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165,200 | 3888049-2 | 24,470,826 | noncomm/PMC003xxxxxx/PMC3888049.xml | Unusual cause of hyperammonemia in two cases with short-term and long-term valproate therapy successfully treated by single dose carglumic acid | A 17-months-old male has a history of mental and motor retardation, microcephaly, and epilepsy. He was admitted to the intensive care unit with seizure and respiratory depression. Supportive care in the form of mechanical ventilation, hydration, and antibiotics were administered. His medications included valproate (50 mg/kg/day po) and phenobarbital (5 mg/kg/day) for the last 1 year. An electroencephalography revealed hypsarrhythmia. Magnetic resonance imaging showed schizencephaly. He was consulted to department of pediatric metabolism due to diagnostic confusion with nonketotic hyperglycinemia. His metabolic tests were normal including tandem mass spectrometry and urine organic acid analysis. His serum ammonia level was 189 μg/dl. His liver function test results including aspartate aminotransferase and alanine aminotransferase were within normal limits. After discontinuation of VPA and initiation of carglumic acid 100 mg/kg by nasogastric route, his serum ammonia concentration decreased to 69 μg/dl within 12 h. His neurologic status improved within a day. | [[17.0, 'month']] | M | {'21981101': 1, '22858088': 1, '19952878': 1, '20184937': 1, '19667003': 1, '22587482': 1, '30034506': 1, '22180549': 1, '21978982': 1, '22305367': 1, '23271612': 1, '21700501': 1, '28007335': 1, '23798907': 1, '32905024': 1, '22619383': 1, '24470826': 2} | {'3888049-1': 2} |
165,201 | 3888095-1 | 24,422,172 | noncomm/PMC003xxxxxx/PMC3888095.xml | Cisplatin-induced haemolytic uraemic syndrome associated with a novel intronic mutation of CD46 treated with eculizumab | A previously well 27-month-old boy with no family history of kidney disease presented with a cervical mass unresponsive to antibiotics. The plasma lactate dehydrogenase (LDH) was elevated at 1600 iu/L (normal 266–500). Biopsy of the mass confirmed neuroblastoma with MYCN gene amplification. Bone marrow examination and metaiodobenzylguanidine (MIBG) scan showed no evidence of distant metastases. Pre-treatment, the plasma creatinine concentration was 21 μmol/L, and the glomerular filtration rate (GFR; measured by plasma disappearance of Technetium (Tc)-99m labelled Diethylene Triamine Pentacaetic Acid (DTPA) was 107 mL/min/1.73 m2 body surface area. Therapy was started with a combination of vincristine, etoposide, carboplatin, cisplatin and cyclophosphamide.\nOn Day 45 of treatment (35 days after the first cisplatin dose, 15 days after the second), the GFR had fallen to 60 mL/min/1.73 m2. This was presumed to be due to acute cisplatin nephrotoxicity. Two days later, the patient became fluid overloaded and hypertensive. He was profoundly pancytopaenic, which was attributed to chemotherapy-induced myelosuppression. The hypertension became increasingly severe (maximum value recorded 160 mmHg systolic) and he required five agents to control the blood pressure.\nHe required seven infusions of platelets and four of red blood cells between Days 50 and 59, suggesting that the pancytopaenia was not solely due to myelosuppression and the plasma creatinine concentration rose from 39 to 140 μmol/L. A diagnosis of HUS was considered. A blood film confirmed the presence of schistocytes, the LDH had risen to 2438 iu/L and the plasma haptoglobin concentration was <0.06 g/L (normal 0.5–2.0 g/L). Serum complement C3 (1.06 g/L) and C4 (0.20 g/L) concentrations were normal. Renal biopsy was considered unsafe at this time, but the results above were considered compatible with a diagnosis of HUS, likely due to cisplatin. Stool and blood cultures were negative, as were serological tests for HIV1&2. ADAMTS13 (von Willebrand factor-cleaving protease) levels were 80% of control values.\nDespite the dearth of information concerning the pathogenesis of cisplatin/carboplatin-associated chemotherapy, we opted for therapy with eculizumab partly because it was felt that his severe hypertension, profound thrombocytopaenia and small size made plasma exchange hazardous. He received the first dose of 600 mg the following day when his plasma creatinine was 155 μmol/L. The next day the plasma creatinine peaked at 160 μmol/L and it steadily decreased thereafter (). He also required progressively less blood product support. After a further dose of 300 mg a week later, he was maintained on fortnightly doses of 300 mg according to the manufacturer's dosing guidelines. Five weeks after administration of the first dose of eculizumab, the plasma creatinine concentration had reduced to 34 μmol/L, the plasma LDH was 532 iu/L and the GFR was 67 mL/min/1.73 m2. A decision was made to avoid further exposure to platinum-containing agents, and therapy was changed to a combination of vincristine, topotecan and doxorubicin. There was little further change in tumour size and, 126 days after starting chemotherapy, the tumour was surgically removed with clear excision margins and eculizumab was discontinued. At this time, the platelet count was 181 × 109/L and the plasma creatinine concentration was 34 µmol/L.\nThe platelet count fell to 138 four weeks after the last eculizumab dose and remained in the range of 98–160 × 109/L for the next 2 months. The plasma creatinine remained stable for 6 weeks, and then rose to 44 µmol/L. Two months after discontinuing the eculizumab, the plasma LDH had risen to 807 iu/L. The serum haptoglobin concentration was mildly reduced at 0.4 g/L and a blood film showed scanty red cell fragments. The plasma concentration of the terminal complement complex (sC5b-9) was elevated at 137 ng/mL (normal range <80). A renal biopsy was therefore performed.\nOf the 20 glomeruli in the light microscopy sections, five were globally sclerosed, and two showed periglomerular fibrosis. The patent glomeruli showed an increase in mesangial cells and matrix with segmental sclerosis and capsular adhesions. There were no platelet thrombi and extraglomerular vessels appeared normal. Immunostains for IgA, IgG, IgM and C3 were negative. There was focal tubular atrophy and interstitial fibrosis around damaged glomeruli. The toludine blue preparation and electron microscopy (EM) showed thickened glomerular capillary loops (double contour appearance), and areas of widening of the sub-endothelial space were seen. This space was filled with electron-lucent ‘fluffy’ material. This marked widening of the sub-endothelial space and fibrillar/particulate material is characteristic of HUS ().\nThe haematological, biochemical and histopathological features suggested active HUS, and eculizumab was therefore recommenced with an initial dose of 600 mg given 105 days after the last dose. Before restarting the eculizumab, the GFR was measured at 54 mL/min/1.73 m2, the serum complement C3 concentration was 0.9 g/L and the C4 was 0.25 g/L. The total haemolytic complement (CH50) was 111%, but the alternative pathway haemolytic complement (AP50) was low at 34% (normal 80–200). The haptoglobin was low at 0.4 g/L and rose to 0.96 g/L a week after the first dose. After 7 months of eculizumab therapy, the patient had normal haemoglobin (122 g/L), normal platelets (248 × 109/L) and a plasma creatinine concentration of 32 µmol/L. The GFR had risen to 71 mL/min/1.73 m2. The plasma concentration of sC5b-9 remained elevated at 133 ng/mL, casting doubt on the suitability of this assay for assessing activity and response to treatment.\nDNA extracted from a buccal smear at the time of diagnosis of HUS was amplified by PCR for all coding exons ± 10 bases of the CFH (factor H), CFI (factor I), C3 (complement component 3), CFB (factor B) and CD46 (membrane cofactor protein, MCP) genes. Amplified products were subjected to bi-directional Sanger sequencing (ABI), as previously described []. CD46 expression on cell surfaces was assessed on peripheral blood neutrophils after recovery from myelosuppression by flow cytometry using CD46 fluorescein isothiocyanate-conjugated antibody (BD Pharmingen, 555949).\nAn intronic sequence variant (c.1027+5G>T) was identified in CD46. This variant had not been previously reported nor was it detected in DNA from 188 normal control subjects. In silico splicing prediction analysis undertaken using Alamut (Interactive Bioscience Software, Seine Biopolis, 70 route de Lyons-la-Foret, 76 000 Rouen, France; ) suggests that this variant may cause aberrant splicing. Flow cytometry analysis showed reduced CD46 expression on neutrophils compatible with haploinsufficiency. After discussion with the parents, a decision was made not to test other family members, because the result was felt to be of limited clinical utility, outweighed by potential anxiety induced in a carrier. | [[27.0, 'month']] | M | {'25135763': 1, '33980166': 2, '28056875': 1, '28621343': 1, '16775594': 1, '9109216': 1, '12537762': 1, '23307876': 1, '33862523': 1, '7954269': 1, '21254897': 1, '19861685': 1, '21148255': 1, '32318323': 2, '27617140': 1, '28980667': 1, '11528253': 1, '27110144': 1, '2667747': 1, '25343125': 1, '10435899': 1, '6203452': 1, '24317637': 1, '22199322': 1, '21902819': 1, '9858517': 1, '24422172': 2} | {'8114690-1': 1, '7171698-1': 1, '7171698-2': 1} |
165,202 | 3888851-1 | 24,427,464 | noncomm/PMC003xxxxxx/PMC3888851.xml | Successful resuscitation of cardiac arrest caused by CO2 embolism with intra-aortic injection of epinephrine during off-pump coronary bypass surgery -a case report- | A 72-year-old male patient with acute coronary syndrome underwent OPCAB. He had a left ventricular ejection fraction of 42% and regional wall motion abnormalities compatible with multi-vessel territories. The patient was in normal sinus rhythm. Coronary angiography findings revealed total occlusion at the proximal left anterior descending artery (LAD), 50-75% stenosis at the mid to distal left circumflex artery, and 90% stenosis at the mid right coronary artery (RCA).\nCardiac surgery was performed through a median sternotomy, and the heart was displaced using a deep pericardial retraction suture, gauze swab, and tissue stabilizer. After confirming the lack of atheroma burden in the ascending aorta by epiaortic ultrasound examination, the left radial artery was connected to the ascending aorta. After completing the LAD grafting using the left internal thoracic artery, grafting was performed on the obtuse marginalis (OM) branch. The patient was in the Trendelenburg position, and norepinephrine was infused at a dose of 0.15 µg/kg/min. After stabilizer application, there was a temporary deterioration in the patient's hemodynamic status, which was stabilized without the aid of incremental doses of norepinephrine dosage.\nAfter opening the anastomotic site at the OM branch, the surgeon informed us the patient was bleeding from the arteriotomy site despite placement of a proximal snare. The CO2 blower was more aggressively used to aid grafting at a flow rate of 3-5 L/min. Bleeding was replaced by colloid solution, and all hemodynamic variables were stable: systemic blood pressure 121/58 mmHg, heart rate 59 beats/min, pulmonary arterial pressure 24/11 mmHg, cardiac index 2.6 L/min/m2 and mixed venous oxygen saturation 82%. Approximately 5 minutes after the commencement of grafting, the surgeon decided to insert an intracoronary shunt for better visualization. Suddenly, the patient's systemic blood pressure decreased to 64/56 mmHg despite increasing the norepinephrine dose from 0.05 µg/kg/min to 0.30 µg/kg/min. The pulmonary arterial pressure increased to 34/20 mmHg, and the mixed venous oxygen saturation decreased to 66%. Vasopressin 0.6 IU was quickly administered intravenously, and the transesophageal echocardiography (TEE) revealed a massive gas floating at the orifice of the RCA (). On the TEE, no gas was visible in the right heart without any patent foramen ovale. Although the patient remained in normal sinus rhythm, complete heart block occurred within minutes, and ventricular pacing was commenced. Over the next several minutes, ventricular fibrillation developed; despite aggressive treatment, including defibrillation, epinephrine, and direct manual cardiac massage, adequate circulation could not be restored, and cardiac massage was continued. Upon preparing for emergent conversion to cardiopulmonary bypass (CPB), epinephrine 300 µg was injected directly to the aortic root by the surgeon using a 26-gauge needle. Subsequently, manual cardiac massage was continued for several cycles, and spontaneous recovery of unspecified cardiac rhythm was observed. Then the patient's systemic mean arterial pressure gradually rose from 38 to 103 mmHg, and recovery of normal sinus rhythm and contractile performance followed immediately. Other hemodynamic parameters, including pulmonary arterial pressure, also returned to normal levels. The remaining grafts were performed successfully without conversion to CPB, and no sign of bleeding was observed at the puncture site in the aorta. The patient had an unremarkable postoperative course without neurologic deficits and was discharged 10 days after the surgery. | [[72.0, 'year']] | M | {'8029539': 1, '1315071': 1, '16159842': 1, '19586779': 1, '8457099': 1, '20154069': 1, '24427464': 2} | {} |
165,203 | 3888852-1 | 24,427,465 | noncomm/PMC003xxxxxx/PMC3888852.xml | Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography in preprocedural evaluation of cortriatriatum -a case report- | A 44-year-old female underwent elective tricuspid valve repair and atrial septal defect (ASD) closure due to known congenital cardiac anomalies suggesting cortriatriatum. These anomalies comprised tricuspid insufficiency, interatrial septal defects, and an abnormal membrane in the LA in preoperative 2D TEE. She presented with peripheral edema, especially in the lower extremities, frequent upper respiratory tract infections and mild exertional dyspnea without any other remarkable medical history.\nAnesthetic induction and tracheal intubation was performed using target-controlled infusion (TCI) of propofol (effect site 2.0 mcg/ml) and remifentanil (plasma 15-20 ng/ml) as well as bolus rocuronium 0.9 mg/kg, adjustment of TCI-propofol (effect site concentration of 1.0-1.2 mcg/ml to maintain BIS value 40-60) and cisatracurium infusion (0.2 mcg/kg/min) were followed for anesthesia maintenance. After anesthetic induction, pulmonary artery catheter placement was placed in the right internal jugular vein under ultrasound-guidance. A 3D TEE probe (X7-2t transducer; Philips Healthcare, Andover, MA, USA) was placed and connected to TEE console (iE33™, Philips Healthcare, Andover, MA, USA), intraoperative 2D and 3D TEE examinations were then performed. The 2D TEE examination showed an enlarged right atrium (RA); a relatively small and septated LA with a solid, thin echogenic membrane (indicating the LA diaphragm) separating the LA into two distinct chambers; a larger (proximal) LA chamber in the superior aspect; and a small (distal) LA chamber in the inferior aspect (). The distal LA chamber had a mitral valve (MV) apparatus and communicated with the left ventricle (LV). Although intraoperative 2D TEE findings corresponded quite well with preoperative TTE findings, they could not provide the detailed information regarding the extent of the LA diaphragm and the shape of the diaphragmatic defect. Important information for understanding the intracardiac flow pattern of the systemic and pulmonary circulation could not be provided by using 2D TEE alone. Additional real time 3D "en face" image and cropped images from the real time 3D volume images facilitated a complete understanding of the whole features of the complex anomalies of this case, including the shape and size of the diaphragm in a considerably easier and faster manner. 3D TEE showed that the RA dimension was much larger than the LA dimension with a thin membranous diaphragm traversing the whole LA to form a horizontal roof between the proximal and distal LA chambers. The LA diaphragm did not have any holes: the proximal LA chamber communicated with the RA through a 2 cm defect in the interatrial septal area, which allowed the drainage of pulmonary venous blood from the proximal LA into the enlarged RA and thus contributed to the role of the RA as a mixing chamber for systemic, pulmonary, and coronary venous blood. The mixed blood in the RA then flowed through the tricuspid valve to reach the right ventricle, as well as through a 4 cm ASD to reach the distal LA chamber. The relatively small distal LA served as a functional LA with a left atrial appendage and MV apparatus at the bottom ().\nRight atriotomy was performed through a median sternotomy after initiation of moderate hypothermic cardiopulmonary bypass. A self-retaining retractor was used to maximize the exposure of all intracardiac structures, including the LA diaphragm, atrioventricular valve apparatus, and coronary and pulmonary venous openings. After confirming the above determinations by surgical perspectives, the following procedures were performed; full resection of the LA diaphragm, tricuspid valve ring annuloplasty, removal of the diaphragmatic defect by constructing of a new interatrial septum using a bovine pericardial patch, and closure of the ASD (). The newly constructed septum separated the pulmonary and systemic flow which draining into LA and RA, respectively. | [[44.0, 'year']] | F | {'1327795': 1, '16581480': 1, '16839391': 1, '21349109': 1, '20553320': 1, '1597232': 1, '24427465': 2} | {} |
165,204 | 3888853-1 | 24,427,466 | noncomm/PMC003xxxxxx/PMC3888853.xml | Respiratory insufficiency and dynamic hyperinflation after rigid bronchoscopy in a patient with relapsing polychondritis -a case report- | A 35-year-old man who had a history of RP (66 kg and 168 cm) was scheduled for rigid bronchoscopy to relieve of his worsening dyspnea. Preoperative fiberoptic bronchoscopy revealed subglottic stenosis (6 mm in diameter, 70% narrowing) (), and laser splitting of the subglottic web was planned. Notable physical findings are flabby ears and nose. Preoperative chest tomography showed diffuse narrowing of the trachea (9.4 mm in diameter) and main bronchi (7.6 mm in diameter), in addition to right lower lobe partial atelectasis ().\nGeneral anesthesia was induced with propofol (target plasma concentration 5 ug/ml) and remifentanil (target plasma concentration 4 ng/ml), using a target controlled infusion pump (Orchestra IS3, Fresenius Vial, Breezins, France) after injection of lidocaine 40 mg. Ninety seconds after injection of succinylcholine 100 mg, a rigid bronchoscope was inserted by a pulmonologist. Ventilation was manually assisted with 10 L/min of oxygen. In addition to subglottic stenosis, cartilage loss in the entire trachea and airway narrowing, due to luminal collapse, was observed (). Fibrotic band was cut radially by a laser () and ID 7.5 tube was intubated and placed right above the carina. Total procedure time was about 10 minutes. At the present time, stent insertion was not considered as necessary by the pulmonologist.\nHydrocortisone 100 mg was injected to reduce airway edema by request of the pulmonologist. Although the patient's spontaneous respiration was returned right after the end of the procedure, it was very weak and ineffective. The tidal volume was detected as less than 50 ml and assisted ventilation could not augment expiratory tidal volume significantly (50-100 ml). We encouraged the patient to breathe deeply, but there was no improvement of the tidal volume and minute ventilation, and eventually 20 minutes after the return of spontaneous ventilation, end-tidal carbon dioxide (ETCO2) level increased gradually from 60 mmHg to 110 mmHg. He became irritable with jerky movement of the four limbs, and facial flushing accompanied. His blood pressure (BP) and heart rate (HR) increased to 180/110 mmHg and 110/min, respectively. Presuming that the patient's excessive respiratory effort and anxiety could interfere with the effective ventilation assistance, we restarted the infusion of propofol (2 ug/ml) to sedate the patient. However, the ventilation assistance was still non-effective.\nWe concluded that the patient was in a state of respiratory failure and recommended the pulmonologist for mechanical ventilation. Waiting for the preparation of ICU bed, the pulmonologist wanted to encourage the patient to breathe in a sitting position after extubation, but the trial was not successful and his SpO2 decreased to 90%. The patient was reintubated with ID 6.5 tube with stylet after an injection of 3 mg of midazolam. Tube was fixed at 24 cm and breathing sound was generally coarse, and in the right lower lung field, breathing sound decreased more prominently. There was no secretion on suction. After injection of additional 100 mg of succinylcholine, we started hyperventilation to reduce ETCO2 level. In pressure controlled mode (PCV), the setting was pressure above positive end-expiratory pressure (PEEP) 28 cmH2O, PEEP 5 cmH2O, peak inspiratory pressure 33 cmH2O, RR 20 /min, I : E ratio 1 : 1.5 and tidal volume was measured as 250 ml. ETCO2 decreased from 110 mmHg to 60 mmHg over 20 minutes and SpO2 was well maintained as 100% at FiO2 0.5.\nAfter 20 minutes of mechanical ventilation, HR increased from 110 /min to 150 /min, and BP decreased from 120/70 mmHg to 80/40 mmHg abruptly. On the presumption of near tampon status from dynamic hyperinflation (DHI), we immediately changed the mechanical ventilation into manual ventilation, decreased RR into half, and permitted abundant expiration time after several seconds of apnea period. We could not feel any build-up of high pressure through the reservoir bag. The right radial artery was cannulated for continuous hemodynamic monitoring.\nFew minutes after manual ventilation, the patient's hemodynamic status was stabilized (BP 120/70 mmHg, HR 110 /min). Mechanical ventilation was resumed at different settings to avoid DHI. In PCV mode, the setting was pressure above PEEP 28 cmH2O, no PEEP, RR 13 /min, I : E ratio 1 : 2, FiO2 1.0 and tidal volume was measured as 230 ml. ETCO2 was maintained at 60 mmHg without showing further increase or decrease. Ten minutes after resuming mechanical ventilation, arterial blood gas showed pH 7.25, PaCO2 75 mmHg, PaO2 356 mmHg, and HCO3- 33 mEq/L. We decreased FiO2 to 0.5 and transferred the patient to the ICU. Thirty minutes after ICU admission, arterial blood gas revealed pH 7.28, PaCO2 66 mmHg, PaO2 104 mmHg, and HCO3- 31 mEq/L under the same setting of mechanical ventilation as in the operating room.\nDuring the repeated weaning and extubation failure, his lung condition has aggravated with increased lung infiltrative opacity. He received tracheostomy at postoperative 16th day and on ventilator support for 27 days, postoperatively. In fiberoptic bronchoscopy taken at postoperative 27th day, generalized tracheobronchomalacia and edematous change were present in the entire trachea and main stem bronchi, and total luminal collapse was observed during coughing or suctioning. He was recommended with Y stent insertion, but refused, and is taking supportive care on the ward. | [[35.0, 'year']] | M | {'1989814': 1, '15984823': 1, '9813506': 1, '16088607': 1, '26711694': 1, '9042655': 1, '775252': 1, '7075306': 1, '10492294': 1, '2393145': 1, '19762318': 1, '12077711': 1, '24427466': 2} | {} |
165,205 | 3888854-1 | 24,427,467 | noncomm/PMC003xxxxxx/PMC3888854.xml | Anesthetic management of a patient with undiagnosed paraganglioma -a case report- | A 55-year-old female patient (weight 52 kg, height 155 cm) with multiple myoma was admitted for transabdominal hysterectomy (TAH). She suffered from severe dysmenorrhea and menorrhagia for several years. The patient had reported intermittent chest tightness, feeling of palpitations and a headache prior to admission. She had no history of diabetes, hypertension or any other systemic disease. At admission she had vital signs of blood pressure 130/75 mmHg, pulse rate 81 beats/min, respiratory rate 20 times/min and body temperature 36.3℃. Preoperative laboratory tests were within normal limit with the exception of severe anemia (hemoglobin = 5.1 g/dl, hematocrit = 19.5%). An abdominal magnetic resonance imaging (MRI) showed multiple and variable sized myomas and two simple hepatic cysts (). She received 4 pints of packed red cells (PRC) for over three days to correct the anemia in preparation for surgery.\nUpon arrival to the operating room, she seemed to be anxious. Standard monitoring with electrocardiogram, pulse oximetry, and noninvasive blood pressure were applied before the induction of anesthesia. The initial vital signs were a blood pressure (BP) of 180/105 mmHg, pulse 77 beats/min, normal sinus rhythm on electrocardiogram (ECG) and arterial saturation of 99%. To reduce anxiety, 3 mg of midazolam was injected and general anesthesia was induced with propofol and remifentanil using a target-controlled infusion (TCI) system. After lidocaine administration, the target effect-site concentration (Ce) of propofol 4 µg/ml and remifentanil 4 ng/ml were started with 100% O2 and rocuronium 0.6 mg/kg was administered and used to facilitate tracheal intubation. Total intravenous anesthesia (TIVA) with propofol-remifentanil-50% N2O in O2 was used for anesthetic maintenance. The target Ce of propofol was 2.5-3.5 µg/ml and of remifentanil 2.5-3.0 ng/ml, respectively. The value of bispectral index (BIS) was maintained in the 35-45.\nDuring the surgical exploration for TAH, a retroperitoneal encapsulated hard mass measuring 5.5 × 4.5 × 5 cm sized was found incidentally with huge uterine myomas (20 × 18 cm). It lay at the para-arotic space along L3 vertebra with adhesion to the aorta. The operation for TAH began and the patient stayed hemodynamically stable as surgery proceeded. Approximately 135 min after abdominal hysterectomy started, a surgical excision for a retroperitoneal mass was continued a general surgery team. When the surgeon manipulated the retroperitoneal mass, the patient's BP suddenly increased to 220/130 mmHg with a pulse rate of 140 (beats/min). The patient showed with frequent bigeminy on the ECG. The depth of anesthesia was deepened by increasing the Ce of propofol from 2.5-3.5 µg/ml to 4.5-6.0 µg/ml and remifentanil from 2.5-3.0 ng/ml to 4.5-5.0 ng/ml, respectively. The value of BIS decreased from 40-50 to the range of 25-30. But the blood pressure continued to rise reaching 180 mmHg for systolic and 100 mmHg for diastolic. To control the increased BP and pulse rates, a continuous infusion of nicardipine (2.0 mg/hr) was started and an intermittent bolus of labetalol (15 mg of labetalol in three doses of 5 mg each) with additional esmolol (total 30 mg) also used. However these treatments were not effective and the BP still remained at 170-180 mmHg for systolic and 95-100 mmHg for diastolic with increased heart rates in the range of 115-125 (beats/min) whenever the surgeon directly manipulated the mass. Radial arterial line was inserted after a modified Allen's test to monitor the labile BP and arrhythmia and to draw arterial blood gas (ABG) analysis sample. The ABG analysis revealed pH of 7.46, PaCO2 33 mmHg, PaO2 246 mmHg, and oxygen saturation 98% on FiO2 0.5. Despite the increased anesthetic depth and anti-hypertensive therapy, the BP remained a wide range BP of 170-100 mmHg/60-80 mmHg. It was difficult to control due to the frequent swing between hypertension and hypotension. Therefore we highly suspected an unrecognized ectopic pheochromocytoma.\nThe retroperitoneal mass was completely removed approximately 60 min. Following the tumor removal, the BP decreased to as low as 75-85 mmHg/45-50 mmHg and there was a slight increased heart rate 90 (beats/min) but it remained as low state despite fluid administration. When 2100 ml of fluid was administered during the whole period of anesthesia (300 min), 420 ml of crystalloid was administered at the time of retroperitoneal paraganglioma removal. After the removal of retroperitoneal mass, we administrated 500 ml of volume expander and 2 pints of PRC and started a continuous dopamine infusion (5 mcg/kg/min) with intermittent phenylephrine 50-100 mcg bolus injection to improve the patient's hemodynamic status. The estimated blood loss during the TAH was about 250 ml and 200 ml for the retroperitoneal mass. The mean urine output was 140 ml/hr and the total was 700 ml. After surgery, the patient showed BP 80-85 mmHg for systolic and 50-60 mmHg for diastolic and pulse 90 beats/min and the patient sent to the intensive care unit for close monitoring. The mass confirmed histopatholgically as an extra-adrenal paraganglioma a week later (). | [[55.0, 'year']] | F | {'17082709': 1, '21862435': 1, '22148096': 1, '3706810': 1, '21826022': 1, '17102068': 1, '18224469': 1, '21584168': 2, '16966036': 1, '17156452': 1, '17989126': 1, '19525677': 1, '24427467': 2} | {'3079871-1': 1} |
165,206 | 3888855-1 | 24,427,468 | noncomm/PMC003xxxxxx/PMC3888855.xml | Rapid identification of spontaneously resolving capnothorax using bedside M-mode ultrasonography during laparoscopic surgery: the "lung point" sign -two cases report- | A 40-year-old woman, 169 cm, 57 kg, underwent laparoscopic right adrenalectomy due to an adrenal pheochromocytoma. Preoperative evaluation of the patient was unremarkable. General anesthesia was induced using thiopental sodium, fentanyl, vecuronium and sevoflurane. A 7.5 Fr 3-lumen catheter was inserted under ultrasonographic guidance (linear probe: UST-5546, 5-10 MHz, machine: Prosound SSD-4400®, Aloka Medical, Co., Ltd., Tokyo, Japan) into the right internal jugular vein, and lung sliding was confirmed in both thoraces. Next, the patient was placed into the left lateral decubitus position. Before incision, ETCO2, Pmax, and peripheral oxygen saturation (SpO2) were determined to be 33 mmHg, 17 cmH2O, and 100%, respectively. Pneumoperitoneum was established using CO2, intraabdominal pressure was maintained < 15 mmHg, and Pmax was 23 cmH2O at the time. Thirty minutes after inducing pneumoperitoneum, the ETCO2 and Pmax levels gradually increased to 43 mmHg and 30 cmH2O, respectively. Thereafter, SpO2 decreased acutely to 92%. On auscultation, the breath sounds from the left lung field were normal. However, the right side of the chest demonstrated no sounds. Immediately, the fraction of inspired oxygen (FiO2) increased from 0.5 to 0.8, and the endotracheal tube was withdrawn back to 2 cm in order to rule out endobronchial intubation. Because the depth of the endotracheal tube was 18 cm at the incisor teeth and confirmed the depth of endotracheal tube by cuff palpation at the sternal notch, we supposed that it was enough to rule out one-lung intubation without using bronchoscope. SpO2 was maintained at between 98-100%, though the right thorax was still silent. Pneumothorax was strongly suspected, and the chest was examined using ultrasonography. Lung sliding and seashore sign were demonstrated in the left lung (), however there was no sliding with barcode sign in the right lung (). Although the surgeon simultaneously inspected the diaphragm in detail, no apparent injuries or defects were found. Because the vital signs were stable and SpO2 and ETCO2 were normal, as indicated by an increased FiO2 and respiratory rate, the operation was laparoscopically completed.\nWhen the operation was concluded, a positive end-expiratory pressure (PEEP) of 5 cmH2O was applied to inflate the collapsed lung. The patient was examined using ultrasonography whilst in the supine position, and at the same time, portable chest radiography was called to assess a pneumothroax. The ultrasonographic probe was placed on the right lower lateral chest wall between anterior and mid axillary line (), and we identified the "lung point" sign, which can be used to diagnose pneumothorax []. Also, chest radiography indicated a < 30% collapse of the right lung (). As the right hemithorax was continuously examined using ultrasonography, auscultation of the right lung improved, as well as the appearance of lung sliding sign and the disappearance of the lung point sign in whole right hemithorax within about 30 minutes after the end of the operation. No hemodynamic instability was noted, and SpO2 was maintained at 100% using only medical air. Hence, pneumthorax was considered to be capnothorax, and the patient was extubated without the insertion of a chest tube. The patient was transferred to the postanesthetic care unit (PACU) and did not complain about any respiratory disturbance. | [[40.0, 'year']] | F | {'21679560': 1, '8053989': 1, '12355007': 1, '21792051': 1, '10589653': 1, '31964200': 2, '7587439': 1, '18186681': 1, '7486090': 1, '12208441': 1, '16141018': 1, '11905868': 1, '14569446': 1, '11126253': 1, '20508801': 2, '8236025': 1, '24427468': 2} | {'3888855-2': 2, '7113711-1': 1, '2876865-1': 1} |
165,207 | 3888855-2 | 24,427,468 | noncomm/PMC003xxxxxx/PMC3888855.xml | Rapid identification of spontaneously resolving capnothorax using bedside M-mode ultrasonography during laparoscopic surgery: the "lung point" sign -two cases report- | A 39-year-old man, 165 cm, 63 kg, was scheduled for living right donor nephrectomy via hand-assisted laparoscopic surgery (HALS). The patient was normal on preoperative evaluation and presented without a specific medical history. The induction of anesthesia with thiopental sodium, fentanyl, vecuronium and desflurane was uneventful. The patient was placed in the left lateral decubitus position. After CO2-pneumoperitoneum was induced, the intraabdominal pressure was maintained < 14 mmHg, and ETCO2, Pmax, and SpO2 were 33 mmHg, 23 cmH2O and 100%, respectively. When the upper pole of the kidney was approached, the diaphragm was injured by the dissector, which was immediately repaired. The surgeon inquired about the status of the right lung because the right hemidiaphragm was bulging. The lung sounds in the right chest were decreased on auscultation, and ETCO2 and Pmax were increased to 42 mmHg and 30 cmH2O, respectively. However, SpO2 was maintained at 100%. At that point, we evaluated the right thorax using ultrasonography (linear probe: L25x, 6-12 MHz, machine: M-turbo System®, Sonosite Inc., Bothell, WA, USA) in the operative field, and the "lung point" sign was found at the right lower anterior axillary line (). Considering the location of the lung point sign, a small amount of pneumothorax was expected. However, because the hemodynamic parameters were maintained in a normal range, the operation was continued via HALS and a PEEP of 5 cmH2O was applied.\nAt the end of the surgery, the surgeon requested a portable chest radiography and we concurrently examined the patient using ultrasonography in the supine position. Chest radiography indicated a pneumothorax < 20% (), and the range of the pneumothorax which was indicated by the lung point sign was gradually diminished. Because signs of cardiopulmonary instability were not found and SpO2 was maintained without an increase in FiO2, the insertion of a chest tube was not necessary and we safely extubated the endotracheal tube. The patient was transferred to the PACU and did not complain of any respiratory discomfort. | [[39.0, 'year']] | M | {'21679560': 1, '8053989': 1, '12355007': 1, '21792051': 1, '10589653': 1, '31964200': 2, '7587439': 1, '18186681': 1, '7486090': 1, '12208441': 1, '16141018': 1, '11905868': 1, '14569446': 1, '11126253': 1, '20508801': 2, '8236025': 1, '24427468': 2} | {'3888855-1': 2, '7113711-1': 1, '2876865-1': 1} |
165,208 | 3888897-1 | 24,459,661 | noncomm/PMC003xxxxxx/PMC3888897.xml | A Case of Fibrous Pseudotumor of the Paratesticular Region | A 78-year-old male who had a medical history of hydrocele formation five years earlier presented to our institution with a hard nodule in the left inguinoscrotal region that had existed for three years. The patient had not sought any medical treatment for the hydrocele and it had resolved spontaneously. On physical examination, the nodule was mobile, hard, and non-tender and measured 3 cm in diameter. A radical orchiectomy was performed, and the nodule, along with the testis and spermatic cord, was excised out through an inguinal incision (). Grossly, the testis, cord, and nodule could be identified separately. The cord was thick and nodular over an area of 2.5×2.5 cm, and a cut section of the nodule was solid and grey-white. On microscopic examination, the lesion showed spindle-shaped cells with a round-to-oval nucleus and a moderate quantity of eosinophilic cytoplasm with indistinct cytoplasmic margins (). Sections from the testis, epididymis, and vas deferens were unremarkable. On immunohistochemistry, the cells were reactive with smooth muscle antigen and muscle specific actin (), and negative for S-100, keratin, and CD34. A final diagnosis of paratesticular fibrous pseudotumor was made. | [[78.0, 'year']] | M | {'11018636': 1, '1536613': 1, '3527934': 1, '26664509': 1, '6538178': 1, '2091005': 1, '1599023': 1, '9060599': 1, '27441080': 2, '22232570': 1, '20957491': 1, '24459661': 2} | {'4935829-1': 1} |
165,209 | 3888898-1 | 24,459,662 | noncomm/PMC003xxxxxx/PMC3888898.xml | An Unusual Presentation of Crossed Testicular Ectopia as an Incarcerated Inguinal Hernia | A healthy 10-month-old boy was admitted to the emergency room with a painful swelling in the left inguinal region. Physical examination showed a tender 2-cm lump in the left inguinal canal. Inguino-scrotal ultrasonography in this patient showed a left inguinal hernia with two gonads in the left scrotal sac and an impalpable right non-scrotal testis (). In addition, we could not find evidence of persistent Müllerian duct syndrome, which is characterized by the presence of a uterus and fallopian tubes in abdominal ultrasonography. There was no evidence of developmental malformations of the external genitalia, such as hypospadias, bifid scrotum, or micropenis. After urgent manual reduction for an incarcerated inguinal hernia, left inguinal exploration was undertaken. A thin-walled inguinal hernial sac was found, containing two normal-sized and normal-shaped testes that were attached to one gubernaculum from the left inguinal ring (). Each had its own blood supply and had separate vasa deferentia. After left inguinal herniorrhaphy, the gubernaculum was divided to strengthen each of the spermatic cord without creating undue tension on either side. The left testis was placed into the left subdartos space and the ectopic right testis was fixed transseptally into the right subdartos space. | [[10.0, 'month']] | M | {'17990043': 1, '15106000': 1, '18826642': 2, '20661610': 1, '17706709': 1, '9681816': 1, '8729871': 1, '18836686': 1, '24459662': 2} | {'2580765-1': 1} |
165,210 | 3888899-1 | 24,459,663 | noncomm/PMC003xxxxxx/PMC3888899.xml | A Case of Duplicated Vas Deferens Found Incidentally during Varicocelectomy | A 22-year-old male patient presented with a worm bag-like scrotal mass accompanied by scrotal pain. His past medical history and family history was insignificant. On physical examination, he was diagnosed with left varicocele (grade 3), and there were no other abnormal findings in the external genitalia. A semen analysis revealed asthenospermia and it was decided to perform varicocelectomy. Using an inguinal approach, varicocelectomy was performed through a small skin incision over the inguinal canal under spinal anesthesia. Upon isolating the left spermatic cord, two vasa deferentia were identified in the spermatic cord (). On Doppler, both structures showed no signal, whereas an arterial signal was noted in the vascular structure lateral to the duplicated vas deferens. They were separated from the level of the internal inguinal ring to the level of the epididymal tail (). After duplication of the vas deferens was confirmed, the enlarged veins were ligated and varicocelectomy was performed. The other side of the scrotum was also carefully examined, but it was confirmed that only one vas deferens was present on that side. The patient's postoperative course was uneventful. The postoperative abdominal-pelvic computed tomography (CT) scan did not identify any genitourinary malformations such as ipsilateral renal agenesis. At the 6-month follow-up, there were no signs of varicocele and the external genitalia were found to be otherwise normal. | [[22.0, 'year']] | M | {'21822600': 1, '3351722': 1, '27840763': 2, '9123691': 1, '8437095': 1, '15602649': 1, '16985813': 1, '16174056': 1, '32231992': 1, '13810868': 1, '8477322': 1, '33828435': 2, '24459663': 2} | {'7993433-1': 1, '5093270-1': 1} |
165,211 | 3888922-1 | 24,454,333 | noncomm/PMC003xxxxxx/PMC3888922.xml | Coarctation of aorta with complete aortic occlusion | An 81-year-old man was referred to our clinic for evaluation and treatment of typical angina during exercise. His medical history included arterial hypertension for many years; there was no history of traumatic injury or Takayasu's arteriitis. He was otherwise asymptomatic. On physical examination, the blood pressure was 140/85 mmHg in both arms. The lower extremity pulses were diminished and delayed. The patient denied symptoms of claudication and weakness of his legs and reported to walk more than one kilometer without any problems. Results of routine blood chemistry and urine analysis were normal. Electrocardiography revealed left ventricular hypertrophy without evidence of prior myocardial infarction. Chest X-ray demonstrated typical rib notching ().\nConcentric left ventricular hypertrophy, a normal tricuspid aortic valve, a normal mitral valve, and normal left ventricular systolic function could be demonstrated on echocardiographic examination. However, the distal part of the aortic arch was not adequately visualizable. Coronary angiography () was performed via the radial route, and severe triple-vessel disease was detected (SYNTAX (SYNergy between PCI with TAXUS™ and Cardiac Surgery) Score of 35 points).\nAortography () revealed a postductal CoA with total occlusion of the aortic arch. Simultaneous pressure tracings in the aortic arch and the descending aorta demonstrated a pressure gradient of 70 mmHg. There was no evidence of clot formation in the blind end of the aorta distal to the coarctation.\nMagnetic resonance (MR) angiography was performed and confirmed the aortic occlusion just below the origin of the left subclavian artery, showed slight post-stenotic dilatation, and distinct collateral circulation ().\nCranial MR was without evidence of intracerebral aneurysm. The patient refused operative treatment of his triple-vessel coronary artery disease, and underwent finally a staged percutaneous coronary intervention procedure. Surgical correction of the CoA was not performed because the patient was asymptomatic with a good exercise tolerance and his hypertension was well controlled with a combination of three antihypertensive agents (β-blocker, diuretic, and angiotensin-receptor-blocker). At clinical follow-up after 8 months the patient remained free of symptoms. | [[81.0, 'year']] | M | {'11789794': 1, '15745298': 1, '5470045': 1, '12084585': 1, '15028367': 1, '9714494': 1, '2246903': 1, '2791247': 1, '10355415': 1, '26781635': 2, '10844392': 1, '9385918': 1, '8874951': 1, '24454333': 2} | {'4717556-1': 1} |
165,212 | 3888988-1 | 24,471,000 | noncomm/PMC003xxxxxx/PMC3888988.xml | A case of Hymenolepis diminuta in a young male from Odisha | An 18-year-old male, farmer by profession presented to the out-patient department (OPD), for intermittent generalized maculopapular pruritic rash with vague left iliac fossa pain for 4-6 months. Patient had been evaluated by many physicians and dermatologists during this period, but without a final diagnosis. Many attributed this as food allergy (to sea foods). He had received albendazole, ivermectol, cetirizine and even short course oral corticosteroid (prednisolone 1 mg/kg for 10 days). At the time of admission temperature was 98°F, pulse 90/min, blood pressure 130/90 mm Hg and respiratory rate was 18/min. Examination of chest and heart did not reveal any specific abnormality. Abdominal examination did not reveal any significant objective finding. Patient was conscious without any focal neurological deficit. A provisional diagnosis of urticaria was made and thoroughly investigated. The initial laboratory investigation revealed hemoglobin was 10.6 g/dl, otal leukocyte count - 8.8 × 103/cmm, differential count - P68%, L26%, E4% and absolute eosinophil count - 380/cmm, total platelet count 220 × 103/cmm. Erythrocyte sedimentation rate - 46 1st h. Random plasma glucose was 118 mg/dl, blood urea nitrogen - 18 mg/dl, serum creatinine - 0.8 mg/dl, serum Na+- 146 mmol/l, serum K+ - 4.6 mmol/l. Urine examinations did not reveal any abnormality. Stool examination revealed numerous bile stained spherical eggs, 70-80 μm in diameter, which lacked polar filaments and presented a thick shelled outer membrane and a thin inner membrane containing six hooklets suggesting H. diminuta [Figures , and ]. Urine and blood culture were sent for aerobic culture. Allergen challenge test result was awaited. Ultrasonography of the abdomen and pelvis did not reveal any abnormality. At the end of this initial evaluation, we were at a dilemma whether to accept the diagnosis of hymenolepiasis and if at all we accept the diagnosis then how to treat it. We again ordered for the stool test for parasite and the second sample also showed eggs of H. diminuta. Three days later both the urine and blood culture did not grow any organisms and computed tomography scan of abdomen did not provide us any further information. Finally we started treatment in the line of hymenolepiasis and the patient was given praziquantel 1000 g (20 mg/kg) with breakfast on day 0. Post-treatment period was uneventful for 24 h. We discharged the patient with advice to repeat the dose after 7 days and visit the OPD after 1 month. Patient turned up after around 5 weeks and there was no relapse of the symptoms. We again searched for H. diminuta eggs in stool for two consecutive days but both the samples were found negative for any parasite. We followed-up the patient for 6 months at varying intervals and there was no sign of relapse both symptomatically and parasitologically in stool. | [[18.0, 'year']] | M | {'6537409': 1, '8762672': 1, '10093431': 1, '2496975': 1, '26290218': 1, '28719963': 1, '30693221': 2, '28719332': 1, '18417890': 1, '20585535': 1, '29062858': 1, '9666029': 1, '5173451': 1, '27047007': 1, '24471000': 2} | {'6329270-1': 1} |
165,213 | 3888999-1 | 24,470,846 | noncomm/PMC003xxxxxx/PMC3888999.xml | Dentigerous Cysts in Four Quadrants: A Rare and First Reported Case | A 24-year-old male reported to the Department of Oral and Maxillofacial surgery in Mayya Multispecialty Hospital, Bangalore, India, complaining of asymptomatic facial swelling of 1 year. An intraoral clinical examination revealed a non-tender bilaterally palpable swelling. The swelling extended from the first premolar to third molar region on the right, and from the first premolar region to the retromolar trigone on the left [Figures and ]. The swelling obliterated the buccal vestibule bilaterally and there was associated mobility of the first and second molars on both sides of mandible. The overlying mucosa appeared normal in color, non-tender, hard in consistency, and smooth on palpation. The third molars were unerupted in all the four quadrants. There was no history of paresthesia in lower lip region. All the sensations were found to be normal in lower lip area on clinical evaluation. Vitality was found to be present in first and second molars, premolars, and anterior teeth after thermal stimulation test using hot gutta percha application on teeth.\nA radiographic investigation by CT scan revealed a unilocular well-defined corticated hypodense lesion involving impacted mandibular third molars bilaterally []. The dimensions of the hypodensities were 31 and 42 mm anteroposteriorly on the right and left, respectively. There were also associated supernumerary teeth on both sides. The supernumerary teeth were small in size than third molars with single conical root and were placed coronally in close relation to third molars on both sides. The hypodensities were associated with radicular resorption of the first and second molars. Radiographs also revealed the inferior displacement of the mandibular canal. Incidentally another bilateral hypodense lesion associated with the crowns of maxillary third molars was observed. CT-Scan revealed a well-defined and corticated margin was observed surrounding the unilocular hypodensity. In maxilla, CT-scan revealed the dimensions of hypodensities around the crowns of third molars to be 15 and 18 mm in diameter on the right and left side, respectively [Figures and ]. There was no root resorption of adjacent teeth observed in maxilla. In all four quadrants the hypodense lesions were attached to the cementoenamel junction of the third molars at an acute angle which is one of the classical radiographic finding in cases of dentigerous cyst. Coronal sections and three-dimensional CT revealed bilateral lingual and buccal cortical perforations in mandible []. On aspiration a straw-colored fluid was obtained from each of these cystic lesions which is diagnostic of a dentigerous cyst [].\nAfter clinical and radiological examination a provisional diagnosis of dentigerous cyst was made. Multiple incisional biopsies were taken and histopathological examination revealed a cystic lumen lined by two to three-layer thick non-keratinized stratified squamous epithelium that resembled reduced enamel epithelium. The connective tissue wall was composed of a fibrous capsule which confirmed the diagnosis of dentigerous cyst [Figures and ].\nUnder general anesthesia the cystic lesions in all four quadrants were enucleated along with impacted third molars and supernumerary teeth. Also in both quadrants of mandible extraction of the first and second molars were carried out as they were mobile. The resultant cavities [] in the mandible after enucleation were packed with bismuth, iodoform, paraffin paste, and healing was by secondary intention []. Follow-up dressing was done after 24 hours postoperatively for the first 2 weeks and then follow-up of intraoral wound irrigation and dressing was carried out once a week for next 2 months for healing of the bony defects in mandible intraorally. Postoperative follow-up orthopantomographs (OPGs) were taken at regular monthly intervals. Six months postoperatively the dimensions of the cystic cavity were reduced both clinically and radiographically [Figures and ]. The patient is still under routine follow-up and will be closely monitored for long-term outcome. | [[24.0, 'year']] | M | {'9973768': 1, '12796888': 1, '12058865': 1, '31496577': 2, '1895249': 1, '8665316': 1, '8170660': 1, '5276738': 1, '24470859': 1, '17082341': 1, '2768620': 1, '2197385': 1, '20833858': 1, '7577733': 1, '17767104': 1, '32487188': 2, '2037921': 1, '9037974': 1, '11838012': 1, '15731795': 1, '32226697': 2, '14969380': 1, '10332381': 1, '11402292': 1, '1739070': 1, '27313912': 2, '21157055': 1, '24470846': 2} | {'6710952-1': 1, '6710952-2': 1, '7268393-1': 1, '7268393-2': 1, '4904078-1': 1, '7093914-1': 1} |
165,214 | 3889000-1 | 24,470,847 | noncomm/PMC003xxxxxx/PMC3889000.xml | Pneumobilia: A Case Report and Literature Review on its Surgical Approaches | An 82-year-old woman presented to the emergency department with a 1 week history of vomiting, mild abdominal discomfort, and absolute constipation. The latter was preceded by gradual worsening of bile-stained non-projectile vomiting. She denied any fever or urinary symptoms. She was a type 2 diabetic and had a history of hypertension. She had no previous abdominal surgery. She was a non-smoker and denied recent alcohol consumption. On physical examination, she was apyrexial, pulse rate was 78 beats per minute, blood pressure was 110/60 mmHg, and respiratory rate was 25 breaths per minute. Her abdomen was soft and non-distended, but there was mild generalized tenderness elicited on palpation. There was no guarding or rebound tenderness. No obvious inguinal or femoral hernia on clinical examination. Digital rectal examination was unremarkable.\nLaboratory tests were as follows: White Blood Cells, 16.55 × 109/L; Hb, 14.1 g/dl; Platelet, 387 109/L × 109/L; Na, 118 mmol/L; K, 2.8 mmol/L; urea, 16.1 mmol/L; creatinine, 101 mmol/L; bilirubin (total), 18 μmol/L; alkaline phosphatase, 72 IU/L; and amylase, 69 IU/L. The arterial blood gas measurement suggested a hypochloremic metabolic alkalosis (pH 7.55, pCO2 6.17 kPa, bicarbonate 39.5 mmol/L, chloride 68 mmol/L, and lactate 1.7 mmol/L). Urine dipstick was negative for glucose, bilirubin, ketone, blood, protein, nitrates, and leukocytes.\nAn erect chest radiograph was normal with no evidence of subdiaphragmatic air []. Abdominal radiograph showed dilated small bowel loop in the central of abdomen []. For a detailed evaluation of the level of bowel obstruction, a contrast computed tomography (CT) of the abdomen and pelvis was requested. CT examination of the abdomen and pelvis showed findings consistent with proximal small bowel obstruction, pneumobilia located in the right hepatic lobe [], and a gallstone in the distal small bowel []. These features strongly suggested the diagnosis of gallstone ileus.\nAfter initial fluid resuscitation with 0.9% sodium chloride, correction of electrolyte imbalance, and nasogastric decompression, the patient underwent midline laparotomy. A proximal longitudinal enterotomy was performed. Numerous small bowel stones [] of variable size were “milked” distally. The largest stone measured 3.5 cm in diameter was retrieved from the small bowel lumen []. Each section of the bowels was inspected in a segmental fashion for sign of ischemia and other intra-luminal faceted gallstones. An abdominal washout was performed using warm saline in order to prevent gross peritoneal contamination. The abdominal incision was closed by a mass closure technique using an absorbable loop Maxon™ suture and staples to the skin. The fistula was left undisturbed and the patient made an uneventful recovery. | [[82.0, 'year']] | F | {'11441553': 1, '22303929': 1, '28138366': 1, '18756345': 1, '21935838': 1, '17436117': 1, '32446989': 2, '15093232': 1, '8269250': 1, '9239802': 1, '17541660': 1, '19335047': 1, '5644101': 1, '9171749': 1, '11493806': 1, '7425220': 1, '9510270': 1, '12658481': 1, '11548836': 1, '3706633': 1, '7949386': 1, '2200556': 1, '15810081': 1, '17701438': 1, '15290590': 1, '18956594': 1, '14985844': 1, '19155624': 1, '5204648': 1, '14598150': 1, '22333461': 2, '8198337': 1, '24470847': 2} | {'7242993-1': 1, '3295700-1': 1} |
165,215 | 3889001-1 | 24,470,848 | noncomm/PMC003xxxxxx/PMC3889001.xml | Primary Tuberculosis of the Appendix: A Rare Cause of a Common Disease | A 20-year-old male patient presented to our outpatient department with complaints of colicky type of pain in right lower abdomen, associated with vomiting and fever since 5 days. On examination, patient was febrile and his vitals were normal. The physical examination showed marked tenderness in right iliac fossa. On initial work up, patients leukocyte count was 17,600/mm3. Since these symptoms were consistent with appendicitis, patient was taken for emergency surgery. On laparotomy, a diffuse inflammatory mass and abscess of the appendix [] was found and appendectomy was done. Exploration of the bowel and mesentery, through the grid iron incision showed normal ileum, cecum, and mesentery. In post-operative period, he had wound infection, which was managed by regular dressing. Histopathological examination of the appendix revealed caseating epitheliod granulomas and lumen filled with neutrophilic infiltrates [Figures and ]. Patient was later evaluated for primary source of TB else where in the body. Computed tomography (CT) abdomen and pelvis showed normal bowel loops and mesentery []. Chest X-ray and colonoscopy [Figures and ] were normal. Three consecutive early morning sputum sample were negative for acid fast bacilli. Tuberculin skin test was negative and erythrocyte sedimentation rate (ESR) was 80 mm/h. Patient was started on standard anti-TB drugs, course similar to pulmonary TB. | [[20.0, 'year']] | M | {'17863824': 1, '6079092': 1, '16940883': 1, '34815873': 2, '29560012': 2, '33898762': 1, '19084940': 1, '3447110': 1, '13292629': 1, '17868413': 1, '17856509': 1, '11142557': 1, '593732': 1, '2584431': 1, '24470848': 2} | {'5845528-1': 1, '8593883-1': 1} |
165,216 | 3889002-1 | 24,470,849 | noncomm/PMC003xxxxxx/PMC3889002.xml | Bone Suture in Management of Mandibular Degloving Injury | A 14-years-old male with a history of “fall” trauma, of his bicycle, experienced soft tissue injuries in the maxillofacial region. The patient, one week later, was referred to the department of Oral and Maxillofacial surgery of Mashhad's university for the management of the lacerated intraoral soft tissue wound in mandibular anterior region.\nIn the extraoral examination, abrasions of the nose, lips, and mentum were present. In addition, the right mandibular incisors had been avulsed. Moreover, silk suture in the lower labial vestibule, from unsuccessful attempts to repair severed mucosa, was noted. Furthermore, debris, necrotic tissue, and exposed bone were present in the vestibular depth [].\nThe patient's hospital discharge card emphasized that tetanus prophylaxis has been introduced. Brain CT scans and orthopantogram were also carried out.\nAfter the administration of local anesthesia (lidocaine 2% with epinephrine 1/80000), debridement of necrotic soft tissue and copious irrigation with high pressure volumes of normal saline was rendered. In the next step, suturing of soft tissue was attempted. Firstly, bone between the left lower canine and lateral lower incisor root was penetrated by a surgical round bur (number 2). Secondly, 3-0 plain gut suture in 26 mm curved needle was modified to straight one so that it can be passed through this hole and exit through the lingual mucosa. By the means of this plain gut suture, the buccal soft tissue flap, 10 mm below free margin, was grasped and sutured to the lingual mucosa []. Likewise, the same procedure was repeated on the right side in the intact bone, apical to the avulsed lateral incisor. The suture knots were placed in the buccal vestibule.\nFurthermore, despite of the intact remaining lower anterior teeth and supporting bone, Essig wiring technique was applied to support the mucosal free edge suturing []. As far as medications are concerned, clindamycin antibiotic 150 mg tabs qid was prescribed for one week. Analgesics (acetaminophen 500 mg) and cholorhexidine mouthwash were also ordered. Additionally, proper manner of tooth brushing was emphasized to the patient and parents.\nThe follow-up, which was carried out for one month after the treatment, has shown excellent results. Consequently, healthy gingiva without scar tissue was noticed []. | [[14.0, 'year']] | M | {'19169157': 1, '9028207': 1, '11310117': 1, '16568914': 1, '9486444': 1, '17395063': 1, '6465639': 1, '24470849': 2} | {} |
165,217 | 3889003-1 | 24,470,850 | noncomm/PMC003xxxxxx/PMC3889003.xml | Left Side Appendicitis with Midgut Malrotation in an Adult | A 37-year-old man was admitted at the emergency unit of our hospital with acute abdominal pain, which started the previous night. Patient's history revealed no previous illness or surgery. Pain was diffused, with tenderness mainly in upper left quadrant, and the temperature was 37.5°C. Laboratory tests showed an elevated blood cell count (15,000) with normal C-reactive protein. A diagnosis of peritonitis was suspected, either by perforated gastroduodenal ulcer or diverticulitis. Contrast-enhanced abdominal computed tomography showed acute left side appendicitis with midgut malrotation [Figure -]. Appendix was enlarged, with a transverse diameter measured to 13 mm, associated with four stercoliths visualized in the plane of the left renal vein. The entire small bowel was found in the left half of the abdomen and the entire colon was found in the right half. The superior mesenteric vein (SMV) was to the left of the SMA rather than in the normal right ventral position. The patient was planned for surgery and a laparotomy was performed. Surgical findings confirmed the severe inflammation of the appendix and the ileocecal region(s) located in the left quadrant. A Ladd's procedure was performed, including derotation of the bowel, appendectomy, division of the mesenteric bands lying across the duodenum from cecum to right upper quadrant, widening of the base of the mesentery, taking down the ligament of Treitz, moving the duodenum to the right, and finally returning the bowel to a position of nonrotation with the cecum placed into the left upper quadrant []. The patient was discharged on the seventh postoperative day with no complication. | [[37.0, 'year']] | M | {'30978255': 1, '16379346': 1, '16518597': 1, '15890694': 1, '14655161': 1, '8337878': 1, '18347850': 1, '21105193': 1, '21105191': 1, '7277164': 1, '8306846': 1, '19560159': 1, '24470850': 2} | {} |
165,218 | 3889004-1 | 24,470,851 | noncomm/PMC003xxxxxx/PMC3889004.xml | Single Incision Laparoscopic Surgery for a Large Endometriotic Cyst | A 27-year-old single nulliparous lady (body mass index = 17.5) presented with a 3-day history of left iliac fossa and suprapubic pain which progressively got worse despite analgesia. The pain score of 8/10 upon presentation. There was no vaginal bleeding or discharge. She reported dysmenorrheal during her periods, requiring analgesia.\nAbdominal examination revealed a normal-sized uterus with tenderness over the left iliac fossa and suprapubic region with no signs of peritonism. Abdominal ultrasonography revealed a left ovarian cyst measuring approximately 8 × 5 cm (suggestive of endometrioma) without septae or echogenicity or any surface excrescences. Color Doppler examination of the cyst revealed no abnormal vasculature. The right ovary and uterus was normal in appearance and there was no ascites. Preoperative CA-125 levels were elevated at 73.7 U/mL but other ovarian tumor markers were within normal limit. The patient was counseled for diagnostic laparoscopy with subsequent ovarian cystectomy. | [[27.0, 'year']] | F | {'16034946': 1, '19347400': 1, '22211916': 1, '21036069': 1, '19589520': 1, '19481243': 1, '20070967': 1, '20169051': 1, '11172118': 1, '27231167': 1, '21082898': 1, '22022112': 2, '20045759': 1, '24470851': 2} | {'3193693-1': 1, '3193693-2': 1} |
165,219 | 3889005-1 | 24,470,852 | noncomm/PMC003xxxxxx/PMC3889005.xml | Non-operative Management of Gallbladder Perforation After Blunt Abdominal Trauma | A 64-year-old man with a background of alcoholic liver disease presented to our Emergency Department following high velocity blunt abdominal trauma. He had been driving at 60 miles/h when he lost control and car rolled-over. He was seat-belt restrained and collision air bags were deployed. He managed to self-extricated on scene. Initial management and resuscitation was in accordance with Advanced Trauma Life Support® principles.\nAdmission Computed tomography (CT) scans were reported as unremarkable. He was admitted under cardiology for further management of a fast narrow complex tachycardia, atrial fibrillation as this was the only outstanding issue. A transthoracic echocardiogram 2 days later revealed a right ventricular thrombus and he was therefore commenced on therapeutic low molecular weight heparin.\nOn day eight post-trauma, this gentleman was referred to General Surgeons for abdominal distension and mild pain. He was stable hemodynamically and clinically he was found to have a soft, distended abdomen, with localized upper peritonism. A repeat CT scan reported free fluid and a perforated gallbladder [].\nIn view of his comorbidities, the patient was considered high risk for a general anesthetic and major abdominal surgery. After multidisciplinary discussion conservative management was agreed. An endoscopic retrograde cholangio-pancreatogram (ERCP) with stent insertion was performed and a radiologically-guided intra-peritoneal drain inserted. A diagnosis of perforated gallbladder fundus was confirmed at ERCP []. Intravenous antibiotics were commenced.\nOver the next few days, the patient's condition improved. The intra-peritoneal drain was removed at day 12 post ERCP and the patient was discharged, uneventfully 35 days after the injury.\nA follow-up ERCP 2 month later revealed a normal cholangiogram with no obvious leak and no filling defects. Stents were removed and sphincterotomy performed.\nHe was reviewed at 3 months and was doing well. Magnetic resonance cholangio-pancreatogram at 12 months showed no evidence of abnormality. | [[64.0, 'year']] | M | {'34306287': 2, '21610404': 1, '11591987': 1, '17243883': 1, '27048215': 1, '7006529': 1, '7473927': 1, '25293685': 1, '31248359': 2, '15345997': 1, '29644320': 1, '10505132': 1, '21851630': 2, '17634139': 2, '7849173': 1, '24470852': 2} | {'1936994-1': 1, '6598236-1': 1, '3169498-1': 1, '8283152-1': 1} |
165,220 | 3889007-1 | 24,470,854 | noncomm/PMC003xxxxxx/PMC3889007.xml | Laparoscopic Colectomy for a Patient with Congenital Renal Agenesis | A 57-year-old man presented to our institute for further evaluation following a positive result in an fecal occult blood test. Approximately 20 years earlier, he was diagnosed with congenital agenesis of the right kidney. He was otherwise entirely healthy without any other significant past or current medical problems. A physical examination showed no abnormalities of the genitourinary system. A contrast-enhanced computed tomography of the abdomen indicated the absence of the right kidney and a hypertrophic left kidney [], and indicated the presence of the right testicular vessels located behind the renal fascia [], but no other anomalies were observed. Total colonoscopy revealed the presence of a tumor, measuring 1.5 cm × 1.0 cm in the ascending colon; the tumor could not be elevated by injection of saline into the submucosal layer. Because endoscopic treatment was impossible, we performed laparoscopic colectomy and lymph node dissection.\nThe operative procedures and findings are as follows. The subumbilical trocar was initially placed using the open laparoscopic technique. After CO2 pneumoperitoneum was established, three other ports were placed. No particular findings such as ascites, adhesion, peritoneal seeding, or anatomical anomalies were noted in the abdominal cavity. The right colon was mobilized to the root of mesocolon by lateral-to-medial extension of retroperitoneal dissection between the fusion fascia and the anterior renal fascia. This procedure was performed in the usual manner. The right testicular vessels were observed behind the anterior renal fascia; however, the right ureter could not be detected []. Furthermore, we could not detect the right renal and adrenal vessels within the operative field. The ileocolic and right colic vessels were ligated near these origins using endoscopic clips, and were mobilized divided. After the segment of the colon was completely mobilized, the ileum and colon were extracted from the abdominal cavity via a right pararectal incision and were then divided. After Gambee's hand-sewn end-to-end anastomosis was performed, the intestine was placed back into the abdominal cavity. During laparoscopy, the abdominal cavity was irrigated, a drain tube was placed at the paracolic gutter, and all other ports were removed. The incisions were closed using absorbable sutures and staples. Histological examination showed a well-differentiated adenocarcinoma that invaded to the submucosal layer without infiltration to the vessels or lymph ducts. No lymph node metastases were detected. The postoperative course was uneventful except for ileus, which was treated conservatively. The patient is currently healthy; he is receiving regular follow-up examination, and has no signs of recurrence and other malignancies. | [[57.0, 'year']] | M | {'1108342': 1, '14841802': 1, '5890929': 1, '10797622': 1, '5945096': 1, '2682777': 1, '24470854': 2} | {} |
165,221 | 3889008-1 | 24,470,855 | noncomm/PMC003xxxxxx/PMC3889008.xml | The Use of T-tube Cholangiocatheter Stents in the Treatment of Pediatric Tracheomalacia | A 42-day-old baby boy who underwent mechanical ventilation in the second day of life gradually weaned off from the respirator but while extubated, he could not tolerate extubation. He had severe tracheomalacia on rigid bronchoscopy. Patient had Echocardiography and spiral computed tomography scan for ruling out of extrinsic pressure, after being certain of abnormal vasculature or mass, we decided to insert some kinds of stent which available. T-tube tracheal stent was rigid and not suitable in size and pliability for trachea of neonate. T-tube cholangiogram has the same shape but a very pliable and suitable size #16 (SUPA/Iran) with low cost for small neonate. We performed 1-2 cm incision above sternal notch and through a tracheotomy and trimming the catheter to appropriate size was placed []. He tolerated the tube and discharged and 9 months later tube can be discontinued. | [[42.0, 'day']] | M | {'12488172': 1, '18299200': 1, '10037287': 1, '9021568': 1, '15532081': 1, '16517777': 1, '15999055': 1, '9556287': 1, '24470855': 2} | {} |
165,222 | 3889009-1 | 24,470,856 | noncomm/PMC003xxxxxx/PMC3889009.xml | Carcinoid Tumor in Accidental, Asymptomatic Meckel's Diverticulum | A 75-year-old female patient had a history of appendicectomy. Following blunt abdominal injury she was admitted due to lack of bowel movements, abdominal cramps, pain, distension and vomiting. Ileus of the small bowels was established as the underlying cause of her complaints and urgent operation was performed. During abdominal exploration adhesions were found on an approximately, 15 cm section of the terminal ileum and adhesiolysis was carried out. During the operation, Meckel's diverticulum without any sign of inflammation was found and wedge excision was performed. No ectopic tissue could be palpated intraoperatively. Patient passed a smooth post-operative period and the bowel movements returned post-operatively and she was discharged with no complaints.\nPathological work-up of the resected Meckel's diverticulum revealed ectopic tissue in addition to the small bowel, mucosa and gastric glands were found. However, a well-circumscribed lesion of 0.5 cm was also detected that was well-distinguishable from the adjacent tissues. It infiltrated the muscle layer of the bowel, but no further layers were involved. The round, cuboidal cells built up nests and fascicles in the involved area. The nuclei were centrally located the chromatin was finely granulated. Immunohistochemical studies were also performed that proved the suspected diagnosis of carcinoid tumor. They were positive for synaptophysin, but negative for chromogranine, cytokeratin (CK) 7 and CK20. No vascular or lymphatic invasion was found and no abnormal lymph node could be detected. The final diagnosis was neuroendocrine carcinoma of Meckel's diverticulum based on the pathological finding []. Patient has been followed-up by oncologists since the operation. | [[75.0, 'year']] | F | {'1812259': 1, '15599742': 1, '952346': 1, '30083336': 1, '7944666': 1, '11693808': 1, '1582362': 1, '17152574': 1, '10986608': 1, '11333103': 1, '24470856': 2} | {} |
165,223 | 3889302-1 | 24,281,763 | noncomm/PMC003xxxxxx/PMC3889302.xml | Acute Kidney Injury Due to Interaction of Methyl-1-testosterone with Ciclosporin Metabolism in a Patient with Severe Atopic Dermatitis | A 29-year-old male patient with longstanding atopic dermatitis was referred to the dermatology outpatient department (Dermatology Department, York Hospital, UK) with a history of rapid deterioration of his condition despite optimal topical therapy. Due to the severity of the symptoms and condition, he was started on systemic ciclosporin (3.0 mg/kg, twice daily). His ultimate ciclosporin dose was 4.0 mg/kg which was gradually increased from the initial dose of 3.0 mg/kg. The patient’s baseline findings are presented in Table . Good clinical response was achieved whilst on ciclosporin and he was maintained on it for 4 months (the later 3 months on the maximum dose) with stable serial blood tests.\nDuring routine follow-up, he was found to be in acute renal impairment with urea of 17 μmol/L, creatinine of 266 μmol/L and deranged liver function tests with bilirubin 37 μmol/L, alanine transaminase 304 U/L and aspartate transaminase 48 IU/L. Investigations included a urine dipstick and renal ultrasound which were both normal. The ciclosporin level during routine follow-up was elevated (trough level 622 μmol/L) despite consistency with the dose over 3 months and two stable previous blood tests.\nOn direct questioning, the patient admitted that he had been recently taking a “supplement”. The patient had purchased this over the Internet from an online shop and this was dispatched along with some written information. Subsequently, the “supplement” was found to be oral methyl-1-testosterone (systematic name: 17 alpha methyl-17beta-hydroxy-androst-1-ene-3-one). The patient discontinued both ciclosporin and methyl-1-testosterone and his renal function and liver function tests returned to normal within 1 week. The patient had been administered irregular amounts of methyl-1-testosterone with no regular pattern. Atopic dermatitis gradually flared up over 3 months and was treated with ultraviolet B phototherapy as he was reluctant to restart ciclosporin treatment.\nInformed consent was obtained from the patient for being included in the study. This article does not contain any studies with human subjects performed by any of the authors. | [[29.0, 'year']] | M | {'17970889': 1, '4058536': 1, '1944742': 1, '21093659': 1, '3285527': 1, '21990312': 1, '2868196': 1, '24281763': 2} | {} |
165,224 | 3889308-1 | 24,318,415 | noncomm/PMC003xxxxxx/PMC3889308.xml | Hydroxychloroquine-Associated Hyperpigmentation Mimicking Elder Abuse | A 66-year-old white woman presented for an evaluation of her skin. Informed consent was obtained from the patient for being included in the study. Additional informed consent was obtained from all patients for which identifying information is included in this article. The patient’s past medical history was significant for systemic lupus erythematosus and myasthenia gravis. Since 1980, the patient has been treated with hydroxychloroquine at a daily dose of 400 mg.\nThere was diffuse hyperpigmentation. The patient’s forehead, face, neck, v-area of the upper central chest, and upper back were black (Figs. , ), and her right upper chest was blue (Figs. , ). Hyperpigmentation was absent from her oral mucosa and nails.\nFive years earlier, the patient had visited a new clinician on a Friday afternoon. The patient’s clinician misinterpreted her black and blue dyschromia to be trauma-induced and had notified Adult Protective Services. The following Monday morning, a worker from the agency was at her home to investigate the family for elder abuse. Eventually the situation was resolved and the family was cleared of all suspicion of elder abuse.\nDuring her current cutaneous evaluation, a skin biopsy from the area of blue dyschromia on the patient’s right upper chest was performed. Microscopic examination showed both intracellular and extracellular yellow-to-brown granules scattered throughout the reticular dermis. Pigmented granules were seen between the collagen bundles with some accentuation around eccrine glands. The granules stained positively for both Fontana Masson and Perl’s stains.\nCorrelation of the patient’s medical history, clinical presentation, and pathology findings confirmed the diagnosis of hydroxychloroquine-induced hyperpigmentation. | [[66.0, 'year']] | F | {'19138249': 1, '19519613': 1, '18727667': 1, '2072759': 1, '9169265': 1, '22671572': 1, '449253': 1, '23190463': 1, '23074585': 2, '20950247': 1, '6165744': 1, '30001781': 1, '25460494': 1, '21342157': 1, '23522422': 1, '21409966': 1, '7614181': 1, '17080761': 1, '8675829': 1, '11705252': 1, '22955256': 1, '6268671': 1, '22010621': 1, '23242889': 1, '9865239': 1, '23219556': 1, '26089648': 1, '14723734': 1, '26430491': 1, '26506993': 2, '21348540': 1, '836692': 1, '14051353': 1, '20040265': 1, '20694448': 1, '23058735': 1, '12115210': 1, '23177610': 1, '2931455': 1, '18415776': 1, '19393848': 1, '11173934': 1, '24318415': 2} | {'4674452-1': 1, '3466837-1': 1} |
165,225 | 3889309-1 | 24,318,412 | noncomm/PMC003xxxxxx/PMC3889309.xml | Isomorphic Sclerotic-Type Cutaneous Chronic Graft-Versus-Host Disease: Report and Review of Chronic Graft-Versus-Host Disease in a Cutaneous Immunocompromised District | A 74-year-old man with a history of mantle cell lymphoma had received two prior hematopoietic cell transplants. The patient experienced several weeks of asymptomatic, yet progressive, stiffening of the skin on the distal right extremity and lower abdomen. The patient also noted that the skin on the lateral lower chest and upper abdomen had a rippled appearance.\nThe mantle cell lymphoma was diagnosed in 2005. In September 2008, the patient underwent an autologous stem cell transplant using BEAM (carmustine, etoposide, cytarabine, and melphalan) as a conditioning regimen. The patient achieved a complete remission.\nThe patient’s lymphoma relapsed in July 2009 and he participated in a clinical trial receiving intranodal injections of an immunotherapy Ad-ISF35 (immune stimulating factor 35). The patient was withdrawn from the study after injection #3 because of lack of clinical improvement. From October 2009 to April 2010, the patient completed six cycles of bendamustine and rituximab. The patient achieved a complete clinical response, but had residual inguinal lymphadenopathy; subsequently, new nodes were discovered.\nThe patient underwent an allogeneic hematopoietic peripheral blood stem cell transplant using a sex-matched unrelated donor in May 2010; the conditioning regimen was fludarabine, melphalan, and rituximab. The patient engrafted without complications and again achieved a complete remission. The patient subsequently developed biopsy-confirmed acute cutaneous GVHD that resolved after treatment with topical corticosteroids.\nIn early February 2013, the patient noted that his right forearm and hand were becoming stiff and indurated. Similarly, the area of his abdomen that came in contact with the waistband of his pants was becoming indurated. Also, the area of his lateral abdomen above his waistband became rippled. The observed changes continued to progress.\nCutaneous examination in late March 2013 showed the patient’s right forearm to be hyperpigmented and indurated; similarly, his dorsal hand was also firm and there was no elasticity of the overlying skin (Fig. ). The patient’s lower abdomen, particularly the areas that came in contact with the waistband of his pants and belt, was smooth and hyperpigmented with areas of erythema; in addition, the lower abdomen had developed a confluent morphea-like sclerotic dermal induration (Figs. a, b, , ). The skin of the patient’s lateral lower chest and abdomen had a “cellulite” appearance (Figs. , ).\nBiopsy from the right forearm, the waistband area, and the lateral upper abdomen all showed similar findings: sclerotic and thickened collagen in the reticular dermis. In the waistband area, these changes were predominantly in the mid reticular dermis; there was also loss of the perieccrine fat and a sparse lymphocytic superficial perivascular infiltrate. In the forearm and the upper abdomen, the sclerosis began in the deep reticular and extended into the subcutaneous fat; lymphoplasmacytic inflammation was noted at the junction of the deep reticular dermis and subcutaneous fat in the forearm, and extravasated erythrocytes were observed in the reticular dermis of the abdomen.\nCorrelation of the clinical presentation and pathology findings established the diagnosis of chronic sclerotic-type cutaneous GVHD; the localization of GVHD to the waistband area demonstrates an isomorphic response to the repetitive irritation, friction, and pressure from the patient’s belt and pants. The patient was treated with oral prednisone (initially at 10 mg per day for 2 weeks, and tapered to 5 mg per day and 2.5 mg per day for 2 weeks each) and topical tacrolimus 0.1% gel twice daily. Clinical improvement was observed, with the dermal plaques becoming less firm. | [[74.0, 'year']] | M | {'18794477': 1, '9001991': 1, '16338616': 1, '24891671': 1, '19586515': 1, '16911292': 1, '19415807': 1, '22421123': 1, '76022': 1, '16198778': 1, '21931046': 1, '19548975': 1, '30674472': 1, '8023213': 1, '21855722': 1, '1732335': 1, '2924034': 1, '8285743': 1, '7607796': 1, '11896422': 1, '17085303': 1, '6103411': 1, '14988701': 1, '17419693': 1, '10583085': 1, '12839612': 1, '21791415': 1, '10847551': 1, '7096662': 1, '9159958': 1, '24318412': 2} | {} |
165,226 | 3889310-1 | 24,318,418 | noncomm/PMC003xxxxxx/PMC3889310.xml | Combined Reduced-Antigen Content Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine-Related Erythema Nodosum: Case Report and Review of Vaccine-Associated Erythema Nodosum | A healthy 39-year-old Japanese woman visited her primary care physician for an annual examination. She had received all of her childhood vaccinations without any complications. She did not have any history of preceding infections, sore throat or diarrhea. She also had no prior or current skin or systemic diseases and her laboratory studies were normal. There was no personal or family history of tuberculosis. Her physician recommended prophylactic vaccination with combined tetanus-diphtheria-pertussis (Tdap) vaccine since her booster immunization was due. Informed consent was obtained from the patient for being included in the study and for the publishing of photographs. This article does not contain any studies with human subjects performed by the author.\nWithin 24 h of receiving Tdap vaccine, she noted several areas of pruritus and swelling on her distal lower extremities. During the next 24 h these areas enlarged and developed into tender red nodules. The painful nodules persisted and she sought dermatologic medical attention.\nCutaneous examination, 7 days after receiving Tdap vaccine, revealed tender erythematous nodules on her legs (Fig. ). There was a large, 12 by 8 cm, erythematous nodule on distal pretibial left leg (Fig. ). Multiple, individual and grouped, nodules were present on her right leg; they were located on the distal lateral thigh (4.0 by 2.5 cm), the proximal lateral calf (6.0 by 3.5 cm), the distal lateral calf (2.0 by 2.0 cm), and the distal lateral leg proximal to the ankle (each of 3 lesions measuring 2.5 by 2.5 cm) (Fig. ).\nCorrelation of her medical history, clinical symptoms, and lesion morphology were compatible with a diagnosis of Tdap vaccine-related erythema nodosum; however, the differential diagnosis also included an Arthus-like phenomenon induced by immunization and erythema nodosum secondary to another etiology with immunization being associated by chance. Several circumstances favored Tdap vaccine-related erythema nodosum. Specifically, she had not receiving any topical or systemic medications. Also, she had no recent streptococcal pharyngitis or systemic conditions such as Crohn’s disease, sarcoidosis, or tuberculosis. Therefore, the temporal association between her recent Tdap vaccination and the development of the skin lesion suggested that the development of her erythema nodosum was related to her receiving Tdap vaccine.\nSymptomatic treatment was initiated: oral ibuprofen 600 mg four times daily. Since a drug-induced etiology was suspected, daily oral systemic therapy with an antihistamine and a corticosteroid was started: 180 mg of fexofenadine and prednisone (60 mg for 4 days, followed by 40 mg for 3 days, and followed by 20 mg for 2 days). Her symptoms began to improve and the nodules started to flatten within 3 days.\nFollow-up examination occurred 2 weeks after her initial visit. Her symptoms had completely resolved. One of the nodules proximal to her right ankle was smaller, yet palpable with mild erythema of the skin. All of her other nodules had completely flattened and there was macular hyperpigmentation at the sites. | [[39.0, 'year']] | F | {'18612426': 1, '18713602': 1, '4059905': 1, '17375516': 1, '23193719': 1, '18793974': 1, '21949151': 1, '34656402': 1, '17560306': 1, '5130258': 1, '31472022': 1, '34547126': 1, '15530319': 1, '21435755': 1, '19697967': 1, '34934549': 2, '23142308': 1, '22727350': 1, '21920404': 1, '33683567': 1, '2529439': 1, '2144199': 1, '16750957': 1, '22931522': 1, '32674495': 1, '20666819': 1, '13607185': 1, '2877208': 1, '30269303': 1, '17544964': 1, '13536754': 1, '24318418': 2} | {'8668049-1': 1} |
165,227 | 3889311-1 | 24,318,417 | noncomm/PMC003xxxxxx/PMC3889311.xml | Vulval Crohn’s Disease in Childhood | A 10-year-old girl presented to the dermatology department at York Hospital with a 12-month history of asymptomatic erythema and swelling of the vulva. The patient was systematically well, and had no gastrointestinal symptoms. There was no personal or family history of inflammatory bowel disease. On examination, the patient was a healthy-looking girl with normal height and weight for her age. Examination of the patient’s vulva revealed a “peau d’orange” appearance, with a large skin tag in the anterior peri-anal area (Fig. ). Examination of the oral mucosa, rectum, and the rest of the skin was unremarkable. Biopsy of the affected vulva showed non-caseating granulomata with negative Ziehl–Nielson stains and culture. The patient was treated with tacrolimus ointment 0.03% which resulted in good control of the disease. A year after the initial presentation, the patient developed mouth ulcers and bloody diarrhea. The patient was diagnosed with CD, confirmed on intestinal biopsies. | [[10.0, 'year']] | F | {'34454474': 2, '15953068': 1, '14263727': 1, '16731418': 1, '20507839': 1, '19421856': 1, '6459345': 1, '19800432': 1, '24318417': 2} | {'3889311-2': 2, '8399794-1': 1} |
165,228 | 3889311-2 | 24,318,417 | noncomm/PMC003xxxxxx/PMC3889311.xml | Vulval Crohn’s Disease in Childhood | A 13-year-old girl presented with a 9-month history of asymptomatic vulval swelling. The patient was diagnosed with CD at the age of 5 years and had been well-controlled on methotrexate. Physical examination revealed a healthy-looking girl. Examination of the vulva demonstrated asymmetrical dusky-colored edematous skin with a “peau d’orange” appearance. Examination of the peri-anal skin showed fissures and skin tags (Fig. ). Examination of the rest of the skin, oral mucosa, and other systems was unremarkable. Biopsy of the affected vulval area showed typical features of non-caseating granulomata with negative stains and culture for organisms. The patient was treated with intralesional triamcinolone and oral metronidazole, which resulted in a clear improvement in terms of swelling after 3 months. | [[13.0, 'year']] | F | {'34454474': 2, '15953068': 1, '14263727': 1, '16731418': 1, '20507839': 1, '19421856': 1, '6459345': 1, '19800432': 1, '24318417': 2} | {'3889311-1': 2, '8399794-1': 1} |
165,229 | 3889682-1 | 23,539,323 | noncomm/PMC003xxxxxx/PMC3889682.xml | Effective treatment of a steroid-induced femoral neck fracture nonunion with a once-weekly administration of teriparatide in a rheumatoid patient: a case report | An 88-year-old female was referred to our hospital in February 2011 after a fall from her bed 3 days earlier. Her past medical history included colon cancer at the age of 67 years and gastric cancer at the age of 85 years. She suffers from rheumatoid arthritis (RA), with a drug history of 50 mg bucillamine and 5 mg prednisolone per day for more than 10 years. Two months prior to her fall, her prednisolone dosage had been reduced to 2.5 mg per day. Clinical and radiological examination revealed a Garden type II displaced femoral neck fracture. The patient underwent surgery with a Hansson hook-pin system within 3 h after her arrival (Fig. ).\nAt 3 months post-operatively, CT imaging suggested the presence of delayed union in the femoral neck, which was treated with LIPUS (Fig. ). At 11 months, the patient still complained of mild groin pain on ambulation. A diagnosis of nonunion was given but LIPUS therapy was discontinued because the patient rejected the therapy (Fig. ). Bone mineral density (BMD) tests of the right hip revealed severe osteoporosis measuring 38 % of the young adult mean, with a BMD score of 0.303 g/cm2 and a T score of −4.4.\nThe patient accepted treatment with a once-weekly injection of 56.5 μg chemically synthesized TPTD. At 18 months post-operatively, CT imaging after 20 consecutive weekly administrations of TPTD revealed signs of healing and the patient reported a gradual decrease in groin pain on ambulation (Fig. ). Complete union of the fracture was obtained at 23 months (Fig. ). Serum examination after 36 weekly injections of TPTD was as follows: C-reactive protein, 0.2 mg/dl; rheumatoid factor, 170 U/ml; alkaline phosphatase, 208 U/l; albumin, 4.0 g/dl; calcium, 8.8 mg/dl. The patient reported no side effects during the entire period of TPTD treatment. | [[88.0, 'year']] | F | {'18174942': 1, '24676988': 2, '32911581': 1, '22723322': 1, '15490267': 1, '29268728': 1, '23076681': 1, '22001129': 1, '20051918': 1, '33849491': 1, '19778182': 1, '28583752': 1, '19859645': 1, '1991779': 1, '21132409': 1, '20846618': 1, '22026995': 1, '28740522': 1, '25649182': 1, '11041577': 1, '18057352': 1, '31992929': 1, '25187868': 2, '33573004': 2, '23539323': 2} | {'4149994-1': 1, '7931020-1': 1, '7931020-2': 1, '7931020-3': 1, '7931020-4': 1, '7931020-5': 1, '4254865-1': 1} |
165,230 | 3890009-1 | 23,821,495 | noncomm/PMC003xxxxxx/PMC3890009.xml | Cardiac metastasis of malignant melanoma: a case report | A 42-year-old Caucasian woman, who had lived in Africa for 3 years, presented herself in the Emergency Department. She reported shortness of breath on mild exertion during the last few weeks, a swollen face, abdominal pain and oedema in the legs.\nHer medical history disclosed a malignant melanoma on the right shoulder 4 years earlier. The tumour had a Breslow thickness of 5 mm (Clark level 5 with satellite lesions) and was radically excised and consequently re-excised with a margin of 2 cm. During re-excision a sentinel node procedure was performed without metastasis. An enlarged lymph node was noticed at the right side of the neck during follow-up, which contained melanoma cells at cytological examination. Since no dissemination could be demonstrated elsewhere, a lymph node dissection of the right neck (level 2a, 3, 4 and 5) was performed 11 months after the first excision. One lymph node tested positive for metastatic melanoma. She had been free of symptoms since the dissection.\nPhysical examination of the lungs was unremarkable. Heart sounds were muffled, without murmurs. Extremities showed a normal arterial circulation; however, both ankles demonstrated oedema. There were no signs of ascites or splenohepatomegaly. The most remarkable laboratory examinations were a haemoglobin level of 6.2 mmol/l (normal: 7.5–10.0 mmol/l), thrombocyte count of 59 × 109/l (normal: 150–400 × 109/l) and lactate dehydrogenase level of 1,393 U/l (normal: <450 U/l).\nAbdominal ultrasonography showed a mass in the right lower abdomen, ascites, three masses in the liver and lymphadenopathy around the portal vein. CT of neck and thorax revealed a large inhomogeneously enhancing mass within the right cardiac atrium measuring 7.5 × 6.5 cm (Fig. ). The mass protruded into the right ventricle and into the superior caval vein and showed signs of vascularisation. There was a large amount of pericardial and pleural effusion. CT of the abdomen demonstrated a mass in the right ovary and confirmed the other abnormalities demonstrated on ultrasound. It was concluded that the patient was suffering from metastases of the melanoma or from a primary gynaecological neoplasm. Diagnostic biopsy of the right adnex confirmed metastatic melanoma.\nDue to cardiac tamponade, ultrasound-guided pericardial drainage was performed and resulted in evacuation of 700 cc of clear yellow fluid. Immunohistochemistry showed the presence of macrophages; however, malignant cells were not found. After drainage, ECG-triggered magnetic resonance imaging (MRI) of the heart was performed to characterise the cardiac mass. The intra-atrial mass showed a relatively high signal intensity on the T1 weighted black-blood images and after the injection of gadolinium contrast agent, the intra-atrial mass showed inhomogeneous enhancement. There was a large amount of pleural effusion but no residual pericardial effusion (Fig. ) The MRI image was highly suggestive for intracardial metastasis of the melanoma due to melanotic signal intensity on T1-weigthed images.\nBoth surgery and systemic chemotherapy were considered not achievable due to the severe, worsening, condition of this patient. Therefore, palliative sedation was started and patient died 23 days after initial presentation. Autopsy was not performed. | [[42.0, 'year']] | F | {'20978580': 1, '8607700': 1, '33082690': 1, '22434379': 1, '34306093': 2, '27695188': 1, '21487745': 2, '25631243': 1, '33790519': 2, '5650736': 1, '22113594': 1, '21251317': 2, '29463229': 1, '21119277': 1, '19650576': 1, '26043925': 1, '23821495': 2} | {'3167246-1': 1, '8263222-1': 1, '3037322-1': 1, '7991753-1': 1} |
165,231 | 3890465-1 | 24,431,918 | noncomm/PMC003xxxxxx/PMC3890465.xml | The Successful Implantation of Continuous-Flow Left Ventricular Assist Device as a Destination Therapy in Korea: Echocardiographic Assessment | A 75-yr-old male with a prosthetic aortic valve complained of his ongoing exacerbation of dyspnea which started at December, 2010. He had visited regularly the outpatient clinic of cardiology in our institution since June, 2002. Twelve years ago, he had received aortic valve replacement with Medtronic-Hall valve (24 mm) due to severe rheumatic aortic regurgitation. However, in spite of good prosthetic valve function and medical treatment including angiotensin receptor blocker and beta-blocker, his left ventricular (LV) systolic function and LV dilation gradually deteriorated. In consequence, he was suffered from dyspnea of New York Heart Association (NYHA) functional class III to IV. He had no history of hypertension or diabetes mellitus, but had atrial fibrillation. Laboratory findings were within normal range except mild azotemia (serum creatinine 1.75 mg/dL) and prolonged prothrombin time (INR 1.97). Because his old age and functional deconditioning caused by long-term illness prevented him from being a good candidate for heart transplantation, he was recommended for LVAD implant as a destination therapy. The level of LVAD risk was medium with score 12 by Lietz () and high with score 2.95 by HeartMate II Risk Score (). However, because the patient's prolonged INR was caused by anticoagulation for prosthetic valve rather than pathologic coagulopathy, his actual risk of LVAD implant was thought to be lower than the calculated risk score.\nOn preoperative evaluation, he had insignificant stenosis in the coronary arteries in coronary angiography. In transthoracic echocardiography, LV dimensions were dilated (70/69 mm at diastole/systole), and LV ejection fraction by Simpson's method was only 20%. But, the right ventricular (RV) function was relatively preserved and RV cavity size was normal [tricuspid annular plane systolic excursion (TAPSE)=14 mm, s'=0.07 m/sec, RV fractional area change (RVFAC)=60%, and RV diastolic dimension base/mid=33/17 mm]. Mild mitral regurgitation (MR) and moderate tricuspid regurgitation (TR) were observed. Inferior vena cava (IVC) was dilated without plethora, and RV systolic pressure by TR peak velocity was 39 mmHg. The prosthetic valve continued to function well with physiologic aortic regurgitation; Vmax=1.9 m/sec, mean pressure gradient=7.7 mmHg, effective aortic valve area by continuity equation=2.1 cm2. Although the function of prosthetic aortic valve was good, the closure of aortic valve was determined after the surgical consultation in concern of possible secondary pump flow upregulation by physiologic aortic regurgitation.\nAfter informed consent was obtained from the patient and his family, LVAD implantation with HeartMate II (Thoratec, Pleasanton, CA, USA) proceeded. For the surgery of LVAD implantation, he admitted to our hospital on 11th, August, 2012. And the implantation of LVAD was performed on 17th, August, 2012. To insert a propulsion pump in upper abdomen, a midline sternotomy was extended to the upper abdomen. An outflow graft was connected to the aorta with end to side anastomosis. After the removal of some chordae that could cause turbulent flow in the LV chamber, the inflow conduit was inserted at LV apical position. The mechanical prosthetic aortic valve was closed with two round 24 mm and 22 mm-sized Teflon felts. During the procedure, we checked the presence of patent foramen ovale (PFO) with transesophageal echocardiography by injecting agitated saline via a central venous catheter, but microbubbles were not observed in the left side of the heart. We additionally performed cryoablation at cavo-tricuspid isthmus for 2 min and 45 sec and resected left atrial appendage. The postoperative chest X-ray clearly shows the positions of inflow conduit, LVAD as propulsion pump, outflow cannula and power cable connected to extracorporeal controller ().\nOn the day following LVAD implantation, he was extubated in a stable hemodynamic condition. We checked the patient's volume status and the function of LVAD with daily bed-side echocardiographic assessment (). We manipulated the revolutions per minutes (rpm) of LVAD in the range of 8,800-9,200 to maintain midline position of interatrial septum (IAS) and interventricular septum (IVS). The size of IVC was monitored to assess his volume status. For example, at postoperative day (POD) 10, we had to decrease rpm from 8,800 to 8,400 to maintain the mid-position of IAS and IVS, because the septum deviated to the left side at a higher rpm. However, at the same time, the IVC was observed to be collapsed with a diameter of 0.7 cm. So, after enough volume replacement for 2 days, we could elevate rpm to the level of 8,800 again, monitoring the echocardiographic parameters.\nDuring the hospital stay, he acquired aspiration pneumonia several days after the surgery. As a result, he stayed in intensive care unit until postoperative day 11. He could not participate in the cardiac rehabilitation program until he recovered fully from aspiration pneumonia. During the rehabilitative period, he and his family members were properly educated about how to manage the device and potential emergency situations. Eventually, the patient was discharged in a condition of NYHA functional class II with LVAD rpm 9,200, 4 months after the implantation. Additionally, obviously improved hemodynamic change by decreased LV filling pressure was observed in follow-up echocardiography (). LV dimension and IVC diameter were decreased, and IVS and IAS lay in midline position instead of deviating to the right side due to increased LV filling pressure, and functional MR was significantly decreased.\nThe patient maintains NYHA functional class II currently over 240 days after the LVAD implant. | [[75.0, 'year']] | M | {'17540997': 1, '31316945': 1, '22282104': 1, '23265328': 1, '11794191': 1, '21331332': 1, '15947534': 1, '19920052': 1, '33447412': 1, '22230137': 1, '17638928': 1, '24431918': 2} | {} |
165,232 | 3890466-1 | 24,431,919 | noncomm/PMC003xxxxxx/PMC3890466.xml | Pyeloduodenal Fistula Successfully Treated By Endoscopic Ligation without Surgical Nephrectomy: Case Report | A 74-yr-old woman was transferred to our hospital from a local clinic because of generalized weakness and high fever with chills on January 17, 2013. She had been complaining of abdominal discomfort. She had no underlying illness such as diabetes mellitus, hypertension, hepatitis, or tuberculosis. Her family history and social history were non-specific. For 15 days, prior to admission, she received conservative treatment for herpes zoster infection on the anterior chest without an anti-viral agent.\nAt the time of admission, her body temperature was 37.8℃ and blood pressure was 110/80 mmHg. Her heart rate was 112 beats per minute being faster than normal with sinus rhythm on ECG. Laboratory examination revealed pyuria, isomorphic hematuria, positive leukoesterase and bacteria on urinalysis. Systemic leukocytosis with a predominance of neutrophils (white blood cell count of 21,650/µL) and a high C-reactive protein level of 35.63 mg/dL were shown in the blood test. Blood urea nitrogen and serum creatinine level had risen to 69.4 mg/dL and 4.28 mg/dL, respectively, from normal values at baseline. Serum potassium was 6.0 mM/L, and coagulation test results were lengthened to a PT INR of 1.4 and an aPTT time of 70.2 sec.\nPhysical examination was otherwise unremarkable except diffuse abdominal tenderness. Through laboratory tests and physical examinations, the patient was suspicious of urinary tract infection combined with acute kidney injury. Next, a computed tomogram (CT) was checked and it revealed hydronephrosis with upper ureteral stones and multiple ill-defined hypodense lesions suggestive of acute pyelonephritis in both kidneys.\nPercutaneous nephrostomy (PCN) was performed in both kidneys, and during this procedure, right PDF was visualized. Pyelography revealed a fistula to the descending part of the duodenum (). We prescribed total parenteral nutrition and intravenous antibiotics and planned surgery for PDF. However she was too old and was considered to be emaciated to tolerate nephrectomy and general anesthesia. Also, the surgeon was not able to find out the exact leakage site on CT. Therefore, gastroendoscopy was decided to avoid surgery. The gastroenterologist discovered PDF in the duodenal second portion and clipped the lesion 4 times (). After an appropriate course of parenteral antibiotics therapy with the clipping procedure, her temperature and white blood cell count returned to normal, and her urine culture grew Klebsiella pneumoniae which showed all sense to the antibiotics. The patient, however, had to undergo one more endoscopic procedure after 1 week because her follow-up fistulography revealed that there was still a communication between the pelvis and duodenum, but the amount of leakage was significantly reduced. The gastroenterologist ligated the fistula site with a detachable snare which is an elliptically shaped nylon loop used to tighten around the fistula site. This device has recently been used for closure of gastrointestinal fistula followed by application of a clip in the field of gastroenterology (). Follow-up fistulography was performed after 1 week, and we were able to confirm there was no more leakage (). Her blood urea nitrogen and serum creatinine levels recovered to normal showing 10.7 mg/dL and 0.86 mg/dL, respectively. Her urine culture was returned to negative finding. She was discharged after confirmation of appropriate oral intake on admission day 30. The urologist removed PCN in the outpatient clinic, and then finally treated her stones by extracorporeal shockwave lithotripsy. | [[74.0, 'year']] | F | {'2267215': 1, '32309478': 1, '12745733': 1, '31619401': 1, '3341103': 1, '4815111': 1, '29556472': 1, '7771759': 1, '2666006': 1, '10368259': 1, '11339393': 1, '2115528': 1, '1875505': 1, '19375738': 1, '1590093': 1, '31908820': 2, '8638375': 1, '9522992': 1, '4012927': 1, '15657865': 1, '6649212': 1, '12137849': 1, '6887377': 1, '12925297': 1, '24431919': 2} | {'6937454-1': 1} |
165,233 | 3890467-1 | 24,431,920 | noncomm/PMC003xxxxxx/PMC3890467.xml | Localized Thymic Amyloidosis Presenting with Myasthenia Gravis: Case Report | A 46-yr-old woman was referred to Chungbuk national university hospital for thymectomy in February, 2013. Two months ago, she admitted for first developed ptosis, weakness in the neck, and dyspnea, and was diagnosed with acetylcholine receptor-positive MG. A chest computed tomography (CT) scan revealed a mass with calcification in the anterior mediastinum, which was suggestive of thymoma (). While undergoing cholinesterase inhibitor (Mestinon®) therapy, the patient developed a myasthenic crisis and was given immunoglobulin (Ig) therapy for 5 days under managed ventilator care. Treatment with corticosteroids then continued for a month. After the symptoms regressed, the patient was discharged. She visited the hospital again 2 months later for resection of the mediastinal mass. Given the clinical impression of thymoma-associated MG, mass resection and total thymectomy were performed.\nMacroscopically, the resected mass, which measured 4×3×1.5 cm, was a relatively well-demarcated nodule that was surrounded by fat. The cut section was hard, yellow to gray, and calcified (). Microscopically, the mass was composed of amorphous eosinophilic hyaline materials surrounding islands of thymic tissues (). Stromal calcification and ossification were noted. The associated inflammatory reaction consisted of small lymphocytes and occasional plasma cells. These eosinophilic substances displayed apple-green birefringence under polarized light microscopy after Congo red staining (). Immunohistochemical analysis revealed that they were positive for kappa and lambda light chains and negative for serum amyloid A. These findings were consistent with primary (light chain) amyloidosis. Further examinations were done to rule out plasma cell dyscrasia or lymphoproliferatvie disorder. The serum IgG, IgA, and IgM levels were normal. Serum and urine protein electrophoresis did not detect any abnormal bands. Serum and urine immunoelectrophoresis did not indicate any definite abnormalities. The serum calcium levels were also within normal limits. To screen for systemic amyloidosis, complete blood count, erythrocyte sedimentation rate, echocardiogram, basic metabolic and biochemical panel, and liver function tests were performed. All returned values that were within normal limits. This suggested that the thymic amyloidosis was localized. Therefore, the final diagnosis of primary localized amyloidosis that only involved the thymus was made. The symptoms of MG were relieved dramatically after thymectomy. | [[46.0, 'year']] | F | {'571572': 1, '19393650': 1, '8440029': 1, '15966479': 1, '18974302': 1, '8290725': 1, '12102609': 1, '17080188': 1, '16409147': 1, '28877738': 2, '26288650': 2, '18826487': 1, '6611507': 1, '15170548': 1, '19626465': 1, '19076171': 1, '12904524': 1, '24431920': 2} | {'4527044-1': 1, '5588697-1': 1} |
165,234 | 3890720-1 | 17,017,666 | noncomm/PMC003xxxxxx/PMC3890720.xml | Benign Pulmonary Metastasizing Leiomyomatosis: Case Report and a Review of the Literature | A 51-year-old Korean woman was referred to our pulmonary medicine outpatient clinic for the evaluation of her known multiple lung nodules: the nodules were first detected 4 months before the referral (). However, the sizes of the nodules were very small at the time of discovery, reaching 0.7 cm diameter for the largest one on chest CT. The doctor, who was treating her for osteoporosis, maintained close observation and this included short term CT follow-up. The follow-up chest CT was done 4 months later just before the referral; it showed that the sizes of the masses were increased and multiple masses had been developed (). She complained of mild, non-productive cough and general weakness of several weeks duration, but any other respiratory symptoms like hemoptysis, purulent sputum or exertional dyspnea were absent. She denied any fever, chill, weight loss, headache, myalgia or any other major symptoms. Her past medical history was remarkable in that she was previously diagnosed with uterine leiomyoma and underwent hysterectomy with right-sided oophorectomy approximately 16 years ago. She also underwent surgery due to acute appendicitis 27 years ago. She did not smoke and she rarely drank alcohol. She was previously diagnosed with osteoporosis a few years ago and was taking medication for it.\nThe physical examination revealed that she was afebrile and appeared comfortable. There was no pallor, jaundice, cyanosis, or cold sweating. Her respiratory rate was 20 per minutes, the pulse rate was 90 per minute, the blood pressure was 140/90 mmHg and her body weight was 52 kg. Examination of the head, ears, eyes and throat was unremarkable. No lymphadenopathy or thyroid gland enlargement was noted. There was no neck vein distention. Auscultation of the lung revealed no definite crackle or wheeze. Examination of the heart revealed normal sounds without any gallops or murmurs. Examination of the abdomen and extremities was unremarkable without any palpable masses, hepatosplenomegaly or ascites. There were scars from a previous hysterectomy and previous appendectomy. The neurologic examination was normal. A 12-lead electrocardiogram revealed normal sinus rhythm. Laboratory studies including a complete blood count, a serum metabolic assay with liver function tests, the erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-nuclear antibodies; all the tests showed normal results. Routine urine analysis for the cell count and casts, and the thyroid function test were also normal. Gynecologic examination revealed a normal hysterectomy status.\nA chest radiograph taken at the time of first detecting the lung nodules demonstrated lung nodules that were especially scattered at the left perihilar and retrocardiac areas. The follow-up chest radiograph taken after admission showed newly developed peribronchial infiltration at the right middle lung field and the previously detected lung nodules had increased in size and number. Further evaluation led to a computed tomography scan of the chest, sputum studies and a tumor marker study; fine needle aspiration of the nodules was also performed. A computed tomography scan of the abdomen, a whole body bone scan, gastrofiberoscopy, sigmoidoscopy and breast sonography were also performed to search for the primary origin of suspicious metastatic lung nodules. Sputum specimens were all negative for bacterial, mycobacterial and fungal pathogens. The sputum cytology revealed no malignant cells. The serum tumor marker study, including alpha-feto protein, CEA, CA 19-9, CA 125, SCC and NSE, were all in the normal ranges. The computed tomography scan of the abdomen showed focal wall thickening in the right portion of rectum and a 4.1×3.2 cm-sized benign-looking cystic lesion in the left ovary. Yet the sigmoidoscopy revealed no abnormal findings. Gastrofiberoscopy revealed atrophic gastritis at the antrum and body of the stomach. The sample from the fine needle aspiration of the nodule was insufficient for diagnosis. Therefore, open lung biopsy was eventually performed. The pathologic findings from the open lung biopsy revealed a diagnosis of multiple leiomyomas of the lung. The tumor was composed of interlacing bundles of spindle cells with cigar shaped nucleus and eosinophilic myofibrils in the cytoplasm. The tumor was rather cellular, but there were no mitotic figures or cellular pleomorphism. The immunohistochemical staining results of the specimen were positive for SMA, desmin and MSA, all of which are smooth muscle antigens, and the specimen was also positive for Ki-67 (2%) (). In addition to the positive results, it was negative for the c-kit, CD34, EBC-LMP, p53 and cytokeratin. We later performed staining for estrogen and progesterone receptors, and the result was positive for both receptors. We tried to compare these findings to the pathology of the previous uterine leiomyoma. Because of the long time interval between the patient's hysterectomy and open lung biopsy, her medical records and the pathologic specimen from her previous operation was lost. So, we could not compare each specimen. During the open lung biopsy procedure, all the visible nodules were excised.\nBecause any malignant potential was not completely ruled out in view of her previous history of uterine leiomyoma and the progressive enlargement on follow-up, we considered starting chemotherapy. Yet we decided on close observation instead of adjuvant chemotherapy due to the lack of evidence for achieving any benefit from chemotherapy for the metastasizing leiomyomatosis and also because side effects were possible. In addition, our previous experience and also the published reports have shown that benign metastasizing leiomyomatosis might regress spontaneously with menopause; we are now considering anti-hormonal therapy. | [[51.0, 'year']] | F | {'30074141': 1, '7850080': 1, '11317453': 1, '24134076': 2, '25774240': 1, '1392332': 1, '14528073': 1, '318914': 1, '11373202': 1, '24977035': 1, '11037349': 1, '8553286': 1, '2167037': 1, '9166348': 1, '10506455': 1, '28426767': 1, '29977634': 1, '22384439': 2, '9555121': 1, '15068329': 1, '10665925': 1, '10713035': 1, '17017666': 2} | {'3842688-1': 1, '3842688-2': 1, '3842688-3': 1, '3842688-4': 1, '3283070-1': 1} |
165,235 | 3890721-1 | 17,017,667 | noncomm/PMC003xxxxxx/PMC3890721.xml | Photodynamic Therapy in Early Lung Cancer: A Report of Two Cases | A 70-year-old Korean man presented with squamous carcinoma\nin situ at, a previously treated, left main anastomotic pneumonectomy site. A left pneumonectomy was performed for squamous lung cancer 20 months previously; at that time the surgical margin was positive for squamous cell carcinoma. The patient was treated with concurrent chemoradiotherapy with six cycles of weekly paclitaxel (45 mg/m2) plus cisplatin (20 mg/m2) during radiotherapy with 5,040 cGy, and received four cycles of consolidation chemotherapy by paclitaxel plus cisplatin every three weeks. Follow-up bronchoscopic findings, after 20 months, showed that the mucosa in the anastomotic site had progressed with hypervascular infiltrative change; a biopsy revealed progression of cancerous changes. Bronchoscopic PDT was performed under local anesthesia with conscious sedation (Midazolam 2 mg intravenous injection). Before the PDT procedure, the photosensitizer (Photogem®: Lomonosov Institute of Fine Chemical, Russia) was injected intravenously at a dose of 2.0 mg/kg body weight. After an injection of Photogem, the patients were instructed to avoid direct sunlight exposure for at least two weeks. The laser beam was transmitted via a quarz fiber (400 mm) inserted through the instrumentation channel of a fiberoptic bronchoscope. A light using Diode laser (Biolitec Inc., Germany, wavelength; 633 nm) was delivered to the anastomotic site at 200 J/cm2 with a 3 cm diffuser and 100 J/cm2 with a 2 cm diffuser for 500 seconds, respectively. Fourty-eight hours after the procedure, bronchial toilet was performed. Necrotic changes at the PDT treated site were noted. There were no immediate complications. We performed a follow up bronchoscopic biopsy after three and 12 months. The histology at the PDT site regressed to focal squamous metaplasia and inflammatory conversion (). Clinical and histological findings were consistent with complete remission; there was no evidence of recurrence during 30 months of follow-up. | [[70.0, 'year']] | M | {'667856': 1, '21716589': 1, '25048340': 1, '10077365': 1, '8156487': 1, '9212759': 1, '9543288': 1, '25048064': 1, '9149603': 1, '6276108': 1, '1532341': 1, '9363151': 1, '20866097': 1, '11451811': 1, '13762612': 1, '17017667': 2} | {'3890721-2': 2} |
165,236 | 3890721-2 | 17,017,667 | noncomm/PMC003xxxxxx/PMC3890721.xml | Photodynamic Therapy in Early Lung Cancer: A Report of Two Cases | A 64-year-old Korean man was treated for squamous lung cancer IIIa (T1N2M0) 26 months prior to presentation; he now presented with subepithelial stroma that contained a very tiny nest of squamous cell carcinoma cells in the left upper lobe bronchus. The patient previously, 26 months ago, had surgery to remove the right upper and middle lobes of the lung; the patient received six cycles of adjuvant chemotherapy and chest radiation therapy with 5,520 cGy. We provided PDT at the left upper bronchus with 200J and a 2 cm diffuser for 400 seconds. After 48 hours, there were no necrotic conversions observed but edematous hyperemic mucosal changes were present. At eight months after the first PDT, a nodular mass was noted at the left upper apical segment. The pathology results from a bronchoscopic biopsy identified a squamous cell carcinoma. Light was delivered at 250 J/cm2 with a diffuser length for 625 seconds, and 100 J/cm2 for 250 seconds at the same site and again after 48 hours, respectively. After PDT, there were no immediate complications such as hemoptysis or respiratory failure. We performed a follow up bronchoscopy at one and four months. The previous cancer site showed inflammatory conversion; there was no remnant tumor tissue (). The patient is alive and well at 30 month follow up. | [[64.0, 'year']] | M | {'667856': 1, '21716589': 1, '25048340': 1, '10077365': 1, '8156487': 1, '9212759': 1, '9543288': 1, '25048064': 1, '9149603': 1, '6276108': 1, '1532341': 1, '9363151': 1, '20866097': 1, '11451811': 1, '13762612': 1, '17017667': 2} | {'3890721-1': 2} |
165,237 | 3890722-1 | 17,017,668 | noncomm/PMC003xxxxxx/PMC3890722.xml | Two Cases of Interstitial Pneumonitis Caused by Rituximab Therapy | A previously healthy 73-year-old man visited our hospital because of a left cervical mass. Incisional biopsy of the cervical node revealed a diffuse large B-cell lymphoma stage IIIA. The patient received seven cycles of R-CEOP combination chemotherapy (rituximab 375 mg/m2, cyclophosphamide 750 mg/ m2, epirubicin 50 mg/m2 and vincristine 2 mg IV on D1 and prednisolone 100 mg PO on D1-5). The response was partial after the 6th cycle. After the 3rd cycle of R-CEOP, he complained of cough and purulent sputum. A chest computed tomography revealed sub segmental consolidation with peripheral ground glass opacity (GGO) in left upper lobe of the lung. After the administration of parenteral antibiotics, symptomatic improvement and disappearance of the infiltration on X-ray were observed. After an additional four cycles of chemotherapy, he complained of cough, sputum and exertional dyspnea, NYHA class II. Auscultation revealed end-expiratory Velcro-like rales at both lower lung fields. Arterial blood gas analysis was PH; 7.49, PaCO2; 29.2 mmHg, PaO2; 74.3 mmHg, and HCO3; 22.5 mmol/L. The cultures of blood and sputum were all negative for bacteria, tuberculosis and fungi. Chest computed tomography showed a markedly increase in the extent of sub pleural GGO at both lungs (). Pulmonary function testing showed a mild restrictive pattern with FEV1; 2.19 L/min (87% of normal predicted value), FVC; 2.60 L/min (68% of normal predicted value), FEV1/FVC; 84%, and DLCO; 10.3 mL/mmHg/min (59% of normal predicted value). A bronchoalveolar lavage sample showed a lympho-dominant nature with a CD4/CD8 ratio of 1.5. After the diagnosis of interstitial pneumonitis, methylprednisolone 60 mg qd was administered for five days. Symptomatic improvements were followed by a change of dose to prednisolone 20 mg once daily. After five weeks of steroid therapy, pulmonary function testing showed an objective response with FEV1; 1.90 L/min (71% of normal predicted value), FVC; 2.57 L/min (63% of normal predicted value), FEV1/FVC; 74%, and DLCO; 13.4 mL/mmHg/ min (74% normal predicted value). | [[73.0, 'year']] | M | {'12826649': 1, '20195409': 1, '11208830': 1, '15765788': 1, '12475811': 1, '10807768': 1, '11920277': 1, '12796182': 1, '15681517': 1, '18306483': 2, '11807147': 1, '23131960': 1, '18551203': 1, '15307117': 1, '15483015': 1, '22778751': 2, '12649096': 1, '15244399': 1, '17017668': 2} | {'3890722-2': 2, '2615269-1': 1, '3388422-1': 1} |
165,238 | 3890722-2 | 17,017,668 | noncomm/PMC003xxxxxx/PMC3890722.xml | Two Cases of Interstitial Pneumonitis Caused by Rituximab Therapy | This 66-year-old man visited our hospital because of a right testicular mass (8×6 cm), which was detected one year prior to presentation and recently grew larger and became painful. After orchiectomy, the pathologic diagnosis was diffuse large B-cell lymphoma, stage IVA with unilateral involvement of bone marrow. He received five cycles of R-CEOP combination. His had a complete response after the 3rd cycle. After the 5th cycle of R-CEOP, he complained of cough and dyspnea, NYHA class II. Auscultation revealed end-expiratory Velcro-like rales at both lower lung fields. Chest computed tomography showed a markedly increased centrilobular and subpleural GGO and multiple consolidations in both lung fields (). Pulmonary function testing showed a mild obstructive pattern and decreased diffusing capacity with a FEV1; 1.95 L/min (76% of normal predicted value), FVC; 3.09 L/min (83% of normal predicted value), FEV1/FVC; 63%, and DLCO; 10.8 mL/mmHg/min (70% of normal predicted value). Bronchoalveolar lavage was refused by the patient. Symptomatic improvements were achieved two weeks after a prednisolone 10 mg qd daily regimen. After two months of steroid therapy, pulmonary function testing showed an objective response with a FEV1; 1.84 L/min (67% of normal predicted value), FVC; 3.33 L/min (83% of normal predicted value), FEV1/FVC; 56%, and DLCO; 15.5 mL/mmHg/min (89% of normal predicted value). Chest computed tomography demonstrated improvement () | [[66.0, 'year']] | M | {'12826649': 1, '20195409': 1, '11208830': 1, '15765788': 1, '12475811': 1, '10807768': 1, '11920277': 1, '12796182': 1, '15681517': 1, '18306483': 2, '11807147': 1, '23131960': 1, '18551203': 1, '15307117': 1, '15483015': 1, '22778751': 2, '12649096': 1, '15244399': 1, '17017668': 2} | {'3890722-1': 2, '2615269-1': 1, '3388422-1': 1} |
165,239 | 3890723-1 | 17,017,669 | noncomm/PMC003xxxxxx/PMC3890723.xml | Transluminal Removal of a Fractured and Embolized Indwelling Central Venous Catheter in the Pulmonary Artery | A 39-year-old woman with a 10-year history of liposarcoma had an implantable intravenous access devices (Celsite ST 201, 8.5 Fr, B/Braun medical Inc, France) placed in the left subclavian area, using the standard technique, to allow the administration of adjuvant chemotherapy. Three-months after implantation of the intravenous access device, the patient complained of chest and jaw pain for several days; she denied palpitations, dyspnea and syncope. There was no jugular venous distension. Cardiac auscultation revealed a regular rate and rhythm without any murmur, gallops or rubs; a normal S1 and S2 was present. The chest X-ray two months prior to presentation showed a grade two "pinch-off sign" () and the chest X-ray on admission showed a fractured and embolized catheter in the pulmonary artery (). Several days later, transesophageal echocardiography was performed and revealed no thrombus and spontaneous echo contrast in the right side of the heart and pulmonary artery. Computed tomography of the chest confirmed the catheter artifact in the pulmonary artery ().\nFirst a retrieval of the fractured fragment of the catheter was attempted via the right femoral vein with a goose neck snare (10 mm loop, er3, USA) an H1 catheter (5 Fr, Cook, USA). Although we could grasp the foreign body using a snare, it was impossible to retrieve it; the patient continued to complain of severe chest and jaw pain. We, therefore, changed the catheter with a pigtail catheter (5 Fr, Cook, USA). With accompanying fluoroscopic monitoring, we were able to successfully grasp the fragmented catheter () and to retrieve it ().\nAt a Three-month follow up the patient was doing well without any complication detected. | [[39.0, 'year']] | F | {'3334972': 1, '8104491': 1, '9630859': 1, '8667632': 1, '8565809': 1, '15378119': 1, '27642604': 1, '9739444': 1, '8281004': 1, '26023465': 1, '6496853': 1, '2217768': 1, '12554037': 1, '15996367': 1, '23569475': 1, '2054760': 1, '27429915': 1, '17017669': 2} | {} |
165,240 | 3890724-1 | 17,017,670 | noncomm/PMC003xxxxxx/PMC3890724.xml | Small Cell Carcinoma of the Kidney | A 52-year-old woman had a 2-week history of right flank pain and intermittent hematuria with iron deficiency anemia. Physical examination of the patient was unremarkable, except for an abdominal mass and CVA tenderness. Laboratory data were as follows: white blood count 8,280/µL, platelet 346,000/µL, hemoglobin 9.5 g/dL, MCV 74.3 fl, MCH 24.4 pg, MCHC 32.8 g/dL; serum blood urea nitrogen 12.7 mg/dL, serum creatinine 0.89 mg/dL. Urinalysis showed microscopic hematuria. A computed tomography (CT) scan of the abdomen revealed a relatively well defined, large heterogeneous tumor in the right kidney (). CT scans of the brain and chest, as well as a bone scan were carefully examined to look for signs of metastatic disease. There were no evident metastases at regional lymph nodes or at any distant organs. The preoperative impression was a renal cell carcinoma; the patient underwent a right radical nephrectomy. Macroscopically, a very large mass measuring 10×15 cm, from the right kidney, was identified (). Cut sections were grey-yellow in color and contained bloody and serosanguinous fluid. The tumor penetrated the capsule, but there was no infiltration into the renal pelvis, hilus of the kidney or adjacent lymph nodes. Histological examination revealed a pure small cell carcinoma with scant cytoplasm and stippled nuclear chromatin (). Immunohistochemical stains revealed that the tumor cells were strongly positive for synaptophysin, weakly positive for chromogranin, and negative for S-100, leukocyte common antigen (). We concluded that this case represented a pure small cell carcinoma of the kidney. Postoperatively, the patient received six courses of adjuvant chemotherapy consisting of etoposide and cisplatin. Upon completion of the chemotherapy, all oncological investigations, including abdominopelvic CT and chest X-ray, revealed no evidence of recurrence. Outpatient follow-up of laboratory and radiographic studies were performed at regular intervals. The patient is currently well without any evidence of recurrence at 28 months following the primary diagnosis. | [[52.0, 'year']] | F | {'15231859': 1, '22138976': 1, '6302908': 1, '12908782': 1, '12627507': 1, '9128989': 1, '19672338': 1, '19096940': 1, '9704349': 1, '19579058': 1, '17017670': 2} | {} |
165,241 | 3890725-1 | 17,017,671 | noncomm/PMC003xxxxxx/PMC3890725.xml | High-grade Hepatic Mucosa-associated Lymphoid Tissue (MALT) Lymphoma Probably Transformed from the Low-grade Gastric MALT Lymphoma | A 67-year-old woman visited our hospital with complaints of abdominal discomfort, indigestion and constipation for five days. Physical examination and laboratory findings were not specific, and her performance was excellent. Gastroscopic examination showed an ulcero-infiltrative lesion at the greater curvature side of the antrum (). Histological examination revealed mucosal ulceration with diffuse infiltration of lymphoid cells. Diffuse and nodular aggregates of lymphoid cells were composed of monotonous small to medium-sized lymphocytes with round to cleaved nuclei and clear cytoplasm. In some areas, relatively large atypical lymphoid cells were also present in less than 10% of tumor cells. There were a few foci of lymphoepithelial lesions (). Immunohistochemical stains were positive for CD20 and CD79a, but negative for CD45RO, CD3, CD5, CD23, Bcl-2 and Cyclin D1. H. pylori infection was detected using the rapid urease test and histology. An abdominal CT scan revealed focal wall thickening on the greater curvature side of antrum without any lymph node enlargement. Unfortunately, a bone marrow biopsy was not performed, thus staging work-up of the lymphoma was not fully performed. The patient was diagnosed with a low-grade gastric MALT lymphoma and treated for H. pylori infection for 14 days with omeprazole 20 mg bid, clarithromycin 500 mg bid and amoxicillin 1,000 mg bid. Follow-up gastroscopic examinations, one and three months after H. pylori eradication, showed marked improvement of gastric lesions. H. pylori infection was absent by rapid urease testing and histology, but MALT lymphoma was still present on histology evaluation. Thereafter the patient was lost to follow-up.\nFour years later, the patient visited our hospital again with complaints of indigestion and constipation. Gastroscopy showed diffuse erythematous changes of the antral mucosa with an irregular surface at the site of the previous MALT lymphoma that appeared to be a scar. Gastric mucosal biopsy showed well preserved foveolar epithelium, and sparsely scattered inflammatory cells in the lamina propria devoid of residual lymphoma. H. pylori infection was not found using the rapid urease test and by histology. Abdominal CT scan showed neither gastric wall thickening nor lymph node enlargement (). These findings were interpreted to represent complete remission of the gastric MALT lymphoma. The patient was then again lost to follow-up.\nAbout two years later, the patient returned to our hospital with complaints of general weakness and epigastric discomfort. Blood tests on admission showed a hematocrit of 36.1%, a white blood cell count of 4,200/mm3, a platelet count of 77,000/mm3, a protein of 4.6 g/dL, an albumin of 2.4 g/dL, a total bilirubin of 3.0 mg/dL (0.2-1.0 mg/dL), a direct bilirubin of 2.5 mg/dL (0.0-0.2 mg/dL), an alkaline phosphatase of 588 U/L (32-104 U/L), an alanine aminotransferase of 196 U/L (10-36 U/L), an aspartate aminotransferase of 357 U/L (10-30 U/L), a lactate dehydrogenase of 1,871 U/L (211-423 U/L), and a prothrombin time of 11.8 sec (10-14 sec). Gastroscopic examination showed several round superficial ulcerations and diffuse mucosal erythema at the antrum. Histological examination revealed only chronic inflammation and intestinal metaplasia with the absence of H. pylori infection and MALT lymphoma (). Abdominal sonography and liver MRI showed multiple hepatic nodules with multiple celiac and para-aortic lymphadenopathy (). Ultrasonography-guided percutaneous core needle biopsy was performed on the hepatic nodules; histological examination revealed a patchy infiltration, of atypical lymphoid cells, replacing the liver parenchyma. There were conspicuous medium to large lymphoid cells admixed with monocytoid cells. The composition of the large lymphoid cells, found in the liver biopsy, was significantly increased when compared to the previous gastric MALT lymphoma. Immunohistochemical stains were positive for CD20, but negative for: CD45RO, CD3, CD5, CD23, Bcl-2 and Cyclin D1 (). Immunohistochemical stains for Ki-67 were performed both on the biopsy from the previous low-grade gastric MALT lymphoma and the liver core biopsy. The Ki-67 labeling index, from the liver biopsy sample, was much higher (70%) than in the previous gastric biopsy (20%) (). These pathological findings suggested a hepatic MALT lymphoma that represented a transformation from the previously treated low-grade gastric MALT lymphoma to a high-grade MALT lymphoma. The patient, and her family, refused further treatment and her clinical status deteriorated rapidly; she died from sepsis one month later. | [[67.0, 'year']] | F | {'7783535': 1, '9178679': 1, '12960515': 1, '6193858': 1, '9402171': 1, '8579126': 1, '30921228': 2, '9989495': 1, '10751367': 1, '11675358': 1, '10319863': 1, '11262391': 1, '7717599': 1, '23767042': 2, '11984515': 1, '9181363': 1, '2613920': 1, '3166533': 1, '1682595': 1, '26435907': 2, '9520941': 1, '17017671': 2} | {'3678069-1': 1, '3678069-2': 1, '4580714-1': 1, '6456129-1': 1} |
165,242 | 3890726-1 | 17,017,672 | noncomm/PMC003xxxxxx/PMC3890726.xml | A Case of Benign Metastasizing Leiomyoma with Multiple Metastasis to the Soft Tissue, Skeletal Muscle, Lung and Breast | A 39-year-old woman was referred to our hospital. At the age of 19, she was treated for miliary pulmonary tuberculosis because multiple pulmonary nodules were found on her chest radiograph, although she had no symptoms. At the age of 31, she was diagnosed uterine leiomyoma, but she was not treated; four years later, she underwent myomectomy. At the age of 39, she visited a local clinic due to bilateral, multiple small nodular lesions that were seen on a chest radiograph and both breasts had palpable breast masses. She had undergone excisional biopsy of the breast before being referred to our hospital.\nThe patient was asymptomatic on admission to our clinic, but bilateral, multiple small nodular lesions were still noted on the chest radiograph (). There was no abnormality on the physical examination, and her breathing sounds were clear. A complete blood count, blood chemistry, c-reactive protein, arterial blood gas analysis and pulmonary function test were all within the normal ranges. The serum levels of tumor markers including alpha-fetoprotein (AFP), squamous cell carcinoma (SCC) antigen and carcinoembryonic antigen (CEA), CA19-9, CA-125 and CA15-3 were within the normal ranges.\nThe chest radiograph showed multiple, variable-sized nodules in both lungs, suggesting hematogenous metastasis (). Chest CT scans with intravenous contrast enhancement demonstrated multiple well-enhancing masses in both breasts (), the left pectoralis minor muscle (), and the right infraspinatus muscle (). A CT scan obtained with a lung window setting showed multiple variable-sized nodules in both lungs, which suggested hematogenous metastasis (not shown).\nWe initially planned to treat her with progesterone under the clinical impression of BML or lymphangioleiomyomatosis (LAM). However, the follow-up chest radiologic findings showed progressive disease, and so we performed a hysterectomy, bilateral oophorectomy and wedge resection of the lung for the purpose of both treatment and diagnosis.\nThe pathologic findings of the lung, breast (), and retroperitoneal tissue showed nodular proliferations of spindle cells. The tumor showed occasional mitotic activity (4-7/50HPF) (), but no nuclear atypia, hemorrhage or necrosis. Immunohistochemial staining of the lung mass showed a positive reaction for smooth muscle actin and a negative reaction for thyroid transcription factor-1 (TTF-1), a 10% positive cell area with a weak intensity for estrogen receptor, a 95% positive cell area with a strong intensity for progesterone receptor and a low mitotic index (less than 5%) for Ki-67.\nAfter surgical hormonal ablation, she was prescribed tamoxifen. Follow-up chest radiography () showed the decreased size of the multiple nodular lesions. This response has been sustained until the present. | [[39.0, 'year']] | F | {'10506455': 1, '28426767': 1, '23986835': 2, '24977035': 1, '22682624': 1, '30074141': 1, '30989050': 1, '23018207': 1, '9555121': 1, '15099894': 1, '23465706': 1, '27511755': 1, '30225333': 1, '3730334': 1, '8857651': 1, '23956897': 1, '183531': 1, '17017672': 2} | {'3738344-1': 1} |
165,243 | 3890727-1 | 17,017,673 | noncomm/PMC003xxxxxx/PMC3890727.xml | A Case of Nonsecretory Multiple Myeloma with Atypical Imaging Features | A 45-year-old man was admitted to our hospital because of a one month history of fatigue and severe back pain for two days prior to presentation. There were no specific findings on physical examination. Results of routine laboratory tests showed a mild anemia (hemoglobin, 11.4 g/dL; normal range, 14~18 g/dL). A corrected reticulocyte count was slightly decreased (0.4%; normal range, 0.5~2.5%), suggesting impaired marrow synthesis of erythrocytes. The albumin to globulin ratio (A/G ratio) was normal (A/G ratio, 1.43; albumin, 3.0 g/dL; globulin, 2.1 g/dL). The serum C-reactive protein was markedly increased (151.0 mg/dL; normal range, 0.0~0.5 mg/dL). The serum creatine and total calcium levels were normal. The serum and urine protein electrophoreses, and immunofixation electrophoreses to detect protein more than 20 mg/dL, were repeatedly negative. The level of β2 microglobulin was also normal.\nThere was no evidence of lytic bone lesions on plain radiograph. Contrast enhanced chest CT obtained on admission showed multiple, well-defined, osteolytic lesions at the 8th and 11th thoracic vertebrae (). MRI showed the lesions to be hypointense on T1-weighted image (500/15) () and heterogeneously hyperintense on T2-weighted image (1800/90) (). Although these were very small foci of enhancement, at the lesions of 8th and 11th thoracic vertebrae, most of the lesions were poorly enhanced on T1-weighted image () after intravenous administration of gadopentetate dimeglumine (Magnevist; Schering, Seoul, Korea). The radiological differential diagnosis was multiple myeloma, metastasis and tuberculosis. Two days after the MRI, a CT-guided gun biopsy was performed on the poorly enhancing portion of the lesion at the 8th thoracic vertebra. The biopsy showed a coagulation necrosis within a population of uniform, monotonous cells (). However, the definite diagnosis was not made at that time because the pathologist considered this finding to be nonspecific. Polymerase chain reaction (PCR) was performed with part of biopsy specimen obtained from the 8th thoracic vertebra using an M tuberculosis kit (Amplicor; Roche Diagnostic Systems, Somerville, NJ), which amplified part of the 16S rRNA gene. The result of the PCR was positive for M tuberculosis. Although pathologic confirmation of tuberculous granuloma with caseation necrosis was not proven, a presumptive diagnosis of tuberculous spondylitis was made. Combination chemotherapy with isoniazid (Yuhan-zid; Yuhan, Seoul, Korea), rifampin (Yuhan), etambutol (myambutol; Yuhan), and pyrazinamide (Yuhan) was started. Twenty-five days after the biopsy, the patient complained of more severe and constant back pain. A thoracolumbar roentgenogram showed compression fractures of the 8th and 11th thoracic vertebral bodies. Follow-up CT examination showed a new osteolytic lesion (), with a well-defined outer margin and cortical disruption, at the junction of the spinous process and the lamina of the 12th thoracic vertebra; this lesion showed strong enhancement after intravenous administration of contrast media. On a retrospective review of the previous CT studies, this lesion () had been overlooked. The next day, a CT guided gun biopsy of the lesion at the 12th thoracic vertebra was performed. Histological examination of the biopsy tissue showed a proliferation of plasma cells (). There was a strong positive reaction for the lambda light chain (). On the basis of these findings, we considered that the lesion at the 8th thoracic vertebra was also a plasma cell lesion with coagulation necrosis. The tissue from a bone marrow biopsy of the right posterior iliac bone showed 40% plasmacytosis. A diagnosis of a stage I nonsecretory myeloma was made. Combination chemotherapy with intravenous adriamycin (Il-dong Pharmaceuticals, Seoul, Korea), vincristine (Boryung Pharmaceuticals, Seoul, Korea), and dexamethasone (Il-sung Pharmaceuticals, Seoul, Korea) was started in a dose of 13.5 mg, 0.4 mg and 400 mg per day for four days, respectively. | [[45.0, 'year']] | M | {'8819407': 1, '9844655': 1, '10882284': 1, '8599984': 1, '3934904': 1, '31620322': 2, '1535904': 1, '1582977': 1, '14990813': 1, '12034612': 1, '8470574': 1, '8677762': 1, '17017673': 2} | {'6793598-1': 1} |
165,244 | 3890728-1 | 17,017,674 | noncomm/PMC003xxxxxx/PMC3890728.xml | Hepatic Subcapsular Steatosis in a Diabetic CAPD Patient Receiving Intraperitoneal Insulin | A 46-year-old woman presented with general weakness that had lasted for several weeks. She was diagnosed with type 2 diabetes mellitus (DM) 15 years ago and began continuous ambulatory peritoneal dialysis (CAPD) three years ago. An abdominal sonography obtained before CAPD began revealed a normal liver. The patient received CAPD with four daily exchanges of 2 L each time and switched to three exchanges with 2.5% glucose and one with 4.25% glucose solution; this was required because the ultrafiltration capacity was not sufficient and she became volume overloaded. A peritoneal equilibrium test was not performed. The patient had insulin administered subcutaneously when she started the CAPD but changed to intraperitoneal insulin treatment combined with subcutaneous treatment two years later. Hyperlipidemia treated with simvastatin and fenofibrate were started one year previously but stopped three months later because the drugs caused rhabdomyolysis. Lipid profiles began to worsen and she had to resume with atovastatin but did not develop rhabdomyolysis. Plasma glucose was poorly controlled despite the combination therapy of subcutaneous and intraperitoneal insulin injections. Insulin doses increased from 102 units daily up to 110 units daily during the previous month. The patient was 158 cm tall and weighed 58 kg. When she visited our clinic, her body mass index was 23 kg/m2. Vital signs were a blood pressure of 130/80 mmHg, pulse rate 68/min, respiratory rate 20/min, and body temperature 36.6℃. Her abdomen was soft and mildly distended. The initial complete blood count was white blood cells 8,000/mm3 (neutrophils 70.7%, lymphocytes 18.5%, eosinophils 3.2%), hemoglobin 11.5 g/dL, hematocrit 33.3%, and platelet 288,000/mm3. Her blood chemistry values were, fasting glucose 293 mg/dL, blood urea nitrogen 46.6 mg/dL, creatinine 10.3 mg/dL, sodium 134 mEq/L, potassium 4.4 mEq/L, chloride 90 mEq/L, AST 119 IU/L, ALT 192 IU/L, alkaline phosphatase 850 IU/L, amylase 110 U/L, total protein 6.8 g/dL, albumin 4.0 g/dL, calcium 11.1 mg/dL, phosphorus 6.2 mg/dL, CPK 43 IU/L, LDH 468 IU/L, total cholesterol 450 mg/dL, and triglyceride 1,096 mg/dL. Hepatitis B antigen and hepatitis C antibody were negative. ANCA, anti-liver kidney microsome antibody, and anti-smooth muscle antibody were all negative. Sonography of the abdomen revealed an increased echogenicity of the liver. A CT scan of the abdomen showed extensive low attenuated lesions in the liver capsule, the parenchyma of the left hepatic lobe and a small nodular lesion in the capsular area of the right lobe of the liver (). The MRI findings were consistent with the CT findings. The hepatic subcapsular area showed bright signals in the on-phase T1weighted images, but a marked signal decrease in the off-phase T1-weighed sequences; these findings suggested that the subcapsular area was composed of fat tissue. Hepatic subcapsular steatosis due to high dose intraperitoneal insulin was suspected; the patient was changed from CAPD to HD. Insulin was given only subcutaneously after changing to HD. A CT scan performed two months after starting HD showed complete resolution of the hepatic subcapsular steatosis (). Laboratory values were also improved: AST 34 IU/L, ALT 81 IU/L, alkaline phosphatase 733 IU/L, total cholesterol 259 mg/dL, and triglyceride 177 mg/dL. The blood sugar has been well controlled insulin therapy could be discontinued. Six months after changing from CAPD to HD, oral hypoglycemic agents have been sufficient to maintain adequate plasma glucose levels. Furthermore, liver enzyme levels are within normal range; the total cholesterol level was 206 mg/dL, and triglyceride level 157 mg/dL without requirement for lipid-lowering agents. | [[46.0, 'year']] | F | {'1523289': 1, '2068804': 1, '11216552': 1, '11159098': 1, '11350293': 1, '2657721': 1, '20418464': 1, '8728195': 1, '8163703': 1, '6331737': 1, '12760927': 1, '17017674': 2} | {} |
165,245 | 3890729-1 | 17,017,675 | noncomm/PMC003xxxxxx/PMC3890729.xml | A Case of Multiple Organ Failure due to Heat Stoke Following a Warm Bath | A 68-year-old man was admitted to emergency room for loss of consciousness. He was discovered in bathtub filled with warm water and he was unconscious. He was presumed to have been in a warm bath for 3 hours at the time of discovery. He had been taking an oral hypoglycemic agent for his diabetes for 9 years.\nHis body temperature was 41℃, the blood pressure was 80/50 mmHg, the pulse rate was 124 beats/min and the respiratory rate was 48 breaths/min. On arrival, he was semicomatous, areflexic and flaccid, but he had no lateralizing signs or neck stiffness. His skin was hot and dry. His blood glucose was 150 mg/dL, and the arterial blood gas analysis showed a mixed high anion gap metabolic acidosis and respiratory alkalosis (pH: 7.42, pO2: 47.2 mmHg, pCO2: 28 mmHg, and HCO3-: 18 mmol/L). On admission, laboratory findings were as follows: WBC: 6,300/L, Hb: 17.5 g/dL, platelets: 70,000/L, prothrobin time (PT): 12.8 sec (89%, INR 1.12), activated partial thromboplastin time (aPTT): 21.7 sec, aspartate aminotrasferase (AST): 98 IU/L, alanine aminotransferase (ALT): 97 IU/L, bilirubin: 0.7 mg/dL, amylase: 39 IU/L, Na/K/Cl: 140/4.1 /100 mmol/L, BUN: 32 mg/dL, creatinine: 2.3 mg/dL and myoglobin: 223 ng/mL. Brain MRI showed no hemorrhage or infarction and there was no abnormal finding on the chest X-ray.\nAfter 30 min, his body temperature was still 39.5℃. Despite further decreasing the body temperature to 38℃ via external cooling and infusion of fluids, the semicomatous mentality was not changed and so endotracheal intubation and mechanical ventilation were started. On day 2, the PT decreased to 13% (INR 7.57), and the aPTT was also prolonged to an uncheckable range. The AST/ALT increased to 2136/1838 IU/L and the total bilirubin increased to 3.2 mg/dL (). The fibrinogen decreased to 185.6 mg/dL (normal range: 230-480), and the fibrin/fibrinogen degradation products (FDPs) were elevated to >20 ug/dL. The laboratory findings were considered to represent acute hepatic failure combined with acute renal failure (ARF) and disseminated intravascular coagulation (DIC) following heat stroke. Other causes of fulminant liver failure like viral hepatitis and fulminant Wilson's disease were ruled out by the patient's history and/or the appropriate laboratory tests. On the third day, continuous venovenous hemofiltration (CVVHF) was started because of the progressive oligouria despite continuous infusion of diuretics and the worsening metabolic acidosis (pH: 6.93, pO2: 117 mmHg, pCO2: 41.8 mmHg and bicarbonate: 8.6 mmol/L). The serum transaminase was decreased, but the PT remained prolonged despite daily infusion of fresh frozen plasma (FFP). The serum bilirubin level increased further to 50 mg/dL.\nOn day 15, abdominal distension developed and the ascitic fluid analysis showed inflammatory exudates. At the same time, Acinetobacter baumannii and Enterococcus faecium were cultured in the blood and the appropriately sensitive antibiotics were started under the impression of septic peritonitis. In spite of treatment with CVVHF and the best supportive care, the hepatic failure (bilirubin to 53 mg/dL) and DIC progressed with superimposed infection. The patient passed away on day 25. | [[68.0, 'year']] | M | {'12172074': 1, '32292608': 2, '12067009': 1, '28978590': 1, '25834708': 1, '10229168': 1, '9588849': 1, '12075060': 1, '14758154': 1, '9696724': 1, '17017675': 2} | {'7149357-1': 1} |
165,246 | 3890730-1 | 17,017,676 | noncomm/PMC003xxxxxx/PMC3890730.xml | Tachycardiomyopathy Induced by Ventricular Premature Complexes: Complete Recovery after Radiofrequency Catheter Ablation | A 32-year-old male patient visited the emergency room and presented with resting dyspnea and palpitations. He had suffered from intermittent palpitations and dyspnea (class II) for more than 10 years. He had undergone a radiofrequency catheter ablation procedure 10 years ago for these frequent VPCs without success at another hospital. He had received intensive heart failure medications including beta-blockers, angiotensin-converting enzyme inhibitors and spironolactone from a local hospital during the last two years.\nA physical examination revealed jugular vein engorgement and slightly rapid and irregular heart sounds. His vital signs were as follows: a blood pressure of 110/70 mmHg, a pulse rate of 88 beats/min and a respiration rate of 21 breaths/min. The standard 12-lead electrocardiography (ECG) revealed frequent VPCs. The right ventricular outflow tract was suspected as being the origin of this condition due to the negative deflection of the VPCs in lead V1, the positive deflection in leads II, III and aVF, and the QRS transition in lead V4 (). The chest X-ray revealed cardiomegaly and increased broncho-vascular markings. The echocardiography demonstrated dilatation of the left ventricle (LV) and a decreased LV contractile function (LV end-diastolic dimension: 66 mm, LV end-diastolic volume: 211 mL and an ejection fraction: 34%) (). A 24 hour ambulatory ECG showed very frequent VPCs; there were 22,256 isolated VPCs and 16,081 couplets out of 123,139 total heart beats (31%) during 22 hours.\nAn electrophysiological study and radiofrequency catheter ablation were performed after obtaining an informed written consent on the following day after hospital admission. A 6 Fr. Quadripolar electrode catheter was positioned in the right ventricular (RV) apex. A 7 Fr. deflectable quadripolar ablation catheter (Boston Scientific EP Technologies, Natick, Massachusetts) with a 4-mm-tip electrode was introduced percutaneously into the RV using an 8 Fr. SR0 sheath (Daig®). The origin of the spontaneous VPCs was determined based on the 12-lead-surface ECG and it was further located with the mapping catheter that was placed into the RV outflow tract. The triggering focus of the VPCs was located in the high anteroseptal region ().\nThe electrograms recorded from the ablation catheter were very tiny in the area that was mapped, and this was probably due to the scar formation created by the previous unsuccessful radiofrequency catheter ablation. The onset of the bipolar electrogram of the spontaneous VPCs recorded by the ablation catheter was 38 ms earlier than that of the surface ECG, and the unipolar electrogram had abrupt negative deflections without an initial positive component at the site we chose for ablation (). Radiofrequency energy was delivered for 60 seconds with a preset temperature of 60℃ and power limit of 40 W. The VPCs disappeared within 5 seconds after reaching a tissue-electrode temperature of 50℃. A booster application of energy was delivered to four sites around the successfully ablated focus for 30 seconds each.\nA 24 hour ambulatory ECG taken the same day as the radiofrequency catheter ablation procedure recorded only a few atrial premature complexes without any VPCs. The medications that has been administered for heart failure before the treatment were continued thereafter. No VPCs were observed throughout a series of ECGs that were recorded during the 6 months following his discharge. The LV dimensions and function returned to normal, as determined by the 6 month follow-up echocardiography: the LV end-diastolic dimension was 51 mm and the ejection fraction was 55% (). | [[32.0, 'year']] | M | {'2945673': 1, '15018870': 1, '1384411': 1, '29536334': 1, '6481531': 1, '1659503': 1, '12419942': 1, '8465727': 1, '22875587': 1, '26668581': 1, '3953440': 1, '1311723': 1, '1378858': 1, '5088355': 1, '2328442': 1, '2375409': 1, '2337189': 1, '2058725': 1, '10749356': 1, '1567354': 1, '8214113': 1, '8238398': 1, '1650296': 1, '26064834': 1, '15837259': 1, '6700253': 1, '17017676': 2} | {} |
165,247 | 3890733-1 | 16,913,441 | noncomm/PMC003xxxxxx/PMC3890733.xml | Concurrence of Sjögren's Syndrome in a Patient with Chlamydia-induced Reactive Arthritis; An Unusual Finding | A 40-year-old man presented with a history of swelling and pain of both ankle joints and plantar surfaces, and inflammatory back pain for 5 years. He also had dry mouth and eyes, and fatigue. The patient had a medical history of urethritis with a recurrent dysuria and pyuria, which was intermittently treated with systemic antibiotics.\nA physical examination revealed significant swelling of both ankle joints and severe tenderness around the bony insertion portions of the Achilles tendon. Tenderness was also noted in the: iliac crest (bilaterally), tibial tuberosities, and calcaneus. Bilateral keratoconjunctivitis sicca was confirmed by an ophthalmologic examination which included the Schimer's test (3 mm left eye and 2 mm right eye). However characteristic manifestations of ReA including keratoderma blennorrhagica, circinate balanitis, and painless oral ulcer were absent.\nLaboratory analyses on admission demonstrated a C-reactive protein of 2.0 mg/dL (normal: < 0.3 mg/dL) and a erythrocyte sedimentation rate of 36 mm/hr (normal: 0-20 mm/hr). Complete blood count and blood biochemistry produced normal findings. Routine analysis and culture of urine showed pyruia (WBC 10-19/high power field) without identification of any bacterial organisms. HLA-B27 was positive. ANA was detected at a titer of 1:320. RF and anti-Ro antibody were elevated to 56 IU/mL (normal: < 15 IU/mL) and 460 AAU (normal: < 150 AAU), respectively. However, anti-neutrophil cytoplasmic antibody, double-strand DNA antibody, anti-Sm antibody, anti-RNP antibody, and anti-La antibody were all negative. IgG titer for Chlamydia trochomonas was 4.0 (normal: <0.9); this value is almost four fold elevated compared to the cut-off value using the ELISA method.\nThe radiological finding of the sacroiliac joints revealed mild marginal irregularity and subchondral sclerosis at the left joint surface (). In addition to periostitis, soft tissue thickening, and subchondral sclerosis along the inferior and posterior aspects of the calcaneus, bony erosion was also present at the bony insertion site of the Achilles tendon (). A whole body bone scan using Tc99m-MDP showed more increased uptake at the left sacroiliac joint compared to the right joint; in addition, increased uptake of the left foot compared to the right was observed (). A reduced excretion or abnormal uptake of the salivary glands was not noted in the evaluation by salivary scan.\nOn the basis of: inflammatory back pain, asymmetrical sacroiliitis, evidence of urethritis by Chlamydia infection, recurrent pyuria, peripheral arthritis dominant in lower extremities, and enthesitis of Achilles tendon with radiological changes, a diagnosis of ReA combined with SS was assigned to the patient. The criteria were fulfilled for the diagnosis of ReA based ib the European Spondylarthropathy Study Group (ESSG) and SS of European-American Consensus Group, respectively, . For the enthesitis and arthritis, we administered low dose corticosteroid (prednisolone 5 mg/day), sulfasalazine (1,000 mg bid/day), and non-inflammatory anti-inflammatory drugs (NSAIDs). Intra-articular injection or intra-lesional infiltration of steroid was also performed for swollen joints and tender lesions of enthesopathy. Only 1 gram of oral azithromycine for urethritis was needed. Dry eyes were controlled by replacement with an artificial tear solution. The use of pilocarpine for dry mouth was withdrawn because of an erosive gastric lesion confirmed by endoscopy. After discharge from the hospital, inflammatory back pain, swollen joints, and enthesitis subsided. Laboratory findings indicating disease activity were also gradually improved. Pyuria resolved on repeat urine analysis. | [[40.0, 'year']] | M | {'15077311': 1, '328881': 1, '9433880': 1, '9558175': 1, '1734908': 1, '15222650': 1, '30344882': 1, '398729': 1, '12110134': 1, '12006334': 1, '317236': 1, '15498797': 1, '7352730': 1, '12737333': 1, '8035411': 1, '11604590': 1, '9891706': 1, '15226160': 1, '22679320': 1, '12184435': 1, '12069564': 1, '3437415': 1, '2347546': 1, '1930310': 1, '16913441': 2} | {} |
165,248 | 3890734-1 | 16,913,442 | noncomm/PMC003xxxxxx/PMC3890734.xml | Thrombotic Thrombocytopenic Purpura after Percutaneous Coronary Intervention | A 65-year-old female was admitted with complaints of dyspnea and chest discomfort. She had a 9-month history of dyspnea on exertion prior to her admission and a 20-year history of diabetes. She had no allergies and did not take any illicit drugs. Diagnostic studies included cardiac enzymes, in which the cTn-I was mildly elevated at 0.98 ug/L On a transthoracic echocardiogram, the ejection fraction was 39% and hypokinesia was present in the anteroseptal, anterior, septal and apical regions. Gated myocardial scintigraphy demonstrated a reversible reperfusion defect and hypokinesia in the anterior and inferior cardiac walls. The clinical diagnosis was a non-ST elevation myocardial infarction. A complete blood cell count revealed a hematocrit of 29.9%, a white blood cell count of 6,750/µL, and a platelet count of 226×103/µL. Additional laboratory tests performed at the time of admission revealed a blood ureanitrogen level of 40 mg/dL, a creatinine level of 2.0 mg/dL, and a creatinine clearance of 19 mL/min. Liver function tests were normal.\nAspirin and clopidogrel were started as antiplatelet therapy for 3 days before the coronary procedure. Coronary angiography revealed a 90% diameter stenosis of the proximal left anterior descending artery (LAD) and total occlusion of the proximal right coronary artery (RCA). After a 0.5 mm balloon predilation, a 3.0×28 mm sirolimus-eluting stent (SES) was successfully deployed at the LAD lesion. An attempt was made to open the chronic total occlusion in the proximal RCA. A floppy wire was successfully passed into the lesion. With balloon predilation, a 3.0×28 mm SES was successfully deployed at the proximal RCA. After stent implantation, the patient complained suddenly of dizziness and became agitated. The blood pressure dropped to 80 mmHg systolic and the pulse rate decreased to 40 beats per minute for a few minutes. A temporary pacemaker was immediately implanted. After stabilization of her vital signs, additional SESs (2.75×33 mm, 2.5×33 mm) were implanted at the distal and mid RCA. After the PCI, the patient was transferred to the cardiac intensive care unit. Although thevital signs were stable, her mental status was characterized by fluctuating confusion and irritability without any focal neurological findings. The body temperature was elevated to 38.4℃ at that time. To evaluate the cause of her abnormal mentation, serologic laboratory tests were performed. Arterial blood gas analysis demonstrated a metabolic acidosis. The platelet count was decreased to 147×103/µL. The prothrombin time (PT) was 13.9 seconds, the partial thromboplastin time was 43.6 seconds, and the serum ammonia level was normal. Several hours after the PCI, the platelet count rapidly decreased to 55×103/µL, and the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels increased to 1516 U/L and 789 U/L, respectively. This was in contrast to the nearly normal level of alkaline phosphatase (ALP). Lactate dehydrogenase (LDH) increased to 3,504 U/L. On the first day after the PCI procedure, the platelet count decreased to 35×103/µL and the hematocrit decreased to 21.9%. The blood urea nitrogen increased to 60 mg/dL, the creatinine to 3.6 mg/dL, the AST and ALT levels peaked at 6,500 U/L and 2,063 U/L, respectively, and the LDH rose to 3,504 U/L. Serum amylase was also increased. The peripheral blood smear was consistent for microangiopathic hemolysis with schistocytes and burr cells. The Coombs direct and indirect tests were negative as were viral markers. An ultrasound study of the abdomen was unremarkable. A chest radiograph demonstrated no abnormality and an abdominal radiograph demonstrated contrast enhancement in both kidneys.\nPacked cells and fresh frozen plasma were transfused immediately. After 3 days, the creatinine rose to 5.5 mg/dL. The amylase and lipase levels had steadily risen to 609 U/Land 1,475 U/L, respectively, for several days with no abdominal pain The patient's general condition and mental status stabilized, and the platelet count s increased to 51×103/µL, 3 days after the procedure; and to 117×103/µL, 1 week later. She was discharged with a platelet count of 178×103/µL, a hematocrit of 28.1%, and a creatinine level of 1.6 mg/dL, with resolution of contrast on the abdominal radiograph. 4 weeks later, the platelet count increased to 275×103/µL and the hematocrit improved to 33.1%. After stabilization of all laboratory findings, the EF improved to 49% on a follow-up transthoracic echocardiogram. The patient experienced no adverse cardiovascular events at the time of her 6-month clinical follow-up. | [[65.0, 'year']] | F | {'9483176': 1, '8813090': 1, '10967151': 1, '2062331': 1, '10071001': 1, '2062330': 1, '14624653': 1, '15493057': 1, '12627668': 1, '15162901': 2, '16913442': 2} | {'3886298-1': 1} |
165,249 | 3890735-1 | 16,913,443 | noncomm/PMC003xxxxxx/PMC3890735.xml | A Case of Primary Pancreatic Non-Hodgkin's Lymphoma | A 61-year old female was admitted to the hospital with the complaint of right upper abdominal pain in February 2003. On admission, the patient had a temperature of 36.9℃, blood pressure of 115/58 mmHg, and a pulse of 68 beats per minute. Physical examination revealed a palpable non-tender mass in the right upper abdomen and icteric sclera. The hemoglobin was 8.2 g/dL with 6,400 leukocytes/mm3 and 247,000 platelets/mm3. The alanine aminotransferase was 129 U/L (normal range (NR), 5-40 U/L) and aspartate aminotransferase was 65 U/L (NR, 5-33 U/L). The alkaline phosphatase was 615 U/L (NR, 35-129 U/L) and gamma-glutamyltranspeptidase was 212 U/L (NR, 8-61 U/L). The total bilirubin was 16 mg/dL with 12 mg/dL of direct bilirubin. The serum carbohydrate antigen 19-9 (CA19-9) was 36.9 U/mL (NR, 0-37 U/mL). The abdominal ultrasound demonstrated a hypoechoic 3.4 cm sized mass located at the head of pancreas; there was dilatation of the bile duct and the gallbladder appeared to be filled with sludge. Computed tomography (CT) of the abdomen showed a well defined mass located at the head of the pancreas which was slightly enhanced during the arterial phase (). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis of the distal common bile duct by extrinsic compression. Percutaneous transhepatic biliary drainage was performed because of the clinical signs of fever and leukocytosis, suggesting acute cholangitis.\nLaparotomy was performed, revealing a prominent mass located at the head of the pancreas accumulated with the duodenum and the portal area. A frozen section of pancreas revealed lymphoma and partial excision of the mass located at the pancreatic head was performed instead of the Whipple procedure. Microscopic examination revealed a malignant lymphoma which consisted of large anaplastic lymphocytes (). The round or oval nuclei showed condensation of chromatin patterns with nucleoli. The cytoplasm was scanty or eosinophilic. Mitotic figures were easily identified. Tumor cells showed strong membrane staining for the B cell marker protein (CD20) and were negative for the T cell marker protein (CD3) (). Therefore, according to the Ann Arbor classification, the patient had stage IE disease.\nSix cycles of CHOP chemotherapy (cyclophophamide, doxorubicin, vincristine, and prednisone) were administered without any further complications. Follow-up abdominal CT showed no visible mass in the pancreas (). The patient is currently in complete remission and in good general condition. | [[61.0, 'year']] | F | {'9622727': 1, '32176677': 1, '28356755': 2, '31966438': 1, '10703858': 1, '10962538': 1, '20357994': 1, '11180896': 1, '15011880': 1, '8451443': 1, '33981170': 1, '23450175': 1, '2910212': 1, '7809023': 1, '26414831': 1, '8877636': 1, '9551063': 1, '16913443': 2} | {'5367597-1': 1, '5367597-2': 1} |
165,250 | 3890736-1 | 16,913,444 | noncomm/PMC003xxxxxx/PMC3890736.xml | Longlasting Remission of Primary Hepatic Mucosa-associated Lymphoid Tissue (MALT) Lymphoma Achieved by Radiotherapy Alone | A 67-year-old man, who was undergoing treatment for a bleeding duodenal ulcer, was admitted to our hospital for evaluation of a liver mass incidentally found on abdominal ultrasonography. The patient had a past medical history of angina pectoris, drug induced hepatitis, myocardial infarction, congestive heart failure and old pulmonary tuberculosis. The family history was none contributory. The patient complained of general weakness, easy fatigability and anorexia. He had no complaints of abdominal pain, weight loss, fever or night sweats. The blood pressure was 125/90 mmHg, pulse rate 90/min and body temperature 36℃. He appeared chronically ill and had an alert mental status. There was no tenderness on abdominal examination. Hepatomegaly of two fingers breadth was noted below the right costal margin; there was no ascites. His spleen and lymph nodes were not enlarged. Laboratory blood tests showed a hemoglobin of 12.8 g/dL, hematocrit 37%, white blood cell 5,400/µL with 42.8% neutrophils, platelet count 122,000/µL, blood urea nitrogen 14.2 mg/dL, creatinine 1.4 mg/dL, total protein 7.8 g/dL, albumin 3.8 g/dL, total bilirubin 0.8 mg/dL, alkaline phosphatase 53 IU/L, alanine aminotransferase (ALT) 30 IU/L, aspartate aminotransferase (AST) 35 IU/L, gamma glutamyl transferase (r-GT) 53 IU/L, lactate dehydrogenase (LDH) 250 IU/L (within normal range), prothrombin time 23 sec (98% of normal) and alpha-fetoprotein 3.5 ng/mL (within normal range). Hepatitis B surface antigen (HBsAg), antibody against hepatitis B surface antigen (anti-HBs) and antibody against hepatitis C (anti-HCV) were all negative. Abdominal magnetic resonance imaging (MRI) showed a well defined homogeneous mass 5.7×4.8 cm in size at segment 5 (). The following neck and chest computerized tomography (CT) scan showed no sign of other organ involvement or lymphadenopathy. Abdomen-pelvic CT scan showed no evidence of splenomegaly or lymphadenopathy. The whole body bone scan (WBBS) had no evidence of bone involvement. Gallium scan also showed no abnormal radioactivity. There were no malignant infiltrations noted on the bone marrow biopsy. Additional diagnostic evaluation included hepatic angiography and ultrasonograpy guided liver needle aspiration biopsy, using the gun shot approach, of the hypoechoic lesion in the right liver lobe. Hepatic angiography did not show any stained tumor, and lipiodol injection failed. Liver biopsy histology showed a severely distorted architecture due to lymphoreticular cell infiltration of the portal tract (). The cells had the following features: they were uniform in size, had a slightly irregular outline and showed an increased nuclear-cytoplasmic ratio. They showed no particular arrangement representative of a specific organ. The cells expressed CD20 () with a low Ki-67 labeling index supporting the diagnosis of a low grade tumor (). The cells had no immunoreactivity for CD5 and CD23 (, ). The final pathologic diagnosis was an extranodal marginal zone B-cell lymphoma of MALT according to the WHO classification. The patient underwent radiotherapy with a total dose of 4,140 cGy (1,980 cGy on the entire liver and an additional 2,160 cGy focused on the tumor area).\nAbdominal ultrasonography, performed 5 years after radiotherapy, revealed complete remission of the lymphoma in the liver. In addition, the liver MRI, studied 5 years after radiotherapy, showed fibrous contraction due to post radiation change of right lobe of the liver. There was no evidence of tumor recurrence in the liver parenchyma (). However, a newly developed well-enhancing solid mass, highly suggestive of a malignancy, at the posterior basal segment of right lower lobe of lung, was incidentally discovered by MRI at this time.\nSix years after diagnosis, he was readmitted due to complaints of dyspnea. The chest X-ray, chest CT scan and Whole body bone scan showed progression of the mass from the right lower lobe of the lung, pleural effusion, and multiple bone metastases. The patient refused additional diagnosis and treatment, and died as result of an undefined disease of the lung. | [[67.0, 'year']] | M | {'9382982': 1, '15533225': 1, '2029991': 1, '26435907': 2, '3010899': 1, '11596015': 1, '15718146': 1, '29850362': 2, '9586910': 1, '12402372': 1, '26956381': 2, '30921228': 2, '28353562': 2, '33786155': 1, '18807227': 1, '9684927': 1, '16913444': 2} | {'6456129-1': 1, '5914115-1': 1, '4580714-1': 1, '4782304-1': 1, '5380246-1': 1} |
165,251 | 3890737-1 | 16,913,445 | noncomm/PMC003xxxxxx/PMC3890737.xml | Pancreatic Metastasis and Obstructive Jaundice in Small Cell Lung Carcinoma | A 65-yr-old woman was presented with jaundice and weight loss. Hypertension was the only significant past medical history. She also complained about general weakness and malaise. A physical examination revealed a jaundiced woman with good performance. Examination of the cardiorespiratory system was unremarkable. The abdomen was soft, and no evidence of organomegaly. The initial laboratory workup revealed a normal complete blood count and chemistry panel. The hepatic panel revealed alkaline phosphatase levels of 339 U/L (Normal range: 40-120 U/L), AST of 512 U/L (Normal range: 10-36 U/L), ALT of 441U/L (Normal range: 7-38 U/L), total bilirubin of 9.2 mg/dL (Normal range: 0.2-1.3 mg/dL) and a direct bilirubin of 4.72 mg/dL (Normal range: 0.0-0.35 mg/dL). A chest radiograph showed a mass in the left lower lung field, later confirmed by a tomographic chest scan. Subsequently, a magnetic resonance cholangio-pancreatography of the abdomen was done, which revealed a mass in the head and tail of the pancreas ().\nThe patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), which conformed the presence of a mass in the head of the pancreas, causing an extrahepatic bile duct obstruction. During ERCP, the guidewire couldn't pass over the obstructive lesion, therefore the bile duct obstruction was relieved with a stent placement (). The patient underwent an aspiration cytologic exam of the pancreas, which revealed many clusters of small tumor cells. The patient underwent a bronchoscopic biopsy of the left lower lobe mass which revealed a small cell carcinoma ().\nExtensive staging workup did not reveal any other metastatic site. The patient was treated with combination chemotherapy (irinotecan, cisplatin) and a complete remission was achieved in six months (). There was no recurrence of the disease during follow-up for 11 months, and the patient is doing well. | [[65.0, 'year']] | F | {'24587774': 1, '27864300': 1, '22090704': 2, '27824020': 2, '23754881': 1, '19014447': 2, '9484937': 1, '23999821': 1, '12512922': 1, '9713480': 1, '15405683': 1, '31014441': 1, '6248647': 1, '23119202': 2, '2999994': 1, '16913445': 2} | {'2615008-1': 1, '3479941-1': 1, '6106157-1': 1, '3214475-1': 1} |
165,252 | 3890738-1 | 16,913,446 | noncomm/PMC003xxxxxx/PMC3890738.xml | A Case of Acute Eosinophilic Myopericarditis Presenting with Cardiogenic Shock and Normal Peripheral Eosinophil Count | A 25 year-old woman was transferred to the The Heart Center of Chonnam National University Hospital because of shortness of breath and hypotension for one day. Four days before admission, the patient complained of fever and sore throat, but took no medications. Three days earlier, the patient had nausea, vomiting, loose stools, lower abdominal pain and a general feeling of weakness. The patient visited a local clinic and was admitted for conservative treatment for acute gastroenteritis. At that time of admission, her body temperature was normal and blood pressure was 100/60 mmHg. On hospital day 2, the patient complained of feeling dizzy, had chest discomfort and progressive shortness of breath; the blood pressure dropped to 80 mmHg in systole. The patient was then transferred to our hospital.\nThe patient was a student and resided in a local area. There was a history of occasional alcohol. There was no history of smoking, drugs or allergies prior to admission. On physical examination, the patient was drowsy, but oriented, and had shortness of breath. The blood pressure was 85/40 mmHg with a continuous intravenous infusion of dopamine (15 µg/kg/min) and norepinephrine (0.02 µg/kg/min), the pulse 150 beats per minute, the respiratory rate 24 breaths per minute, and the body temperature 36℃. The oxygen saturation was 100 percent with oxygen supplied at 3 L/min by nasal cannula. The lung sounds were coarse on both lower lung fields, the heart was rapidly beating without murmur, and the r neck veins were slightly engorged. The skin was cool and clammy, but had no eruption, and no pitting edema. The remainder of the physical examination including neurological examinations revealed no abnormalities. The laboratory findings showed a complete blood count with increased white blood cells (17,500/mm3 (neutrophil 75%, eosinophil 2.6%)) and normal hemoglobin (12.7 g/dL), hematocrit (37.9%), and platelet count (267,000/mm3). Blood chemistries showed the following: aspartate aminotransferase 299 U/L, alanine aminotransferase 422 U/L, alkaline phosphatase 44 U/L, total protein 5.6 g/dL, albumin 3.0 g/dL, and lactate dehydrogenase 1,226 U/L, blood urea nitrogen 26.7 mg/dl, creatinine 1.2 mg/dL, amylase 23 U/L, sodium 135 mEq/L, and potassium 4.1 mEq/L. Cardiac enzymes were elevated (myoglobin 148 ng/mL, creatine kinase 215 U/L, CK-MB 14.3 U/L, troponin I 4.49 ng/mL), and NT-proBNP >35,000 pg/mL and C-reactive protein 9.0 mg/dL were also increased. A chest radiograph revealed increased pulmonary vascular markings and a normal cardiac silhouette (). Electrocardiogram revealed a sinus tachycardia (heart rate 147 bpm), low voltage and right axis deviation, but no definite ST-T change was noted (). Titers of serum neutralizing antibodies for coxsackievirus, adenovirus, Epstein-Barr virus, cytomegalovirus, herpes virus, hepatitis B and C virus, and HIV were all negative. Echocardiography demonstrated a mild hypokinesis of left ventricular (LV) anteroseptal wall with LV wall thickening, and hyperdynamic LV function with reduced stroke volume, moderate amount of pericardial effusion, dilated inferior vena cava with increased hepatic echogenicity, and no significant valvular abnormalities (, ). The endomyocardial biopsy specimen from the right ventricle revealed extensive interstitial edema associated with focal necrosis of myocytes, diffuse infiltration of inflammatory cells with lymphocytes, neutrophils, and eosinophils suggesting acute eosinophilic myocarditis (). Skin tests for allergy and stool ova were negative.\nWith conservative treatment, the blood pressure was normalized on day 3 after the admission, and the cardiac enzymes were also normalized during the hospitalization. However interestingly, the peripheral blood eosinophil count increased through hospital day 8, from an initial count 450/mm3 to peak 4,300/mm3 (). The patient complained of chest pain on motion, and the electrocardiogram was sinus rhythm with T inversions on all leads (), but no definite friction rub was auscultated. We treated the patient with oral prednisolone, 1 mg/kg of body weight, for the symptoms of pericarditis and it subsided 2 days later. Blood eosinophil count was normalized over 6 days after administration of steroids. The follow up chest radiograph was clear, () and the echocardiography showed good LV wall motion and function with decreased LV wall thickening and normal LV cavity size, and a minimal amount of pericardial effusion remaining (, ). The patient was discharged and followed up at the outpatient clinic with a tapering dose of prednisolone over next 3 months. After 3 months, the electrocardiogram had returned to normal, and the pericardial effusion cleared (, ). | [[25.0, 'year']] | F | {'30930448': 2, '6466521': 1, '22065913': 2, '24344829': 2, '7298049': 1, '6720598': 1, '11665801': 1, '23668918': 2, '15343520': 1, '30546587': 1, '2058874': 1, '14520487': 1, '16913446': 2} | {'6528500-1': 1, '3656792-1': 1, '3207060-1': 1, '3878496-1': 1, '3878496-2': 1} |
165,253 | 3890739-1 | 16,913,447 | noncomm/PMC003xxxxxx/PMC3890739.xml | A Case of a Composite Adrenal Medullary Tumor of Pheochromocytoma and Ganglioneuroma Masquerading as Acute Pancreatitis | A 48-year-old male was referred to our endocrinologic clinic for the evaluation of an adrenal incidentaloma. Two months ago, he had been admitted to our gastroenterologic clinic at which time he complained of acute, severe intense abdominal discomfort. He claimed that the discomfort had a rapid onset reaching a maximum in 10 to 20 minutes. Further, he had band-like radiation on/to the back. He consumed small amounts of alcohol but had no significant medical and family history. Laboratory data revealed elevated serum pancreatic amylase and lipase levels (reference range shown parenthetically) of 98.8 U/L (8~53) and 603.4 U/L (0~60), respectively. A diagnosis of acute alcoholic pancreatitis was suggested. He was managed with conservative treatments including restriction of caloric intake. Ten days later, he was discharged with significant clinical improvements.\nHowever, seven days after he was discharged, the same symptoms and signs re-developed at which time he also described palpitation, facial flushing and resting hand tremor in the previous five months that were developed slightly, briefly and occasionally. On admission, the patient's body temperature was 36.6℃ while blood pressure was 110/70 mmHg. The pulse rate was 72 beats/minute and the respiratory rate was 19/minute. His height and body weight were 158 cm and 52 kg, respectively. The physical examination was unremarkable except for direct tenderness in the epigastric area. Laboratory data revealed normal blood cell counts, plasma glucose and serum electrolyte levels. The results of liver and renal function tests were also within the normal ranges. However, serum pancreatic amylase and lipase levels were elevated to 81.4 U/L (8~53) and 100.9 U/L (0~60), respectively. The serum calcium level was 2.22 mmol/L (2.15~2.50) and triglyceride level was 0.66 mmol/L (<2.83). The serum CPK-MB (creatinine phosphokinase-MB isoform) level was 1.8 µg/L (0.7~3.8) and the troponin-I level was 0.3 µg/L (0~0.5). The findings of a chest roentgenogram, electrocardiogram, and 24-hour holter monitor showed nothing signigficant. Echocardiographic findings were normal except for mild concentric left ventricular hypertrophy. An abdominal computed tomographic scan showed a mildly enlarged pancreatic change without abnormal fluid collection and necrosis. In addition, he showed a left adrenal mass, 3×3 cm in diameter, which was heterogeneously low attenuated and enhanced after intravenous contrast administration ().\nAbout one month after the second discharge, we performed medical tests for discriminating the functional status of the adrenal incidentaloma. The urinary metanephrine level was elevated to 24.7 µmol/24h (0.5~8.1) and the urinary VMA (vanillylmandelic acid) level was normal at 27.5 µmol/24h (7~33). The results of plasma catecholamines, baseline plasma ACTH and cortisol, urinary-free cortisol, uplight plasma renin activity and aldosterone and serum DHEA-S (dehydroepiandrosterone sulfate) levels were also within normal ranges. The results of 5-HIAA (5-hydroxyindoleacetic acid) and thyroid function tests were also normal. 131I-MIBG (Metaiodobenzyl guanidine) scintigraphy was performed for the confirmation of the provisional diagnosis and localization of additional extra-adrenal tumors. 131I-MIBG scintigraphic findings showed a marked uptake in a single location corresponding to the left adrenal mass (). Ultrasonographic findings of the neck were unremarkable and serum intact PTH and calcitonin levels were 14.39 pg/mL (15~65) and 1.4 ng/mL (0~10), respectively. Therefore, we could exclude pheochromocytoma from familial association of multiple endocrine neoplasia type II. An -adrenoceptor blocker (doxazocin mesylate 4mg qd for 11 days) was prescribed preoperatively to prevent an operative adrenal crisis. Then, the left adrenal gland was surgically removed trans-abdominally through a subcostal incision.\nOn pathologic examination, a composite adrenal medullary tumor of pheochromocytoma and ganglioneuroma was confirmed. On gross examination, a well-defined solid tumor measuring 2.8×2.5×2.5 cm was found within the adrenal gland and cut surface of the tumor was yellowish brown. The microscopic appearance of the tumor showed an abrupt transition of two different patterns of typical pheochromocytoma and a large area of ganglioneuroma (). In the pheochromocytoma area, organoid nests, called "Zellballen" pattern, of polygonal cells surrounded by fibrovascular stroma were observed. Each cell had granular basophilic or amphophilic cytoplasm and intracytoplasmic hyaline globules, positively stained by PAS (periodic acid-Schiff's reagent). Its round or oval nuclei had a prominent nucleoli which contained inclusion-like structures and showed moderate pleomorphism with hyperchromasia (). At the ganglioneuroma area, uncapsulated clusters of fully matured ganglion cells surrounded by fascicles of spindle (Schwann-like) cells were shown (). On immunohistochemical staining, it was weakly positive for NSE (neuron-specific enolase), chromogranin and synaptophysin, negative for HMB45 and CK in the pheochromocytoma component, and positive for S-100 protein in the ganglioneuroma component. The patient tolerated the operation well and had an smooth recovery. He was discharged on the 7th post-operative day. After surgery, there were no episodes of intense abdominal discomfort. Further, palpitation, facial flushing and hand tremor were resolved. Now, the patient has remained well and free of any symptoms for more than eight months. | [[48.0, 'year']] | M | {'7514507': 1, '10880429': 1, '24455524': 1, '21346832': 2, '4906187': 1, '12918898': 1, '742604': 1, '3048784': 1, '31966391': 1, '14532724': 1, '2723339': 1, '33651160': 1, '3838664': 1, '7513373': 1, '6625139': 1, '844016': 1, '11211805': 1, '7808088': 1, '3389453': 1, '34261040': 1, '2470532': 1, '7716605': 1, '16913447': 2} | {'3036999-1': 1} |
165,254 | 3890740-1 | 16,913,448 | noncomm/PMC003xxxxxx/PMC3890740.xml | Coronary Artery Intervention after Cytostatics Treatment in Unstable Angina Patient with Essential Thrombocythemia. A Case Report and Literature Review | A 45-year-old male was admitted to our hospital due to substernal chest discomfort on mild exertion, which occurred three weeks prior to presentation. The frequency and severity of his angina increased over time and the patient described a squeezing chest pain with an onset three days prior to presentation. The past medical history included hypertension, diagnosed three years ago, and smoking history of ten pack-years. There was no family history of coronary artery or hematologic disease. At the time of admission he was on aspirin and anti-hypertensive medications. On physical examination, the blood pressure was 130/80 mmHg and the heart rate was 70 beats per minute. The heart sounds were unremarkable with normal S1 and S2 sounds. The lungs were clear on auscultation. The electrocardiogram showed no ST-segment change, T wave inversion or pathologic Q waves suggestive of myocardial ischemia. No abnormality was found on chest roentgenogram. On complete blood count, the hemoglobin was 13.9 g/dL, white blood cell count was 9,400/L, and the platelet count was 106×104/µL. Electrolytes, renal and liver function tests were not remarkable. Levels of CK-MB and Troponin-T were within normal range. Total serum cholesterol was 161 mg/dL, triglyceride was 95 mg/dL and high-density lipoprotein was 39 mg/dL. Serum homocystein level was 12.7 nmol/mL (reference range 5-15 nmol/mL), and hsCRP was 1.91 mg/L (reference range <3 mg/L). Prothrombin time, activated partial thromboplastin time and fibrinogen level were within normal range. The iron profile was not remarkable. Bone marrow study showed a hypercellular marrow with markedly increased megakaryocytes, and a normal myeloid/erythroid ratio (). Chromosomal analysis of bone marrow cells revealed a normal 46, XY karyotype with no evidence of bcr/abl rearrangement. Liver and spleen were not enlarged on sonogram images. An elective coronary angiography, two days after admission, showed total occlusion at the mid right coronary artery (RCA) with well-developed collaterals from proximal RCA to PD and PL branches. In addition, there was diffuse irregular, up to 70%, luminal narrowing with haziness noted at the proximal RCA. The left coronary angiography showed a 40% luminal narrowing at the mid left anterior descending artery (LAD). The echocardiography, performed three days after admission, showed no regional wall motion abnormality with about 60% of left ventricular ejection fraction. On color Doppler imaging, there was no significant valvular stenosis or regurgitation noted. There was a relaxational abnormality observed in the diastolic filling pattern. The patient was taking aspirin 100 mg/day, clopidogrel 75 mg/day, atenolol 25 mg/day, diltiazem 90 mg/day and nicorandil 15 mg/day from the day of admission. The chest pain was controlled by medical treatment; therefore, we decided to postpone coronary artery intervention until the platelet count reached a normal level. Treatment with hyroxyurea 500 mg/day and anagrelide HCl 1 mg/day was started as cytostatic therapy. The platelet count was normalized (23×104/µL) five weeks after initiation of cytostatic therapy, and coronary artery intervention was then performed. The totally occluded mid RCA lesion was thought to be a chronic total occlusion because of the presence of good collateral flow from the proximal RCA. We thought that the proximal RCA, stenotic lesion with haziness, resulted from a plaque rupture resulting in an occlusive thrombus, and caused the ischemic symptoms that the patient presented with. Two coronary stents were placed at the proximal and mid RCA. No residual stenosis was observed after the procedure (). The LAD lesion was not treated. The patient was discharged two days after the procedure without any hemorrhagic or thrombotic complication; he remained on aspirin, clopidogrel, hydroxyurea, and anagrelide. The patient was free of symptoms for six months during the follow-up period, and his platelet count remained within normal range. | [[45.0, 'year']] | M | {'9491958': 1, '15710584': 1, '9863754': 1, '12925457': 1, '9136963': 1, '15003898': 1, '15028825': 1, '11155408': 1, '12934770': 1, '10436140': 1, '15667529': 1, '30626836': 1, '10647877': 1, '16913448': 2} | {} |
165,255 | 3890741-1 | 16,913,449 | noncomm/PMC003xxxxxx/PMC3890741.xml | Hemorrhagic Fever with Renal Syndrome Complicated with Pregnancy: A Case Report | A 31-year-old, otherwise healthy, woman, (gravida 0 and para 0), at 15 weeks of gestation was admitted to our hospital on October 29, 2004 due to fever, chills, eyeball pain and back pain of 4 days' duration. The patient had undergone intrauterine insemination on June 24, 2004 before achieving pregnancy. She began to complain of facial edema and blurred vision just after admission. She denied having a cough, diarrhea or dysuria. She and her husband were beef cattle-breeders in the rural Yangju area of Gyeonggi Province, Korea. On examination, her blood pressure was 110/80 mm Hg and her temperature was 38.3℃. She displayed flushing of the face, conjunctival hemorrhage and bulbar conjunctival edema. Her chest auscultation was normal. Mild tenderness was bilaterally found on her costovertebral angle, but no skin rash was evident. The laboratory tests revealed the following: leukocyte count: 21,300/µL (normal range: 4,000-10,000/µL), platelets: 83,000/µL (normal range: 150,000-400,000/µL), creatinine: 0.9 mg/dL (normal range: 0.7-1.4 mg/dL), aspartate transaminase: 67 U/L (normal range: <40 U/L), sodium: 135 mmol/L (normal range: 135-145 mmol/L), and potassium: 3.8 mmol/L (normal range: 3.5-5.5 mmol/L). Urinalysis revealed proteinuria and hematuria. Cultures of her blood and urine were sterile. Fetal ultrasound showed fetal growth that was consistent with the gestation dates.\nHer condition deteriorated over the following days. Her blood pressure dropped to as low as 60/40 mmHg despite massive administration of physiologic saline on day 2, and her platelet count decreased to 15,000/µL on day 5. Her oliguria and elevated serum creatinine levels of up to 4.2 mg/dL necessitated the administration of diuretics intermittently from day 3 to day 7. However, from day 8 her renal functions progressively improved. The patient recovered completely and was discharged on day 14. The antibody titer for Hantaan virus, which was determined using a high-density particle agglutination test (Hantadia, Greencross, Korea) was 1:640 on day 5. A repeat titer showed an increase to 1:2,560 at the time of discharge, but it was 1:1,280 two weeks after discharge. Serologic tests for Leptospira, Orientia tsutsugamushi and HIV were negative.\nThe pregnancy continued uneventfully, and the patient was lost to follow-up. Six months later, she vaginally delivered a 2,900-g healthy female infant without complications at another hospital. However, no additional tests for Hantaan virus were performed on her or her baby at the time of delivery. | [[31.0, 'year']] | F | {'12971153': 1, '9454562': 1, '6987581': 1, '8099010': 1, '2568676': 1, '8059840': 1, '9351417': 1, '24784571': 1, '12665941': 1, '24670': 1, '8096661': 1, '33074475': 1, '2894925': 1, '10073292': 1, '10585809': 1, '7911857': 1, '1970741': 1, '16913449': 2} | {} |
165,256 | 3890912-1 | 24,459,312 | noncomm/PMC003xxxxxx/PMC3890912.xml | Dothiepin-induced transient hypomania and extrapyramidal syndrome | Mrs. P, a 25-year-old married female and a homemaker, was admitted to our adult psychiatry inpatient service for management of her depressive disorder, which did not show any response to outpatient treatment. She had been suffering from an illness, of 2 years duration, with an insidious onset, continuous course, with partial remissions and periods of exacerbations, beginning after the demolition of her husband's general store, leading to a loss of the only source of family income. After the financial setback, she had been accusing him of not earning enough for their livelihood. Her symptoms included frequent irritability, persistent sadness of mood, ideas of hopelessness, helplessness, and worthlessness, occasional suicidal idea, decreased sleep, decreased appetite, and multiple somatic complaints. Since the onset of her illness, she also experienced four panic attacks. There was no other significant history, apart from the fact that there had been marital discord, leading to regular verbal fights with her husband, due to less involvement by her husband in their children's affairs. Medical history was remarkable only for reports of dysmenorrhea and menorrhagia, for the last several months. Six months prior to this admission, patient was started on treatment on an outpatient basis, and was prescribed tablet mianserin 30 mg HS; it was gradually increased to 45 mg per day, in divided doses. Initial improvement was shortlasting, and hence mianserin had to be increased to 60 mg per day and capsule fluoxetine 20 mg per day had to be added. However, patient did not show any response to the combination, and hence her antidepressant medications were gradually tapered off and she was admitted to review the diagnosis and formulate a fresh management plan. Mental status examination on the day of admission revealed decreased pitch, tone, and volume of speech, sadness of mood, and depressed affect, which was reactive to the environment. There were ideas of hopelessness, helplessness, and death wish, and insight into the illness was partial. On admission, patient was started on tablet sertraline 50 mg per day, which was increased to 100 mg per day, over a 4-day period. Patient complained of epigastric pain for which referral to gastroenterologist was made, and she was prescribed tablet pantoprazole 40 mg before breakfast. However, as the pain did not show any sign of improvement, sertraline was discontinued, and dothiepin, 75 mg per day, was started from the next day []. After about 1½ days of starting dothiepin, it was noted that the patient was speaking more than usual. The next day, additionally, patient had an elated affect, reported increased self-confidence, and was making new, but big plans for future to makeup the monetary loss. Young Mania Rating Scale (YMRS)[] was administered, and the patient scored 18 on the scale. In addition, it was noted that the patient had bradykinesia, fine tremors in the hands, and sialorrhea. At this time, the patient also developed cough with fever, and was sent to the medical OPD where she was prescribed tablet amoxicillin 500 mg TID along with tablet ibuprofen 400 mg TID, for 5 days.\nPatient continued in this state for the next 4½ days, after which her mood and her behavior became normal. YMRS was repeated on that day, and the patient's score was 8. However, sialorrhea, bradykinesia, and tremors persisted.\nPatient was euthymic for 1 day, after which, following an altercation with her husband, who came to visit her in the ward, her depressive symptoms re-emerged and continued subsequently. Throughout her subsequent inpatient stay, the hypomanic symptoms did not reappear. Sialorrhea, bradykinesia, and tremors gradually decreased, and by the time of discharge, after about 10 days of the onset of her hypomanic and extrapyramidal syndrome, the patient did not have any extrapyramidal symptom. | [[25.0, 'year']] | F | {'3314536': 1, '7074184': 1, '7851836': 1, '7943454': 1, '7516443': 1, '5517898': 1, '728692': 1, '9213080': 1, '34462699': 2, '24459312': 2} | {'8390837-1': 1} |
165,257 | 3890920-1 | 24,459,315 | noncomm/PMC003xxxxxx/PMC3890920.xml | Forensic evaluations in psychiatry | Mr. A, a 38-year-old male, who was accused of homicide, was referred for assessment with questions, whether he was of unsound mind, and whether he can understand the proceedings of the court? His only complaint was of hearing barking dogs. He had been diagnosed as having schizophrenia in the jail hospital and held an old prescription from a general practitioner with a diagnosis of schizophrenia, which also mentioned about him having been hospitalized in a teaching psychiatric hospital in 1995. He was admitted for observation. A request was sent to the old hospital where he was admitted in the past. It was confirmed from the previous hospital that he was admitted there for about 2 weeks and had received a provisional diagnosis of schizophrenia. He had also attended the follow-up twice after discharge. However, during his current hospitalization, no abnormality could be found on observation and psychological assessment. He often came up with ‘I don’t know response’.\nMr. A probably believed that if he got a certificate from the hospital of his being mentally ill, he would be acquitted. He was always emphatic that he had not committed any crime, but was never able to tell how and why he reached the jail. He was able to give details of his earlier life in Mysore and Bangalore. A medical report was sent to the court, given as below:\n“Mr. A had suffered from a psychotic disorder in the past in …………. At present he does not have any psychiatric illness needing treatment. He does not give any details about the criminal charges he has been accused of or details regarding defense saying that he does not know. Objectively there is no significant memory impairment. There is no evidence to suggest that he is of unsound mind and he can’t understand the proceedings of court”. | [[38.0, 'year']] | M | {'29284802': 1, '11200952': 1, '30983659': 1, '26664094': 1, '24459315': 2} | {'3890920-2': 2} |
165,258 | 3890920-2 | 24,459,315 | noncomm/PMC003xxxxxx/PMC3890920.xml | Forensic evaluations in psychiatry | Mr. C., a 40-year-old male, who was accused of triple murder, was sent by the court for assessment, whether he suffered from a mental illness. Mr. C had been trying to get bail, which had been denied. He was hospitalized for observation. After 2-3 days of hospitalization, he started accusing the clinical unit head of being against him. On the next day, he broke the glass of the nursing station and also attempted to assault the consultant in charge of treatment. The hospital staff took protective steps, but did not initiate any treatment. No abnormality was detected on observation and mental health assessment. Apparently, he had been advised by his lawyer to show a violent outburst in the hospital, which might lead to his being given some injections. This would have supported a diagnosis of a mental illness.\nMr. C was discharged and sent back to jail. A report was sent to the court that he did not suffer from a mental illness. | [[40.0, 'year']] | M | {'29284802': 1, '11200952': 1, '30983659': 1, '26664094': 1, '24459315': 2} | {'3890920-1': 2} |
165,259 | 3890925-1 | 24,459,314 | noncomm/PMC003xxxxxx/PMC3890925.xml | Emetophobia: A fear of vomiting | An 8-year-old girl, studying in second grade was brought by parents with complaints of fear of vomiting and feeling nauseated since about seven and half months. Around 20 days before the starting of symptoms, child had episode of acute and severe abdominal pain, high grade fever with 3 bouts of vomiting with nausea for a day. She was diagnosed as having acute appendicitis by a surgeon and was operated subsequently. Within around 10 days after operation, patient started having fear of similar episode of vomiting with repeated remembrance of the episode. She complained of feeling nauseated with excessive salivation and gastric regurgitation. The treating doctor did not find anything significant and was treated symptomatically. Parents were reassured about the symptoms. She started attending her classes but gradually her complaints increased. She had constant thoughts of feeling nauseated. She started eating less, avoiding outside food which she used to ask for previously. She would worry about the pungent smell of vomitus in toilet and ask mother to clean it frequently. The fear increased slowly to the extent that, she started avoiding playing with other children in a fear that they will avoid her and tease her if she vomited in front of them. She avoided school for the same reason and thought that teachers will have bad impression about her if she vomits in the classroom. Meanwhile, parents asked their close relatives to console her. But symptoms went on increasing and she started refusing to use a lift, travel in bus, going to park, market places, etc., Fear became generalized and patient started worrying that her parent may suffer vomiting, she would request parents not to go outside, not to travel in bus or use lifts. Her father was working in a different city and job required frequent traveling. She had persistent fear that he may suffer vomiting as he eats outside food and there is no one to take care of him. She would call him repeatedly on phone and ask to change his job. She also developed reduced and non-refreshing sleep with constant thoughts/worries about vomiting at night with complaints of nausea and regurgitation after having her dinner. History of occasional nocturnal enuresis was also present during this period.\nShe was referred for a psychiatric consultation. She refused separate interview of parents because of the fear that they will hide the illness from her. She elaborated all the complaints and said “I feel nauseated even when I hear a word ‘vomitus’ or ‘vomiting’ or if I see anybody vomiting”. She elaborated the incidence when she vomited after witnessing the same in the neighborhood. Besides this, there was no history of depressive or obsessive-compulsive features or eating disorder and no symptoms suggestive of other phobias. Past history was not significant. There was significant family history and both of her parents are suffering from anxiety disorder and taking regular treatment from a psychiatrist. Birth and developmental history did not reveal any significant abnormality. She was good in academics.\nOn mental status examination, patient described her mood as anxious with appropriate affect. In thought, there was preoccupation about the worries of having nausea and vomiting along with number of questions e.g., whether I will get better; Do I have some severe illness; Will your medicines have side effect of vomiting, etc., She was diagnosed as a case of Specific Phobia of Vomiting i.e., Emetophobia.\nAs it was very difficult to involve the child in counseling or psychotherapy because of severe anxiety, she was prescribed tablet Clobazam 5 mg in divided doses and Cap Fluoxetine 10 mg. She was admitted to a child unit to reassure her as she was not willing to take medicines due to fear of side effects. After a week, she and her parents perceived mild improvement in anxiety and she was somewhat comfortable. On further follow-up, child was taught relaxation and started on Graded Exposure therapy along with the medications. She was exposed to the materials or activities related to vomiting. First, she was asked to read hand written article which contained the word ‘vomitus/vomiting’ (multiple times) as many times as possible. After about a week, she was asked to witness the action of vomiting by parents which they were pretending, followed by behavior as if vomiting has caused no trouble and anyone can suffer it for a short duration. After around 15 days, she was advised to attend school with a facility to go to rest room whenever she has thoughts of vomiting followed by feeling of nausea. She used the rest room only for initial 2 days after which she was as regular to the classes as before the start of illness. She was asked to play with other children only for 15 minutes to begin with. This time was increased slowly from 15 minutes to 1 hour. When she didn’t have even a single vomiting during this period, she started accepting the fact that it was an irrational fear and that she can achieve a mastery over it. Slowly, she was exposed to the activities that can induce vomiting like smelling the toilet, spinning around, etc., She had nausea and she hesitated to do it initially, but with intermittent counseling and relaxation and frequently doing above activities, she could face the feeling of nausea with less fear than before. In view of severity of symptoms and family history of anxiety disorders in parents, patient was advised to continue medications. | [[8.0, 'year']] | F | {'474458': 1, '28331505': 1, '28867936': 1, '16050615': 1, '3985916': 1, '21695748': 1, '27514691': 1, '11668669': 1, '22813942': 1, '24459314': 2} | {} |
165,260 | 3890932-1 | 24,459,313 | noncomm/PMC003xxxxxx/PMC3890932.xml | A case of Hallervorden-Spatz disease presenting as catatonic schizophrenia | A 28-year-old married man presented to the psychiatry outpatient department with complaints of staring spells, maintaining odd postures for long time, decreased sleep, not eating or drinking, tremulousness in the body, stiffness of hands and legs and deviation of the angle of mouth. All these complaints were present since 10-15 days. His illness started 4 years back when, without any precipitating stressors, he developed gradual onset suspiciousness on neighbors, irrelevant talk, muttering and gesticulating to self with occasional history of aggressiveness. Although he was taking treatment from some psychiatrist, details of this treatment were not known and moreover he was not maintained on regular treatment. He was brought to the psychiatry outpatient department for acute deterioration in his symptoms.\nThere was no history of affective features, substance use, any other psychiatric illness and other medical or surgical illness. He was born full-term and had attained childhood milestones normally. He had poor scholastic performance from 5th grade, after which he left studies. Even after his school he did not seem very keen on doing some work. He would frequently change his jobs for no apparent reasons. He was temperamentally quiet, introvert and shy.\nHis general examination was within normal limits but nervous system examination revealed rigidity and diminished reflexes in all four limbs. Systemic examination did not reveal anything substantial.\nIn view of his past psychiatric history of four years and increased presenting complaints since 10-15 days, he was provisionally given a diagnosis of catatonic schizophrenia with neuroleptic induced extrapyramidal reaction (EPR). He was admitted to the psychiatry inpatient unit.\nIn the psychiatric ward, he was started on clozapine (25 mg HS), trihexyphenidyl (6 mg) and diazepam (5 mg) along with monitoring of vitals and adequate hydration. Since the patient was suspected to have drug induced EPR and clinically he had catatonia, we wanted to make sure that he does not develop drug induced EPR that may have complicated the picture, hence clozapine was the best choice in this case. His routine blood investigations (such as complete blood count, renal and liver function tests) and fundus examination were within normal limits. Brain CT scan revealed bilateral basal ganglia calcification [].\nAs there was no improvement in his catatonic features, he was started on electroconvulsive therapy (ECT) on fourth day of his admission (ECT being the best treatment for catatonia). However, even after 3 ECTs there was no improvement in his rigidity; instead he started remaining confused. Hence all his medications and ECTs were stopped. His serum electrolytes were within normal limits but serum creatine phosphokinase (CPK) levels were elevated to 3493 U/L (Normal limit: 35-232 U/L). A neuromedicine reference was taken and he was subsequently diagnosed as neuroleptic malignant syndrome (NMS) and started on bromocriptine 2.5 mg thrice daily.\nAfter 3 days of bromocriptine, there was improvement in his condition; his confusion and rigidity had decreased considerably. By day 15, his serum CPK levels had decreased (220 U/L) after which he was restarted on clozapine 12.5 mg for psychosis (clozapine being the least D2 antagonist is the safest choice in such cases). However, within the first day of clozapine re-dosing, his confusion increased and condition deteriorated. Hence clozapine was stopped. In view of his increasing psychosis, ECTs were restarted by day 17th. His repeat serum CPK levels on days 18 and 29 showed an increasing level (386 U/L and 563 U/L). His rigidity had also increased by 7th ECT. Valproate was added as he developed affective features in the form of excessive cheerfulness and jocularity, singing songs, and over-familiarity in the ward. Along with this, baclofen and injection magnesium sulfate (4 gm once a day for 3 days) were also added. However, patient's condition further deteriorated and he developed urinary and fecal incontinence. Again both ECTs and valproate were stopped for nearly 15 days during which he was given bromocriptine (2.5 mg thrice daily; dopamine agonist), baclofen (30 mg at bedtime; muscle relaxant) and diazepam (5 mg at bedtime).\nDespite these medications, his early morning rigidity, urinary and fecal incontinence did not improve. He was again referred for a neuromedicine opinion in view of persistently rising serum CPK levels and rigidity. The patient was given a differential diagnosis of Hallervorden-Spatz Disease, Wilson's disease, neuroleptic malignant syndrome, Huntington's disease and hypoparathyroidism. Wilson's disease was ruled out by serum ceruloplasmin level (49.23 mg/dl), serum copper (94 μg/dl) and 24 hrs urine copper level (32 μg/24 hrs) and ophthalmic examination for KF ring (which was negative). Huntington's disease was ruled out by genetic testing for CAG repeats. Hypoparathyroidism was ruled out when serum calcium (9.1 mg/dl), serum phosphate (3.6 mg/dl), serum magnesium (2.4 mg/dl), alkaline phosphatase (98 U/L) and PTH (42 pg/ml) levels were reported within normal limits. MRI brain (T2W images) revealed bilaterally symmetric hyperintense signal changes in globus pallidus with surrounding hypointensity [] suggestive of tiger-eye appearance found in Hallervorden-Spatz disease. Genetic testing could not be done due to non-availability of the test in our set up. Finally he was given a diagnosis of Hallervorden-Spatz disease by day 49 of admission to psychiatric ward. He was maintained on baclofen 10 mg four times a day and bromocriptine 5 mg thrice a day. Patient showed a gradual improvement, with his psychosis, rigidity and serum CPK level (50 U/L) decreasing. He was discharged at request by 50th day.\nAfter a fortnightly follow-up, patient was much improved in so far as his psychotic or catatonic symptoms were concerned. He did not have any rigidity, dystonia or neurodeficits. His last CPK levels were within normal limits (67 IU). However the patient was subsequently lost to follow-up after a month. | [[28.0, 'year']] | M | {'21557313': 1, '21494068': 1, '21877312': 1, '11579912': 1, '11240570': 1, '19147629': 1, '2914882': 1, '14531762': 1, '3202617': 1, '20046400': 2, '29844889': 1, '21999968': 1, '11045680': 1, '11479594': 1, '8944032': 1, '21791473': 1, '26952824': 1, '24459313': 2} | {'2796072-1': 1, '2796072-2': 1} |
165,261 | 3891025-1 | 17,249,502 | noncomm/PMC003xxxxxx/PMC3891025.xml | Diagnostic Usefulness of the Janus Kinase 2 Mutation in non BCR/ABL Myeloproliferative Disorders | This 25 year-old woman visited our hospital in September 2002 with the complaints about a poor oral intake and abdominal discomfort. The abdominal examination revealed hepato-splenomegaly and ascites. Computer tomography of the abdomen showed obstruction of intrahepatic inferior vena cava. Insertion of two stents into hepatic vein was performed. The initial hemoglobin level was 14.2 g/dL, WBC 15,520/µL and PLT 375,000/µL. The BM aspiration and biopsy results showed an increased cellularity (80%) with a decreased M:E ratio (0.7). Iron staining revealed a depleted storage of iron. The initial diagnosis was Budd-Chiari syndrome with secondary polycythemia. During one year of the observation, her hematologic profile was within the normal range, except for leukocytosis (ranges: 12,33 0~28,550). The patient experienced recurrent episodes of spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome. In September 2003 she was admitted to the emergency room and was found dead on arrival. We assume that the cause of the lethal outcome was hepatic failure aggravated by sepsis. After consideration of the JAK2 result, the patient's disease was re diagnosed as PV with a low hemoglobin level resulting from hypersplenism and irondeficiency anemia. | [[25.0, 'year']] | F | {'15793561': 1, '12634946': 1, '15920007': 1, '8343951': 1, '16007902': 1, '15863514': 1, '15889449': 1, '15837627': 1, '15860661': 1, '15477203': 1, '16247455': 1, '7729418': 1, '30519338': 1, '6580527': 1, '15983426': 1, '16191089': 1, '15858187': 1, '16210034': 1, '18850308': 1, '15781101': 1, '9930551': 1, '16081687': 1, '17249502': 2} | {'3891025-2': 2, '3891025-3': 2} |
165,262 | 3891025-2 | 17,249,502 | noncomm/PMC003xxxxxx/PMC3891025.xml | Diagnostic Usefulness of the Janus Kinase 2 Mutation in non BCR/ABL Myeloproliferative Disorders | This 37 year-old male patient came to our emergency room with a severe back pain in February 2002. The chest X-ray and cardiologic evaluation revealed no abnormality. Gastrofibroscopy showed an active duodenal ulcer. His hemoglobin level was decreased to 10.0 g/dL. The peripheral blood smear showed microcytic and hypochromic RBCs with a serum ferritin level of 3.63µg/L. The WBC was 14,690/µL and PLT 885,000/µL. The BM examination showed a slightly increased cellularity (60%) with a normal M:E ratio. His initial diagnosis was duodenal ulcer and iron deficiency anemia with reactive thrombocytosis. At his last visit on June 2003, his CBC profile showed: 15.6 g/dL of hemoglobin, 12,600/µL of WBC, 563,000/µL of PLT. After that, no further information on his hematologic change and clinical course has been available. After the JAK2 testing, we re-diagnose this patient's disease as PV associated with duodenal ulcer bleeding that caused transient low hemoglobin levels. | [[37.0, 'year']] | M | {'15793561': 1, '12634946': 1, '15920007': 1, '8343951': 1, '16007902': 1, '15863514': 1, '15889449': 1, '15837627': 1, '15860661': 1, '15477203': 1, '16247455': 1, '7729418': 1, '30519338': 1, '6580527': 1, '15983426': 1, '16191089': 1, '15858187': 1, '16210034': 1, '18850308': 1, '15781101': 1, '9930551': 1, '16081687': 1, '17249502': 2} | {'3891025-1': 2, '3891025-3': 2} |
165,263 | 3891025-3 | 17,249,502 | noncomm/PMC003xxxxxx/PMC3891025.xml | Diagnostic Usefulness of the Janus Kinase 2 Mutation in non BCR/ABL Myeloproliferative Disorders | A 72 years-old woman presented with gangrene of the second and third fingers of her right hand in May 1997. The CBC revealed 12.3 g/dL of hemoglobin, 26,500/µL of WBC and 1,254,000/µL of PLT. The RBCs were micorcytic and hypochromic. Gastrofibroscopy showed a scar of the gastric ulcer. The cellularity and megakaryocyte were increased. Her initial diagnosis was essential thrombocythemia. During the long period of the follow-up (101 months), her hemoglobin level increased to 15.1g/dL, and the PLT count dropped to 300,000/µL in February 2002, and the PLT maintained was around the lower limit of the normal. Only hydroxyurea was prescribed, and its dosage was reduced to 500 mg/day since February 2002. The PLT and WBC showed a decreasing tendency, while the hemoglobin level was increasing upto 16.5g/dL. With a JAK2 mutation, the diagnosis was changed to PV.\nA 69 years-old woman was transferred to our hospital from a dental clinic in April 2001 due to an abnormal CBC. Her initial hemoglobin level was 16.4 g/dL, WBC 23,890/µL and PLT 1,116,000/µL. The patient had no symptoms or signs of bleeding. The BM aspiration and biopsy results showed an increased cellularity, megakaryocytes and an increased M:E ratio. The serum erythropoietin was below 1.7U/L. The CBC pattern was similar to that of the above mentioned 72 year old patient; the hemoglobin level was in excess of 16.5 g/dL twice over the period of 58 months. With a JAK2 result, her diagnosis was changed to PV. | [[72.0, 'year']] | F | {'15793561': 1, '12634946': 1, '15920007': 1, '8343951': 1, '16007902': 1, '15863514': 1, '15889449': 1, '15837627': 1, '15860661': 1, '15477203': 1, '16247455': 1, '7729418': 1, '30519338': 1, '6580527': 1, '15983426': 1, '16191089': 1, '15858187': 1, '16210034': 1, '18850308': 1, '15781101': 1, '9930551': 1, '16081687': 1, '17249502': 2} | {'3891025-1': 2, '3891025-2': 2} |
165,264 | 3891028-1 | 17,249,505 | noncomm/PMC003xxxxxx/PMC3891028.xml | Agenesis of the Dorsal Pancreas: A Case Report and Review of the Literature | A 25-year-old woman was admitted to Chonnam National University Hospital with a four-week history of intermittent abdominal pain. She had an 11-year history of insulin-dependent diabetes mellitus. There was no previous history of peptic ulcer diseases, hepatobiliary disease, cholecystitis with gallstones or pancreatitis. On admission, her abdomen was soft and not distended, but was tender to deep palpation in the epigastric region. Physical examination was otherwise within normal limits. Laboratory evaluation revealed a white blood cell count of 5,700/mm3 (normal: 6,000-10,000), hemoglobin 11.0 g/dL (normal: 12-16), platelet count 285,000/mm3 (normal: 130,000-450,000), serum albumin 3.5 g/dL (normal: 3.0-5.0), aspartate aminotransferase 32 U/L (normal: 5-37), alanine aminotransferase 43 U/L (normal: 5-40), alkaline phosphatase 431 U/L (normal: 39-117), and γ-glutamyl transpeptidase 524 U/L (normal: 7-49). The total bilirubin was 0.38 mg/dL with 0.06 mg/dL direct fraction (normal: 0.2-1.2/0.05-0.3). Serum amylase and lipase were within normal range. An abdominal computed tomography (CT) scan showed a normal-appearing pancreatic head and complete absence of the body and tail (). Endoscopic retrograde cholangiopancreatogram (ERCP), opacified from the major papilla, showed a short duct in the uncinate process and head and the duct of Santorini draining into the minor papilla (). Abdominal magnetic resonance imaging (MRI) showed a pancreatic head, but the body and tail were not visualized (). These findings were similar to those of the CT and ERCP. The combined CT, ERCP and MRI findings were considered diagnostic of a partial agenesis of the dorsal pancreas. After symptomatic treatment, she was discharged and followed regularly. | [[25.0, 'year']] | F | {'2197855': 1, '11105708': 1, '12851784': 1, '8462806': 1, '28690992': 2, '4593099': 1, '5906622': 1, '8566643': 1, '9423620': 1, '8631173': 1, '8439753': 1, '25544484': 1, '33928176': 1, '15332050': 1, '18618254': 1, '7728339': 1, '8050322': 1, '1924843': 1, '20165948': 1, '9831413': 1, '2199969': 1, '3805410': 1, '10436244': 1, '17249505': 2} | {'5495979-1': 1} |
165,265 | 3891029-1 | 17,249,506 | noncomm/PMC003xxxxxx/PMC3891029.xml | Diffuse Alveolar Hemorrhage Associated with Antineutrophil Cytoplasmic Antibody levels in a Pregnant Woman Taking Propylthiouracil | A 25-year-old woman in her first trimester of pregnancy was admitted to our hospital because of dyspnea and cough that developed three days prior to admission. The patient had a history of hyperthyroidism, which had developed at 16 years of age. She had been taking PTU for five years and was euthyroid. One month prior to admission PTU was resumed due to hyperthyroidism. On admission the temperature was 37.8℃, the blood pressure 120/70 mmHg, the pulse 110 beats per minute and the respiration rate 24 breaths per minute. The oxygen saturation was 96 percent while she was breathing ambient air. On physical examination, a few crackles were heard bilaterally and the thyroid gland was enlarged. Laboratory values showed a leukocyte count of 13,620/mm3, hemoglobin of 10.1 g/dL, platelet of 21,400/mm3 and a CRP of 1.27 mg/dL. Renal and liver function tests were normal. The prothrombin time was 11.2 seconds and the activated partial-thromboplastin time was 20.7 seconds. The T3 was 2.62 ng/mL (normal range, 0.79-1.49 ng/mL), free T4 0.42 ng/dL (normal range, 0.71-1.48 ng/dL) and thyroid stimulating hormone 0.004 IU/mL (normal range, 0.35-4.93 IU/mL). Urinalysis showed three to four red cells per high power field without proteinuria. A chest X-ray after abdominal protection showed bilateral heterogeneous pulmonary opacities (). The patient was diagnosed as having pneumonia and was treated with ceftriaxone and azithromycin. On the third day of hospitalization, the patient rapidly deteriorated. She was transferred to the ICU. Mechanical ventilatory support was initiated for hypoxic respiratory failure. The CT scan showed multifocal areas of ground-glass opacities and consolidation in both lung fields (). A surgical lung biopsy was considered but was not performed because of the risk of thyrotoxicosis. A bronchoscopy was performed and revealed active bleeding from segmental bronchi in the right and left lobes of the lung. The hemoglobin dropped to 7.3 g/dL and the serum p-ANCA was a strong positive and MPO-ANCA was positive with a titer of 255 AAU/mL (reference laboratory range, positive if 180 > AAU/mL; ). Tests for antinuclear antibody, anti-DNA antibody, rheumatoid factor, anti-glomerular-basement-membrane antibody, anti-proteinase 3 ANCA (PR3-ANCA), hepatitis serology and HIV were all negative. All additional biochemical testing was within normal limits. The PTU was discontinued and high dose intravenous corticosteroid therapy (methyprednisolone 125 mg every 6 hour) was started. Because of the pregnancy, methimazole was substituted for PTU. After initiation of corticosteroid therapy, the patient rapidly improved. Corticosteroid therapy was tapered slowly over four weeks, and the patient was discharged after one month. She remains in clinical remission six months later and the level of the MPO-ANCA has decreased to 159 AAU/mL. | [[25.0, 'year']] | F | {'11148710': 1, '2159305': 1, '8103148': 1, '10559122': 1, '12848957': 1, '10822221': 1, '14708556': 1, '9366584': 1, '7725110': 1, '20107567': 2, '24783017': 1, '2912104': 1, '17249506': 2} | {'2809019-1': 1} |
165,266 | 3891030-1 | 17,249,507 | noncomm/PMC003xxxxxx/PMC3891030.xml | Extensive venous thrombosis of the upper extremity in a diabetic patient with a hyperosmolar hyperglycemic state | A 38-year-old man with diabetes mellitus presented to the emergency room with a five day history of vomiting, lethargy and drowsiness. 5 days prior to admission he had been drinking heavily. He had a 10 year history of diabetes, treated with an oral hypoglycemic agent.\nOn admission he was afebrile, severely dehydrated and drowsy. No infectious focus was found on clinical examination, and there were no neurological manifestations. Admission laboratory data were notable for a plasma glucose of 1314 mg/dL (72.2 mmol/L), a serum osmolarity of 423 mOsm/kg, a potassium level of 5.1 mEq/L and a creatinine level of 2.1 mg/dL. Arterial blood gas analysis on room air showed a pH of 7.37, PaO2 of 74.5 mmHg, PaCO2 of 53.1 mmHg, and HCO3- level of 30.1 mmol/L. There was 1+ ketonuria. The blood count demonstrated a polycythemia, with a hemoglobin of 20.2 g/dL, a white cell count of 12,400/µL and a platelet count of 256,000/µL. The coagulation screen, PT and aPTT were normal. His electrocardiogram revealed a sinus tachycardia.\nThe diagnosis of a hyperosmolar hyperglycemic state with severe dehydration was made. A right subclavian catheter was placed for fluid replacement in the emergency room. The patient was treated with intravenous insulin, fluid infusion and empirical antibiotics. By the next day, his condition was much improved and he was mentally alert.\nThirty hrs after central venous catheter placement the patient complained of pain in his right arm; moderate edema and erythema of the arm were noted. The right subclavian catheter was removed and the patient was closely observed. On hospital day three, his right arm edema was aggravated, and he developed neck edema. Thrombocytopenia was observed. A color Doppler ultrasonogram of the extremity demonstrated acute thrombosis from the right internal jugular and subclavian veins to the brachial and basilic vein. An upper extremity venogram confirmed occlusion at these sites (). The patient denied any prior history of venous thromboembolism. Coagulation profile studies including plasma prothrombin time, antithrombin III, homocysteine, protein C, protein S, lipoprotein and Factor VIII concentrations were within normal limits.\nThe patient was treated with intravenous heparin and thrombolysis. Thrombolysis was performed using a bolus injection of urokinase, 300,000 units, with a multisided hole infusion catheter positioned at the right basilic and cephalic veins. The thrombolytic infusion was continued overnight via catheter. The next day, a follow-up venogram showed partial lysis of the clot. On discharge, the swelling and pain in the right arm were much improved; the platelet count improved and the patient was kept on warfarin until follow up. Two months later, the patient had no symptoms and the follow up color Doppler ultrasonogram showed no evidence of a thrombus in the previously damaged vein (, ). | [[38.0, 'year']] | M | {'2512473': 1, '16241945': 1, '6616416': 1, '2314526': 1, '15778859': 1, '10407691': 1, '12796173': 1, '9326350': 1, '14734512': 1, '2360175': 1, '14702496': 1, '14533970': 1, '11157645': 1, '10739487': 1, '11259926': 1, '12356644': 1, '8732706': 1, '3046028': 1, '12823246': 1, '17249507': 2} | {} |
165,267 | 3891031-1 | 17,249,508 | noncomm/PMC003xxxxxx/PMC3891031.xml | Primary malignant melanoma of the lacrimal sac: A case report | A 53-year-old woman was referred to the department of ophthalmology with a palpable mass at the left medial canthal region. She complained of a six month history of tearing and a two month history of occasional bloody discharge from the left eye as well as left medial canthal region swelling. The swelling was not associated with pain or visual disturbance. The patient had no previous history of regional surgery or trauma or excessive sun exposure. There was no history of a cutaneous primary melanoma.\nThe physical examination revealed a cystic, localized, non tender palpable mass at the left medial canthus consistent with an enlargement of the lacrimal sac. Computed tomography scanning of the paranasal sinus showed a soft tissue mass in the left lacrimal sac, attached to the medial orbital wall (). However, neither orbital cavity involvement nor bony destruction was detected. In addition, infiltration of the surrounding soft tissue was not detected, and the mass did not extend into the nasolacrimal duct. There was no associated cervical lymphadenopathy. The patient was taken to the operating room for a scheduled dacryocystectomy. A brown-pigmented soft tissue containing cystic mass filled the lacrimal sac and did not protrude through the nasolacrimal duct. The mass was removed from the nasal and lacrimal bone and dissected from the medial canthal tendon. The cystic mass was thought to be benign and therefore only a dacryocystectomy was performed.\nBiopsy and histological examination of the surgical specimen showed solid growth of malignant cells characterized by production of melanin pigments and hyperchromatic nuclei with prominent nucleoli (). The tumor cells showed strong immunoreactivity to melanoma specific antibody, HBM-45 in the immunohistochemical examination, consistent with a diagnosis of malignant melanoma (); whereas the immunoreactivity to the S 100 protein was negative. This histological examination confirmed the diagnosis of malignant melanoma and the resection margins were not free of tumor. A complete metastatic workup including computed tomography scanning of the head and neck, chest, abdomen and pelvis failed to demonstrate lymphadenopathy or other evidence of metastasis. A general physical examination and routine laboratory tests were all within normal limits. The patient underwent 6000 rad of adjuvant irradiation therapy at the left lacrimal region for four weeks after surgery. During the two months follow up after surgery and radiation therapy, the patient had no evidence of local recurrence; however, since then she has been lost to further follow up. | [[53.0, 'year']] | F | {'33240474': 2, '31747798': 2, '22891020': 1, '16253035': 1, '32408870': 2, '7977578': 1, '15365559': 1, '7947444': 1, '15004500': 1, '2765227': 1, '12878873': 1, '7478659': 1, '10512146': 1, '15878522': 1, '25540768': 1, '17249508': 2} | {'7222429-1': 1, '6873277-1': 1, '7675887-1': 1, '7675887-2': 1} |
165,268 | 3891032-1 | 17,249,509 | noncomm/PMC003xxxxxx/PMC3891032.xml | Capecitabine and Oxaliplatin (XELOX) for the Treatment of Patients with Metastatic Gastric Cancer and Severe Liver Dysfunction | A 62-year-old man was admitted due to his recent jaundice and abdominal distention. He was diagnosed about 2 years ago with gastric adenocarcinoma and he underwent radical subtotal gastrectomy. After surgery, he received five cycles of adjuvant chemotherapy with 5-FU and leucovorin. A physical examination showed his height to be 170 cm and the body weight was 68 kg. The condition of the chest and heart was normal. His vital signs were within normal limits. His sclera was deep icteric, but he showed neither hepatomegaly nor right upper quadrant tenderness. The neurological examination was normal. There were no specific findings on the occupational, familial and social histories. The laboratory tests on admission showed an elevated level of serum total bilirubin to 10.9 mg/dL (normal level: 0.3~1.2 mg/dL), a direct bilirubine of 8.5 mg/dL (normal level: 0~0.2 mg/dL), alanine aminotransferase of 374 U/L (normal level: 10~40 U/L), alkaline phosphatase of 480 U/L (normal level: 20~100 U/L) and lactate dehydrogenase of 2,133 U/L (normal level: 208~378 U/L). An abdominal and pelvic CT scan was performed to verify the biliary obstruction and metastatic lesions in the abdominal cavity, including the liver and biliary system. CT scan of the abdomen showed multiple metastatic nodules in the liver with no evidence of biliary tree obstruction (). The diagnosis of the patient was confirmed to be recurrent gastric cancer with advanced liver metastases and severe hepatic dysfunction. His performance status was estimated to be ECOG 2. Given his poor liver function, the patient was treated with oxaliplatin (130 mg/m2) on day 1 and capecitabine (1,000 mg/m2 orally twice daily) on days 1~14 of a 21-day cycle. After the first cycle of chemotherapy, his total bilirubin dropped to 4.5 mg/dL. After two cycles of chemotherapy, his total bilirubin and alkaline phosphatase decreased to near normal levels at 2.1 mg/dL and 116 U/L, respectively. No treatment-related grade 3 or above toxicities were noted during the first 4 cycles of treatment. He continued to well tolerate chemotherapy with excellent performance and normalization of all the liver enzymes ( and ). He displayed a major radiological response on the follow-up CT scans (); he has received 5 cycles of XELOX with ongoing clinical benefit. | [[62.0, 'year']] | M | {'14709934': 1, '28480070': 1, '7533517': 1, '8508427': 1, '15625379': 1, '10430071': 1, '28979726': 1, '9093725': 1, '33995923': 1, '14523790': 1, '27239232': 1, '17249509': 2} | {} |
165,269 | 3891033-1 | 17,249,510 | noncomm/PMC003xxxxxx/PMC3891033.xml | Pancreatitis from Metastatic Small Cell Lung Cancer: Successful Treatment with Endoscopic Intrapancreatic Stenting | A 45-year-old female was admitted to the Kyung Hee Medical Center in April 2005 with a 20-day history of gnawing epigastric pain radiating to the back. In November 2001, she visited our hospital complaining of a chronic cough. Bronchoscopic washing cytology results revealed a SCLC in the left lower lung field, which was treated with chemotherapy and radiation therapy. It appeared that the SCLC responded to the therapy at that time, but follow-up computed tomography (CT) showed a new mass at the right lower lung field. A biopsy revealed that the SCLC had relapsed and she was admitted for additional chemotherapy treatments. Unfortunately, she did not respond to therapy, and a right lung lobectomy was performed. In July 2004, a submandibular mass was found incidentally, and a biopsy indicated metastatic SCLC. Another chemotherapy treatment was started. One month later, PET/CT revealed a left adrenal gland mass suggestive of a metastatic lesion. Additional chemotherapy regimens were provided with no improved response. In January 2005, chemotherapy was discontinued and the patient received only supportive care.\nThe patient had a history of heavy drinking and a 15-pack-year smoking history. However, she had stopped drinking and smoking during the last four years. In addition, she was not taking any other medication. She appeared acutely ill and dehydrated. On physical examination, the patient's body temperature was 38.5℃, blood pressure was 120/80 mmHg, her pulse was 78/minute and her respiratory rate was 20/minute. The breath sounds were decreased in the right lung field. Mild tenderness was noted at the epigastrium but there was no palpable mass. The initial laboratory data were as follows: WBC 6,710/mm3 (82.1% neutrophils, 9.6% lymphocytes, and 4.5% monocytes), hematocrit 36.3%, platelets 170,000/mm3, glucose 110 mg/dL, BUN 7 mg/dL, creatinine 0.6 mg/dL, sodium, 139 mmol/L, potassium 3.9 mmol/L, and calcium 8.4 mg/dL. Serum AST 27 IU/L, serum ALT 15 IU/L, serum gamma glutamyl transpeptidase 13 IU/L, serum alkaline phosphatase 66 IU/L, and amylase 2,650 U/L (normal, 25 to 125 U/L). The chest X-ray revealed the right lower lobectomy and lymph node calcifications at the anterior posterior window area. The abdominal CT revealed multiple low attenuated masses in the pancreatic head, a dilated upstream pancreatic duct and a left adrenal metastasis (6.8 × 5.3 cm) (). No peripancreatic infiltration or fluid collection was noted. Endoscopic ultrasonography (EUS) showed several, well demarcated, irregular hypoechoic masses at the head portion of the pancreas, which compressed the pancreatic duct resulting in a dilatation of the upstream pancreatic duct (). The patient was initially treated with intravenous fluids, dietary restrictions and intravenous analgesics. However, her pain continued unabated. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) was performed to relieve the pancreatic ductal pressure. The ERCP (JF-240, Olympus, Tokyo, Japan) showed an irregular stricture of the pancreatic duct at the head portion of the pancreas along with mild dilatation of the upstream pancreatic duct (). Accordingly, a naso-pancreatic drainage tube (5 Fr, Wilson-Cook, USA) was inserted across the stricture up to the tail of the pancreatic duct. After the pancreatic drainage procedure, the patient's epigastric pain dramatically improved. In addition, the serum amylase and lipase level decreased to 189 U/L and to 143 U/L respectively, one day after the pancreatic drainage procedure. On the sixth day of hospitalization, a second ERCP was done to replace the naso-pancreatic drainage tube with a plastic pancreatic stent. However, selective cannulation of the pancreatic duct was impossible due to the subcutaneous edema of the major papilla caused by incorrect injection of the dye used. Fortunately, the patient did not complain of any discomfort for several days, even after eating regular meals. The patient was discharged without any problems.\nA few days later the patient was readmitted with epigastric pain. On physical examination, she presented with epigastric tenderness and equivocal rebound tenderness. The serum amylase level was 1,867 U/L. Recurrent acute pancreatitis due to a pancreatic metastasis was suspected. An emergency ERCP was performed. The pancreatography showed a short stenosis of the main pancreatic duct, which was identical to the portion found during the first ERCP. A 5 Fr pancreatic stent, 9 cm in length, was inserted at the pancreatic duct through the stenotic area (). After inserting the stent, the patient's abdominal pain continued to decrease and she could take food po; she was discharged without problems. | [[45.0, 'year']] | F | {'2155057': 1, '15316227': 1, '31014441': 1, '28855030': 1, '1278639': 1, '19014447': 2, '15747027': 1, '3523591': 1, '8390948': 1, '23119202': 2, '10102535': 1, '1568614': 1, '15855973': 1, '24587774': 1, '3028735': 1, '10713023': 1, '27808144': 1, '34987855': 2, '220925': 1, '26075124': 2, '9713480': 1, '8391965': 1, '32775057': 2, '17249510': 2} | {'7402425-1': 1, '4446459-1': 1, '2615008-1': 1, '3479941-1': 1, '8713578-1': 1} |
165,270 | 3891034-1 | 17,249,511 | noncomm/PMC003xxxxxx/PMC3891034.xml | Anorectal and gastric peripheral T-cell lymphoma, unspecified in a non-AIDS patient | A 29-year-old man was referred to our hospital with complaints of hematochezia and tenesmus for 2 months. He underwent colonofiberscopic examination without biopsy by a primary clinician. The colonofiberscopic examination showed a huge multiple fungating submucosal mass at the anorectal region (). On admission, the patient complained hematochezia, tenesmus and abdominal discomfort, but there was no specific findings noted on the abdominal physical examination. The vital signs revealed a blood pressure of 100/70 mmHg, a pulse rate of 68/min, a respiratory rate of 22/min and his temperature was 36.5℃. The laboratory test showed a white blood cell count of 9,110/µL (84.1% polymorphonuclear cells and 9.2% lymphocytes), a hemoglobin level of 12.3 g/dL, a hematocrit of 36.8%, a platelet count of 412,000/µL, an erythrocyte sedimentation rate of 10 mm/hour and a C-reactive protein level of 0.03 mg/dL (normal range: 0-0.5). The partial thromboplastin time and prothrombin time were within normal ranges. The results of liver function tests were as follows protein 8.7 g/dL, albumin 4.5 g/dL, bilirubin 1.6 mg/dL, aspartate transaminase 26 IU/L, alanine transaminase 53 IU/L, alkaline phosphatase 51 IU/L, cholesterol 138 mg/dL and lactic dehydrogenase (LDH) 514 IU/L. The renal function tests were normal. The serum electrolytes showed sodium 138 mM/dL, potassium 4.9 Mm/L, chloride 100 mM/L, calcium 9.2 mg/dL and phosphate 4.8 mg/dL. Urinalysis was negative for occult blood and there was a trace of protein. No antibodies against syphilis, hepatitis B, hepatitis C or human immunodeficiency virus were detected. Under the clinical impression of anal and rectal submucosal tumor, the patient underwent excisional biopsy. The histologic findings of the specimen showed dense infiltration of angulated lymphoid cells into the lamina propria together with perivascular infiltrations (). On immunohistochemistry, these lymphoid cells were positive for CD3 (), lymphocyte common antigen, Ki-67 and CD45RO, but they were negative for CD20 and CD56. These morphologic features and the immunophenotype profiles were compatible with PTCLu. For further evaluation, he underwent gastrofiberscopy and bone marrow biopsy. Gastrofiberscopic examination showed mottled or patched hyperemic mucosa and round-shaped, flat elevated lesions on the gastric antrum (). Biopsy of the gastric lesion gave the same diagnosis, but there was no lymphoma that involved the bone marrow. The chest CT scan was normal; the abdominal-pelvic CT scan showed wall thickening from the lower rectum to the rectosigmid junction, and there were multiple lymphadenopathies in the perirectal area, sigmoid mesocolon and paraaortic area, and enlarged nodes were noted along the hepatoduodenal ligament.\nFinally, the patient was diagnosed as suffering with rectal and gastric PTCLu. The Ann Arbor stage was IVA and the age-adjusted international prognostic index was 3. He was in the high risk group. He was treated with six cycles of combination chemotherapy including cyclophosphamide, adriamycin, vincristine, etoposide and prednisone (CHOEP). After two cycles of chemotherapy, the initially observed rectal wall thickening disappeared on the follow-up abdominal-pelvic CT scan; we observed markedly decreased size of the lymph nodes of the paraaortic and portocarval space. On follow-up gastrofiberscopic biopsy, a few lymphoid cells had infiltrated to the lamina propria, and these were probably reactive lymphocytes. He underwent autologous stem cell transplantation after six cycles of systemic CHOEP chemotherapy. Regular follow-up was done with CT, gastroscopic biopsy and colonofiberscopic biopsy every 3 months. He has been in complete remission for over 300 days after autologous stem cell transplantation. | [[29.0, 'year']] | M | {'9298875': 1, '3926171': 1, '9439161': 2, '5796708': 1, '8147786': 1, '10649269': 1, '10411444': 1, '9708949': 1, '11230650': 1, '3754810': 1, '9789607': 1, '10071340': 1, '12195476': 1, '2791789': 1, '2957043': 1, '3887261': 1, '1836440': 1, '12029536': 1, '7691923': 1, '17249511': 2} | {'4531979-1': 1} |
165,271 | 3891035-1 | 17,249,512 | noncomm/PMC003xxxxxx/PMC3891035.xml | Four Cases of Non-Hodgkin's Lymphoma in AIDS patients | A 37-year-old male was admitted to our hospital because of his left sided hemiplegia that he had experienced for 3 months. He was known to be positive for HIV, as was determined during evaluation for idiopathic thrombocytopenic purpura in a foreign country about 6.5 years before this admission. At that time, he had been treated with zidovudine, lamivudine and saquinavir for the management of AIDS for 9 months and then he discontinued therapy of his own will. He was advised to restart treatment with zidovudine, lamivudine and indinavir at our hospital 4 years ago. He noticed weakness on the left side of his body during movement, which had slowly progressed and he finally developed left-sided hemiplegia 3 months previously. At the time of admission, he had complaints of headache and night sweats. He was diagnosed as having idiopathic thrombocytopenic purpura about 6.5 years ago and so splenectomy was done. Even after splenectomy, the thrombocytopenia continued. He was treated with steroid, vincristine, intravenous gammaglobulin, rituximab and danazole. He had also experienced liver abscess 4 years ago. He had received radiation for Kaposi sarcoma about 8 months before admission. On admission, the blood pressure was 90/60 mmHg, the pulse rate 100/min, the respiration rate 22/min and the body temperature was 38℃. Upon physical examination, the patient was in poor general condition with anemic conjunctiva. There were no signs of hemorrhagic diathesis or icterus. The laboratory finding were as follows; hemoglobin 7.4 g/dL, WBC 8,300/mm3 (neutrophila: 79.5%, lymphocytes: 14.6%, monocytes: 4.6%), platelets 10,000/mm3, erythrocyte sedimentation rate (ESR) 2 mm/h, AST 24 IU/L, ALT 9 IU/L, total bilirubin 0.7 mg/dL, LDH 473 IU/L, protein 3.9 g/dL, albumin 2.3 g/dL, BUN 9.5 mg/dL, creatinine 0.42 mg/dL, calcium 7.3 mg/dL, phosphorus 3.1 mg/dL, Na 130 mmol/L, K 3.0 mmol/L, the total number of CD4 and CD8 T lymphocytes was 46/mm3 and 621/mm3, respectively, and the ratio of CD4/CD8 was 0.07. The chest X-ray was not remarkable. Brain MRI () shows 4 cm-sized round mass involving the right frontal lobe. The T1 weighted image and the T2 weighted image () showed extensive areas of perilesional edema involving the right frontoparietal region and there was a mass effect upon the right lateral ventricle. Stereotactic biopsy of the brain lesion was performed, and histological examination disclosed atypical lymphoid cells with a predominant perivascular arrangement (). Immunohistochemical examination showed positivity for CD20. The diagnosis of diffuse large B-cell lymphoma involving the CNS was made. The patient was treated with brain radiation. Sadly, he died of pneumonia 13 days after brain radiation therapy. | [[37.0, 'year']] | M | {'11298581': 1, '9711914': 1, '11433410': 1, '12688356': 1, '9398040': 1, '16020424': 1, '6611504': 1, '2536124': 1, '6265753': 1, '10508483': 1, '9171066': 1, '1973886': 1, '11719381': 1, '9652666': 1, '11078759': 1, '11417298': 1, '1672911': 1, '17249512': 2} | {'3891035-2': 2, '3891035-3': 2, '3891035-4': 2} |
165,272 | 3891035-2 | 17,249,512 | noncomm/PMC003xxxxxx/PMC3891035.xml | Four Cases of Non-Hodgkin's Lymphoma in AIDS patients | A 40-year-old man was hospitalized due to jaundice and lethargic fatigue that started 10 days prior to admission. The patient had complaints of weight loss and night sweats. Four months prior to this admission, he had visited to the Department of ENT at another hospital with the complaint of nasal stuffiness. At that time, the serologic testing for hepatitis B antigen and anti-HIV antibody were positive. He has been treated with zidovudine, lamivudine and efavirenz for two months until admission. He assumed that his AIDS was transmitted from heterosexual contact at abroad ten years ago. On admission, the blood pressure was 120/70 mmHg, the pulse rate 90/min, the respiratory rate 20/min and the body temperature was 36.6℃. He was icteric on the physical examination. The liver was tender and firm in consistency. It was palpated at a three-finger breadth below the right costal margin. His spleen and lymph nodes were not enlarged. The laboratory results were normal apart from an ESR of 120 mm/h; leukopenia 3,930/mm3 (neutrophils: 58.8%, lymphocytes: 31% and monocytes: 8.4%) and hemoglobin 9.4 g/dL. The liver function tests were abnormal: total bilirubin 8.9 mg/dL (direct bilirubin: 6.05 mg/dL), AST 171 IU/L, ALT 100 IU/L and LDH 1063 IU/L. The total number of CD4 and CD8 T lymphocytes was 290/mm3 and 568/mm3, respectively, and the ratio of CD4/CD8 was 0.51. Abdominal enhanced CT scanning revealed multifocal and variable sized homogenous hypodense masses in both hepatic lobes (). A liver biopsy showed a heavy infiltration composed mainly of large lymphoid cells (). Immunohistochemical staining revealed the atypical cells to be CD20 positive (), which established a diagnosis of diffuse large B-cell lymphoma according to the WHO classification. Bone marrow biopsy demonstrated normal cellularity with normal maturation of all three cell lines. There was no malignant cell infiltration. After the patient was diagnosed as having diffuse large B-cell lymphoma, he received VAD (vincristine 0.4 mg, adriamycin 9 mg/m2, dexamethasone 40 mg on days 1-4, and additional dexamethasone on days 9-12 and days 17-20). The patient seemed to show a little clinical improvement, but before starting the second chemotherapy, he developed signs of spinal cord compression (). Emergency radiation therapy was delivered to the spine lesion. CHOP chemotherapy (cyclophosphamide 750 mg/m2, adriamycin 50 mg/m2 and vincristine 1.4 mg/m2 on day 1 and prednisone 100 mg/m2 on days 1-5) and laminectomy induced temporary improvement (). Alas, the paraplegia continued and his clinical condition progressively worsened. He passed away 103 days after starting the second round of chemotherapy from complications of pressure sores, deep vein thrombosis and pulmonary thromboembolism. | [[40.0, 'year']] | M | {'11298581': 1, '9711914': 1, '11433410': 1, '12688356': 1, '9398040': 1, '16020424': 1, '6611504': 1, '2536124': 1, '6265753': 1, '10508483': 1, '9171066': 1, '1973886': 1, '11719381': 1, '9652666': 1, '11078759': 1, '11417298': 1, '1672911': 1, '17249512': 2} | {'3891035-1': 2, '3891035-3': 2, '3891035-4': 2} |
165,273 | 3891035-3 | 17,249,512 | noncomm/PMC003xxxxxx/PMC3891035.xml | Four Cases of Non-Hodgkin's Lymphoma in AIDS patients | A 38-year-old male with AIDS presented with a palpable mass he'd had for 5 months in the left cervical region. HIV infection was possibly through heterosexual contact and he was diagnosed two years earlier, but no particular treatments were established before admission. On physical examination, 0.8 cm-sized lymph nodes were palpable in the left cervical areas. The heart and lungs were normal, and the chest X-ray was normal. A CT scan of the head and neck () showed enlarged left sided cervical lymph nodes that measured 1.6 cm × 2.4 cm in diameter. Excisional biopsy of a cervical lymph node was performed, and the histologic study suggested diffuse large B-cell lymphoma (). Immunohistochemical staining showed the atypical cells to be CD20 positive (). On admission, the patient did not declare any discomfort and the physical examination was normal. The laboratory finding were as follows; hemoglobin 14.4 g/dL, WBC 5,310/mm3 (neutrophils: 55.9%, lymphocytes: 39% and monocytes: 4.1%), platelet 178,000/mm3, ESR 9 mm/h, AST 39 IU/L, ALT 32 IU/L, total bilirubin 1.5 mg/dL, LDH 378 IU/L, protein 7.9 g/dL, albumin 4.0 g/dL, BUN 15.9 mg/dL, creatinine 0.88 mg/dL, calcium 8.5 mg/dL, phosphorus 4.2 mg/dL, Na 137 mmol/L, K 4.5 mmol/L, the percent of the CD4 and CD8 T lymphocytes was 20.5% and 70% of the total lymphocyte count, respectively, and the total number of CD4 cells was 420/mm3. The CD4/CD8 ratio was 0.36. He was treated via immunochemotherapy with Rituximab and CHOP for six cycles. After 5 cycle of R-CHOP, the CD4 cell count decreased from 420 to 95/mm3 and a regimen of zidovudine, lamivudine and didanosine were used as HAART. After 6 cycles of R-CHOP, the follow-up CT revealed marked regression in the size of the lymph nodes at both internal jugular channels (). He is currently under follow-up for the lymphoma. | [[38.0, 'year']] | M | {'11298581': 1, '9711914': 1, '11433410': 1, '12688356': 1, '9398040': 1, '16020424': 1, '6611504': 1, '2536124': 1, '6265753': 1, '10508483': 1, '9171066': 1, '1973886': 1, '11719381': 1, '9652666': 1, '11078759': 1, '11417298': 1, '1672911': 1, '17249512': 2} | {'3891035-1': 2, '3891035-2': 2, '3891035-4': 2} |
165,274 | 3891035-4 | 17,249,512 | noncomm/PMC003xxxxxx/PMC3891035.xml | Four Cases of Non-Hodgkin's Lymphoma in AIDS patients | A 67-year-old male was admitted to our hospital because of a protruding swollen chest wall mass on his right side, and he had noticed this mass for 1 month. He also had a complaint of night sweats. His past medical history included an electrical burn about 30 years ago and herpes zoster four months prior to this admission. Serological HIV positivity was detected four months ago while he was being treated for his herpes. His HIV infection was assumed to be transmitted through blood transfusion. He denied ever having homosexual contact or drug abuse. He was on zidovudine, lamivudine and lopinavir. On admission, his blood pressure was 120/80 mmHg, the pulse rate 68/min, the respiration rate 18/min and the body temperature was 36.2℃. The patient appeared generally well on physical examination. The heart and lungs sounds were normal. A chest wall mass measuring 15 cm × 18 cm in diameter was palpable on the right side of his chest. The laboratory finding were as follows: hemoglobin 12.2 g/dL, WBC 6,990/mm3 (neutrophils: 36.5%, lymphocytes: 52.5% and monocytes: 8.9%), platelets 131,000/mm3, ESR 8 mm/h, AST 37 IU/L, ALT 22 IU/L, total bilirubin 0.55 mg/dL, LDH 2,024 IU/L, protein 6.5 g/dL, albumin 3.5 g/dL, BUN 13.7 mg/dL, creatinine 1.2 mg/dL, calcium 7.6 mg/dL, phosphorus 3.4 mg/dL, Na 139 mmol/L, K 4.3 mmol/L, the total number of CD4 and CD8 T lymphocytes was 317/mm3 and 3,085/mm3, respectively, and the ratio of CD4/CD8 was 0.1. The chest X-ray was unremarkable except for marked soft tissue swelling of the right chest wall. The initial chest CT () showed extensive heterogeneously infiltrative lesions that involved the right side of the chest wall musculature with accompanying edematous change of the overlying skin and subcutaneous layer. The microscopic finding of the mass showed a starry-sky pattern with diffuse proliferation of small to medium sized neoplastic cells (). Immunohistochemical examination showed positivity for CD20 (). The pathological diagnosis was Burkitt's lymphoma. The patient received 4 cycles of dose adjusted EPOCH regimen (a 4-day infusion of etoposide 50 mg/m2, doxorubicin 10 mg/m2 and vincristine 0.4 mg/m2 with dose-adjusted cyclophosphmide 375 mg/m2 on day 5 and prednisone 60 mg/m2 for 5 days) every 3 weeks. Granulocyte colony-stimulating factor was used uniformly, beginning at day 6, and all HAART was withheld until day 6 of the last dose of chemotherapy. The soft tissue lesion responded very well to chemotherapy. The chest wall mass decreased in size after the first cycle of chemotherapy. After four cycles of chemotherapy, follow-up CT revealed marked regression of the lymphoma in the right chest wall (). He is currently alive and well in a state of complete remission of the lymphoma for more than 18 months. | [[67.0, 'year']] | M | {'11298581': 1, '9711914': 1, '11433410': 1, '12688356': 1, '9398040': 1, '16020424': 1, '6611504': 1, '2536124': 1, '6265753': 1, '10508483': 1, '9171066': 1, '1973886': 1, '11719381': 1, '9652666': 1, '11078759': 1, '11417298': 1, '1672911': 1, '17249512': 2} | {'3891035-1': 2, '3891035-2': 2, '3891035-3': 2} |
165,275 | 3891036-1 | 17,249,513 | noncomm/PMC003xxxxxx/PMC3891036.xml | A case report of nonepisodic angioedema with eosinophilia in a Korean patient and a review of the Korean literature | A 26-year-old Korean woman presented with edema of her hands and lower legs, which had developed 2 weeks prior to her hospital visit. Her body weight had increased by 2 kg over those 2 weeks, and this was her first episode of the reported symptoms. The edema was distributed symmetrically on both of the patient's upper and lower extremities, and was pitted. She denied any febrile sensation and had a pruritic rash on her lower legs (), and had also experienced mild joint pain in both knees 1 week after the onset of the edema. Her family and past medical histories, including any allergic diseases, were unremarkable. She also denied taking any drugs, including Oriental medications, with the exception of one acetaminophen tablet (300 mg) 1 week prior to the onset of edema. Her symptoms did not appear to be related to her menstrual cycle.\nLaboratory tests revealed leukocytosis (12,250/mm3; normal range: 4,000-10,000/mm3) with 51.5% eosinophils (normal range: 0~7%) in the peripheral blood. The eosinophil count was 6,300/mm3. Serum IgE had increased to 1,423 IU/mL (normal range: 0-170 IU/mL), but IgA, IgG, and IgM levels were all within normal limits. Antinuclear antibody was negative, as were stool ova and serum antibodies to parasites. No clinical findings were suggestive of autoimmune disease or parasite infestation. No abnormal findings were observed in the serum chemistry that would be reflective of renal or hepatic dysfunction. No proteinuria was detected. The rash on the patient's lower legs was examined histologically, and identified as perivascular eosinophil infiltration (). Lymphocyte phenotyping was conducted, but did not indicate the presence of any abnormal lymphocyte clones.\nWe diagnosed the patient with NEAE, and prescribed an oral antihistamine to control the pruritus. One week after the patient began taking antihistamines, the edema and rash began to evidence improvements. The knee arthralgia also clearly improved. The eosinophil count decreased to 1,530/mm3 after 2 weeks and to 736/mm3 after 8 weeks. The patient was free of symptoms at 4 months, and had an eosinophil count of 550/mm3. We followed the patient for 18 months, and observed no recurrence of either the symptoms or the eosinophilia (the eosinophil count was 180/mm3). | [[26.0, 'year']] | F | {'2521494': 1, '10511609': 1, '18379787': 1, '9395727': 1, '10569307': 1, '14565669': 1, '24991461': 1, '16220225': 1, '8452319': 1, '9641577': 1, '9873168': 1, '15180753': 1, '6727934': 1, '11167701': 1, '2208795': 1, '17249513': 2} | {} |
165,276 | 3891037-1 | 17,249,514 | noncomm/PMC003xxxxxx/PMC3891037.xml | Case of Pseudomembranous Necrotizing Tracheobronchial Aspergillosis in an Immunocompetent Host | A 44-year-old Korean male presented with a fever, non-productive cough, and myalgias for 10 days. For the previous 5 years, he had been treated for hypertension with an angiotensin-converting enzyme inhibitor. Prior to admission, he was treated with oral quinolone for 7 days by the outpatient department, but his condition progressively worsened with resting dyspnea, a productive cough, and a fever for 2 days before admission to the Wonkwang University Hospital, Iksan, Korea. The patient was a 30-pack-a-year ex-smoker, and had no history of previous respiratory diseases nor a specific family history.\nOn admission, he had a temperature of 38.6℃, blood pressure of 120/80 mmHg, heart rate of 90 b.p.m, and respiratory rate of 30 breaths/min. Chest auscultation was significant for bilateral inspiratory coarse, crackles and end-expiratory wheezing around the perihilar areas. Arterial blood gas values on room air were: pH 7.343, PaCO2 41.2 mmHg, PaO2 59.2 mmHg, and SaO2 90.7%. The WBC was 19,580/mm3 (neutrophils 82.5%); the ESR was 71 mm/h; and the C-reactive protein was 184.6 mg/L. The percentage of hemoglobin A1c in the blood was 5.8%. The blood urea nitrogen was 32.4 mg/dL and the creatinine was 1.32 mg/dL. The random glucose of capillary blood on admission was 117 mg/dL. A chest X-ray obtained on admission demonstrated bilateral bronchial wall thickening with perihilar area and lower lobe predominance (). The results of the initial sputum stains and sputum and blood cultures were all negative. The HIV test also was negative.\nThe patient received empirical therapy with cefoperazone/sulbactam and vancomycin for 4 days, but rapidly deteriorated with a high fever, increasing dyspnea, and hypoxemia. He developed respiratory failure with severe CO2 retention, and was admitted to the intensive care unit and mechanically ventilated. On the fifth day of therapy, chest CT and fiberoptic bronchoscopy were performed because of a rapidly increasing respiratory acidosis with hypoxemia in contrast to the chest X-ray lesions. A chest CT scan revealed only bilateral peribronchial infiltrates with patent bronchi and no consolidation of the parenchyma (). A bronchoscopy demonstrated extensive whitish exudative membranes covering the trachea and both mainstem bronchi (). The endobronchial biopsy specimens and bronchial washing fluid revealed Aspergillus species without parenchymal invasion (). A high fever persisted and 2 days later the patient developed refractory septic shock and hypoxemia. Despite using IV amphotericin B and supportive care, acute deterioration followed with refractory hypoxemia and oliguria, resulting in a fatal cardiac arrest on the fifth day of the intensive care unit stay. We could not perform a post-mortem examination because of the refusal of his family members. | [[44.0, 'year']] | M | {'1988763': 1, '10435898': 1, '15955156': 1, '31205923': 1, '22194666': 1, '15818187': 1, '10525567': 1, '10721324': 1, '11452056': 1, '28740687': 1, '10957902': 1, '14758182': 1, '14716226': 1, '14998475': 1, '12783174': 1, '23269890': 2, '12065367': 1, '27177455': 1, '27625454': 2, '28423094': 1, '17249514': 2} | {'3529248-1': 1, '5006340-1': 1} |
165,277 | 3891038-1 | 17,249,515 | noncomm/PMC003xxxxxx/PMC3891038.xml | Successful Treatment of Ischemic Dysfunction of the Sinus Node with Thrombolytic Therapy: A Case Report | A 56-year-old male was admitted to the hospital with resting chest pain that developed three days before admission. He had effort-induced chest pain for three years, but did not take any medications and had no prior cardiac evaluations. Physical examination findings, blood pressure and heart rate were all normal. An echocardiography showed normal left ventricular wall motion and a normal ejection fraction. The electrocardiogram showed T wave inversions in lead aVL. The coronary angiography revealed a 50% discrete stenosis at the ostium of the left anterior descending artery (LAD), an 80% tubular stenosis at the intermedius branch, and a 90% tubular stenosis at the distal LCX (). A ramus intermedius angioplasty was successfully performed with placement of a sirolimus-eluting stent (Cypher, Johnson & Johnson). We performed a balloon dilatation with a balloon, 2.25 mm in diameter (Aqua, Johnson & Johnson). A coronary angiography immediately after balloon removal from the LCX demonstrated a patent distal LCX but total occlusion of the sinus node branch (). About 1 minute later, the patient complained of dyspnea and chest pain and the ECG showed a junctional rhythm with a heart rate of 40/min and the blood pressure dropped to 90/60 mmHg (). A temporary pacemaker was inserted through the right subclavian vein and dopamine was continuously infused (10 µg/kg/min) to increase the heart rate and blood pressure. The patient also received nitroglycerin (200 µg) and abciximab (0.25 mg/kg) bolus through a guiding catheter; the abciximab was infused intravenously (10 µg/min) for 12 hours. Then, an infusion catheter (Microferret, Cook) was placed in the SN artery where nitroglycerin 100 ug and nicorandil 1 mg were infused to rule out coronary spasm. Distal flow was not established; then urokinase 100,000 IU for 5 minutes through the catheter () was infused. A coronary angiogram performed shortly after the urokinase infusion showed thrombolysis in acute myocardial infarction (TIMI). | [[56.0, 'year']] | M | {'16008158': 1, '1222433': 1, '10785686': 1, '34317546': 1, '17670227': 1, '15721108': 1, '6829433': 1, '9286539': 1, '3180856': 1, '10878637': 1, '6478849': 1, '11061076': 1, '1844351': 1, '6039178': 1, '17249515': 2} | {} |
165,278 | 3891039-1 | 17,249,516 | noncomm/PMC003xxxxxx/PMC3891039.xml | Skin Necrosis after a Low-Dose Vasopressin Infusion through a Central Venous Catheter for Treating Septic Shock | An 84-year-old male was admitted to our hospital for edema on both legs that had developed 1 month earlier. Diabetes mellitus had been diagnosed 15 years earlier, and the patient had been controlling his blood sugar levels with insulin. Hypertension had been diagnosed one year earlier, hypertension, and the patient was regularly taking an angiotensin converting enzyme inhibitor and a calcium channel blocker. In addition, 7 years earlier, due to the right hand tremor, idiopathic Parkinsons disease had been diagnosed in this patient due to right hand tremor.\nOn the day of admission, the abdominal ultrasound examination showed alcoholic liver cirrhosis and small ascites around the liver. The serum albumin concentration was 2.5 g/dL, the serum bilirubin concentration was 2.4 mg/dL and the prothrombin time was 88%; this corresponded to Childs classification B. He had thrombocytopenia (platelets 79,000 /mm3) and diabetic chronic renal failure (creatinine 2.2 mg/dL). The chest radiograph revealed mild cardiomegaly, and the brain natriuretic peptide was 193 pg/mL. The echocardiography showed that the left ventricle ejection fraction was 55%, which was within the normal range.\nOn hospital day 2, the leg edema was diagnosed as being caused by uncompensated liver cirrhosis combined with diabetic chronic renal failure. After administration of diuretics and albumin, the leg edema improved. However, he complained of a sudden onset of dyspnea on hospital day 8. By that time, he had developed tachycardia (123 beats/min), tachypnea (30 breaths/min) and hypoxemia (SaO2 80%). The creatine kinase, CK-MB and troponin-I levels were within the normal range. The electrocardiography showed no significant ST depression or elevation, essentially ruling out the possibility of acute myocardial infarction. The lung perfusion scan also eliminated the possibility of pulmonary embolism. Despite oxygen supplementation (a mask with reservoir bag 10 L/min), the patient failed to maintain a SaO2 above 90%, and his severe tachypnea (32 breaths/min) was also exacerbated. After the preliminary diagnosis of septic shock and endotracheal intubation, the patient was transferred to the intensive care unit.\nOn the first day in the intensive care unit, his vital signs were indicative of hypotension (the blood pressure 75/40 mm Hg; the mean arterial pressure 48 mm Hg), exacerbated tachycardia (130 beats/min) and hypothermia (34℃). The laboratory examination results showed that the WBC was 700/mm3, the Hb was 9.7 g/dL, the platelet count was 59,000/mm3, the BUN/Cr was 57/2.2 mg/dL, C-reactive protein was 8.3 mg/dL and the lactic acid concentration was 4.4 mmol/L. The urinalysis showed no evidence of nitrate or pyuria, and the urine culture showed no growth. His chest radiograph showed no evidence of definite pneumonic consolidation. We could not perform a diagnostic ascites tapping because the patient's ascites was very small. After the preliminary assessment of hospital-acquired infection and a blood culture examination, the patient was treated with piperacillin/tazobactam, ciprofloxacin and intravenous fluid. The central venous pressure became 12 mmHg, but the systolic blood pressure remained at 80 mmHg. Therefore, we started an infusion of dobutamine (10 µg/kg/min), dopamine (25 µg/kg/min) and norepinephrine (100 µg/min) through the central venous catheter in the right subclavian vein. Due to anuria subsequent to the exacerbated azotemia caused by the septic shock, we began continuous veno-venous hemodialysis (CVVHD).\nAlthough norepinephrine was being infused for about 26 hours, the patients systolic blood pressure remained at 80 mmHg and the mean arterial pressure was also intractably low. The skin necrosis did not develop before vasopressin was administered. We began infusion with vasopressin (40 units mixed with 40 mL of normal saline, and then 0.02 unit/min) through the central venous catheter in the right subclavian vein. The systolic blood pressure increased to 120 mmHg, and the mean arterial pressure increased to 80 mmHg.\nAfter the four hours infusion of low-dose vasopressin, the patient developed multiple purpura on both wrists and both lower legs. In time, the region of skin necrosis expanded to both arms, both thighs and the whole abdomen. At that point, the skin lesions progressed to extensive superficial erosion with variably sized bullous lesions (). We assessed the erosion as low-dose vasopressin induced skin necrosis and then after 22 hours we discontinued the infusion of low-dose vasopressin. So we didnt perform biopsy or culture of the skin lesions.\nEscherichia Coli growth was confirmed by the blood culture. Despite the continuous infusion of dobutamine and norepinephrine, the patient died due to hemodynamic instability. | [[84.0, 'year']] | M | {'15774080': 1, '3525622': 1, '3086204': 1, '12732600': 1, '16505698': 1, '29319574': 1, '3490956': 1, '29854775': 2, '15305765': 1, '3260096': 1, '305380': 1, '30174571': 1, '12771608': 1, '12163813': 1, '31245021': 1, '15103461': 1, '15616384': 1, '15090974': 1, '7416138': 1, '17249516': 2} | {'5964422-1': 1, '5964422-2': 1} |
165,279 | 3891062-1 | 16,646,563 | noncomm/PMC003xxxxxx/PMC3891062.xml | Acute Respiratory Failure Associated with Cryptococcal Pneumonia and Disseminated Cryptococcosis in an AIDS Patient | A 36-year-old man was admitted to our hospital, with a 30-day history of fever and headache. The patient, a homosexual Mexican, had entered Korea 4 months prior to admission. One year prior to admission, the patient had experienced a mild fever, diarrhea, and 20 kg of weight loss. On admission, this patient's body temperature was 38.5℃, and his blood pressure was 130/80 mmHg. He was alert, and was found to have oral thrush. The patient's breath sounds were clear, and his heart sounds were regular, with no murmur. Hepatomegaly and splenomegaly were noted. Upon neurological examination, neck stiffness and Kernig signs were noted. Upon a cerebrospinal fluid examination, the patient's white blood cell count was 1,580/L, total protein was 26 mg/dL, sugar was 17 mg/dL, and intracranial pressure was 23 cmH2O.\nThe patient was diagnosed with HIV (Human Immunodeficiency Virus) infection via serum Western blotting assay. The total number of CD4+ T lymphocytes and CD8+ T lymphocytes were 7 and 60/L. The patient also had an HIV RNA level of 41,000 copies/mL. Cryptococcus neoformans was isolated on cultures of blood and cerebrospinal fluid.\nOn the day of admission, an initial chest roentgenogram revealed no specific abnormal findings, and the patient was treated with intravenous amphotericin B and ceftriaxone as empirical therapy for possible bacterial and fungal infection.\nOn the patient's 4th day in our hospital, a chest roentgenogram revealed diffuse interstitial infiltrations in both lung field, and computerized tomography revealed diffuse reticulonodular infiltration and a ground-glass appearance in both perihilar areas, suggesting PCP or cryptococcal pneumonia ().\nOn the patient's 6th day in our hospital, bronchoalveolar lavage and transbronchial lung biopsy were conducted via bronchoscopy, and antiretroviral therapy (didanosine, lamivudine, nelfinavir) was initiated. Results of methenamine silver staining of the bronchoalveolar lavage fluid revealed no specific abnormal findings. After the patient's 6th day in our hospital, the patient's breathing difficulties and arterial hypoxemia worsened.\nOn the patient's 9th day in the hospital, his arterial oxygen pressure and saturation level were measured at 32.7 mmHg and 61.6%, and mechanical ventilation was initiated.\nCultures of the patient's blood and CSF samples, obtained at the time of admission, revealed Cryptococcus neoformans. Pathological findings and the special stain results of lung biopsy specimens, obtained at the time of bronchoscopy, also revealed cryptococcal pneumonia (, ).\nThis patient died on his 14th day in our hospital, as the result of acute respiratory failure, associated with cryptococcal pneumonia and disseminated cryptococcosis. | [[36.0, 'year']] | M | {'3898951': 1, '7985710': 1, '2017634': 1, '3060529': 1, '10498175': 1, '8356267': 1, '8054420': 1, '8153787': 1, '11914999': 1, '3260347': 1, '9827275': 1, '22246551': 1, '16646563': 2} | {} |
165,280 | 3891063-1 | 16,646,564 | noncomm/PMC003xxxxxx/PMC3891063.xml | Unpredicted Severe Toxicity after 5-Fluorouracil Treatment due to Dihydropyrimidine Dehydrogenase Deficiency | A 37-year-old female patient underwent curative resection for a stage II (pT3N0M0) poorly differentiated gastric adenocarcinoma, and this was followed by adjuvant chemotherapy consisting of 5-FU (600 mg/m2, i.v. on days 1 and 8) and epirubicin (50 mg/m2, i.v. on day 1) in 3-week cycles. However, the patient developed erythematous rashes on her hands and oral mucositis on day 5. Thus, day 8 of 5-FU administration was skipped. On day 14, the patient experienced fever, stomatitis, diarrhea, leucopenia (0.290×109/l), neutropenia (0.012×109/l), and thrombocytopenia (34×109/l). After supportive care with a granulocyte-colony stimulating factor (G-CSF) and broad-spectrum antibiotics, her fever decreased and her general condition and blood counts recovered after 1 week. On day 35, the patient then resumed her treatment with oral doxifluridine (200 mg t.i.d., a prodrug of 5-FU), but 3 days later she developed oral mucositis, and thus further medication was cancelled. Two weeks after this initial oral doxifluridine treatment, the patient presented at the emergency room due to severe oral pain and diarrhea (over 500 mL per day). A physical examination revealed grade 3 oral mucositis and erythematous rashes on her hands and feet. Her CBC revealed leucopenia (1.600×109/l), neutropenia (0.421×109/l), and thrombocytopenia (41×109/l), and after admission, the patient also manifested a fever of unidentified etiology. After 2 weeks of supportive care, the patient's CBC and systemic symptoms improved. Real-time quantitative polymerase chain reaction (PCR) then demonstrated that her DPD mRNA level was 2.5 (control group levels 30-80, cut-off value 3.0. Twenty-nine days after initial oral doxifluridine administration, the patient was discharged, and at the last follow-up 1 year after this after, she was doing well without any evidence of disease recurrence or sequelae of 5-FU toxicity. | [[37.0, 'year']] | F | {'20622967': 1, '11251164': 1, '9816193': 1, '10213225': 1, '12562666': 1, '10778957': 1, '8698850': 1, '33046724': 1, '3335642': 1, '2293556': 1, '2989687': 1, '10027340': 1, '10744051': 1, '10439055': 1, '12651209': 1, '3931905': 1, '9817272': 1, '3829006': 1, '1648430': 1, '11384742': 1, '10027339': 1, '30551585': 1, '11156223': 1, '16646564': 2} | {} |
165,281 | 3891064-1 | 16,646,565 | noncomm/PMC003xxxxxx/PMC3891064.xml | Epstein-Barr virus-associated Hodgkin's disease following renal transplantation | A 41-year-old man received a kidney transplant 116 months previously for chronic renal failure of unknown origin. The post-transplant immunosuppressive agents consisted of cyclosporine, mycophenolate mofetil, and prednisone. He remained well with stable renal function for almost 10 years, maintaining a serum creatinine level in the range of 2 mg/dL.\nIn April 2004, he was admitted to the hospital because of right cervical lymphadenopathy and a 6 kg weight loss over the previous 2 months. There was no history of fever or night sweats. Laboratory findings showed a hemoglobin level of 9.1 g/dL, white blood cell count 8.4×109/L, platelet count 445×109/L, creatinine 2.5 mg/dL, lactic dehydrogenase 229 U/L, and an erythrocyte sedimentation rate of 50 mm/hr. Liver function tests were normal. Estimated glomerularfiltration rate was 37.0 mL/min/1.73 m2. Serologic tests for EBV were negative for EBV (VCA) IgM, positive for EBV IgG and positive for EBNA. Magnetic resonance imaging (MRI) of the neck showed multiple lymph nodes ranging from 1~3 cm in the right cervical level II to V, and a single lymph node on the left at level II. There were no abnormal findings on plane film chest X-ray, abdominal computerized tomography or bone marrow biopsy. The patient was clinically stage IIB. The right cervical lymph node at level III was excised and microscopically revealed mixed cellularity Hodgkin's disease with typical Reed-Sternberg cells. Immunohistochemical staining was positive for CD30 and EBV-latent membrane protein-1 (LMP-1) in the Reed-Sternberg cells (), but CD15 staining was negative. CD20, CD79a (B cell markers) and CD3 were positive for reactive lymphocytes and CD56 was negative. The doses of immunosuppressive agents were reduced (mycophenolate mofetil was discontinued, cyclosporine dose reduced from 200 mg to 150 mg and prednisone continued 5 mg) and the patient received 2 cycles of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Neck ultrasonography following the second course of chemotherapy revealed a marked decrease in the size of the cervical lymph nodes. Radiation therapy (3600 cGy) was then administered to both cervical fields. Whole body positron emission tomography CT (PET-CT) performed 3 months following completion of radiotherapy showed no abnormal fluorodeoxyglucose (FDG) uptake in the neck. Based on a follow up ultrasonography study 8 months after completion of therapy, he was in complete remission and his creatinine level remained stable at 2.5 mg/dL. | [[41.0, 'year']] | M | {'8740790': 1, '7725503': 1, '8016484': 1, '19365835': 1, '12072308': 1, '7796951': 1, '10782732': 1, '29380181': 1, '12962767': 1, '31730878': 1, '12453197': 1, '9326409': 1, '8888750': 1, '11374404': 1, '7579436': 1, '14986084': 1, '8560577': 1, '8049419': 1, '12614729': 1, '15009846': 1, '8167350': 1, '26239296': 2, '26928381': 1, '16646565': 2} | {'4523567-1': 1} |
165,282 | 3891065-1 | 16,646,566 | noncomm/PMC003xxxxxx/PMC3891065.xml | A Case of Behçet's Disease with Pericarditis, Thrombotic Thrombocytopenic Purpura, Deep Vein Thrombosis and Coronary Artery Pseudo Aneurysm | A 37-year-old woman was transferred to our emergency room with the history of syncope. Three days previously, she experienced chest discomfort, dyspnea, palpitations and a low grade fever, but had no relevant past medical history or co-morbidity. At presentation her blood pressure was 80/50 mmHg, pulse rate 76/min, respiratory rate 36/min and body temperature 37.5℃. The physical examination was remarkable for: dyspnea, orthopnea, absence of normal heart sounds, and jugular vein dilatation; Additional tests revealed: low voltage ECG, sinus tachycardia and a large cardiac shadow on X-ray. Laboratory findings showed a pH of 7.37, PaCO2 18.8 mmHg, PaO2 88.5 mmHg, HCO3- 10.8 mmol/L on ABGA, hemoglobin 9.2 g/dL, white blood cell of 12900/µL, and platelet 476000/µL on CBC. ANA, rheumatoid factor, and VDRL were all negative and non- reactive. The patient had a suspected cardiac tamponade therefore a transthoracic echocardiography (TTE) was performed immediately and revealed moderate pericardial effusion and a hypokinetic LV at the anterior, anterolateral and apex portions of the heart (). Pericardiectomy with a window formation was performed to remove the effusion and hematoma. The drained fluid had a white blood cell 225 (PML 100%), red blood cell 90,000/µL LDH 1064U/L, and glucose 190 mg/dL; there were no organism on gram stain and culture. A class I cytology, indicating acute and chronic inflammation was revealed. On postoperative day 3, fever, dyspnea, oliguria and mental status changes developed and the patient deteriorated rapidly. A follow-up evaluation showed the serum hemoglobin to be 6.9 g/dL, white blood cell 14900/µL, platelets 18000/µL and AST, ALT and CPK of 272, 151, and 247 U/L, respectively. Blood urea nitrogen was 40.6 mg/dL, creatinine 4.9 mg/dL, LDH 2279 U/L, PT 11.6 seconds and aPTT of 32 seconds.\nA chest X-ray revealed a ground glass appearance in both lungs. The brain MRI was reported as normal. A peripheral blood smear was remarkable for schistocytosis, anisocytosis, normoblasts and a thrombocytopenia, suggestive of microangiopathic hemolytic anemia (). All of these findings were compatible with the diagnosis of thrombotic thrombocytopenic purpura (TTP). Treatment with methylprednisolone pulse therapy was started (1 g/day for 3 days). Investigation for the etiology of TTP revealed that the patient had suffered from severe recurrent oral and genital ulcers. The ulcers were reported to be as frequent as 3 to 4 per month and were exacerbated by menstruation after the age of 20. The patient also reported taking medications intermittently for painful skin indurations and eruptions as well as arthralgia. Considering the clinical symptoms in total the diagnosis, of Behcet's disease complicated by TTP and hemorrhagic pericarditis, was made. Treatment with methylprednisolone pulse therapy resulted in a dramatic response with improvements of the CBC, LFT, azotemia, and improved mental status. The patient went on to fully recover and returned to normal activities of daily living within a few days. Follow-up evaluation with TTE after complete recovery showed a normal right and left ventricular heart function and a minimal pericardial effusion. After discharge, the patient continued taking medication including colchicine 1.2 mg/day and prednisolone 5 mg/day. The patient continued to be followed.\nSix months after discharge, the patient required readmission to the hospital. She presented with a sudden onset left leg swelling and pain that was diagnosed as a left proximal femoral vein thrombosis by duplex scan. There were no associated signs or symptoms such as dyspnea or fever. A venogram demonstrated that a filling defect obstructed the left proximal femoral vein. the patient was treated with catheter directed thrombolysis using urokinase, thrombectomy and venoplasty and then started on combination anticoagulation therapy (). Six months after maintenance therapy with coumadin, colchicines, and sulfasalazine was started, a homogenous soft tissue mass was found, incidentally, on routine laboratory and radiologic follow up. The soft tissue density was attached to the left perihilar area by the pulmonary conus (). The laboratory tests showed a hemoglobin of 11.1 g/dL, platelet 324000/µL, WBC 6000/µL, ESR 39 mm/H, CRP 1.59 mg/dL, albumin 4.5 g/dL, LDH 503 U/L, BUN 11.8 mg/dL, creatinine 1.0 mg/dL, PT 29.7 second, INR 2.95.\nChest CT angiography and cardiac MRI revealed a 5x5cm sized round aneurysmal sac between the left atrium and left ventricle adjacent to the proximal pulmonary artery, but no definite stalk from the origin could be found (). A doppler echocardiography demonstrated holosystolic ejection flow from the surface of the left ventricle (). Despite the fact that the origin of aneurysmal stalk could not be identified, the pressure gradient calculated by the color doppler flow from the aneurysmal stalk to lumen was about 9 mmHg. The dilated vascular sac appeared to be a pseudo aneurysm with a coronary artery origin. A Tc99m sestamibi scan was performed to investigate the possibility of myocardial ischemia. The scan revealed a reversible perfusion defect on the antero-septal wall (). Subsequent coronary angiography allowed us to confirm the diagnosis of a pseudo aneurysm from the mid-left anterior descending artery (LAD), which interrupted distal flow by creating indentations and diffuse stenotic lesions along the whole length of the right coronary artery (RCA). In addition, a well developed collateral circulation was observed from the LAD and the left circumflex artery (LCX). An emergency operation was planned for aneurysmal resection and coronary artery bypass grafting (CABG). However, because of the size and thus the risk of rupture, we opted instead for balloon angioplasty with a U-pass and graft stent. Implantation proceeded using a Graftmaster 3.0×19 mm at the mid LAD the origin of pseudo aneurysm (). Because of the compromised distal flow of the RCA, the LAD would be of no advantage to the outcome of the CABG. If packed completely, it was expected that the aneurysmal sac would not grow any more and would regress by resorption and fibrosis. The administration of high dose glucocorticoid therapy (prednisolone 1 mg/kg/day) with azathioprine (150 mg/day) in addition to the mechanical intervention were both highly effective management as demonstrated by a follow-up TTE and coronary angiography which showed no further diversion of flow from the LAD and regression of the aneurysmal size to 3.9×3.8 cm from 5×5 cm Initially. and a preserved heart function (LVEF 60%) (). Six months after discharge, the patient was asymptomatic and only a vestige of the aneurysm was evident by routine chest X-ray (). | [[37.0, 'year']] | F | {'22530146': 1, '22279486': 2, '9620153': 1, '15019683': 1, '19430524': 2, '1970380': 1, '10528040': 1, '11205670': 1, '11812405': 1, '32550966': 1, '12558133': 1, '19830382': 1, '22761229': 1, '12183866': 1, '11063293': 1, '15043021': 1, '33708172': 2, '25984424': 1, '2257701': 1, '15604898': 1, '12746932': 1, '33603502': 1, '8151529': 1, '9069461': 1, '11914141': 1, '30546727': 1, '16646566': 2} | {'3263087-1': 1, '2627529-1': 1, '7940375-1': 1} |
165,283 | 3891066-1 | 16,646,567 | noncomm/PMC003xxxxxx/PMC3891066.xml | Peripheral T-cell Lymphoma-Unspecified (PTCL-U) Presenting with Hypereosinophilic Syndrome and Pleural Effusions | A 43-year-old woman was hospitalized in January 2004, with a 2-month history of a fever, a dry cough and a sore throat, which were refractory to antibiotic therapy. She had received supportive care for eosinophilia in another hospital. A physical examination demonstrated a 1×1 cm non-tender cervical lymph node, hepatosplenomegaly 3 cm below the costal border, peritonsillar exudates and pretibial pitting edema. Diffuse crackles were auscultated in the left lower lung field, and no heart murmur was detected. The peripheral blood counts were: hemoglobin, 11.3 mg/dL; platelets, 182,000/mm3; and white blood cells, 20,730/mm3 (neutrophils 46%, lymphocytes 13%, monocytes 3%, eosinophils 36%, basophils 1%, and plasma cell 10%). The absolute eosinophil count was 7,462/mm3. LDH was 1,529 IU/L, serum IgE 9.5 IU/mL and b2-microglobulin 2.70 mg/L. The sputum culture, blood culture, throat swab culture and pleural fluid culture provided negative results. Hepatitis B, hepatitis C, VDRL, and HIV diagnostic tests were negative. The EBV VCR IgG antibody was positive; while the IgA and IgM antibody tests were negative. Multiple examinations of stool specimens for ova and parasites were negative.\nClonorchis sinensis, paragonimus westermani skin test and cysticercus, paragonimus, sparganum, clonorchis, and toxocara specific IgG antibody tests gave negative result.\nAn electrocardiogram and an echocardiogram were normal. The CD3/CD4 lymphocyte percentage was 66.1%, and the CD3/CD8 lymphocyte percentage was 14.6%. The total CD3/CD4:CD3/CD8 (Helper:Suppressor) ratio was 4.53, which was increased compared to the normal reference range of 0.9-3.6.\nA chest X-ray revealed mild pulmonary congestion and a left pleural effusion (). Computed tomography of the chest and abdomen demonstrated diffuse hepatosplenomegaly, bilateral pleural effusions, and left paraaortic, subcarinal, and paratracheal lymphadenopathy (). Bone marrow aspiration and biopsy revealed a markedly increased number of eosinophils (24.8%), and a significant number of plasma cells and lymphocytes (). The patient's cytogenetic analysis demonstrated a normal karyotype, 46 XX. Despite treatment with empirical antibiotics, the fever and the sore throat persisted.\nPleural cytology demonstrated lymphocyte dominant exudates with a few atypical cells. These atypical lymphocytes were suspected to be malignant lymphoma cells, based on the results of immunocytochemistry (CD3, positive; CD20, negative; Ki-67, positive) (). A liver biopsy demonstrated a few atypical lymphoid cells and eosinophils in the sinusoids and the portal space, based on the results of immunocytochemistry (CD3, positive; CD20, negative; Ki-67, positive) ().\nBased on the results of the liver biopsy, the pleural cytology, and the bone marrow biopsy, a diagnosis was made of peripheral T-cell lymphoma with hypereosinophilic syndrome. The patient was treated with two courses of CHOP chemotherapy (cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 1.4 mg/m2, and prednisolone 100 mg). During chemotherapy, the fever and the eosinophilia improved.\nHowever, the CT of the abdomen, performed on March 25, 2004, demonstrated that the hepatosplenomagaly and the lymphadenopathy, were unchanged. Peripheral blood counts were: hemoglobin, 9.4 mg/dL; platelets, 253,000/mm3; and white blood cells, 7,240/mm3 (neutrophils 41%, lymphocytes 20%, monocytes 10%, eosinophils 29%, basophils 1%, and plasma cell 2%). In addition, a high-grade fever persisted.\nThe chemotherapy regimen was then changed to IMVP-16 (ifosfamide 1,000 mg/m2, mesna 200 mg/m2, methotrexate 50 mg/m2, and ectoposide 100 mg/m2) plus prednisolone 100mg. After two courses of this chemotherapy, the eosinophilia, the fever and the pleural effusions improved. After the sixth course of chemotherapy, the CT of the abdomen, performed on July 29, 2004, demonstrated that the hepatosplenomagaly and lymphadenopathy had decreased by more than 50 percent (). After the eighth course of chemotherapy, 18F-fluorrodeoxyglucose positron emission tomography (FDG-PET), performed on September 15, 2004, demonstrated no hypermetabolic lesions.\nTwo months later, follow-up peripheral blood counts were: hemoglobin, 12.4 mg/dL; platelets, 165,000/mm3; and white blood cells, 8,870/mm3 (neutrophils 38%, lymphocytes 8%, monocytes 5%, eosinophils 49%, basophils 0.6%, and plasma cell 1.7%). However, a CT of the abdomen, performed on October 24, 2004, demonstrated that the lymphadenopathy had increased in both size and extent (). This was considered a relapse of the disease.\nAlthough the patient was subsequently treated with ESHAP chemotherapy (ectoposide 40 mg/m2, methylprednisolone 500 mg, cisplatin 25 mg/m2, and cytarabine 2000 mg/m2), her condition deteriorated. After completion of a course of this chemotherapy, 18F-fluorrodeoxyglucose positron emission tomography (FDG-PET), performed on November 24, 2004, demonstrated multiple metabolic lesions in the abdominal lymph nodes, the heart, the axillae, the mediastinal lymph nodes, and both lungs. High dose chemotherapy was then recommended, but the patient refused. Supportive care was provided for the continued eosinophilia, the uncontrolled fever, and the sore throat. Two months after the disease become refractory to treatment, the patient died of a cardiac tamponade. | [[43.0, 'year']] | F | {'21139921': 1, '6345623': 1, '11785603': 1, '5653621': 1, '20111739': 2, '3262407': 1, '11882909': 1, '1090795': 1, '1991253': 1, '12950242': 1, '28885361': 2, '7046556': 1, '16646567': 2} | {'6392760-1': 1, '2810472-1': 1} |
165,284 | 3891067-1 | 16,646,568 | noncomm/PMC003xxxxxx/PMC3891067.xml | A Case of Gastric Tuberculosis Mimicking Advanced Gastric Cancer | A 36-year-old male presented to the emergency room after 2 days of hematemesis and melena at volumes of approximately 300 cc. He had experienced epigastric pain and nausea for the last several days, but no other symptoms, including weight loss, were evident.\nThe patient had no past or family history of tuberculosis. He was a 16 pack-per-year-smoker, but was not a heavy drinker. He had lived in Seoul, where he was employed as an electrician. His physical examination proved unremarkable, revealing no lymphadenopathy and normal pulmonary findings. The abdomen of the patient was soft and was not tender, and a digital rectal examination revealed no blood. He had a normal body temperature, and exhibited stable vital signs. Laboratory data recorded a hemoglobin level of 10.6 g/dL, a white blood cell count of 9,400/mm3, platelet count of 185,000/mm3, an erythrocyte sedimentation rate of 2 mm/hr, and C-reactive protein < 0.8 mg/dL. Liver and renal function tests revealed normal findings. Tests for the viral markers of hepatitis and HIV were both negative.\nThe chest X-ray revealed no pathologic findings (). Gastroscopic findings on admission revealed a large, ulceroinfiltrative mass with irregular margins on the posterior wall of the high body (). Blood clots and exposed vessels as recently bleeding stigmata were observed. Additionally, converging and disrupted thickened folds were observed on the surrounding mucosa. Secondary gastroscopy after two days showed more prominent abnormalities of the marginal folds as cut, bitten, and converging shapes, although the clots and vessels had disappeared (). The bases of the irregular ulcers were uneven. These findings strongly suggested gastric malignancy. Consequently, biopsies were obtained from the described areas. A CT scan of the abdomen was conducted in order to rule out other malignant metastatic lesions. The CT scan revealed a thickening of the gastric upper body () with enlargement of the perigastric () and paraaortic lymph nodes (). The CT scan also revealed a mass lesion at the cecum and the ascending colon with pericolic fat infiltration and regional lymphadenopathies (). Colonoscopic examination revealed an ulceroinfiltrative lesion encircling the lumen of the ascending colon, through which the scope was unable to pass (). Endoscopic biopsies from the stomach and colon revealed noncaseating granulomas with no malignant cells, and detected no acid-fast bacilli (). However, the PCR tests for the detection of Mycobacterium tuberculosis from gastric and colonic biopsy specimens were positive. No culture tests were performed.\nAs the patient exhibited no more bleeding, he was treated conservatively, with antituberculous medications of isoniazide 400 mg, rifampicin 600 mg, ethambutol 800 mg, and pyrizinamide 1.5 g daily, beginning nine days after admission. On the follow-up endoscopic examinations, two and eight months after the start of this treatment, marked improvements were observed in the ulcerations with distortion of the mucosal folds at the high body of the stomach () and in the ascending colon (), respectively. On the CT scan performed after eight months of treatment, the previous lymphadenopathies were improved, and no more wall thickness was seen in the gastric and colonic areas. The patient is currently doing well, and antituberculosis treatment is being maintained with no side effects. | [[36.0, 'year']] | M | {'11832556': 1, '14562420': 1, '12082338': 1, '10197496': 1, '12717865': 1, '10452689': 1, '12703983': 1, '10531727': 1, '8317433': 1, '32293275': 2, '12353853': 1, '32000710': 2, '1568653': 1, '9248187': 1, '11059734': 1, '16646568': 2} | {'6990527-1': 1, '6990527-2': 1, '6990527-3': 1, '7158059-1': 1} |
165,285 | 3891068-1 | 16,646,569 | noncomm/PMC003xxxxxx/PMC3891068.xml | Delayed Puberty due to Pituitary Stalk Dysgenesis and Ectopic Neurohypophysis | A 22-year old man was referred to our clinic because of the absence of the development of secondary sexual characteristics. The past medical history was unremarkable there were no significant pregnancy or perinatal problems. The family history was negative for growth failure, pituitary or thyroid disease. During childhood, the patient reported that he had always been short for his age. However, after a delayed growth spurt, he began to grow steadily at 20 years of age. At the time of admission, he was 183 cm. He weighed 75 kg and his body mass index (BMI) was 22.4 kg/m2. He had normal intelligence and normal body proportions. His bone age was 15 years, which was slightly below expected. X-ray evaluation of both hands showed open epiphysis (). Physical examination revealed a micropenis, no pubic or axillary hair and palpable though small testes (). These findings were compatible with a Tanner stage I development. The patient had a high pitched voice and appeared young for his stated age. The patient denied physical discomfort, had no signs of gynecomastia, no signs of orthostatic hypotension, nor any symptoms that could be associated with hypothyroidism.\nThe laboratory findings showed normal erythrocyte sediment rate, hematological parameters, blood glucose, serum sodium, potassium, calcium, phosphate, magnesium, and creatinine. Random testosterone (0.08 ng/mL, reference range 2.4~18.3 ng/mL) and luteinizing hormone (LH) (below 0.1 mLU/mL, reference range 0.4~5.7 mLU/mL) levels were all low; the follicle stimulating hormone (FSH) levels were within normal limits. The karyotype was normal, 46,XY. As a result of the random sexual hormone levels and karyotyping analysis, we could classify the delayed puberty as hypogonadotropic hypogonadism. Therefore, we performed a combined pituitary function stimulation test and pituitary MRI for further assessment. We injected regular insulin (0.1 u/Kg), TRH (200 ug), and LHRH (100 ug) and observed that 2 hours later the blood sugar fell to 60 with patient complaint of hypoglycemic symptoms. The combined pituitary function stimulation test showed no increase in serum LH, FSH, growth hormone (GH), adrenocorticotropin hormone (ACTH) level, and the serum levels of prolactin and thyroid stimulating hormone (TSH) showed a normal increment (). The MRI showed decreased pituitary stalk enhancement and an enhancing structure in the hypothalamic area, which appeared to be ectopic neurohypophysis ().\nTherefore, considering the results of the above evaluation, the delayed puberty, in this 22 year old man, was the result of hypopituitarism due to pituitary stalk dysgenesis and ectopic neurohypophysis.\nThe patient was started on hormone replacement therapy with prednisolone 5 mg/day, levothyroxine 0.1 mg/day and testosterone 250 mg IM every 3 weeks. After 3 months of treatment, secondary sexual characteristics began to develop; pubic and axillary hair was noted and the voice changed to a lower pitch. The serum testosterone level, previously 0.08 ng/mL, increased to 0.57 ng/mL. | [[22.0, 'year']] | M | {'9432184': 1, '10592450': 1, '3659371': 1, '12466332': 1, '11932291': 1, '31468085': 1, '2723165': 1, '9329385': 1, '8043090': 1, '10404812': 1, '7359232': 1, '1806462': 1, '11136712': 1, '11567216': 1, '12414875': 1, '9805128': 1, '9365063': 1, '8950615': 1, '3138279': 1, '16646569': 2} | {} |
165,286 | 3891069-1 | 16,646,570 | noncomm/PMC003xxxxxx/PMC3891069.xml | A Patient with Primary Squamous Cell Carcinoma of the Thyroid Intermingled with Follicular Thyroid Carcinoma that Remains Alive more than 8 Years after Diagnosis | A 56-year-old man presented with a hoarse voice and a rapidly progressive mass on the right side of his thyroid gland that had developed over the previous three months. He had no clinical symptoms related to thyroid dysfunction. There was no history of radiation exposure to the neck and no family history of thyroid cancer. Five years earlier, he had been diagnosed with a carcinoid tumor in the left lobe of the lung by percutaneous biopsy at another hospital; the patient has been asymptomatic throughout the prior five-year period.\nA physical examination revealed a hard, non-tender mass with a maximum transverse diameter of 3 cm on the right side of the thyroid gland. Palpable lymphadenopathy was absent in the cervical and supraclavicular area, and a laryngoscopic examination showed no abnormal findings from the oral cavity to the larynx. Laboratory examination showed a serum TSH level of 3.22 mU/L (reference range 0.30~5.00), T3 1.66 nmol/L (0.92~2.78), T4 78 nmol/L (58~140), anti-thyroglobulin antibody 1 U/mL (0~100), anti-microsomal antibody 1 U/mL (0~100), and thyroglobulin 170.1 ng/mL (0~25). There were no abnormal findings on the hematologic and biochemical laboratory tests. Neck computed tomography (CT) showed a low attenuated, calcified mass with a maximum diameter of 3 cm on the right side of the thyroid gland (). An ultrasonography-guided fine needle aspiration and cytology (FNAC) showed a small number of benign follicular cells without atypical cells. Chest X-ray and CT showed a 1 cm sized nodule in the upper lingular segment of the left lung; this nodule was previously diagnosed as a carcinoid, and was noted to have decreased in size. However, three small nodules were newly detected in the left lower lobe of the lung by comparison with prior films (). The new nodules noted in the left lower lobe of the lung were diagnosed as follicular neoplasm by FNAC.\nThe patient underwent a total thyroidectomy without neck lymph node dissection for the presumed diagnosis of follicular thyroid carcinoma with lung metastasis. However, the histopathologic evaluation revealed a well-differentiated squamous cell carcinoma 3 cm by 3 cm in size in conjunction with follicular carcinoma (). Intermingled and transitional zones of squamous cell carcinoma and follicular carcinoma were present. The tumor was confined to the thyroid gland with internal necrosis and dystrophic calcification. Immunohistochemical staining for cytokeratin 19 was strongly positive for squamous cell carcinoma and negative for follicular carcinoma (). Immunohistochemical staining for thyroglobulin and thyroid transcription factor-1 (TTF-1); was positive for follicular carcinoma and negative for squamous cell carcinoma ().\nTwo weeks after surgery, a 18F-FDG whole body positron emission tomography (PET) was performed and abnormal uptake was identified in a right submandibular lymph node, bilateral jugulodigastric lymph nodes, T7 spine, and lingular segment of the left upper lung; these findings favored the presence of a malignancy. Magnetic resonance imaging (MRI) also demonstrated a Bull's eye lesion with slight enhancement at the T7 vertebral body, suggesting metastasis (). Metastatic squamous cell carcinoma was excluded by laryngoscopy, esophagogastroscopy, abdominal ultrasonography, neck and chest CT, and whole body PET. The patient underwent 5000 rads of adjuvant radiotherapy to the neck postoperatively. Considering the poor prognosis for patients with primary squamous cell carcinoma of the thyroid, we did not pursue a further work-up or aggressive treatment. The patient was treated with TSH suppressive therapy with 200 µg of L-thyroxine only.\nThree years later, lower extremity paraplegia suddenly developed after the patient had a fall. The thoracic spine MRI demonstrated a metastatic lesion with a compression fracture and an epidural mass formation at the T7 spine, and other newly appeared metastatic lesions on T1, T4, T5, T6 and T8 (). These lesions were treated with external radiotherapy. The patient seemed to have almost completely recovered from paraplegia after radiotherapy. At that time, a chest X-ray showed that the pre-existing nodules noted in the left lower lobe of the lung had increased in size, and that multiple nodules were newly present in the right upper lobe of the lung. Serum thyroglobulin levels were increased to 423.2 ng/mL on T4 suppression therapy.\nSeven years later, colon cancer was detected. A preoperative chest CT showed multiple new nodules in the left lower lobe of the lung. Percutaneous biopsy directed to a new nodule in the left lower lobe of the lung was undertaken, and histopathologic findings revealed metastatic follicular carcinoma originating from the thyroid. High dose radioactive iodine therapy was administered after the patient underwent colectomy for colon cancer. At that time, the serum thyroglobulin level was 530.7 ng/mL and the anti-thyroglobulin antibody titer was 1 U/mL on the T4 suppression therapy. The patient now remains alive in satisfactory condition more than eight years after being diagnosed with primary squamous cell carcinoma of the thyroid. Recently, his serum thyroglobulin level had increased to 1164 ng/mL on T4 suppression therapy. | [[56.0, 'year']] | M | {'13304848': 1, '10556008': 1, '3978516': 1, '14874967': 1, '9099982': 1, '5698652': 1, '6469655': 1, '3899366': 1, '21203862': 1, '7427886': 1, '11532039': 1, '13820008': 1, '14209716': 1, '3984364': 1, '12988185': 1, '3045277': 1, '3125674': 1, '3394892': 1, '22452749': 2, '12357501': 1, '8062273': 1, '7822183': 1, '7057643': 1, '25588631': 2, '2910191': 1, '655339': 1, '14149689': 1, '338999': 1, '8774670': 1, '5099785': 1, '11014583': 1, '16646570': 2} | {'3331844-1': 1, '4284486-1': 1} |
165,287 | 3891070-1 | 16,646,571 | noncomm/PMC003xxxxxx/PMC3891070.xml | Hemobilia from Ruptured Hepatic Artery Aneurysm in Polyarteritis Nodosa | A 39-year-old man was admitted with severe right upper quadrant abdominal pain. The history was significant for partial small bowel resection for intestinal infarction about 5 years prior to this presentation. The patient was otherwise stable without any further investigations or management, and had been asymptomatic until the current episode.\nOn admission, his vital signs were as follows: blood pressure 160/100 mmHg, pulse rate 72/min, respiratory rate 18/min, temperature 36.3℃. He had minimal conjunctival injection and icteric sclerae. Abdominal examination revealed normal bowel sounds with no palpable abdominal mass or organomegaly. There was tenderness to palpation over the right upper quadrant and epigastrium. He did not have any rebound tenderness and Murphy's sign was negative. Laboratory studies showed WBC 5700/mm3, Hb 12.3 g/dL, hematocrit 35.0%, and platelets 183,000/mm3. Liver function tests revealed a total bilirubin of 5.2 mg/dL, AST 175 IU/L, ALT 185 IU/L, alkaline phosphatase 899 IU/L, and GTP 615 IU/L. Abdominal CT demonstrated multiple high attenuation areas in the biliary duct and gallbladder (). Endoscopic retrograde cholangiopancreatography (ERCP) showed a mild but active blood leak and adherent clots at the ampulla of Vater (). Cholangiography revealed multiple tubular filling defects in the common bile duct as well as the intrahepatic ducts (). Endoscopic sphincterotomy and nasobiliary drainage were performed. During the procedure, hemobilia spontaneously stopped. He reported an improvement in his abdominal pain after the procedure. However, the following day, the patient developed a massive hematemesis and hematochezia, with a drop in his blood pressure to 70/50 mmHg and Hb to 7.5 g/dL. Emergency selective hepatic angiogram demonstrated multiple microaneurysms in the branches of the hepatic arteries () and a slow leak of the contrast medium into the bile duct from the arteriobiliary fistula (). This fistulous tract was blocked with coil and gelfoam (). Following this procedure, his blood pressure stabilized rapidly. There was no evidence of rebleeding. Superior mesenteric, inferior mesenteric and renal artery angiography revealed multiple stenoses, smooth occlusions and microaneurysmal changes in small- to mid-sized vessels. Antinuclear antibody, antineutrophil cytoplasmic antibodies, rheumatoid factor, antiphospholipid antibody and lupus anticoagulant were all negative. A clinical diagnosis of polyarteritis nodosa was made and he was managed with prednisolone 25 mg per day, which was tapered to 5 mg per day, in combination with cyclophosphamide 50 mg per day. He is entirely asymptomatic at six month follow up. | [[39.0, 'year']] | M | {'15176541': 1, '8307643': 1, '6852441': 1, '9754107': 1, '1677243': 1, '7913144': 1, '445252': 1, '6402924': 1, '9366584': 1, '7025304': 1, '322339': 1, '8079933': 1, '11904113': 1, '9265674': 1, '16646571': 2} | {} |
165,288 | 3891071-1 | 16,646,572 | noncomm/PMC003xxxxxx/PMC3891071.xml | A Case of Pulmonary Cryptococcosis by Capsule-deficient Cryptococcus neoformans | A 25-year-old woman was admitted to our hospital with nonresolving pneumonia. The patient had felt well until two weeks before her admission, when she began to experience a dry cough, dyspnea and pleuritic pain. Her respiratory symptoms did not respond to a 5-day course of oral cephalosporin, and macrolide antibiotics had been prescribed before her admission. She was a non-smoker with unremarkable past medical history.\nOn admission the body temperature was 36.6℃, the heart rate was 84/min, the respiration rate was 20/minute and the blood pressure was 100/80 mmHg. On physical examination, the patient was alert and not in great discomfort. There was a crackle sound over the left lower lung zone. There was no organomegaly or lymphadenopathy. Detailed examination of the cardiovascular system and abdomen was unremarkable. Chest radiography disclosed a pneumonic infiltration on the left lower lung field and there was no cardiomegaly (). Computed tomography (CT) scanning of the chest revealed a consolidation with air-bronchogram in the left lower lobe and a small amount of pleural effusion (). The complete blood count showed a normal white cell count (8.4×109/L). There was no hypoxemia on the blood gas analysis (pH 7.4, PaCO2 37.2 mmHg, SaO2 98%) when she was breathing room air. The other laboratory investigations showed normal electrolytes and renal and liver function tests. The fasting glucose was normal. The serum anti-HIV antibody was negative. The serum immunoglobulin levels (including IgG, IgA and IgM) were normal. Pulmonary function testing showed a mild restrictive pattern (the forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) was 2.50/2.32L; the ratio was 93%), and there was a normal diffusion coefficient for carbon monoxide (DLco: 109%). The initial examination of the sputum for acid-fast bacilli with gram staining and culture did not reveal any organisms. The blood culture was sterile after 7 days incubation. We then conducted a bronchoscopic examination. There were no endobronchial abnormalities. Bronchoalveolar lavage (BAL) revealed the lymphodominant nature (a lymphocyte count of 70%, the macrophages were 28%). The BAL fluid culture was negative and there were neither acid-fast bacilli nor any pathogens.\nDuring the first six days of this patient's admission to our hospital, her annoying respiratory symptoms and lung consolidation did not improved for all the combination antibiotic treatment (intravenous cefuroxime and oral clarithromycin). We performed a subsequent computed tomography guided percutaneous needle biopsy on the sixth hospital day. The tissue pathology revealed granulomatous lesion including multinucleated giant cells and fungal spores. The specimens were stained with Hematoxilin-Eosin, mucicarmine, Gomori-Methenamine silver (GMS), and periodic-acid-Schiff (PAS). The Hematoxilin-Eosin and GMS stain showed granulomatous inflammation with numerous yeast-like organisms that were surrounded by clear halos, and these organisms were present within multinucleated giant cells and in the intercellular spaces (). Mucicarmine staining for capsular material was negative. With performing additional Fontana-Masson silver staining (FMS), the black color in the walls of the organism was disclosed (). This special stain pattern is a characteristic of C. neoformans, and especially for the capsule deficient form. Subsequently, the antibiotic regimen was replaced by 1-week of once-a-day intravenous fluconazole treatment and the patient was discharged on oral fluconazole. Further cultures of the lung specimen yielded moderate growth of Cryptococcus neoformans afterward. During the 6-months follow up period her respiratory symptoms and abnormal radiologic feature were markedly improved (). | [[25.0, 'year']] | F | {'4594090': 1, '6162857': 1, '11115750': 1, '1096863': 1, '24765421': 1, '27525140': 2, '157594': 1, '7235394': 1, '1775849': 1, '7076234': 1, '11552084': 1, '3541845': 1, '10084485': 1, '10770733': 1, '3867000': 1, '11981875': 1, '16646572': 2} | {'4971305-1': 1} |
165,289 | 3891079-1 | 16,491,831 | noncomm/PMC003xxxxxx/PMC3891079.xml | A Case of Septic Shock and Disseminated Intravascular Coagulation Complicated by Acute Myocardial Infarction Following Amniocentesis | A 40-year-old female patient presented to us with dyspnea, fever, chills and hematuria. She was at the 17th week of gestation and amniocentesis had been done 2 days previously for the prenatal evaluation of fetal anomalies at a private clinic. After amniocentesis, she complained of fever, chills, progressive dyspnea, hematuria and abdominal pain. Her systolic blood pressure was less than 80 mmHg. Ultrasonographic examination demonstrated that the fetus had died. Intravenous antibiotics were started and a therapeutic abortion was performed. After this, the patient was transferred to our hospital for the management of her septic complications.\nOn admission, her blood pressure was 80/50 mmHg, the pulse rate was 105/min, the body temperature was 38.6℃ and the respiration rate was 30/min. Chest auscultation revealed basal rales in both lower lung fields. Vaginal spotting and oliguria were observed.\nThe complete blood cell count showed leukocytosis (white blood cell count: 28,300/mm3) and thrombocytopenia (platelet count: 13,000/mm3). The blood chemistry revealed elevated liver enzymes (aspartate aminotransferase: 645 IU/L, alanine aminotransferase: 170 IU/L), azotemia (blood urea nitrogen: 41.7 mg/dL, creatinine: 3.1 mg/dL) and an increased level of inflammatory markers (C-reactive protein 10.1: mg/dL, erythrocyte sedimentation rate: 67 mm/hour). The coagulation profiles showed a prolongation of the prothrombin time (international normalized ratio: 2.63) and the activated partial thrombin time (87 seconds), a low level of fibrinogen level (83 mg/mL), a decreased level of anti-thrombin III (2.81 mg/dL) and increased levels of fibrin degradation products (105.2 µg/mL) and d-dimer (9.65 mg/L). Escherichia coli was isolated from the culture of the amniotic fluid and blood. Therefore, we concluded that the patient had septic shock and disseminated intravascular coagulation (DIC) following her intrauterine infection, and this was possibly complicated by the amniocentesis.\nIntravenous antibiotics, diuretics and inotropic agents, including dopamine and norepinephrine, were infused continuously. Four units of fresh frozen plasma and 12 units of platelet concentrates per day were infused. Five thousands units of anti-thrombin III per 6 hours were also administered.\nSeveral hours later after the admission, she complained of continuous substernal and epigastric pain that was associated with cold sweating. Electrocardiography (ECG) showed sinus tachycardia with non-specific ST segment changes (), and the cardiac enzymes were markedly elevated (creatinine kinase: 326 U/L, MB fraction of creatine kinase: 256 U/L, cardiac specific troponin T: 2.17 ng/mL, cardiac specific troponin I: 9.19 ng/mL, myoglobin: 190.2 ng/mL). Trans-thoracic echocardiography (TTE) showed the dilated left ventricle (LV) with a chamber size of 60 mm for the end-diastolic dimension; akinesia of the anterior and, septal wall motion and LV systolic dysfunction (ejection fraction: 38%) were also observed (). We could not perform immediate coronary angiography (CAG) due to the oliguria and renal dysfunction, and the patient was treated conservatively for AMI.\nAfter treatment, the patient's vital signs were stabilized and the subjective symptoms of the patient were improved. However, the thrombocytopenia was not improved for several days despite the replacement of the platelet concentrates, and the renal function progressively deteriorated despite the normalized urine output. On the fourth hospital day, myocardial single photon emission computed tomography (M-SPECT) was performed and the M-SPECT revealed a large, partly reversible perfusion defect in the anterior wall on stress, and the resting image suggesting anterior wall myocardial infarction ().\nThe coagulation profiles and thrombocytopenia were normalized on the eighth hospital day. Follow-up TTE was done on the eighth hospital day, and it revealed normalized LV wall motion (). The blood urea nitrogen (BUN) and creatinine reached their peak levels on the ninth hospital day (blood urea nitrogen: 110.9 mg/dL, creatinine: 8.0 mg/dL) and then they progressively declined. On the thirteenth hospital day, the patient was discharged.\nDuring clinical follow-up at the outpatient clinic, the renal function was normalized at 3 weeks after discharge. The patient was readmitted for diagnostic CAG. The CAG revealed no significant stenosis in both the coronary arteries (). Follow-up M-SPECT revealed markedly improved perfusion in the territory of the left anterior descending coronary artery with the remaining perfusion defect (). | [[40.0, 'year']] | F | {'7578749': 1, '15178899': 1, '804570': 1, '11310393': 1, '30143672': 1, '7339111': 1, '12428695': 1, '11680986': 1, '2653639': 1, '12224071': 1, '15000346': 1, '14764970': 1, '9585703': 1, '15290165': 1, '14502252': 1, '12901123': 1, '16491831': 2} | {} |
165,290 | 3891080-1 | 16,491,832 | noncomm/PMC003xxxxxx/PMC3891080.xml | Non-Hodgkin's Lymphoma Manifest as Gingival Hyperplasia in a Renal Transplant Recipient | A male, 41 years old, visited the clinic in April 2002 after experiencing bleeding, pus discharge, edema, and pain of the gingivae over the previous three months (). He had previously been diagnosed with end stage renal failure because of IgA nephropathy. Additionally, continuous ambulatory peritoneal dialysis was initiated in January 1994. He underwent a kidney transplantation with 40 minutes of cold ischemia in November 1995. His brother, who had haploid-identical HLA typing, was the donor. The patient was maintained on medication consisting of 75 mg of cyclosporine twice daily, 12 mg of deflazacort once daily, and 750 mg of mycophenolate mofetile (MMF) administered twice daily. His post-operative progress was good until he developed gingival bleeding, discharged pus, and pain.\nThree months before entering our clinic, he was admitted to the outpatient dental clinic for treatment of hyperplastic gingivae (which at that time was considered to have been induced by cyclosporine). The lesion, however, did not improve despite scaling, oral antibiotics, and a reduction in the cyclosporine doses. Moreover, the gingival hyperplasia exhibited focal papillary growth and bled in response to light pressure. He had also lost 5 kg of body mass over the preceding six months.\nA laboratory examination, including complete blood counts, blood chemistry, and urinary analysis, revealed that his hemoglobin concentration was 11.1 g/dL, blood urea nitrogen concentration was 27.5 mg/dL, and creatinine concentration was 1.46 mg/dL. The white cell count was 6370/µL while the platelet count was 256,000/µL. Other variables remained normal. Serum cyclosporine levels were low ().\nWe did a biopsy of the lesion to identify other potential causes. The biopsy established the presence of leukemic cell infiltration including a malignant lymphoma or histiocytic tumor (). Muramidase and immunohistochemical stains specific for LCA (), L26 (), UCHL1, and CD68 revealed a large diffuse B cell type of malignant lymphoma. The latent membrane protein for the Epstein-Barr virus (EBV-LMP) immunohistochemical stain was positive ().\nIn the initial stage of the lymphoma, computed tomography (CT) scan of the neck indicated a 2×1.5 cm enlarged lymph node present in the right submandibular area several enlarged lymph nodes were also in the bilateral parapharyngeal space. Lung and intestinal CTs showed no evidence of lymphadenopathy. A bone marrow aspiration and biopsy revealed a slight hypocellularity (30%) and normal maturation. The final stage of the lymphoma was stage II (B) according to the Ann Arbor Staging System.\nAdministration of MMF and cyclosporine was stopped, but prednisolone treatment was continued. The patient started chemotherapy with a CHOP regimen of 1087 mg of cyclophosphamide (750 mg/m2), 72 mg of doxorubicin (50 mg/m2), 2 mg of vincristine, and 100 mg of prednisolone. After three serial CHOP chemotherapies, a neck CT showed a marked regression of the right submandibular lesion but no clearly enlarged lymphadenopathy in the other neck areas. CHOP therapy and external radiotherapy of the gingivae was performed a total of six times.\nIn 2004, the patient's gingivae were normal upon examination, and CT scans could not detect lymphadenopathy. Presently, his renal function is good and is treated by daily doses of 100 mg azathioprine and 7.5 mg prednisolone. | [[41.0, 'year']] | M | {'6578477': 1, '7500247': 1, '11112039': 1, '10708105': 1, '7839414': 1, '11271240': 1, '11027379': 1, '8083830': 1, '7707124': 1, '11578286': 1, '3499589': 1, '2051050': 1, '9580648': 1, '12390426': 1, '8841894': 1, '10783833': 1, '9341901': 1, '9462239': 1, '9723412': 1, '9793938': 1, '11993065': 1, '8827296': 1, '15191596': 1, '14508366': 1, '9674863': 1, '10342310': 1, '10995990': 1, '16491832': 2} | {} |
165,291 | 3891081-1 | 16,491,833 | noncomm/PMC003xxxxxx/PMC3891081.xml | Management of a Pregnant Patient with Graves' Disease Complicated by Propylthiouracil induced Agranulocytosis | A 28-year-old woman in her 24th week of pregnancy visited our hospital experiencing febrile sensation and palpitation. The woman was diagnosed with hyperthyroidism 10 years earlier and had taken thionamide periodically. She had not taken any medication recently because she did not display any signs or symptoms of hyperthyroidism. At the 20th week of gestation, she had a relapse of hyperthyroidism and resumed taking the thionamide (propylthiouracil 300 mg) that she had received at a local clinic. At that time, her blood count was within the normal range.\nAt her initial visit to the hospital, her blood pressure was 110/70 mmHg, pulse rate 110/min,respiratory rate 23/min and body temperature 39℃. Her height and body weight were 163 cm and 55 kg. On physical examination, the patient was alert, her heart rhythm was regular and there was no sign of a murmur. She had a diffuse goiter and mild ophthalmopathy, and there was no evidence of any upper respiratory tract infection.\nHer full blood count showed total WBCs at 1,600/mm3 with neutrophils 213/mm3 and lymphocytes 963/mm3, platelets 233×103/mm3 and hemoglobin 9.1 g/dL. Level of free T4 was 5.7 ng/mL (0.7~1.9), total T3 was 6.51 ng/mL (0.6~1.7), and TSH was<0.005 mU/mL (0~4.7). TBII (TSH-binding inhibitory immunoglobulin) was 61% (< 14.9%). AST/ALT were 49/47 IU/L and BUN/Creatinine were 12/1.0 mg/dL. An EKG showed sinus tachycardia and chest X-rays were normal. A fetal ultrasound examination revealed a normal sized fetus for the gestation period. The fetal heart rate was 160 beats/min and a non-stress test showed a reactive response.\nFollowing the discontinuation of propylthiouracil, we began intravenous antibiotics (cephalosporin) and hydration (5% sodium dextrose fluid). Due to the possibility of teratogenecity, we excluded the use of G-CSF (granulocyte-colony stimulating factor). The patient's neutrophil count recovered to normal range with supportive care and her fever resolved after 10 days, yet her symptoms of hyperthyroidism were aggravated. At this point it was difficult to choose the optimal treatment method which would save both the mother and fetus. After considering all treatment options, it was decided that a total thyroidectomy rather than a subtotal thyroidectomy was the better option in this case, in order to prevent any future relapse. We also prescribed a beta-adrenergic blocker (propranolol 80 mg/day) and a Lugol solution (5% Lugol solution 1.2 mL/day) because a thyroidectomy without preoperative management was viewed to be too risky due to the high risk of thyrotoxic crisis. The treatment consisting of the beta-adrenergic blocker and the Lugol solution led to a rapid decline ofserum free T4 and total T3 concentration back to their normal ranges within 2 week (). At 28 weeks of gestation, the patient underwent a total thyroidectomy without complications. Thyroxine replacement began on the first day following the operation and the patient's thyroid hormone levels were normalized after levothyroxine (synthyroid) 0.2 mg replacement.\nThe maternal TBII level at 38 weeks of gestation decreased to 23% and labor was induced at 40 weeks. A 3,370 g healthy male infant was born without any clinical features of thyrotoxicosis. | [[28.0, 'year']] | F | {'8626813': 1, '29181135': 2, '4185884': 1, '1680727': 1, '2912104': 1, '9534033': 1, '4192504': 1, '7985089': 1, '1915643': 1, '11255792': 1, '8957489': 1, '22888365': 1, '25759801': 1, '1517362': 1, '3055981': 1, '9536566': 1, '24783017': 1, '573555': 1, '16491833': 2} | {'5667530-1': 1} |
165,292 | 3891082-1 | 16,491,834 | noncomm/PMC003xxxxxx/PMC3891082.xml | A Case of Polychondritis in a Patient with Behçet's Disease | A 40-year-old man was referred to our hospital for further evaluation of his fever, oral ulcers and skin rashes that had lasted for 10 days. He had previously suffered from intermittent oral ulceration and uveitis that had been treated with oral prednisolone and intraocular injections of triamcinolone at another hospital 1 year prior to this admission.\nOn the physical examination, his blood pressure was 130/80 mmHg, the pulse rate was 80 per minute and the body temperature was 38.4℃. He had conjunctival injections in both eyes and several aphthous ulcers on the tongue () and buccal mucosa. A small round ulcer with tenderness was found on the penile root (). Several round erythematous skin lesions were present on the chest and thigh (). His left knee joint was swollen () and tender, and needle aspiration revealed turbid inflammatory synovial fluid.\nThe laboratory findings were as follows: hemoglobin 14.8 g/dL, white blood cell count 10,400/µL, platelet count 291,000/µL, erythrocyte sedimentation rate 104 mm/hr and C-reactive protein 205 mg/L (normal range, 0~3.4 mg/L). The renal and liver function tests were normal and the tests for rheumatoid factor and antinuclear antibody were negative. The urinalysis was normal and no microorganisms were grown on both the blood and urine cultures. His chest radiography showed no abnormal findings and mild splenomegaly was observed on abdominal sonography. Gastroduodenoscopy revealed a gastric ulcer and no ileocecal lesion was found on colonoscopy examination. Skin biopsy was performed and the histologic examination showed perivascular mononuclear cell infiltrations, extravasation of the red blood cells and fibrinoid necrosis of the blood vessel walls; all of these findings were compatible with cutaneous vasculitis combined with BD ().\nOn the 5th day of admission, both ear auricles became swollen, red and tender (). He remembered having a similar auricular inflammation 2 years ago that had improved after taking non-steroidal anti-inflammatory drugs. After he was administered with colchicine 1.2 mg/day and prednisolone 30 mg/day, his clinical symptoms improved and he was discharged on the tenth day of admission. | [[40.0, 'year']] | M | {'9488961': 1, '8474085': 1, '21243389': 1, '32914210': 1, '9203024': 1, '1970380': 1, '9656217': 1, '2592624': 1, '8023212': 1, '3327645': 1, '8230032': 1, '2189160': 1, '4014306': 1, '2360844': 1, '9365335': 1, '714080': 1, '12847697': 1, '7743745': 1, '11807775': 1, '25674454': 2, '7751087': 1, '8489544': 1, '16491834': 2} | {'4320181-1': 1} |
165,293 | 3891083-1 | 16,491,835 | noncomm/PMC003xxxxxx/PMC3891083.xml | Infected Pneumatocele Following Anaerobic Pneumonia in Adult | A 64-year-old man was admitted with a history of severe right pleuritic chest pain of a few days duration. He had been treated for diabetes mellitus and hypertension for twenty years, which were well controlled, without any complications. He also had a history of pulmonary tuberculosis, but denied alcoholism and drug abuse.\nOn admission, he had respiratory symptoms, including a mild cough, yellowish sputum and severe right pleuritic chest pain. He also had mild fever, with a body temperature of 37.3℃, pulse rate 103/min, respiratory rate 18/min and blood pressure 150/80 mmHg. A chest examination revealed decreased breathing sound in the right lower lung. Laboratory studies revealed the following values: leukocytes 21,500/cu mm with 84% segmental neutrophil, 3% band forms, 10% lymphocyte and 4% monocytes; arterial pH 7.41, PCO2 37.5 mmHg, PO2 60.7 mmHg on room air.\nThe chest radiography taken on admission revealed a loculated pleural effusion, with suspicious consolidation in the right lower lung. A blood culture was obtained and treatment was started with intravenous antibiotics (cefpiramide 1 g every 12 hours and amikacin 500 mg every 24 hours). Sono-guided thoracentesis was performed. The pleural fluid contained a pus-like material: WBC > 1,000/mm3 almost PMNL; glucose 346 mg/dL; protein 4.3 mg/dL; LDH 2211 u/L. Bacteria, fungi and tuberculosis cultures were all negative, as were the blood and sputum cultures. On the fifth day of hospitalization, chest radiography revealed an air cyst and air fluid level in the right lower lung (). On the ninth day, the size of the air-cyst had rapidly increased to about 9×11 cm in size; the air fluid level had also increased ().\nComputed tomography of the chest was performed, and the enhanced chest CT scan showed a 9×11 cm-sized thin-walled cavitary lesion, with an air fluid level, pleural effusion and consolidation in the right lower lung ().\nA percutaneous pig-tail catheter was inserted into the pneumatocele with the air fluid level, and foul-odored pus drained. The bacterial culture was positive for Bacteroid species, Peptostreptococcus asaccharolyticus and Fusobacterium species. On the same day, antibiotics were changed to intravenous clindamycin, 600 mg every 8 hours. On the next day, after percutaneous catheter drainage, the patient became afebrile, and the size and amount of the air fluid level of the pneumatocele progressively decreased. On the twenty-seventh day, there was no further drainage and the catheter was removed. Eventually, the patient was discharged on the thirty-sixth day of hospitalization. | [[64.0, 'year']] | M | {'13752814': 1, '3259364': 1, '29374641': 1, '14502169': 1, '5300709': 1, '33243155': 2, '13658401': 1, '3885205': 1, '5129527': 1, '1130343': 1, '8740134': 1, '9380455': 1, '8605809': 1, '1574227': 1, '6839622': 1, '3652757': 1, '33764376': 1, '16491835': 2} | {'7688446-1': 1} |
165,294 | 3891084-1 | 16,491,836 | noncomm/PMC003xxxxxx/PMC3891084.xml | Neutrophilic Myositis without Cutaneous Involvement as the First Manifestation of Acute Myeloid Leukemia | A previously healthy 35-year-old male complained of intermittent fever and myalgia of 1-month duration. On admission, he was febrile (39.2℃), with painful tenderness of the edematous upper arm; however, the overlying skin had no grossly abnormality. Ultrasonography showed a diffusely increased echogenicity in his thickened triceps, brachialis and gluteus muscles. Therefore, a magnetic resonance imaging study was performed ().\nA confirmatory muscle biopsy was performed on his left triceps and brachialis muscles. These histological specimens showed severe myositis, with predominantly dense infiltration of mature neutrophils, associated disruption of the muscle architecture and tissue necrosis (). Microbiological studies and serology for auto-antibodies were negative.\nThe initial complete blood count revealed an elevated white blood cell count of 20,440/mm3, with a differential count of 7% segmented neutrophils, 22% lymphocytes and 40% blast cells, which were strongly suggestive of leukemia. The serum chemistry studies disclosed an elevated lactate dehydrogenase level of 977 U/L. The patient subsequently underwent a diagnostic bone marrow aspiration and biopsy, which showed replacement of the normal bone marrow with myeloblasts. The flow cytometric findings were positive for CD13, but negative for CD33, CD14 and HLA-DR. Cytogenetic studies showed a normal karyotype (46,XY[20]). PCR of AML1/ETO was negative. On the basis of the flow cytometry and cytogenetic studies, the final diagnosis was confirmed as a M2 subtype of acute myeloid leukemia, with paraneoplastic neutrophilic myositis. Concomitant treatment with corticosteroid and induction chemotherapy was started. The fever, myalgia and swelling of both the upper arms were resolved after 5 days of steroid therapy.\nAn ultrasonography after 6 weeks of therapy demonstrated resolution of the muscle swelling seen at diagnosis. After the induction chemotherapy, and 2 courses of consolidation, followed by autologous stem cell transplantation, hematological remission was maintained for 15 months. The lack of stem cell sources limited the salvage therapy for the first relapse due to chemotherapy. At present, the patient is on close follow-up in the third hematological relapse. After the initial diagnosis, neither myalgia nor fever reappeared for 36 months. | [[35.0, 'year']] | M | {'3058878': 1, '21298430': 1, '10856659': 1, '11148492': 1, '10629576': 1, '3072677': 1, '14201182': 1, '7774902': 1, '17655751': 1, '12185512': 1, '16491836': 2} | {} |
165,295 | 3891160-1 | 16,295,784 | noncomm/PMC003xxxxxx/PMC3891160.xml | Delayed Ventricular Septal Rupture after Percutaneous Coronary Intervention in Acute Myocardial Infarction | A 70-year-old female had chest pain for three days prior to admission as well as hemiplegia and dysarthria for 5 days. She was referred to our hospital for aggravating chest pain. At the previous hospital, she was admitted for the treatment of type 2 diabetes mellitus and tentorial ischemia. Four years ago, she was diagnosed as mucinous ovarian cystadenoma and underwent bilateral oophorectomy and total hysterectomy. She has no history of smoking or alcohol use. Her father had a history of cardiogenic shock.\nOn admission, the pulse was 112 beats per minute, the respiration 20 per minute, the blood pressure 120/70 mmHg and the body temperature 36℃. The patient was alert at the time of admission. However, she appeared to be acutely ill, and presented with pale conjunctiva and non-icteric sclera. There was no jugular vein distension, and the heart rhythm was irregular without S3 or heart murmur. The lung was clear without rale or crackles. The level of initial CK was 282 IU/L (normal 0~185), CK-MB was 19.2 ng/mL (normal 0~5.0), and TnT was 1.93 ng/mL (normal 0~0.01), and these levels decreased following admission. Hs-CRP level was 2.88 mg/dL (normal 0~0.4). WBC count was 15,800/µL (normal 4000~10,000), and neutrophil count 78.9% (normal 42.2~75.2%). The glucose level was 279 mg/dL and LDL-cholesterol level 157 mg/dL. Other blood chemical and enzyme levels were normal. The urine was normal. On the initial electrocardiogram, 3 mm ST segment elevation in leads V2 through V4 and Q wave in lead II, III, and aVF was observed (). The chest X-ray revealed no abnormalities (). On transthoracic echocardiography, the estimated left ventricular ejection fraction was 45%. There was severe hypokinesia of the cardiac apex and along the inferior wall with moderate pulmonary hypertension (right ventricular systolic pressure was estimated as 55 mmHg). No mural thrombus was seen. She was given conservative care with medications consisting of heparin, IV nitrate, clopidogrel, and aspirin.\nOn the fourth inpatient day, coronary angiography and PCI was performed. From the coronary angiography, 70% and 90% stenosis was observed on the proximal and mid--portion of the LAD, respectively. Ninety percent stenosis on the 2nd obtuse marginal branch was also observed (). PCI with stent implantation for LAD lesions was successful ().\nOn the seventh inpatient day, the patient experienced dyspnea but her heart rhythm was regular and no cardiac murmur was heard. The lung sounds were not coarse but fine crackles were heard at both lung bases. The chest radiograph revealed pulmonary congestion on both sides (). The patient was treated with diuretics, and she managed well.\nOn day 20, her heart rhythm was regular but a grade 4/6 pansystolic murmur was heard at the mid-left sternal border. Echocardiography revealed improved wall motion of the anterior wall and the cardiac apex, but a ventricular septal defect approximately 1.3 cm in diameter was observed at the apical septum (). Because she did not show any serious symptoms related to the ventricular septal rupture and was nearly bed-ridden due to right hemiplegia as a sequel of cerebral infartion, only medical treatment was done. One month after discharge, she complained of dyspnea, and the chest radiograph showed pulmonary congestion with bilateral pleural effusion, but transthoracic echocardiography revealed normal wall motion of the cardiac apex and no change in the size of the defect. The diuretic dose was adjusted and she managed well. After 11-months of medical therapy, she died of an unknown cause. | [[70.0, 'year']] | F | {'12151656': 1, '9328698': 1, '6351573': 1, '2803872': 1, '12918526': 1, '1193118': 1, '7475183': 1, '10618300': 1, '12409546': 1, '16295784': 2} | {} |
165,296 | 3891161-1 | 16,295,785 | noncomm/PMC003xxxxxx/PMC3891161.xml | A Case of Uterine Cervical Cancer Presenting with Granulocytosis | A 56-year-old woman was admitted to our hospital on December 22, 2002, complaining of vaginal spotting. The symptom developed initially about six months before admission. Colposcopic examination revealed a 5-cm sized cauliflower-like mass in the uterine cervix with upper vaginal invasion. A biopsy specimen was taken from the mass. Microscopically, the biopsy specimen revealed a keratinizing type invasive squamous cell carcinoma (). There was a 5.5×3.5 cm high signal intensity mass in the uterine cervix with invasion of the left parametrium and a 1 cm lymph node in the left external iliac area on MRI scan (). A chest X-ray revealed no abnormality. A blood sample showed the following findings: WBC, 12.7×103/µL (78% neutrophils, 15% lymphocytes, 6% monocytes, 1% eosinophils); RBC, 3.54×106/µL, Hb, 8.7 g/dL, Hct, 34.6%, platelets, 413×103/µL, C-reactive protein, 7.0 mg/dL, blood urea nitrogen, 13 mg/dL, creatinine, 0.6 µg/dL, alkaline phosphatase, 207 IU/mL, AST, 29 IU/mL, ALT, 8 IU/mL, and total protein, 7.4 g/dL. There was no evidence of HIV and hepatitis infection by serological studies. The radiological diagnosis was uterine cervical cancer stage IIB, but physical examination revealed a movable cervix. Consequently, she was assessed as a potential candidate for radical hysterectomy.\nConsidering potential resectability, we treated the patient with neoadjuvant chemotherapy with MVC regimen (mitomycin-C 10 mg/m2, vincristine 1.0 mg/m2 and cisplatin 70 mg/m2) every three weeks, . After two cycles of treatment, the tumor size had increased as detected by a follow-up colposcopic examination. Simultaneously, the WBC count became markedly elevated to 69,000/µL. We performed a comprehensive evaluation of the newly developed severe leukocytosis, including blood culture, bone marrow aspiration and biopsy to rule out infection and hematological malignancy. No abnormalities were found.\nThe hematological diagnosis was a granulocytic reactive marrow. There was no evidence of bone marrow involvement of malignant tumor (). Furthermore, there was no specific infection or drug intake history, including steroid and herb medication. Therefore, we considered the granulocytosis to be associated with the tumor itself. However, we could not determine the levels of G-SCF, GM-CSF, and IL-6 in serum because the patient refused these lab tests. Accordingly, we confirmed immunochemical expression of G-CSF and IL-6 by using paraffin block. Staining for G-CSF and IL-6 was mainly observed in the cytoplasm of cancer cells ().\nAfter the diagnosis of granulocytosis, we changed the treatment plan. We started external radiation for six weeks (4000 cGy), six cycles of chemotherapy with weekly cisplatin administration (40 mg/m2), and two cycles of sequential intra-cavitary radiation (ICR). After these treatments, the cervical mass was no longer seen in the follow up MRI scan (). The WBC count returned to the normal range (4,100/µL) at that time. The follow-up complete blood count profile revealed: WBC, 4,100/µL (65% neutrophils, 15% lymphocytes, 16% monocytes); RBC, 2.77×106/µL; Hb, 10.3 g/dL; and platelets, 366×103/µL.\nOne month later, a cavitary nodule was found in the left upper lobe of the lung in the chest X-ray, and a vulval mass was detected. Both lesions were confirmed pathologically as metastatic squamous cell carcinoma by percutaneous needle aspiration cytology. At that time, the WBC count became elevated again to 29,600/µL. Lastly, we changed the chemotherapy regimen to paclitaxel plus cisplatin. Over three months, four cycles of this combination chemotherapy were carried out. After four cycles of treatment, a marked increase in metastatic lung nodules was found on the follow-up chest X-ray (), with severe granuocytosis (52,700/µL). The patient refused further chemotherapy and symptomatic management. She died three months later. | [[56.0, 'year']] | F | {'11908271': 1, '8349158': 1, '1699851': 1, '3871951': 1, '9472215': 1, '11087187': 1, '28180148': 1, '19809554': 1, '20810794': 1, '2787682': 1, '7542171': 1, '23589799': 2, '3484805': 1, '9166942': 1, '10785476': 1, '7515769': 1, '16295785': 2} | {'3625010-1': 1} |
165,297 | 3891162-1 | 16,295,786 | noncomm/PMC003xxxxxx/PMC3891162.xml | Congenital Double-Orifice Mitral Valve with Mitral Regurgitation due to Flail Leaflet in an Elderly Patient | A 75-year-old woman was referred to our hospital because of her mild exertional dyspnea and cardiac murmur. She had a long history of hypertension: 5 years earlier, she underwent a coronary angiographic study at our hospital because of her chest pain; no significant stenosis was found except for some minimal narrowing that was noted at the middle portion of the left anterior descending artery. During the same period, the precordial echocardiographic study revealed a slight left atrial enlargement and mild mitral regurgitation, but the quality of imaging resolution was poor and any further evaluation was not performed. The patient reported that she had been doing well until a few weeks earlier when she started suffering from a shortness of breath during mild exercise. Three days before her referral to the hospital, she had visited a general practitioner to get an evaluation of her symptoms. The doctor heard the murmur during the examination of the heart and he found blunting of the right costophrenic angle on the chest X-ray, so he referred her to us for further evaluation.\nAt the time of her second presentation, the patient had light dyspnea and a harsh pansystolic murmur (grade 3/6) was heard at the apex of the heart. The blood pressure was 140/80 mmHg. The EKG showed a sinus rhythm with nonspecific ST-T segment abnormalities. Echocardiography (Vivid 7, GE) revealed left ventricular hypertrophy and dilatation of the left atrium. The ventricle was not dilated and it had good contractility. There was also a very eccentric mitral regurgitation, but the morphology of the valve and the severity of the mitral regurgitation could not be precisely determined due to the poor image quality of the patient's test results.\nTransesophageal echocardiography (TEE) clearly showed that the mitral valve was composed of two distinct orifices that were separated by a central fibrous bridge. It is interesting that each orifice had its own chordae tendineae tethered to a different papillary muscle (). The transgastric short axis view revealed a larger posteromedial orifice and a smaller anterolateral orifice (). The posteromedial orifice was competent without any evidence of regurgitation or stenosis. At the level of anterolateral orifice, the color Doppler revealed moderate to severe eccentric regurgitation due to the flail posterior leaflet (). No other congenital cardiac anomalies were noted except for the persistent left superior vena cava that was demonstrated by injecting agitated saline at the antecubital vein of the left arm (). The patient became asymptomatic with the administration of angiotensin-converting enzyme inhibitor and diuretics. She was scheduled for long term follow-up and prophylaxis was recommended for any potential infectious endocarditis. | [[75.0, 'year']] | F | {'10496505': 1, '1825079': 1, '11916585': 1, '28977206': 2, '15122192': 1, '8975859': 1, '8439430': 1, '3276118': 1, '31147411': 2, '14611832': 1, '4019924': 1, '12019431': 1, '9436589': 1, '16295786': 2} | {'5613729-1': 1, '6557421-1': 1} |
165,298 | 3891163-1 | 16,295,787 | noncomm/PMC003xxxxxx/PMC3891163.xml | A Case of Avascular Necrosis of the Femoral Head as Initial Presentation of Chronic Myelogenous Leukemia | A 21-year-old male patient was presented with pain in the right hip joint for 2 months. He was a soldier and went to the dispensary of the unit that he belonged to. He was referred to our hospital for further evaluation of abnormal complete blood cell count which was performed at the dispensary. The patient suffered from weight loss, mild dyspnea, fatigue, intermittent fever, and night sweat. The further history was uneventful.\nUpon physical examination, it was observed that the patient was in poor general condition with pallor skin and anemic conjunctiva. There were no signs of hemorrhagic diathesis or icterus. The spleen was palpable below the umbilicus and had a firm consistency. Cervical and inguinal lymph nodes were palpable. Heart and lungs were without any pathologic findings. The chest X-ray and electrocardiography were normal.\nLaboratory investigations revealed leukocytosis with leukocyte count of 96,800/mm3, increased platelets with a count of 684,000/mm3, and hemoglobin level of 10.4 g/dL. The peripheral blood smear revealed 1% blast cells. Microbiology findings were sterile cultures of blood and urines.\nBone marrow examination revealed that the entire marrow space was packed with granulocytes and megakaryocytes. The bone marrow biopsy showed marked hypercellularity and the estimated cellularity was near 100%. The bone marrow aspiration showed 0.4% myeloblasts, 6% promyelocytes, 13.2% myelocytes, 15.2% metamyelocytes, 14.7% band neutrophils, 40% segmented neutrophils, 2.7% eosinophils, 0% basophils, 0.8% monocytes, 0.4% pronormoblasts, 0% lymphoblasts, 0% immature lymphocytes, 0.4% lymphocytes, 0.4% plasma cells, and 0% histiocytes suggesting chronic phase of CML. Chromosomal analysis of bone marrow revealed Philadelphia chromosome, t (9;22) and molecular cytogenetics also showed bcr-abl positive.\nTreatment with hydroxyurea was induced, combined with immediate evaluation of right hip joint pain. Radiolucency superimposing the right femoral head was seen on the pelvic X-ray (). Whole body bone scan showed increased uptake of the right hip joint. Magnetic resonance imaging (MRI) of both the hips revealed inhomogenously decreased signal intensity in the both proximal femur and acetabulum on T1 weighted images. The outer areas surrounding these areas had increased signal densities on T2 weighted images (). On application of contrast medium, area with former decreased signal density on the cranial part of the right femoral head and some smaller areas of the left femoral head, showed a lack of signal enhancement. Bilateral joint effusion, worse in the right than the left, was also seen. All together, MRI showed signs of necrosis of both the femoral heads.\nThe leukocyte count decreased from 96,800/ul to 26,300/mm3 with the treatment of hydroxyurea (3 g/day) for 2 weeks and subsequently hydroxyurea was replaced with imatinib mesyalte. With this treatment leukocytes were reduced from 96,800/mm3 to 8,900/mm3 within 3 weeks. The size of the spleen decreased to 3 cm below the costal margin within 1 month.\nFollowing normalization of the peripheral blood counts, the patient was transferred to the department of Orthopedics. He underwent a bipolar hemiarthoplasty of the right hip joint, because the necrosis of the right hip joint was more severe than the left and he had no pain in the left hip joint. The postoperative course was complicated due to bleeding from the operative site possibly due to thrombocytopenia which may have been induced by imatinib mesylate. Temporarily, the medication of imatinib mesylate was stopped, and the patient was transfused with platelets and packed red cells. The biopsy revealed focal subchondral necrotic areas in the right hip joint ().\nThe patient was on a continuous follow up and showed no complications with complete cytogenetic response and has been on medication of imatinib mesylate (400 mg/day). | [[21.0, 'year']] | M | {'12733144': 1, '12427153': 1, '2606043': 1, '9639528': 1, '22802985': 1, '12093241': 1, '10975379': 1, '6585928': 1, '1566743': 1, '1574093': 1, '29439082': 1, '24380033': 1, '11264180': 1, '8235665': 1, '3175694': 1, '11886572': 1, '31031129': 1, '7890797': 1, '26279632': 1, '3327563': 1, '12725271': 1, '12574965': 1, '4509637': 1, '16295787': 2} | {} |
165,299 | 3891164-1 | 16,295,788 | noncomm/PMC003xxxxxx/PMC3891164.xml | Cutaneous Metastases of Pancreatic Carcinoma as a First Clinical Manifestation | A 68-year-old Korean man was seen in the dermatology department because he had a painless subcutaneous right forearm nodule for 3 months. Two firm, 1.0 cm, subcutaneous nodules were noted on the physical examination (). The histology revealed neoplastic gland cords or nests in the desmoplastic stroma, and this was consistent with metastatic adenocarcinoma (). He was referred to the gastroenterology department to further investigate the source of the cutaneous lesion. He was totally asymptomatic except for the multiple subcutaneous nodules on his forearm, but he complained of a 5 kg weight loss during the last six months. His past medical history and family history were non-contributory. Apart from the subcutaneous nodules, the remainder of the exam was normal, including both the rectal and abdominal examinations that showed no masses. No enlarged lymph nodes were present, and the prostate was normal in size and consistency. The routine blood chemistry tests revealed only a slightly elevated alkaline phosphatase of 238 U/L (normal: 30~110 U/L), but there was a remarkable elevation in the tumor markers CA 19-9 to 486.9 U/mL (normal: 0.139 U/mL). The gastroscopy and colonoscopy exams revealed no specific abnormality except for a hyperplastic gastric polyp. The abdominal computed tomography (CT) detected a low-density mass located in the tail of the pancreas along with multiple liver metastases (). The CT and ultrasonography findings of the abdomen were compatible with pancreatic cancer with multiple liver and cutaneous metastases. The immunohistochemical staining of the skin biopsy showed a positive reaction to monoclonal antibodies for CK 7, CK 19 and thyroid transcription factor (TTF), and these markers are normally present in adenocarcinoma of the lung (). The patient declined pancreatic fine needle aspiration biopsy and chemotherapy. Therefore, he was scheduled for follow-up. | [[68.0, 'year']] | M | {'5030236': 1, '7510926': 1, '6715609': 1, '214741': 1, '10844494': 1, '24293536': 1, '4682547': 1, '23307465': 1, '22514766': 1, '28096990': 1, '2298962': 1, '23745161': 1, '22295135': 1, '10923083': 1, '8335743': 1, '32806580': 1, '33250968': 2, '8511104': 1, '23236247': 1, '28589449': 1, '12630040': 1, '9322122': 1, '8968868': 1, '7622642': 1, '19882039': 2, '11554137': 1, '3391711': 1, '34805470': 1, '25995674': 1, '16295788': 2} | {'2763770-1': 1, '7667456-1': 1} |
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