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165,300 | 3891165-1 | 16,295,789 | noncomm/PMC003xxxxxx/PMC3891165.xml | Adult Onset Still's Disease as a Cause of Acute Severe Mitral and Aortic Regurgitation | In October 2003, a 55-year-old woman with chronic polyarthritis and myalgia was referred by the local tertiary hospital to our hospital. Four months prior, she developed general myalgia and polyarthralgia, mainly in the ankles and shoulders, and recorded body temperatures up to 39.8℃. She was admitted to the local tertiary hospital and intravenous ampicillin/sulbactam was empirically administered. After 3 days, the body temperature of the patient normalized, while polyarthralgia and myalgia remained. Two weeks later, the patient's body temperature again rose to 39.4℃, and an erythematous skin rash developed on both legs and the upper arms. She was empirically administered intravenous vancomycin and ciprofloxacin, and the body temperature normalized and the erythematous skin rash disappeared after 5 days. Polyarthralgia and myalgia persisted.\nThe patient underwent a series of blood tests which revealed the following: leukocytes 18,400/mL (4,000-10,000/mL, neutrophil 90.2%), hemoglobin 10.5 g/dL (12-16 g/dL), platelets 467,000/mL (150,000-350,000/mL), AST/ALT 110/111 IU/L (0-40 IU/L), ALP 730 IU/L (40-120 IU/L), GTP 473 IU/L (8-35 IU/L), LDH 567 U/L (120-250 U/L), ESR 64 mm/hr (0-20 mm/hr), CRP 23 mg/dL (0-0.6 mg/dL), and ferritin 998 ng/mL (10-290 ng/mL). Testing for rheumatoid factor (RF) and antinuclear antibodies (ANA) returned negative results. Repeated blood cultures returned negative results. Bone marrow examination showed marked granulocytic hyperplasia without evidence of hematologic malignancy, and no growth was observed on bacterial, fungal, or mycobacterial culture plates. Echocardiogram showed minimal mitral regurgitation without evidence of infectious endocarditis. Abdominopelvic computed tomography (CT) showed mild hepatomegaly with four hepatic hemangiomas. Skin biopsy showed diffuse neutrophilic infiltration in the entire dermis, consistent with Sweet's syndrome.\nOn the basis of the clinical and laboratory findings, the patient was administered 40 mg prednisolone per day, after which the symptoms of polyarthralgia and myalgia were relieved. The patient was discharged two weeks later (August 13, 2003) with a treatment regime of 15 mg prednisolone per day. Two weeks later, she revisited the local hospital outpatient clinic with signs that the polyarthralgia and myalgia had resurfaced, and that ESR and CRP were elevated. The prednisolone dose was increased to 60 mg per day and the symptoms were alleviated for 2 months. However, on October 30, 2003, the patient was transferred to our hospital and, due to complaints of polyarthralgia involving both first metatarsophalangeal joints, both ankles, both hips, both shoulders, and general myalgia, was admitted. Upon physical examination, tenderness and swelling were observed at both metatarsophalangeal joints, the left ankle, and the left sternoclavicular joint. Laboratory testing revealed that ESR, CRP, and ferritin levels were elevated (ESR 70 mm/hr, CRP 11 mg/dL, ferritin 1792 ng/mL).\nAccording to her clinical history and local tertiary hospital laboratory data, the patient was diagnosed with AOSD using Yamaguchi's classification criteria: fever lasting 1 week or longer, arthralgia lasting 2 weeks or longer, leukocytosis, liver dysfunction, and negative RF and ANA tests.\nFollowing admission, we administered 30 mg prednisolone twice per day and 10 mg methotrexate per week. The polyarthralgia and myalgia were subsequently alleviated. On follow up laboratory tests, ESR, CRP, and ferritin levels had decreased (ESR 52 mm/hr, CRP 2.01 mg/dL, ferritin 789 ng/mL). The patient was discharged five days later. She was readmitted one week later for dyspnea and general edema. Systolic murmurs and diastolic murmurs at the apex were observed upon cardiac auscultation. Chest X-rays showed cardiomegaly and bilateral pulmonary edema. Transthoracic echocardiogram showed severe mitral regurgitation (MR) due to prolapse of the posterior mitral valve leaflet, and moderate to severe aortic regurgitation (AR) due to right coronary cusp prolapse. Transesophageal echocardiogram also showed severe MR and AR due to valve leaflet prolapse. The valve prolapse appearance was notable because the prolapsing posterior mitral valve was focally fixed in the left atrium during systolic and diastolic cycles (). The patient underwent a mitral valve replacement (MVR) and Bentall's operation on November 22, 2003.\nHistological examination of heart tissue showed fibromyxoid degeneration with chronic active inflammation in the aortic wall, and chronic active inflammation with fibrinoid necrosis of the aortic and mitral valves (). Ziehl-Neelson, Periodic acid shiff, and Gram staining failed to identify any organisms. The presence of extensive fibrinoid necrosis, which is unusual in the case of ordinary valvulopathy, suggested valvulopathy associated with connective tissue disease. After MVR and Bentall's operation, the patient acquired normal mitral and aortic valvular function. She was, thereafter, administered oral medication through the outpatient clinic. Upon outpatient follow-up laboratory testing, ESR, CRP, and ferritin levels were 28 mg/hr, 1.30 mg/dL, and 720 ng/mL, respectively. The patient is currently taking 10 mg prednisolone per day and 17.5 mg methotrexate per week without relapse. | [[55.0, 'year']] | F | {'1578458': 1, '8746917': 1, '15097938': 1, '1190852': 1, '5315135': 1, '10648058': 1, '29094181': 1, '32974464': 2, '2321888': 1, '7092964': 1, '1578459': 1, '36563': 1, '3325642': 1, '1743786': 1, '2724261': 1, '11997716': 1, '9068291': 1, '16295789': 2} | {'7501920-1': 1} |
165,301 | 3891166-1 | 16,295,790 | noncomm/PMC003xxxxxx/PMC3891166.xml | Clear Cell Hepatocellular Carcinoma with Spontaneous Regression of Primary and Metastatic Lesions | A previously healthy 72-year-old man visited Kyungpook National University Hospital in August 2002 because of intermittent right-upper quadrant discomfort which had recently developed. Physical examination revealed a hard, tender liver that extended to 5cm below the right costal margin. He had been consuming more than 70 g/day alcohol for the last 20 years. A biological evaluation showed a normal complete blood count (WBC 7800/mm3, Hemoglobin 14.2 g/dL, Platelet 164000/mm3), a normal total protein/albumin (7.4 and 4.5 g/dL, respectively), and a normal bilirubin (total bilirubin 0.6 mg/dL), but his liver enzymes were elevated (AST/ALT 118/43 IU/L). Prothrombin time was 89.8%. He was negative for surface antigen and antibodies to HBV, HBc-IgG, and HCV. Ultrasonography of the abdomen revealed a huge mass of about 9×11 cm on the right lobe of the liver. Abdominal enhanced computerized tomography (CT) scanning also revealed the same findings with right portal vein invasion (). The lesion was shown not to be high-density on an arterial phase because of the hugeness and central necrosis. Instead, it was low-density on a portal phase. There were no abnormalities on either kidney or on other intra-abdominal organs. His serum alpha-fetoprotein (AFP) was above 500 ng/mL. His Child-Pugh score was 5 (class A). HCC (modified UICC stage IV-A, T4N0M0) was clinically diagnosed, and we recommended him for transarterial chemoembolization (TACE). However, he refused the procedure, and we decided to follow-up regularly. Three months later (November 2002), he complained of pain in the left anterior chest region. A chest X-ray showed a lesion which was invading the rib on the left upper lung (). A follow-up CT scan revealed an aggravated primary lesion of the liver, and he attended the outpatient clinic regularly where he received painkillers. He was later hospitalized because of the intermittent aggravated pain in the left anterior chest region. The mass size slowly increased up to 10×10 cm in diameter during the follow-up period (). Fourteen months later (October 2003), he complained of pain in his left hip joint. A CT scan revealed a mass invading the left sacrum. On scanned upper abdominal imaging, however, it was noted that the primary HCC had decreased in size (about 4×3 cm) (). His serum AFP was above 500 ng/mL. To rule out other rare conditions, we performed an incisional biopsy on the chest mass. Microscopic examination showed necrosis and eccentric nucleoli with vacuolated foamy-to-clear cytoplasm that did not stain with hematoxylin and eosin (). These findings were consistent with clear cell carcinoma. Seventeen months later (January 2004), he felt better than before and did not complain of chest pain. It was a surprise to see upon physical examination that no palpable mass was found. A chest X-ray also showed no mass lesion. A CT scan revealed the same findings, and on the scanned upper-abdominal imaging, a further decrease in the primary lesion (about 3×2 cm) was noted (). His serum AFP, however, was still above 500 ng/mL. Now (June 2004), it has been about 23 months since the diagnosis. He no longer complains of discomfort and he attends the outpatient clinic regularly. On imaging study, there has been no progression in chest, liver, or sacral lesions. Additionally, his serum AFP has decreased to 8.0 ng/mL (). | [[72.0, 'year']] | M | {'2408740': 1, '25228980': 2, '6282440': 1, '8870006': 1, '6174388': 1, '2996742': 1, '2983534': 1, '11592607': 1, '2546879': 1, '6166811': 1, '227575': 1, '21468325': 1, '2157513': 1, '8607517': 1, '6261918': 1, '7525432': 1, '6305477': 1, '2990661': 1, '27038447': 1, '11922591': 1, '8119543': 1, '16295790': 2} | {'4164250-1': 1} |
165,302 | 3891180-1 | 24,459,391 | noncomm/PMC003xxxxxx/PMC3891180.xml | A holistic approach to the management of Erb's palsy | A 4.5-month-old female baby was brought to Physiotherapy Department of Sri Ganapati Sachchidananda Hospital by her parents with complaints of inability to move her right upper limb and abnormal position, progressive since birth.\nArm was internally rotated, adducted, elbow extended, forearm pronated and with a closed fist of right upper limb Passive range of motion was not full and free at shoulder patient was crying on flexion and abduction beyond 150° and 130° respectively Elbow, wrist, metacarpophalangeal joints and inter phalangeal joints of right upper limb were full and free passively. There was no grasp reflex All developmental milestones were normal, except for movements of right upper limb Muscular contractions of deltoid, biceps, triceps, supinator, flexor and extensors of wrist, metaca rpophalangeal and interphalangeal were elicited suggestive of C5, C6, and C7 nerve damage[] Muscle power was assessed for all the muscle groups of right upper limb and were of grade 0.[]\nAccording to patient's mother, doctors had suggested delivery by caesarean section due to the breech presentation; however, considering personal request and financial conditions of the parents, forceps assisted vaginal delivery was performed. Both mother and baby were healthy following the delivery. Later, the parents noticed that the baby was not using her right upper limb completely, with gradual progressive deformity. It was diagnosed as Erb's palsy by a pediatrician and suggested for physiotherapy as an early measure of treatment, before electing surgical options.\nElectrical stimulation was administered by placing active electrode on skin at the nerve root, i.e. base of the neck. Pen electrode was placed on motor point and muscle mass in faradic and galvanic currents respectively.[] Patient was treated for 28 days of physiotherapy treatment, in three divided sessions [Tables and ].\nQuantity sufficient of indirectly heated ABL Taila was applied in Anuloma Gati (downward) for 15 min 25 g of Bala Mula (roots of Sida cordifolia Linn.) was processed with 500 ml of Ksheera (milk) where in milk was boiled to reduce the quantity to half and filtered. 25 g of Shastikashali was cooked very soft and made like paste with above filtrate of Ksheera Yukta Bala Mula. This paste was applied with gentle circular movements for 20 min in Anuloma Gati. Patient was treated with a total of 35 days of Ayurvedic treatment, in three divided sessions [Tables and ]. | [[4.5, 'month']] | F | {'18505571': 1, '19439090': 1, '10956379': 1, '10831997': 1, '24459391': 2} | {} |
165,303 | 3891181-1 | 24,459,392 | noncomm/PMC003xxxxxx/PMC3891181.xml | Kshara application for turbinate hypertrophy | A 45-year-old male presented with the complaints of frequent nasal obstruction, nasal discharge, discomfort in nose, and headache since 3 years.\nOn local examination of the nose [] the external nose was normal with widened anterior nares. On anterior rhinoscopic examination, inferior turbinate in left side of the cavity was markedly hypertrophied with congestion of the nasal mucous membrane []. In right side of the nasal cavity also there was mild hypertrophy of middle turbinate present. Routine hematology tests (hemoglobin, total count, differential count, erythrocyte sedimentation rate, and absolute eosinophil count) investigations were done. The erythrocyte sedimentation rate and absolute eosinophil count were slightly increased. Hemoglobin, total count, and differential count were within normal limits.\nPatient had taken medical management which included a variety of antihistamines, decongestants, and topical and systemic corticosteroids since 3 years; but was of no use. After discontinuation of medication recurrence of the nasanaha was observed.\nAs the disease was not manageable with medical treatment and leading to complications like sleep apnea and mouth breathing, kshara application was selected in this case.\nAll the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4 h preceding the ksharakarma procedure. Ligno × 10% spray was sprayed into the left nostril to anesthetize the turbinate in order to avoid sneezing reflex and sensitivity. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose the nasal cavity properly. A gauze piece soaked in lime water was placed into the left side of the nasal cavity away from the turbinate to avoid involvement of other normal structures.\nThe left nasal cavity was exposed using Thudicum's Nasal Speculum and a secretion over the turbinate was wiped out using gauze piece. Apamargakshara was applied over the medial surface of the exposed turbinate, by using the cotton rolled over Jobson probe. Applied kshara was kept for 2 min.[] After sometime, the color changed to reddish brown (Jambuphalavat, i.e. the fruit of Syzizium cumini Linn.). The kshara was then removed with cotton rolled with Jobson probe. Lemon juice was applied over the turbinate to neutralize the remaining kshara. Yastimadhu ghrita was applied over the burnt wound to overcome daha (burning sensation).\nThe patient was advised to avoid exposure to air or breeze, dust, smoke, etc., The patient was advised to take light diet.\nThe patient was advised to follow-up for twice weekly for 15 days. | [[45.0, 'year']] | M | {'11801946': 1, '34364738': 1, '8326220': 1, '19839242': 1, '23120733': 1, '23120020': 1, '3431839': 1, '24459392': 2} | {} |
165,304 | 3891195-1 | 24,459,626 | noncomm/PMC003xxxxxx/PMC3891195.xml | Use of dexmedetomidine to facilitate non-invasive ventilation | A 91-year-old female was admitted to the hospital after a syncopal episode. The patient had a past medical history of COPD, CHF, hypertension, depression, atrial fibrillation, fourth thoracic spine compression fracture, and pneumonia. Surgical and social histories were negative. Furosemide was given once per day at home and in the Intensive Care Unit to treat congestive heart failure, and the patient was given nebulizer treatments of albuterol, ipratropium, levalbuterol, and budesonide throughout her stay in the hospital to treat her COPD.\nThe patient's admission Glasgow Coma Scale was 13 and her baseline vital signs were heart rate of 101 beats per minute, tachypnea with a respiratory rate of 32 breaths per minute, a blood pressure of 156/65 mm Hg, and an oxygen saturation by pulse oximetry (SpO2) of 91%. Admission blood chemistry showed mild hyponatremia, and an elevated brain natriuretic peptide of 199 ng/L (normal < 99 ng/L). Admission chest radiography taken before bilevel positive airway pressure (BIPAP) showed focal pneumonia in the right lower lung, a widened mediastinum, and enlargement of the cardiac silhouette. Due to respiratory distress, the patient was transitioned from a 50% facemask to BIPAP (settings: FIO2= 50%, 8/4 cm H2O, 14 BPM) and became agitated shortly after. To mitigate her agitation, she was administered dexmedetomidine, without a bolus, at a starting dose of 0.2 μg/kg/hr, and continued on doses ranging from 0.2 to 0.5 μg/kg/hr titrated to a sedation scale. The patient received dexmedetomidine for a total of 40 h. After 1 h the dexmedetomidine was given, the patient was no longer agitated, with a Ramsey Score of three. Her vital signs showed no significant hemodynamic changes 2 h post-dexmedetomidine initiation, while her respiratory rate returned to normal (19 breaths per minute) and SpO2 increased to 97%. The patient did not experience bradycardia or hypotension, which are possible side effects of dexmedetomidine. The echocardiogram while on dexmedetomidine and BIPAP showed an ejection fraction of 60-65%, trace mitral and tricuspid regurgitation, and moderate to severe aortic stenosis. After discontinuation of the dexmedetomidine infusion, and given the previous agitation, haloperidol 1 mg every 6 h intravenously was given for an additional 2 days to maintain the non-agitated state. The total length of non-invasive ventilation was 3 days and 14 h. The patient was neither intubated nor received invasive mechanical ventilation, and was discharged from the hospital and ICU without other respiratory complications. | [[91.0, 'year']] | F | {'20458462': 1, '26559350': 1, '10556125': 1, '17717491': 1, '11282759': 1, '18635484': 1, '34237813': 1, '17717495': 1, '12907562': 1, '24459626': 2} | {} |
165,305 | 3891196-1 | 24,459,627 | noncomm/PMC003xxxxxx/PMC3891196.xml | Esophageal perforation following cervical spine surgery: A review with considerations in airway management | A 24-year-old man presented to an outside hospital following a motor vehicle accident with cervical spine fractures of C5 - C7, anterolisthesis of C6 and associated spinal cord transection with resulting quadriplegia. The patient was taken to the operating room and underwent anterior cervical decompression and fusion (ACDF) of C5-7, C6 corpectomy with polyetheretherketone (PEEK) cage and C4 - T1 posterior fusion []. Postoperatively the patient did well and was discharged to a rehabilitation center at our institution.\nApproximately four months following his surgeries the patient began to develop increased sputum production, cough and fever. Chest X-ray revealed bilateral infiltrates consistent with aspiration pneumonia. At this time, the aspiration was thought to be due to the patient's poor pulmonary clearance from his immobility and quadriplegia. While on antibiotic therapy for aspiration pneumonia the patient developed acute dysphagia. Computed tomography (CT) scan demonstrated air surrounding the implant at C6 as well as the anterior fusion plate []. Upper endoscopy and bronchoscopy did not demonstrate any esophageal or airway defects. Barium swallow revealed an esophageal defect with contrast tracking down the prevertebral space to the level of T1 anterior to the cervical fusion plate as well as a tracheo-esophageal fistula [].\nThe patient underwent removal of the anterior plate, which was visualized in the pharyngoesophagus during intraoperative video-assisted laryngoscopy,[] removal of PEEK cage and placement of antibiotic impregnated bone cement, primary repair in conjunction with a sternocleidomastoid muscle flap being placed on the esophageal defect []. Although the barium swallow study revealed a tracheoesophageal fistula, none was seen intraoperatively. A nasogastric tube (NGT) was placed under direct endoscopic visualization as well. Postoperatively, the patient remained intubated with the NGT to remain in place for one week. The patient was extubated over a soft 22-french exchange catheter without incident and repeat barium swallow study demonstrated resolution of the esophageal perforation []. | [[24.0, 'year']] | M | {'30643847': 1, '34510250': 1, '28451488': 1, '18261766': 1, '11423266': 1, '19769513': 1, '26842882': 1, '34350371': 1, '18082458': 1, '12933429': 1, '16227880': 1, '18224356': 1, '20422686': 1, '10710155': 1, '21775144': 1, '17906571': 1, '32405557': 1, '16151718': 1, '28588368': 1, '20091412': 1, '24459627': 2} | {} |
165,306 | 3891197-1 | 24,459,628 | noncomm/PMC003xxxxxx/PMC3891197.xml | Acute lung injury following the use of granulocyte-macrophage colony-stimulating factor | A 77-year-old Black female with a past medical history significant for hypertension, peripheral vascular disease, hypercholesterolemia, chronic obstructive pulmonary disease (COPD) without recent exacerbation and gastroesophageal reflux disease. Her history is negative for coronary disease, stroke or diabetes. She presented with an acute osteomyelitis of the left foot, which required debridement of the 2nd and 3rd metatarsal bones. The social history revealed a former smoker, with a 70-pack-year smoking history who quit 1 year ago and denied alcohol use. Her surgical history was significant for a left femoral-popliteal bypass followed by a transmetatarsal amputation for gangrenous toes.\nPre-operative evaluation showed a chest X-ray significant for cardiomegaly []. A transthoracic echocardiogram revealed an ejection fraction of 55%, with moderate concentric left ventricular hypertrophy, Grade I diastolic dysfunction, trace mitral regurgitation, trace tricuspid regurgitation and no evidence of aortic regurgitation. Laboratory data showed a white blood cell count of 12.1 × 103/μL and a normal albumin of 3.6 g/dL.\nShe underwent a 17 min operative procedure under local anesthesia with midazolam and ketamine for sedation. This consisted of a debridement of the osteomyelitis of the left foot at the previous amputation site without any blood loss. At the conclusion of the debridement, 500 μg recombinant GM-CSF (sargramostim [Leukine, Genzyme]), which was injected locally into the operative site to stimulate wound healing (off label use). Intraoperatively, the patient was hemodynamically stable without hypotension and received minimal intravenous fluid.\nAfter a brief period in the post-anesthesia care unit, where the patient was asymptomatic and hemodynamically stable with oxygen saturation of 95% by pulse oximetry via 3 L nasal cannula, patient was transferred to floor care. Twenty-two hours post-operatively, she developed acute onset of severe dyspnea with respiratory distress manifested by hypertension (blood pressure 180/95 mmHg), tachycardia (heart rate of 122), diaphoresis and tachypnea (respiratory rate of 26). Auscultation revealed diffuse rales without inspiratory or expiratory wheeze or stridor. Cardiovascular examination was negative for jugular venous distension and the absence of an S3 gallop. Oxygen saturation was 90% on a 50% FiO2 via an oxygen venturi mask and an arterial blood gas performed revealed a pH 7.35, PaO2 76 mmHg and PCO2 56 mmHg and the PaO2/FIO2 ratio was 152 with a calculated A-a gradient of 217.5 mmHg (expected 18.7 mmHg adjusted for age). Repeat laboratory studies showed a leukocytosis, with the white blood cell count of 23.6. A chest X-ray revealed an interval development of bilateral fluffy infiltrates consistent with acute pulmonary edema []. A 12 lead electrocardiogram showed no evidence of ischemia and serial cardiac biomarkers were negative. A repeat echo showed no changes from the prior study, with a preserved ejection fraction of 55%. Patient was placed on non-invasive ventilation (bilevel positive airway pressure [BIPAP] mode, inspiratory positive airway pressure = 12 cm H2O, expiratory positive airway pressure = 5 cm H2O, FiO2= 50%), given furosemide 40 mg intravenously and promptly transferred to the surgical intensive care unit.\nThe following day, despite negative fluid balance and BIPAP ventilation, the PaO2/FIO2 ratio remained low at 132, without any evidence of radiographic improvement. Given the absence of fluid overload, a lack of response to diuresis, no cardiogenic dysfunction and no apparent clinical exacerbation of COPD and given the temporal sequence of the event after the GM-CSF injection, a presumptive diagnosis of ALI was suspected and high dose methylprednisolone 500 mg once daily for 5 days was initiated. Over the next 5 days, the patient's symptoms improved and she was gradually weaned off BIPAP to nasal cannula, with daily chest X-rays confirming radiographic clearing of the ALI with resolution of the bilateral pulmonary infiltrates []. | [[77.0, 'year']] | F | {'34830303': 1, '1703454': 1, '14718443': 1, '32110933': 1, '9468275': 1, '1375123': 1, '18437014': 1, '17426195': 1, '1672790': 1, '30288347': 1, '18260828': 1, '10793167': 1, '33824579': 1, '17482987': 1, '12169573': 1, '24942811': 1, '1375975': 1, '32576980': 1, '1376442': 1, '15753051': 1, '24459628': 2} | {} |
165,307 | 3891198-1 | 24,459,629 | noncomm/PMC003xxxxxx/PMC3891198.xml | An iatrogenic metabolic encephalopathy in a nonagenarian: The dilemma of a critical miss as a possible social dismissal | A 93-year-old male, 70 kg, 165 cm, was admitted to (the first of three hospitals) with a diagnosis of congestive heart failure attributed to right ventricular dysfunction. He required a walker for ambulation. He had a past medical history of a coronary artery disease, atrial fibrillation, mitral regurgitation, aortic stenosis, diverticular bleeding, hypertension, advanced chronic kidney disease, gout (remote), and nonAlzheimer's dementia. His surgical history included coronary artery bypass grafting with mitral valve and aortic valve replacement (tissue valves). His medications were donepezil for dementia, calcium carbonate, potassum chloride, isosorbide mononitrate, metamucil, pantoprazole, diltiazem, hydralazine, and bumetanide.\nThe laboratory evaluation demonstrated: Sodium 140 mmol/L, potassium 4.0 mmol/L, chloride 95 mmol/L, serum bicarbonate 36 mmol/L, phosphorus 3.4 mg/dl, magnesium 2.2 mg/dL, glucose 108 mg/dL, blood urea nitrogen (BUN) 73 mg/dL, creatinine 2.13 mg/dL, glomerular filtration rate (GFR) 29 mL/min, occult blood negative, total protein 6.3 g/dL, albumin 3.8 g/dL, thyroid function tests were normal, hemoglobin 9.7 g/dL, hematocrit 29.3%, white blood cell count 4.6 K/μL, and platelets 90 K/μL.\nPhysical examination revealed bilateral pulmonary rales, tachypnea, pedal edema, and rate-controlled atrial fibrillation (confirmed by electrocardiogram). Chest roentgenogram showed bilateral pleural effusions and pulmonary edema.\nA furosemide infusion promoted a 6 kg loss in 5 days; tachypnea, pedal edema, pulmonary edema, and pleural effusions improved. Concurrently he complained of leg pain and received tramadol 50 mg every 8 hours. His cognitive function worsened over 72 hours (days 3-5 of diuresis). He also became incontinent, needed skilled nursing care, and was transferred to a covalesent facility where he was difficult to arouse upon arrival. He had lost intravenous access and none was started. No laboratory studies were drawn. The staff suggested that the patient be made “comfort care” only. The next morning his condition remained unchanged. The family expressed concern and transferred the patient to a third institution.\nSubsequent examination revealed a Glasgow coma scale of 10, mild bilateral rales, rate controlled atrial fibrillation, no pretibial edema, and an edematous left foot with an erythematous, warm great toe. Urine output was diminished. Laboratory examination revealed a BUN of 81 mg/dL (GFR < 30 mL/min), potassium, sodium, and chloride were normal, and serum bicarbonate 43 mmol/L, and arterial blood gas was pH of 7.37, PaCO2 65, and PaO2 of 90 (2 liters nasal cannula). His uric acid level was 450 μmol/L.\nHe received crystalloid fluids at 100 mL/hour for 24 hours, and bilevel noninvasive mechanical ventilation 12/4 cm H2O. He subsequently improved over 36 hours. His ME from a compensated metabolic alkalosis with hypercapnea was corrected, and urine output improved. He could now converse, feed himself, and walk 50 feet with his walker. | [[93.0, 'year']] | M | {'12913099': 1, '9605783': 1, '19347026': 1, '16758506': 1, '17296459': 1, '18668637': 1, '16944413': 1, '12242532': 1, '24459629': 2} | {} |
165,308 | 3891287-1 | 24,473,729 | noncomm/PMC003xxxxxx/PMC3891287.xml | Dental manifestations of patient with Vitamin D-resistant\nrickets | A 5 year-old boy was referred to the Pediatric Dentistry Clinic with the complaint of "a\nsmall ball that appeared in the mouth". During the anamnesis, the patient was diagnosed\nas having hypophosphatemic vitamin D-resistant rickets. The child was the third twin;\nhowever, the parents as well as the siblings, did not have the metabolic disorder. The\nmedicines taken by the patient were calcitriol and phosphate supplements. He presented\nshort stature and several skeletal abnormalities.\nClinical examinations revealed fistula at the periapical region of primary maxillary\nleft lateral incisor without caries or trauma (). The patient presented complete primary dentition and none of the teeth\nexamined showed evidence of caries ().\nRadiographic examinations included periapical, panoramic and occlusal views showing pulp\nchambers enlarged, with pulp horns extending to the dentino-enamel junction, poorly\ndefined lamina dura and hypoplastic alveolar ridge (). The patient presented a large physiologic wear of the incisors,\ngeographic tongue and primary mandibular right lateral incisor (#82) and canine (#83)\nwith crown alteration (). There were\nareas of rarefaction around the apices of the primary maxillary right and left central\nincisor (#51,61), primary maxillary right and left lateral incisor (#52,62), primary\nmaxillary right and left canine (#53,63) and primary maxillary right and left first\nmolar (#54,64), primary mandibular right and left central incisor (#81,71) ( and ).\nInitially, two sections of management were performed. The treatment was divided into two\nphases: at first, the extraction of the teeth was performed: #51, 61, 81 and 71. At the\nsecond phase, endodontic treatment of the teeth: #52, 62, 53 and 63. These procedures\nwere executed with local anesthesia and rubber dam isolation. The root canals were\nsubmitted to preparation with Kerr files and dressing with paramonoclorofenol\n(Biodinâmica LTDA, Brazil) for 48 hours. Canals were filled with zinc oxid-eugenol and\niodoform paste and restored with resin glass ionomer cement (Vitremer, 3M/ESPE,\nUSA).\nDuring the aforementioned treatment, primary mandibular right first molar (#84), primary\nmaxillary right and left first molar (#54,64) and primary mandibular left second molar\n(#75) showed periapical fistula without evidence of caries or trauma in a short-term.\nThese teeth were extracted. However, the child was constantly sick and did not attend\nthe consultations. In the other teeth, the primary mandibular right second molar (#85),\nlateral incisor and canine (#82,83), primary maxillary right and left second molars\n(#55,65), primary mandibular left first molar and lateral incisor and canine\n(#74,73,72), the choice of treatment was to open the pulp chambers and make a dressing\nwith formocresol (Biodinâmica LTDA, Brazil). After a 7-day period, the dressing with\nformocresol was removed and the root instrumentation was performed and filled with zinc\noxid-eugenol and iodoform paste, afterwards the teeth were restored with resin glass\nionomer cement (Vitremer, 3M/ESPE, USA) ().\nIn order to maintain the space of primary maxillary right and left second molars and\nprimary mandibular right second molar, a fixed space-maintainer was made and cemented\nwith resin modified glass ionomer cement (Rely X, 3M/ESPE, USA) (). The postoperative clinic course was uneventful and\nafter six months of follow-up, the child did not show clinical abscesses. | [[5.0, 'year']] | M | {'30783081': 1, '29575674': 1, '30967742': 2, '29460029': 1, '9558542': 1, '3024137': 1, '6311883': 1, '34539639': 1, '33456267': 1, '34479530': 1, '32349265': 1, '25999324': 1, '31168978': 1, '21902707': 1, '14640368': 1, '31006822': 2, '8863313': 1, '3003172': 1, '12640383': 1, '23430969': 1, '9130929': 1, '12212880': 1, '22244648': 1, '12789152': 1, '17714351': 1, '25677243': 1, '10982952': 1, '6094631': 1, '31496578': 2, '24473729': 2} | {'6710950-1': 1, '6475631-1': 1, '6421925-1': 1, '6421925-2': 1} |
165,309 | 3891386-1 | 16,134,772 | noncomm/PMC003xxxxxx/PMC3891386.xml | Kimura's Disease Involving Thoracic and Abdominal Lymph Nodes in a Hemodialysis Patient | A 45-year-old man was admitted for evaluation of a series of painless, firm, movable neck masses. He had a history of tuberculous pleurisy 25 years prior to this complaint. He was also a carrier of hepatitis B virus surface antigen. He denied experiencing asthma, urticaria, or any other allergic reactions. He had received maintenance hemodialysis for 3 years, for end-stage renal disease resulting from chronic glomerulonephritis. Hemodialysis was performed 3 times weekly for 4 hours per session, using polysulfone dialysis columns. In the preceding 4 months, the patient had discovered masses in his neck. These masses had gradually increased in size. The patient had no history of fever, cold sweating, or weight loss. During the physical examination, firm and movable masses, measuring up to 3×3×2 cm (the largest one) were found. These masses were palpable with no tenderness, and were located primarily in the right anterior triangle of the neck. Although there were also several palpable masses in both the axillary and inguinal areas, no hepatosplenomegaly was detected. No warm sensations or erythema manifested on the overlying skin. Stool examinations, including ova and parasite evaluations, were negative. Laboratory findings included a hemoglobin level of 7.3 g/dL, platelet count of 200×109/L, and a white blood cell (WBC) count of 6.2 × 109/L: the differential WBC count revealed 68.9% segmented neutrophils, 10.2% lymphocytes, 8.4% monocytes, 12.1% eosinophils, and 0.4% basophils. Serum total IgE level was 261.0 IU/mL. The blood urea nitrogen and serum creatinine level were 56 mg/dL and 4.8 mg/dL. Neoplastic disease appeared to be the most likely differential diagnosis. Fine needle aspiration cytology of the neck mass revealed findings of nonspecific reactive lymphadenitis. A computed tomography (CT) scan of the neck and chest revealed masses adjacent to both sternocleidomastoid muscles, numerous lymph nodes of varying size in both axillary areas, and over lymph nodes of over 1 cm in size in the paratracheal, subcarinal, and intrapulmonary areas (). A CT scan of the abdomen and pelvis displayed multiple lymph nodes of varying size, which were enhanced in the hepatic hilum, peripancreatic area, celiac axis, and paraaortic area (the largest was 4.5 cm) (). A tumor scan using Gallium-67 demonstrated more noticeable increased uptake lesions in the left lower cervical, left axillary, paraaortic, right iliac, and both inguinal lymph nodes (). The findings from fine needle aspiration cytology were inconclusive with regard to diagnosis, thus an open biopsy was recommended. An excisional biopsy of neck masses and inguinal lymph nodes was performed. Results of histopathological examinations of the neck mass and lymph nodes revealed dense infiltration of eosinophils, lymphocytes, and histiocytes, along with many small vessels, mild fibrosis, and results consistent with KD, with no evidence of malignant lymphoma ().\nThereafter, the patient has received no specific treatment, as his symptoms, with the exception of the mass, were clinically unremarkable. After two months, physical examination revealed no neck masses, and a follow-up abdominal CT scan showed that the numerous lymph nodes of varying size had subsided spontaneously (). Until now, the patient has been progressing well on maintenance hemodialysis. | [[45.0, 'year']] | M | {'28549475': 2, '2919716': 1, '10872190': 1, '9761524': 1, '9865639': 1, '12205289': 1, '765004': 1, '15087670': 1, '28764210': 1, '11234448': 1, '10743766': 1, '32180608': 1, '19468829': 1, '16134772': 2} | {'5446720-1': 1} |
165,310 | 3891387-1 | 16,134,773 | noncomm/PMC003xxxxxx/PMC3891387.xml | Autoimmune Chronic Pancreatitis Relapsing Despite the Maintenance Dose of Steroid | A 59 year old man was admitted to another hospital because of epigastric pain and jaundice. The patient had been healthy until three months earlier when he began to experience postprandial epigastric pain and he lost 9 kg of weight. Abdominal US revealed diffuse swelling of the pancreas that was especially more prominent in the head portion. The patient was transferred to Asan Medical Center under the impression of pancreatic cancer.\nThe patient drank only a little alcohol and had no history of diabetes mellitus, hypertension, pancreatitis and biliary stone disease. On physical examination, there was a mild tenderness over the epigastric area. The other physical examination findings were unremarkable. The total bilirubin was elevated to 7.9 mg/dL (normal range: 0.2~1.2 mg/dL). Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated to 214 IU/L (normal range: < 40 IU/L) and 68 IU/L (normal range: < 40 IU/L), respectively. γ-Glutamyl transpeptidase (γ-GTP) and alkaline phosphatase (ALP) were also elevated to 385 IU/L (normal range: 11~63 IU/L) and 213 IU/L (normal range: 40~120 IU/L), respectively. Serum amylase was 46 U/L (normal range: 30~110 U/L), and serum lipase was 22 U/L (normal range: 22~51U/L). The CA19-9 was 24.5 U/mL (normal range: < 37 U/mL).\nThe total IgG concentration was normal (1,230 mg/dL, normal range: 694~1,618 mg/dL), but the serum IgG4 had not been initially measured. The test for lupus anticoagulant was positive, while the other autoantibodies such as anti-nuclear antibody, anti-mitochondrial antibody, rheumatoid factor and anti-smooth muscle antibody were all negative. Anti-carbonic anhydrase II antibody and anti-lactoferrin antibody were not measured.\nA dynamic CT scan revealed diffuse enlargement of the whole pancreas. An ERCP showed diffuse, irregular narrowing of the main pancreatic duct () and narrowing of the intrapancreatic common bile duct. An US-guided core needle biopsy was preformed, and we targeted the enlargedportion of the pancreatic head for differentiating between benign and malignant disease of the pancreas. Pancreatic histology confirmed marked lymphoplasma cell infiltration and fibrosis with acinar atrophy.\nThe patient was diagnosed as having autoimmune chronic pancreatitis based on the diagnostic criteria (characteristic pancreatic imaging, histologic findings and positive autoantibody) for autoimmune pancreatitis proposed by the Japan Pancreas Society. He was treated with prednisolone (40 mg/day) and by inserting a plastic stent (10 Fr, 5 cm) for the narrowing of the common bile duct. Three months after treatment with prednisolone (40 mg/day), a follow-up ERCP showed dramatic improvement of the narrowing () of both the main pancreatic duct and the common bile duct. The swollen pancreas returned to normal size on dynamic CT scan. The abnormal laboratory findings were normalized and he gained about 4 kg of weight. As a result, the biliary stent was removed and the daily dose of prednisolone was then gradually tapered to 5 mg over a period of 6 months. Since then, the patient had taken low dose steroid (5 mg/day) without discontinuation.\nNine months after maintenance therapy with 5mg prednisolone/day (sixteen months after the start of steroid treatment), the patient again complained of epigastric pain and jaundice of two days' duration. The total bilirubin was elevated to 7.4 mg/dL. AST, ALT and γ-GTP were elevated to 366 IU/L, 268 IU/L and 170 IU/L, respectively. Serum ALP and amylase were within normal range, while serum lipase was mildly elevated to 64 U/L. Characteristically, the serum IgG4 concentration was markedly increased (840 mg/dL, normal range: 6~121 mg/dL) with a normal concentration of total IgG. The test for the initially positive lupus anticoagulant was negative. A dynamic CT scan again revealed diffuse swelling of the pancreas. The ERCP showed segmental irregular narrowing of the main pancreatic duct in the tail portion () and the narrowing of the intrapancreatic common bile duct.\nIn spite of the maintenance therapy of low dose prednisolone (5 mg/day), the patient's relapse into autoimmune pancreatitis was strongly suspected. High dose prednisolone (40 mg/day) was administered again and the biliary stent was re-inserted into the common bile duct. Three months after therapy with a daily dose of 40 mg prednisolone, the abnormal liver function tests were normalized and serum IgG4 concentration also returned to normal. Yet it is interesting that the test for anti-nuclear antibody, which was negative on the first attack and on relapse, turned positive with a titer of 1:80 and with a nucleolar pattern during the retreatment for relpase. A follow-up ERCP demonstrated obvious improvement for the narrowing of both the main pancreatic duct () and the common bile duct. His symptoms including the epigastric pain also disappeared. Six months after maintenance therapy with 10 mg prednisolone/day and tapering by 5 mg per month, he is in good health. | [[59.0, 'year']] | M | {'12924637': 1, '8239251': 1, '11051349': 1, '12826900': 1, '11236777': 1, '11388391': 1, '12826899': 1, '10406367': 1, '11923760': 1, '7628283': 1, '9468255': 1, '14978368': 1, '12435868': 1, '12883257': 1, '9246047': 1, '16134773': 2} | {} |
165,311 | 3891388-1 | 16,134,774 | noncomm/PMC003xxxxxx/PMC3891388.xml | A Case of Pulmonary Inflammatory Pseudotumor: Recurrence Appearing as Several Consolidative Lesions after Complete Resection | A 56-year-old man with no significant medical history was admitted to our hospital for a lung mass on August 3, 1998. He was a 30 pack-year smoker, and worked as a scavenger. He complained of chronic cough with purulent sputum, and weight loss of about 5 kg in the past year. Upon physical examination, no abnormalities were found. The plain chest radiograph and CT scan revealed a relatively well-defined soft mass in the left lower lobe of the lung (). Transbronchial lung biopsy and percutaneous fine needle aspiration proved not to be diagnostic.\nA left lower lobectomy was performed on August 14, 1998. Upon gross examination, a well-demarcated lobulated, solid mass, measuring 4.3×3.4 cm, was detected in the lateral basal segment of the left lower lobe. The tumor exhibited a grayish-yellow, focally fibrotic cut surface, with anthracitic pigmentation. Probing of the lateral basal segmental bronchus revealed an obstruction located 3.0 cm from the resection margin. Microscopic examination revealed this to be a circumscribed lesion without a capsule. The alveolar architecture was obliterated, with a small number of residual airways appearing at the periphery of the lesion. The lesion itself consisted of a mixture of fibroblasts, myofibroblasts, and inflammatory cells, especially plasma cells, lymphocytes, occasional eosinophils, and histiocytes. The spindle cells were arranged in a storiform pattern, and clusters of plasma cells were interspersed with the lymphocytes. Lymphoid follicles were also occasionally seen (). The interlobar and inferior pulmonary ligament lymph nodes exhibited reactive hyperplasia. This lesion was diagnosed as an inflammatory pseudotumor, of the lymphoplasmacytic variety.\nThis patient returned to our hospital on December 26, 2002, complaining of aggravated cough and excessive sputum, which had persisted for 4 months. He also complained of intermittent hemoptysis. The plain chest radiograph and chest CT scan revealed three ill-defined consolidative lesions. One of these lesions was about 3.6 cm in size, with an internal air bronchogram, in the right upper lobe. The other lesions were about 3.5 cm in size, and they were located in the lingular division of the left upper lobe; these exhibited an appearance similar to that of the lesion in the right upper lobe (). Ill-defined small nodules were also noted around these lesions. Transbronchial lung biopsy was again performed. The biopsy specimens through the posterior segment of the right upper lobe revealed marked interstitial lymphoplasmocytic infiltrations with fibrosis. Biopsies through the superior segment of the lingular division in the left upper lobe also revealed marked interstitial lymphoplasmocytic inflammation with fibroblast proliferation. Microscopically, the specimens also exhibited massive infiltrations of inflammatory cells, including plasma cells, lymphocytes, and neutrophils, admixed with fibroblasts and myofibroblasts. These findings were similar to those from the previous mass (). We recommended a thoracoscopic biopsy, but the patient refused. We began oral prednisolone at 40 mg/day, and after gradually tapering the dosage, maintained it at 10 mg daily. We used this regimen for a total of 14 months, discontinuing it in March, 2004. On serial chest radiographs, all lesions appeared to have completely disappeared. On the patient's last visit, on August 31, 2004, the patient still complained of cough and sputum. There was, however, no evidence of a third recurrence on the follow-up chest radiograph. | [[56.0, 'year']] | M | {'401674': 1, '10974727': 1, '14577073': 1, '9580519': 1, '10647841': 1, '9457206': 1, '25562011': 1, '6031838': 1, '553662': 1, '26029612': 1, '11974867': 1, '981599': 1, '12647641': 1, '2841219': 1, '10320231': 1, '9606802': 1, '22004917': 2, '1941485': 1, '31384203': 1, '10434553': 1, '16134774': 2} | {'3215646-1': 1} |
165,312 | 3891389-1 | 16,134,775 | noncomm/PMC003xxxxxx/PMC3891389.xml | A Case of Extramedullary Plasmacytoma Arising from the Posterior Mediastinum | A 64-year-old man was referred to the pulmonary department of Korea University Ansan Hospital for an evaluation of a lung mass. He had received a medical checkup 1 month previously, when the mass-like lesion was incidentally found on plain chest X-ray. He was asymptomatic and had well controlled hypertension and diabetes; he also had a smoking history of 40 pack-years. On physical examination, no palpable lymphadenopathy or other abnormality was noted. His hemoglobin, white cell count, platelets, urea and electrolytes, glucose, liver function tests, and serum calcium were normal. The plain chest X-ray revealed a smooth marginated 3×4 cm sized mass-like lesion in the right upper mediastinal area (). Chest computerized tomographic (CT) studies, performed after the intravenous administration of a contrast agent, revealed a 2.5×2 cm sized, well defined, bilobed, homogeneously enhancing mass lesion in the right upper posterior mediastinum (). No definite evidence of bony erosion of the thoracic vertebrae was observed. On magnetic resonance imaging (MRI), the tumor was visualized as a homogeneous signal intensity mass with a signal intensity similar to muscle on T1-weighted images, whereas on T2-weighted images, the signal intensity was moderately higher than that of muscle. Moderate heterogeneous enhancement was noted with gadolinium-enhancement ().\nA provisional diagnosis of neurogenic tumor was made and percutaneous needle aspiration was performed for diagnosis. However, the histologic examination showed aggregates of small round cells. Therefore, a right lateral mediastinotomy was performed for a confirmatory diagnosis. Histologically, the tumor was characterized by a well circumscribed proliferation of plasma cells (). Immunohistochemical staining was positive for IgG and kappa light chain (), but not for lambda chain. The tumor cells were positive for CD79a (a pan-B cell marker) (), and CD45, and were negative for CD3 (a pan-T cell marker) and cytokeratin, which was consistent with plasma cell differentiation. Based on these findings, the tumor was diagnosed as a plasmacytoma. We investigated the possibility of multiple myeloma. Serum protein electrophoresis analysis showed a monoclonal gamma globulin peak of 1.8 g/dL (0.6~1.7 g/dL), and serum immunoelectrophoresis revealed IgG kappa type monoclonal gammopathy, but this was insufficient to meet the diagnostic criteria of multiple myeloma. Surveys for a skeletal lesion, bone marrow biopsy, and Bence-Jones protein in urine were all normal. 99mTc-scintigraphy did not detect any other systemic lesions. Accordingly, multiple myeloma was ruled out, and the patient was finally diagnosed as having EMP of the posterior mediastinum. The patient received treatment with 40 Gy of radiation for five consecutive weeks to a field covering the right upper mediastinum. Six months after his diagnosis, the patient is doing well without further evidence of disease. | [[64.0, 'year']] | M | {'6153562': 1, '10580871': 1, '8669215': 1, '12427612': 1, '2343147': 1, '26175782': 2, '8664190': 1, '7819027': 1, '6513309': 1, '1540888': 1, '26811561': 1, '6668499': 1, '7617650': 1, '10626148': 1, '11197455': 1, '8638902': 1, '27446469': 1, '16134775': 2} | {'4499596-1': 1} |
165,313 | 3891390-1 | 16,134,776 | noncomm/PMC003xxxxxx/PMC3891390.xml | A Case of Erythema Nodosum and Serositis Associated with Myelodysplastic Syndrome | A 34-year-old woman was diagnosed with MDS French-American-British (FAB) subtype refractory anemia in March, 2000. The patient did not receive any special treatment except intermittent transfusion of packed red cell.\nIn May, 2003 the patient presented with fatigue, myalgia, fever as well as multiple edematous, tender, erythematous to brownish subcutaneous nodular lesions on both upper and lower extremities and trunk (). Laboratory finding indicated hemoglobin 5.8 g/dL, white blood cell count 6.8×109/L, platelet 4.8×1010/L, and normal liver and kidney function test. Biopsy of skin lesion revealed lobular panniculitis consistent with erythema nodosum (). The skin lesion had improved with 20 mg of prednisone per day.\nOne month later, dyspnea, chest pain and fever developed and the skin lesions were aggravated. She was taking a tapering dose of prednisone (10 mg). The laboratory tests showed hemoglobin 6.0 g/dL, white blood cell count 4.8×109/L, platelet 8.0×109/L, uric acid 2.3 mg/dL, LDH 474 U/L (normal 211-423), serum ferritin 1831 ng/mL, serum iron/TIBC 145/162 µ g/dL. Antinuclear antibody, rheumatoid factor and ANCA were all negative. The levels of C3 and C4 were normal. Blood and urine culture were sterile. Chest X-ray and chest CT scan showed cardiomegaly with pulmonary edema (). Echocardiography revealed normal ejection fraction with large amounts of pericardial effusion. After the dose of prednisone was increased to 40 mg/day, the pericardial effusion and skin lesions had remarkably improved, suggesting that these newly developed symptoms might be attributed to the immune-mediated complications of MDS. The repeated bone marrow biopsy performed one month later revealed no evidence of progression to acute leukemia. However, the dysplastic changes in the myeloid, erythroid and megakaryocytes lineages had progressed compared to the examination in the prior month. While gradually tapering prednisone until July 2004, she was taking 5 mg/day of prednisone without pericardial effusion. Platelet count slowly increased and maintained above 2.0×1010/L. | [[34.0, 'year']] | F | {'11488828': 1, '1865418': 1, '11890302': 1, '8547082': 1, '10229317': 1, '7799343': 1, '3257709': 1, '9762816': 1, '3707859': 1, '1702927': 1, '9324739': 1, '3305727': 1, '16134776': 2} | {} |
165,314 | 3891391-1 | 16,134,777 | noncomm/PMC003xxxxxx/PMC3891391.xml | Eosinophilic Fasciitis Associated with Autoimmune Thyroiditis | A 45-year-old woman was referred to our hospital to evaluate the swelling on both the forearms lasting from past 3 months. She had intermittent cramp-like pain on both the forearms, which got aggravated by movement. The patient was placed on non-steroidal anti-inflammatory drugs intermittently. Raynaud's phenomenon was absent on past history.\nUpon physical examination, both the upper extremities showed marked swelling without pitting or erythematous change, and there was no swelling in the hands. However, physician was able to pinch her skin on both the forearms. Laboratory findings revealed the white cell count of 7,200/mm3 with 13.8% of eosinophils (absolute counts 993/mm3), hemoglobin of 10.8 g/dl and platelet count of 319×103/mm3. Stool examination for the presence of parasites was negative. Peripheral blood smear showed normocytic and normochromic red blood cells and no atypical leukocytes were seen except for an increased level of eosinophils. Liver function test, renal function test, and levels of CRP, glucose, creatinine kinase, calcium, and phosphate were normal. Esophagogastroduodenoscopy, colonoscopy, ultrasonography, and chest radiography revealed no abnormal findings. The titer level of anti-nuclear antibody in IT-1 cell was 1:40 with speckled pattern, but rheumatoid factor and anti-neutrophil cytoplasmic antibody wrere negative.\nBased on thyroid function test, the levels of thyroid stimulating hormone (TSH) and free thyroid hormone-4 (FT4), were 4.86 uIU/mL (normal 0.27~4.2 uIU/mL) and 0.85 ng/dL (normal 0.93-1.7 ng/dL), respectively. The titre values of antithyroglbulin antibodies and antimicrosomal antibodies were 1:1600 and 1:1600, respectively. No nodule was detected during ultrasonography of thyroid and there was no hot uptake by thyroid scan.\nMRI demonstrated swelling and increased signal of muscles like extensor carpi ulnaris, extensor digitorum longus, and extensor carpi radialis, and there was thickening and edematous change of fascia around the muscles (). Full-thickness wedge biopsy on extensor carpi radialis revealed the presence of thickened fibrous fascia with perivascular infiltration of lymphocytes, plasma cells and few eosinophils, and these findings were compatible with eosinophilic fasciitis (). To the patient, we initially prescribed prednisone 30 mg/day, cetirizine 10 mg/day and levothyroxine sodium 0.1 mg/day. Hypereosinophilia disappeared immediately after treatment with prednisone and induration on both the forearms also improved gradually. | [[45.0, 'year']] | F | {'6542592': 1, '10555099': 1, '33846906': 1, '3232080': 1, '26248532': 1, '11890876': 1, '2671538': 1, '7954202': 1, '23429351': 1, '34403405': 1, '1863073': 1, '28473954': 1, '1735088': 1, '10895980': 1, '10354391': 1, '7125411': 1, '16134777': 2} | {} |
165,315 | 3891392-1 | 16,134,778 | noncomm/PMC003xxxxxx/PMC3891392.xml | A Case of Primary Plasmacytoma of Lymph Nodes | A 56-year-old man was admitted to the otorhinolaryngology department, complaining of multiple palpable masses in the right cervical and submandibular areas, which slowly progressed in size during the past 8 years. The patient had neither any remarkable past medical history, nor a family history relevant to such a complaint. On physical examination, no palpable lymph nodes or masses in any other area of the body were noted. Initial laboratory values revealed mild anemia (Hb 11.6 g/dL), but normal leukocyte and platelet counts. Blood urea nitrogen (BUN), creatinine, calcium, inorganic phosphate, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum electrolyte levels were found to be normal. Serum albumin was 3.3 g/dL, and total protein was 8.9 g/dL. There were no abnormalities on the routine urine analysis. Neck and paranasal sinus computed tomography (CT) scans were conducted as part of an evaluation for surgical resection. Numerous enlarged lymph nodes were found to be conglomerated in the right submental and submandibular areas (level II, III, IV, V). The largest of these measured about 6.7×4.7 cm, and the right internal jugular vein was appeared to have been severely compressed by multiple enlarged lymph nodes. The tonsil, salivary gland, paranasal sinus, and nasal cavity yielded no abnormal findings (). The patient underwent surgery for the removal of the masses, but some small remnant masses persisted. Upon the gross examination of the removed lymph nodes, multiple grayish-white masses were seen, ranging from 2.5×1.8×1.5 cm to 6.5×5×4.5 cm in dimensions. Upon sectioning of the lymph nodes, the cut surfaces were grayish-white with focal hemorrhaging (). Histologically, the masses were composed of dense and diffuse infiltrations of atypical plasma cells, with a few residual atrophic lymphoid follicles. These secreted immunoglobulin (Lambda positive) aggregates with extensive amyloid deposits (Congo Red positive, Lambda positive/Kappa negative) in both the stroma and blood vessel walls (). After the operation, the patient was transferred to the hemato-oncologic department, for further evaluation and treatment. A full work-up was conducted in order to ascertain whether there was any other evidence of plasma cell dyscrasia. Serum and urine protein electrophoresis (PEP) and immunoelectrophoresis (IEP) were also conducted. Serum PEP revealed an M-spike in the gamma region, and serum IEP revealed abnormal arcs against anti-IgG and anti-Lambda antisera (), but urine PEP was not performed due to the small amount of available protein, and urine IEP revealed no abnormal arcs. The β2-microglobulin level was found to be normal (1.6 mg/L), and no osteolytic lesions were noted on the skeletal evaluation, which included a skull series. Rouleux formations were seen on the peripheral blood smear. However, bone marrow aspiration and biopsy from the iliac crest revealed trilineage elements of normal hematopoiesis, as well as no evidence of plasma cell dyscrasia. Accordingly, the patient was diagnosed with primary lymph node plasmacytoma, and was treated via radiotherapy (total dose of 50 Gy in 25 fractions). The residual mass is about 1×2 cm sized, so we are planning to monitor the patient with PET CT scans, as well as a neck CT, in order to assess the viability of the remaining mass. | [[56.0, 'year']] | M | {'455224': 1, '31113466': 2, '8892456': 1, '31412808': 1, '2343147': 1, '10357398': 1, '11316553': 1, '9227234': 1, '9308734': 1, '1540888': 1, '10629591': 1, '28424097': 2, '15009059': 1, '11190797': 1, '1272069': 1, '15042315': 1, '16134778': 2} | {'6530079-1': 1, '5397765-1': 1} |
165,316 | 3891393-1 | 16,134,779 | noncomm/PMC003xxxxxx/PMC3891393.xml | Percutaneous Transluminal Coronary Angioplasty for Coronary Artery Stenosis in a Young Patient with Long Term Kawasaki Disease | A 14-year-old boy was admitted to our institution for elective PTCA to relieve stenosis of the coronary arteries. At 4 years and 7 months of age, the patient presented to our institution with typical signs and symptoms of KD (persistent fever up to 39℃ for 10 days accompanied with conjunctival injection and a strawberry tongue). Consequently, the patient received intravenous gamma globulin and aspirin, which resulted in a prompt resolution of the fever and improvement of symptoms. Two-dimensional echocardiography performed during the acute phase of the illness demonstrated fusiform aneurysms of the right coronary artery (RCA) (10 mm in diameter), left anterior descending (LAD) branch (7 mm), and left circumflex (3.7 mm), as well as dilatation of the left main coronary artery (LMCA) (4 mm). However, there was normal systolic ventricular function without regional wall motion abnormalities. The patient was given low-dose aspirin and discharged from the institution. After discharge the patient was free of symptoms. An echocardiogram performed 15 months after the onset of illness demonstrated mildly improved fusiform aneurysms of the RCA (8.4 mm) and LAD (5 mm), as well as improved dilatation of LMCA (3.4 mm). However, there was no change in the left circumflex lesion. The patient was continued on a therapy of low-dose aspirin and remained asymptomatic. A 24 hour Holter monitor at 20 months, 40 months, and 68 months after presentation indicated normal heart rhythm with no evidence of ischemia. A treadmill test performed 9 years after presentation revealed no arrhythmias or ischemic changes. Nine years and 5 months after disease onset, selective coronary angiography revealed two saccular aneurysms in the proximal portion of the LAD, and in the proximal portion of the RCA as well as stenosis (minimal lesion in the proximal portion of the LAD, discrete lesion in the left circumflex, and total obstruction in the RCA with collateral arteries supplying blood to the distal portion of the RCA.)(). The patient retrospectively reported symptoms of intermittent chest discomfort for 5 months prior to catheterization. On admission, his blood pressure was 120/80 mmHg. His heart rhythm was regular and his heart rate was 76 bpm. The patient looked well and his physical examination and laboratory results did not reveal any abnormalities. Accordingly PTCA was performed at 9 years and 6 months after the onset of illness. The procedure employed a 3.5 mm balloon catheter in the stenotic lesion of the proximal portion of the left circumflex. The balloon was then inflated with diluted contrast medium to a pressure of 10 atm. The area of stenosis was 80% before PTCA and there was no residual stenosis after PTCA (). An intravascular ultrasound (IVUS) study was performed immediately after PTCA. The IVUS imaging revealed a calcified lesion and atheroma at the site of the left circumflex coronary artery (). The patient tolerated the procedure well with no electrocardiographic changes. He was discharged home on aspirin, ticlopidine, and isosorbide dinitrate. To date, he has been well. Currently, the patient is following a regimen of low-dose aspirin. | [[14.0, 'year']] | M | {'236368': 1, '3494796': 1, '10677411': 1, '2961993': 1, '2007710': 1, '7788031': 1, '9310527': 1, '7081062': 1, '2319795': 1, '2319403': 1, '1432415': 1, '8653877': 1, '7057330': 1, '8281655': 1, '11737728': 1, '7970970': 1, '6600576': 1, '8822996': 1, '16134779': 2} | {} |
165,317 | 3891405-1 | 15,906,964 | noncomm/PMC003xxxxxx/PMC3891405.xml | Malignant Peripheral Nerve Sheath Tumor in Neurofibromatosis Type I : Unusual Presentation of Intraabdominal or Intrathoracic Mass | Case I : A 31 year-old woman with a known neurofibromatosis was admitted complaining of a painful abdominal mass. A physical examination revealed a large, hard soft-tissue mass bulging out from the middle abdomen, and numerous, small subcutaneous neurofibroma nodules and brownish-pigmented lesions (café au lait spots) in the trunk and extremities (). An abdominal CT scan demonstrated a large (approximately 9×10 cm) inhomogeneous mass with an area of central necrosis (). The histopathology of the circumscribed and encapsulated mass obtained by a wide excision indicated a MPNST from the mesentery showing frequent mitoses in more than five per one high power field (). In the immunohistochemical stain, the tumor cells stained positively to the S-100 protein, which is a cytoplasmic marker used for identifying Schwann cells (). One month after surgery, the masses of the right paracolic gutter and the left supravesicle area appeared in the CT scan. The patient was then treated with 6 cycles of MAID chemotherapy (ifosfamide 2000 mg/m2 for 3 days, doxorubicin 20 mg/m2 for 3 days, and dacarbazine 300 mg/m2 for 3 days), which was followed by radiotherapy (5400 cGY). The masses began to disappear after chemoradiotherapy but the disease progressed 2 months later. She was treated with a further 6 cycles of VIP chemotherapy (etoposide 75 mg/m2 for 5 days, ifosfamide 1,000 mg/m2 for 5 days, and cisplatin 20 mg/m2 for 5 days), with a partial response being observed. However, she died as a result of disease progression 21 months after the initial diagnosis. | [[31.0, 'year']] | F | {'3083258': 1, '6791802': 1, '34796455': 1, '26604833': 2, '6766081': 1, '14050005': 1, '9400508': 1, '11769579': 2, '21418642': 2, '157612': 1, '3082508': 1, '9764434': 1, '24066249': 1, '858125': 1, '6796886': 1, '12504660': 1, '2614511': 1, '26155547': 1, '8753103': 1, '24133387': 1, '2134734': 1, '15906964': 2} | {'3891405-2': 2, '4531729-1': 1, '3070674-1': 1, '4630200-1': 1} |
165,318 | 3891405-2 | 15,906,964 | noncomm/PMC003xxxxxx/PMC3891405.xml | Malignant Peripheral Nerve Sheath Tumor in Neurofibromatosis Type I : Unusual Presentation of Intraabdominal or Intrathoracic Mass | Case II : A 33 year-old woman with a known neurofibromatosis was admitted due to left upper chest pain. A chest PA and CT scan demonstrated a homogenous mass measuring 3.5×2.5 cm at the left upper lung field with a well-demarcated margin (). A wide excision was performed. The microscopic findings showed a MPNST with focal neurofibroma area and positive immunohistochemical staining for the S-100 protein on the cytoplasm of the tumor cells. She was rehospitalized 6 months later due to persistent coughing and dyspnea. A chest CT scan demonstrated an inhomogeneous mass and a large amount of a left pleural effusion (). A needle biopsy of the mass showed a tumor recurrence. After 6 cycles of MAID combination chemotherapy, a CT scan showed that the mass was markedly reduced (). She is currently being treated with radiotherapy. | [[33.0, 'year']] | F | {'3083258': 1, '6791802': 1, '34796455': 1, '26604833': 2, '6766081': 1, '14050005': 1, '9400508': 1, '11769579': 2, '21418642': 2, '157612': 1, '3082508': 1, '9764434': 1, '24066249': 1, '858125': 1, '6796886': 1, '12504660': 1, '2614511': 1, '26155547': 1, '8753103': 1, '24133387': 1, '2134734': 1, '15906964': 2} | {'3891405-1': 2, '4531729-1': 1, '3070674-1': 1, '4630200-1': 1} |
165,319 | 3891406-1 | 15,906,965 | noncomm/PMC003xxxxxx/PMC3891406.xml | Ovarian Granulosa Cell Tumor presenting as Meigs' Syndrome with elevated CA125 | A 69-year-old Korean woman was admitted to our hospital complaining of abdominal fullness and dyspnea. Her family and medical histories were unremarkable. On physical examination, there was dullness to percussion, with decreased breath sounds in the lower half of the right lung field, a huge palpable mass in the lower abdomen, and on a rectovaginal examination a large, smooth solid mass was palpated on the left adnexa.\nLaboratory data on admission were within normal limits. A chest X-ray () and CT scan () showed massive right pleural effusion, and ultrasonography, CT and MRI scans revealed a 6×10×12 cm in sized intrapelvic huge solid mass, including cystic components involving both adnexae and the uterus, and a moderate amount of intra-abdominal fluid collection (, ). The MRI and CT scans showed no evidence of a metastatic disease involving the lymph nodes, bone or abdominal organs. The serum CA125 concentration was 82.49 U/mL (normal, 0~35 U/mL). The serum levels of carcinoembrionic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) were normal. A cytological examination of both the ascites and pleural fluid showed no signs of malignant cells. An explorative laparotomy was performed based on the suspicion of ovarian cancer. Serous ascites, a moderately enlarged uterus and a large right ovarian mass were found, but there were no signs of metastatic spread. A total abdominal hysterectomy (TAH) was performed, with a bilateral salpingo-oophorectomy (BSO), partial omentectomy and pelvic lymph nodes sampling. During the operation, the ovarian tumor ruptured in the pelvic cavity and 2,500 mL of serous ascites were drained during the laparotomy. Due to the right pleural effusion, a trocar tube was inserted into the right thorax, with a total of 650 ml of serous fluid collected.\nThe specimens of the left ovary and salpinx, macroscopically, showed a previously ruptured fragile, with numerous grayish brown ovary tissues. Necrosis or hemorrhage was not found. Microscopically, this neoplasm was composed of diffuse sheets of round to oval cells. The nuclei of this tumor were pale and round and oval or angular and have occasional nuclear grooves (). The totally removed uterus measured 7×4×2.2 cm in size, and showed adenomyosis and senile endometrium. The right ovary and salpinx were grossly clean, but no definitive lesion was found. The resected partial omentum showed no malignant findings. Resected left and right pelvic lymph nodes were no tumor in 13 lymph nodes. A cytological examination of the ascites drained during the operation showed no sign of malignant cells. The final diagnosis of the left ovarian mass was that of a granulosa cell tumor. The pathologic stage of the tumor was designated as T1cNOMO and IC, according to the TNM stage and to the International Federation of Gynecologists and Obstetricians (FIGO) staging system, respectively.\nThe hydrothorax and ascites rapidly resolved in the early postoperative period (), and the trocar tube was removed on the seventh postoperative day. Four cycles of postoperative chemotherapy were planned due to the tumor rupturing during the operation. The adjuvant chemotherapy consisted of CAP (cyclophosphamide 500 mg/m2, adriamycin 50 mg/m2 and cisplatin 50 mg/m2 on day 1) regimen. Each cycle was repeated every 28 days. The patient had an uneventful postoperative course. The serum CA125 level declined, and had normalized 2 months after surgery. | [[69.0, 'year']] | F | {'13148256': 1, '9764648': 1, '1495739': 1, '10021290': 1, '1275030': 1, '4501545': 1, '4316407': 1, '8096944': 1, '1390308': 1, '15154651': 1, '10192495': 1, '9022600': 1, '11053957': 1, '13760748': 1, '19225930': 1, '26430671': 2, '11228486': 1, '1563658': 1, '8522265': 1, '13154792': 1, '15906965': 2} | {'4588851-1': 1} |
165,320 | 3891414-1 | 15,906,955 | noncomm/PMC003xxxxxx/PMC3891414.xml | Visualization of Jejunal Bleeding by Capsule Endoscopy in a Case of Eosinophilic Enteritis | A 62-year-old man visited the emergency room complaining of epigastric and periumbilical pain, which had developed 3 hours prior to his admission. The nature of his complaint was colicky pain, but he had experienced neither nausea nor vomiting. He had no history of abdominal surgery, allergic disease, or food sensitivity. Physical examination revealed right lower quadrant abdominal tenderness, but no rebound tenderness. The patient's leukocyte count was 10,420/mm3 (2.9% eosinophils, normal range [NR], 0~5%). Abdominal computed tomography (CT) examination showed segmental wall thickening of the small bowel and proximal dilatation, mesenteric edema, and focal fluid collection in the adjacent peritoneal cavity (). However, there was no abrupt transition in the luminal diameter at either end of the pathologic bowel loop, suggesting a radiological abnormality, other than the strangulation normally observed in a case of intestinal obstruction. The radiological differential diagnosis included segmental enteritis of unclear cause, and focal mesenteric ischemia by a certain kind of systemic vasculitis, or post- strangulation state following the relief of obstruction. Twelve hours after his admission to the emergency room, the abdominal pain progressed, rebound tenderness developed, and finally, an exploratory laparotomy was performed. Exploration revealed edema, congestion, and bluish discoloration of the distal ileum, 50 cm from the ileocecal valve. Only a 15 cm segment was involved, and the remaining bowel was seen to be normal. The proximal bowel was dilated and the distal bowel had collapsed. The involved ileal segment was resected, and end-to-end anastomosis was performed. Gross examination showed an ill-defined mass-like wall thickening with multifocal erosion of the overlying mucosa, 7 centimeters in length, and the surrounding small intestinal mucosa was moderately edematous. Histologically, extensive eosinophilic infiltration was found in the mass-like lesion, which was found from submucosa to subserosa (). In the surrounding mucosa, edema with increased eosinophils was also observed. There was found to be no evidence of parasites, granulomas, malignancy, vasculitis, or embolism in the surgical specimen, either in the bowel wall or in the mesenteric vessels. The final diagnosis was eosinophilic enteritis. Two days after the operation, the patient's leukocyte count decreased to 8,070/mm3 (8.7% eosinophils). The pain disappeared and he was discharged normally. At the outpatient clinic, 12 days after the operation, the patient's total IgE was 1,310 u/mL above the normal range (0~100 u/mL), but skin prick test was normal, suggesting no specific allergic etiology. Seventeen days after the operation, similar characteristic abdominal pain developed again in the patient's periumbilical area, but to a milder degree than before the operation. The patient was advised to undergo gastroenterological testing in order to evaluate the abdominal pain, but he refused. Instead he (60 kg-weight) received 40 mg intramuscular injections of methylprednisolone acetate for two days, and simultaneously took 10 mg prednisolone three times per day, resulting in improvement of abdominal pain. Two weeks after this abdominal pain attack, hematochezia occurred for 4 days, in spite of continuous 30 mg prednisolone per day. The patient experienced dizziness, and his hemoglobin decreased from 13.6 g/dL (NR, 13-17 g/dL) to 9.5 g/dL. He was readmitted for a diagnostic work-up. Emergency colonoscopy showed no evidence of bleeding after bowel preparation with colyte, nor did it reveal any definite mucosal abnormality up to the ileocecal valve. Although there was no definite intrinsic mucosal lesion, six pieces of blind biopsy were taken from the hepatic flexure and 40 cm above the anal verge, but the pathologic results indicated only nonspecific change. In addition, gastroduodenoscopy up to the 3rd portion of duodenum revealed no abnormalities, and there was no evidence of bleeding. On the next day, the initial negative 99mTc-tagged red blood cell scan showed a small amount of bleeding from the right iliac artery 2 hours and 30 minutes after injection of 99mTc-tagged red blood cells, and migration of blood into the right ileal lumen after 4 hours and 30 minutes. However, CT angiography and arteriography, which were taken successively, showed no focus of bleeding, indicating that the bleeding had already stopped, or that the bleeding speed was slower than 0.5 mL/min. On the next day, M2A™ capsule endoscopy was performed. It showed that multiple hemorrhagic spots were scattered throughout the proximal jejunum (). After the normal jejunal segment, abrupt spurting of fresh arterial bleeding was detected in the mid-to-distal jejunum, but no ulcer, mass or vascular abnormalities were detected (). The ileum was normal, and the anastomotic site at the ileum was not noticed, suggesting no definite lesion around the previous operation site. Just 8 hours after the capsule endoscopy examination, a large amount of hematochezia, dizziness, and diaphoresis occurred, along with a decrease in hemoglobin level, from 9.7 g/dL to 6.9 g/dL. The patient did not take oral prednisolone during the 2 days of examination due to the unavailability of an oral intake state. Immediately after the detection of massive hematochezia, intravascular injections of 125 mg methylprednisolone sodium succinate per every 8 hours were started, and an emergency operation was prepared. Surprisingly, the hemoglobin increased to 10.7 g/dL with 3 packs of RBC transfusion, suggesting termination of the bleeding. Thereafter, the patient's hematochezia was undetected, and his hemoglobin remained stable. Five days later, the methylprednisolone sodium succinate injections were replaced with oral prednisolone treatment, 60 mg per day for 2 days, which was to taper down over a two-week period. The patient has been asymptomatic for 15 months with no medical therapy. | [[62.0, 'year']] | M | {'31559331': 1, '6731416': 1, '1951258': 1, '3497626': 1, '820590': 1, '9302934': 1, '12744585': 1, '9632875': 1, '2318432': 1, '8674794': 1, '17429740': 1, '12806199': 1, '8420276': 1, '16968606': 1, '9265579': 1, '22448186': 1, '14603834': 1, '9715314': 1, '12865269': 1, '15906955': 2} | {} |
165,321 | 3891415-1 | 15,906,956 | noncomm/PMC003xxxxxx/PMC3891415.xml | Cases of Swallow Syncope Induced by the Activation of Mechanorecepters in the Lower Esophagus | A 59-year-old man was admitted to hospital for the evaluation of syncope. The patient had been in good health except for when hypertension was detected 20 years earlier, and he had subsequently been treated for 3 years. Since he was about 30 years old, he had experienced many episodes of syncope when drinking a carbonated beverage (eg., a soda pop) and beer. About 4 years ago, syncope occurred while drinking cold water when he was taking a bath. Eating sticky foods such as a sweet potato, or even fast running caused syncope. The physical examination and routine laboratory results were normal except for a slightly increased serum creatinine level (132.6 µmol/L). Electrocardiography and chest X-ray findings were not specific. The left ventricular ejection ventricular hypertrophy was detected. A brain CT was normal. A carotid massage did not evoke any abnormal rhythms. Holter monitoring showed a sinus arrest with a maximum 7.2 seconds pause while drinking beer and a carbonated beverage (). An esophagogastroscopy, performed to search for an abnormality in the esophagus and stomach, showed only superficial gastritis at the fundus. Gastric distension by air could not induce syncope or an abnormal rhythm. An esophageal manometry showed no specific esophageal motility disorder except for transient low pressure in the lower portion of the esophagus. The patient was treated with a permanent pacemaker. After backing up the permanent pacemaker, esophageal balloon inflation by a Sengstaken-Blakemore tube with the pressure of 40 mmHg at the lower esophagus induced marked sinus bradycardia (). However, no response was observed at the middle and upper esophagus. | [[59.0, 'year']] | M | {'22493619': 2, '31391000': 2, '26504869': 1, '29209540': 2, '10577085': 1, '34336496': 2, '10406995': 1, '9058856': 1, '29123712': 1, '4343104': 1, '10932658': 1, '9182479': 1, '3995448': 1, '21263060': 1, '32328389': 2, '10461434': 1, '3825877': 1, '10383284': 1, '1020737': 1, '30546515': 1, '15906956': 2} | {'3891415-2': 2, '3318096-1': 1, '6686266-1': 1, '5676362-1': 1, '5676362-2': 1, '7176328-1': 1, '8319163-1': 1} |
165,322 | 3891415-2 | 15,906,956 | noncomm/PMC003xxxxxx/PMC3891415.xml | Cases of Swallow Syncope Induced by the Activation of Mechanorecepters in the Lower Esophagus | A 59-year-old male was referred to hospital for the evaluation of about four episodes of syncope which he had experienced for 1 year. The first episode occurred with a loss of consciousness for 5 minutes following eating foods with feeling obstruction in the esophagus. No specific kinds or forms of foods had been associated with the symptom. He had experienced syncopal episodes usually right after eating, but sometimes while eating foods. The patient had been in good health except for having about ten episodes of an obstructive feeling while eating for 3 years. The result of an esophagogastroscopy conducted 1 year ago had been normal. Physical examination results showed no abnormality. The laboratory FT4: 26.445 pmol/L, TSH receptor antibody 30.5%). The blood count and liver function tests were normal. An electrocardiography showed sinus bradycardia (57 beats per minutes). A chest X-ray showed a compression fracture at the lower thoracic spine. A thyroid scan showed no demonstrable abnormal finding. The Holter monitoring test could not be done for refusal of patient and rarity of the symptoms. Inflation of the balloon in the lower esophagus and gastroesophageal junction that was at the 9th thoracic spine level resulted in junctional rhythm (32~36 beats per minutes) with lightheadedness (, ). However, an atropine pretreatment blocked this response (). A syncopal episode was considered to occur with eating a bolus of food in a hurry; thus, he was treated by changing his eating habits for syncope and given propylthiouracil for Graves' disease. | [[59.0, 'year']] | M | {'22493619': 2, '31391000': 2, '26504869': 1, '29209540': 2, '10577085': 1, '34336496': 2, '10406995': 1, '9058856': 1, '29123712': 1, '4343104': 1, '10932658': 1, '9182479': 1, '3995448': 1, '21263060': 1, '32328389': 2, '10461434': 1, '3825877': 1, '10383284': 1, '1020737': 1, '30546515': 1, '15906956': 2} | {'3891415-1': 2, '3318096-1': 1, '6686266-1': 1, '5676362-1': 1, '5676362-2': 1, '7176328-1': 1, '8319163-1': 1} |
165,323 | 3891416-1 | 15,906,957 | noncomm/PMC003xxxxxx/PMC3891416.xml | Solitary Intra-abdominal Tuberculous Lymphadenopathy Mimicking Duodenal GIST | A 22-year-old woman presented with epigastric discomfort and intermittent dark-colored stools of two months duration. She had no previous illness and denied constitutional symptoms such as fever, weight loss, or night sweating. A physical examination detected no abdominal mass or tenderness, and no rebound tenderness. Laboratory studies showed a hemoglobin of 13.9 g/dL, leukocytes of 7,580/mm3, and an ESR of 17 mm/hr. Other biochemical tests results were within normal ranges, and anti-HIV Ab was negative. Stool occult blood was also negative. An esophagogastroduodenoscopic (EGD) examination revealed a round mass of about 3-cm at the duodenal bulb, with normal surrounding mucosa and central ulceration (). Several red or black spots on the base of the ulceration evidenced recent bleeding. An endoscopic biopsy taken at the ulceration margin identified chronic duodenitis.\nChest X-ray films showed inactive pulmonary tuberculosis at the left upper lobe, and abdominal computed tomography (CT) revealed a well-defined round mass that enhanced as gastric mucosa, at the posterior wall of the duodenal bulb suggestive of duodenal GIST (). Endoscopic ultrasonography (EUS) showed an ulcerative hypoechogenic mass at the submucosal layer of the duodenal bulb ().\nExploratory laparotomy was performed to exclude the possibility of malignant GIST of the duodenum. During laparotomy, a solitary mass was detected around the hepatic artery, which penetrated the duodenal bulb. The mass was excised and a histopathological analysis revealed lymphadenopathy with caseous granuloma (). Polymerase chain reaction of DNA extracted from the node was positive for tuberculosis and acid-fast bacilli were found by Ziehl-Neelsen tissue staining. The patient was diagnosed with solitary tuberculous lymphadenopathy and discharged on anti-tuberculosis medication. No evidence of recurrence has been observed during nine months\nof treatment. | [[22.0, 'year']] | F | {'7610239': 1, '7555442': 1, '7797832': 1, '7528472': 1, '11206225': 1, '22046094': 1, '24949696': 1, '18769984': 1, '1735086': 1, '1551503': 1, '11756912': 1, '3171223': 1, '2661873': 1, '8480741': 1, '10341698': 1, '9771382': 1, '1580128': 1, '8317433': 1, '8055387': 1, '32811429': 2, '12435870': 1, '9888707': 1, '15906957': 2} | {'7436982-1': 1} |
165,324 | 3891417-1 | 15,906,958 | noncomm/PMC003xxxxxx/PMC3891417.xml | Ileovesical Fistula Caused by Hepatocellular Carcinoma | A 27-year-old man was referred to our hospital for the evaluation of hepatic masses. He had consumed 30.0 g alcohol twice weekly for 8 years. On presentation, his vital signs were stable and the physical examination was normal. Liver function test was nonspecific. Viral marker study showed that HBs antigen was negative, anti-HBs antibody positive, and anti-HCV negative. α-fetoprotein (αFP) was over 50,000 IU/mL and carcinoembryonic antigen (CEA) was 4.94 ng/mL. Abdominal computed tomography (CT) with enhancement revealed two heterogeneous hypodense masses in the right hepatic lobe of about 2.4 × 2 cm and 3.4 × 4 cm. No cirrhotic change was observed in the liver. Upper intra-abdominal lymphadenopathy was absent. Liver magnetic resonance imaging (MRI) revealed two relatively well-defined masses in the right hepatic lobe (). These lesions were homogeneous low signal intensity on T1-weighted image and slightly inhomogeneous high signal change on T2-weighted image. The tissue diagnosis was obtained by percutaneous biopsy (). Immunohistochemical stains were positive for cytokeratin (CK), epithelial membrane antigen (EMA), αFP, and hepatocyte-specific antigen (HSA). These findings were compatible with HCC. However, evidence of cirrhosis and chronic injury were absent. Under the diagnosis of HCC, he was treated with transarterial chemoembolization (TACE). Abdominal CT scan was performed during the third week after TACE. The scan showed two lipiodol uptake lesions in the right hepatic lobe. Two months later, follow-up CT scan showed a newly developed mass in the caudate lobe about 4.5 × 4.0 cm in size, with several daughter nodules. A second TACE was performed. Follow-up CT scan after 3 weeks showed defective lipiodol uptake masses in both the right hepatic lobe and the caudate lobe with remnant tumoral enhancement. Thrombus was also observed in the inferior branch of the right portal vein. Several days later, the patient complained of dysuria, fecaluria, and intermittent lower abdominal pain. Pelvic CT scan showed a lobulated soft tissue mass about 6 cm in size (). The mass was abutting on\nthe distal ileum which was downwardly displaced. Barium study of the small bowel showed a fistula between the small bowel loop and the urinary bladder (). We diagnosed this as ileovesical fistula and referred him to the surgical unit.\nLaparotomy was performed under the diagnosis of ileovesical fistula. There were soft tissue masses between the ileum and the bladder and multiple lymphadenopathies at the mesenteric root. Adhesion and fistula were found between the ileum at 10 cm proximal to the ileocecal valve and the dome of the bladder.\nFistula and soft tissue mass were excised. The distal 65 cm of ileum was segmentally resected and anastomosed end-to-end. The bladder was partially resected and closed. Microscopic examination of the surgical specimen showed similar findings to those of liver biopsy. We confirmed that ileovesical fistula had been caused by implanted intraperitoneal metastases of HCC. | [[27.0, 'year']] | M | {'3689119': 1, '15235879': 1, '6721047': 1, '1925872': 1, '10966697': 1, '7074531': 1, '14222567': 1, '6272177': 1, '15906958': 2} | {} |
165,325 | 3891419-1 | 15,906,959 | noncomm/PMC003xxxxxx/PMC3891419.xml | Acute Exacerbation of Hepatitis in Liver Cirrhosis with Very High Levels of alpha-Fetoprotein But No Occurrence of Hepatocellular Carcinoma | A 59-year-old male with confirmed hepatitis C-related liver cirrhosis of over 10 years duration was admitted to our hospital in March 2003 for an evaluation of his functional and histopathologic status of the liver, and his levels of aminotransferases and alpha-Fetoprotein (AFP) that were checked at the outpatient department had persistently risen. At the time of the admission, he presented with general weakness and loss of appetite, and the vital signs were normal. The initial serology revealed mild hyperbilirubinemia with a total bilirubin of 1.3 mg/dL. The aminotransferase levels were 116 IU/L and 33 IU/L for aspartate (AST) and alanine (ALT) aminotransferase, respectively, with an alkaline phosphatase (ALP) 233 IU/L and γ-glutamyl transpeptidase (GGT) 109 IU/L. The AFP level checked on the admission was 4,720 ng/mL. The HBsAg and anti-HBs tests were negative and nonreactive. The anti-HCV (IgG) was reactive with a titer of 181.14 S/CO and the HCV (PCR) was 4+. A quantitative measurement of HCV-RNA was not carried out. The other serologic findings were normal. He was a type II diabetic and had no history of variceal bleeding, ascites, encephalopathy or any intake of herbs or alcohol before the admission. He had been followed up at the Department of Gastroenterology of the hospital since May 2002, and the aminotransferase levels checked since then were shown to be gradually increasing, and the AFP levels had increased markedly at the time of her admission (). As shown in the , the aminotransferases (AST/ALT) and AFP levels had increased from 57/18 IU/L and 18.1 ng/mL, respectively, in May 2002 to 196/71 IU/L and 4,720 ng/mL, respectively, in February 2003 until the commencement of antiviral therapy. Computed tomography (CT) of the liver taken during the admission showed no definite mass or intrahepatic focal lesion in the liver (). There were no other clinically significant abnormalities found on the CT scan. Hepatic angiography was carried out for the markedly elevated AFP level to rule out any possibility of hepatocellular carcinoma, but no definite tumor staining was noted in liver parenchyme (). The sequentially performed liver biopsy showed severe porto-periportal inflammatory activity, mild lobular inflammatory activity and septal fibrosis, and these findings were compatible with chronic active hepatitis in liver cirrhosis (). The post-lipiodol hepatic CT scan taken 2 weeks after the angiography for detecting any hidden tumor also showed no focal lesion or remnant of lipiodol staining in the liver ().\nThe patient was treated with antiviral therapy of Interferon (IFN) 3 million units three times a week along with Ribavirin 500 mg twice a day, and then the patient was discharged. The aminotransferases (AST/ALT) and AFP levels taken on follow up at the outpatient department after discharge decreased to 89/90 IU/L and 40.6 ng/mL, respectively, over a period of 3 months. He has taken the anti-viral therapy (IFN and Ribavirin) for over 6 months, and the aminotransferase levels have not changed significantly, and the AFP level did not increase any further. Moreover, the HCV (PCR) that was checked at the end of the antiviral therapy had converted to 'negative'. During the course of the therapy, follow-up imaging studies, abdominal ultrasonography and liver CT scan were undertaken along with serologic evaluation, and yet no evidence of tumor in the liver parenchyme was discovered. | [[59.0, 'year']] | M | {'6610488': 1, '16534867': 1, '30643846': 1, '33490235': 1, '1702350': 1, '2426173': 1, '6162548': 1, '26386723': 1, '6198238': 1, '2416627': 1, '2426756': 1, '7684823': 1, '25755491': 1, '26140083': 1, '76587': 1, '2430736': 1, '25755518': 1, '1329836': 1, '23372355': 1, '27246404': 2, '30854081': 1, '1698703': 1, '48562': 1, '34194888': 1, '75817': 1, '2461890': 1, '12394228': 1, '2411132': 1, '15906959': 2} | {'3891419-2': 2, '4888519-1': 1} |
165,326 | 3891419-2 | 15,906,959 | noncomm/PMC003xxxxxx/PMC3891419.xml | Acute Exacerbation of Hepatitis in Liver Cirrhosis with Very High Levels of alpha-Fetoprotein But No Occurrence of Hepatocellular Carcinoma | A 58-year-old female with confirmed hepatitis B-related liver cirrhosis was hospitalized for a detailed evaluation on the hepatic status in February 2003 because the AFP level checked at the outpatient department had tenaciously risen. From March 2002 to February 2003, the aminotransferases levels were slightly elevated, but the AFP level has increased from 8.55 ng/mL in March 2002 to 5,480 ng/mL in February 2003 (). At the time of the admission, she presented with no specific complaint. The physical examination showed no abnormalities except mild icteric sclerae. She had no past history of variceal bleeding, ascites, encephalopathy or intake of herbs or alcohol before her admission. The initial serology revealed macrocytic hyperchromic anemia (Hb 11.1 g/dL, Hct 27%) and thrombocytopenia (29,000 mm3), moderate hypoalbuminemia (2.7 mg/dL), mild hyperbilirubinemia (total bilirubin 2.3 mg/dL) and elevated aminotransferase levels (AST/ALT 130/42 IU/L). The AFP level checked on the admission was 5,480 ng/mL. The laboratory study on viral markers showed reactive HBsAg/nonreactive Anti-HBs, reactive HBeAg and an HBV-bDNA level of 5,582 pg/mL. A quantitative measurement of HbeAg was not carried out, and the other serologic findings were normal. A liver CT scan carried out during the admission confirmed liver cirrhosis with splenomegaly, ascites and portal hypertension, but there was no mass or focal lesion found in the liver (). There was no definite tumor staining on both lobes of the liver on the hepatic angiography (). A liver biopsy could not be carried out on account of the patient's adamant refusal. A post-lipiodol hepatic CT scan was subsequently undertaken 2 weeks after the angiography for detecting any hidden tumor, and it showed neither focal lesion nor lipiodol staining in the liver (). Since the initiation of antiviral therapy with Lamivudine 100 mg once a day, the aminotransferases (AST/ALT) and AFP levels have decreased approximately to 35/19 IU/L and 28.6 ng/mL, respectively, over a period of 3 months. The patient is currently still on the medication as the HBV (PCR) remains positive, but the aminotransferase levels are normal and the AFP level has fallen to 5.37 ng/mL after 9 months of therapy. | [[58.0, 'year']] | F | {'6610488': 1, '16534867': 1, '30643846': 1, '33490235': 1, '1702350': 1, '2426173': 1, '6162548': 1, '26386723': 1, '6198238': 1, '2416627': 1, '2426756': 1, '7684823': 1, '25755491': 1, '26140083': 1, '76587': 1, '2430736': 1, '25755518': 1, '1329836': 1, '23372355': 1, '27246404': 2, '30854081': 1, '1698703': 1, '48562': 1, '34194888': 1, '75817': 1, '2461890': 1, '12394228': 1, '2411132': 1, '15906959': 2} | {'3891419-1': 2, '4888519-1': 1} |
165,327 | 3891420-1 | 15,906,960 | noncomm/PMC003xxxxxx/PMC3891420.xml | Non-small Cell Lung Cancer Initially Presenting with Intracardiac Metastasis | A 64-year-old male was admitted to our hospital with the chief complaints of exertional dyspnea and vague chest discomfort that had developed a few weeks ago. On review of the symptoms, he also complained of fever and cold sweating that began 7 days before admission. He was an active smoker, and he did not have any allergies or familial medical history. The initial vital signs were as follows: blood pressure 100/75 mmHg, pulse rate 86 per minute, temperature 38℃, and a respiration rate of 20 per minute. There was no evidence of cervical lymphadenopathy, and there were no abnormal findings on chest and abdomen examination. Electrocardiography (EKG) showed a complete right bundle branch block (RBBB), and chest X-ray revealed a mass-like lesion in the right lower lung. Transthoracic and transesophageal 2-D echocardiography showed a large mass tightly attached to its akinetic apical wall in the right ventricular chamber (). Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a large tumor having involvement of the epicardium and myocardium in the right ventricle, and there was a mass in the right lower lobe of the lung and multiple lymphadenopathies (). The cytologic examination of the percutaneous fine needle aspiration of a lymph node in the anterior mediastinum revealed malignant epithelial cell nests that were strongly suggestive of squamous cell carcinoma (). Subsequent FDG PET confirmed that the intracardiac mass had an abnormally increased FDG uptake, which was strongly suggestive of malignancy (). Although there was no histologic confirmation, we diagnosed the heart mass as intracardiac metastasis by systematically considering these imaging studies. We discussed the treatment options with the patient and his family, such as surgical resection with histologic confirmation for the intracardiac tumor followed by palliative chemotherapy, or whether to perform palliative chemotherapy alone. Thereafter, we administered palliative chemotherapy with the combination of gemcitabine and cisplatin in consideration of the absence of right ventricular outflow obstruction and patient's preference. | [[64.0, 'year']] | M | {'3942141': 1, '1977851': 1, '9622051': 1, '27826577': 1, '7146861': 1, '30279827': 1, '8298329': 1, '2306690': 1, '10069723': 1, '29725564': 2, '9596162': 1, '32308579': 2, '26998153': 1, '21655905': 1, '2322057': 1, '11259706': 1, '26258073': 1, '12897654': 1, '3411785': 1, '8130618': 1, '9867146': 1, '28680205': 2, '34567334': 1, '14608547': 1, '15906960': 2} | {'5482017-1': 1, '7154231-1': 1, '5931410-1': 1} |
165,328 | 3891421-1 | 15,906,961 | noncomm/PMC003xxxxxx/PMC3891421.xml | Two Cases of Broncholith Removal under the Guidance of Flexible Bronchoscopy | A 65-year-old male patient was admitted to the hospital for the evaluation of atelectasis, and he had a history of recurrent hemoptysis and pneumonia for a few years. The broncholith was impacted at RB9, and there was inflammation of the surrounding mucosa on bronchoscopy. We removed the broncholith using a tripod forcep and the inflammation subsided afterwards (). | [[65.0, 'year']] | M | {'30505529': 1, '23236321': 2, '11796470': 1, '642158': 1, '1853800': 1, '682348': 1, '10471594': 1, '27848115': 2, '1186271': 1, '15906961': 2} | {'3891421-2': 2, '3517948-1': 1, '3517948-2': 1, '5147552-1': 1} |
165,329 | 3891421-2 | 15,906,961 | noncomm/PMC003xxxxxx/PMC3891421.xml | Two Cases of Broncholith Removal under the Guidance of Flexible Bronchoscopy | A 37-year-old female patient was referred from a general hospital due to a calcified lymph node from an unknown cause that was discovered on computerized tomography during the treatment for her pneumonia and parapneumonic effusion. Bronchoscopy revealed the impacted broncholith and exudate at the right lower opening. Fungus was cultured from the bronchoaleveolar lavage fluid. We removed the broncholith using a balloon catheter and tripod forcep after antifungal treatment (). | [[37.0, 'year']] | F | {'30505529': 1, '23236321': 2, '11796470': 1, '642158': 1, '1853800': 1, '682348': 1, '10471594': 1, '27848115': 2, '1186271': 1, '15906961': 2} | {'3891421-1': 2, '3517948-1': 1, '3517948-2': 1, '5147552-1': 1} |
165,330 | 3891422-1 | 15,906,962 | noncomm/PMC003xxxxxx/PMC3891422.xml | Renal Transplantation in a Patient with Idiopathic Thrombocytopenic Purpura | A 35-year-old man was hospitalized for generalized weakness and exertional dyspnea. He had developed ITP at 15 years of age and chronic glomerulonephritis at 27 years of age. However, he had been well without receiving a definite treatment.\nUpon admission, his vital signs were stable except for an increased blood pressure (150/100 mmHg), and a physical examination was unremarkable. His laboratory data were as follows: hematocrit, 24.4% (normal range, 42% to 52%); hemoglobin, 8.1 g/dL (normal range, 13 to 18 g/dL); white blood count, 6,100/µL (normal range, 4,000 to 10,500/µL); platelet count, 12,000/µL; serum blood urea nitrogen, 86.9 mg/dL (31.0 mmol/L) (normal range, 9 to 20 mg/dL [3.2 to 7.1 mmol/L]); and serum creatinine, 7.71 mg/dL (681.6 µmol/L) (normal range, 0.8 to 1.5 mg/dL [71 to 133 µmol/L]). His 24-hour urine protein excretion was 7.6 g. Blood chemistry showed a serum sodium level of 142 mmol/L (normal range, 135 to 145 mmol/L); potassium, 4.6 mmol/L (normal range, 3.5 to 5.5 mmol/L); albumin, 3.4 g/dL (normal range, 3.8 to 5.0 g/dL); calcium, 7.9 mg/dL (normal range, 8.3 to 10 mg/dL); and phosphate 4.6 mg/dL (1.49 mmol/L) (normal range, 2.5 to 5.0 mg/dL [0.80 to 1.60 mmol/L]). Liver function tests were all within normal ranges. All serologies were negative or normal, including antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, hepatitis B surface antigen and hepatitis C antibody. Serum immunoglobulin levels were normal and C3 and C4 complement levels were normal.\nUrinalysis revealed a specific gravity of 1.010, pH 7.5, 3+ protein, and macrohematuria. A chest X-ray was negative and a renal ultrasound revealed normal-sized kidneys. Bone marrow biopsy findings were compatible with ITP.\nThe patient was initially treated with steroids (1 mg/kg/day) for two weeks, but there was no increase in his platelet counts. Meanwhile, the blood urea nitrogen level increased gradually (to 55.3 mmol/L), and his uremic symptoms (nausea, poor oral intake and generalized weakness) became aggravated. Hemodialysis was initiated, and renal transplantation and a splenectomy were scheduled to be performed simultaneously as the optimal management of end stage renal disease and ITP.\nThe donor was the patient's 28-year-old sister, and HLA typing confirmed a haploidentical donor-recipient match. Before renal transplantation, a prophylactic pneumococcal vaccination was performed and intravenous immunoglobulin (IVIG, 1 g/kg) was given one day before transplantation. Cyclosporine, prednisolone, and mycophenolate mofetil (MMF) were used as initial immunosuppressive agents. At the time of renal transplantation, his platelet count was 89,000/µL.\nThe patient's initial graft function was good. Intraabdominal bleeding had developed just after transplantation, but bleeding was not observed thereafter (). His platelet count gradually increased on the tenth post-transplant day and the patient was discharged on the 37th post-transplant day with a normal serum creatinine level (114 µmol/L) and a platelet count of 124,000/µL (). The native kidney biopsy findings were consistent with IgA nephropathy ().\nTwo months later, the patient was readmitted because of fever, chill and headache. Cryptococcus neoformans was recovered from the blood, cerebrospinal fluid and pleural fluid. Systemic cryptococcosis was well-controlled with the reduction of immunusuppressants and an intravenous amphotericin B treatment.\nA two-year follow-up of the patient showed a favorable clinical course. His platelet count was stable and the graft function was well maintained. No further overwhelming sepsis was observed. | [[35.0, 'year']] | M | {'11688823': 1, '29554892': 2, '11798256': 1, '11703816': 1, '12043187': 1, '33976951': 2, '2440183': 1, '9704663': 1, '2484888': 1, '7917864': 1, '10419881': 1, '11919310': 1, '15906962': 2} | {'5859404-1': 1, '8087480-1': 1} |
165,331 | 3891423-1 | 15,906,963 | noncomm/PMC003xxxxxx/PMC3891423.xml | An Adult with Aplastic Crisis induced by Human Parvovirus B19 as an Initial Presentation of Hereditary Spherocytosis | A 34-year-old female was admitted to the hospital with the chief complaint of presyncope, which had developed a few hours previously. She also complained of febrile sensation and myalgia which had begun 4 days prior to admission. She had no allergies or past medical history, and her family history was unremarkable. The physical examination revealed a blood pressure of 90/60 mmHg, a pulse rate of 96 beats per minute, a temperature of 37.8℃, and a respiration rate of 18 times per minute. Her skin and conjunctivae were pale, and sclera was yellowish. No evidence of cervical lymphadenopathy or abnormal findings upon chest examination was found. The low margin of the spleen was palpable at 5 cm from the costal margin. The initial complete blood counts were as follows: hemoglobin (Hb) 3.0 g/dL, hematocrit (Hct) 8.4%, MCV 81.7 fl, MCHC 36%, white blood cell (WBC) count 3,160/mm3 (segmented neutrophil 66%, lymphocytes 30.5%, monocytes 1.5%), platelets count 163,000/mm3, and reticulocytes 0.2%. Liver function tests showed an aspartate aminotransferase 81 IU/L, alanine aminotransferase 52 IU/L, total bilirubin 5.2 mg/dL with indirect bilirubin of 3.5 mg/dL, and lactate dehydrogenase 763 IU/L. Serum iron, total iron binding capacity, and ferritin level were within normal ranges, and haptoglobin had been decreased to 38.0 mg/dL. The peripheral blood smear revealed spherocytosis with reticulocytopenia and pancytopenia (). The direct antiglobulin (Coombs) test was negative, and osmotic fragility of patient's red cells was increased. Bone marrow aspirate smears showed a few giant pronormoblasts with deep blue cytoplasm, pseudopods, and poorly demarcated intranuclear inclusions (). These results indicate that the diagnostic hypothesis was an aplastic crisis induced by HPV B19 infection in a patient with underlying HS. Using the patient's peripheral blood and bone marrow aspirate, we performed polymerase chain reaction (PCR) for the detection of HPV B19 DNA. The PCR of the patient's materials resulted in an amplification of the 496 base pair (bp) band, which was confirmed by the nested PCR, where a 232 bp band was amplified (). The patient was subsequently given eight units of packed red blood cells. During the course of admission, the WBC count decreased to 1,170/mm3 on the 2nd day and platelet count fell to 93,000/mm3 on the 4th day. We requested a serologic test for anti-HPV B19 IgM and IgG antibodies on the 10th day of hospitalization. Hematologic recovery began 12 days after admission. At discharge on the 15th day, the Hb was 8.4 g/dL, Hct 24.3%, WBC count 5,840/mm3, platelet count 233,000/mm3, and reticulocyte 5.1%. HPV B19 serology was pending at the time of discharge. One week later, the patient's Hb and Hct rose to 10.0 g/dL and 30%, with a reticulocyte count of 10%. Tests for anti-HPV B19 IgM and IgG antibodies were positive. | [[34.0, 'year']] | F | {'3008804': 1, '46024': 1, '6835376': 1, '8483154': 1, '9670826': 1, '3013275': 1, '7097899': 1, '24618088': 2, '14556276': 1, '9308316': 1, '26379354': 2, '14647664': 1, '20872096': 1, '2805616': 1, '2838911': 1, '12858419': 1, '1349370': 1, '2846031': 1, '15906963': 2} | {'3995927-1': 1, '4567607-1': 1} |
165,332 | 3891663-1 | 24,531,503 | noncomm/PMC003xxxxxx/PMC3891663.xml | Acute anterior uveitis after discontinuation of tocilizumab in a patient with rheumatoid arthritis | A 72-year-old woman presented with sudden loss of vision without pain in the left eye. Bilateral cataract surgery has been performed 6 months prior. At around 4 months before presentation, she was diagnosed with RA and had started tocilizumab monotherapy at a dose of 8 mg/kg every 4 weeks. However, the tocilizumab was discontinued after the third infusion, due to severe malaise and dizziness. Five weeks after the third infusion, she experienced a sudden decrease of vision. At presentation, the best corrected visual acuity (BCVA) was less than 2/200 in her left eye. An ophthalmological examination revealed severe anterior uveitis with hypopyon () and anterior vitritis but no apparent retinal lesion. There were no symptoms related to Behçet’s disease or human leukocyte antigen (HLA)-B27-associated acute anterior uveitis, and serologic tests for HLA typing were negative for HLA-A26, A29, B27, and B51. Because of the recent history of cataract surgery, the inflammatory symptoms led to a strong suspicion of delayed postoperative endophthalmitis. In addition to intravenous antibiotics, a diagnostic and therapeutic vitrectomy was performed. The obtained aqueous humor and vitreous samples were subjected to culture for bacteria and fungus, as well as multiplex polymerase chain reaction (PCR) for detection of human herpes viruses 1–8, bacterial 16S ribosomal ribonucleic acid (rRNA), and fungus 28S rRNA. However, no pathogens were detected from any ocular samples by these tests. Intravenous infusions of betamethasone 4 mg/day were initiated in addition to antibiotics, and the ocular inflammation improved gradually. After treatment with antibiotics and betamethasone was terminated on the eleventh postoperative day, cell infiltration into the anterior chamber increased on the next day, and the intravenous infusions of betamethasone 4 mg/day was restarted. Subsequently, the uveitis was ameliorated, and the anti-inflammatory treatment with intravenous betamethasone 4 mg/day was replaced by oral prednisolone 20 mg/day, on the 18th postoperative day.\nHowever, the uveitis recurred again in the left eye on the 43rd postoperative day despite the ongoing treatment with prednisolone 20 mg/day, and the IL-6 level in the aqueous humor was 46,100 pg/mL. The recurrent uveitis was improved by an additional subconjunctival injection of 2 mg of betamethasone. The patient has since remained relapse-free, with BCVA maintained at 20/20 (). No symptom of inflammation was observed in the right eye during the follow-up period.\nThis case report did not require Institutional Review Board/Ethics Committee approval. | [[72.0, 'year']] | F | {'17621174': 1, '26270662': 1, '32055765': 2, '18408082': 1, '1424743': 1, '18779787': 1, '28528519': 1, '9856775': 1, '16565012': 1, '16249505': 1, '20875797': 1, '18784373': 1, '20065633': 1, '25284976': 1, '17485422': 1, '20872595': 1, '2335453': 1, '8689490': 1, '20699242': 1, '20675730': 1, '22527320': 1, '9375862': 1, '24531503': 2} | {'7006420-1': 1, '7006420-2': 1} |
165,333 | 3892607-1 | 24,470,961 | noncomm/PMC003xxxxxx/PMC3892607.xml | Streptococcus pyogenes aortic aneurysm infection: forgotten but not gone | A 60 year old man had a past history of smoking, non-alcoholic steatohepatitis and a left ileofemoral bypass with a Polyethylene Terephthalate (Dacron) graft 7 years earlier. His only regular medication was esomeprazole. He became unwell during a trip to the United Kingdom, with sore throat, fevers and sweats. On return to Australia, fever and night sweats persisted, and he had 8 kg weight loss. Four weeks later he presented with back pain, an abdominal computed tomography (CT) scan revealed a para-aortic mass (), and he was referred to our emergency department for further management. On examination he was afebrile, heart rate 60 beats/min, normotensive with a pulsatile non-tender abdominal mass. White cell count (WCC) was 13.9×109/L and C-reactive protein (CRP) 207 mg/L. As he was clinically stable, empiric antibiotic therapy was withheld. Multiple blood cultures were obtained and a CT-guided biopsy of the periaortic mass was performed. Following the biopsy, he developed fever (40°C) and rigors, and intravenous ceftriaxone 2 g every 24 hours, vancomycin 1.5 g every 12 hours and metronidazole 500 mg every 12 hours were commenced. Blood cultures and biopsy specimens revealed pure growth of Streptococcus pyogenes, later confirmed as emm type 44. Antimicrobial therapy was modified to iv benzylpenicillin 2.4 g q4h alone. Transoesophageal echocardiography revealed no evidence of endocarditis. He was progressing well until day 7 when he developed worsening abdominal pain. Repeat abdominal CT scan revealed a contained rupture of the aneurysm. He underwent urgent endovascular aortic aneurysm stent graft repair. Fever resolved in 72 hours, and inflammatory markers reduced (Day 4: WCC 15.3×109/L and CRP 430 mg/L; Day 13 WCC 6.8×109/L and CRP 66 mg/L). He was discharged on day 15 and continuous infusion intravenous benzylpenicillin was continued via an outpatient antimicrobial therapy program, with a plan for 6 weeks therapy followed by lifelong oral amoxicillin.\nHowever he had ongoing weight loss, anorexia, his inflammatory markers failed to normalise. On day 53, he underwent graft explantation and axillo-bifemoral bypass. This was complicated by graft occlusion requiring therapeutic anticoagulation, and subsequent intra-abdominal haemorrhage. This ultimately resulted in irreversible ischemia of his left lower limb requiring below knee amputation. Culture of the explanted graft revealed Klebsiella oxytoca, Enterococcus faecalis, and methicillin-sensitive Staphylococcus capitus and Staphylococcus epidermidis, but Streptococcus pyogenes was not reisolated. Repeat CT imaging revealed no source of infection, and there was no evidence of intestinal pathology at the time of laparotomy. He was treated with intravenous piperacillin/tazobactam 4.5 g every 8 hours for a further 6 weeks, followed by oral amoxicillin/clavulanate, with a plan for lifelong antimicrobial therapy. On review 4 months after the initial presentation, he was recovering uneventfully and inflammatory markers had normalised. | [[60.0, 'year']] | M | {'9404777': 1, '7993259': 1, '30704409': 2, '18046585': 1, '12058219': 1, '22673141': 1, '33364037': 2, '28174648': 2, '28503338': 2, '30947680': 1, '22230680': 1, '15343514': 1, '30186637': 2, '19231471': 1, '23171095': 1, '1520802': 1, '10818188': 1, '1616380': 1, '31467741': 2, '21458201': 1, '24470961': 2} | {'6701359-1': 1, '6357504-1': 1, '6357504-2': 1, '7750026-1': 1, '5414497-1': 1, '6116405-1': 1, '5290507-1': 1} |
165,334 | 3892608-1 | 24,470,960 | noncomm/PMC003xxxxxx/PMC3892608.xml | A case of Creutzfeldt-Jakob disease: diagnostic dilemmas of a rapidly fatal disease | A 66 yr old male was admitted to the hospital following a fall on 12/29/2011. The fall was under strange circumstances wherein he felt sudden vertigo sensation while shutting his car door. He sustained an intertrochanteric fracture of hip during the fall. His initial evaluation indicated that he had profound dysmmetria in both upper extremities and absent proprioception. Further discussion with patient’s wife, indicated he had problems with balance since 2 months prior to presentation. He saw an otorhinolaryngologist for the same and underwent canolith repositioning procedure with the presumed initial diagnosis of benign positional vertigo. She felt that his balance problems had gotten worse since then.\nDuring post operative course of hip surgery patient spiked temperature and also had mental status changes. A lumbar puncture was done and meningeal infection was rule out. CSF was also sent for 14-3-3 assay along with complete paraneoplastic panel. He was then also noted to have slurred speech. An MRI of the brain was done which showed on FLAIR (fast fluid attenuated inversion recovery) images that there were T2 hyper intense signal changes and restricted diffusion in the bilateral basal ganglia(caudate and putamen nuclei) and right frontal cortex (). Although the official radiology report stated the diagnosis as basal ganglia infarct, teleradiology service hinted at the possibility of CJD along with toxic/metabolic encephalopathy. EEG revealed diffuse slowing but no sharp wave activity. Patients fever subsided but he continued to have severe ataxia.\nBased on the CDC criteria (), since patient had cerebellar problem with myoclonus and also MRI findings a diagnosis of probable CJD was made. Brain biopsy was suggested so that definitive diagnosis of CJD could be made but family refused. Patient was then send to inpatient rehab unit to work on balance and coordination while being closely followed by medicine service.\nIn the Rehab Unit patient had more myoclonus, a kinetic mutism along with worsening cognitive decline. Repeat MRI was obtained which did reveal changes of CJD more clearly. By this time his CSF immunoassay was positive for 14-3-3 protein and a diagnosis of CJD was established. When the diagnosis was told to family they choose palliative care, patient was then discharged to home with hospice. Patient expired 5 days after discharge to home.\nAutopsy an performed at University of Chicago Medical center revealed spongiform changes in basal ganglia, thalamus, substantia nigra and cerebellum with relative cortical sparing (). The spongiform changes in cerebellum were associated with atrophic changes in internal granular layer and Purkinje cell layer (). The morphologic changes fitted into one of the strains associated with relative cortical sparing and more prominent basal ganglia/cerebellar disease. Immunohistochemical exam done at National Prion Disease Pathology Surveillance Center, Cleveland (USA) confirmed sporadic CJD of VV2 type. The VV2 phenotype was based on molecular subtype determined by PRNP genotype and pathologic prion protein according to classification of sporadic CJD proposed by Parchi et al. VV2 is an ataxic variant which has ataxia at onset in 15% and has longer duration of illness. The PrP gene sequencing ruled out the presence of pathogenic mutation in the coding region of PrP gene and further abnormal prion protein type was characterized by Western Blot. | [[66.0, 'year']] | M | {'15582065': 1, '9450766': 1, '14515932': 1, '9710052': 1, '8707472': 1, '8410083': 1, '32122460': 1, '16958834': 1, '8782499': 1, '10778571': 1, '10720280': 1, '12563377': 1, '22505361': 1, '17179914': 1, '23795314': 1, '9639484': 1, '19773352': 1, '9300662': 1, '371520': 1, '24470960': 2} | {} |
165,335 | 3892609-1 | 24,470,964 | noncomm/PMC003xxxxxx/PMC3892609.xml | A case of emphysematous cystitis diagnosed by exploratory laparotomy | An 83 year old female, who had been hospitalized for years due to schizophrenia, complained of vomiting and diarrhea for 2 days. She had no history of diabetes mellitus, neurogenic bladder, or previous antimicrobiotic therapy, but had a urinary catheter in place for a considerable period since she was bedridden for many years. The diagnosis was acute enterocolitis and intravenous fluid was administered. After she developed a chill and lower abdominal pain with muscular defense, she was diagnosed as surgical acute abdomen and transferred to our emergency department.\nOn arrival, her body temperature was 38.2°C, blood pressure was 150/70 mmHg with a regular heart rhythm of 110 beats/min, and her respiratory rate was 22 breaths/min. Physical examination revealed tenderness over the lower abdomen with muscular defense, rebound tenderness, and loss of bowel sounds. Laboratory examination revealed a normal white blood cell count with elevated C-reactive protein (24.9 mg/dL). Urinalysis was unremarkable. An X-ray of the abdomen showed gas collection in the pelvic cavity, and CT scans of the abdomen revealed intraperitoneal fluid collection and abnormal gas accumulation in the pelvic space. The distribution of this abnormal gas was between the abdominal wall and retroperitoneal cavity including the urinary bladder wall, and its association with the intraperitoneal cavity was unclear ().\nIn accordance with the history, physical examinations, and radiological findings, the patient was diagnosed as acute peritonitis with possible perforation or penetration of the lower intestine, and exploratory laparotomy was performed. At laparotomy, severe inflammatory changes were observed in the peritoneum from just below the umbilicus to the lower abdomen (). Ascites in the peritoneal cavity was slightly turbid, but without a stool smell and there was almost no intraperitoneal inflammation. Other abdominal structures were intact, however, the bladder was swollen. When the bladder wall was pushed from the peritoneal cavity side, an unusual crackling sensation was felt and purulent urine was excreted via the urethral catheter. Dull dissection of the retroperitoneal cavity toward the bladder wall showed markedly loose connective tissue around the bladder due to severe emphysematous change, and the boundary with the bladder wall was unclear. These findings indicated emphysematous cystitis. The patient was placed on 1.5 g/day of intravenous doripenem for broad antibiotic coverage. Afterwards, K. pneumoniae was isolated from cultures of peritoneal fluid, urine, and blood (). Antimicrobiotic therapy was changed to intravenous administration of ceftriaxone at 2.0 g/day for 2 weeks. The patient recovered uneventfully and follow-up CT imaging after 3 weeks demonstrated resolution of the bladder wall emphysema. | [[83.0, 'year']] | F | {'30181931': 2, '15861946': 1, '17506870': 1, '17220755': 1, '2056576': 1, '24470964': 2} | {'6118292-1': 1} |
165,336 | 3892610-1 | 24,470,962 | noncomm/PMC003xxxxxx/PMC3892610.xml | First case report of infection by Mycobacterium wolinskyi after mammoplasty in Brazil | On September 15th, 2009, a 29-year-old woman, 61 kg, 1.69 m stature, Caucasian, with no comorbidities, post-graduated, Brazilian, from Recife-PE was submitted to an elective bilateral reductive mammoplasty on a private hospital of Recife-PE to remove 200 mL of each breast using the L technique for resections of excess of skin and breast tissue. Then an ampoule of adrenaline was infiltrated into her breasts, the bandage was realized using saline and Polivinilpirrolidone-iodine. The surgical procedure was concluded in 3 hours. The patient made her bandages at home using water, soap and an antiseptic solution of chlorhexidine gluconate. Healing occurred normally, with no trauma and no presence of inflammatory signs. One year after surgical procedure, on October 17th, 2010, the patient referred edema, heat and pain on her left breast. Although left breast presented no blush and normal aspect of scar.\nIt was requested a breast ultrasonography (USG) and it was prescribed a non-hormonal anti-inflammatory, Nimesulide 100 mg, one pill a day for 5 days, with no improvement of the signs and symptoms. USG revealed an image of a fluid collection filled by thin echoes, extending from 9 o’clock to 3 o’clock, with an antero-posterior diameter with approximately 2.3 cm, far around 2 cm of the skin with an increase of the echogenicity of the subcutaneous tissue on the region (). It was then prescribed treatment with cephalexin, 500 mg every six hours and Nimesulide, 100 mg, one pill a day for 5 days.\nAs there was no improvement of the clinical conditions, an aspiration of the fluid collection was performed in November 23rd, 2010 on patient’s left breast with an entry on the intern superior upper quadrant, obtaining a greenish secretion which was sent for automatized culture and antibiogram, both negative for bacterial growth. After the procedure, it was prescribed ciprofloxacin, 500 mg, 2 pills every twelve hours for 2 days and one pill every twelve hours totaling 10 days, without improvement of the condition. On November 30th, 2010, the patient was submitted to a surgery to drain the breast’s abscess, maintaining ciprofloxacin 500 mg, one pill every twelve hours, Diclofenac sodium, 100 mg one pill a day and Dipyrone one pill every six hours for 7 days.\nThe sample collected in this procedure was sent for automatized culture with antibiogram and for smear tests on acid fast bacilli (AFB), both showing negative results.\nAfter the end of the treatment with antibiotics, on December 13th, 2010 an USG showed an increase of the echogenicity on the cellular subcutaneous tissue and on the breast’s fat, associated with 2 collections which presented debris in suspension and irregular and inaccurate contours, measuring: 8.8×3.1×1.7 cm (vol =24.2 cm3), located on the superior upper quadrants of the left breast and another with 2.2×1.2×0.8 cm (vol=1.1 cm3); deeper than the previous one, which was located on the transition of the left lower quadrants, presenting 2 reactive lymph nodes on the left axilla, measuring 1.8 cm and the 1.4 cm, respectively.\nAfter confirming the presence of the collections, another aspiration was performed using USG, on the same breast in December 14th, 2010, and it was also requested in a private laboratory of the city. Another culture and cytological exam of the collected sample, showed one inflammatory cyst and growth of AFB on a specific culture medium, but the mycobacterium specie was not identified due to fungus contamination on the sample.\nA Chest X-ray was requested, and it didn’t show abnormalities, another USG was performed on January 24th, 2011, which revealed a new fluid collection, homogeneous, measuring: 2.0×0.7×1.5 cm located on the internal superior upper quadrant of the left breast. It was then prescribed vibramycin, 100 mg, one pill every twelve hours and trimethropim sulfamethoxazole, 400/160, one pill every twelve hours for 6 months, and it was also requested a new drainage. The drained material was sent to the Public Health’s Central Laboratory – Dr. Milton Bezerra Sobral (LACEN-PE), being isolated non-tuberculous mycobacteria in the culture medium. Mycobacterium wolinskyi was identified by sequencing specific genes; this technique was performed at Aggeu Magalhães Research Center, FIOCRUZ-PE. As the patient presented an evident improvement of the clinical conditions, the treatment scheme proceeded for more 6 months, independent on the antibiogram’s result () remaining asymptomatic for almost 11 months.\nAfter this period, on January 9th, 2012, the inflammatory signs and symptoms reappeared on the left breast, an USG showed 4 cystic images, the biggest at 12 o’clock measuring: 0.7×0.6 cm; the second had slightly thick walls associated with hyperechogenicity of the cellular subjacent subcutaneous tissue at 1 o’clock, measuring: 0.7×0.6×0.5 cm, far 1 cm of the skin and about 4 cm of the nipple; the third cyst presented an heterogeneous content with two adjacent cysts, located at 10 o’clock and measuring: 1.4×1.3×1 cm and 1.3×1.1×0.8 cm, far 3 cm of the nipple and 2 cm of the skin; and the fourth image was located at 5 o’clock measuring: 2.9×1.9×1 cm, far 1 cm of the skin and 4 cm of the nipple. The patient was then submitted to a new surgical procedure to drain the collection and to withdraw the necrotic tissue. This tissue culture revealed one more time the presence of Mycobacterium wolinsky, identified by sequencing specific genes. The prescribed therapy was an association of antibiotics, initially under hospital regimen, amikacin 1 g injectable per day with ciprofloxacin 500 mg every twelve hours and doxycycline 100 mg. Amikacin was maintained for 10 weeks under domiciliary regimen, 1 g intramuscular 3 times a week. The other 2 classes of antibiotics were also maintained for 6 months. After this period the patient was released from the therapeutic scheme with complete regression of the clinical symptoms.\nThe bacilloscopy performed with the samples was negative for AFB. The culture on Löwenstein-Jensen medium revealed AFB growth on less than 7 days, suggesting RGM. The colonies did not show any coloring, they were resistant to the para-nitrobenzoic acid (PNB) and to the Hydrazide of the 2-carboxilic acid (TCH); they did not show rope spoilage and the test for the presence of niacin was negative.\nA 764-bp fragment was amplified and sequenced with primers MycoF (5_-GCAAGGTCACCCCGAAGGG-3_) and MycoR (5_-AGCGGCTGCTGGGTGATCATC-3_). A total of 5 μL of each DNA solution (50 μg/mL) was added to 45 μL of a PCR mixture containing 50 mM KCl, 20 mM Tris-HCl (pH 8.4), 2.5 mM MgCl2, 200 μM each dNTP, 1 μM primers, and 1.0 U of Taq DNA polymerase (Promega). PCR mixtures were heated at 95°C for 1 min and then subjected to 35 cycles of denaturation at 94°C for 30 s, annealing at 64°C for 30 s, and extension at 72°C for 90 s, with a final step of 72°C for 5 min. Amplicons were purified with GFX PCR DNA and a Gel Band purification kit (G&E) and sequenced in an ABI PRISM 3100 sequencer with a BigDye Terminator cycle sequencing kit (Applied Biosystems). The sequences found were edited and aligned by analyzing the sequencing electropherograms using the program BioEdit v7.0.9. The sequences obtained were compared with those deposited in the GenBank database by using BLAST (http://www.ncbi.nlm.nih.gov/BLAST). The isolate had partial sequence of the rpoB gene with 99% (683/689) similar to GenBank accession number AY262743, which corresponds to Mycobacterium wolinskyi type strain ATCC 700010. The in vitro susceptibility test to antibiotics was performed using the microdilution broth assay (MIC) (). | [[29.0, 'year']] | F | {'23001976': 1, '17277290': 1, '22127408': 1, '14662964': 1, '10555330': 1, '27462223': 2, '19624503': 1, '26988052': 1, '22133415': 1, '28943571': 1, '21945390': 1, '20084322': 1, '18976585': 1, '24470962': 2} | {'4943297-1': 1} |
165,337 | 3892611-1 | 24,470,958 | noncomm/PMC003xxxxxx/PMC3892611.xml | A Pediatric Case of Cardiobacterium Hominis Endocarditis | A 12 year old boy, who was status post repair (shortly after birth) of Tetralogy of Fallot with pulmonary atresia and subsequent replacements of right ventricle to pulmonary artery conduit 4 years prior to current evaluation, was seen in an outside Pediatric cardiology clinic for his annual follow-up appointment. The appointment had been scheduled one month earlier on the patient’s request, due to the onset of generalized fatigue and decreased endurance of 2-3 weeks duration. The patient denied symptoms of fever, chest pain, dizziness or syncope.\nThe patient had a history of poor dentition, poorly controlled asthma, sleep apnea, and allergic symptoms, which led to an adenoidectomy two years prior to current presentation. The most recent right ventricle to pulmonary artery conduit replacement occurred 4 years prior to presentation which was complicated by Staphylococcus aureus mediastinitis. In clinic, by report, the physical examination revealed a well looking boy with thin habitus, in no acute distress with a heart rate of 102 beats/min, respiratory rate of 16 breaths/min and a blood pressure of 94/70 mmHg. Respiratory examination was significant for mild end expiratory wheezes. Cardiovascular examination demonstrated a regular rate and rhythm with a normal S1 and split fixed S2. A 3/6 graded harsh, early peaking, mid pitch systolic ejection murmur and a soft 2/4 graded diastolic murmur were heard best at the left sternal border. Of note, there were no peripheral stigmata of endocarditis (splinter haemorrhages, Osler nodes or Janeway lesions) and the remainder of the physical examination was unremarkable. A routine echocardiogram showed a bright and thickened conduit valve with a suggestion of mass attached to the leaflet. This was not present on the previous echocardiogram (approximately 2 years prior).\nBlood work at the clinic appointment was significant for a mildly elevated ESR of 25 mm/hour, CRP of 11.5 mg/L and a WBC of 5.92 cell/cm3 with 16% of monocytes. Repeat blood work 2 days later showed slight improved CRP of 7.6 mg/L, unchanged ESR and CBC, normal electrolytes, LFT, CXR, and sinus films. A throat culture was positive for Streptococcus and ASO titre was elevated. The patient was started on amoxicillin for Streptococcal pharyngitis. At this time, the patient spiked a fever of 38.3°C. The blood cultures taken both at presentation and two days later became positive for a slow growing gram negative rod.\nBased on the positive blood cultures and the findings on the ECHO, the patient was referred for admission at University of Michigan C.S. Mott Children’s Hospital with the diagnosis of subacute bacterial endocarditis four days after the initial clinic visit. Upon admission the patient was continued on amoxicillin for the Streptococcal pharyngitis and empirical treatment for bacterial endocarditis with intravenous (i.v.) vancomycin and i.v. piperacillin/tazobactam was initiated. Infectious Diseases was consulted three days after admission and the antibiotics were narrowed to i.v. ceftriaxone 1700 mg q 12 hours since blood cultures had become negative after the first few doses of amoxicillin. At this time, oropharyngeal flora was suspected and organisms such as Kingella and Haemophilus species are not particularly virulent and are susceptible to ceftriaxone.\nAerobic and anaerobic blood cultures obtained on admission and on the subsequent day remained negative. A trans-thoracic echocardiogram on the second day after admission demonstrated evidence of a new oscillating mass on a pulmonary valve leaflet concerning for a possible vegetation. The local laboratory was initially unable to identify the gram negative rod isolated from their clinic and the organism was sent to the University of Michigan microbiology laboratory where it was identified as Cardiobacterium hominis (C. hominis) that was susceptible to amoxicillin/clavulanate, meropenem, ceftriaxone and levofloxacin and resistant to ampicillin. The combined susceptibilities from the two laboratories are shown in .\nThroughout the duration of admission, the patient remained afebrile and well-appearing and was discharged home on the fifth hospital day in stable condition on i.v. ceftriaxone therapy through a right upper extremity peripherally inserted central catheter line to complete a 6 week course of antibiotics. Two weeks into the course of treatment, the patient developed an intense pruritic rash near his peripherally inserted central catheter (PICC) site and along the PICC line track concerning for allergy. Ceftriaxone was discontinued and ampicillin/sulbactam was started. However, the patient developed another lacy rash and ampicillin/sulbactam was then switched to levofloxacin 10 mg/kg/day orally for the remaining two weeks of antibiotic therapy. | [[12.0, 'year']] | M | {'10768915': 1, '7474277': 1, '14218438': 1, '11986458': 1, '11794152': 1, '9046942': 1, '11314361': 1, '18159562': 1, '625144': 1, '6622885': 1, '10885844': 1, '24470958': 2} | {} |
165,338 | 3892612-1 | 24,470,953 | noncomm/PMC003xxxxxx/PMC3892612.xml | Lymph Node Co-Infection of Mycobacterium Avium Complex and Cytomegalovirus in an Acquired Immunodeficiency Syndrome Patient | A 31-year-old homeless man with severe cachexia presented with abdominal pain for 2 hours prior to admission. During the preceding 3 years, he had several sexual contacts in addition to a history of IV drug addiction. He had previously been in good health. He was unaware of any family history of immunodeficiency disorder or infectious disease. He had a history of night sweats and a 12 kg weight loss in a period of three months. For the preceding 3 weeks, he had suffered from mild dyspnea. He was afebrile (Temperature: 36.5°C) and his pulse and respiratory rates were 88 and 26 per minute, respectively.\nA physical examination showed diffuse abdominal tenderness. Neither peripheral lymphadenopathy nor hepatosplenomegaly was detected. Auscultation of the heart revealed normal sounds. Diffuse rales were heard in a chest examination. An examination of the oral cavity, pharynx, larynx, salivary glands and skin was unremarkable. A neurological examination showed bilateral normal ankle-tendon reflexes, and sensory and motor exams were normal.\nA chest X-ray showed a diffuse miliary pattern. Sonography revealed several para-aortic lesions of varying size, which were consistent with lymphoma. Laboratory data showed leukopenia [white blood cells: 1200/mL, lymphocytes: 26%; polymorphonuclear leukocytes (PMN): 68%], normocytic anemia [Hemoglubin (Hb): 115 g/L], first hour erythrocyte sedimentation rate (ESR) was 76 mm/h, C-reactive protein (CRP) was 40 mg/L (normal, <5 mg/L), lactate dehydrogenase (LDH) and alkaline phosphatase were not high (400 IU/L; and 250 IU/L, respectively), and alanine amino-transferase (ALT) and aspartate amino-transferase (AST) levels were in the normal range (45 and 40 IU/L, respectively). Blood cultures remained sterile. Several other workups were all unremarkable.\nThe patient continued to have abdominal pain and tenderness after admission, while no source of acute abdominal pain was identified. Diagnostic laparotomy was performed for the multiple para-aortic lymph nodes and they were removed for histopathological examination. Unfortunately, the patient developed respiratory arrest and died in the operating room. The cadaver was shifted to Legal Medicine Organization of Fars and an autopsy was performed 24 hours after death to determine the exact cause of death.\nMultiple para-aortic lymphadenopathy was identified, and the diameter of the largest lymph node was 25 mm. Gross examination of the lungs showed diffuse congestion and patches of consolidation. The liver and spleen were grossly unremarkable with a normal size. The central nervous system, heart, gastrointestinal tract, kidneys, bladder and all other organs showed no significant changes. Microscopic examination of the lungs showed a predominantly mononuclear inflammatory infiltrate in conjunction with edema and hyperplasia of the alveolar epithelium. A characteristic intra-nuclear CMV inclusion body was detected (). The immunoperoxidase technique using monoclonal antibody (Clone DDG9 + CCH2, Dako, Denmark) confirmed the diagnosis of CMV infection. Examination of the enlarged lymph nodes showed diffuse replacement of nodal architecture by foamy, large and plump macrophages.\nThe cytoplasm of these macrophages contained large amounts of a diastase resistant Periodic Acid Schiff (PAS) positive material due to the presence of bacilliform bodies. Acid fast stain showed macrophages containing innumerable organisms (). CMV intra-nuclear inclusions were also detected in these lymph nodes (). No fungi or bacteria were identified with Gram, PAS, metenamin silver or Warthin-Starry stains. Serological studies for HIV antibody on peripheral blood (preserved in the hospital blood bank) were positive for enzyme immunoassay, which confirmed a western blot assay. Serological tests for hepatitis A, B, C and syphilis showed negative results. Examination of other organs showed no specific changes, either grossly or microscopically. | [[31.0, 'year']] | M | {'16732891': 2, '15083089': 1, '12799150': 1, '24470903': 1, '18588499': 1, '9691498': 1, '9780266': 1, '9241969': 1, '21420653': 1, '21390885': 1, '24470953': 2} | {'1488855-1': 1} |
165,339 | 3892613-1 | 24,470,952 | noncomm/PMC003xxxxxx/PMC3892613.xml | Brain Tuberculoma in a Non-Endemic Area | A 24 year-old man who had immigrated from Ethiopia six years prior presented to our Emergency Department with intermittent left leg shaking for two days. His left leg felt tired and he was reluctant to stand on it. He was previously healthy and had no history of fever, chills, night sweats, or weight loss. He was well appearing with no abnormal findings on physical and neurological examination. A computed tomography (CT) scan showed right frontoparietal edema. A contrast-enhanced scan was performed, revealing an associated frontoparietal enhancing mass. magnetic resonance imaging (MRI) of the brain demonstrated a 2.6×1.6 cm mass with surrounding edema (). CT of chest, abdomen, and pelvis revealed periceliac and peiraortic lymphadenopathy, and questionable but no definitive pulmonary nodules. Having received the Bacillus Calmette-Guérin vaccine, his tuberculin sensitivity test was positive. He was started on levetiracetam for treatment of simple partial seizures, and dexamethasone for treatment of vasogenic edema. He underwent right parietal craniotomy with intraoperative monitoring for resection of the lesion and tissue diagnosis. The underlying dura was soft and uninvolved. Opening the dura revealed a superficial mass with well defined margins that easily peeled away from the underlying parenchyma (). Pathological examination demonstrated necrotizing granulomas with peripheral palisading epithelioid histiocytes, giant cells, and acid fast bacilli, consistent with cerebral tuberculoma (). Blood cultures and HIV testing were negative. Following surgery, he had no neurological deficits and had no further seizure activity. He was rapidly tapered from steroids and continued on levetiracetam for an additional month. He completed a six-month regimen of isoniazid, rifampin, ethambutol, and pyrizinamide, and was doing well without neurological sequelae five months after completion of therapy. | [[24.0, 'year']] | M | {'564480': 1, '3729203': 1, '12742798': 1, '19643501': 1, '17920686': 1, '8553259': 1, '13611575': 1, '5673313': 1, '4650782': 1, '1545907': 1, '12889171': 1, '12472215': 1, '6371589': 1, '629659': 1, '5828909': 1, '2046896': 1, '9559986': 1, '2723675': 1, '3760972': 1, '24470952': 2} | {} |
165,340 | 3892614-1 | 24,470,954 | noncomm/PMC003xxxxxx/PMC3892614.xml | Staphylococcus Intermedius Infections: Case Report and Literature Review | A 73 year old Caucasian female with a history of severe osteoarthritis developed fever, pain, redness, and swelling of her left elbow one month following a revision left elbow total arthroplasty. The original arthroplasty 10 years earlier had been complicated by infection that was successfully treated with several weeks of intravenous antibiotics according to the patient; the details of this remote infection and treatment were unattainable. She was subsequently well for many years without antibiotics until about 2 years prior to presentation when she began to develop gradually progressive joint instability and pain. She was admitted for elective total arthroplasty of the left elbow. Following surgery, she noted continuous serosanguinous drainage. Her orthopedist aspirated the joint on post-operative day 22. The joint fluid was described as cloudy with 26,000 red blood cells, 1300 white blood cells and 31% neutrophils. No organisms were seen on Gram stain, and bacterial cultures were negative. Patient was not started on antibiotics at this time. A few days later (post-operative day 25) she developed progressive elbow pain and fever and was admitted to the hospital. On admission, her temperature was 102.2°F and her white blood cell count was 11,000 cells/mm.\nOn surgical exploration, a large fluid collection was found in the elbow. The joint capsule appeared intact, however both wound and joint fluid cultures grew S. intermedius, as identified by the Vitek II automated microbiology system without further subspeciation. The wound was irrigated but the elbow prosthesis was not removed. Blood cultures were negative. In accordance with CLSI standards, the elbow isolates were determined to be resistant to penicillin and tetracycline but susceptible to oxacillin, erythromycin, clindamycin, chloramphenicol, gentamicin, rifampin, levofloxacin, linezolid, and vancomycin. The patient was treated with intravenous cefazolin and rifampin for six weeks and then transitioned to oral levofloxacin and rifampin with plan for a prolonged course given retention of infected prosthesis. She has not had any recrudescence of disease after 10 months on this regimen and will be reevaluated for possible cessation of therapy at one year’s time.\nThe patient was an avid dog lover. Although she did not recall her dog licking or biting her elbow after surgery, she did report that her dog frequently licked her face. She admitted to frequent close contact with her dog including sharing her bed at night. She denied any recent illness or skin lesions in her dog. | [[73.0, 'year']] | F | {'3103090': 1, '17596353': 1, '10747154': 1, '18065673': 1, '20601356': 1, '22132141': 1, '26301242': 1, '15605196': 1, '33779509': 1, '27086303': 1, '16014483': 1, '21300509': 1, '11506928': 1, '1168014': 1, '2913039': 1, '28042159': 1, '19826243': 1, '7963622': 1, '15583331': 1, '7494062': 1, '6429188': 1, '2705672': 1, '33209954': 1, '9887159': 1, '2584388': 1, '20348087': 1, '20164279': 1, '2687313': 1, '14738778': 1, '22170938': 1, '14991518': 1, '8062882': 1, '20934636': 1, '20178486': 1, '1562653': 1, '28663821': 1, '17050817': 1, '21075051': 1, '10433599': 1, '21420256': 1, '1474272': 1, '21824350': 1, '26509181': 1, '24470954': 2} | {} |
165,341 | 3892618-1 | 24,470,957 | noncomm/PMC003xxxxxx/PMC3892618.xml | Hyperimmunoglobulin E Syndrome Presenting as Osteogenesis Imperfecta in a 3 Year Old Child | A three and a half year old boy was referred to Pediatric Infectious Disease clinic with a history of asthma, environmental allergies, multiple lung infections, long bone fractures, and hand-foot-mouth disease, for evaluation of recurrent skin abscesses and bullae. By the time of evaluation in Pediatric Infectious Disease Clinic a, referral to genetics had already been initiated to evaluate the child for Osteogenesis Imperfecta because of the history of recurrent long bone fractures.\nAccording to the patient’s mother, the abscesses and bullae usually occurred on the face and were generally of rapid onset. Most often, they began as a pimple on the cheek in the morning and progress forming large mildly erythematous bullae by the afternoon. Multiple lesions had been lanced and cultured, most often revealing Staphylococcal species. The mother first noticed very bad lesions on the patient’s face as a small infant, initially attributing these lesions to bad baby acne; however, the complexion was much worse than her other children, as well as other children who she knew. Additionally, the patient also experienced multiple, severe blisters over the leg when a cast was removed due to a distal tibia fracture. Additionally, approximately one and a half months prior to evaluation the patient was admitted to an outside hospital for recurring bullae on the medial aspect of the left foot. These bullae were surgically debrided and the fluid expressed was cultured, revealing budding yeast. The patient had a similar infection when he was three years old. At that time a culture from the lesion revealed yeast and the patient improved with oral fluconazole.\nThe patient was the product of a 37 week 2 day uncomplicated pregnancy, but was hospitalized in the NICU for ten days, requiring mechanical ventilation secondary to pulmonary edema.\nA review of the patients past medical history revealed a combination left tibia and fibula fractures at age 21 months, a combination left radius and ulna fracture at 29 months, and a fracture of the left tibia at 41 months. Each instance was due to minor trauma.\nLaboratory studies obtained from the outside hospitalization revealed a white blood cell count of 11.4 cell/cm, hemoglobin of 12.0 g/dL, and platelets of 385,000 cell/cm. The differential demonstrated 52% lymphocytes, 5% monocytes, 11% eosinophils, 31% neutrophils, and 1% basophils. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both normal. A biopsy of the debrided tissue on his left foot revealed dermal changes consistent with a hypersensitivity reaction to a fungal infection. Direct immunofluorescence shows weakly patchy granular dermal-epithelial junction of IgM and C3.\nThe lesions responded to intravenous ambisome followed by Itraconazole. The subtyping of IgG were within normal limits, IgG1 of 894 mg/dL, IgG2 of 164 mg/dL, IgG3 of 17 mg/dL, and IgG4 of 133 mg/dL, with a normal antibody response to the Diptheria toxoid and Tetanus toxoid and T and B cell subtypes were normal.\nPartial immunizations had been given to date and the patient history revealed allergies to sulfa drugs, eggs, and some wheat products by skin test. His family history was significant for a paternal grandmother with CVID and asthma, asthma and allergies on the paternal side, and the patient’s mother and maternal grandmother had systemic lupus.\nOn physical exam, in Pediatric Infectious Disease Clinic at the University of Michigan, the height was in the 89th percentile, the weight is in the 96th percentile, and he appeared as a playful young boy in no apparent distress. There were multiple small, non-erythematous, hard papules over the cheeks and bridge of his nose. The facies were not dimorphic and the dentition was good. No blue tint of hue was noted in the sclera and the pupils were equal round and reactive to light. There was no cervical lymphadenopathy with no other masses in the neck were appreciated. The lungs were clear to auscultation bilaterally. The abdomen was soft, non-tender, non-distended with no hepatosplenomegaly. The medial aspect of the left foot had new granulation tissue with a lesion approximately 3 cm by 4 cm from a previous bulla. New bullae formation was occurring on the periphery of the healing lesion. Muscle mass, strength and tone were within normal limits and the joints were not hyper-extensible. The neurologic exam was grossly intact.\nLaboratory studies obtained from Pediatric Infectious Disease Clinic revealed an immunoglobulin panel with an IgA level of 214 mg/dL (normal 15-160 mg/dL), IgG level of 1260 mg/dL (normal 405-1160 mg/dL), IgM level of 117 mg/dL (normal 40-190 mg/dL), and an IgE level of >10,000 kU/L (normal 0-150 kU/L). The subtyping of IgG were within normal limits, IgG1 of 947 mg/dL, IgG2 of 92 mg/dL, IgG3 of 18.3 mg/dL, and IgG4 of 42 mg/dL, with a normal antibody response to the Rubella. A CH50 level was normal at 101 units (normal 52-128 units). The ESR and CRP were normal and a Gram stain and culture from the left foot were negative. | [[3.5, 'year']] | M | {'20816194': 1, '4161105': 1, '20159255': 1, '19190525': 1, '10441580': 1, '17881745': 1, '14722525': 1, '22451222': 1, '10053178': 1, '17804589': 1, '21178271': 1, '22268731': 1, '24470957': 2} | {} |
165,342 | 3893332-1 | 24,454,007 | noncomm/PMC003xxxxxx/PMC3893332.xml | Tumor Lysis Syndrome in a Solid Tumor: A Case Report of a Patient with Invasive Thymoma | A 40-year-old female presented to the emergency room with a three-day history of progressive dyspnea due to pleural effusion in February 2010. A computed tomography (CT) scan of the chest showed an extensive soft-tissue mass, measuring 12×8 cm in size, in the anterior mediastinum extending into the right hemithorax and pericardial space (). Percutaneous gun biopsy of the right anterior mediastinal mass confirmed WHO type B3 thymoma (), classified according to the Masaoka clinical staging system. Due to the unresectable state of disease, neoadjuvant chemotherapy was scheduled in order to reduce the tumor size prior to surgery. From February 19 to April 5, 2010, the patient received three cycles of systemic chemotherapy with a regimen consisting of docetaxel (75 mg/m2 i.v. over 1 hour on day 1) and cisplatin (75 mg/m2 i.v. over 1 hour on day 1). Despite a slight interval decrease in the size of thymoma and a decreased amount of pericardial and pleural effusion after three cycles of chemotherapy, two more cycles of chemotherapy were administered due to incomplete resectability and patient's reluctance.\nDue to disease progression during follow-up, the patient received four additional cycles of systemic chemotherapy with a regimen consisting of cyclophosphamide (500 mg/m2 i.v. over 1 hour on day 1), doxorubicin (50 mg/m2 i.v. over 30 minutes on day 1), and cisplatin (50 mg/m2 i.v. over 1 hour on day 1) from May 11 to July 26, 2010. The disease status remained stable for 11 months after second-line chemotherapy, and thereafter showed slow progress. On April 12, 2012, the patient complained of aggravation of dyspnea and chest X-ray showed massive pleural effusion on the right side of the chest. Chest CT showed aggravation of anterior mediastinal thymoma with extension into the middle mediastinum and surrounding pericardium as well as the entire right side of pleura (). A percutaneous pig-tail catheter was inserted into the right pleural space for drainage of malignant pleural effusion. Third-line chemotherapy was started on April 18, 2012, with a regimen consisting of paclitaxel (175 mg/m2 i.v. over 3 hours on day 1), ifosfamide (2,500 mg/m2 i.v. over 2 hours on days 1 and 2), and mesna (500 mg/m2 i.v. over 15 minutes on days 1 and 2). After completion of one cycle of chemotherapy, tachypnea, tachycardia, and oligouria were detected on the second day of chemotherapy. Blood chemistry showed the following: potassium, 5.3 mmol/L (3.5-5.1 mmol/L); phosphorus, 20.0 mg/dL (2.5-4.5 mg/dL); uric acid, 25.0 mg/dL (2.4-6.0 mg/dL); calcium, 5.5 mg/dL (8.4-10.2 mg/dL); arterial blood gas analysis, pH 7.24 (7.35-7.45); bicarbonate, 9.8 mmol/L (21.0-31.0 mmol/L); urea nitrogen, 73.6 mg/dL (8.0-22.0 mg/dL); creatinine, 3.74 mg/dL (0.6-1.1 mg/dL); lactate dehydrogenase (LDH), 4,153 IU/L (240-480 IU/L); and urine pH, 5.5 (5.0-8.0). Based on the patient's clinical symptoms and consequent laboratory findings, it was determined that the patient had developed classical signs of TLS, including acute kidney injury. The patient was immediately transferred to the intensive care unit for treatment, including aggressive hydration, intravenous bicarbonate for urine alkalinization, allopurinol, and repeated hemodialysis. On day 3, continuous renal replacement therapy was started and continued until day 5. During the following days, the patient's clinical symptoms and signs, such as dyspnea, tachypnea, and tachycardia, showed improvement, and the biochemical markers, including metabolic acidosis, hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia, returned to normal (). The plasma level of LDH was 1,139 IU/L before chemotherapy, increasing to 4,153 IU/L on day 3, and decreased to 498 IU/L on day 22 ().\nHemodialysis was performed twice per week from April 25 to May 9, due to persistent azotemia despite adequate urine output (). Serum urea nitrogen and creatinine concentration decreased to 15.2 mg/dL and 1.45 mg/dL, respectively, on day 35; therefore, further hemodialysis was not required. Of particular interest, remarkable regression of the preexisting tumor after one cycle of third-line chemotherapy was observed on a follow-up chest CT scan (). The patient has remained on the same regimen with partial response to chemotherapy without recurrence of TLS. | [[40.0, 'year']] | F | {'20420966': 1, '17168213': 1, '25002953': 1, '20331465': 1, '12655435': 1, '10091788': 1, '18628171': 1, '21561350': 1, '7977169': 1, '24454007': 2} | {} |
165,343 | 3893333-1 | 24,454,008 | noncomm/PMC003xxxxxx/PMC3893333.xml | Sunitinib Treatment for Metastatic Renal Cell Carcinoma in Patients with Von Hippel-Lindau Disease | A 42-year-old female was found to have masses in both kidneys four years ago and was transferred to Asan Medical Center. Her family history included VHL disease in her father and her older sister. She also had hemangioblastoma in the cerebellum, which was removed 16 years ago. Abdominal computed tomography (CT) scan performed at this hospital showed masses in both kidneys which were suspected to be RCC; thus, the patient underwent partial nephrectomy of the left kidney. Two months later, the patient underwent radical nephrectomy of the right kidney. Pathology of the samples revealed clear cell RCC in both kidneys. The patient developed local recurrent RCC in the left kidney two years after nephrectomy and was subsequently treated by radiofrequency ablation. The patient then developed multiple metastases in the lungs and was transferred to the oncology department.\nChest CT subsequently confirmed multiple metastases in both lung fields and the patient was diagnosed with lung metastases of RCC and started treatment of sunitinib (50 mg for two weeks, followed by a one-week rest period). The metastatic tumors were found to have regressed following sunitinib administration and reached partial response according to the Response Evaluation Criteria in Solid Tumors (RECIST) criteria (). After administration of sunitinib for 16 months, the patient suffered hand and foot neuropathy (grade 2), and wanted a dose reduction; we decided on a dose reduction of sunitinib (25 mg for two weeks, followed by a one-week rest period). After that, this patient became tolerable to treatment. This partial response has been maintained at a steady state for three years and three months with sunitinib administration. No changes in pancreatic mass lesions or hemangioblastoma of the cerebellum during administration of sunitinib were observed during that period of time (). After that, a chest CT scan showed disease progression in the lung; therefore, the patient's treatment was changed to everolimus (Afinitor, Novartis, Basel, Switzerland). Chest CT at two months of treatment with everolimus showed progression of the disease, therefore, the medication was changed again to sorafenib (Nexavar, Bayer, Leverkusen, Germany). The patient also achieved partial response to sorafenib and is currently receiving treatment with sorafenib for five months. | [[42.0, 'year']] | F | {'22105611': 1, '17215529': 1, '31326218': 1, '25866969': 1, '20368553': 1, '8778606': 1, '17538086': 1, '21105118': 1, '9562581': 1, '32606780': 1, '12814730': 1, '33329393': 1, '12546356': 1, '22056247': 1, '31737565': 1, '20457723': 1, '10630173': 1, '11040195': 1, '26500709': 1, '27852035': 1, '25715769': 2, '29947576': 1, '24454008': 2} | {'3893333-2': 2, '3893333-3': 2, '3893333-4': 2, '4720105-1': 1} |
165,344 | 3893333-2 | 24,454,008 | noncomm/PMC003xxxxxx/PMC3893333.xml | Sunitinib Treatment for Metastatic Renal Cell Carcinoma in Patients with Von Hippel-Lindau Disease | A 45-year-old male patient was diagnosed with bilateral RCC five years ago and subsequently underwent partial left nephrectomy and radical right nephrectomy. Pathology of the samples revealed clear cell RCC in both kidneys. At this time, the patient was found to have multiple pancreatic cysts and was diagnosed with RCC and VHL disease. At three months post-operative follow-up, the patient was admitted to the hospital with right flank pain. Abdominal CT scan showed a recurrent RCC measuring 2.5 cm in size in the right psoas muscle adjoining the partially nephrectomized kidney. The patient started on sunitinib treatment (50 mg, four-week treatment with a two-week rest period). Treatment with sunitinib resulted in regression of the tumor, and at six months, the patient had achieved a partial response (). At 21 months, the patient is still undergoing treatment with sunitinib and is being followed up. | [[45.0, 'year']] | M | {'22105611': 1, '17215529': 1, '31326218': 1, '25866969': 1, '20368553': 1, '8778606': 1, '17538086': 1, '21105118': 1, '9562581': 1, '32606780': 1, '12814730': 1, '33329393': 1, '12546356': 1, '22056247': 1, '31737565': 1, '20457723': 1, '10630173': 1, '11040195': 1, '26500709': 1, '27852035': 1, '25715769': 2, '29947576': 1, '24454008': 2} | {'3893333-1': 2, '3893333-3': 2, '3893333-4': 2, '4720105-1': 1} |
165,345 | 3893333-3 | 24,454,008 | noncomm/PMC003xxxxxx/PMC3893333.xml | Sunitinib Treatment for Metastatic Renal Cell Carcinoma in Patients with Von Hippel-Lindau Disease | A 49-year-old male patient was diagnosed with RCC in the right kidney five years ago and underwent radical nephrectomy of that kidney. Pathology of the sample revealed clear cell RCC. At that time, the patient was also found to have hemangioblastoma in the right retina and the cerebellum and was diagnosed with VHL disease. On surveillance chest CT, multiple lung and pleural metastases were found. The patient was treated with sunitinib (50 mg, four-week treatment with a two-week rest period) and achieved partial response according to RECIST criteria four months after treatment with sunitinib (), which lasted four years and three months. Follow-up chest CT showed disease progression and the patient's medication was changed to everolimus. After two months of treatment with everolimus, response studies showed further disease progression and the patient is now receiving supportive care without further chemotherapy due to poor general condition. | [[49.0, 'year']] | M | {'22105611': 1, '17215529': 1, '31326218': 1, '25866969': 1, '20368553': 1, '8778606': 1, '17538086': 1, '21105118': 1, '9562581': 1, '32606780': 1, '12814730': 1, '33329393': 1, '12546356': 1, '22056247': 1, '31737565': 1, '20457723': 1, '10630173': 1, '11040195': 1, '26500709': 1, '27852035': 1, '25715769': 2, '29947576': 1, '24454008': 2} | {'3893333-1': 2, '3893333-2': 2, '3893333-4': 2, '4720105-1': 1} |
165,346 | 3893333-4 | 24,454,008 | noncomm/PMC003xxxxxx/PMC3893333.xml | Sunitinib Treatment for Metastatic Renal Cell Carcinoma in Patients with Von Hippel-Lindau Disease | A 44-year-old male patient presented to the hospital with left flank pain four years ago. Abdominal CT scan showed bilateral RCC and the patient subsequently received left radical nephrectomy and right partial nephrectomy. Pathology of the samples showed clear cell RCC in both kidneys. His older sister had been diagnosed with VHL disease and the patient also had several pancreatic cysts and VHL gene mutation (3p26-p25) resulting in a diagnosis of VHL disease. Three years prior to admission, the patient was found to have lung metastases in the right middle and lower lobes and underwent wedge resection of the right middle and lower lobes. Chest CT scan performed during post-operative follow up showed enlarged right hilar lymph nodes along with a metastatic mass invading into the superior vena cava. The patient was started on sunitinib treatment (50 mg, fourweek treatment with a two-week withdrawal period). After three months of treatment with sunitinib, the patient achieved partial response according to RECIST criteria (). Following treatment with sunitinib for one year and 11 months, the patient's abdominal and chest CT scan showed disease progression and the treatment was changed to everolimus. The patient is currently receiving treatment with everolimus for two months (). | [[44.0, 'year']] | M | {'22105611': 1, '17215529': 1, '31326218': 1, '25866969': 1, '20368553': 1, '8778606': 1, '17538086': 1, '21105118': 1, '9562581': 1, '32606780': 1, '12814730': 1, '33329393': 1, '12546356': 1, '22056247': 1, '31737565': 1, '20457723': 1, '10630173': 1, '11040195': 1, '26500709': 1, '27852035': 1, '25715769': 2, '29947576': 1, '24454008': 2} | {'3893333-1': 2, '3893333-2': 2, '3893333-3': 2, '4720105-1': 1} |
165,347 | 3893334-1 | 24,454,009 | noncomm/PMC003xxxxxx/PMC3893334.xml | Sarcoidosis Mimicking Cancer Metastasis Following Chemotherapy for Ovarian Cancer | A 52-year-old female was admitted to our hospital with a one-month history of abdominal pain on the left side. Her abdominal computed tomography (CT) scan showed ascites, omental caking, and peritoneal thickening. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. The final diagnosis was stage III ovarian cancer (serous papillary cystadenocarcinoma). She received combination chemotherapy comprising paclitaxel 175 mg/m2+carboplatin 400 mg/m2 for eight cycles for seven months after surgery. There were few serious complications during chemotherapy. However, four months later, she presented with a dry cough, and multiple painless subcutaneous nodules that had developed on her right arm and leg. A plain chest radiograph showed bilateral hilar enlargement compared with a previous film (). Whole-body positron emission tomography and computed tomography (PET/CT) scan for evaluation of cancer recurrence showed no uptake in the subcutaneous nodules, however, multiple areas of high uptake were observed in the enlarged paratracheal, left supraclavicular, retrocrural, and diaphragmatic lymph nodes (the maximum standardized uptake value [SUVmax] of the lymph nodes ranged from 12.3 to 21.5) () and cancer recurrence in these areas was diagnosed clinically. The same features were observed on both chest CT scan and PET/CT (). However, her serum levels of carbohydrate antigen 125 (CA125) and carbohydrate antigen 19-9 (CA19-9) were unremarkable; CA125 level was 9.42 U/mL (reference range, 0 to 35.0 U/mL) and CA19-9 level was 3.12 U/mL (referencerange, 0 to 37 U/mL).\nTo be certain of the diagnosis of cancer recurrence, biopsy of the mediastinal lymph nodes using endobronchial ultrasound-guided transbronchial needle aspiration and biopsy of the subcutaneous nodules were performed under general anesthesia. The pathological findings showed noncaseating granulomas with no evidence of malignancy (). Ziehl-Neelsen and polymerase chain reaction detection of Mycobacterium tuberculosis in tissues were negative for mycobacterial infection, and a serum interferon-gamma release assay test was also negative. The serum level of angiotensin-converting enzyme (ACE) was 101.4 U/L (reference range, 9 to 47 U/L).\nShe was diagnosed with sarcoidosis in the lymph nodes and skin. She had mild symptoms, including intermittent dry cough, and no specific treatment was required. She was observed closely at our clinic for three months, and the multiple painless subcutaneous nodules resolved spontaneously. Her follow-up chest CT scan showed an interval decrease in the size of multiple mediastinal lymph nodes (). However, newly developed perilymphatic and centrilobular nodules were detected in both lungs on the same CT scan (). Lymphangitic metastasis of ovarian cancer was suspected radiologically, therefore, she underwent video-assisted thoracoscopic wedge resection of the nodules in the right upper lobe. However, the pathological findings of the lung nodules showed noncaseating granuloma, which was similar to that of the mediastinal lymph nodes and skin (). She was finally diagnosed with sarcoidosis. She was observed closely at our clinic. | [[52.0, 'year']] | F | {'29344212': 1, '11907791': 1, '3536088': 1, '26181571': 1, '17925421': 1, '272865': 1, '7666100': 1, '25663873': 2, '27904442': 1, '31559285': 2, '17560310': 1, '19520211': 1, '14513992': 1, '3009099': 1, '3126625': 1, '4830144': 1, '20703868': 1, '25656675': 1, '5504464': 1, '7874925': 1, '9110911': 1, '24454009': 2} | {'6745330-1': 1, '4315069-1': 1} |
165,348 | 3893346-1 | 24,454,466 | noncomm/PMC003xxxxxx/PMC3893346.xml | Invasive Breast Carcinoma Arising in Microglandular Adenosis: Two Case Reports | Case 1 was a 44-year-old woman with a previous history of breast-conserving surgery because of ductal carcinoma in situ (DCIS) in her right breast 4 years ago. After breast-conserving surgery, she received radiotherapy on her right breast but no hormonal therapy or chemotherapy. During a regular follow-up, ultrasound examination revealed an abnormal nodular lesion in her left breast. She had no symptoms or signs associated with a breast mass. On physical examination, no palpable mass was found in either breast. Mammography showed heterogeneously dense breast tissue and a newly developed small nodular density at the left upper outer quadrant of the breast (). Ultrasound examination revealed an ill-defined irregular hypoechoic nodule measuring approximately 8 mm and an ill-defined hypoechoic nodule measuring approximately 7 mm (BI-RADS category 4b) at the 1 to 2 o'clock region and 5 cm from the left nipple. Both nodules were adjoining (). Ultrasound guided localization excisional biopsy and frozen section revealed that the lesion was invasive carcinoma. She underwent modified radical mastectomy (MRM) with sentinel lymph node biopsy (SLNB). No definite mass-like lesion was found on gross examination (). Microscopic examination revealed widely spread round proliferative glands lined by a single layer of flat to cuboidal epithelial cells and lacking a myoepithelial layer, indicating typical MGA. In part of the lesion, the glandular lumen was obliterated by proliferation of monotonous, atypical small cells with frequent mitotic figures, indicating carcinoma in situ. A cord-like arrangement and irregular aggregates of highly atypical cells were scattered in the stroma and extended into the adipose tissue (). Immunohistochemical (IHC) staining revealed the following: S-100 protein (+), estrogen receptor (ER) (-), progesterone receptor (PR) (+, Allred score 3), human epidermal growth factor receptor 2 (HER2) (-), lysozyme (+), α1-antitrpysin (+), calponin (-), and p63 (-). The SLNB showed no evidence of metastasis. The final diagnosis was multifocal invasive carcinoma associated with DCIS (grade 3) arising in MGA with stage 1A, T1 (<1 cm, in the largest one), N0 (0/1), M0, and lymphovascular invasion (-). After surgery, she received adjuvant chemotherapy and hormonal therapy. After 14 months of medical follow-up, no evidence of recurrence has been found. | [[44.0, 'year']] | F | {'12101208': 1, '11494007': 1, '17824796': 1, '28372347': 2, '7504394': 1, '3706610': 1, '8422116': 1, '25337293': 1, '12521372': 1, '10963383': 1, '18300793': 1, '6859388': 1, '34616829': 2, '30039060': 1, '10809602': 1, '6660348': 1, '24454466': 2} | {'3893346-2': 2, '5525030-1': 1, '8464440-1': 1} |
165,349 | 3893346-2 | 24,454,466 | noncomm/PMC003xxxxxx/PMC3893346.xml | Invasive Breast Carcinoma Arising in Microglandular Adenosis: Two Case Reports | Case 2 was a 57-year-old woman with a palpable mass in her right breast. No other symptoms were associated with the mass. On physical examination, a firm, movable mass measuring approximately 3 cm was palpable at the right upper outer quadrant of the breast. Nipple retraction was observed. She had no medical or familial history of cancer. Mammography revealed a huge mass-like lesion at the right upper breast and ultrasound revealed a lobulating heterogeneous hypoechoic mass measuring 2.6×2.2 cm at the 11 o'clock region of the right breast (). Positron emission tomography revealed fluorodeoxyglucose (FDG) uptake at a 2.7 cm hypermetabolic mass in the upper outer quadrant of the right breast (SUVmax: 15.4) and FDG uptake in lymph nodes of the right axilla (level 1). A core needle biopsy of the lesion suggested invasive carcinoma and encapsulated papillary carcinoma. The patient underwent right MRM with SLNB. A well-demarcated solid mass measuring 2.8×2.4 cm was found on gross examination (). Microscopic examination revealed encapsulated papillary carcinoma arising in MGA, which exhibited atypia and variable proliferation (approximately 5.2 cm in the largest dimension). Most areas of the MGA were atypical and were lined by large pleomorphic cells with nuclear hyperchromasia and prominent nucleoli. A 0.3×0.25 cm focus of invasion was associated with an altered chondromyxoid stroma adjacent to the encapsulated papillary carcinoma. Typical MGA tubules with intraluminal colloid-like secretory material were found at the more peripheral area of the lesion (). IHC staining revealed the followings: S-100 protein (+), smooth muscle myosin-heavy chain (-), ER (-), and PR (-). No metastasis was observed in the sentinel lymph nodes. The final diagnosis was invasive ductal carcinoma (grade 2) associated with encapsulated papillary carcinoma arising in MGA with stage IA, T1 (0.3×0.25 cm), N0 (0/5), M0, and lymphovascular invasion (-). The patient showed no evidence of recurrence on medical follow-up at 19 months. We consulted Dr. Fattaneh Tavassoli, a breast pathologist at the Yale School of Medicine, USA, about these two cases. | [[57.0, 'year']] | F | {'12101208': 1, '11494007': 1, '17824796': 1, '28372347': 2, '7504394': 1, '3706610': 1, '8422116': 1, '25337293': 1, '12521372': 1, '10963383': 1, '18300793': 1, '6859388': 1, '34616829': 2, '30039060': 1, '10809602': 1, '6660348': 1, '24454466': 2} | {'3893346-1': 2, '5525030-1': 1, '8464440-1': 1} |
165,350 | 3893347-1 | 24,454,467 | noncomm/PMC003xxxxxx/PMC3893347.xml | Expander/Implant Breast Reconstruction after Reconstruction Using an Extended Cutaneous Thoracoabdominal Flap: A Case Report | In July 2008, a 44-year-old woman underwent extended modified radical mastectomy including only the pectoralis fascia with extensive skin paddle resection for advanced cancer of the left breast (). Immediate chest wall reconstruction was achieved using an extended cutaneous thoracoabdominal flap, 18×20 cm in size, drawn on the homolateral abdominal wall, rotated clockwise in the left chest wall, and adapted to the defect (, ); no complications were recorded. The patient received adjuvant chemotherapy over a 6-month period.\nAfter 2 years of uneventful follow-up, the patient required breast reconstruction. We planned two-stage implant breast reconstruction using a Natrelle 133-850 cc Full Height biodimensional tissue expander (Allergan Inc., Irvine, USA) placed in the subcutaneous plane under the flap through a 5-cm incision overlapping the previous scar on the anterior axillary line. The size of the expander implant was selected according to contralateral breast width, which was measured preoperatively. The inferior border of the expander was placed symmetrical to the contralateral side as planned preoperatively. The expander was then inflated with saline solution at weekly intervals postoperatively to achieve a total volume of 850 cc.\nFour months after expansion, the second stage of the procedure was performed using a Natrelle 410 FF 740-cc anatomical permanent silicone cohesive gel implant (Allergan Inc.); a circumferential basal capsulotomy was performed and the inframammary fold was reconstructed, with the anterior leaf cranially advanced on the chest wall in a "slingshot" fashion. Contralateral augmentation mammaplasty was performed to achieve symmetry between breasts; two closed-suction drains were placed and removed after 6 days. The esthetic outcome was good, as assessed by a blinded expert using standardized patient photographs with frontal and bilateral oblique views, taken at the 1-year follow-up (). Follow-up evaluations included total body computed tomography, ultrasonography of the reconstructed breast, and contralateral mammography of the healthy breast, which did not indicate recurrence. | [[44.0, 'year']] | F | {'31620390': 2, '15096930': 1, '23629074': 1, '23791293': 1, '18843123': 1, '16861999': 1, '11773742': 1, '15145731': 1, '12078759': 1, '14769300': 1, '24454467': 2} | {'6779953-1': 1} |
165,351 | 3893348-1 | 24,454,468 | noncomm/PMC003xxxxxx/PMC3893348.xml | Random Synchronous Malignancy in Male Breast: A Case Report | This 58-year-old male Indian male presented with an indurated lesion of size 2×2 cm in the posterior 1/3rd of right side of tongue, not crossing midline with normal tongue movements. Biopsy confirmed a poorly differentiated squamous cell carcinoma of base of tongue (). Subsequently he underwent a contrast enhanced whole body 18F-FDG PET/CT (head to mid thigh) on our General Electric Discovery PET 8 slice CT scanner. Standardized uptake value (SUVmax) of the lesions were calculated for body weight and expressed in gram per milliliter (g/mL). Apart from the known base of tongue lesion ( and ) in the right posterior 1/3rd (SUVmax, 8.2), a right level II cervical lymph nodal metastases (SUVmax, 5.3). Incidental FDG avid enhancing subcutaneous soft tissue lesion with spiculated margins of size 15×14 mm, in retro areolar region of right breast was noted (SUVmax, 2.1) ( and ). On subsequent physical examination, a right breast lump of size 2×2 cm at 9 o'clock position with surrounding periareolar nodularity was noted with no palpable axillary lymph nodes. Left breast and axilla were normal. Excision biopsy revealed an invasive ductal carcinoma, not otherwise specified, modified Bloom Richardson grade 1 (tubule 2, atypia 1, mitosis 1), tumor size of 1.5×1.3×1 cm. Immunohistochemistry revealed estrogen and progesterone receptor positive (). He underwent a right modified radical mastectomy. Histopathology showed no residual tumor while one lymph node was positive for metastases. After percutaneous endoscopic gastrostomy tube placement, concurrent chemoradiation for poorly differentiated squamous cell carcinoma of base of tongue (T1N1M0) was started. Patient received intensity modulated radiation therapy with 69 Gy to the tumor in 30 fractions, 60 Gy to level II-IV lymphnodes and 54 Gy to low anterior neck and weekly chemotherapy with Cisplatin 50 mg. Patient tolerated the concurrent chemoradiation well. On follow-up after 1 month of completion of concurrent chemoradiation, there was no visible base of tongue growth on endoscopy or on palpapation. Subsequently, patient received six cycles of adriamycin, cyclophosphamide, and 5-flurouracil for carcinoma breast (pT1cN1M0). Patient was subsequently on tamoxifen. Apart from a positive family history, patient does not have any known risk factors like alcoholism, liver cirrhosis, etc. One of his brother is known to have breast carcinoma. Genetic mutation testing was not done as this is locally not available to us in our hospital and outsourced testing for the same was not insisted upon taking in consideration the poor financial status of the patient. | [[58.0, 'year']] | M | {'12527496': 1, '332330': 1, '7440181': 1, '12576929': 1, '21271578': 1, '21658269': 2, '12174988': 1, '22007238': 2, '26975010': 1, '20502060': 1, '13094644': 1, '33209111': 2, '26668534': 1, '21505586': 1, '33451072': 1, '19205699': 1, '22807945': 2, '10091736': 1, '24454468': 2} | {'3191849-1': 1, '3127834-1': 1, '7652543-1': 1, '3395751-1': 1} |
165,352 | 3893945-1 | 24,479,008 | noncomm/PMC003xxxxxx/PMC3893945.xml | Hyperglycemia: An Unusual Cause for Hemichorea | A 35-year-old female came to the outpatient department with involuntary movements of the left half of the body since 3 days, progressive, preceded by a short febrile illness. Movements were sudden in onset and persisted throughout the day making it difficult for her to fall asleep. However they disappeared during sleep.\nThe patient was not known a diabetic or a hypertensive. There was no history of thyroid dysfunction and history of no similar episodes in the past.\nOn examination, the patient was vitally stable. The patient was having choreiform movements of left upper and lower limb. She could not voluntarily suppress the movements. Plantar reflex showed bilaterally flexor response. Sensory system was intact. Systemic examination of all other systems was unremarkable.\nInvestigations revealed that her blood counts, thyroid profile, liver function test, renal function test, serum electrolytes were all within the normal limits. Her Antistreptolysin O (ASLO) titer was also negative. Her random blood sugar was 572 mg/ dl. The patient was started on tab. Haloperidol 1 mg three times a day and was slowly uptitrated to 1.5 mg three times a day. Meanwhile the patient was also started on regular insulin of 8 units subcutaneously tid which was adjusted according to her blood sugars. The patient gradually improved with haloperidol and with control of her blood sugars. As her blood sugars were controlled, her choreiform movements subsided remarkably. It was decided to start Haloperidol as the movements were severe and disabling. Slit lamp examination was done which ruled out the presence of K-F ring. Her cranial CT scan was normal.\nHence a diagnosis of hemichorea due to hyperglycemia was made. | [[35.0, 'year']] | F | {'8006661': 1, '11861689': 1, '16514597': 1, '11746619': 1, '17114863': 1, '24479008': 2} | {} |
165,353 | 3893949-1 | 24,479,009 | noncomm/PMC003xxxxxx/PMC3893949.xml | Revisiting Endosulfan | A 17-year-old female presented with history of ingestion of about 35 ml of an insecticide (containing endosulfan 35% EC) 4 hours ago following which she developed continuous involuntary jerky movements and associated up-rolling of eyes and frothing from the mouth. She was taken to the local hospital where she was given benzodiazepines and phenytoin, intubated and mechanically ventilated and rushed to our center for further care. Glasgow coma scale was 3 on arrival. Activated charcoal was given and the prior gastric lavage sample was sent for analysis. The patient continued to seize and midazolam and lorazepam infusions were given with no benefit followed by phenobarbital and propofol. Seizures persisted and Levetiracetam was tried but in vain. Hypotension was noted and inotropic support added. Blood gas analysis showed high anion gap metabolic acidosis. ECG showed sinus tachycardia with ST depressions in II, III, AVF, and V4-V6. 2D Echo showed paradoxical motion of intraventricular septum with dilated right atrium and ventricle without PAH. Labs showed TWBC-44,800 which subsided over the next few days. S creatinine increased from 1.75 to 6.06 mg/dL and SGPT from 19 to 473 IU/L. S-Ca- 7.3 mg/dl; S Mg- 3.1 mg/dL; LLDH- 3347 U/L. The peak serum concentration of endosulfan was 1.82 mg/L about 23 hours after ingestion. Supportive treatment with antibiotics, hemodialysis and hydration continued. CT brain showed evidence of cerebral edema []. Electroencephalogram (EEG) was suggestive of severe anoxic/ischemic encephalopathy. Chest X-ray (CXR) showed mild ground glassing on the right. Multi-organ failure was noted with acute kidney injury, hepatitis, acute lung injury, myocardial depression, and encephalopathy. Her seizures were unrelenting and she developed multiple episodes of bradycardia and cardiac arrest before finally succumbing to death. | [[17.0, 'year']] | F | {'30796443': 1, '19755461': 1, '15461244': 1, '17139397': 1, '20235613': 1, '20572757': 1, '19152551': 1, '19507667': 1, '24479009': 2} | {} |
165,354 | 3893967-1 | 24,479,028 | noncomm/PMC003xxxxxx/PMC3893967.xml | A Case of Pulmonary Tuberculosis Presenting as Multiple Nodular Opacities on a Chest X-Ray | A 30-year-old man presented to the emergency with complaints of fever with chills since 15 days along with progressive dyspnea, cough and sputum since five days. On examination the patient had bilateral diffuse ronchii with extensive coarse crepitations, was dyspenic and tachypnic. He had an SpO2 = 64% without oxygen, blood pressure (BP) = 130/70 mm of Hg, pulse = 110 bpm, temperature-102°F. He was admitted to the intensive care unit and was put on oxygen support using a face mask at a rate of 2–6 liters per min. The patient was empirically placed on piperacillin-tazobactam combination, moximycin and was nebulized with salbutamol. The investigations sent included a chest X-ray, electrocardiography, ultrasound abdomen, sputum examination, urine examination, blood cultures, liver function and renal function tests. A bedside two dimentional trans-thoracic echocardiography was normal. All the blood examination reports were normal and the cultures were sterile. The sputum examination revealed the presence of acid-fast bacilli. The chest X-ray showed bilateral multinodular opacities involving the middle and lower zones with nodules varying in size from 1–3 cm []. The ultrasound abdomen showed hepatomegaly 14 cm below the right costal margin, splenomegaly 9 cm. Based on the chest X-ray a differential diagnosis was made which included lymphoma, benign tumors, septic emboli, inflammatory granulomas (tuberculosis, nocardiosis, fungal infection) or non-infectious granulomas (sarcoidosis, rheumatoid nodules, Wegener's granulomatosis). The patient was initiated on anti-tuberculosis treatment which included rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin. Symptomatic improvement in the clinical status of the patient was noticed after seven days as the dyspnea and tachypnea were relieved, he was afebrile and he maintained saturation above 95% without oxygen support. The patient was discharged after 20 days on anti-tuberculosis therapy. | [[30.0, 'year']] | M | {'17054802': 2, '1582151': 1, '835590': 1, '22701010': 1, '16022147': 1, '10631208': 1, '24479028': 2} | {'1634852-1': 1} |
165,355 | 3893970-1 | 24,479,027 | noncomm/PMC003xxxxxx/PMC3893970.xml | Poly-resistant Tuberculosis in an HIV-infected Child | A 3-year-old HIV-infected boy was referred for further management in January 2005. Mother was diagnosed as tuberculous pleural effusion with HIV infection with acid fast bacillus (AFB) seen on sputum examination and was on Ofloxacin (O), INH (H), and Rifampicin (R) for the same. (Details of mother's investigations are not available.) The child was currently asymptomatic. He had oral thrush and herpes simpler in the past. He had been immunized till date. On examination, his weight was 12 kg and height was 86.5 cm. He had cervical adenopathy (non-tender, non-matted) and other systems were normal. Investigations showed positive Mantoux test (20 × 22 mm) and chest X-ray was suggestive of primary complex. His venereal disease research laboratory (VDRL) test, HBsAg, and anti-hepatitis C were negative. He was started on anti-tuberculous therapy (ATT) consisting of 2 HRZE + 10 HR (Z = Pyrazinamide, E = Ethambutol). His serial CD4 counts are depicted in . ATT was stopped in January 2006. He was asymptomatic till June 2007, when we had mild molluscum contagiosum. In February 2009, at the age of 7 years, he was hospitalized with right lower zone pneumonia and his sputum was positive for AFB. He was restarted on ATT in category 2 regime as per WHO. His sputum culture grew Mycobacterium tuberculous (MTB) complex after 6 weeks and sensitivity after another 2 weeks showed resistance to Streptomycin (S) and H. He was then shifted to REZO in May 2009 and ART was started in the same period in view of decreasing CD4 count, consisting of Zidovudine (AZT), Lamivudine (3TC), and Nevirapine (NVP at 400 mg/m2/day). He was alright and chest X-ray normalized in August 2009. Ofloxacin was stopped in August 2009 and he was advised REZ for another 6 months. | [[3.0, 'year']] | M | {'18181698': 1, '22253159': 1, '28847228': 1, '11769576': 1, '18652996': 1, '17624830': 1, '22728624': 1, '24479027': 2} | {} |
165,356 | 3893975-1 | 24,479,026 | noncomm/PMC003xxxxxx/PMC3893975.xml | Dopa-Responsive Dystonia in a Ten-Year-Old Girl | A ten-year-old girl was brought with complaints of difficulty in walking and stiffness of both lower limbs, for the past six months. She also had a history of frequent falls while walking and was unable to stand for prolonged periods. Her antenatal, birth, and neonatal periods were uneventful and developmental milestones were appropriate for her age. There was no family history of similar illness. On examination, her higher mental functions were normal, speech was hypophonic; she had a gait disturbance characterized by leg stiffness, and a tendency to walk in an equinus posture, resulting in difficulty in balancing. Her tone was slightly increased in all the four limbs, with cog-wheel rigidity. Power in both upper limbs was normal and 4/5 in the lower limbs. Postural tremor and dystonia were noticed on attempted movements of the limbs. Deep tendon reflexes in all the four limbs were exaggerated with extension of both great toes (striatal toes). Clonus was absent. The sensory system and cranial nerve examination were normal. There were no cerebellar signs. In the hospital, it was found that the symptoms and signs were relatively mild in the morning during rounds, whereas, they gradually worsened as the day progressed, rendering the child almost unable to walk by evening. The peripheral blood smear study was normal. Serum electrolytes and serum Ceruloplasmin were in normal range. Slit lamp evaluation for Kayser Fleischer ring was negative. Magnetic resonance imaging (MRI brain and spine were normal. In view of the typical diurnal variation of dystonia, a therapeutic challenge with levodopa/carbidopa was tried and there was a dramatic decrease in dystonia within two days and the child's gait improved. Hence, a diagnosis of DRD was made. The child was treated with a combination of Levodopa, Carbidopa, and Trihexyphenidyl. On follow-up the child showed persistent improvement in the clinical condition. Genetic studies were planned, but could not be done due to lack of resources. | [[10.0, 'year']] | F | {'12891652': 1, '11912106': 1, '19292934': 1, '20108370': 1, '15448133': 1, '20668943': 1, '22373569': 1, '21935284': 1, '24479026': 2} | {} |
165,357 | 3893978-1 | 24,479,030 | noncomm/PMC003xxxxxx/PMC3893978.xml | Salmonella Hepatitis: An Uncommon Complication of a Common Disease | A 16-year-old male patient presented in medical outpatient department with history of high-grade fever with chills and an ill-defined abdominal pain of 7 days duration in October 2011. There was no history of cough, chest pain, dyspnea, dysuria, skin rashes, pruritus, dark color urine, clay color stool, or any hemorrhagic manifestations. He had no significant history of medical illness, drug ingestion, surgical procedures, blood transfusion, sexual promiscuity, and intravenous drug abuse or alcohol consumption. On examination, he was ill looking, mildly dehydrated, and febrile. He had tachycardia with normal blood pressure and respiration. Abdominal examination revealed soft, tender liver, 2 cm palpable below the costal margin at the midclavicular line. Rest of the general and systemic examination was unremarkable. His laboratory investigations showed borderline leukopenia (3800/mm3). Peripheral smear for malarial parasite was negative. Biochemical evaluation showed normal renal functions and electrolytes, albumin, and coagulation parameters. Transaminases were elevated with aspartate aminotransferase (AST) 263 U/l, alanine aminotransferase (ALT) 382 U/l, and alkaline phosphatase (ALP) 126 U/l. Total and conjugated serum bilirubin were1.8 and 1.2 mg/dl, respectively. The blood, urine cultures, hepatic viral markers and serology for enteric fever, dengue and leptospirosis were sent. The patient was treated empirically with antimalarials chloroquine + lumifantrine and flouroquinolone (levofloxacine). Two days later, he was admitted in the emergency ward with vomiting and continuation of high-grade fever. His liver enzymes showed worsening (AST level was 792 U/l and ALT level was 1247 U/l). The icterus was apparent clinically, with a total bilirubin level of 3.6 mg/dl. The serum ALT: Lactate dehydrogenase (LDH) ratio (expressed in multiples of upper limit of normal) was found to be less than 9. The serology for viral hepatitis, dengue, and leptospirosis sent earlier was negative. Widal test was strongly positive in 1:640 dilution for both “O” and “H” antigens. Patient was treated with ceftriaxone 1 g intravenous twice daily and azithromycin 1g oral daily for 1 week. His blood culture yielded a growth of Salmonella typhi after 5 days incubation, with antibiotic sensitivity to ciprofloxacin (MIC < 0.5 mg/l) and ceftriaxone (<0.25 mg/l). The strain was resistant to ampicillin and amoxicillin + clavulinic acid. With treatment, the patient showed rapid clinical improvement along with decline in liver transaminases levels. He was discharged after 7 days of hospitalization. | [[16.0, 'year']] | M | {'33224651': 1, '34131486': 1, '21982051': 2, '4213522': 1, '32728320': 1, '1882803': 1, '1788579': 1, '19671947': 1, '9715430': 1, '3126648': 1, '20710103': 1, '10584470': 1, '2267203': 1, '645689': 1, '8781316': 1, '24479030': 2} | {'3200156-1': 1} |
165,358 | 3894000-1 | 24,479,057 | noncomm/PMC003xxxxxx/PMC3894000.xml | Atypical Presentation of Allergic Bronchopulmonary Aspergillosis: An Unusual Cause of Difficult-to-Treat Asthma | A 28-year-old nonsmoker, male office worker, presented with persistent cough with scanty, mucoid expectoration and gradually progressive breathlessness for last two years. There was no diurnal or seasonal variation of cough or breathlessness. History of intermittent fever along with increased severity of symptoms was present. Past history revealed that since childhood he was suffering from recurrent cough and cold, nasal itching, and obstruction, especially in summer. No history of food or drug allergy and atopic dermatitis were revealed. Family history of asthma or atopy was not documented. Past history of tuberculosis was not present. He complained of retrosternal burning sensation, especially at night. Spirometry before presenting to us revealed obstructive ventilatory defect with partial reversibility to bronchodilator. Therefore, the patient was diagnosed as having asthma and medium dose ICS plus inhaled LABA was advised. Despite adequate compliance and correct inhaler technique, his asthma was uncontrolled; inhaled salbutamol was taken more than twice a week.\nOn general survey at presentation, only mild pallor was seen. His respiratory rate was 24 breaths/minute, and pulse rate 120 beats/minutes. Examination of the respiratory system revealed barrel shaped chest. There were bilateral hyperresonant percussion note, diminished vesicular breath sound, and bilateral crackles with occasional wheezing.\nAbsolute eosinophil count was 1,500/cmm. Sputum smear for acid fast bacilli and sputum culture for Mycobacterium tuberculosis were negative. Chest X - ray (CXR), posteroanterior view showed bilateral hyperinflated lung with reticular shadows. Spirometry in our institution showed mixed pattern with partial reversibility to inhaled salbutamol, although his effort was not adequate. The patient was advised high dose ICS, inhaled LABA, and once daily 10 mg montelukast, and the treatment was gradually stepped up by addition once daily 400 mg sustained release theophylline within two months, as his symptoms were not under control. We also advised once daily 40 mg esomeprazole and 30 mg sustained release domperidone, and once daily mometasone nasal spray (two sprays in each nostril). But our all efforts were in vain. High resolution computed tomogram (HRCT) of thorax revealed bilateral reticulonodular pattern with patchy consolodation []. Further investigations showed total serum immunoglobulin E (IgE) level was 1979.1 U/L and Aspergillus fumigatus specific serum IgE was positive (1.39 U/L). Skin prick test with aspergillin antigen was positive. From these, the diagnosis of ABPA was suggested, although diagnosis was confused with diffuse parenchymal lung disease (DPLD) due to atypical presentation and HRCT pattern. Bronchoalveolar lavage fluid analysis showed only eosinophila. Oral prednisolone at dose of 0.5 mg/kg/day along with oral itraconazole 200 mg twice daily was added. Patient gradually improved within one month. Follow up CXR and spirometry showed significant improvement after six weeks. Oral prednisolone after six weeks was tapered off at the rate of 5 mg/week over six weeks. Total duration of oral prednisolone was planned for six months. Itraconazole was continued as 200 mg twice daily for eight weeks, then 200 mg once daily for another eight weeks. On six month follow up, his asthmatic symptoms were well controlled, and CXR was normal. | [[28.0, 'year']] | M | {'20463254': 1, '7252001': 1, '4947842': 1, '34268029': 2, '16507864': 1, '848802': 1, '13015523': 1, '28469725': 2, '24479057': 2} | {'5399688-1': 1, '8262577-1': 1} |
165,359 | 3894003-1 | 24,479,053 | noncomm/PMC003xxxxxx/PMC3894003.xml | Early Diagnosis of a Large Vesical Calculus Complicating Pregnancy | A 23-year-old primigravida at 13 weeks of gestation presented to the antenatal clinic of the urban health center with urgency, dysuria and increased frequency of urine. On examination a mobile hard mass was felt in the right iliac fossa. On per vaginal examination a large bony mass was felt and a probable diagnosis of bladder stone complicating pregnancy was made. She was referred to the tertiary hospital where an ultrasound showed mild bilateral hydroureteronephrosis and a large vesical calculus measuring 8.3 cm causing dense acoustic shadowing obscuring the bladder base []. There was no significant post void residue. Ultrasound also confirmed the presence of a single live intra uterine fetus corresponding to the gestational age. Urine microscopy showed the presence of pus cells. Urine culture grew Enterococcus which was sensitive to Ampicillin.\nShe was referred to the urologist and underwent open cystolithotomy under spinal anesthesia. Intra operative cystoscopy revealed bladder trabeculation with stone sitting in the anterior wall of trabeculation. Two small diverticuli were seen. Right ureteric orifice was seen refluxing and pus flakes were present. On cystolithotomy a 8 × 7 cm stone was removed. Post operatively she had continuous bladder drainage for 2 weeks and was treated with appropriate antibiotics. She also received antibiotic prophylaxis till delivery. She delivered normally a live-term baby girl of Apgar 9 and 10 and birth weight 2.42 kg at 38 weeks of gestation and is on regular follow up and doing well. | [[23.0, 'year']] | F | {'30594944': 1, '9077643': 1, '24479053': 2} | {} |
165,360 | 3894005-1 | 24,479,061 | noncomm/PMC003xxxxxx/PMC3894005.xml | Recurrent Hydrocoele | GP is a 72-year old man with massive recurrent hydrocoele of his right scrotum. The first episode occurred 4 years ago which he did not notice until the scrotal swelling made walking difficult. He presented to his family doctor who aspirated 480 cc of straw-color fluid. However the problem recurred 5 more times over the next 48 months despite needle aspiration. Repeated ultrasound and magnetic resonance imaging of his pelvis and abdomen had not revealed any specific pathology or obstructive mass that could explain this recurrent lesion. Moreover, bacterial culture, malignant cytology and acid fast bacilli staining had been performed on three of the six previous aspirates, which were all negative. The smallest amount of fluid drained was 400 cc and the largest amount was from the most recent visit (640 cc) []. Patient suffered from multiple comorbidities including hypertension, dyslipidemia, atrial fibrillation, congestive heart failure, generalized epilepsy, and benign prostatic hypertrophy. Past medical history included repaired aortic artery dissection, pneumothorax, transient ischemic attacks, thromboembolism and subarachnoid hemorrhage. Patient is a 60 pack-year smoker with problem of alcohol abuse. He is on disability and lives alone with poor social and family support. He takes a diuretic for his hypertension but there was no previous history of proteinuria. Surgical consult pointed to a patent hernia sac as the contributing cause of the recurrent hydrocoele. Mesh repair of right inguinal hernia was performed six months ago but the hydrocoele recurred shortly afterwards. Further surgical options including resection, eversion orhydrocoelectomy had been considered but were considered as less favorable in view of the co-existing comorbidities of the patient. A primary or metastatic source of malignancy remained on the list of differentials but could not be excluded. The recurrent hydrocoele would never bothered the patient except when it reached a size that he could not walk smoothly. | [[72.0, 'year']] | M | {'19595803': 1, '2585624': 1, '7241678': 1, '12670550': 1, '7876764': 1, '12576845': 1, '24479061': 2} | {} |
165,361 | 3894007-1 | 24,479,055 | noncomm/PMC003xxxxxx/PMC3894007.xml | Oculoauriculovertebral Spectrum with Radial Anomaly in Child | An eight-year-old male child presented to the Pediatric Outpatient Department with complaints of facial asymmetry and polydactyly with bilateral microtia since birth. The child was born by vaginal delivery at a government hospital, with a birth weight of 2.5 kg. He was the second born. There was no family history of malformations. No mental retardation was detected during examination. The child showed undernourishment and weighed 15 kg (<fiftieth percentile) and a height of 110 cm (<fiftieth percentile). On physical examination, facial asymmetry, right side infranuclear facial palsy, bilateral microtia with bilateral ear tag [], short neck, high arched palate, and skin tags on the nape of the neck were present. Dental caries were present, with normal dental development. There was lower motor neuron weakness of the facial nerve on the right side, manifested by an inability to close the right eye and loss of a nasolabial fold on the same side. Asymmetric crying facies was noted with the right lower lip being pulled down while crying or chewing. Left eye closure and nasolabial fold were normal. Left preaxial polydactyly was present [], whereas, the other hand was normal. The length of both the hands was equal. His parents were normal on clinical examination. The first and third of the children, both boys, were normal.\nOn ophthalmological examination, the only positive finding was presence of a right-sided iris coloboma. Cardiac auscultation revealed that S1 and S2 were normal and a soft systolic murmur was present in the pulmonary area. No other abnormality was detected on systemic examination. The patient showed moderate-to-severe bilateral conductive hearing loss on audiometry. Abdominal sonography was normal. Renal function tests, liver function tests, and thyroid function tests were normal. Echocardiography and Color Doppler did not detect any cardiac lesion. X-ray examination of the skull and vertebral column did not show any vertebral abnormality. A computed tomography (CT) scan of the temporal bone revealed bony atresia of the external auditory canal, with absence of mastoid pneumatization of the right ear and left ear, showing auricular tags with bony atresia of the external auditory canal, with a deformed ossicular chain. | [[8.0, 'year']] | M | {'12410187': 1, '21860971': 1, '3146282': 1, '17290277': 1, '20339789': 1, '9741741': 1, '25992144': 1, '21150135': 1, '16378924': 1, '23120253': 1, '24479055': 2} | {} |
165,362 | 3894010-1 | 24,479,052 | noncomm/PMC003xxxxxx/PMC3894010.xml | Acute Renal Failure Due to Rhabdomyolysis Following a Seizure | A 35-year-old male was referred to our tertiary centre by his primary-care physician with a diagnosis of epidermoid cyst in the anterior interhemispherical area. The patient had history of four to five episodes of generalized tonic clonic for last 10 months. He was evaluated for a generalized tonic clonic seizure episode before referring to our center with magnetic resonance imaging of the brain. There was no history of hypertension, diabetes mellitus, fever, oliguria, muscle weakness, ingestion of toxic substance or illicit drug, or alcohol abuse.\nOn presentation, the patient was conscious, oriented, and afebrile with a pulse rate of 84/min, blood pressure 130/74 mmHg, and respiratory rate 16/min. Fundus examination was normal and there were no signs of meningeal irritation or focal neurological deficit. Examination of abdomen, cardiovascular, and respiratory systems was unremarkable.\nThe initial laboratory tests showed a total leukocyte count of 15,800/mm3, blood urea 54 mg/dl, and serum creatinine 2 mg/dl. Other investigations, including hemoglobin, erythrocyte sedimentation rate, random blood sugar, liver function tests, blood urea nitrogen, electrolytes, urine, arterial blood gas analysis and ultrasound examination of the abdomen, were all within normal limits. HBsAg, HCV, and HIV serology was negative.\nHe was managed with antiepileptic drug and optimal hydration. His urine output decreased, and serum creatinine started to rise and reached a level of 6.23 and 7.79 mg/dl on fourth and sixth day after a seizure episode, respectively. His serum creatine phosphokinase peaked at 9882 U/L. Urine myoglobin estimation could not be done.\nA diagnosis of acute oliguric renal failure due to seizure-induced rhabdomyolysis was made. Renal biopsy performed showed patchy tubular cell necrosis with mild interstitial inflammation. Hemodialysis was started and continued until his urine output became normal in 4 weeks time. On follow up at 8 weeks, he attained normal renal function. | [[35.0, 'year']] | M | {'15774072': 1, '5413325': 1, '33712852': 1, '8648915': 1, '33968541': 2, '27980788': 2, '26629236': 1, '17344731': 1, '18687233': 1, '4423658': 1, '20783577': 1, '17623609': 1, '3382301': 1, '20505902': 1, '24479052': 2} | {'8103793-1': 1, '5134258-1': 1} |
165,363 | 3894016-1 | 24,479,059 | noncomm/PMC003xxxxxx/PMC3894016.xml | Purple Urine Bag Syndrome | An 86-year-old woman had a history of osteoporosis and bilateral fracture of neck femur for two years. Her daily activity was limited and she was bedridden most of the day. She could sit for a while with a caregiver's help [].\nShe had Foley catheterization for one year because of neurogenic bladder. She was also suffering from constipation from her early age and it became severe enough in last two years. Urine with purple sediment was found in the urine bag one day before admission [].\nShe did not have fever or a history of drug administration before admission. The patient had a history of recurrent urinary tract infections (UTIs) in the past. Physical examination revealed diffuse tenderness on palpation of the abdomen. Other examinations did not indicate any other noteworthy symptoms. The urinalysis showed alkaline urine with the urinary sediment contained 5-7 white blood cells/high-power-field. She was admitted under the impression of urinary tract infection and constipation. The patient was empirically started on oral cefuroxime. Urine cultures yielded Escherichia Coli and growth was greater than 105/mL. The antibiotic therapy was changed to ceftriaxone 1 gm intravenous injection every day and gentamicin 80 mg intravenous injection 8 hourly according to antibiotic sensitivity tests of the urine cultures. A glycerol containing oral preparation was given for her constipation. The Foley catheter was also changed. The purple urine disappeared and the following urinalysis was sterile. She was discharged in stable condition. | [[86.0, 'year']] | F | {'31508214': 2, '34354830': 1, '19281065': 1, '2846640': 1, '31933590': 1, '29317791': 1, '11982525': 1, '29962654': 2, '31553357': 2, '21977321': 1, '29564123': 1, '16323555': 1, '24479059': 2} | {'6905158-1': 1, '6009141-1': 1, '6720032-1': 1} |
165,364 | 3894017-1 | 24,479,051 | noncomm/PMC003xxxxxx/PMC3894017.xml | Drug Rash with Eosinophilia and Systemic Symptoms Syndrome Due to Anti-TB Medication | A 68-year-old Filipino man with history of diabetes and newly diagnosed pulmonary tuberculosis (TB) on rifampin, INH, ethambutol, and pyrazinamide presented to clinic with diffuse skin eruption for past 7-10 days. The patient initially developed a pruritic rash that began on his neck and eventually covered most of his body. The patient reports soreness with swallowing that started 7 days ago but denies any regurgitation. Exam was significant for diffuse, confluent, blanching, erythematous macular rash on face, scalp, upper extremities, including palms and soles, abdomen, buttocks, upper and lower extremities, no bullae formation, and no excoriation. There were moist mucous membranes, lips slightly edematous, dry, cracking, no blistering, and good dentition without abscesses. There was no conjunctival involvement []. The patient was directly admitted form clinic to University Hospital. The patient was seen by both Dermatology and Allergy/Immunology service. All four TB medications were immediately discontinued because of possible suspicion of allergic reaction. Intravenous hydration was started with normal saline at 100 ml/h with electrolytes supplementation. On admission, the laboratory findings were significant for eosinophilia and transaminitis. The patient was started on steroid cream to face twice a day as per recommendations from Dermatology for erythema multiforme. Next day of admission, the patient had worsen eosinophilia and transaminitis. Punch biopsy skin was found to be erythema multiforme. During the hospital course, the patient had desquamation of skin so he was started on steroids and later was discharged on day 10 on TB therapy and 3-week tapering dose of prednisone as well as second-line TB therapy cycloserine and moxifloxacin, as an outpatient recommended by the Pulmonary team. After 2 weeks of follow up as outpatient, there was regression in rashes of the patient and after 1 month the rashes disappeared. The eosinophils normalized on repeat labs []. | [[68.0, 'year']] | M | {'33025080': 1, '17711546': 1, '15681256': 1, '31620081': 1, '9069593': 1, '26006718': 1, '12165215': 1, '27571915': 1, '11700164': 1, '16442685': 1, '18021270': 1, '17578496': 1, '17952481': 1, '28971606': 1, '31497445': 2, '15605034': 1, '16259349': 1, '19733945': 1, '19581659': 1, '17822451': 1, '16114793': 1, '16882166': 1, '16033627': 1, '18494788': 1, '19665822': 1, '16882184': 1, '16008041': 1, '24479051': 2} | {'6716765-1': 1} |
165,365 | 3894021-1 | 24,479,062 | noncomm/PMC003xxxxxx/PMC3894021.xml | Two Case Reports Indicating the Dilemma in Diagnosing Lupus Cerebritis | A thirty-one-year-old woman, with an episode of generalized seizure, presented to the Emergency, with a history of low-grade intermittent fever and joint pain and swelling for a duration of one-and-a-half months. She was also suffering from irregular menstrual cycles and menorrhagia. She was diagnosed by her primary physician as a case of severe rheumatoid-arthritis with anemia.\nThe bouts of seizures continued and she required intubation. Arterial blood gas analysis showed mild metabolic acidosis. A CT scan of the brain revealed a moderate degree of cerebral edema. Treatment was initiated with the provisional diagnosis of bacterial or viral meningitis and vasculitis.\nHer level of alertness gradually deteriorated. Low-grade, intermittent fever persisted. The sepsis markers were not raised. Hemoglobin, WBC, and platelet counts were low. The CSF report revealed absolute lymphocytosis (100%) and raised protein. There were abnormal diffuse encephalitic changes in the electroencephalogram recordings. ANA by the Hep2 cell method showed a positive, homogeneous pattern. Anti DsDNA was positive. The C3 value was 88.2 mg per dl, while C4 was 21.6 mg per dl, both on the lower side of normal. Antiphospholipid antibody estimates were significant. IgG was 12.92 GPlU per ml and IgM was 3.76 MPl per ml. The final diagnosis was SLE with neuropathy, in the form of cerebritis with nephropathy, anemia, and associated disorder in the mechanism of blood clotting.\nIf we compare the two cases we find certain common features. The initial presentation was confusing. Only a high degree of clinical suspicion could lead to the diagnosis. We summarize the clinical, pathological, and biochemical similarities between the two subjects in . | [[31.0, 'year']] | F | {'12418441': 1, '17523212': 1, '31360498': 2, '7652137': 1, '7748011': 1, '12197258': 1, '29423350': 2, '20065106': 1, '12071439': 1, '15119542': 1, '15256629': 1, '33376654': 2, '9778274': 1, '24479062': 2} | {'7755679-1': 1, '5794200-1': 1, '6637357-1': 1} |
165,366 | 3894025-1 | 24,479,054 | noncomm/PMC003xxxxxx/PMC3894025.xml | Guillain-Barré Syndrome in Pregnancy: An Unusual Case | A 29-year-old primigravida started with pain and mild heaviness in the both lower limbs distally associated with occasional pins and needles sensation in 35th week of pregnancy. Her symptoms were progressive. Over the next 10 days, the patient noticed knee buckling with frequent falls and difficulty in sitting and standing from supine position. At the end of 36th week, an emergency LSCS (lower segment caesarian section) was performed for decreased fetal heart rate. LSCS was uneventful and a healthy baby was born. Second post-partum day, the patient was discharged. On third post-partum day, the patient complained of weakness all the four limbs (in addition to persisting symptoms), more in lower limbs and was not able to maintain the erect posture. In this state, the patient was brought to our accident and emergency department. A detailed history was taken which revealed initiation of symptoms during third trimester of pregnancy without any preceding illness. Subsequent clinical examination revealed sinus tachycardia, fluctuating hypertension, power of 4/5 in upper limbs, 3/5 in lower limbs, hypotonia, areflexia (lower limbs), flexor plantar response, and mild involvement of all the modalities of sensation. A working diagnosis of GBS was made and all other investigations including nerve conduction studies, arterial blood gases, electrolytes, and later cerebrospinal fluid analysis were planned.\nArterial blood gas analysis showed pO2=89 mmHg, saturation = 94.6%, pCO2=42 mmHg, and pH = 7.39. Serum potassium was 4.1 meq/L, sodium 136 meq/L and bicarbonate 25 meq/L. Electrocardiography showed sinus tachycardia and routine blood chemistry was normal. Serological tests for campylobacter jejuni, EBV, cytomegalovirus, and mycoplasma pneumonae were negative. Electrophysiological studies revealed decreased amplitude of compound action potentials in median and common peronial nerves with decreased conduction velocity and abnormal F waves. After 7 days, lumbar puncture was performed and cerebrospinal fluid chemistry revealed raised protein of 7.8 g/L and normal cell count, confirming the diagnosis. The patient received treatment in the form of physiotherapy and close observation of symptoms and signs to which she rapidly responded with respect to power and sense of well-being over next 72 h, without the intervention of immunomodulating drugs. Sinus tachycardia and episodic hypertension was treated with atenolol. The patient was discharged after 2 weeks of hospital stay with power of 5/5 in upper limbs, 4+/5 in right lower limb, and 4/5 in left lower limb with persisting areflexia in lower limbs. | [[29.0, 'year']] | F | {'33775326': 1, '19293590': 1, '28217608': 2, '27582795': 1, '33457125': 2, '28970694': 2, '20075554': 1, '16271648': 1, '17058576': 1, '28694640': 2, '15269509': 1, '26019422': 1, '16585891': 1, '18796075': 1, '21565505': 1, '24479054': 2} | {'5488581-1': 1, '5613433-1': 1, '7797439-1': 1, '5290785-1': 1} |
165,367 | 3894040-1 | 24,479,080 | noncomm/PMC003xxxxxx/PMC3894040.xml | Influenza A Infection Unmasking an Underlying Mitral Valve Stenosis in a 19-Year-Old Boy | A 19-year-old male patient presented to the emergency with complaints of high-grade fever since 8-12 days, not associated with chills, along with difficulty in breathing and hemoptysis since one day. On admission his temperature was 102F, blood pressure (BP) = 94/58 mm of Hg, heart rate (HR) = 152 bpm, SpO2 = 88% with oxygen support. On examination the patient was conscious, tachypneic, dyspneic and was using accessory muscles for breathing. Bilateral coarse crepitations were present and the air entry was reduced bilaterally. Cardiac examination revealed a loud first heart sound, tachycardia; no murmur was, however, audible. Neck veins were engorged and abdominal examination revealed hepatomegaly 4 cm below the costal margins. Routine blood tests, Arterial Blood Gas analysis and a throat swab were sent for examination. Chest X-ray revealed B/L homogenous opacities involving middle and basal lung fields []. ABG showed pH = 7.40, pCO2 = 22 mm of Hg, pO2 = 56 mm of Hg, HCO3 = 23 meq/l. The patient was given Bi-PAP support and empiric treatment was started keeping a possibility of viral pneumonitis among the differentials. Complete blood count (CBC) showed a Total Leucocyte Count of 8820/mm3, DLC = P85%, L13%, E2%, Hb = 11.8g/dl, Platelet count = 94000/mm3, Blood urea = 38 mg/dl, Sr. creatinine = 0.9 mg/dl, Sr.K+ = 3.4 meq/l, Sr. Na+ = 140 meq/l, Sr. bilirubin = 4.2 mg/dl, (direct = 2.1 mg/dl, indirect = 2.1 mg/dl). Total Sr. protein = 4.9 g/dl, Sr. albumin = 2.3 mg/dl, Sr. globulin = 2.6 mg/dl, AST = 116U/L, ALT = 48U/L, Sr. alkaline phosphatase = 91 U/L and CPK-MB = 28 ng/dl. A 2D-ECHO showed severe mitral valve stenosis (valve area = 0.93 cm2), moderate tricuspid regurgitation, moderate pulmonary hypertension and a dilated right and left atrium. The throat swab culture was positive for Influenza A. The patient gradually improved over a period of ten days and was subsequently referred to cardiothoracic surgery for management of mitral stenosis. | [[19.0, 'year']] | M | {'14053694': 1, '13513381': 1, '22211291': 1, '19935413': 1, '24479080': 2} | {} |
165,368 | 3894042-1 | 24,479,081 | noncomm/PMC003xxxxxx/PMC3894042.xml | Liver Abscesses and Hyper IgM Syndrome | A 5-year-old boy presented with recurrent fever for 1.5 months and intermittent pain in right hypochondrium along with vomiting for 1 month. On examination, he had tender hepatomegaly and pallor. Investigations showed multiple small hypodense lesions in the liver suggestive of microabscesses. His investigations showed hemoglobin 8.8 gm/dL, WBC count 17,400/mm3, platelet count 438,000/mm3, bilirubin 0.8 mg/dL, SGOT 102 IU/L, SGPT 68 IU/L, total proteins 5.5 gm/dL, and albumin 2.4 gm/dL. Stool showed cysts of E. histolytica and blood culture did not grow any organism. HIV ELISA was negative. He was treated with IV piperacillin/metronidazole and oral chloroquine for 10 days but had no response. He subsequently had a drop in hemoglobin level along with leukocytosis (34,500/mm3) and thrombocytopenia for which he received 5 units of blood transfusion and antibiotics were changed to vancomycin and ceftazidime. He also developed ascitis and ascitic fluid showed 1920 cells/mm3 (80% polymorphs, 20% lymphocytes). Urine examination showed presence of fungal hyphae and child was treated with amphotericin B. In view of severe infections, he was tested for immunodeficiencies. His HIV ELISA was negative and serum immunoglobulins showed low serum IgG (530 mg/dL (normal = 971-1746 mg/dL)), normal IgA (104 mg/dL (normal = 75-178 mg/dL)), and high serum IgM (183 mg/dL (normal = 66-153 mg/dL)). Nitroblue tetrazolium (NBT) test was normal. Patient responded to above therapy and is currently asymptomatic. | [[5.0, 'year']] | M | {'8993019': 1, '11675497': 1, '20706820': 1, '9143181': 1, '14663287': 1, '20339173': 1, '17006041': 1, '15626470': 1, '7679801': 1, '2671497': 1, '15164532': 1, '24479081': 2} | {'3894042-2': 2} |
165,369 | 3894042-2 | 24,479,081 | noncomm/PMC003xxxxxx/PMC3894042.xml | Liver Abscesses and Hyper IgM Syndrome | A 6-year-old girl presented with fever for 5 days and pain in right hypochondrium for 3 days. There was no jaundice or vomiting. On examination, she had a tender hepatomegaly. Other systems were normal. Investigations showed hemoglobin 6.9 gm/dL, WBC count 57,300/mm3, platelets 290,000/mm3, SGOT 39 IU/L, SGPT 28 IU/L, total proteins 7.9 gm/dL, albumin 2.9 gm/dL, and deranged prothrombin time and partial thromboplastin time. Ultrasound of abdomen showed abscess (size 6 × 5 × 4 cm) in right lobe of liver. Blood culture was negative. Child was treated with IV antibiotics: Ceftraixone and cloxacillin for 1 month and surgical drainage of abscess was done; subsequently, patient was given oral cloxacillin and cotrimoxazole for another 2 months and ultrasound showed complete resolution of abscess. Her HIV ELISA was negative and serum IgG was low (620 mg/dL (normal = 971-1746 mg/dL)), serum IgA was normal (118 mg/dL (normal = 75-178 mg/dL)), and serum IGM was elevated (229 mg/dL (normal = 66-153 mg/dL)). Her Nitroblue tetrazolium (NBT) was normal. | [[6.0, 'year']] | F | {'8993019': 1, '11675497': 1, '20706820': 1, '9143181': 1, '14663287': 1, '20339173': 1, '17006041': 1, '15626470': 1, '7679801': 1, '2671497': 1, '15164532': 1, '24479081': 2} | {'3894042-1': 2} |
165,370 | 3894371-1 | 24,459,567 | noncomm/PMC003xxxxxx/PMC3894371.xml | Asymptomatic Myxoma Originating from the Right Ventricular Outflow Tract | A 42-year-old female presented with general weakness occurring over 3 months. She was a hepatitis B carrier and had undergone prior surgeries for benign breast nodules and a parotid gland tumor. She had also been recently diagnosed with uterine myoma. On admission, she had a normal temperature of 36.5°C, blood pressure of 120/80 mmHg, pulse rate of 100 beats/min, and respiratory rate of 16 breaths/min. There was no history of fever or weight loss. Thoracic auscultation revealed clear lung sounds without crackles and regular heart beat without murmur, but she had pale conjunctiva. Electrocardiogram and chest radiograph were unremarkable. Laboratory data were within normal range for white blood cell count, erythrocyte sediment rate and C-reactive protein level, but there was evidence of microcytic anemia (hemoglobin 6.3 g/dL, mean corpuscular volume of 65.6 fL, serum iron 10 mcg/dL, total iron binding capacity 474 mcg/dL, serum ferritin 1.73 ng/mL). Serologic tests for autoimmune markers were also negative. Although uterine myoma was thought to be the main cause of anemia, abdominal computed tomography (CT) was performed to identify any other possible causes of bleeding, and a large mass in the pulmonary outflow tract was found incidentally. Pulmonary angio CT showed a contrast-enhancing mass in the RVOT (). Transthoracic Doppler echocardiography (TTE) was performed for further evaluation of the RVOT mass and revealed a large, mobile, ovoid mass measuring 24 × 17 mm in diameter, which was prolapsing into the pulmonary trunk during the systolic phase (). Although we were not able to obtain a pulse wave Doppler measurement across the obstruction owing to a non-favorable interception angle, there was no definite flow acceleration around the tumor by color flow Doppler. The right ventricle (RV) chamber was mildly dilated, but there was no significant tricuspid regurgitation or right ventricular hypertrophy, and the estimated RV systolic pressure was 36 mmHg. Transesophageal echocardiography was performed to confirm the size and location of the mass, showing the stalk of the mass originating from the subvalvular infundibulum ().\nThe patient underwent surgery and the mass was completely removed via right atrial approach under cardiopulmonary bypass (). The mass was yellowish, soft and had a wide stalk. Microscopic examination showed stellate and globular cells that were arranged in a cord-like pattern with an abundant myxoid background, consistent with a benign myxoma (). The patient's postoperative course was uneventful and she was discharged 10 days after surgery. | [[42.0, 'year']] | F | {'11547282': 1, '26734471': 2, '16861407': 1, '34866591': 1, '22358285': 1, '14502195': 1, '24459567': 2} | {'4698127-1': 1} |
165,371 | 3894372-1 | 24,459,568 | noncomm/PMC003xxxxxx/PMC3894372.xml | Intermittent, Non Cyclic Severe Mechanical Aortic Valve Regurgitation | A 68-year-old man who had been performed aortic valve replacement with a bileaflet mechanical Tekna valve (23 mm, Baxter Health Care, Santa Ana, CA, USA) 12 years ago presented to the emergency department with an exertional chest pain and short of breath for four days. On presentation, he was clinically stable with blood pressure of 120/70 mmHg, heart rate of 97 bpm and 2/6 systolic murmur, but no diastolic murmur. Chest X-ray showed mild cardiomegaly and tortuous ascending aorta. The electrocardiography showed normal findings. Troponin I was normal at 0.01 ng/mL (normal range 0.00-0.05 ng/mL) and international normalized ratio was suboptimal at 1.04 sec. Transthoracic echocardiogram and transesophageal echocardiogram demonstrated intermittent non cyclic severe acute aortic valve regurgitation with normal systolic excursion of the occluding disk, a mean transprosthetic gradient of 14-23 mmHg (). A small less mobile echogenic mass was seen in the outflow tract immediately above the prosthesis consistent with pannus formation on which possible thrombus superimposed (). Doppler echo showed increased left ventricular filling pressure (E/e' 19) and steep slope of aortic regurgitation (pressure half time 120 msec). Left ventricular size and function were normal. Aortogram showed also non cyclic, intermittent incomplete closing of prosthesis with severe aortic regurgitation (). After short term intravenous heparin infusion, he underwent urgent surgical treatment. At surgery, inspection and visualization of the structure with a cardiac optical fiber device confirmed echocardiographic data showing a focal pannus formation above the aortic prosthesis. The prosthetic valve leaflets were not involved and the disk motion appeared unrestricted (). Pannus was fully excised but the aortic valve was not replaced. Histologic examination revealed a structure of fibroconnective tissue consistent with pannus formation and superimposed thrombus. The patient had an uncomplicated postoperative recovery and was discharged on his 7th postoperative day. After 2 years with meticulous anticoagulation therapy, the patient was stable and follow-up echocardiogram showed normal aortic prosthetic valve function with a mean transprosthetic gradient of 10 mmHg. | [[68.0, 'year']] | M | {'32530931': 1, '17600679': 1, '19074784': 1, '9809956': 1, '19762209': 1, '16020615': 1, '12928636': 1, '17097353': 1, '10456407': 1, '16004902': 1, '24459568': 2} | {} |
165,372 | 3894373-1 | 24,459,569 | noncomm/PMC003xxxxxx/PMC3894373.xml | Organized Prosthetic Tricuspid Valve Thrombosis Treated Successfully with Medical Treatment | A 57-year-old female patient was admitted to the hospital with the complaint of dyspnea [The New York Heart Association (NYHA) Functional class II] in December, 2010. TTE showed left ventricular ejection fraction of 59%, severe mitral stenosis, severe aortic stenosis and severe tricuspid regurgitation. In January 2011, the patient underwent mitral valve replacement with a 25 mm On-X Valve (On-X Life Technologies Inc., Austin, TX, USA), tricuspid valve replacement with a 31/33 mm On-X Valve, and aortic valve commissurotomy. Also, because of persistent atrial fibrillation, she received Cox-maze procedure. Eleven days after valve replacement, TTE revealed that the normal function and gradients of the two prosthetic valves. At the time of discharge, the patient's international normalized ratio (INR) was 2.36. She was discharged from the hospital with the recommendation to use warfarin with goal INR 2.0-3.0.\nIn December 2012, the patient complained of dyspnea again. Her blood pressure was 137/68 mmHg and pulse rate was 55 beats per minute. TTE and TEE demonstrated that two prosthetic valves had normal functions and gradients. Doppler echocardiographic examination of the prosthetic tricuspid valve demonstrated the peak E velocity of 1 m/s, peak pressure gradient of 5 mmHg, and pressure half time of 144 ms (). Fluoroscopic evaluation revealed that both leaflets of the two prosthetic valves moved freely. She complained of intermittent, small amount of melena and microcytic and hypochromic anemia with hemoglobin level of 7.8 mg/dL was detected. Therefore, under impression of iron deficiency anemia caused by gastrointestinal bleeding, oral iron supplement was prescribed and esophagogastroduodenoscopy (EGD) was planned. The patient's INR was 2.51 before procedure. After four days of withholding warfarin therapy without reversal the effect of it, EGD was done. Her INR was 1.82 at that time. EGD showed erosive gastritis without active bleeding focus, no hemostatic intervention was performed and the patient resumed taking warfarin the next day.\nThe patient was hospitalized for evaluation of the causes of worsening dyspnea (NYHA Functional class III) despite correction of anemia in February 2013. On admission day, her blood pressure was 121/59 mmHg, pulse rate was 80 beats per minute and INR was 2.13. TTE revealed that the prosthetic mitral valve had normal function and gradients, whereas the prosthetic tricuspid valve showed limited motion without definite obstruction. Doppler measurements including peak E velocity and mean gradient, however, were within acceptable range. The peak E velocity was 1 m/s and mean gradient was 3 mmHg. The only parameter suggested prosthetic tricuspid valve dysfunction was prolonged pressure half time, 382 ms (). Considering the fact that warfarin was recently discontinued, fluoroscopic evaluation was done. The fluoroscopy showed that one leaflet of the prosthetic tricuspid valve had limited motion (). For evaluation of the cause of impaired prosthetic tricuspid valve motion, MDCT was performed. Computed tomography demonstrated the large thrombus on prosthetic tricuspid valve (, and ). With the diagnosis of prosthetic tricuspid valve thrombosis, the patient was administered 60 mg of low molecular weight heparin twice a day for three days. Her blood pressure and pulse rate were stable during hospitalization. After three days, she discharged from the hospital with the recommendation to adjust warfarin dose with goal INR 3.0-3.5. Two weeks after discharge from the hospital, she visited the outpatient clinic for follow-up. Dyspnea was disappeared and her exercise capacity was improved. Then, after four months, follow-up TTE was done. The images showed unrestricted motion of prosthetic tricuspid valve with normal pressure half time (). | [[57.0, 'year']] | F | {'6837458': 1, '19801036': 1, '18848134': 1, '22000268': 1, '7564433': 1, '22285971': 1, '19733789': 1, '19037643': 1, '14759431': 1, '10097236': 1, '8676934': 1, '23639269': 1, '12024126': 1, '22171905': 1, '22922415': 1, '11078238': 1, '11171726': 1, '20369498': 1, '23323074': 1, '8313552': 1, '24459569': 2} | {} |
165,373 | 3894374-1 | 24,459,570 | noncomm/PMC003xxxxxx/PMC3894374.xml | The Case of Isolated Double Atrial Septum with Persistent Interatrial Space | A 69-year-old male was consulted to cardiology from otolaryngology for pre-operative cardiac evaluation. He had a history of hypertension with no event of cerebrovascular accidents. And he had an operation schedule for oral cavity cancer involving right buccal mucosa (T4N0M0, in TNM staging). His general condition looked poor because of oral cavity malignancy and concurrent chemotherapy. His blood pressure was 103/62 mmHg and pulse rate was 95 bpm with regular heart beat. Chest X-ray showed mild pulmonary edema and bilateral pleural effusion 1 week ago, but improving with negative volume control.\nTwo-dimensional echocardiography showed normal LV systolic function with LV ejection fraction about 56%, concentric hypertrophy of LV and slightly enlarged left atrial (LA) chamber with LA volume index 55 mL/m2. Apical 4 chamber () and parasternal views showed fibrothickened with calcification of mitral valve and aortic valve due to rheumatic heart disease with moderate mitral stenosis (mitral valve area 1.55 cm2, mean diastolic pressure gradient 5.5 mmHg), moderate aortic stenosis (aortic valve area 1.21 cm2, peak/mean systolic pressure gradient 34/19 mmHg) and interatrial septal aneurysm. It also showed mild pulmonary hypertension with 41 mmHg of right ventricular systolic pressure, and inferior vena cava plethora suggestive diastolic heart failure.\nOn standard parasternal and apical views, there was no definite abnormal finding at interatrial septum except aneurismal change of interatrial septum (). However, on subcostal view, there was 3.2 × 1.0 cm sized, crescent shaped, echo-free space was observed between two atria (). This echo-free space was located in center of interatrial septum and consisted of parallel atrial septal structure (). It was highly suspicious of double atrial septum with persistent interatrial space. There is no evidence of thrombus in this space and color Doppler echocardiography revealed communicating flow between this space and LA and small amount of left-to-right shunt flow suggesting patent foramen ovale (PFO) (). The computed tomography (CT) also identified double-layered parallel atrial septal structure with persistent interatrial space, showing contrast enhancement (). We recommended further evaluation for double atrial septum including transesophageal echocardiography (TEE) but patient refused because of oral cavity lesion and had surgery (wide excision of buccal mucosa cancer) at otolaryngology. He was prescribed aspirin and has followed up uneventfully to date. | [[69.0, 'year']] | M | {'1266740': 1, '23046685': 1, '18490273': 1, '34195518': 1, '5805986': 1, '17275715': 1, '30062321': 1, '16950474': 1, '33117921': 1, '24459570': 2} | {} |
165,374 | 3894388-1 | 24,466,554 | noncomm/PMC003xxxxxx/PMC3894388.xml | Nodular lymphoid hyperplasia of the stomach in a patient with multiple submucosal tumors | A 38-year-old man was referred to our hospital for multiple gastric submucosal lesions after an annual medical checkup. The patient did not have a history of congenital or acquired immunodeficiency or symptoms of abdominal pain, weight loss, or fever. He was immunocompetent, as shown by a complete blood count with differential and the absence of serum viral markers, such as anti-human immunodeficiency virus (HIV) antibodies. Esophagogastroduodenoscopy revealed multiple protruding lesions covered with normal mucosa on the body and antrum of the stomach (). The lesions appeared as well-demarcated oval masses that varied in size from several millimeters to 1 cm. In addition, they were hypoechoic and originated in the submucosal layer without invasion into the deeper layers, as shown by endoscopic ultrasonography (). The Campylobacter-like organism (CLO) test was negative. No pathologic lesions were found by colonoscopy. Computed tomography also did not reveal any abnormal thickening of the gastric wall or regional lymphadenopathy. Three mass lesions were resected by endoscopic submucosal dissection and endoscopic mucosal resection.\nThe resected polyps revealed several well-defined submucosal nodules of dense lymphoid infiltrates mimicking ectopic lymph nodes (). These infiltrates had a diffuse and nodular architecture with primary and secondary lymphoid follicles (). A few lymphoid follicles also had a prominent mantle zone and small germinal center (). The lymphoid cells in the diffuse areas and primary follicles were composed predominantly of small cells, although there were a few multinucleated giant cells, which were considered to be Warthin-Finkeldey-type cells (). The infiltrate between the follicles was composed mainly of medium-sized lymphoid cells with abundant clear cytoplasm and indented or round nuclei with small nucleoli, admixed with a small number of plasma cells. In addition, a few large cells with vesicular nuclei and one or two prominent nucleoli were identified (). The gastric mucosa revealed multifocal lymphoid aggregates and some of the epithelial cells were infiltrated by small lymphocytes mimicking lymphoepithelial lesions ().\nImmunohistochemistry tests showed that the lymphoid infiltrates, including the medium-sized cells, in the interfollicular areas expressed CD2, CD3, CD4, CD5, CD8, and CD43, but the small cells in the lymphoid follicles and the large cells in the interfollicular areas did not express these markers (). However, the latter cell types expressed the CD20 antigen (). CD10 and bcl-6-positive B lymphoid cells were confined to small germinal centers (), but were negative for bcl-2. In addition, staining with CD21 and CD23 showed a normal reactive pattern in lymphoid follicles () and expanded follicular dendritic cell networks. CD30-positive large cells were rare. The plasma cells were polyclonal, as shown by kappa and lambda light chain immunohistochemistry.\nResults of in situ hybridization for Epstein-Barr virus-encoded RNA were negative. In addition, no evidence of a chromosomal translocation was found by using interphase fluorescence in situ hybridization analysis of paraffin sections using the API2/MALT1 dual-color, dual-fusion translocation probe, which revealed two orange and two green signals. However, polymerase chain reaction analysis of the immunoglobulin heavy chain and T-cell receptor gene rearrangements using the standard Biomed-2 PCR protocol, demonstrated a polyclonal pattern on Gene Scanning. The patient was followed for 1 year and the polypoid lesions remained unchanged without any additional treatment. | [[38.0, 'year']] | M | {'16610004': 1, '16204012': 1, '16423889': 1, '19474513': 1, '9128979': 1, '17122510': 1, '18820661': 1, '17525089': 1, '736212': 1, '8505036': 1, '8705262': 1, '17204020': 1, '25400867': 1, '11865009': 1, '21481240': 1, '12490983': 1, '24466554': 2} | {} |
165,375 | 3894390-1 | 24,466,556 | noncomm/PMC003xxxxxx/PMC3894390.xml | Successful treatment of steroid resistant hypereosinophilic syndrome with low-dose CsA | A 41-year-old man visited our emergency room with rashes on both legs and his trunk area.\nOn physical examination, only a skin lesion was found. His complete blood count (CBC) showed hypereosinophilia (eosinophils 4,730/mm3). Although he had no history of allergies, a previous CBC reports showed persistent hypereosinophilia over the previous 6 months.\nSubsequent analyses did not reveal any evidence of secondary HES including any autoimmune disease or parasitic infestation. Bone marrow aspirate and biopsy showed marked eosinophilia without dyspoiesis. FIP1L1-PDGFRA, TEL-PDGFRB, or BCR-ABL rearrangement was not detected on fluorescence in situ hybridization. JAK2 V617F mutation analysis performed with a reverse transcription polymerase chain reaction technique was negative. Serum immunoglobulin E (IgE) level (1,599 mg/dL) and eosinophilic cationic protein level (163.35 ng/mL) were elevated.\nSkin biopsy of the leg rash showed perivascular lymphohistiocytic infiltration and many eosinophils. Flow cytometric analysis to evaluate the associated aberrant T-lymphocyte found no abnormal phenotypes such as CD3-CD4+ or CD3+CD4-CD8-, but the T cell receptor (TCR) gene rearrangement was not checked. Although we could not confirm the subclass of HES, clinical findings indicated a lymphocytic variant of HES (L-HES). The patient initially responded well to a high-dose glucocorticoid treatment, but after reducing prednisone, the eosinophil count and IgE level rebounded. Thus, we administered a low dose of CsA (100 mg bid), and his eosinophil count returned to normal after just 1 week of treatment. Prednisone was then tapered to 10 mg per day (). | [[41.0, 'year']] | M | {'16750989': 1, '9093318': 1, '8302319': 1, '16304382': 1, '18344568': 1, '19734412': 1, '19002011': 1, '19910029': 1, '20810155': 1, '11110703': 1, '15995323': 1, '24466556': 2} | {'3894390-2': 2} |
165,376 | 3894390-2 | 24,466,556 | noncomm/PMC003xxxxxx/PMC3894390.xml | Successful treatment of steroid resistant hypereosinophilic syndrome with low-dose CsA | A 41-year-old man who had been suffering from intractable eosinophilic pustular folliculitis for 5 years was referred to our hospital. Skin biopsy from the lesion showed perivascular and periadnexal eosinophilic infiltration. He had no history of allergies. Although he had been taking dapsone, prednisone, and an antihistamine since 2008, his skin lesion had waxed and waned and the CBC showed persistent hypereosinophilia for over 1 year. The laboratory results showed an eosinophil count of 1,790/mm3 and a serum IgE level of 119 IU/mL. Nevertheless, there was no evidence of secondary HES. Sequentially performed bone-marrow aspiration and biopsy showed hyperplasia of the eosinophilic lineage, but the molecular analysis did not show any specific aberrant genetic mutations consistent with the myelocytic variant of HES (M-HES). Unfortunately, we did not analyze the T cell phenotype and T cell clonality. On physical examination, only skin manifestations were found. The patient could not be categorized as L-HES according to the laboratory results; however, considering the relatively gentle clinical course and absence of cardiac involvement, we selected an immune-modulating drug as a second line treatment rather than a cytotoxic agent or imatinib. We administered a low dose of CsA (100 mg bid), and his eosinophil count returned to normal after 1 week of treatment. In addition, his skin lesion disappeared (). | [[41.0, 'year']] | M | {'16750989': 1, '9093318': 1, '8302319': 1, '16304382': 1, '18344568': 1, '19734412': 1, '19002011': 1, '19910029': 1, '20810155': 1, '11110703': 1, '15995323': 1, '24466556': 2} | {'3894390-1': 2} |
165,377 | 3894393-1 | 24,466,559 | noncomm/PMC003xxxxxx/PMC3894393.xml | Acute promyelocytic leukemia with an unusual presentation of secondary postpartum hemorrhage | A 30-year-old woman (gravida 2, para 2, abortus 0) delivered a 2.1 kg baby girl through normal vaginal delivery but was otherwise healthy. She received 2 units of whole blood transfusion during labor and was discharged 3 days later. However, she was re-admitted 6 days following discharge with complaints of excessive bleeding per vaginum and bleeding gums. On examination, she was pale and afebrile with a pulse rate of 72 beats/min and blood pressure of 110/70 mmHg. There was no icterus, pedal edema, or lymphadenopathy, and no complaint of fever or bruising. Ultrasound revealed clots within the uterus possibly due to retained products of conception. There was hepatomegaly but no splenomegaly. Hematological investigations revealed the followings: hemoglobin level, 8.8 g/dL; total leukocyte count, 6.5×106/L; platelet count, 44×109/L; hematocrit, 24.4%; red blood cell count, 2.62×109/L; differential leukocyte count: blasts, 2%; promyelocytes, 65%; neutrophils, 4%; and lymphocytes, 29%. The abnormal promyelocytes were 2-4 times the size of small mature lymphocytes and had a moderate amount of cytoplasm with granules and Auer rods. The nuclei contained fine chromatin and 1-3 prominent nucleoli, and hallmark faggot cells were also observed (). The promyelocytes were strongly positive for myeloperoxidase. She was diagnosed with AML, suggestive of APL. Bone marrow aspiration was advised along with immunophenotyping and cytogenetic studies. The coagulation profile revealed the followings: prothrombin time, 15 sec (control, 13 sec); activated partial thromboplastin time, 31 sec (control, 30 sec); serum fibrinogen level, 110 mg/dL; D-Dimer level, 16-32 µg/mL fibrinogen equivalent units (reference range, <0.5 µg/mL fibrinogen equivalent units). Other biochemical tests were within normal limits. However, the patient died of hypovolemic shock following excessive blood loss. Therefore, further investigations could not be performed. During the antenatal period, the patient had a hemoglobin range of 9-9.5 g/dL, a total leukocyte count of 6-8×106/L, and a platelet count of 160-190×109/L. A peripheral blood smear revealed microcytic hypochromic red cells; however, no abnormal cells or blasts were seen on any smears during the antenatal period. Moreover, she had a normal coagulation profile.\nAcute leukemia during pregnancy is very rare with an estimated frequency of 1 in 75,000-100,000 [, , ]. AML accounts for approximately two-thirds of leukemia cases seen during pregnancy and the diagnosis is generally made during the second and third trimesters [, ]. PPH is occasionally due to an underlying coagulation or hematologic disorder, but PPH as a presentation of APL is extremely rare []. APL is commonly complicated by disseminated intravascular coagulation (DIC), seen in >90% of patients, and a life-threatening hemorrhage can occur in the brain, gut, or less frequently, the uterus. In such cases, it is very important to diagnose the underlying disorder as APL and it is curable with a good prognosis. The treatment of choice for APL is all-trans retinoic acid followed by conventional chemotherapy [-]. This case report is important as it highlights the fact that APL can be a rare cause of PPH. A peripheral blood smear should be performed in all cases of unexplained DIC. | [[30.0, 'year']] | F | {'16341866': 1, '8635026': 1, '12358893': 1, '18837246': 1, '3422173': 1, '14979475': 1, '19061780': 1, '15912518': 1, '24466559': 2} | {} |
165,378 | 3894442-1 | 24,459,647 | noncomm/PMC003xxxxxx/PMC3894442.xml | Severe ischemic bowel necrosis caused by terlipressin during treatment of hepatorenal syndrome | A 46-year-old man with underlying liver cirrhosis and hepatocellular carcinoma (HCC) secondary to chronic hepatitis B presented with abdominal distension. The patient had undergone hepatic segmentectomy 1 year previously due to HCC. After HCC recurrence, he had been receiving transarterial chemoembolization (TACE), and fifth TACE was done 1 month previously. Abdominal computed tomography (CT) which was taken 2 weeks after the last TACE showed no viable tumor in the liver. But, increased size of lymph nodes in the portocaval space and newly developed ascites were noted. Portal vein was patent without thrombosis.\nAt admission, electrocardiography was normal and there was no evidence of cardiac dysfunction. Initial serum creatinine was 1.2 mg/dL and blood urea nitrogen (BUN) was 12 mg/dL. Albumin level was 3.6 g/dL, aspartate transaminase 136 IU/L, alanine transaminase 137 IU/L, alkaline phosphatase 215 IU/L and total bilirubin 3.8 mg/dL. Hemoglobin level was 14.3 g/dL and platelet count was 284,000/uL. Prothrombin time was 12.8 seconds. A moderate amount of ascites was noted, and urine output decreased. Diagnostic paracentesis and ascitic fluid analysis was done. Albumin was 2.2 g/dL, leukocyte count was 300/mm3 (neutrophil 61%, lymphocyte 10%, monocyte and macrophage 29%), lactate dehydrogenase was 541 IU/L, glucose was 101 mg/dL in ascites, and bacteria was not seen on gram stain and culture of ascites. Serum-to-ascites albumin gradient (SAAG) was 1.4, suggesting ascites from portal hypertension. There was no definite evidence of spontaneous bacterial peritonitis. Twenty mg of furosemide combined with 50 mg of spironolactone, was administered for three days.\nThree days after admission, serum creatinine had increased to 3.31 mg/dL and BUN had increased to 37.6 mg/dL. The fractional excretion of sodium was 0.8%. The diuretics were stopped, and a total of 80 g of albumin was administered and hydration with 1.5 L of normal saline was done for two days to rule out the possibility of pre-renal acute kidney injury. Despite such a treatment, there was no improvement of serum creatinine. No nephrotoxic drug was used and the blood pressure was generally stable. There was no evidence of parenchymal kidney disease such as marked proteinuria or hematuria. Abdominal sonography showed normal echogenicity on both kidney, and urinary tract abnormality was not noted. According to the criteria of International Ascites Club in 2007, we diagnosed the patient's renal failure as type I HRS. One mg of terlipressin was intravenously administrated every 6 hours. Because the patient complained of severe abdominal pain after 2 doses of terlipressin, it was stopped. Serum creatinine and BUN increased to 7.95 mg/dL and 84.4 mg/dL, respectively, and hourly urine volume became further decreased (). Continuous renal replace therapy was applied for supporting impaired renal function. But, the patient's abdominal pain aggravated and whole abdominal tenderness appeared. Rebound tenderness was also noted. Abdominal CT revealed that the wall of mid-ileum appeared to be thin and not enhanced with contrast. There were multiple air bubbles in the mesenteric veins and in the bowel wall, suggesting pneumatosis intestinalis (). Otherwise, there was no thrombus within vessel or free air in peritoneal cavity.\nWith these findings, the patient was diagnosed with bowel necrosis due to mesenteric ischemia induced by terlipressin. The patient received an emergency bowel resection.\nOperative findings demonstrated the small bowel segment below the Treitz ligament to be in an ischemic state. The blood flow was improved after adjusting the direction of bowel mesentery but the infarction of ileum was severe, so approximately 30 cm of it was resected. Grossly, the resected bowel also had ischemic change on serosa and mesentery, and the mucosa was atrophied and black-pigmented on the opening of the bowel lumen (). Microscopically, there were necrosis and hemorrhages in the bowel wall ().\nThere were no any immediate complications associated with surgery, but hypotension and metabolic acidosis persisted. Eventually, the patient died 2 days after operation. | [[46.0, 'year']] | M | {'19541582': 1, '3877230': 1, '33162803': 1, '18471512': 1, '2971015': 1, '11976865': 1, '17389705': 1, '19018483': 1, '28056095': 1, '16496352': 1, '19885875': 1, '2035956': 1, '17537358': 1, '18046716': 1, '17880357': 1, '3497079': 1, '15696791': 1, '29081628': 2, '19776409': 1, '30600312': 1, '11600480': 1, '24459647': 2} | {'5642133-1': 1} |
165,379 | 3894443-1 | 24,459,648 | noncomm/PMC003xxxxxx/PMC3894443.xml | Three cases of glycogenic hepatopathy mimicking acute and relapsing hepatitis in type I diabetes mellitus | A 22-year old female was referred to a hepatologist for evaluation of elevated liver enzymes. She had haven Type I DM for 8 years. When she visited our hospital one month ago, her liver function test had showed abnormal aspartate aminotransferase (AST) and alanine aminotransferase (ALT) as 169 U/L (normal value <35) and 172 U/L (normal value <35), respectively. Four weeks later, at the time of the referral, her AST and ALT were elevated strikingly as 1028 U/L and 365 U/L. Other laboratory findings were total bilirubin (TB) 0.5 mg/dL (normal value <1.3), Alkaline phosphatase (ALP) 346 U/L (normal value <85), γ-glutamyl transpeptidase (γ-GT) 321 U/L (normal value <40), hemoglobin A1c (HbA1c) 13.8% (normal value <6), triglyceride(TG) 160 mg/dL, high-density lipoprotein (HDL) 114 mg/dL creatine kinase (CK) 127 UL (normal value <220). Auto-antibody including anti-nuclear antibody (ANA), smooth muscle antibodies (ASMA) and mitochondrial antibodies (AMA) were all negative. Thyroid function test and serum ceruloplasmin were also normal. The serologic findings for viral infection such as IgM anti-HAV, HBsAg, anti-HCV, HCV-RNA, cytomegalovirus and Epstein-Barr virus were also all negative. Her height, weight, body mass index (BMI) and waist circumference were 165.1 cm, 50.8 kg, 18.6 kg/m2 and 72 cm respectively. Abdominal Ultrasonography (US) showed just a mild fatty change of liver and mild hepatomegaly (). She was not an alcohol or drug consumer and was not taking any medication except insulin. In addition, she did not show any symptom and sign compatible with acute hepatitis. So, we recommend her for a liver biopsy to elucidate the cause of acute elevation of liver enzyme. In hematoxylin and eosin (H&E) stain, liver biopsy showed normal liver architecture with no evidence of hepatocellular injury, inflammation, fibrosis, or steatosis. However, the hepatocytes were diffusely swollen with pale cytoplasm. The periodic acid-Schiff (PAS) staining showed abundant glycogen accumulation within hepatocytes. So, histologically, it was diagnosed as a glycogenic hepatopathy (). Eight weeks later, her transaminases were drooped suddenly without any special management. After this event, although we tried to control her sugar level strictly, her sugar control was still poor and HbA1c was maintained above 11% with mild fluctuation. Until now, her liver enzymes also have shown severe fluctuation continuously as like relapsing hepatitis (). | [[22.0, 'year']] | F | {'16625098': 1, '30616577': 2, '8982149': 1, '24926465': 2, '32328105': 2, '34759828': 1, '25512791': 1, '17220798': 1, '14635736': 1, '18691943': 1, '33867669': 1, '8359783': 1, '30283279': 2, '11682042': 1, '11036799': 1, '28042636': 2, '18413180': 1, '9502760': 1, '26269698': 2, '29279489': 1, '25789113': 1, '18413182': 1, '11756758': 1, '29527255': 1, '31027093': 1, '16679704': 1, '28529811': 2, '33763324': 2, '32128265': 2, '31620518': 1, '24459648': 2} | {'3894443-2': 2, '7174941-1': 1, '4520193-1': 1, '4049544-1': 1, '7048907-1': 1, '5278071-1': 1, '5424186-1': 1, '6322227-1': 1, '6167705-1': 1, '7982004-1': 1} |
165,380 | 3894443-2 | 24,459,648 | noncomm/PMC003xxxxxx/PMC3894443.xml | Three cases of glycogenic hepatopathy mimicking acute and relapsing hepatitis in type I diabetes mellitus | A 20-year old female with type I DM during 10 years was referred to a hepatologist for elevated liver enzymes. When she visited our hospital 8weeks ago, her AST and ALT levels were within normal range as 13 and 9 U/L, respectively. At the time of the referral, her AST and ALT were elevated strikingly to 1,310 U/L and 346 U/L. Other laboratory finding such as TB (0.2 mg/dL), ALP (132 U/L), γ-GT (15 U/L), TG (112 mg/dL), HDL (36 mg/dL), CK 86 UL, thyroid function test, serum ceruloplasmin level were all normal. ANA, ASMA and AMA were also negative. The serologic findings for viral infection were also all negative. There was no history of taking alcohol or drug except insulin. Her glycemic control had been poor and HbA1c was 13.6%. Her height, weight, body mass index (BMI) and waist circumference were 149.8 cm, 47.1 kg and 21 kg/m2, respectively. Abdominal US showed just a mild fatty change of liver. As former two cases, she did not show any symptom and sign compatible with acute hepatitis and GH was confirmed by liver biopsy. During the follow up, her glycemic control has been still poor and HbA1c has been maintained above 15%. However, her liver enzyme levels have shown dramatically down and maintenance within normal range (). | [[20.0, 'year']] | F | {'16625098': 1, '30616577': 2, '8982149': 1, '24926465': 2, '32328105': 2, '34759828': 1, '25512791': 1, '17220798': 1, '14635736': 1, '18691943': 1, '33867669': 1, '8359783': 1, '30283279': 2, '11682042': 1, '11036799': 1, '28042636': 2, '18413180': 1, '9502760': 1, '26269698': 2, '29279489': 1, '25789113': 1, '18413182': 1, '11756758': 1, '29527255': 1, '31027093': 1, '16679704': 1, '28529811': 2, '33763324': 2, '32128265': 2, '31620518': 1, '24459648': 2} | {'3894443-1': 2, '7174941-1': 1, '4520193-1': 1, '4049544-1': 1, '7048907-1': 1, '5278071-1': 1, '5424186-1': 1, '6322227-1': 1, '6167705-1': 1, '7982004-1': 1} |
165,381 | 3894445-1 | 24,459,650 | noncomm/PMC003xxxxxx/PMC3894445.xml | Hepatic abscess mimicking hepatocellular carcinoma in a patient with alcoholic liver disease | A 70-year-old man was admitted to our hospital due to general weakness for 2 days. He did not have any specific medical history. However, he had a history of heavy alcohol drinking for more than 30 years. The laboratory tests at the time of admission revealed that elevated serum levels of total bilirubin (6.3 mg/dL), direct bilirubin (5.1 mg/dL), aspartate aminotransferase (450 IU/L), alanine aminotransferase (254 IU/L), gamma-glutamyl transpeptidase (399 IU/L), alkaline phosphatase (180 IU/L), and lactate dehydrogenase (890 IU/L). Serologic tests for hepatitis A, B and C were negative. The complete blood count showed decreased level of white blood cell count (3,200 mm-3) and platelet count (61,000 mm-3). However, the level of hemoglobin was within normal limits. Coagulation profiles and C-reactive protein were also within normal limits. The test for serum tumor markers revealed marked elevated level of CA19-9 (462.2 U/mL) and normal levels of alpha-fetoprotein (5.15 IU/mL) and CEA (3.45 ng/mL).\nThe dynamic contrast-enhanced CT images showed a 6 cm well-encapsulated mass in the right hepatic lobe, with the enhancement pattern of early arterial enhancement and delayed washout. And also, CT images showed enlargement of right and caudate lobe of the liver, and wall thickening and enhancement of both intrahepatic bile ducts (). However, the biliary duct was not dilated. Based on these CT findings in addition to the increased level of CA19-9, the initial tentative diagnosis was a hepatic malignant tumor such as HCC or mass-forming cholangiocarcinoma with underlying alcoholic liver disease and intrahepatic cholangitis. Dynamic gadolinium-enhanced MR imaging was subsequently performed. On fat-suppressed T1-weighted image (), the mass consisted of large area of hypointensity and small area of hyperintensity, which looked reversed with respect to signal intensity on fat-suppressed T2-weighted image (). Small portion of T1 hyperintensity within the mass was interpreted to represent the presence of hemorrhage. The hypointense area of the mass on pre-contrast fat-suppressed T1-weighted image was hyperintense, slightly hypointense and hypointense, respectively, on gadolinium-enhanced T1-weighted arterial, portal, and delayed-phase MR images that were obtained at 30 seconds, 75 seconds and 180 seconds, respectively, after the injection of gadolinium (). According to various imaging findings, such as early arterial enhancement and delayed washout, mosaic pattern of enhancement, internal hemorrhagic component, well defined tumoral capsule, and findings indicative of underlying alcoholic liver disease, the tumor was radiologically diagnosed as a HCC.\nSubsequently, right hepatectomy was decided to perform as a curative treatment. In addition, conservative treatment such as administration of hepatotonic agents and antibiotics to treat underlying alcoholic liver disease and cholangitis had been done for 1 month before operation. The laboratory test performed just before the operation revealed that serum levels of total bilirubin (0.8 mg/dL), direct bilirubin (0.4 mg/dL), aspartate aminotransferase (51 IU/L), alanine aminotransferase (40 IU/L), gamma-glutamyl transpeptidase (101 IU/L), alkaline phosphatase (60 IU/L), and lactate dehydrogenase (441 IU/L) and CA19-9 (14.7 U/mL) were markedly improved. Right hepatectomy was performed at 6 weeks after admission, according to the initial treatment plan.\nThe gross surgical specimen showed that a 6 cm brown to reddish lobulated mass with both solid and cystic portions was surrounded by whitish fibrous capsule, and included hemorrhagic necrosis, necrotic debris and internal whitish septa (). And also, multifocal irregular surface of the liver was demonstrated which was suggestive of chronic alcoholic liver disease. Microscopic examination revealed extensive areas of coagulative necrosis, infiltrations of chronic inflammatory cells including lymphoplasma cells and some eosinophils, fibrosis and focal areas of hemorrhage and hemosiderin pigments (). These histologic features resulted in the diagnosis of hepatic abscess and chronic alcoholic liver disease. He had an uneventful postoperative course, and has been alive for 59 months after surgery. | [[70.0, 'year']] | M | {'30788586': 1, '2891154': 1, '21374666': 1, '29706827': 1, '16629655': 1, '14599973': 1, '22314420': 1, '1316622': 1, '24459650': 2} | {} |
165,382 | 3894775-1 | 22,666,848 | noncomm/PMC003xxxxxx/PMC3894775.xml | Surgical management of dentigerous cyst and keratocystic odontogenic\ntumor in children: a conservative approach and 7-year follow-up | An 8-year-old boy was referred to the Department of Oral Surgery with chief complaint\nof volume augmentation at the left side of mandible, pain and fever for about one\nweek. Panoramic radiograph revealed a unilocular radiolucent cystic lesion with\nsclerotic border associated lateral incisor, canine, first and second premolar\ncrowns. Teeth were dislocated apically and medially. After local bone aspiration and\nincisional biopsy, the histological diagnosis of dentigerous cyst was established\n(). Analysis of capsule fragment\nshowed to be lined by non-keratinized epithelium. Hemorrhagic areas were also\npresent. Under local anesthesia, the patient was submitted to marsupialization after\nextraction of the primary molars ().\nThe oral mucosa was sutured to the cyst capsule and iodoform gauze dressing was\ninserted within lesion cavity. Medication gauze was changed every 5 days until the\nwound edges were epithelialized and afterwards an acrylic plug was inserted in order\nto keep wound opening and decompression. The parents were instructed to irrigate the\ncavity twice a day with saline solution and the acrylic plug was fitted when\nnecessary, attending lumen reduction. Radiographic follow-up was performed\nperiodically. The involved permanent teeth erupted naturally, without any traction\nforces (). Second premolar assumed an\nimpacted position over the first premolar probably because of dental arch space\ndeficiency. Thus, under local anesthesia the second premolar was removed. One year\nafter the first visit, the lesion had completely withdrawn, but the lateral incisor\nstill remained displaced. A space-maintainer was installed and the patient was\nreferred to orthodontic treatment ()\nfor correcting tooth position. The radiographic follow-up of 7 years showed no lesion\nrecurrence (). | [[8.0, 'year']] | M | {'30736811': 2, '33110307': 1, '27022501': 1, '26929702': 2, '19615649': 1, '17082341': 1, '29963439': 2, '31339472': 1, '17368357': 1, '11874012': 1, '30498272': 1, '11978543': 1, '14614418': 1, '12221380': 1, '27335612': 1, '16360602': 1, '32042721': 1, '16163275': 1, '12796876': 1, '12424446': 1, '16487797': 1, '22666848': 2} | {'3894775-2': 2, '4745245-1': 1, '6018295-1': 1, '6367745-1': 1} |
165,383 | 3894775-2 | 22,666,848 | noncomm/PMC003xxxxxx/PMC3894775.xml | Surgical management of dentigerous cyst and keratocystic odontogenic\ntumor in children: a conservative approach and 7-year follow-up | A 10-year-old girl was referred to the Oral Surgery Clinic for treatment of a cyst in\nthe right side of the mandible found casually on a panoramic radiograph taken for\northodontic treatment planning. The patient came without complaint but oral\nexamination revealed a slight swelling of alveolar mucosa related to a primary molar\nand canine. The panoramic radiograph showed a segmented radiolucent area in the right\nmandible body presenting a sclerotic border. Inclusion and dislocation of the\npermanent canine, first and second premolars was also associated (). After local bone aspiration and\nbiopsy, a diagnosis of keratocystic odontogenic tumor was established. The cyst\ncapsule fragment presented a stratified epithelial lining with prominent columnar\nbasal cell layer and parakeratinized daughter microcysts were scattered in the\nconnective tissue wall (). In an\nattempt to maintain the permanent teeth, the patient was submitted to decompression\nprocedure by extraction of the primary molars and insertion of iodoform gauze (). Changing of medication gauze and\nacrylic plug were performed as described for Case 1. The permanent teeth went to\nnatural eruption and 2 years after the first visit lesion had healed (). Patient was submitted to orthodontic\ntreatment and radiographic follow-up of 7 years showed no lesion recurrence (). | [[10.0, 'year']] | F | {'30736811': 2, '33110307': 1, '27022501': 1, '26929702': 2, '19615649': 1, '17082341': 1, '29963439': 2, '31339472': 1, '17368357': 1, '11874012': 1, '30498272': 1, '11978543': 1, '14614418': 1, '12221380': 1, '27335612': 1, '16360602': 1, '32042721': 1, '16163275': 1, '12796876': 1, '12424446': 1, '16487797': 1, '22666848': 2} | {'3894775-1': 2, '4745245-1': 1, '6018295-1': 1, '6367745-1': 1} |
165,384 | 3894776-1 | 22,666,850 | noncomm/PMC003xxxxxx/PMC3894776.xml | Posterior crossbite - treatment and stability | A 12.8 year-old Caucasian girl presented for treatment complaining of an unpleasant\nsmile. This patient showed oral breathing, lip incompetence, and atypical swallowing\naided by the mentonian musculature. Additionally, an increased facial lower third and a\nconvex profile were verified. Intraoral evaluation showed a Class II, division 1\nmalocclusion, and bilateral posterior crossbite ( and , ).\nThe treatment plan proposed was palatal expansion, performed by a modified Haas-type\nexpander (), aiming at increasing the\nmaxillary transversal dimension to correct the bilateral posterior crossbite. Activation\nof the screw was initiated immediately after appliance insertion with a complete turn.\nAfter that (), the patient was instructed\nto keep the activation with 2/4 turns in the morning and 2/4 turns in the afternoon,\nduring eight days. The expander was passively maintained for a period of three months,\nfollowed by a removable retainer, which was used for another six months. At that time, a\ncomprehensive orthodontic treatment was initiated in order to improve the results\nobtained after expansion (). The whole\ntreatment, including maxillary expansion and the comprehensive phase, lasted about 1\nyear and 3 months, when a Hawley appliance and a 3x3 retainer were installed ( and ). The patient has been followed up for 21 years, and has as yet maintained\nstability of the results achieved with maxillary expansion (-). | [[12.8, 'year']] | F | {'6944317': 1, '1628683': 1, '20197181': 1, '7879759': 1, '2593066': 1, '11605867': 1, '7001393': 1, '2617141': 1, '6938933': 1, '6941870': 1, '14580022': 1, '1867168': 1, '3522254': 1, '17319757': 1, '15825776': 1, '16905065': 1, '6597180': 1, '7008619': 1, '11279699': 1, '3477948': 1, '22666850': 2} | {} |
165,385 | 3895046-1 | 24,876,325 | noncomm/PMC003xxxxxx/PMC3895046.xml | Laparoscopic resection of a retroperitoneal pelvic schwannoma | A 54-year-old woman was referred to our hospital with a mass in the pelvic cavity detected on chest-abdominal, CT done for investigation of breast cancer. She had no particular past and family history, and the physical examination was unremarkable. Ultrasonography of the pelvis revealed a 5 × 4.3 cm, solid mass separated from her right adnexa (Fig. ). Contrast enhanced-CT showed a 5 × 4 cm, solid, well-defined, heterogeneous mass in the right side of the pelvic cavity (Fig. ). MRI showed that the tumor demonstrated homogeneous hypointensity on T1-weighted images and heterogeneous slight hyperintensity on T2-weighted images (Fig. a and b). Sagittal sections of MRI demonstrated that the mass was intricately related to the anterior presacral fascia (Fig. ). The preoperative diagnosis was a mesenteric gastrointestinal stromal tumor.\nUnder general anesthesia, the patient was placed in the supine position, and a 4-port technique was used. A 12-mm port was inserted through an umbilical incision for the placement of a flexible laparoscope. Three other ports (one 12-mm and two 5-mm ports for retraction or the working port) were placed. The left-sided port was mainly used for retraction. An initial incision was made in the retroperitoneum, and mainly sharp dissection by Liga-Sure was used to isolate the mass from the surrounding tissues. With careful dissection using sharp and blunt maneuvers, the mass was dissected from the neighboring vessels, such as the right internal iliac vessels and ureter (Fig. ). Although the ureter was easily identified and dissected free, the mass strongly adhered to the right internal iliac vessels, making its dissection difficult. Sponge dissection was very useful in that situation. Once free from the surrounding tissues, the mass was placed into a plastic bag to avoid spillage into the abdomen. It was then received through the enlarged incision of the umbilicus. A suction drainage tube was placed into the pouch of Douglas through a 12-mm port in the right side of the abdomen.\nThe intra-operative blood loss was minimal, and the operation time was 150 min. The specimen was an elastic hard, 5 × 4 cm mass with an integral envelope. On sectioning, it was yellow and white in color, predominantly solid with cystic change (Fig. ). Pathologic examination showed whorls and interlacing fascicles of schwannoma spindle cells, along with alternating Antoni-A and -B patterns with areas of hyalinization and fibrinoid degeneration (Fig. a and b). The cells stained positive for S-100 protein and negative for desmin and muscle-specific actin, consistent with a benign schwannoma. The patient had an uneventful post-operative course and was discharged on the fourth post-operative day. The patient has had no evidence of recurrence so far, 20 months after surgery. | [[54.0, 'year']] | F | {'879406': 1, '26543435': 1, '31374466': 2, '8774661': 1, '34522416': 1, '33585546': 2, '27472696': 1, '27190900': 1, '34040815': 2, '17388825': 1, '10862459': 1, '28343319': 1, '28289669': 1, '29442061': 1, '3855580': 1, '27313735': 1, '12464538': 1, '26943386': 2, '10434330': 1, '29896991': 2, '21113878': 1, '29571063': 1, '12946771': 1, '34476075': 2, '29988943': 1, '27900226': 2, '22902343': 1, '24876325': 2} | {'5120176-1': 1, '7874029-1': 1, '7874029-2': 1, '7874029-3': 1, '6675969-1': 1, '6134648-1': 1, '8121578-1': 1, '4747970-1': 1, '8407031-1': 1} |
165,386 | 3895048-1 | 24,876,323 | noncomm/PMC003xxxxxx/PMC3895048.xml | Complexities of abdominoperineal surgery: synchronous resection of an ano-rectal adenocarcinoma and pelvic schwannoma | A 71-year-old asymptomatic gentleman with known history of colonic polyps underwent a follow-up surveillance colonoscopy through the BCSP. He had a background of type 2 diabetes mellitus, ischaemic heart disease and diverticular disease. Colonoscopy revealed a 1-cm firm polypoid mass at the ano-rectal junction (Fig. ). Subsequent endoscopic mucosal resection was performed and the tissue was sent for histological analysis. This confirmed a tubulo-villous adenocarcinoma. As per national guidelines the patient underwent a staging computed tomography (CT) scan. This revealed a 10 × 15 cm homogenous mass arising from within the pelvis (Fig. ). The mass appeared to be continuous with a neural foramen arising from the sacrum. Further imaging confirmed the mass extending into sacral segment S1 inferiorly, lumbar segments L4 superiorly and the bladder anteriorly. A regional multidisciplinary team discussion concluded that abdominoperineal resection (APR) was the most appropriate surgical approach for removal of both pathologies in their entirety.\nWithin weeks the standard approach to an open APR was commenced.\nThe upper and mid-rectum were successfully mobilized from anterior to posterior behind the seminal vesicles using circumferential dissection techniques. Full rectal mobilization was made complex by the large 10 × 15 cm pre-sacral mass obstructing dissection planes down to the pelvic floor posteriorly. The sigmoid colon was subsequently divided ∼15 cm above the peritoneal reflection and retracted anteriorly to allow access to the tumour (Fig. ).\nOn approaching the mass the pre-sacral fascia was opened to the left side of the midline to gain entry to the tumour pseudocapsule. Upon dissection copious bleeding arose from the common iliac vein to which the tumour was adherent. Intra-operative cell salvage was then commenced and haemostasis was achieved with direct pressure and vascular repair with a 4.0-polypropylene suture. The schwannoma was then fully mobilized from its anterior and lateral fascial attachments leaving it attached to the sacrum posteriorly. Lastly, the tumour was separated from the sacrum. Pre-sacral venous bleeding was packed before complex suture ligation and diathermy of disrupted veins achieved haemostasis. The estimated blood loss was ∼1600 ml and this was replaced with 1000-ml cell salvage product together with one unit of cross-matched red cells.\nThe perineal dissection was then completed and an end colostomy fashioned in the left iliac fossa. The abdominal wound was closed en-mass with clips to the skin. The patients' post-operative haemoglobin was 114 g/l. The patient was discharged home 9 days post-operation and remained very well at his 3-month outpatient follow-up. Pathology reports confirmed removal of a pT1N0M0 adenocarcinoma with clear margins in addition to a benign schwannoma. | [[71.0, 'year']] | M | {'7887865': 1, '5001853': 1, '15690656': 1, '18607625': 1, '22033277': 1, '22461875': 2, '22868300': 1, '20530677': 1, '24876323': 2} | {'3299187-1': 1} |
165,387 | 3895049-1 | 24,876,324 | noncomm/PMC003xxxxxx/PMC3895049.xml | Twenty-year-old female with leiomyosarcoma of the breast | A 20-year-old female with a history of neurofibromatosis, and left breast supernumerary nipple excision presented to her primary care physician, after noticing a lump in her left breast at the site of her previous surgical scar after accidentally bumping her breast in January 2012. Her primary care physician then referred her to the breast surgery clinic at St. Barnabas Hospital. She was seen and examined at the breast clinic, where a palpable firm 1 × 1 cm mass was identified at the 6 O'clock position. She denied any nipple discharge. The decision was made to obtain an ultrasound (seen in Fig. ) with close follow-up in the breast surgery clinic.\nShe returned to clinic later in January after the ultrasound, which revealed a 1.4 × 0.9 × 1.8 cm fluid collection at the 6 O'clock position most likely representing a hematoma; BIRADS #3 likely benign recommend short-term follow-up. She was scheduled for a repeat ultrasound in April 2012 with follow-up in breast clinic following the ultrasound. Repeat ultrasound (seen in Fig. ) revealed a stable fluid collection measuring 1.5 × 1.2 × 2.2 cm, once again BIRADS #3 likely benign recommend short-term follow-up with the breast surgeon. She was seen in clinic following the ultrasound in April and reported decreasing pain and no nipple discharge, she was given a 1-month follow-up appointment.\nThe patient's pain returned prior to her scheduled appointment, thus she went to the emergency room. The emergency room physician noted a 2-cm sub-areolar mass. She was discharged from the emergency room and given follow-up in the breast surgery clinic.\nShe was seen and evaluated in the breast surgery clinic following her emergency room visit. In the breast clinic the mass was noted to be 2.5 cm on examination. She denied any further pain and so a 1-month follow-up was given again. She returned to breast clinic 1 month later in May 2012 where the mass was noted to be 3 cm. Due to increasing size and persistence of the mass, she was scheduled for excisional biopsy.\nThe excisional biopsy was performed in June 2012, which revealed a diagnosis of leiomyosarcoma (slides seen in Figs. –).\nShe followed-up in the breast surgery clinic and was notified of the diagnosis. The patient was then scheduled for total mastectomy with axillary lymph node dissection of the left breast with tissue expander placement by the plastic surgery team. The specimen was again sent for pathology, which revealed residual leiomyosarcoma with no lymphovascular invasion, margins negative for sarcoma and sentinel lymph node biopsy negative for sarcoma. | [[20.0, 'year']] | F | {'14616945': 1, '22953134': 2, '4374517': 1, '24950039': 1, '21530255': 1, '4414079': 1, '1555069': 1, '24876324': 2} | {'3420689-1': 1} |
165,388 | 3895141-1 | 24,876,320 | noncomm/PMC003xxxxxx/PMC3895141.xml | Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump following laparoscopic appendectomy | A 22-year-old female presented to the emergency room with a 24-h history of periumbilical pain, associated with nausea, vomiting and a low-grade fever. On examination, she was afebrile but focally tender in the right lower quadrant over McBurney's point. A computed tomography (CT) scan showed a dilated appendix with fat stranding. She was taken to the operating room for laparoscopic appendectomy. Three trocars were used. The mesoappendix was divided with the harmonic scalpel, and the base of the appendix was divided with an EndoGIA stapler (Ethicon Endosurgery, Cincinnati, OH, USA). The postoperative course was uncomplicated and the patient was discharged the next day.\nSix days later, the patient returned to the emergency room with abdominal pain for <12 h in the periumbilical region. The pain was worse than when she had appendicitis. She reported chills, nausea and vomiting. On examination, she was tender in the periumbilical region and mildly distended. She underwent CT scan, which showed a small bowel obstruction with a transition point in the right lower quadrant (Fig. ). She was taken to the operating room for an exploratory laparoscopy. A staple attached to the appendiceal stump on one end had snagged a loop of small bowel and small bowel mesentery with the other end (Fig. ). It was causing an internal hernia and contained a small bowel loop. The staple was freed and removed laparoscopically with no full thickness defect of the small bowel. The staple line was imbricated with intracorporeal Lembert sutures. The patient did well and was discharged the following evening. | [[22.0, 'year']] | F | {'33133498': 1, '34950421': 1, '19735833': 1, '14603174': 1, '7597615': 1, '22318050': 1, '21304366': 1, '10637709': 1, '31743842': 1, '15942742': 1, '12193829': 1, '24876320': 2} | {} |
165,389 | 3895280-1 | 24,624,322 | noncomm/PMC003xxxxxx/PMC3895280.xml | Placental site trophoblastic tumor: Immunohistochemistry algorithm key to diagnosis and review of literature | A 53-year old G0P0 presumed post-menopausal woman presented to her gynecologist with postmenopausal bleeding. She had been on oral contraceptives for birth control until approximately 12 months prior and had a six-month bleeding-free interval before the onset of intermittent spotting. Pelvic ultrasound noted thickened endometrium measuring 2.2 cm. FSH was elevated to 32.3 mIU/mL (post-menopausal = 23.0–116.3 mIU/mL), indicating of her post-menopausal status. She underwent a dilatation and curettage (D&C).\nInitial pathology was reported as poorly differentiated cancer and the patient was referred to a gynecologic oncologist. On additional review, there was suggestion of gestational trophoblastic disease. The tumor cells formed at least three discernible patterns: (1) large, well-formed, irregularly outlined syncytial aggregates, (2) smaller clusters, often linear, more uniform cells resembling cytotrophoblasts, and (3) collections of large cells with markedly enlarged hyperchromatic nuclei resembling extravillous (intermediate) trophoblasts (A–B). Frequent strong expression of multiple trophoblastic markers within these tumor cells suggested a trophoblastic neoplasm.\nQuantitative hCG was elevated to 1517.7 mIU/mL. She underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omentectomy. Intraoperatively, the tumor appeared deeply invasive and necrotic, without evidence of disease outside the uterus.\nGross examination revealed abundant friable and necrotic tumor involving 80% of the endometrial cavity, abutting the uterine serosa, and measuring 5 cm in largest dimension (A–B). Fallopian tubes, ovaries and lymph nodes were benign.\nMicroscopic examination revealed extensive tumor necrosis. The dominant pattern was cytologically bizarre, large, infiltrative single neoplastic cells (C–D). After extensive sampling, no syncytiotrophoblasts were identified. On immunohistochemical staining, human placental lactogen (hPL), a germ cell tumor marker often positive in PSTTs, was positive. Beta hCG, and placental alkaline phosphatase (PLAP) demonstrated scattered positivity. Tumor cells were positive for inhibin and negative for p63 and CK5/6. Ki-67 highlighted a few scattered positive cells. The immunohistochemical profile argued against choriocarcinoma or epithelioid trophoblastic tumor. However, extensive tumor necrosis and the dominant pattern of cytologically bizarre, large, infiltrative single neoplastic cells are atypical for PSTTs. Taken together, the neoplasm was best characterized as an unusual malignant trophoblastic tumor of intermediate cell type. The monophasic pattern of the tumor without syncytiotrophoblasts plus the immunoprofile was most consistent with PSTTs.\nThe patient underwent a CT scan that was negative for metastatic disease. Since the disease was confined to the uterus, the patient was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I disease.\nAfter discussion with the patient, the decision was made not to pursue adjuvant therapy. Monthly serum hCG and hPL have been negative for 10 months. She remains without evidence of disease. | [[53.0, 'year']] | F | {'23274560': 1, '19552948': 1, '25177610': 1, '25396428': 1, '10735504': 1, '26361566': 1, '15099979': 1, '31850188': 1, '6264815': 1, '17498600': 1, '16085293': 1, '29780773': 1, '11173663': 1, '30254879': 1, '16246400': 1, '24624322': 2} | {} |
165,390 | 3895282-1 | 24,624,323 | noncomm/PMC003xxxxxx/PMC3895282.xml | Desmoplastic small round cell tumor of the ovary: A rare but devastating disease in young women | A 6-year-old female presented to a local hospital with intractable abdominal pain (previously diagnosed as constipation) that was associated with fever and tachycardia. A computed tomography (CT) showed multiple pelvic masses, enlarged para-aortic lymph nodes, and a liver hypodensity concerning for a neoplasm. The patient was transferred to a tertiary care center for further evaluation. Upon arrival, serum tumor markers, HCG and AFP, were normal (CA-125 not done), and she underwent a diagnostic laparoscopy which revealed bilaterally enlarged ovaries with several 1–3 cm masses in the cul-de-sac that were biopsied. Microscopy demonstrated islands of primitive small round blue cells in a fibroblastic stroma with abundant necrosis and scattered calcifications (). The tumor was mildly pleomorphic and composed of small cells with hyperchromatic nuclei, irregular nuclear contours and clear cytoplasm. Immunohistochemistry was strongly reactive for desmin, pan-cytokeratin, NSE, CD56, and EMA, and showed focal immunoreactivity for CD99, NB-84a, and bcl-2. The tumor cells were negative for FLI-1, S-100, myogenin, and LCA. Cytogenetic testing showed an Ewing sarcoma (EWS) gene disruption in the majority of her tumor cells (). The morphology, immunohistochemistry and cytogenetic findings were all consistent with the diagnosis of DSRCT.\nAfter surgery, further evaluation revealed bone marrow, liver, and retroperitoneal lymph node involvement; additionally a PET scan confirmed mediastinal, peri-pancreatic, mesenteric, and retroperitoneal spread. The patient's care was transferred to a regional center specializing in DSRCT where she received the P6 regimen: seven cycles of the sarcoma chemotherapy regimen IE/VDC (Ifosfamide, Etoposide, Vincristine, Adriamycin, and Cytoxan) chemotherapy. She progressed in 3 months with leptomeningeal metastases. After 3600 cGy of craniospinal radiation with a 540 cGy boost to the brain and TMZ-CPT-11 for 12 cycles, she was disease free. However, the patient recurred 11 months later and progressed through 4 months of cyclophosphamide, vinorelbine, and bevacizumab. She was placed on a phase I trial of IMC-A12 and temsirolimus without response. The patient expired 28 months after her initial diagnosis. | [[6.0, 'year']] | F | {'19851210': 1, '9808124': 1, '1563748': 1, '33525546': 1, '8622067': 1, '8600079': 1, '27354996': 1, '26893704': 1, '29480840': 1, '15868593': 1, '28491276': 1, '16643996': 1, '18091312': 1, '25755805': 1, '12445256': 1, '20492402': 1, '27403364': 2, '24624323': 2} | {'3895282-2': 2, '3895282-3': 2, '4925982-1': 1} |
165,391 | 3895282-2 | 24,624,323 | noncomm/PMC003xxxxxx/PMC3895282.xml | Desmoplastic small round cell tumor of the ovary: A rare but devastating disease in young women | A 28-year-old female presented with one month of abdominal pain and pressure. CT showed multiple abdominopelvic masses, mesenteric lymph nodes, and a peri-splenic mass. CA-125 was 42 U/mL. Biopsy results were consistent with DSRCT, and she received 14 cycles of neoadjuvant IE/VDC with the removal of adriamycin after the eighth cycle due to cardiac toxicity. Following an incomplete response, the patient underwent an exploratory laparotomy. Intra-operative findings included a 10 × 8 cm right ovarian cystic mass, an 8 cm nodule between the stomach and the spleen and small implants in the cul-de-sac and omentum. A bilateral salpingo-oophorectomy, resection of cul-de-sac peritoneum, and splenectomy, and omentectomy were performed leaving her without visible disease. Microscopy showed cords of small round blue cells. Immunohistochemistry revealed strong and diffuse positivity for desmin and multifocal keratin positivity. CD99 was negative. Cytogenetics was negative for the EWS-WT1 translocation.\nShe returned on post-operative day 5 with a fascial dehiscence which was repaired without complication. The patient finished the last 2 cycles of her 16 cycle chemotherapy regimen and did well for 6 months. At that time, a CT showed increased abdominopelvic disease and a bone scan was consistent with metastasis. She was started on cytoxan/topotecan which she received from her local oncologist. The patient expired of her disease 40 months after her initial diagnosis. | [[28.0, 'year']] | F | {'19851210': 1, '9808124': 1, '1563748': 1, '33525546': 1, '8622067': 1, '8600079': 1, '27354996': 1, '26893704': 1, '29480840': 1, '15868593': 1, '28491276': 1, '16643996': 1, '18091312': 1, '25755805': 1, '12445256': 1, '20492402': 1, '27403364': 2, '24624323': 2} | {'3895282-1': 2, '3895282-3': 2, '4925982-1': 1} |
165,392 | 3895282-3 | 24,624,323 | noncomm/PMC003xxxxxx/PMC3895282.xml | Desmoplastic small round cell tumor of the ovary: A rare but devastating disease in young women | A 17-year-old female presented with several months of increased abdominal girth associated with pelvic pain and nausea. Ultrasound showed a 10 cm right adnexal mass and ascites. Serum tumor markers were drawn and showed normal AFP, beta-HCG and LDH. CA-125 was 35.9 U/mL, and her inhibin was elevated to 481 pg/mL. She underwent an exploratory laparotomy which found a 15 cm multicystic right ovarian mass with tumor implants on the left ovarian serosa, peritoneum, epiploica, liver, omentum and cul-de-sac. A right salpingo-oophorectomy, peritoneal stripping of the anterior cul-de-sac, appendectomy, and argon laser ablation of tumor nodules were performed. The patient was optimally debulked but visible sub-centimeter disease was present at the end of the procedure. Microscopy was consistent with DSRCT, and immunohistochemistry revealed tumor diffusely positive for keratin, desmin, p63, and focally positive for FLI-1. Stains were negative for S-100, WT-1, CD99, and inhibin. The cytogenetic studies were positive for the EWS-WT1 translocation. The patient is now status post 9 cycles of IE/VDC chemotherapy with interval debulking after seven cycles. She then received whole abdominal radiation with a pelvic boost. She is alive without disease at 11 months from her diagnosis. | [[17.0, 'year']] | F | {'19851210': 1, '9808124': 1, '1563748': 1, '33525546': 1, '8622067': 1, '8600079': 1, '27354996': 1, '26893704': 1, '29480840': 1, '15868593': 1, '28491276': 1, '16643996': 1, '18091312': 1, '25755805': 1, '12445256': 1, '20492402': 1, '27403364': 2, '24624323': 2} | {'3895282-1': 2, '3895282-2': 2, '4925982-1': 1} |
165,393 | 3895283-1 | 24,624,320 | noncomm/PMC003xxxxxx/PMC3895283.xml | Primary invasive breast carcinoma arising in mammary-like glands of the vulva managed with excision and sentinel lymph node biopsy | A 65 year old, multiparous, postmenopausal female status-post total hysterectomy with bilateral salpingo-oophorectomy 39 years prior for symptomatic myomatous uterus, presented for her annual well woman exam. She was without complaints and review of systems was negative; specifically, she denied any recent history of unintended weight loss or gain, fever, chills, nausea, melena or hematochezia, vaginal bleeding or discharge, abdominal pain or fullness. Her last mammogram was 1–2 years prior, after which she was diagnosed with right breast ductal papilloma which was excised. Colorectal screening was up to date.\nIn addition to her prior hysterectomy, gynecologic history was significant for estrogen replacement therapy for 20 years, which she stopped after developing what she reported as “vaginal cysts.” Two years prior to presentation, she had such a lesion removed from her right labia that had been present for one year and pathology was benign, per patient. On further discussion, she reported that the lesion had returned, was not painful, and was not associated with any further growth for the last six months. Clinical breast examination did not demonstrate evidence of palpable masses, retraction, skin changes, or axillary adenopathy. Genital examination revealed a mobile, soft, non-tender, 2.5 × 0.75 cm nodule at 11 o'clock on her right labia majora. Excisional biopsy was performed in clinic, which revealed ductal carcinoma in situ with positive margins. The patient then underwent a wide local excision of the area, which pathologically revealed invasive carcinoma with negative margins.\nThe specimen from the wide local excision revealed a surface which was predominantly dark brown and wrinkled with a smooth, white, flat lesion measuring 0.8 × 0.3 cm; the lesion was 1.2 cm from the 12 o'clock margin and 0.4 cm from the nearest (3 o'clock) margin. On serial sectioning, the lesion was firm and white, and extended to a depth of 0.3 cm.\nMicroscopic examination revealed invasive carcinoma, at least 1.6 mm in greatest dimension (), arising from within a background of mammary-like glands of the vulva demonstrating residual focal DCIS. The invasive lesion was noted to come within 1.3 mm of the margin, but all margins were negative for invasive disease. The histologic features were consistent with a primary carcinoma, not a metastatic lesion. Immunohistochemical (IHC) stains including smooth-muscle heavy chain (SMM-HC), CD 10, and p63 were performed and while there appeared to be some myoepithelial cells present along the smooth contoured edge by SMM-HC only, there were other areas without any definitive basal cell/myoepithelial cell staining (). The area of concern demonstrated an irregular growth pattern (no longer lobulocentric) and was not associated with the prior biopsy site changes. The residual mammary-like ducts () exhibited strong immunoreactivity for all 3 IHC stains. The tissue was then tested for hormone receptor status, and was found to be estrogen receptor (ER) positive, but progesterone receptor (PR) and HER2/CEP17 negative.\nSecondary to narrow margins, re-excision was performed as well as an ipsilateral groin sentinel lymph node dissection, both of which were negative for DCIS or malignancy. After referral to a medical oncologist, she was also administered letrozole, an aromatase inhibitor, as adjuvant therapy for the ER positive cancer. 18 months after excision, she is without evidence of recurrent disease. | [[65.0, 'year']] | F | {'11447997': 1, '21169735': 1, '22753905': 1, '28877932': 1, '25770309': 1, '10094898': 1, '8005737': 1, '22764738': 1, '20863759': 1, '34851570': 1, '16942646': 1, '24624320': 2} | {} |
165,394 | 3895317-1 | 24,459,378 | noncomm/PMC003xxxxxx/PMC3895317.xml | Cycloserine induced mania | The patient 21-year-old male presented 1 year back with fever for over 1 month, after detailed investigations including cerebrospinal fluid (CSF) examinations, he was diagnosed as a case of tubercular meningitis and was under remission and surveillance on anti-tuberculosis treatment-4 (ATT-4) (HRZE: Isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months, followed by ATT-2 (HR) regularly for 9 months, when he reported a swelling over his left supraclavicular region, on fine needle aspiration cytology (FNAC) this enlarged left supraclavicular lymph node showed tubercular abscess. Development of abscess despite being on regular ATT for 11 months was considered as multidrug resistance tuberculosis (MDR-TB); and hence, started on second line ATT, that is, cycloserine 500, ethionamide 500, ofloxacin 800 in two divided doses and streptomycin 750 mg per day along with continuation of ATT-2. After taking these medications for 7-8 days, he developed symptoms of excessive talkativeness, decreased need for sleep, irritable-aggressive behavior, overactivity, overfamilarity, and inflated self-esteem; and referred for psychiatric consultation.\nThere was no past or family history of any significant psychiatric or medical illness; his general physical examinations were confirmatory of left supraclavicular lymph node enlargement. On mental status examinations, he had increased psychomotor activity, pressured speech, elated affect, and delusion of grandiosity. Young Mania Rating Scale (YMRS)[] score was 38, and Brief Psychosis Rating Score (BPRS)[] score was 51. Cycloserine was considered as most possible offending agent and discontinued, whereas other drugs were continued under close observation as inpatient facility.\nHe received tab. divalproex 500 mg and olanzapine 5 mg per day initially, then his divalproex was increased to 750 mg/day. After 3 days, his YMRS score was 15 and BPRS was 33 and on 10th day there was no sign of manic symptoms. A score of 5 on Naranjo algorithm[] (Naranjo et al., 1981) suggests probability of cycloserine causing mania. We gradually tapered off olanzapine first then divalproex within a month, and there is no further affective symptoms reported or found on follow-ups. We have taken written informed consent for publication of this case report. | [[21.0, 'year']] | M | {'20075645': 1, '1663594': 1, '18245177': 1, '15182146': 1, '9718289': 1, '728692': 1, '18425072': 1, '31806629': 1, '25878391': 2, '7249508': 1, '22208150': 1, '24459378': 2} | {'4386140-1': 1} |
165,395 | 3895513-1 | 24,466,468 | noncomm/PMC003xxxxxx/PMC3895513.xml | Anterior Urethrectomy for Primary Carcinoma of the Female Urethra Mimicking a Urethral Caruncle | A 52-year-old woman with a 5-year history of a palpable urethral mass presented at Urology Department with intermittent urethral pain. The patient did not complain of any urinary symptoms or dyspareunia. Her medical history included an appendectomy 30 years previous but was otherwise unremarkable. Pelvic examination showed the presence of a urethral mass approximately 1.7 cm in diameter (). The mass appeared to be a simple urethral caruncle despite a small amount of ulceration; therefore, we did not perform urethroscopy or cystoscopy. Three hours after the carunclectomy, the Foley catheter was removed and the patient reported good voiding ability. She was then discharged, and a follow-up visit was scheduled for 7 days later.\nSix days after the operation, our department received the pathological results of the excised urethral mass, which indicated a squamous cell carcinoma in situ (). We promptly evaluated the case for cancer and consulted with the department of gynecology. Abdominal and pelvic computed tomography, intravenous pyelography, bone scanning, and chest radiography showed no evidence of disseminated disease. The final disease stage was classified as TisN0M0; therefore, partial urethrectomy was planned.\nGeneral anesthesia was used for the surgery. A 22-Fr cystoscope was inserted through the urethra without resistance. A cystoscopic examination revealed erythematous mass-like lesions on the trigone, bladder neck (3- and 7-o'clock positions), and right lateral wall. Frozen biopsy analysis showed the presence of atypical cells on the trigone and bladder neck (at two points), but no malignancy was identified on the right lateral wall. The urethral orifice was tagged with a 2-0 silk suture (12-, 3-, and 9-o'clock positions), and we were able to excise the anterior urethra. The final pathologic analysis indicated a negative surgical margin and a tumor depth of 0.3 cm.\nThe patient was followed up at 6-month intervals. Her medical records were assessed, and a clinical examination was performed. Imaging studies were performed when she reported new symptoms. She remained free of recurrence and reported normal voiding function 50 months after the tumor was diagnosed. | [[52.0, 'year']] | F | {'6823701': 1, '1413309': 1, '15464921': 1, '24466468': 2} | {} |
165,396 | 3895527-1 | 24,466,522 | noncomm/PMC003xxxxxx/PMC3895527.xml | Trial of Oral Metoclopramide on Diurnal Bruxism of Brain Injury | A 51-year-old man was admitted for subarachnoid hemorrhage caused by a rupture of the left anterior communicating artery aneurysm. After acute treatment for a month, he was transferred to the department of rehabilitation for intensive therapy. Physical and neurological examinations were done. The score of the Korean version of the Mini-Mental Status Examination (K-MMSE) was 16. There were no abnormal findings on cranial nerve function tests, and no definite extraocular movement limitations or facial palsies were noted. Manual muscle power test showed that the Medical Research Council (MRC) grade of both the upper and lower extremities was grade II and I, respectively. The patient had been suffering from teeth grinding and jaw clenching, which had begun 3 weeks after the onset of a cerebral hemorrhage. Dystonia of the tongue, face or any other part of the body was absent. This symptom was aggravated during the daytime, especially during meals, and subsided during sleep. Teeth grinding worsened as time went on. An injection of botulinum toxin was given 5 weeks after the onset of bruxism; 40 units to each side of the bilateral masseter, 15 units to each side of the bilateral lateral pterygoid, and 15 units to each side of the bilateral medial pterygoid muscles. The symptom was followed up after 2 weeks, and the injected botulinum toxin showed no effect. His bruxism was also refractory to bromocriptine therapy. Thus, a 10 mg intramuscular metoclopramide HCl injection was administered for treatment of the bruxism. The bruxism subsided dramatically 5 hours after the injection and did not recur for the subsequent 12 hours. Oral metoclopramide medication in dosages of 15 mg per day was initiated the next day, which successfully abolished his bruxism after 2 days. Bruxism did not recur during the metoclopramide therapy. Magnetic resonance imaging of the brain showed a subacute intracranial hemorrhage at the left basal frontal lobe (). Positron emission tomography (PET) also showed a metabolic defect at the left basal frontal lobe, along with diffuse hypometabolism at the bilateral frontal, temporal, and parietal cortexes. A blink reflex study and electroencephalography (EEG) were normal. Transcranial and carotid Doppler were also normal. Anticholinergic agents, which are known to decrease the effectiveness of metoclopramide, were not administered for any reason. Any drug that induced bruxism or decreased the effect of levodopa was not administered either. | [[51.0, 'year']] | M | {'15749418': 1, '18557915': 1, '30842964': 2, '7402361': 1, '34191267': 1, '1015602': 1, '8990057': 1, '9208378': 1, '18516634': 1, '12836498': 1, '26495402': 1, '6138783': 1, '10371243': 1, '26897026': 1, '24466522': 2} | {'3895527-2': 2, '6397809-1': 1} |
165,397 | 3895527-2 | 24,466,522 | noncomm/PMC003xxxxxx/PMC3895527.xml | Trial of Oral Metoclopramide on Diurnal Bruxism of Brain Injury | A 36-year-old male, who had no significant medical history nor neurologic abnormalities, was involved in a motorcycle accident. He was admitted to the emergency room unconscious, and after being diagnosed with bilateral frontal and right temporal intracranial hemorrhage (), he underwent craniectomy and hematoma evacuation. Two years after the onset of the injury, he was transferred to the department of rehabilitation for intensive therapy. The K-MMSE score at the time was 15. A manual muscle power test showed that the MRCs of both the upper and lower extremities of the right side were grade IV, and those of the upper and lower extremities of the left side were grade II and I, respectively. He had suffered from teeth grinding and jaw clenching for 2 years but had not received any treatment. The bruxism occurred during the daytime and subsided during sleep. There was no dystonia of the tongue, face or elsewhere. Bruxism was refractory to bromocriptine therapy. Oral metoclopramide administration of 9 mg per day was started to treat the bruxism, and it improved dramatically three days after the initiation of the medication. Bruxism did not recur during the course of the metoclopramide therapy. A cranial computerized tomography scan revealed extensive encephalomalacia in the bilateral frontal lobes and the right temporal lobe from the previous trauma. The EEG was normal. The patient also did not take any medication that may have induced bruxism or decreased the effects of the metoclopramide or levodopa. | [[36.0, 'year']] | M | {'15749418': 1, '18557915': 1, '30842964': 2, '7402361': 1, '34191267': 1, '1015602': 1, '8990057': 1, '9208378': 1, '18516634': 1, '12836498': 1, '26495402': 1, '6138783': 1, '10371243': 1, '26897026': 1, '24466522': 2} | {'3895527-1': 2, '6397809-1': 1} |
165,398 | 3895528-1 | 24,466,523 | noncomm/PMC003xxxxxx/PMC3895528.xml | Successful Surgery for Scoliosis Supported by Pulmonary Rehabilitation in a Duchenne Muscular Dystrophy Patient With Forced Vital Capacity Below 10% | Herein, we report a 19-year-old male patient who suffered from gait disturbance since the age of 2 years when he often fell and had difficulty with climbing stairs. At the age of 7, he was diagnosed as DMD by muscle biopsy, and follow-up in the out-patient department of Gangnam Severance Hospital was stopped at his parents' will. He had not walked since 10 years of age and had been suffering from symptoms of hypercapnea, such as sleeping during the daytime and headache upon awakening from sleep. In July 2010, when he turned 18 years old, he was visited by the home visiting service of Gangnam Severance Hospital, and his partial pressure of end-tidal carbon dioxide (EtCO2) was above 50 mmHg. He was admitted to the Department of Physical Medicine and Rehabilitation at Gangnam Severance Hospital on August 7, 2010. In the arterial blood gas analysis, partial pressure of carbon dioxide (PaCO2) was 49.9 mmHg and partial pressure of oxygen (PaO2) was 91.8 mmHg. In the evaluation of pulmonary function, FVC in sitting position was 460 mL (8.6% of predictive value), FVC in supine position was 500 mL (9.4% of predictive value), unassisted peak cough flow (UPCF) was 80 L/min, and maximum insufflation capacity (MIC) was 1,390 mL. In the overnight transcutaneous monitoring of partial pressure of carbon dioxide (SenTec Digital Monitor System with V-Sign Sensor; SenTec AG, Therwil, Switzerland), retention of carbon dioxide was noticed, as the maximal PaCO2 was 76.6 mmHg and the mean PaCO2 was 64.6 mmHg. He received training for noninvasive intermittent positive pressure ventilation (NIPPV), which mode is assist-controlled ventilation (ACV). During application of NIPPV, the overnight monitoring showed a reduction in carbon dioxide retention, as the maximal PaCO2 was 46.1 mmHg and the mean PaCO2 was 40.6 mmHg. He was prescribed a home ventilator, and the ventilator settings were the mode of ACV, tidal volume of 1,150 mL, and respiration rate of 16 times per minute. Based on the daytime monitoring of PaCO2, after 6-hour discontinuance of home ventilator, hypercapnea had redeveloped; he was therefore educated to apply the home ventilator while sleeping and additionally in the daytime. Furthermore, he was educated to exercise air-stacking using a manual resuscitator bag and home ventilator, more than 3 times a day. After application of home ventilator, the symptoms of hypercapnea were resolved.\nAfter being discharged, the patient had no complaints related to respiratory failure, but he suffered from difficulty sitting even if he leaned back, due to severe scoliosis; Cobb's angle was 58.1°. He was considered high risk for scoliosis operation due to a very low FVC of less than 10% of predictive value. Although he was thought to be safe from respiratory complications after the scoliosis correction, he was trained on a home ventilator for 6 months to maintain proper ventilator states via NIPPV immediately after extubation. At the Department of Orthopedic Surgery, he underwent surgeries for anterior fixation from the fifth lumbar vertebra to the first sacral vertebra on February 10, 2011, and for posterior fixation from the second thoracic vertebra to the first sacral vertebra on February 22, 2011. During the operations, his vital signs were stable. From the time of admission, noninvasive PaCO2 monitoring was conducted during sleep. After serial surgeries, he was transferred to the intensive care unit with maintenance of the intubation tube; expectoration of sputum and air-stacking were implemented by mechanical insufflator-exsufflator (MIE). The first day after the operation, NIPPV via home ventilator was applied right after intubation tube removal. Upon confirmation that there were no complications and hypercapnea (the maximal and mean PaCO2 were 25 and 20.5 mmHg, respectively), he was transferred to the general ward.\nAt 8 days after the surgery, intravenous antibiotics were injected due to infection of the surgical wound. On April 9, 2011, 46 days after the operation, all stitches were removed. Cobb's angle was changed from 58.1° preoperatively to 48.5° postoperatively (). He still can sit only with a supporting back, but subjective comfort was improved by the reduction of the inclination in the sitting position. At postoperative day 51 and 300, pulmonary function was reevaluated. FVC, assisted peak cough flow (APCF), and MIC increased; MIC was particularly improved from 1,010 mL preoperatively to 1,880 mL postoperatively, although UPCF showed no significant change (). | [[19.0, 'year']] | M | {'20155495': 1, '16807978': 1, '16205339': 1, '17253553': 1, '17023858': 1, '8728627': 1, '20683386': 1, '28325281': 1, '11176364': 1, '29340778': 1, '6490869': 1, '29246319': 1, '24466523': 2} | {} |
165,399 | 3895529-1 | 24,466,524 | noncomm/PMC003xxxxxx/PMC3895529.xml | Diffusion Tensor Tractography in Two Cases of Kernohan-Woltman Notch Phenomenon | A 67-year-old man was admitted to the emergency room after an assault. The patient showed altered mentality and initial Glasgow Coma Scale was 3/15. Initial brain CT scan showed an acute frontotemporoparietal subdural hemorrhage (SDH) on the right side (). An emergent craniectomy and hematoma removal was done. After the operation, his cognitive function gradually improved to a Rancho Los Amigos level of function V. However, increased spasticity and weakness of muscles were noted on the right side: Motor grade, 2/5; Fugl-Meyer assessment, upper 6+lower 10=16/100; Manual Function Test, right 0/32. MRI was taken 5 days after injury. However, there were no abnormal signal changes on the cortical and subcortical areas of the left hemisphere or brainstem including the cerebral peduncle (). Nonetheless, his paradoxical ipsilateral motor weakness persisted.\nDTI images were obtained 4 weeks after onset of the injury. DTI was acquired using a 3.0-T Philips Gyroscan Intera MRI scanner (Philips Healthcare, Best, The Netherlands) with a six-channel phased array sensitivity encoding (SENSE) head coil. Images were obtained based on the single-shot echo-planar image sequence. The DTI data parameters were as follows: field of view 224×224 mm2; matrix 112×112; repetition time (TR)=9,131 ms; echo time (TE)=85 ms; slice thickness=2 mm; SENSE factor=2; and b=1000 s/mm2. We obtained 70-75 gapless, contiguous transverse images with each of 32 noncollinear diffusion-sensitizing gradients.\nFiber tracking was analyzed using the "FiberTrak" package included in the Extended MR Workspace R 2.6.3.1 software (Philips Healthcare). The setting parameters for the tractography were as follows: minimum fractional anisotropy (FA)=0.15; maximum angle change=30°; minimum fiber length=10 mm. Two regions of interests (ROI) were selected to reconstruct the CST. One ROI was placed on the CST portion of the anterior lower pons and the other was placed on the CST portion of the anterior mid pons.\nIn the fiber tracking with the DTI image, constructed fibers passed through the CST. However, disruption of fibers was observed around the left pons. The FA and apparent diffusion coefficient (ADC) values were obtained from posterior limb of internal capsule (PLIC), cerebral peduncle, and anterior pons of both hemispheres (). The FA values of the left cerebral peduncle and anterior pons were decreased compared to those of the contralateral side. The DTI images were obtained again 9 months after the onset of injury, and previously disrupted fibers were unchanged (). FA values of cerebral peduncle and pons on the affected side were increased, while there was no significant difference in the relative decrease of the previously acquired FA value on the left side. ADC values of the left hemisphere were similar or slightly higher than those of the right hemisphere in initial and follow-up images (). At 15 months post-injury, he was able to ambulate with a quad-cane under supervision, but was unable to grasp and release freely: Fugl-Meyer assessment, upper 24+lower 8=32/100; Manual Function Test, right 4/32. | [[67.0, 'year']] | M | {'9161379': 1, '18940992': 1, '3257624': 1, '22083801': 1, '21812586': 1, '19699493': 1, '2385337': 1, '2928523': 1, '11113240': 1, '24466524': 2} | {'3895529-2': 2} |
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