGFR alterations at both gene and protein levels by CISH (EGFR spot-Light amplification probes from Zymed® Laboratories Inc., South San Francisco, CA, USA) and immunohistochemistry (anti-EGFR polyclonal antibody, dilution 1:100, clone 31G7, Zymed® Laboratories Inc., San Francisco, CA, USA), respectively.[] The meningioma and primary gliosarcoma were negative for EGFR protein expression [ and ]. EGFR immunohistochemistry showed a focal region with strong immunoreactivity in the recurrent gliosarcoma. In both meningioma and primary gliosarcoma, it was observed the presence of 2 signals per neoplastic cell, representing absence of EGFR gene copy number alterations [ and ]. EGFR gene amplification, represented by clusters of more than 5 signals per neoplastic cell, was observed only in the recurrent gliosarcoma, in the same region with strong focal positivity for EGFR protein [ and ].\nFinally, we studied the expression of COX-2 by immunohistochemistry, using the anti-COX-2 monoclonal antibody (dilution 1:50, clone SP21, Neomarkers, Fremont, CA, USA).[] We observed positivity only in meningioma lesion []. Both gliosarcomas (primary and recurrent) were negative for COX-2 expression [ and ]. | [[51.0, 'year']] | F | {'15148503': 1, '2401915': 1, '18230932': 1, '17110285': 1, '14693827': 1, '20063176': 1, '8568553': 1, '19937755': 1, '17618441': 1, '17665342': 1, '16078109': 1, '12637065': 1, '12383424': 1, '17581404': 1, '30533274': 2, '18048012': 1, '10666371': 1, '19332771': 1, '15073599': 1, '2308674': 1, '25337286': 1, '15261243': 1, '16373964': 1, '11699553': 1, '28644110': 1, '14997945': 1, '956884': 1, '15719270': 1, '1927605': 1, '15662974': 1, '16739104': 1, '20052717': 1, '189579': 1, '18507036': 1, '15931312': 1, '20030624': 1, '11389063': 1, '20428822': 1, '20632878': 1, '19809523': 1, '15980972': 1, '7753363': 1, '19618114': 1, '24381794': 2} | {'6238322-1': 1} |
164,881 | 3872649-1 | 24,381,793 | noncomm/PMC003xxxxxx/PMC3872649.xml | Extracranial aneurysms of the distal posterior inferior cerebellar artery: Resection and primary reanastomosis as the preferred management approach | A 76-year-old Hispanic female suddenly collapsed and was brought to the emergency room of an outside hospital where a head computed tomography (CT) revealed diffuse subarachnoid hemorrhage (SAH) with blood in the fourth, third and lateral ventricles. Upon arrival at our institution, she was a Hunt and Hess grade III SAH. Repeated CT showed the SAH and hydrocephalus [ and ] and right frontal external ventriculostomy drain (EVD) was placed emergently. A diagnostic cerebral angiogram demonstrated the presence of a right PICA aneurysm measuring approximately 2-2.5 mm in diameter with a broad neck []. Decision was made that due to its morphology, the aneurysm should be treated with microsurgical clipping.\nA SOC with C1 and partial C2 laminectomies was performed. The cisterna magna was found to be full of blood; it was explored and the hematoma evacuated. Both segments of the PICA, proximal and distal to the aneurysm, were identified. The caudal loop of the PICA was seen under the C2 lamina and the aneurysm itself projected under the lamina of C1, and was located on the tonsillomedullary segment. Under temporary clipping distal and proximal, the aneurysm neck was defined and the aneurysm was clipped. The dura was then closed at the more distal cervical region, and Duragen (Integra LifeSciences Corporation, NJ) was placed more cranially. Cervical fascia and skin were closed in the usual fashion.\nThe patient recovered well from the surgery and passed EVD challenge. CT on postoperative day (POD) 19 revealed resolution of the SAH, and no blood in the posterior fossa around the aneurysm clip. Postoperative skull X-ray (XR) showed the clip located below the foramen magnum []. The patient was scheduled to be discharged to an inpatient rehabilitation facility, and on POD 25, following a physical therapy session including active range of motion of bilateral upper extremities, was found unresponsive on the floor. Emergent CT scan of the head showed the presence of blood in the fourth, third and lateral ventricles, and right frontal EVD was placed. A repeat diagnostic angiogram revealed findings consistent with rebleed from the previously clipped right PICA aneurysm. | [[76.0, 'year']] | F | {'6847911': 1, '7330767': 1, '12870549': 1, '9632192': 1, '18295840': 1, '9650904': 1, '19651470': 1, '10507387': 1, '17963931': 1, '16575325': 1, '9189879': 1, '19468672': 1, '1695329': 1, '3748335': 1, '2191090': 1, '11794593': 1, '2384786': 1, '6759978': 1, '10983304': 1, '11059679': 1, '15257482': 1, '3216980': 1, '17976992': 1, '8232818': 1, '8710055': 1, '12405360': 1, '16175868': 1, '5635959': 1, '3760965': 1, '3352880': 1, '7264746': 1, '7205355': 1, '7070615': 1, '4012560': 1, '4058734': 1, '3041637': 1, '5921326': 1, '6827323': 1, '7891199': 1, '19147205': 1, '2377268': 1, '11070378': 1, '2195372': 1, '3791805': 1, '14505854': 1, '18091258': 1, '5327711': 1, '24381793': 2} | {'3872649-2': 2, '3872649-3': 2} |
164,882 | 3872649-2 | 24,381,793 | noncomm/PMC003xxxxxx/PMC3872649.xml | Extracranial aneurysms of the distal posterior inferior cerebellar artery: Resection and primary reanastomosis as the preferred management approach | This is a 70-year-old female who was found unresponsive, and was brought to an outside hospital where head CT showed SAH in the basal, peripontine, and foramen magnum cisterns, as well as intraventricular hemorrhage (IVH) in the occipital horns, third and fourth ventricles. The patient arrived as Hunt and Hess grade III SAH. A repeat CT demonstrated moderate enlargement of the ventricular system correlating with hydrocephalus and a right frontal EVD was placed. A four vessel cerebral angiogram showed an approximately 9 × 9 mm left PICA aneurysm located at the level of the caudal loop (tonsillomedullary segment). The aneurysm was single lobed, fist shape in appearance, angiographically located at the skull base, likely at the level of the VA dural penetration, with what appeared to be both intracranial and extracranial components [ and ]. Subselective angiography demonstrated separate inflow and outflow branch vessels []. Coil embolization was attempted but the procedure was aborted as it was felt that there was high risk of a left PICA occlusion and subsequent ischemic infarct. | [[70.0, 'year']] | F | {'6847911': 1, '7330767': 1, '12870549': 1, '9632192': 1, '18295840': 1, '9650904': 1, '19651470': 1, '10507387': 1, '17963931': 1, '16575325': 1, '9189879': 1, '19468672': 1, '1695329': 1, '3748335': 1, '2191090': 1, '11794593': 1, '2384786': 1, '6759978': 1, '10983304': 1, '11059679': 1, '15257482': 1, '3216980': 1, '17976992': 1, '8232818': 1, '8710055': 1, '12405360': 1, '16175868': 1, '5635959': 1, '3760965': 1, '3352880': 1, '7264746': 1, '7205355': 1, '7070615': 1, '4012560': 1, '4058734': 1, '3041637': 1, '5921326': 1, '6827323': 1, '7891199': 1, '19147205': 1, '2377268': 1, '11070378': 1, '2195372': 1, '3791805': 1, '14505854': 1, '18091258': 1, '5327711': 1, '24381793': 2} | {'3872649-1': 2, '3872649-3': 2} |
164,883 | 3872649-3 | 24,381,793 | noncomm/PMC003xxxxxx/PMC3872649.xml | Extracranial aneurysms of the distal posterior inferior cerebellar artery: Resection and primary reanastomosis as the preferred management approach | The patient is a 52-year-old right handed African-American woman who suffered a sudden onset of severe headache and neck pain with multiple episodes of vomiting. Head CT at an outside hospital showed mild amount of SAH in Sylvian fissures and temporoparietal cortical sulci bilaterally, and intraventricular blood within the fourth, and left lateral ventricles, and mild hydrocephalus. The patient had a magnetic resonance angiogram (MRA) done the following day, which was unremarkable for any vascular abnormality, however, a conventional cerebral angiogram done subsequently was suspicious for a left PICA aneurysm. She was transferred to our institution for further management. Upon admission to our center, she was a Hunt and Hess grade II SAH with only a very mild left-sided arm and leg weakness. A four vessel cerebral angiogram was performed, which showed an 8 × 6 mm fusiform left PICA aneurysm at the tonsillomedullary segment (caudal loop) behind the arch of C1, not amenable to endovascular coiling [Figure –]. | [[52.0, 'year']] | F | {'6847911': 1, '7330767': 1, '12870549': 1, '9632192': 1, '18295840': 1, '9650904': 1, '19651470': 1, '10507387': 1, '17963931': 1, '16575325': 1, '9189879': 1, '19468672': 1, '1695329': 1, '3748335': 1, '2191090': 1, '11794593': 1, '2384786': 1, '6759978': 1, '10983304': 1, '11059679': 1, '15257482': 1, '3216980': 1, '17976992': 1, '8232818': 1, '8710055': 1, '12405360': 1, '16175868': 1, '5635959': 1, '3760965': 1, '3352880': 1, '7264746': 1, '7205355': 1, '7070615': 1, '4012560': 1, '4058734': 1, '3041637': 1, '5921326': 1, '6827323': 1, '7891199': 1, '19147205': 1, '2377268': 1, '11070378': 1, '2195372': 1, '3791805': 1, '14505854': 1, '18091258': 1, '5327711': 1, '24381793': 2} | {'3872649-1': 2, '3872649-2': 2} |
164,884 | 3872659-1 | 24,381,454 | noncomm/PMC003xxxxxx/PMC3872659.xml | Hemangiopericytoma invading the craniovertebral junction: First reported case and review of the literature | This study reports a case of a 56-year-old fairly healthy male patient presented complaining of neck pain that radiated into his head and both shoulders. His pain was present for several months and no longer relieved by anti-inflammatory medications.\nOn neurological exam, he had intact motor and sensory responses bilaterally, with normal reflexes. Romberg, cerebellar and gait examinations were normal as well. The gadolinium-enhanced cervical spine magnetic resonance imaging (MRI) revealed an intradural extra-medullary lesion extending from the occiput to C4 in the ventrolateral position with central stenosis and cord compression []. In addition, there was a small enhancing lesion seen at the upper thoracic spine []. Both neural foramina were normal. MRIs of the brain and lumbar spine were both within normal limits.\nA suboccipital craniectomy and C1-4 complete laminectomy were performed. With the aid of the microscope, a midline dural incision was made to expose a solid, red tumor in the dorsolateral right gutter, displacing the spinal cord to the left and bordered by clear arachnoid.\nThe tumor was removed in several large fragments and debulked away from a number of nerves in its proximity with a Cavitron. It was found to be densely adherent to the spinal cord at the C1 level around dentate ligaments, extending ventrolaterally. Multiple lobules of tumor were removed in a clear arachnoid plane except where there was adherence to the spinal cord at the C1 level. There was pial invasion on one side, which with cauterization of the pia, the residual tumor was removed and a gross total excision was attained. Careful hemostasis and closure were achieved without issues.\nGrossly, the tumor was a large hemorrhagic mass. The pathologic specimens were designated as intradural extra-medullary and partially invasive intradural intramedullary at the C1 level. On microscopy, the tumor cells had widened nuclei with spotted chromatin and mitotic figures (up to 30 per 10 high-power fields). There were foci of hemorrhage, but no areas of necrosis. There was minimal reticulin deposition. Immunostaining revealed the tumor was positive for CD34 and B-cell lymphoma 2, but negative for smooth muscle actin, epithelial membrane antigen, synaptophysin and glial fibrillary acidic protein and a Ki-67 proliferative index of 12% []. On electron microscopy, the tumor was highly vascular and contained numerous extravasated erythrocytes and other cellular blood elements. Final histology was a tumor borderline grade between HPC WHO grade II based on morphology and anaplastic HPC WHO grade III based on elevated mitotic count and intratumoral hemorrhage.\nThe post-operative course was uneventful and there was complete resection of the tumor as evidenced on MRI. Initially, the patient experienced mild right deltoid weakness without tingling, numbness, headaches or other neurologic symptoms. A post-operative MRI at 6-months revealed the remaining enhancing drop metastasis at the T2-3 level. At an outside facility, the patient underwent successful radiosurgery of the area. His reported right periscapular shoulder girdle atrophy has been responding to physical therapy and other treatments. Five years post-operatively, he is neurologically at baseline and follow-up MRI [] reveals no evidence of recurrence in either the cervical or thoracic regions. | [[56.0, 'year']] | M | {'18981882': 1, '12816261': 1, '34845431': 2, '11841738': 1, '17335652': 1, '12234396': 1, '23291785': 1, '17858068': 1, '25210342': 2, '24381454': 2} | {'4158640-1': 1, '8627340-1': 1} |
164,885 | 3872660-1 | 24,381,455 | noncomm/PMC003xxxxxx/PMC3872660.xml | Cauda equina aspergilloma in an immunocompetent individual: A case report | A 70-year-old gentle man, fruit vendor walked with difficulty into our outpatient department. He described shooting pain from low back into both legs and buttocks since 3 months. He has hypertension and is taking antihypertensives for 25 years. Neurological examination revealed saddle region parasthesia. Bladder and bowel were intact and there were no deficits in legs.\nMagnetic resonance imaging (MRI) scan of spine and brain [Figures and ] showed enhancing T1 intermediate and T2 hypointense three soft tissue nodulations along the cauda equina at L2, L4, and L5-S2 filling the thecal sac in the lumbosacral region. At S2 level the soft tissue mass was scalloping the canalicular cortex. There was no intracranial abnormality. Considering age of patient serum electrophoresis was done which was not suggestive of myeloma. Prostate specific antigen was normal. X-ray chest was normal, ultrasound scan of the abdomen and pelvic did not show any abnormality or enlarged lymph nodes. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) I and II was nonreactive. Complete hemogram, blood sugar, and Hb1Ac were in normal range.\nPatient was operated in prone position, under general anesthesia. L5 to S2 laminectomy and total excision of lower lesion was done. The lesion was involving the filum terminale and firmly stuck to the nerve roots and both S3 roots had to be sacrificed. The higher nodular lesions at L2 and L4 were left untouched. Operative specimen was sent for histopathological examination [] which showed large granuloma with multinucleate giant cells lining zones of necrosis (A). Within the granuloma are numerous septate branching hyphae of Apsergillus spp highlighted by Gomori methenamine silver stains (B). Diagnosis of aspergiloma was established.\nPatient received 4 weeks course of intravenous amphotericin B 35 mg daily and oral itraconazole 200 mg twice a day. Patient tolerated antifungal course well. | [[70.0, 'year']] | M | {'14989142': 1, '9239928': 1, '24381455': 2} | {} |
164,886 | 3872662-1 | 24,381,457 | noncomm/PMC003xxxxxx/PMC3872662.xml | Intramedullary conus metastasis from carcinoma lung | A 46-year-old male had presented with progressive paraparesis associated with sensory impairment in both lower limbs since 2 months. He had incontinence of urine and stool. At the time of presentation he had flaccid paraplegia with a sensory level at 11th dorsal vertebral level (D11). One month prior to presentation to us, the patient had undergone an unsuccessful attempt at excision of the conus mass. Magnetic resonance imaging (MRI) of the dorsolumbar spine showed a discrete homogenously enhancing mass within the conus at the D12 level []. D11 to L1 laminectomies were noted []. The tumor was seen as on the earlier scan as it had not been biopsied. The previous midline incision over D11 to L1 was reexplored. The conus was exposed. A posterior midline myelotomy was performed on the conus at the site of the tumor bulge. A grey colored firm mass was noted. A gross total excision of the tumor could be achieved. Histopathology showed a poorly differentiated metastatic carcinoma []. There was cellular and nuclear atypia, mitotic activity, pleomorphism along with scattered bizarre cells. There were vascular emboli with areas of hemorrhage.\nThe patient underwent a positron emission tomography-computed tomography (PET-CT) scan of the whole body that revealed hypermetabolic activity in the hilum of the right lung. A review of the chest radiograph showed a right hilar lung mass, which had been missed earlier []. A CT guided biopsy of the hilar mass confirmed the diagnosis of lung adenocarcinoma.\nThe patient was advised chemotherapy for the primary and radiotherapy for the secondary spinal metastasis. At 1 month follow-up the patient was undergoing chemoradiation treatment. The patient had improvement in the motor functions of both lower limbs. | [[46.0, 'year']] | M | {'21273077': 1, '11154816': 1, '8857717': 1, '3437960': 1, '17143209': 1, '3554916': 1, '11485245': 1, '4052974': 1, '16463993': 1, '12595811': 1, '11105839': 1, '12795190': 1, '11198775': 1, '14706385': 1, '24381457': 2} | {} |
164,887 | 3872663-1 | 24,381,458 | noncomm/PMC003xxxxxx/PMC3872663.xml | Giant posterior fossa arachnoid cyst causing tonsillar herniation and cervical syringomyelia | This was a case report of a 28-year-old female patient presented with a history of paraesthesia involving right upper limb of 8 months duration. She had a spontaneous abortion 3 weeks ago. Following that, she developed sudden onset of weakness of both lower limbs (left side greater than the right side). There was a history of headache on and off increased by coughing. Her bowel and bladder functions were normal and also general and systemic examination was normal. Cranial nerves were normal. Fundus examination was normal. She had a weakness of all four limbs (lower limbs more than upper limbs). Deep tendon reflexes were exaggerated in lower limbs and sluggish in upper limbs. Planters were extensors. There was also dissociated sensory loss on her right arm and shoulder. Patient was investigated with magnetic resonance imaging (MRI) brain and cervical spine and it showed giant retrocerebellar arachnoid cyst extending into the left cerebellopontine angle causing descent of the cerebellar tonsils across the foramen magnum with a syringomyelic cavity extending from C1 down and associated ventriculomegaly []. The patient underwent midline suboccipital craniectomy, foramen magnum decompression and C1 arch excision with duroplasty. Part of the cyst wall was excised. Histopathological examination of the cyst wall showed a cuboidal layer of arachnoid cells suggestive of arachnoid cyst []. Follow-up images showed a reduction in the size of the cyst and reduction in the mass effect over cerebellum and brain stem structures []. At 10 months follow-up, patient made an uneventful recovery and doing well. | [[28.0, 'year']] | F | {'15040721': 1, '17622461': 1, '15841687': 1, '11593259': 1, '1876240': 1, '9301200': 1, '11013645': 1, '16397818': 1, '26512273': 2, '16148987': 1, '19779293': 1, '26728365': 1, '16698611': 1, '10819260': 1, '17764831': 1, '10751821': 1, '21647327': 1, '23691470': 2, '10199290': 1, '18826365': 1, '12021887': 1, '22159062': 1, '24381458': 2} | {'3643653-1': 1, '4623173-1': 1} |
164,888 | 3872672-1 | 24,381,467 | noncomm/PMC003xxxxxx/PMC3872672.xml | A rare case of lipoleiomyoma of the vulva: Cytological and immunohistopathological study | A 38-year-old female, gravida 2 and para 2, presented to gynecology outpatient department with a left sided mass in the vulvar region. It was noticed one year back, which was small initially and gradually increased to the present size. Local examination showed 3 × 3 cm, nontender, well defined, soft to firm swelling in the labium majus. Overlying skin was unremarkable. Systemic examination findings were noncontributory. Fine needle aspiration cytology (FNAC) was advised.\nFNAC revealed moderately cellular smears composed of tissue fragments of cells with indistinct cell margins, moderate amount of eosinophilic cytoplasm and spindly nuclei of varying size. Few adipocytes were seen entrapped within the spindle cell fragments []. Background was hemorrhagic. Cytological report of benign spindle cell lesion with differential diagnosis of spindle cell lipoma and leiomyoma was offered. The complete excision of the lesion was advised for histopathological confirmation.\nOn gross examination, the tumor was ill circumscribed, partly encapsulated, soft to firm measuring 6 × 2.5 × 2 cm. On cut section, the tumor appeared whitish with yellowish and few tiny hemorrhagic areas [].\nOn microscopic examination, an ill circumscribed tumor mass composed of spindle cells arranged in interlacing fascicles and whorls, regularly interspersed with single and at places collections of mature adipocytes was observed. The spindle cells showed bland oval nuclei and moderate amount of eosinophilic cytoplasm []. No areas of necrosis and abnormal mitosis were noted. Based on histomorphologic appearance, differential diagnosis of lipoleiomyoma and neurofibroma with lipomatous differentiation was considered and representative sections were subjected for immunohistochemical studies. | [[38.0, 'year']] | F | {'19001649': 1, '32922615': 1, '7166124': 1, '21792008': 1, '1318812': 1, '8669526': 1, '21263242': 1, '7434562': 1, '12701642': 1, '21716761': 2, '24381467': 2} | {'3122497-1': 1} |
164,889 | 3872673-1 | 24,381,468 | noncomm/PMC003xxxxxx/PMC3872673.xml | A rare case of fondaparinux-induced major bleeding in postmenopausal woman prescribed for non-ST segment elevation Ml | We hereby report a rare case of fondaparinux-induced major bleeding in a 58-year-old postmenopausal woman, a known hypertensive and Type 2 diabetes mellitus (T2DM) patient prescribed for NSTEMI reported in our ADRM Centre.\nThe patient presented in the emergency with complaints of chest pain not relieved by sublingual nitrate. On examination there was no pallor, cyanosis, pedal edema, signs of atherosclerosis. Pulse rate was 94/min, regular, normal volume, no radio-femoral delay, and vessel wall not palpable. Blood pressure (BP) measured in both limbs was 160/90 mmHg. On auscultation of CVS and respiratory system showed no abnormality. Laboratory investigations revealed Hb 11g%, TLC 8400/cmm, platelet count 2.4 lacs/cmm, RBS 194 mg%, blood urea 29 mg, serum creatinine 0.9 mg, HbA1c 7.8%, serum cholesterol 245 mg%, serum triglyceride 185 mg%, HDL 35 mg%.\nECG was done immediately, which showed NSTEMI and a positive 10 hour troponin-T assay. Angiography was not done. Patient was treated with oxygen, morphine, beta blocker, ACE inhibitor, statins, aspirin, and clopidogrel, fondaparinux 2.5 mg once daily by subcutaneous route. Third day patient developed purpura and extensive ecchymosis in right arm and forearm [Figures and ]. The patient also developed epistaxis lasting >10 min, which required ENT intervention as well as macroscopic hematuria lasting for 3 days. Patient also presented with per vaginal bleeding, which continued till 7 days. Patient on subsequent investigations showed platelet count 45000/cmm. Hb was 6.9 g%. HIT antibodies were not done due to lack of facility. There were no signs of deep venous thrombosis, pulmonary embolism, gangrene, retroperitoneal, intracranial, or intraocular hemorrhage in the patients as suggested by USG abdomen and MRI brain. USG of pelvic organ revealed small postmenopausal sized uterus and normal adnexa. Based on clinical and laboratory findings, a diagnosis of fondaparinux-induced major bleeding was established. Patient required four units of platelet fraction and three unit of blood transfusion. After which platelet count and Hb rapidly reestablished to 1.5 L/cmm and 8.9 g%. She was discharged in a satisfactory condition after 15 days of hospitalization and is now regular follow up and prophylaxis treatment of MI. Since the ADR was serious and most likely thought to be associated with fondaparinux because of its previous known few reports.[]\nDe-challenge of drug and blood/platelet transfusion caused ADR to ameliorate. Further re-challenge was not done with the fear of reappearance of ADR and due to ethical constrains. Thus, the appearance of major bleeding could not be explained by a concurrent disease as such, drug or chemicals and de-challenge improved the condition. | [[58.0, 'year']] | F | {'18955665': 1, '29962798': 1, '18998758': 1, '11072960': 1, '17964037': 1, '19943881': 1, '21076279': 1, '18803278': 1, '23884865': 1, '7249508': 1, '23832870': 1, '24381468': 2} | {} |
164,890 | 3872694-1 | 24,381,893 | noncomm/PMC003xxxxxx/PMC3872694.xml | Hyperthyroidism: A rare cause of pulmonary embolism: Report of two cases | A 32 year-old man, with a family history of Graves’ disease in a maternal aunt, was admitted to the hospital with a history of weight loss, excessive sweating, palpitation, tremors of the hands and irritability of sixmonths duration.\nOn clinical examination, he was found to be toxic. Pulse was 132 per minute and irregular. Blood pressure (BP) was 110/70 mmHg. He had moderate bilateral exophtalmos associated with a large elastic vascular goiter. He also had clinical signs of right heart failure, including edema of lower limbs, hepatomegaly and hepatojugular reflux. Laboratory tests revealed normocytic normochromic anemia with a hemoglobin level of 11.8 g/dL. The rest of the laboratory results were within normal range. Thyroid function tests confirmed a state of thyrotoxicosis with free T4 (FT4) of 51 pmol/L (reference range 10-24), and TSH of 0.07 μU/mL (reference range 0.4-4.5). High titer of antithyroid-stimulating antibodies confirmed the diagnosis of Graves’ disease. Electrocardiogram (ECG) showed complete arrhythmia due to atrial fibrillation (CA/FA). A cervicothoracic scan indicated a non-compressing and non-dipping homogeneous goiter.\nEchocardiography revealed dilated right cavities, mild tricuspid insufficiency, and elevated pulmonary pressure reaching 64 mmHg. There were no signs of left ventricular enlargement or reduced function.\nThe diagnosis of PE was suspected by the presence of significant pulmonary hypertension, and was confirmed by a lung perfusion-ventilation scan test that showedhypoperfusion of the left lung [].\nNo conventional venous thromboembolism risk factors were identified. Thrombophilia screen, including protein C and S, antithrombin, activated protein C resistance, lupus anticoagulant, and anti-cardiolipin antibody were negative.\nThe patient was diagnosed as Graves’ disease complicated by cardiothyreosis and PE. The patient received heparin, followed by oral anticoagulant therapy. Benzylthiouracil (Basdène®) treatment was also initiated at a dose of 225 mg daily, associated with beta-blocker propranolol. Two months later, radioactive iodine treatment (8 mCi) was administered, resulting in incomplete recovery from thyrotoxicosis. Repeated echocardiography showed normal pulmonary artery pressure (29 mmHg). The patient died of acute heart failure secondary to a chest infection 2.5 months after radioactive iodine treatment. | [[32.0, 'year']] | M | {'17440013': 1, '19135742': 1, '19367377': 1, '16303831': 1, '15798145': 1, '16487444': 1, '21249601': 1, '19671566': 1, '16845575': 1, '21729238': 1, '12814979': 1, '12235324': 1, '18791628': 1, '6411844': 1, '20308594': 1, '10669145': 1, '20647670': 1, '15692260': 1, '20308227': 1, '18787930': 1, '12030606': 1, '18160944': 1, '16475038': 1, '21249600': 1, '21077792': 1, '20738759': 1, '3722331': 1, '16118502': 1, '9893018': 1, '24381893': 2} | {'3872694-2': 2} |
164,891 | 3872694-2 | 24,381,893 | noncomm/PMC003xxxxxx/PMC3872694.xml | Hyperthyroidism: A rare cause of pulmonary embolism: Report of two cases | A 23-year-old female patient, whose sister was affected by Graves’ disease, had been treated since 2007 for Graves’ disease. This diagnosis was made on the basis of hyperthyroid symptoms, moderate homogenous and elastic goiter, elevated FT4 level (94.9 pmol/L, normal range 10-24) with suppressed TSH (0.05 μU/mL, normal range 0.4-4.5), and elevated titer of antithyroid-stimulating antibodies (43.3 UI/L, normal range <2).\nThe patient was put under antithyroid drugs: Benzylthiouracil (Basdène®) at a dose of 225 mg daily in combination with a beta-blocker (Propranolol, 60 mg daily). The patient showed poor compliance and frequent discontinuation of her treatment. Facing the reappearance of hyperthyroidism, she was hospitalized in June 2010. On examination, she had a body mass index of 21.38 kg/m2, BP of 140/80 mmHg. In addition to the signs of thyrotoxicosis, the patient had a moderate bilateral exophthalmos associated with a moderate homogenous and vascular goiter. Her ECG showed sinus tachycardia with right axis deviation, and Sokolow-Lyon criteria for left ventricular hypertrophy.\nOn hormonal investigations, FT4 was higher than 100 pmol/L (normal range 10-24) and TSH was 0.005 μU/mL (normal range 0.4-4.5). During hospitalization, the patient developed a severe chest pain, dyspnea with an exaggeration of tachycardia. ECG showed right bundle branch block. Chest radiography revealed no abnormalities. Arterial blood gas analysis showed hypoxia and hypocapnia. Serum level of D-Dimer was higher than 500 ng/ml. PE was suspected and was confirmed by a lung perfusion-ventilation scan test confirmed which showed several bilateral segmental perfusion defects []. The patient was put under heparin relayed by anticoagulants. In addition, radioactive iodine treatment was administered (7 mCi), and then the patient was again put under Benzylthiouracile. Etiological investigation of PE has revealed a 200% elevation of plasma concentration of coagulation factor VIII. The patient consulted three months following radioiodine treatment without any hormonal tests. She was clinically euthyroid, and since then she was lost to follow-up. | [[23.0, 'year']] | F | {'17440013': 1, '19135742': 1, '19367377': 1, '16303831': 1, '15798145': 1, '16487444': 1, '21249601': 1, '19671566': 1, '16845575': 1, '21729238': 1, '12814979': 1, '12235324': 1, '18791628': 1, '6411844': 1, '20308594': 1, '10669145': 1, '20647670': 1, '15692260': 1, '20308227': 1, '18787930': 1, '12030606': 1, '18160944': 1, '16475038': 1, '21249600': 1, '21077792': 1, '20738759': 1, '3722331': 1, '16118502': 1, '9893018': 1, '24381893': 2} | {'3872694-1': 2} |
164,892 | 3872695-1 | 24,381,894 | noncomm/PMC003xxxxxx/PMC3872695.xml | Spinal polyostotic fibrous dysplasia in two adults: Does only biopsy unravel the mystery? | A 44 year old male presented with insidious onset gradually progressive symmetrical, inflammatory polyarthralgia predominantly involving small joints of hands of six months duration; diagnosed and treated as seronegative arthritis with analgesics and methotrexate. There was no history of bone pains, deformity of the joints/bones or systemic symptoms. General and systemic examination was unremarkable except arthritis, of which clinical disease activity index was 32 (maximum of 76; ≥21 indicating severe disease activity).\nLaboratory evaluation revealed a haemoglobin of 15.1 g/dL, total leucocyte count of 8,700 cells/cu.mm, normal differential count, erythrocyte sedimentation rate of 45 mm fall at one hour (0-10). All his biochemical parameters were normal except for elevated alkaline phosphatase – 350 IU/L. C-reactive protein was 12 mg/dL (<10), rheumatoid factor was 7.0 IU/mL, anti-cyclic citrullinated peptide antibody was 4.2 IU/mL (<5), anti-nuclear antibody was 4.8 U (<20), anti-dsDNA was 32.2 IU/mL (<35), HLA-B27 negative and anti-neutrophilcytoplasmic autoantibodies were negative. Skeletal survey revealed multiple mixed lytic and sclerotic lesions in vertebral bodies and posterior elements from 8th thoracic to 5th lumbar vertebra [] and expansile lytic lesions were seen in 8th, 11th and 12th rib. Magnetic resonant image (MRI) of the spine showed destructive changes in the vertebral bodies and posterior elements from 8th dorsal vertebrae to 5th lumbar vertebrae. Bone scan showed increased uptake in the areas described above []. His bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) was normal (T-score-0.9 and Z-score-0.4 at lumbar spine). Serum electrophoresis didn’t reveal M band and bone marrow aspiration was cellular and reactive. Oncological markers such as serum prostate specific agent (PSA), carcino-embryogenic agent (CEA) and carbohydrate antigen (CA)-19.9 were within normal limits. An open biopsy from left 8th rib revealed the diagnosis of fibrous dysplasia in 2005. Severity of fibrous dysplasia as interpreted by bone scan[] was 0.66. There was no evidence of café-au-lait spots and his endocrinal evaluation including thyroid adrenal and pituitary function tests were normal.\nHe was started on intravenous pamidronate, along with calcium and vitamin D supplements. Six months later he noted weight loss of 12 kgs in spite of preserved appetite. He also had noted palpitations, heat intolerance and tremulousness. There was no goitre, ophthalmopathy or dermopathy. His thyroid function test was consistent with thyrotoxicosis [Tri-iodothyronine (T3) - 2.9 mg/dL (0.9-2.6), thyroxin (T4) -20.0 μg/dL (5.5-13.0) and thyroid stimulating hormone (TSH) - 0.04 μIU/mL]. Thyroid antibodies were negative. 99mTechnicium scan showed homogenous increased uptake in the thyroid with suppressed salivary uptake suggestive of hyperthyroid status. He was also detected to have diabetes mellitus (DM) by oral glucose tolerance test (OGTT, fasting 142 mg/dL and two hour 219 mg/dL). There was also evidence of transaminitis (SGOT/SGPT – 134/175) which persisted even after stopping methotrexate and test was positive for anti-HCV antibodies; however HCV viral count was zero. Modified KnodellIshak score showed grade 1/18 and stage 1/6 on liver biopsy. In view of association of hyperthyroidism with fibrous dysplasia and underlying HCV infection he was radioablated with 10 mCi of radioiodine and in addition advised diabetic diet. He developed post ablative hypothyroidism three months later and has been on thyroxine replacement since then. Once euthyroidism was achieved, result of repeat OGTT was suggestive of DM and started on metformin. Presently he is receiving zoledronic acid 4 mg twice yearly, methotrexate 7.5 mg weekly, thyroxine, metformin, calcium and vitamin D supplements. His annual bone scans have showed stable disease. At his latest review 18F-FDG PET was performed for the first time which showed both active and healed osseous lesions []. He has not sustained any fracture till date. | [[44.0, 'year']] | M | {'19809567': 1, '18489744': 1, '1944469': 1, '21623035': 1, '10673080': 1, '16369891': 1, '15126527': 1, '9226216': 1, '18506282': 1, '11150888': 1, '7747188': 1, '17229019': 1, '24083194': 1, '14996879': 1, '24381897': 2, '20680622': 1, '3720157': 1, '15005844': 1, '17228999': 1, '9403700': 1, '8410501': 1, '18987778': 1, '17665224': 1, '14036060': 1, '20649485': 1, '24381894': 2} | {'3872695-2': 2, '3872698-1': 1} |
164,893 | 3872695-2 | 24,381,894 | noncomm/PMC003xxxxxx/PMC3872695.xml | Spinal polyostotic fibrous dysplasia in two adults: Does only biopsy unravel the mystery? | A 27 year old man became symptomatic following repeated falls on a slippery surface with chronic low backache and neck pain for one year. He also noticed bone pains and the severity progressed over six months to an extent that he had gross limitations of his daily activities, had to be bed bound and developed chronic insomnia. He didn’t have arthralgia, deformity of the joints/bones or systemic symptoms. He weighed 69 kgs for a height of 170 cm (he reported his height was 173 cm at the age of 18 years). He had tenderness at lower thoracic and lumbar spine. He had no deformity. His general and systemic examination was normal.\nInvestigations revealed a haemoglobin of 14.2 g/dL (14 ± 2.5), total leucocyte count 7,500/cu.mm (4,000-11,000), platelets 1,87,000/cu.mm (1,50,000-4,50,000), erythrocyte sedimentation rate 5mm fall at first hour (0-10), fasting blood glucose 97mg/dL (70-100), blood urea nitrogen 12 mg/dL (7-19), creatinine 0.8mg/dL (0.5-1.6), sodium 140 mEq/L (135-149), potassium 4.1mEq/L (3.5-5.0), bilirubin 0.9mg/dL (<1), aspartate trasaminase 85 U/L (<40), alanine trasaminase 78 U/L (<40), alkaline phosphatase 354 U/L (<250), protein 7.9 g/dL, albumin 4.2 g/dL, calcium 8.6 mg/dL (8.5-10.5), phosphorous 3.8 mg/dL (2.5-4.5), lactate dehydrogenase 811 U/L (230-460) and uric acid 7.2 mg/dL (2-6). CRP was 6mg/L (<6), HLA-B 27 was negative. X-ray of spine showed multiple lytic lesions with collapse of 8th dorsal vertebra and ill-defined radiolucencies in both pubic rami and ischium []. Computed tomography of spine showed extensive involvement of spine, sternum, pelvis, heads of humerus and femur []. MRI spine showed extensive marrow infiltration of spine and pelvic bone and collapse of C3, D1 and D8 vertebrae []. He was evaluated for multiple myeloma with serum electrophoresis which was negative for “M” band, light chain assay was negative and bone marrow aspiration was dry and bone marrow biopsy showed extensive fibrosis (?secondary). Bone scan showed increased uptake in involved areas []. FDG-PET confirmed increased metabolic activity in above area and was suggestive of malignancy with highest SUV of 7.6 in sacrum []. Parathormone (PTH) was 13 pg/mL (10-65), 25(OH) vitamin-D was 65 ng/mL (30-150) and endocrinal evaluations (thyroid, adrenal and pituitary function tests) were normal. Oncological markers including PSA, CEA and CA 19.9 were normal. BMD z-score at spine, hip and forearm were -2.6, -0.8 and 0.5 respectively. With the suspicion of lymphoma, infective etiology, or secondary a CT guided fine needle aspiration was done; but was inconclusive. To obtain tissue diagnosis an open biopsy of left sacral ala and a repeat bone marrow aspiration and biopsy from matched involved area from bone scan and CT scan at iliac spine was performed. Histopathology of bone biopsy was consistent with fibrous dysplasia []. Severity of fibrous dysplasia as interpreted by bone scan[] was 11%. He was started on intravenous zoledronic acid 4 mg quarterly, calcium and vitamin D supplements. Opioid analgesics were required to control his bone pain. | [[27.0, 'year']] | M | {'19809567': 1, '18489744': 1, '1944469': 1, '21623035': 1, '10673080': 1, '16369891': 1, '15126527': 1, '9226216': 1, '18506282': 1, '11150888': 1, '7747188': 1, '17229019': 1, '24083194': 1, '14996879': 1, '24381897': 2, '20680622': 1, '3720157': 1, '15005844': 1, '17228999': 1, '9403700': 1, '8410501': 1, '18987778': 1, '17665224': 1, '14036060': 1, '20649485': 1, '24381894': 2} | {'3872695-1': 2, '3872698-1': 1} |
164,894 | 3872697-1 | 24,381,896 | noncomm/PMC003xxxxxx/PMC3872697.xml | A case of autoimmune hypoglycemia outside Japan: Rare, but in the era of expanding drug-list, important to suspect | A 72-year-old man of Indian origin had first episode of hypoglycemia 2 months earlier when, 4-5 h after taking lunch, he was found to be disoriented. He was taken to the nearby hospital where level of his plasma blood glucose was found to be 20 mg/dL and intravenous 10% dextrose infusion reversed his symptoms. During hospital stay, he continued to have hypoglycemic episodes in the postabsorptive state. He was not a known diabetic and was not taking any drug known to cause hypoglycemia. There was no family history of diabetes. Result of routine investigations, including hemogram and renal, liver and thyroid function tests, were not significant. During one such episode, plasma blood glucose level was 15 mg/dL and the corresponding serum insulin was 123 mU/L. With provisional diagnosis of insulinoma, imaging studies, including ultrasonography, dual phase computed tomography (CT) and magnetic resonance (MR) imaging of abdomen, MR and CT angiography of the abdomen and contrast-enhanced CT of chest, were done sequentially. All these imaging modalities failed to detect any lesion. At this stage, the patient was referred to us. Review of past history revealed that the patient had ischemic cerebral infarct 8 years back when he was detected to have hypertension. One year back, he suffered from coronary ischemia. The patient never had gastrointestinal surgery. At the time of presentation, he was taking drugs – Pantoprazol, Aspirin, Clopidogrel, Torsemide, Isosorbide dinitrate, Atenolol, Atorvastatin and Amlodipine. General and systemic physical examination did not reveal any abnormality. During his stay in the Endocrine Ward, the patient continued to have hypoglycemia in the postabsorptive state. During one such episode, the plasma blood glucose level was 29 mg/dL, serum insulin was 3162 mU/L and serum C-peptide was 19.05 ng/mL (latter two measured by electrochemiluminescence immunoassay, using a Roche Elecsys 2010 immunoassay analyzer, GmBH, Mannheim, Germany], while serum cortisol and growth hormone responses were adequate. Serum proinsulin level was 420 pmol/L (normal fasting value < 20 pmol/L, measured by radioimmunoassay; Millipore Corporation, Merck Millipore Headquarters, 290 Concord Road, Billerica, MA 01821 USA). Trans-esophageal ultrasonography also failed to locate any lesion. Extended oral glucose tolerance test (OGTT) with 75 g of glucose showed paradoxical hyperglycemia followed by hypoglycemia with very high insulin levels []. These findings were highly suggestive of IAS. Other immunological findings of the patient showed elevated rheumatoid factor titers (>256, normal 0-20) and antinuclear antibody titers on Hep-2 substrate (1:80, normal < 1:20). The serum immunoglobulin G (IgG) level was 2416 mg/dL (normal 960-1968 mg/dL), IgM was 473 mg/dL (normal 125-380 mg/dL) and IgA was 146 mg/dL (normal 90-242 mg/dL), as measured by enzyme-linked immunosorbent assay. Samples for human leukocyte antigen (HLA) studies were collected, which showed HLA-A*02, A * 11, B * 35, B * 51, DRB1 * 0403 and DRB1 * 0404.\nReview of patient's drug intake revealed that he was taking three drugs, viz. Pentoprazol, Clopidogril and Torsemide, which contained sulfur and hydrogen atoms. Under the plan to stop usage of these drugs one by one, to begin with, Pentoprazole was discontinued and the patient was advised to take meals in small quantities frequently. As a follow-up thereof, the patient was observed keenly during the next week for any hypoglycemic symptoms, which were noticed to have subsided gradually. Eventually, the patient was discharged with the said advice. Review after 3 months, with extended OGTT, showed quantum decrease in serum insulin levels along with disappearance of the hyperglycemic phase, which feature was subsisting earlier. In the changed scenario, maximum blood glucose level reached was 183 mg/dL at 1 h []. Subsequent follow-up during the next 6 months revealed that the patient did not have any symptoms of hypoglycemia and was healthy. | [[72.0, 'year']] | M | {'34925575': 1, '7556962': 1, '19440117': 1, '33117451': 1, '10445096': 1, '30306074': 1, '28989869': 1, '27621535': 1, '2645123': 1, '32308449': 1, '7859945': 1, '10500933': 1, '27855237': 1, '24381896': 2} | {} |
164,895 | 3872698-1 | 24,381,897 | noncomm/PMC003xxxxxx/PMC3872698.xml | Sarcomatous transformation (Leiomyosarcoma) in polyostotic fibrous dysplagia | We have previously reported detailed history of this case and follow-up in our journal.[] In brief, this 27-year-old male presented with pain in neck and extensive osteolytic lesion in the spine. After extensive evaluation for malignancy on biopsy, he was diagnosed as a case of polyostotic fibrous dysplasia.[] On follow-up, he developed severe pain and weight loss; and repeat investigation showed progression of lesion with increased CA19.9 levels, hepatic space occupying lesion, and increased standardized uptake value (SUV) on Fluoro-deoxy-glucose positron emmission tomography (18-FDG-PET) in liver and anterior superior iliac spine. However, open biopsy from anterior superior iliac spine did not reveal any malignancies and was consistent with diagnosis of polyostotic fibrous dysplasia. He was on treatment with injection zoledronic acid, vitamin D, and narcotic analgesics.[]\nPatient continued to deteriorate and presented with complaints of jaundice and breathlessness for last 2 weeks in August 2012. Breathlessness was present at rest and progressive in nature. Patient was bed-ridden since last 4-5 days. On examination, he was sick looking and his vitals were normal. He had pallor, icterus, pedal edema, bilateral axillary, left supraclavicular and left cervical lymph nodes, and a single, tender, bony swelling of 3.0 × 2.0 cm in size on right chest wall near right nipple. Systemic examination revealed tender hepatomegaly and bilateral basal crepts with occasional rhonchi on right side. On central nervous system examination, he had generalized muscular wasting, mainly of small ones of hands and feet with power of 3/5 in left lower limb and 4/5 in rest all other limbs. Tone was decreased in all muscles. Deep tendon reflexes were absent; left ankle and depressed in right suggestive of lower motor neuron type of weakness. Cardiovascular system examination was within normal limits. His laboratory investigation showed - Hb-7.5 gm/dl, TLC-12300/cumm, platelets- 81000/cumm, total protein-5.4 mg/dl, albumin-1.7 mg/dl/SGOT/SGPT- 86/39 IU/ml, serum alkaline phosphatase-332, GGT- 389, LDH-43, calcium/phosphate-8.0/2.9. On USG abdomen, liver was 17 cm in longitudinal scan with heteroechoeic texture. There was evidence of multiple rounded, nodular, iso- to hypo-echoeic lesions studded in both lobes of liver; largest measuring 2.5 × 3.5 cm in segment II, leading a variegated appearance of the parenchyma with evidence of necrosis within the lesion and bilobar dilatation of intra-hepatic biliary radicles. These lesions showed mild to moderate color flow on color Doppler application. Portal vein was 8.7 mm at confluence, and 9 mm at porta. Patient was treated with broad-spectrum antibiotics in addition to analgesics. Repeat fine needle aspiration cytology of right chest wall lesion was performed, which was suggestive of spindle cell tumor. Patient's condition deteriorated and was kept on inotropic support along with ventilatory support. However, he did not respond and succumb to his illness.\nAutopsy was performed. Salient findings on internal gross examination were heavy boggy congested lungs with multiple sub-pleural white patches, enlarged liver with congested spleen. Multiple grey-white nodules were present in liver, spleen, greater omentum of stomach, small and large intestine, left lobe of thyroid, expanded right rib, right and left sacro-iliac joints and L4-L5 []. On histopathological examination, effacement of normal bony architecture by tumor cells arranged in fascicles, intersecting bundles and storiform pattern was observed. These tumor cells were elongated spindle-shaped cells with abundant eosinophilic cytoplasm, cigar-shaped nucleus []. Occasional multinucleated giant cells were noted. Mitosis was present (>10/10 hpf), and pleomorphic areas were noted. On immunohistochemistry, tumor was positive for smooth muscle antigen (SMA) and vimentin and negative for CD-117, S-100, HMB-45, CK, epithelial membrane antigen (EMA), myogenin, desmin, Myo D1, BCl2, CD68, Mic 2, and Ki-67. With these finding, a diagnosis of leiomyosarcoma of bone with metastasis to pancreas, liver, spleen, left kidney, thyroid, small and large intestine, lungs, and heart was made. | [[27.0, 'year']] | M | {'1944469': 1, '11828332': 1, '12970318': 1, '8504604': 1, '4506620': 1, '17858625': 1, '9378741': 1, '17229019': 1, '16850130': 1, '22000283': 1, '19575869': 1, '24083194': 1, '18560851': 1, '17441665': 1, '18238909': 1, '8111708': 1, '15214819': 1, '14106874': 1, '24381894': 2, '9403700': 1, '14691924': 1, '16897210': 1, '24381897': 2} | {'3872695-1': 1, '3872695-2': 1} |
164,896 | 3872699-1 | 24,381,898 | noncomm/PMC003xxxxxx/PMC3872699.xml | An unusual case of paraganglioma | A 32 year old African male an accounting clerk by profession presented with history of Weight loss of around 6 kilograms over a period of two years and episodes of Palpitations accompanied by Headaches. He also had episodes of perspiration and sometimes Giddiness. On several occasions he had been admitted in a local hospital with the above Symptoms. He however had no loss of vision at any time and there was no relief by the intake of sugar. A few times there was pain in the abdomen during such episodes which though he says was severe but short lasting. There were no bowel disturbances. He was taking multiple anti hypertensives and also Tab Morphine for pain during these episodes.\nOn initial presentation the patient was a thinly built, anxious looking individual and his palms were moist to touch. His thyroid was not enlarged and there were no unusual skin findings. The blood pressure recorded both in the ward and by us averaged 150/96mmHg. He had tachycardia to the tune of around 100/mins. Other than that the lungs, Central and peripheral nervous system examinations were normal. On examining his abdomen a vague, ill defined, mildly tender mass was felt in right hypochondrium and extending up to the epigastric region. Based on the symptomatology and general physical examination of this patient; a battery of investigations were ordered for establishing the cause of the hypertension. Blood sugars Serum electrolytes, Calcium, Phosphorous etc., all were normal. The Liver, Kidney parameters were also normal. The Renal Artery Doppler was normal. The ECG showed a Left Ventricular Hypertrophy pattern and the Echocardiogram revealed a concentric Left Ventricular Hypertrophy consistent with long standing hypertension. A 24hrs Urinary Metanephrines and normetanephrines study was ordered and an MRI abdomen scheduled.\nA large mass found indenting the great vessels. and .\nClinically correlating with the symptomatology a catecholamine producing lesion was suspected and the Urinary Normetanephrines-55217 nmol/L (normal 72-505) were grossly elevated. The Urinary Metanephrines 698 nmol/L (normal 9.3-122) too were very high. To finally confirm that the mass in abdomen was indeed responsible, an meta iodo benzyl guanidine (MIBG) scan was done .\nThe MIBG scan uses meta-iodobenzylguanidine[] scintigraphy that has a specificity of almost 100%in localising a pheochromocytoma. As shown above the tumor is clearly visualized.\nAlpha receptor blockade initiated first with Prazosin (minipres) a short acting alpha-one blocker. The Patient was given four pints of normal saline per day to prevent volume depletion and minimise the postural hypotension that usually accompanying alpha blockade. An Effective alpha blockade is signalled by >20mm fall in BP on upright posture. This was achieved. Beta blockade was then initiated with non-selective agent propranolol to control tachycardia due to catecholamines. His Blood pressure was maintained at approx. 110/78mm Hg. The Patient was operated successfully by the Oncosurgeon and intra operative pressure managed by the Anesthesiologist. Post operatively patient was monitored closely and propranolol restarted to cater for still circulating catecholamines. The Patient made a full and complete recovery and was eventually taken off anti hypertensives on discharge. | [[32.0, 'year']] | M | {'26688704': 1, '24381898': 2} | {} |
164,897 | 3872843-1 | 24,391,372 | noncomm/PMC003xxxxxx/PMC3872843.xml | Presumed late recurrence of Acanthamoeba keratitis exacerbated by exposure to topical corticosteroids | A 28-year-old female with keratoconus initially presented with a 1 week history of pain and photophobia in her left eye (OS). She was a rigid gas permeable contact lens wearer who admitted to regularly “cleaning” contact lenses in tap water supplied from a water tank. On examination, her best spectacle corrected vision (BSCVA) was 20/20 OD and 20/32 OS. A dendritic-like epithelial lesion was observed on the left cornea and she was treated with oc. acyclovir 5 times daily for presumed herpes simplex keratitis. However, 10 days later she remained symptomatic and a persistent dendritic epithelial lesion with granular subepithelial haze was noted. A diagnosis of AK was suspected and in vivo confocal microscopy (IVCM) confirmed the presence of Acanthamoeba cysts in the basal corneal epithelium OS []. A corneal scrape confirmed the diagnosis of AK.\nShe was treated with topical propamidine isethionate (Brolene 0.1%) and chlorhexidine (0.02%), both drops six times daily, with rapid clinical improvement. This treatment was tapered off over 11 months. The keratitis resolved leaving minor, mid-peripheral, anterior stromal scars. She confirmed that she completely discontinued contact lens wear following resolution of the keratitis, but maintained a BSCVA of 20/30.\nFive years later, she represented with a 5 month history of increasing discomfort and photophobia in the left eye although there was no associated redness. She had treated these symptoms herself intermittently with non-prescribed, across-the-counter Brolene 0.1% eye drops but as her symptoms failed to settle, she consulted her optometrist who prescribed topical corticosteroids without further investigation. Her symptoms initially improved, however, 3 weeks later she presented to the ophthalmology service with increasing pain and reduced vision. BSCVA was 20/30 OS and slit-lamp examination revealed localized, inferior corneal stromal edema []. IVCM confirmed Acanthamoeba cysts at the level of the basal epithelium []. Although there were no obvious cysts visible in the stroma, the view was partially obscured by stromal haze []. In view of the history, clinical findings, IVCM results, and absence of an epithelial defect; a corneal scrape was not performed. Treatment with topical polyhexamethylene biguanide (PHMB) 0.02% and Brolene 0.1% were commenced hourly by day and the keratitis subsequently improved over the following 4 weeks. The treatment was tapered over 9 months and she retained a BSCVA of 20/30. | [[28.0, 'year']] | F | {'15221303': 1, '32970675': 1, '11687533': 1, '9930269': 1, '19660733': 1, '19723132': 1, '18650660': 1, '20447096': 1, '8125716': 1, '19942941': 1, '12917179': 1, '24391372': 2} | {} |
164,898 | 3873319-1 | 24,380,070 | noncomm/PMC003xxxxxx/PMC3873319.xml | Pericoronal radiolucency associated with incomplete crown | A 7-year-old female patient was referred from a private dental clinic to evaluate a pericoronal radiolucency at the right lower molar region. On clinical examination, there was no sign of swelling or infection. A panoramic radiograph revealed a well-defined round unilocular radiolucency touching the developing crown of the right lower second molar, which was displaced downwardly. The cemento-enamel junction of the involved tooth was incomplete (). The CBCT images showed bucco-lingually expanded cortical plates associated with the lesion and a mandibular canal displaced toward the inferior cortex (). A provisional diagnosis of odontogenic keratocyst was made, and the lesion was excised but the tooth was preserved. The histopathological diagnosis proved to be an odontogenic keratocyst. The 6-month follow-up panoramic radiograph showed uneventful healing of the lesion with upward movement of the more developed lower right second molar (). | [[7.0, 'year']] | F | {'21731287': 2, '18230385': 1, '7018647': 1, '12022092': 1, '11402292': 1, '12405469': 1, '23120487': 1, '22442592': 1, '23714999': 1, '24380070': 2} | {'3873319-2': 2, '3873319-3': 2, '3873319-4': 2, '3873319-5': 2, '3873319-6': 2, '3873319-7': 2, '3873319-8': 2, '3125666-1': 1} |
164,899 | 3873319-2 | 24,380,070 | noncomm/PMC003xxxxxx/PMC3873319.xml | Pericoronal radiolucency associated with incomplete crown | A 12-year-old female patient was referred from a private dental clinic for evaluation of a cystic lesion in the left mandibular posterior region. On clinical examination, there was a swelling of the left mandible that was hard to the touch, but the pain and soft tissue swelling, which was the initial chief complaint of the patient, had subsided after the administration of antibiotics for several weeks. A panoramic radiograph revealed a well-defined round unilocular radiolucency surrounding the developing crown of the left lower third molar which had not developed to the cementoenamel junction yet (). The CBCT images showed a lingually expanded cortical plate associated with the lesion, but the buccal cortical plate was perforated. The mandibular canal was identified inferior and lingual to the lesion (). A provisional diagnosis of odontogenic keratocyst was made, and the lesion was excised with the extraction of the involved tooth. The histopathological diagnosis proved to be an odontogenic keratocyst with chronic inflammation and a foreign body reaction, and the cyst wall showed periosteum adhesion. | [[12.0, 'year']] | F | {'21731287': 2, '18230385': 1, '7018647': 1, '12022092': 1, '11402292': 1, '12405469': 1, '23120487': 1, '22442592': 1, '23714999': 1, '24380070': 2} | {'3873319-1': 2, '3873319-3': 2, '3873319-4': 2, '3873319-5': 2, '3873319-6': 2, '3873319-7': 2, '3873319-8': 2, '3125666-1': 1} |
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