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AISC Team B1 5

3927095-1

noncomm/PMC003xxxxxx/PMC3927095.xml

Gowers’ intrasyringeal hemorrhage associated with Chiari type I malformation in Noonan syndrome

A 39-year-old female presented with progressive gait disturbance and urinary dysfunction of acute onset in 2010. She had been treated for tetralogy of Fallot in childhood and had been diagnosed with Noonan syndrome on the basis of molecular genetic analysis. She had short stature, webbing of the neck, low-set ears, ocular hypertelorism, ptosis, and developmental delay. She also had multiple untreated cerebral aneurysms. She had CM1 with cerebral hydrocephalus and a large syringomyelia extending from C1 level to the conus []. Although she underwent foramen magnum decompression and a cervical syrinx-subarachnoid shunt in 2003, a large syringeal cavity remained throughout the spinal cord.\nOn admission in 2010, she experienced gait disturbance and dysesthesia of both the legs and perineal region, which indicated conus medullaris syndrome. Routine hematological, serological, and blood coagulation examinations were all normal. Magnetic resonance (MR) imaging showed a large syringomyelic cavity extending from the C1 level to the conus. Both T1- and T2-weighted images showed a heterogeneous mass on the caudal end of the syringomyelic cavity, suggesting hematomyelia []. Partial gadolinium enhancement was revealed at the centre of the hematomyelia.\nEmergent laminectomy was performed from the T12 to L3 level because she developed complete urinary retention. A swollen spinal cord showed xanthochromic deposits because of hematomyelia. After midline myelotomy, dark-red hematoma flowed out, and was carefully removed with suction and CUSA®. During surgery, we could not detect the precise bleeding point. The cranial and caudal edge of the hematoma showed transition into yellowish and firm tissue. Since we suspected this tissue to be intramedullary neoplasm, several pieces of this neoplasm-like tissue were sampled. However, histological examination of the resected tissue showed gliotic spinal cord tissue with hemosiderin pigmentation. The surgical specimen revealed diffuse growth of spindled astrocytic cells with Rosenthal fibers that had no atypical features. We diagnosed spontaneous intrasyringeal hemorrhage associated with CM1, that is, Gowers’ intrasyringeal hemorrhage.\nPostoperatively, the patient's symptoms disappeared except for the sensory disturbance of the lower limbs. Repeated MR imaging performed up to 3 years after the operation showed marked reduction of spinal cord diameter and shrinkage of the syringeal cavity []. There was peripheral hemosiderin deposition but no intramedullary neoplasms in the syringomyelic cavity.

[[39.0, 'year']]

F

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{}

3927176-1

noncomm/PMC003xxxxxx/PMC3927176.xml

Double Eye Brow: A Rare Case Report

The present case report is about a 6-year-old girl presented to Department of Pediatric and preventive dentistry, Guru Nanak Institute of Dental Science and Research, Kolkata for routine dental check-up. There was no relevant medical history with normal built, gait and intelligence. On facial examination, there was no gross asymmetry of face or any abnormal swelling. Dermatological examination revealed that the eyebrows on the both the sides were sparser on the medial sides when compared with the lateral sides. The eye brows were free from any pathology except a double layer of eyebrow was present above the left eye. Second layer of eye brow was just present above the first layer [Figures and ]. The distribution and density of hair in the second layered eye brow was dissimilar. There was no significant dermatological findings present elsewhere in the body. Family history revealed no systemic disease or any extra layer of eye brow in either of maternal or paternal individual. The parents were unrelated and unaffected by any other skin related problem. No cosmetic/aesthetic or therapeutic treatment has been received by the child for double eyebrow. Routine laboratory tests (complete blood count, liver function test, urine analysis, abdominal ultrasound) were all normal. Considering the clinical features, a diagnosis of double eyebrow was concluded. We did not detect any dermatological pathology or accompanying systemic disease in our case.

[[6.0, 'year']]

F

{'7969205': 1, '31129634': 1, '3578473': 1, '17918734': 1, '12729380': 1, '2736796': 1, '17910076': 1, '12372052': 1, '3359678': 1, '24574697': 2}

{}

3927177-1

noncomm/PMC003xxxxxx/PMC3927177.xml

Pemphigus Vulgaris with Loss of Hair on the Scalp

We report on a 32-year-old female patient who presented with a 2-year history of flaccid bullae over her upper trunk, erosions over her oral mucosa and hard palate, and several crusted erosions over her scalp. The clinical as well as the pathological and direct immunofluorescence findings supported the diagnosis of pemphigus vulgaris and the patient was treated with systemic steroids and mycophenolate mofetil as a steroid sparing agent with clinical improvement, except for the lesions on her scalp. The erosions on the scalp were treated with high potency topical steroids with good clinical response; however several months later the patient returned with scalp folliculitis, which later progressed to indurative tender plaques with loss of hair over the involved areas on her scalp []. Biopsy taken from the lesion was compatible with the diagnosis of pemphigus vulgaris, demonstrating acantholysis of the epidermal as well as the outer root sheath keratinocytes []. Direct immunofluorescence demonstrated immunoglobulin G deposition on the intercellular spaces within the epidermis []. Scalp swab taken from the lesion cultured Staphylococcus aureus.\nThe patient was treated initially with systemic steroids, and later on the steroids were gradually replaced with mycophenolate mofetil, combined with low dose triamcinolone tablets given for her mucosal lesions. In addition, she was treated locally with high-potency topical steroid. The above mentioned treatment led to the regression of the lesions on her scalp, and later to re-growth of hair.

[[32.0, 'year']]

F

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{'8647706-1': 1}

3927178-1

noncomm/PMC003xxxxxx/PMC3927178.xml

Novel Frameshift Mutation in TRPS1 in a Ukrainian Patient with Trichorhinophalangeal Syndrome Type I

The present case report is about a 17-year-old female patient, born to a non-consanguineous family of a Ukrainian origin, who presented with short and sparse scalp hair, most pronounced in the temporal area [] and in a unique triangular shape in the mid occipital scalp []. Additional findings included beaked nose with a long philtrum and an allergic crease [], widened proximal interphalangeal joints [], short toes [] and onycholysis of finger- and toenails. Sequence analysis of the TRPS1 gene revealed a novel c. 2396_2397 insG frameshift mutation in exon 5, leading to a premature stop at codon 800 [].

[[17.0, 'year']]

F

{'7537130': 1, '11112658': 1, '13318598': 1, '10615131': 1, '11950061': 1, '11708946': 1, '11807863': 1, '24574699': 2}

{}

3927187-1

noncomm/PMC003xxxxxx/PMC3927187.xml

Posterior reversible encephalopathy syndrome in children with kidney disease

A five-year-old-male child weighing 14 kg was admitted with ARF and serum creatinine of 6.4 mg/dl, and respiratory acidosis. He was prepared by acute peritoneal dialysis for PCN diversion of obstructed solitary functioning kidney. Postoperatively after 12 h of diversion child developed convulsion. Clinically, his pulse and hydration was normal and BP was 130/90 mmHg (grade 2 HT) which was controlled with oral nifedipine. Biochemically, electrolytes were normal except for ionized serum calcium which was 2.26 mg/dl, phosphate 5.4 mg/dl, Magnesium 1.77 mg/dl, pH of 7.32 and serum bicarbonate level was 17.5 meq/L. Patient was treated by sodium bicarbonate drip in one IV line and calcium gluconate drip in another IV line. In first 12 h the child received 15 ml of calcium gluconate and 10ml in next 12 h. He was given 0.5 ml of magnesium sulphate (i.e., 250 mg; 25% w/v) intramuscularly. The child's venous blood gas and electrolytes were studied every 6 hours and child persisted to be severely hypocalcemic though he received 15 ml of calcium gluconate on second day and 10 ml for further two days. So in total 50 ml of calcium gluconate was given in three days of PCN diversion in a 14 kg child. Childs hypocalcemia was within normal range on fourth day only when we reduced 24 h calcium dose in stepwise fashion. His BP was well controlled with oral nifedipine. Throughout the course, his urine output, serum urea, and serum creatinine were improving day by day after diversion. We measured 24 h urinary calcium also on 2nd day after diversion which was 30 mg/24 h which was high in face of very low ionized serum calcium level. The amount of calcium gluconate the child required parenterally to correct hypocalcemia was surprisingly high which we have observed first time in such a setting. His iPTH, five days after PCN diversion was 408 pg/ml which was 540 pg/ml when he presented with ARF. Logically, we hypothesized that calcium gluconate given iv was increasingly being taken up by bone due to decreasing hyperparathyroidism in association with improving renal function and it was wasted to some extent in urine also because of defect in tubular reabsorption leading to persistent hypocalcemia. Calcium has unique intracellular messanger role and it is complexed with numerous ligands in cytosol, including adenosine and vitamin D dependent calcium binding protein, calmodulin.[] Persistent hypocalcemia may be expected to affect directly or indirectly mechanisms involved in autoregulation and endothelial function.

[[5.0, 'year']]

M

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{'3263062-1': 1, '7813126-1': 1, '7813126-2': 1, '6042172-1': 1, '5972267-1': 1}

3927189-1

noncomm/PMC003xxxxxx/PMC3927189.xml

Hemolytic uremic syndrome associated with Plasmodium vivax malaria successfully treated with plasma exchange

A 29 year old previously asymptomatic male was admitted in a peripheral hospital with fever and jaundice of 1 week duration. He had anemia (hemoglobin [Hb] 8.8 g/dl), thromocytopenia (platelet count 55,000/μl), renal impairment (serum creatinine [s. creatinine] 1.5 mg/dl) and direct hyperbilirubinemia (total bilirubin 3.9 mg/dl, direct 1.9 mg/dl). Peripheral smear showed the presence of schizonts of Plasmodium vivax. Antigen test for Plasmodium falciparum was negative. He was treated with Artesunate and Clindamycin for 7 days and was discharged when asymptomatic, although improvement in thrombocytopenia or renal impairment was not observed. Two week later (1 week after being afebrile and getting discharged) he presented to us with vomiting and pain in the abdomen for 3 days and decreased urine output. He did not have fever, loose motions, rash, bleeding or alteration in sensorium. There was no history of treatment with quinine. He was hypertensive, pale, did not have edema and had unremarkable systemic examination except for the presence of haemic murmur. Severe anemia (hemoglobin 4.8 g/dl), thrombocytopenia (platelet count 61,000/μl) and azotemia (s. creatinine 8.3 mg/dl) were noted. Presence of schistocytes on peripheral smear, elevated reticulocyte count (13%), elevated serum lactate dehydrogenase (LDH 1242 U/L) and indirect hyperbilirubinaemia indicated ongoing microangiopathic hemolytic anemia. Urinalysis showed microhematuria and proteinuria of 3.75 g/day. Coagulation profile was normal. Serum C3 level was low (50 mg/dl), C4 level being normal. Antinuclear antibodies and enzyme-linked immuno sorbent assay for human immunodeficiency virus were negative. Hepatitis B surface antigen and anti-hepatitis C antibodies were negative. He underwent five sessions of 1.5 volume plasma exchanges with replacement with fresh frozen plasma. Hypertension was controlled. Intermittent hemodialysis was done. Anemia was corrected with packed red cells transfusion. After five sessions of plasma exchanges, platelet count increased to 150,000/μl Hb stabilized at 6 g/dl and then increased. S. LDH decreased to 206.3 U/L and s. creatinine stabilized at 5.5 mg/dl, patient being dialysis-independent. This hematological remission persisted at 4th week (Hb 9.1 g/dl, platelet count 163,000/μl) with C3 level being normal. Kidney biopsy was performed at this time. Enlarged glomeruli had capillary wall thickening, with double contours seen on silver Methanamine stain, endothelial swelling and increased mesangial cellularity. Arterioles with onion peel appearance were seen [Figures and ]. No immune deposit was seen on immunoflorescence study.\nAt the end of 4 months, he requires two antihypertensive drugs, has Hb 13.5 g/dl, platelet count 229,000/μl, s. creatinine 1.4 mg/dl and poteinuria 1.2 g/day.

[[29.0, 'year']]

M

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{'4557153-1': 1}

3927190-1

noncomm/PMC003xxxxxx/PMC3927190.xml

Partially thrombosed aneurysm of the abdominal aorta: Unusual cause of chronic inflammation and resistance to recombinant human erythropoietin

A 72-year-old male with nephroangiosclerosis was on maintenance hemodialysis (three sessions per week) for 10 years. He was a chronic smoker and had dyslipidemia treated with diet alone. His medications included: furosemide 500 mg in non-dialysis day, oral folic acid and vitamin B12, and monthly 75-150 μg of methoxy-polyethylene-glycol epoetin-beta. Biological monitoring revealed episodic elevations of C-reactive protein (CRP) ranging from 1 mg/l to 60 mg/l associated with a decrease of hemoglobin (Hb) levels without any other obvious cause of resistance to rHuEPO []. Serum ferritin, intact parathyroid hormone and aluminum levels were within the normal ranges. The mean Kt/v was 1.15. The patient had no malnutrition and his native fistula showed no malfunction.\nPhysical examination found no evidence for any local or systemic cause of this inflammation. His vital signs were: Temperature 37°C, pulse 74 beats/min, blood pressure 128/68 mmHg and respiratory rate 20 breaths/min. Biological tests including liver parameters and serum protein electrophoresis were normal. Serology for hepatitis B virus showed negative hepatitis B surface (Hbs) antigen, positive anti-Hbs, and anti-hepatitis B core antibodies with no current biological or morphological signs of chronic hepatitis. Serology for syphilis, hepatitis C, and HIV viruses were negative. Chest radiography and radiography of the sinuses were normal. Sputum examination for acid-fast bacilli and tuberculin skin test was negative. The ear-nose-throat and stomatological examination were normal. Tumor markers were normal. Main laboratory tests are summarized in .\nTransthoracic echocardiogram, blood culture, abdominal and pelvic ultrasound, eso-gastric endoscopy, and colonoscopy showed no abnormalities. As part of a screening study of vascular calcifications in hemodialysis, our patient underwent a lateral abdominal X-ray, which demonstrated diffuse calcifications of the abdominal aorta and a large aneurysm extending from the second to the fourth lumbar vertebra []. Multislice spiral computed tomography-angiography with 3D-reconstruction showed a saccular dilatation of the infrarenal segment of the abdominal aorta measuring 70 mm in height, 41 mm of anteroposterior diameter and 40 mm in transverse diameter with diffuse calcification of both anterior and posterior wall of the aorta extending to the primitive iliac arteries []. There was no evidence of dissection or rupture. Cross sections showed a partial thrombosis of the aorta wall []. The diagnosis of CIS complicating a partially thrombosed aneurysm of the abdominal aorta was then made. Antiplatelet therapy by lysine acetylsalicylate 160 mg/day was introduced to prevent embolic complications. Follow-up over last 6 months showed regression of inflammation, improvement of Hb level, and reduction of rHuEPO doses [].

[[72.0, 'year']]

M

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{}

3927191-1

noncomm/PMC003xxxxxx/PMC3927191.xml

Plasmablastic myeloma presenting as rapidly progressive renal failure in a young adult

A 28-year-old male patient presented with the complaints of generalized weakness and exertional dyspnea of 1 month duration. He did not give a history of frothing of urine, pedal edema, hematuria or breathlessness in the past. Clinically he appeared pale and dehydrated, blood pressure was 120/80 mmHg and systemic examination was unremarkable. Investigations revealed that he had normocytic normochromic anemia (hemoglobin: 7.5 g/dl), thrombocytopenia (80,000/cumm) with normal leukocyte count (7400/cumm), moderate renal failure (serum creatinine: 3 mg/dl), normal liver function tests (serum albumin: 4.92 g/dl and serum globulin: 2.4 g/dl), and normal serum electrolytes, serum calcium: 10 mg/dl, serum phosphorous: 4.7 mg/dl and elevated serum uric acid (9.5 mg/dl). Urine examination showed proteinuria 1+ on dipstick, 24 h urine protein was 8504 mg. With a high index of suspicion for a tubular proteinuria, along with a hypo proliferative marrow (reticulocyte productive index: 0.7%), the possibility of plasma cell dyscrasia was considered. Serum protein electrophoresis and urine Bence Jones protein were negative. Serum immunofixation using capillary method showed immunoglobulin G, kappa monoclonal immunoglobulin. Urine electrophoresis showed M band and serum free light chain (SFLC) assay showed a significantly elevated kappa level (4383 mg/l; normal range: 3.3-19.4) with a suppressed lambda level (4.5 mg/l; normal range: 5.7-26.3), kappa/lamba ratio was 974 (normal range in renal failure: 0.37-3.1). Skeletal survey did not show any evidence of lytic lesions. BM biopsy done showed 79% of plasma cells with plasmablastic morphology [], which were CD138 positive with kappa restriction. These atypical cells showed Ki 67% of 20-25% with very few cells positive for terminal deoxynucleotidyl transferase and CD79a was negative, which suggested plasmablastic myeloma phenotype. Fluorescence in-situ hybridization on BM was negative for del13q14.3, t (11;14), t (4;14), t (14;16). Renal function deteriorated rapidly; he underwent a renal biopsy, which showed pale eosinophilic, Schiff poor fractured casts in the renal tubules [], which were kappa restricted.\nHe was started on chemotherapy, with each 21 days cycle consisting of parenteral bortezomib (1.3 mg/m2/dose on days 1, 4, 8 and 11) and oral dexamethasone (40 mg/day on days 1-4, 9-12). After the first cycle of bortezomib and dexamethasone, his renal functions started to improve. He was started on lenalidomide 25 mg/day at cycle 2 (when renal function started to improve) along with bortezomib and dexamethasone. With this intensive chemotherapy, his renal functions improved further (serum creatinine 1.77 mg/dl at 6 weeks).\nPatient was reevaluated after four cycles of chemotherapy with BM examination and free light chain assay. BM showed less than 1% of plasma cells and serum free kappa light chain was 67.69 mg/l. Serum creatinine improved to 1.4 mg/dl at 6 months and he was planned for autologous peripheral blood stem cell transplantation (APBSCT). However, due to technical delay, he was given additional two cycles of CyBorD chemotherapy (weekly cyclophosphamide, bortezomib and dexamethasone). Patient then underwent APBSCT with Melphalan conditioning 140 mg/m2. Post-transplant patient achieved neutrophil and platelet engraftment on day +9 and did not encounter any infections. Day +100 evaluation showed serum creatinine to be 1.3 mg/dl and he was in stringent complete remission (negative serum and urine immunofixation and normal SFLC ratio).

[[28.0, 'year']]

M

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{'6475702-1': 1}

3927193-1

noncomm/PMC003xxxxxx/PMC3927193.xml

Pregabalin-associated myoclonic encephalopathy without evidence of drug accumulation in a patient with acute renal failure

A 64-year-old woman was admitted in the Emergency Department (ED) for altered consciousness and abnormal movements. Her medical history included arterial hypertension and type 2 diabetes mellitus. There was no history of epileptic seizures. She was treated since 1 year in the Hematology Department for a multiple myeloma complicated with chronic inflammatory demyelinating polyneuropathy (CIDP). Her current medications included clonazepam, amlodipine, L-thyroxin, metformin, repaglinide, spironolactone, furosemide, minoxidil, irbesartan, hydrochlorothiazide, acyclovir, pantoprazole, and fenofibrate. During the recent hospital stay, the patient started taking pregabalin (75 mg/day for 9 days and then 75 mg bid) to treat CIDP-related pain. At the time of discharge from the hospital, her serum creatinine concentration was 90.2 μmol/l. Five days later, when admitted in the ED, the patient had already received a cumulative dose of 1,350 mg pregabalin for more than 14 days. The last dose of 75 mg had been ingested 36 h before the hospital admission. The medication was stopped by the patient following the symptoms of confusion, speech difficulties, visual hallucinations, and continuous limb and head movements.\nWhen admitted in the ED, the Glasgow Coma Score was 11/15 (E3, V3, M5). Spontaneous myoclonus of the legs was observed, with involuntary movements of the arms and face, which were increased when the patient was stimulated (). She aroused but was unable to speak. The main findings of the laboratory investigations were an acute renal failure, with serum urea, 22.9 mmol/l (normal <8.3); serum creatinine, 451.3 μmol/l (normal <115); and hypercalcemia (total calcium: 3.1 μmol/l). The clearance of creatinine was reduced to 9 ml/min/m2. Acute renal failure was multifactorial: Multiple myeloma, hypercalcemia, and drug interactions. There was no evidence for urinary tract obstruction.\nThe patient was transferred to the intensive care unit. Sedation with benzodiazepines was transiently required to insert venous and arterial catheters, and the intensity of the abnormal movements was decreased. It was not possible to perform an electroencephalogram due to incessant movements of the head. As urine output was maintained, and in the absence of severe metabolic disorders, hemodialysis was not required. Renal function rapidly recovered following fluid therapy. The neurological condition improved after 24 h of supportive care, with a resolution of myoclonus. Confusion and speech disorder persisted for 48 h, but ultimately the patient made a complete neurological recovery, with a total amnesia of the recent events. Pregabalin was not reintroduced. Renal function returned to previous values.\nLater, the results of the toxicological analysis were obtained []. At the time of admission, the concentration of plasma pregabalin was 3.42 μg/ml (therapeutic range: 3-12). The terminal elimination half-life was 11.5 h and was calculated from five consecutive time points up to 31 h after admission. Based on these pharmacokinetic data and considering the delay of 36 h between last drug ingestion and hospital admission, a maximal plasma pregabalin concentration of 13.70 μg/ml could have been reached 12 h after the last drug administration (last theoretical trough concentration).

[[64.0, 'year']]

F

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{}

3927194-1

noncomm/PMC003xxxxxx/PMC3927194.xml

Intravenous albumin infusion is an effective therapy for hyponatremia in patient with malignant ascites

A 58-year-old African American female was referred to renal service with hyponatremia and a 2-day history of weakness, anorexia and headache. The patient had a medical history significant for metastatic breast cancer and ascites requiring frequent therapeutic paracentesis. On physical exam, the patient was noted to have marked ascites with a prominent fluid wave and bulging flanks, bilateral pitting edema below the knees. Her vitals were significant for a pulse of 78 beats/min, blood pressure of 102/68 mm/Hg. Significant laboratory studies included a white blood cell count of 4.3 × 109/L, aspartate transaminase of 111 U/L, alanine transaminase of 49 U/L, albumin of 2.4 g/dl, serum sodium concentration of 121 mEq/L, and serum osmolality of 260 mosm/kg. Patient's serum sodium was 130-131 mEq/L at baseline. However, in the past 3 days, she was given dextrose 5% in 0.45% normal saline (D5 ½ NS) infusion because of her poor oral intake. Urine electrolytes showed urine sodium concentration of <10 mmol/L, and the urine osmolality was 412 mos/kg. Computed tomography scan of the abdomen and pelvis showed innumerable metastasis throughout the liver. A liver sonogram ruled out Budd Chiari's syndrome. The low urinary sodium is consistent with low effective circulating volume depletion, in this case, secondary to large amount of ascites and cirrhotic state. The urine osmolality of 412 mos/kg indicated an inability to normally excrete free water, likely because of persistent secretion of ADH (SIADH). Therefore, a diagnosis of hypervolemic hyponatremia in the setting of liver metastasis was made. SIADH was excluded based on the volume status of the patient (not euvolemic).\nThe patient was treated with 100 ml 25% albumin intravenous infusion every 8 h for 2 days for her symptomatic hyponatremia. She was on fluid restriction to <1200 cc/day and appropriately with sodium restriction to less than 2300 mg/day. Her serum sodium concentration increased to 134 mEq/L over 48 h [] and her weakness, anorexia, and headache significantly improved. She was discharged from the hospital with recommendations for fluid restriction. Her serum sodium concentration maintained in the range of 134-140 mEq/L in the next 2 months after her discharge.

[[58.0, 'year']]

F

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{'2851673-1': 1}

3927195-1

noncomm/PMC003xxxxxx/PMC3927195.xml

A case of fatal disseminated Apophysomyces elegans infection in a renal allograft recipient

A 55-year-old Australian indigenous male, with chronic kidney disease of uncertain etiology, received a deceased donor renal transplant in September 2008. Prior to renal transplantation, he was treated for latent tuberculosis. His immunosuppression included induction with basiliximab followed by maintenance with tacrolimus, mycophenolate mofetil and prednisolone. There was no history of foreign travel.\nEight months after transplantation, he presented with 2 days history of a well circumscribed discolored lesion on the anterior abdominal wall and the left thigh, following insect bites while camping in the “bush”.\nHe was afebrile vital signs were normal. An indurated, well demarcated, hyperpigmented tender lesion, 4 cm × 4 cm was present on the right anterior abdominal wall and another lesion 10 cm × 3 cm on the anterior aspect of his left thigh. He also had a tender swelling on the posterior aspect of the right calf. The lesions over the anterior abdominal wall and the left thigh increased in size with the breakdown and necrosis of the overlying skin. Neurological examination revealed Grade 4 power in the left leg with reduced pin prick in L2/3/4 dermatomal distribution with absent left knee and ankle reflexes. Plantar response was equivocal on the left foot.\nHis investigations were – total leukocyte count 3.7 × 109/L, neutrophils 2.5 × 109/L, lymphocytes 0.4 × 109/L, hemoglobin 12.9 g/dl, platelet count 1.53 lakhs/mm3, creatinine kinase 722 U/L, serum 2.5 mg/dl, C-reactive protein 209 mg/L, bilirubin 0.52 mg/dl, alkaline phosphatase 314 U/L, alanine aminotransferase 22 U/L, Gammaglutamul transpeptidase 34 U/L, serum albumin 41 g/L, total protein of 7.8 g/dl Chest X-ray showed a small right lower lobe consolidation. Hepatitis A, B and C antibodies were not detected. Q fever, rickettsial serology and Cryptococcus neoformans antigen negative in the serum. Urine and blood cultures were sterile.\nIn the hospital, he developed intermittent fever up to 39.5°C. He was empirically commenced on intravenous cephazolin for presumed cellulitis after blood and urine cultures were drawn.\nUltrasound examination showed edema of the subcutaneous tissues, but no focal collections. Skin biopsies of the abdominal and right calf lesions were obtained. Initial gram stain of the biopsy specimen did not show any organism. Subsequent urine and blood cultures were sterile. Computed tomography (CT) scan of the thorax [], abdomen and lumbar spine showed an inflammatory mass lesion within the right lower lobe lung with edema of the left iliopsoas muscle.\nFour days after presentation, he became confused and restless. He developed hypotension. In the intensive care unit, he was initiated on inotropes, was intubated and ventilated. Meropenem, doxycycline, vancomycin and intravenous voriconazole were administered.\nA whole body CT scan was carried out, which showed a large left occipital infarct with hemorrhagic transformation, [], and wide spread infarctions in the spleen, liver, native kidneys, and transplanted kidney. These were presumed to be secondary to the spread of the fungal infection. Echocardiographic examination was normal.\nThe patient's general condition continued to deteriorate, and he died 6 days after presentation. An autopsy was not performed.\nFungal cultures obtained from skin biopsies, subsequently showed growth of a zygomycete, identified as A. elegans.

[[55.0, 'year']]

M

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{}

3927196-1

noncomm/PMC003xxxxxx/PMC3927196.xml

Membranous nephropathy superimposed on Churg-Strauss syndrome

A 37-year-old man was treated for Churg-Strauss syndrome 6 years back. It was diagnosed when he had history of problems such as breathlessness, wheezing, sticky sputum, weight loss, and myalgias. He also had history of cough and expectoration. He had these symptoms for 10 years before that presentation. He had joint pains, particularly metacarpophalangeal, interphalangeal, and wrist joints. He complained of subcutaneous nodules over upper and lower limbs. He also had rhinorrhea and later he was found to have nasal polyp. He had no symptoms such as abdominal pain, diarrhea, gastrointestinal bleeding, weakness of limbs and symptoms related to stroke, ophthalmologic involvement, and cardiac failure. His previous investigations are reported in .\nAt present, he complained of facial puffiness which gradually progressed to entire body. There was no antecedent history of fever or skin disease. There was history of increased frothiness of urine. There was no history of oliguria and hematuria. He also complained of breathlessness, wheezing, cough, and expectoration, particularly in the morning. His blood pressure was 160/90 mm of Hg. The present investigations are reported in .\nOn light microscopy, kidney biopsy revealed the following: 15 glomeruli, 3 sclerosed, and 5 showed focal necrosis and cellular crescents. Glomeruli showed diffuse thickening of glomerular basement membrane []. Spikes were present. Tubules, vessels, and interstitium were unremarkable. Immunofluorescence assay revealed: IgG 3+, IgM 1+, κ 1+, and λ 1 + in glomeruli. Electron microscopy was not performed. HbsAg Hepatitis B surface antigen and anti-HCV anti- hepatitis C virus antibodies were negative. Human immunodeficiency virus was non-reactive. Cytoplasmic antineutrophilic cytoplasmic antibody cANCA, anti nuclear antibody ANA, and anti double stranded DNA antibody anti-dsDNA were negative. Complements were within normal limits.\nAt first presentation, he was treated with methylprednisolone 15 mg/kg/d intravenous for 3 days followed by oral prednisolone 0.5 mg/kg/d for 3 months and was tapered to 10 mg/day by 6 months. He was continued on that dose, till the present complaints.\nAt present, he received intravenous methylprednisolone 15 mg/kg/d intravenous for 3 days followed by intravenous cyclophosphamide 500 mg and oral prednisolone 0.5 mg/kg/d. He also received monthly doses of intravenous cyclophosphamide 500 mg for 6 months. At the end of 6 months, azathioprine (2 mg/kg/d) was started and angiotensin-converting inhibitors and angiotensin receptor blockers were continued. After 18 months of follow-up, the proteinuria was 0.2 g/day, RBCs in urine were absent, and serum creatinine was 1.2 mg/dl.

[[37.0, 'year']]

M

{'17295665': 1, '22833809': 1, '25738112': 2, '9175062': 1, '10543328': 1, '16157986': 1, '21292302': 1, '19158367': 1, '25984116': 1, '9392363': 1, '11758012': 1, '24574636': 2}

{'4330666-1': 1}

3927249-1

noncomm/PMC003xxxxxx/PMC3927249.xml

Shared or induced obsessive compulsive disorder: Is it a reality?

The first case was a 27 year old married woman from a rural area, seen in a psychiatry out-patient department (OPD) with the complaints of preoccupation with contamination and cleanliness, apprehension about lizards falling in food and washing hands and utensils repeatedly since 3 years.\nShe was living in a joint family which consisted of her husband, father-in-law and mother-in-law. Her mother-in-law was a dominating person. Patient's husband was a submissive type of person generally obeying his mother.\nAs per the observation and history given by her relatives, the mother-in-law was suffering from OCD with predominant obsessions of contamination since 7 years. She had no insight into her illness and was not willing for treatment. Patient could not adjust well with her mother-in-law for the initial 2 years after her marriage. The mother-in-law would satisfy her own obsessions by compelling the patient to wash the house, utensils and clothes repeatedly. The patient would be repeatedly scolded by her mother-in-law for mistakes in the household chores regarding cleanliness. The patient tried her best to follow her instructions with lot of mental resistance for 2 years.\nSince 3 years the patient started doubting her own work. She used to get repeated thoughts of contamination, which made her perform the cleaning activities frequently to reduce her anxiety. Over 1 year the patient's compulsive activities increased to such an extent that she started spending more than 5-6 h in a day washing utensils and clothes while the mother-in-law would spend most of her day time in cleaning the house. She used to experience the obsessions for about 5-6 h daily. She had serious distress and disruption in her daily functioning due to the obsessions and compulsions. She tried to resist the obsessions and compulsions but had little control over it. The Yale-Brown obsessive compulsive scale (Y-BOCS) was used to measure the severity of her symptoms.[] Her total Y-BOCS score was 28.\nShe had no other psychiatric comorbidities. She was not suffering from any significant medical or surgical illness. There was no past history of any significant psychiatric problem. Family history was not significant.\nShe was the eldest among three siblings. Her parents were educated and supportive of her and her sisters. The patient was educated up to higher secondary. Her performance in school was average. Her adolescence was without any significant psychological problems. She had been married since 5 years. Her pre-morbid personality assessment revealed her as quiet, submissive, suggestible and cooperative.\nOn mental status examination, her mood was anxious with appropriate affect and thought evaluation revealed obsessions of contamination and ideas of helplessness due to the obsessions. She had insight into her illness.\nPatient was treated with tablet escitalopram 10 mg OD and tablet clonazepam 0.5 mg OD. The dose of Escitalopram was increased to 20 mg/day after 15 days. Clonazepam was reduced and then subsequently tapered off. Patient was assessed every 2 weeks. She did not report any significant improvement for 3 months. We advised separation of the patient from her mother-in-law by considering this illness as an induced OCD without any further change in medications. After 1 month of separation, patient's obsessions and compulsions were reduced by around 60%. Escitalopram 20 mg/day was continued over this duration. She was not willing for any psychotherapy and hence this could not be undertaken. Medications were tapered and stopped over the next 6 months. During this period, she continued to stay separated from her mother-in-law. She was further assessed every month for next 6 months. The residual obsessions improved completely over 3 months. She has no obsessions and compulsions since last 3 months.

[[27.0, 'year']]

F

{'3288439': 1, '16895601': 1, '20815674': 1, '16424681': 1, '15347408': 1, '13998751': 1, '28615788': 1, '2684084': 1, '9350949': 1, '24574562': 2}

{'3927249-2': 2, '3927249-3': 2}

3927249-2

noncomm/PMC003xxxxxx/PMC3927249.xml

Shared or induced obsessive compulsive disorder: Is it a reality?

The second case is about a 20-year-old female patient from urban area seen in psychiatry OPD with the complaints of excessive preoccupation with cleanliness and repeated hand washing since 1 year.\nThe patient was apparently alright 1 year back. She belonged to a nuclear family including her parents. Her father reported that she was excessively attached to her mother. Patient's mother was suffering from OCD, moderate to severe in degree, since 10 years and was under treatment from same hospital. She had predominant obsessions of contamination. Her response to treatment was not good. She was not a dominating figure.\nThe patient was excessively close to her mother. She used to help her mother in household activities and would also take care that adequate cleanliness is maintained so that her mother is not distressed. In her attempts to help her mother, she was excessively involved in compulsive rituals.\nSince last 1 year the patient herself started doubting her work. She would perform the cleaning activities repeatedly to reduce her own distress. She used to spend 2-3 h a day to clean the house leading to disruption in her daily activities. She would try to resist the obsessions and compulsions but had little control over it. Her total Y-BOCS score was 18.\nPatient had no other psychiatric co-morbidities. She was not suffering from any medical or surgical illness and her past history was not significant.\nPatient was studying in the 2nd year of her undergraduate training in engineering. Her pre-morbid personality assessment showed that she was anxious, submissive, social and cooperative.\nOn mental status examination her mood was anxious with appropriate affect and thought evaluation revealed obsessions of contamination. She had insight into her illness.\nWe advised separation of the patient from her mother by considering the probability of induced OCD. Patient's father cooperated for the same. We suggested the patient to stay at the college hostel for 6 months. She was allowed to talk to her parents on phone. She insisted on spending the Sundays with parents. We allowed that in the 2nd month of separation. The patient had significant distress for the 1st month. She was anxious about her mother's health. At the end of the 2nd month of separation patient showed 30-40% reduction in her symptoms. Her Y-BOCS score was 12. We continued the separation for next 4 months with monthly follow-up. At the end of 6 months, the patient had significant improvement. Patient decided to stay in hostel for her further education and to stay with her parents on weekends.

[[20.0, 'year']]

F

{'3288439': 1, '16895601': 1, '20815674': 1, '16424681': 1, '15347408': 1, '13998751': 1, '28615788': 1, '2684084': 1, '9350949': 1, '24574562': 2}

{'3927249-1': 2, '3927249-3': 2}

3927249-3

noncomm/PMC003xxxxxx/PMC3927249.xml

Shared or induced obsessive compulsive disorder: Is it a reality?

A 50-year-old female patient from rural area was seen in psychiatry OPD with the complaints of repeated checking of doors, gas knobs and electrical switches, excessive involvement in cleanliness such as cleaning floors, utensils and bathing idols of God. This started 5 years back and had increased over last 2-3 years.\nThe patient was staying with her husband, two children and mother-in-law. Patient's mother-in-law was 70 years old. She was under treatment for OCD since last 40 years with poor response to treatment. She was debilitated and bed-ridden since last 5 years due to complications of osteoarthritis. It was not possible for her to perform her compulsive activities due to arthritis, which in turn would result in increase in her distress. Hence she started forcing the patient to perform the compulsive rituals for her. The patient was submissive. The patient could not refuse her dominating mother-in-law for performing cleaning activities. For the initial few years the patient started performing compulsions with a lot of resistance. Gradually her resistance reduced and since 2-3 years she started doubting her own work.\nShe started spending 5-6 h a day in doubting her work and performing compulsive rituals. She had significant distress and interference in her life due to obsessions and compulsions. She tried to resist the obsessions and compulsions but had little control over it. Her total Y-BOCS score was 30.\nPatient was started on tablet sertraline 100 mg/day and the dose was increased to 200 mg/day on follow-up. The patient was also treated with tablet clonazepam 0.5 mg/day for first 4 weeks.\nWe advised separation from her mother-in-law considering her illness as shared OCD. The patient and her family members were not willing for separation in view of the mother-in-law's medical condition. There is no other caretaker for mother-in-law apart from the patient. Pharmacotherapy reduced patient's restlessness, but there was no significant improvement in her obsessive compulsive symptoms even after 6 months of treatment.

[[50.0, 'year']]

F

{'3288439': 1, '16895601': 1, '20815674': 1, '16424681': 1, '15347408': 1, '13998751': 1, '28615788': 1, '2684084': 1, '9350949': 1, '24574562': 2}

{'3927249-1': 2, '3927249-2': 2}

3927250-1

noncomm/PMC003xxxxxx/PMC3927250.xml

Marchiafawa bignami disease possibly related to consumption of a locally brewed alcoholic beverage: Report of two cases

Mr. A, 39-year-old married Hindu male from low socioeconomic class and urban background, a known case of chronic alcoholism, brought by wife and uncle with 3-month history of forgetfulness in form of forgetting his way back home, whether bath was taken, where he kept the things. It was progressive in nature affecting his daily routine and socio-occupational life. He used to consume locally made alcohol called Mahuwa Daru occasionally one pouch (100 ml) since 8 years, gradually increasing to one to two pouches three times a day since last one and half year. There is history of withdrawal symptoms in form of tremors, insomnia and irritability in past. No history of any other psychiatric illness. There is family history of alcohol dependence in father.\nPatient was first taken to physician. His routine investigations were normal. MRI showed abnormal signal intensity with restricted diffusion in corpus callosum with demyelination in genu and splenium. He was treated for withdrawal and discharged. Patient restarted alcohol after discharge.\nPatient was referred to our hospital for fitness. He was admitted. Last consumption was day prior to admission and he developed tremors next day. Routine investigations and neurological examination were normal. MMSE was 21/30. He was started on anti-withdrawal line of management with Inj. Thiamine (100 mg) OD, Tab. Multivitamin BD and Tab. Lorazepam 10 mg in divided doses. Repeat MRI brain showed hyper intense signal alterations involving posterior body and splenium, as well as anterior body and genu of the corpus callosum. This represent progressive demyelination and necrosis of the corpus callosum []. All these characteristic findings confirmed the diagnosis of MBD.

[[39.0, 'year']]

M

{'19934570': 1, '17583421': 1, '19934569': 1, '27114628': 2, '15372245': 1, '17383087': 1, '20329440': 1, '23417939': 1, '24574563': 2}

{'3927250-2': 2, '4820555-1': 1}

3927250-2

noncomm/PMC003xxxxxx/PMC3927250.xml

Marchiafawa bignami disease possibly related to consumption of a locally brewed alcoholic beverage: Report of two cases

Mr. ABC, a 57-year-old male patient from low socio-economic status from rural area with history of chronic alcohol abuse since 35 years, gradually increasing to 4-5 (400-500 ml) pouches of Mahuwa Daru over 2 hours daily in the evening. Patient never abstained. Patient was forced to stop alcohol by relatives for financial and health reasons, the following day he developed tremors and sleep impairment and on third day he was found disoriented in disheveled state with fecal and urinary incontinence by the coworkers and was admitted. General examination showed malnourishment and thickening of post-auricular and ulnar nerve. Vital signs were normal. Mental state examination showed disorientation. Pupillary reactions were symmetrical. There were no lateralizing deficits and no signs of meningeal irritation. Laboratory tests showed a normal haemogram, liver and renal function tests and serum electrolytes. Patient was started on Inj Thiamine 100 mg and anti withdrawal line of management. He had four episodes of seizures over three days of admission. His EEG was normal. His MRI-Brain showed hyper intense signal intensities involving genu, body and splenium of corpus callosum on T2W and FLAIR []. Patient gradually improved. On 20th day he was symptom free, MSE was clear, MMSE was 30/30 and was discharged and advised to follow up. After one month he resumed his work. Patient did not follow up in OPD for further evaluation.

[[57.0, 'year']]

M

{'19934570': 1, '17583421': 1, '19934569': 1, '27114628': 2, '15372245': 1, '17383087': 1, '20329440': 1, '23417939': 1, '24574563': 2}

{'3927250-1': 2, '4820555-1': 1}

3927251-1

noncomm/PMC003xxxxxx/PMC3927251.xml

Methylphenidate and suicidal ideation: Report of two cases

An 8-year-old male child, attending the Child Guidance Clinic at our institute was diagnosed as a case of ADHD, combined type as per DSM-IV TR by the consultant Psychiatrist. The patient had marked hyperactivity at school, home, and in social settings. The child reportedly also had impulsivity and poor concentration as was apparent from history, observation, and mental status examination. The patient had average Intelligent Quotient, but due to hyperactivity and inattention, he was not performing well in academics. He also had behavioral problems at home.\nThe patient was prescribed methylphenidate immediate release at the dose of 5 mg per day. Parents reported after a week as was scheduled. They mentioned that during the initial 2 days, the child reported suicidal ideation. In the evening when all family members were sitting and talking, the child said without any context (in vernacular language) on the first day “I wish to commit suicide” and on the second day he said “don't cremate me if I die”. During these two days, he was interacting well, playing adequately and his biological functioning was normal. Also there were no other behavioral problems or any other unusual behavior. No other side effects of methylphenidate were reported by the parents.\nParents were alarmed by child's utterances and stopped methylphenidate after 2 days and thereafter no suicidal ideation was expressed by the child. Following this, atomoxetine was prescribed, no side effects have been observed since then and the patient has been coming to child guidance clinic regularly. The case had no family history of mental illness or suicide.

[[8.0, 'year']]

M

{'20158630': 1, '10907387': 1, '21332245': 1, '29744873': 1, '9306050': 1, '9109529': 1, '23234585': 1, '24574564': 2}

{}

3927253-1

noncomm/PMC003xxxxxx/PMC3927253.xml

Onset of schizophrenia at 100 years of age

Family members of Mrs. D, a 100-year-old illiterate widow, complained that for the last 9 months she remained fearful and said that someone wanted to kill her and harm her family members. She held that belief firmly, which according to everyone in the family was baseless. She would appear to be muttering abusive words and gesticulating to herself and, on being questioned by family members, she would say that she was reacting to voices of some unknown persons who were discussing about her and were planning to kill her. Her sleep also remained disturbed. There had been no complaint of forgetfulness. She had no significant medical, surgical, or psychiatric illness in the past or any significant family history. She had never used any substance. According to her family, she was an independent, intelligent, and cooperative person.\nOn physical examination, Mrs. D had persistently raised (borderline high) blood pressure (had never been checked earlier). She had kyphosis of spine and walked with the help of a walking stick. Her neuromuscular examination including examination for hearing and vision was within normal limits. On Mini-Mental State Examination (MMSE), she scored 25/27, with points lost for not answering for year and date. Also, reading, writing, and copying the interlocking pentagons could not be done (she had never used a pen). On mental status examination, she was alert and cooperative. She had unshakable belief that there was someone who was after her to kill her. She acknowledged hearing the voices of unknown males for the past few months who discussed among themselves the plan to kill her. She heard those voices through her ears in clear consciousness. She had good immediate, recent, and remote memory and had a good fund of general information and could correctly perform simple verbal calculations. Abstraction and test judgment ability was intact and she had no insight into her psychiatric illness.\nShe was prescribed tablet olanzapine 5 mg at bedtime and slept well in the ward. Her hemogram, renal, hepatic and thyroid function tests, lipid profile, serum electrolytes, and routine urinary examination were within normal range. Her chest roentgenogram and electrocardiogram were normal, echocardiography revealed type I diastolic dysfunction that was age related as per the cardiologist's opinion; magnetic resonance imaging (MRI) of brain revealed generalized age-related cerebral atrophy and electroencephalogram (EEG) was a normal awake record. She was prescribed hydrochlorthiazide 12.5 mg at bedtime by the cardiologist, and her subsequent blood pressure recordings were within normal limits. The dose of olanzapine was increased to 7.5 mg at bedtime on the seventh day. Her suspiciousness, fearfulness, and auditory hallucinations started decreasing in the second week of admission, and she was discharged on the tenth day. She achieved full remission in 3 weeks and is on regular follow-up now. She is maintaining well thereafter until date (more than 10 months).

[[100.0, 'year']]

F

{'12948993': 1, '17600177': 1, '16513874': 1, '16844897': 1, '10478904': 1, '17221001': 1, '11673800': 1, '10671383': 1, '24574565': 2}

{}

3927254-1

noncomm/PMC003xxxxxx/PMC3927254.xml

Body dysmorphic disorder: Borderline category between neurosis and psychosis

Mr. S is a 27-year-old male from middle socio-economic status. The patient was referred to psychiatry outpatient department from the plastic surgery department for clearance for rhinoplasty surgery. Patient was interviewed in detail and his history dated back to 17 years of age when he was in his final year of schooling. He started noticing pimples and acne on his face, which embarrassed him to face his peers. He observed that few of the acne cleared, but few on the face left black marks and those on the nose turned into comedones. Most of them cleared with the treatment from a dermatologist. But the patient's concern with the healed scars on the face and nose started increasing and he started becoming preoccupied with them. He felt embarrassed to face his classmates and would feel shy to face the public or relatives visiting his house.\nThe patient adopted measures like covering his nose with his hands while speaking to others or while listening to the lectures in the class so as to hide the marks. Over a period of time, he started developing rituals such as repeatedly watching his nose in the mirror, frequently washing his face after he returns back home from outside, applying powder over the nose to cover up the imagined area of scars on the nose, and trying to reshape his nose on his own using a stone, which resulted in bleeding and worsening of the condition.\nThe patient developed anxiety in social situations because of his referential thinking involving his imagined ugly appearance. He also developed misinterpretations of other people's behavior and comments linking them to his facial disfigurement. He spent enormous amount of time and money in reshaping his nose, at times resorting to stealing money from home. He developed depressed mood, death wishes, and suicidal thoughts as a result of lack of improvement with treatment from various doctors. Patient had frequent change of jobs giving the reason as his inability to cope up with works involving social contact as a result of his ugly nose. He also started attributing his failures in academics and professional life to the imagined deformity in the nose. The patient did have recurrent suicidal ideation secondary to preoccupation with imagined deformity and occupational dysfunction, but there was no active attempt.\nThe patient did have history of stammering since childhood, which exacerbated after his social anxiety increased. He has a history of alcohol and tobacco abuse. He is the first among his five siblings. His mother used to be very critical of his appearance from his childhood. There is family history of stammering, but there was no other significant mental illness in the family. He had difficult temperament from his childhood, although adequate information could not be got.\nAt the time of presentation to us, the patient had non pervasive sad mood, decreased concentration in his work, significant social anxiety, and avoidance of social situations due to referential thinking, stammering, strong beliefs that his nose is ugly and deformed (amounting to delusional level) with absent insight, and he attributed all his failures to the physical problem. There was significant impairment in social, occupational, and academic functioning. There were obsessions related to contamination and compulsive washing, checking, and obsessive images, blasphemous thoughts, and sexual obsessions.\nThe patient was diagnosed to have BDD-delusional variant with obsessive compulsive disorder mixed type, social anxiety disorder, dysthymia with mild depressive episode without somatic complaints, and stammering, according to DSM-IV criteria.

[[27.0, 'year']]

M

{'8871796': 1, '11815686': 1, '16000674': 1, '12923704': 1, '8262881': 1, '16229856': 1, '10688713': 1, '15276662': 1, '9862601': 1, '24574566': 2}

{}

3927268-1

noncomm/PMC003xxxxxx/PMC3927268.xml

Role of newer imaging modalities for airway assessment in dynamic tracheal compression

A 45 year old female, with body mass index (BMI) 24 Kg/cm2, presented to our hospital with shortness of breath on lying supine for the past 3 months, more so when lying on right side, hence she preferred to sleep on the left side. She had two episodes of hemoptysis. She had been able to perform her daily activities without any distress.\nShe was treated elsewhere as bronchial asthma and referred to our center for evaluation of hemoptysis. On examination, she was found to have a swelling in the left lobe of the thyroid, compressing and pushing the trachea to the right. Auscultation of her chest revealed bilateral inspiratory and expiratory wheeze. CT of the neck and thorax revealed an enlarged left lobe of thyroid measuring 3.4 × 3.3 × 3.4 cm with dense nodular calcification, causing short segment external compression and tracheal luminal narrowing. The stenosis extended from upper margins of C7 to T2 vertebrae, with a length of 3.1 cm and minimal diameter of 0.31 cm []. Fine needle aspiration cytology (FNAC) of the swelling revealed colloid goiter and she was posted for a left hemithyroidectomy.\nRoom air arterial blood gas analysis showed Partial pressure of arterial oxygen (PaO2) of 80.5 mmHg, PaCO2 of 41 mmHg, pH of 7.41. Pulmonary function tests could not be performed because of hemoptysis.\nPreoperative fiberoptic bronchoscopy with a 4.8 mm bronchoscope revealed tracheal compression by extraluminal mass with a smooth margin 1.5 cm below the glottis. Tracheal lumen was narrowed by 80% []. The bronchoscope could not be passed beyond the narrowed segment.\nWhen the patient was explained about the risks and options, she was not willing for any major resection or procedure. After written informed consent, patient was nebulized with 5 ml of 4% lignocaine and pre oxygenated with 100% O2 for 10 min through a nasopharyngeal airway. She was placed supine with a slight left tilt. Intravenously (IV), Glycopyrrolate 0.2 mg, incremental doses of midazolam (2 mg) and fentanyl (100 μg) were given. A 4.5 mm fiberoptic bronchoscope (FOB) threaded through a 5 mm internal diameter (ID) microlaryngeal tracheal tube (MLT) was passed nasally. The FOB was introduced close to the mass, and gently pushed past the obstruction. Lower part of trachea and carina were visualized. There was no bleeding or tumor debris visualized. The MLT was advanced over the FOB. A little resistance was noted but the tube could be passed below the mass without undue force. The FOB was withdrawn and trachea ventilated with a tidal volume of 450 ml, 8 breaths /min, and I: E = 1:3. The left lobe of the thyroid being stony hard and densely adherent to trachea could not be completely resected. As the patient was not willing for tracheal resection and reconstruction, an isthumectomy and release of fibrotic tissue around the trachea was done. Before closure, the 5.0 mm (ID) MLT was replaced with a 6.0 mm ID MLT over an Aintree Intubating Catheter. As this could be passed without any resistance, it was followed by the passage of a 7.0 mm ID endotracheal tube with little resistance. Postoperatively, patient was electively ventilated, anticipating airway edema. Under steroid cover, 24 h later, the patient was extubated over a tube exchanger, with standby tracheostomy. She had no respiratory distress and was discharged on the 6th postoperative day. Histopathology report revealed papillary carcinoma. As the patient did not want any major definitive surgery; she was referred to a regional cancer institute for further management.

[[45.0, 'year']]

F

{'4087108': 1, '13729909': 1, '20234304': 1, '15465839': 1, '25425803': 1, '2938523': 1, '2344054': 1, '7762852': 1, '24574605': 2}

{}

3927269-1

noncomm/PMC003xxxxxx/PMC3927269.xml

Anaphylaxis from atracurium without skin manifestation

A 23-year-old female patient suffering from the chronic pancreatitis was posted for pancreatico-jejunostomy under general anesthesia. She did not have history of any other medical illness, no history of allergy; no history of previous surgery under anesthesia; her clinical examination and laboratory investigations were essentially normal. In the operating room, we secured an 18 G IV cannula, attached standard ASA (American Society of Anesthesiologists) monitors and recorded a baseline heart rate (HR) 85/min, blood pressure (BP) 115/74 mm Hg and a SpO2 of 97% on room air.\nInitially, she received 100 mcg fentanyl intravenously (I.V). After preoxygenation of 3 min, anesthesia was induced with 100 mg propofol and muscle relaxation for endotracheal (ET) intubation was facilitated by 75 mg succinylcholine. After confirmation of proper placement of ET tube by auscultation and EtCO2, ET tube was fixed at 18 cm. Anesthesia was maintained with 66% N2O, 33% O2 and 1% isoflurane. Three minutes after intubation, when respiratory efforts were seen, 15 mg atracurium was given I.V. Within 20-30 s after atracurium administration, we noticed a tachycardia of 140-160/min; BP was unrecordable and a peak airway pressure of 50 cm H2O with a SpO2 of 92%; however, we did not find any skin manifestations. On auscultation an essentially silent chest was found. We made a presumptive diagnosis of anaphylactic reaction; lungs were ventilated with 100% oxygen, intravenous 50 mcg adrenalin was administered in a dilution of 1:10000 and a rapid infusion of Ringer's lactate was initiated. After 1 min BP was 65/35 mm Hg, SpO2 - 94% and airway pressure was 40 cm H2O. Electrocardiography displayed sinus rhythm with a HR of 140/min. After another 2 min we repeated same IV dose of adrenaline and continued rapid infusion of Ringer's lactate. After 2 min of second dose of adrenalin, we recorded a BP of 85/55 mm Hg, SpO2 96%, peak airway pressure of 30 cm H2O, sinus tachycardia with a HR of 135/min. Wheezing was ausculated all over the lung fields. We then administered 10 mg chlorpheniramine and 200 mg hydrocortisone by slow IV injection. We decided to postpone the surgery for that day. After attainment of hemodynamic stability and resumption of spontaneous breathing activity, we reversed residual neuromuscular blockade by 2.5 mg neostigmine and 0.5 mg of glycopyrrolate. Trachea was extubated after 1 h of the incident and patient was kept on oxygen via face mask and monitored for the next 24 h in the post-anesthesia care unit (PACU). A post-operative chest X-ray done in the PACU was essentially normal. After 2 h of the event we collected blood sample for serum tryptase assay and after 4 weeks we arranged an intradermal test for atracurium. Serum tryptase value was 51.7 mcg/l and intradermal test for atracurium was found to be positive according to Société française d’anesthésie et réanimation criteria.[] However, it was negative for vecuronium and rocuronium. She underwent surgery uneventfully using the vecuronium as muscle relaxant 6 weeks later.

[[23.0, 'year']]

F

{'22014924': 1, '18991700': 1, '28738893': 2, '15181405': 1, '12091990': 1, '12074414': 1, '7535078': 1, '8342772': 1, '16398392': 1, '12960536': 1, '2735579': 1, '24574606': 2}

{'5525218-1': 1, '5525218-2': 1}

3927270-1

noncomm/PMC003xxxxxx/PMC3927270.xml

Successful living donor kidney transplantation in a patient with prothrombin gene mutation: Case report and literature review

A 69-year-old female with a history of prothrombin gene mutation was scheduled for living donor kidney transplantation. After developing spontaneous left subclavian and brachial artery thrombosis 17 years ago, patient underwent therapeutic anticoagulation and maintenance on warfarin for 1 year. With therapy, her thrombosis was found to have completely resolved; however, 8 years later following an arthroscopic procedure on her right knee, she developed venous thrombosis of her right lower extremity. She was subsequently found to have a heterozygous form of the prothrombin gene 20210 mutation and hence was maintained on chronic anticoagulation with warfarin. Over the past 2 years, patient developed end-stage renal disease in the setting of diabetes and hypertension.\nAfter careful discussion and institutional approval, patient and her son elected to undergo living donor kidney transplantation. Patient underwent general endotracheal anesthesia with smooth intravenous induction. She had a tunneled internal jugular double-lumen central venous catheter placed preoperatively and radial arterial line placed after induction. Access is sometimes difficult in renal transplant recipients and more so in our patient due to history of spontaneous subclavian and brachial artery thrombosis. As a routine practice in our institution, we place tunneled catheters preoperatively with interventional radiology for our scheduled kidney transplant recipients. There was no evidence of clots or thrombi in the internal jugular vein or vessels prior to placement of the line with ultrasound examination. A peripheral intravenous cannula was placed intra-operatively for additional access.\nShe received methylprednisolone and thymoglobulin for immunosuppression. In view of the patient's history of prothrombin gene mutation and history of prior thrombosis, she was maintained on a heparin infusion with a aim of maintaining the partial thromboplastin time (PTT) in the range of 70-75. To achieve this target PTT we gave a 2000 units bolus of heparin followed by an infusion of 1000 units/h. She remained stable throughout, maintaining a mean arterial pressure goal of > 80-85 mmHg after reperfusion. Trachea was extubated in the operating room and she was transported stable to the surgical intensive care unit. She received 2 l of albumin, 4.5 l of normal saline and 2 units of packed red blood cells during the case.\nOn the 3rd day post-operative, due to continued anticoagulation with heparin, patient developed retroperitoneal hematoma requiring re-exploration and washout. However, her allograft demonstrated good function and her creatinine remained stable post-operatively. She was transitioned to warfarin for anticoagulation and discharged home. Her continued immunosuppressive regimens include prednisone, tacrolimus and mycophenolate. Patient subsequently developed ureteral calculus, hydronephrosis and acute renal failure requiring nephrostomy tube placement. She has since had the nephrostomy tube removed and to date, her allograft continues to function well fifteen months later.

[[69.0, 'year']]

F

{'16352621': 1, '15919499': 1, '20172331': 1, '12506156': 1, '10480419': 1, '15134466': 1, '17452895': 1, '10477778': 1, '8916933': 1, '16357049': 1, '15087754': 1, '11684560': 1, '9569177': 1, '16499600': 1, '9719183': 1, '24574607': 2}

{}

3927300-1

noncomm/PMC003xxxxxx/PMC3927300.xml

Dapsone-induced methemoglobinemia: “Saturation gap”—The key to diagnosis

A 36-year-old woman was diagnosed with immune thrombocytopenic purpura in July 2012 and started on oral prednisolone and dapsone 100 mg/day. About 3 months later, she was admitted to the hospital with fatigue, headache, arthralgia, and severe dyspnea. Physical examination was normal except for peripheral cyanosis. She had a platelet count of 1,000/cmm, hemoglobin of 7.9 gm%. SpO2 on room air was 84%, respiratory rate was 52/min. Owing to intolerance for non-invasive ventilation (NIV) and low saturation, the patient was intubated and ventilated.\nArterial blood gas (ABG) analysis revealed a pH of 7.43, PaO2-180 mmHg, PaCO2-32 mmHg, SaO2-99.1% on oxygen by facemask. In view of history of dapsone intake, cyanosis, low SpO2 with normal PaO2 and SaO2(on ABG) a diagnosis of methemoglobinemia was considered and dapsone was stopped, however, the facility for methemoglobin (methHb) estimation was not available. After 48 hrs of mechanical ventilation, she improved symptomatically and was extubated following a weaning trial. She was shifted to high dependency unit with oxygen 5l/min. The SpO2 continued to remain low ranging from 88-92% over the next 3 days though the SaO2 was normal. As the patient remained clinically stable, no further intervention was carried out and she made an uneventful recovery.

[[36.0, 'year']]

F

{'22967308': 2, '23287806': 1, '22557834': 2, '22698859': 1, '1389948': 1, '31249693': 2, '22642026': 1, '23136811': 1, '23237281': 1, '32934050': 1, '2912291': 1, '19224799': 1, '23148399': 1, '33417185': 1, '22593785': 1, '15342970': 1, '7073040': 1, '30155279': 1, '23201463': 1, '24574600': 2}

{'3927300-2': 2, '3338240-1': 1, '3338240-2': 1, '6585036-1': 1, '3444913-1': 1, '3444913-2': 1}

3927300-2

noncomm/PMC003xxxxxx/PMC3927300.xml

Dapsone-induced methemoglobinemia: “Saturation gap”—The key to diagnosis

An 8-year-old girl, a known case of immune thrombocytopenic purpura, with treatment history of oral prednisolone 20 mg/day and dapsone 50 mg/day since 1 year, was planned for laparoscopic splenectomy.\nPre-operative assessment revealed cushingoid features, skin discoloration all over the body and splenomegaly [].\nShe had a platelet count of 20,000/cmm but the other hematological variables were normal. Oxygen saturation on room air was 88%. During maintenance of general anesthesia with a 60:40 (nitrous oxide:oxygen) gas oxygen ratio, the SpO2 rose to 92%. Vital signs, physical examination including bilateral air entry was normal, end tidal carbon dioxide and airway pressures were unremarkable. Intraoperative ABG analysis revealed a PaO2 of 260 mmHg, pH 7.40, PaCO2 38 mmHg, HCO3 22.4 meq.l-1 and SaO2 of 99%. Filter paper test done on the patient's blood comparing it with blood from a normal patient [] which showed that the patient's blood remained dark even after exposure to atmospheric oxygen.\nDeoxyhemoglobin can be distinguished from methHb by this simple bedside test. By placing 1 or 2 drops of the patient's blood on a white filter paper: Deoxyhemoglobin brightens after exposure to atmospheric oxygen, but methHb does not change color.[]\nShe was transferred to the pediatric intensive care unit (ICU) with oxygen therapy by polymask at 5 l/min, as SpO2 remained 86% on room air. Blood analysis showed methHb levels of 28.6%. Dapsone was stopped and the patient remained asymptomatic with supplemental oxygen by facemask. As the methHb levels were less than 30% and the patient was stable, therapy with methylene blue was not considered.

[[8.0, 'year']]

F

{'22967308': 2, '23287806': 1, '22557834': 2, '22698859': 1, '1389948': 1, '31249693': 2, '22642026': 1, '23136811': 1, '23237281': 1, '32934050': 1, '2912291': 1, '19224799': 1, '23148399': 1, '33417185': 1, '22593785': 1, '15342970': 1, '7073040': 1, '30155279': 1, '23201463': 1, '24574600': 2}

{'3927300-1': 2, '3338240-1': 1, '3338240-2': 1, '6585036-1': 1, '3444913-1': 1, '3444913-2': 1}

3927301-1

noncomm/PMC003xxxxxx/PMC3927301.xml

Platelet cold agglutinins and thrombocytopenia: A diagnostic dilemma in the intensive care unit

A 32-year-old lady was admitted with a 3 day history of bilateral upper and lower limb weakness. A diagnosis of Guillain-Barre syndrome (GBS) was suspected and patient was shifted to the ICU. The nerve conduction studies were consistent with that of acute motor axonal neuropathy type of GBS. The patient received a 5 day course of intravenous immunoglobulin (Ig). The platelet count at admission was 60,000. The white blood cells and red blood cell (RBC) counts were found to be normal. Repeated counts were on the lower side ranging from 3,000 to 15,000. However, the patient was not symptomatic and had no evidence of bleeding.\nClinical hematology opinion was sought and a suspicion of sepsis, heparin induced thrombocytopenia, drug/immune mediated thrombocytopenia and dengue were entertained. Accordingly patient was extensively worked up. Immunological work-up including titers of anti-neutrophilic cytoplasmic antibody/anti-nuclear antibody and other investigations such as dengue serology were obtained. However, this extensive work-up did not reveal anything.\nA review of the treatment chart was done to exclude any drug induced low platelet count. The patient was on supportive measures and medications as directed by ICU protocol. The patient received ranitidine for stress ulcer prophylaxis and multi-vitamins. These are not known to cause thrombocytopenia. Noinvasive procedures were undertaken in the interim period and deep venous thrombosis (DVT) prophylaxis with heparin was discontinued in view of the suspicion of heparin induced thrombocytopenia. Mechanical prophylaxis was instituted for DVT.\nThe hematologist was consulted and it was found that there was in-vitro clumping of platelets with ethylene diamine tetra acetic acid (EDTA). After further discussion and in accordance with the hematologist's suggestion, EDTA, citrate and heparinized samples were dispatched to the lab. The problem of clumping; however, persisted. The hematologist suspected the presence of cold agglutinins against platelets and analyzed the count by raising the temperature and this revealed a normal platelet count. The count thus obtained was 213,000. The hematologist made a diagnosis of spontaneous EDTA independent platelet agglutination and these platelet cold agglutinins were responsible for considerable diagnostic confusion.

[[32.0, 'year']]

F

{'16190355': 1, '10351132': 1, '16986719': 1, '9883813': 1, '24574601': 2}

{}

3927303-1

noncomm/PMC003xxxxxx/PMC3927303.xml

Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery

An 18-year-old, female patient, presented for surgery for mandibular prognathism. She was taken up for orthognathic surgery. Pre-operatively, as per protocol, she received intravenous (IV) dexamethasone 16 mg on the day of surgery at 6 am. Patient was pre-medicated with IV fentanyl 75 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 4 h. After extubation, she was transferred to the post-operative care unit (PACU) awake and calm. On arriving at PACU, she was given another dose of dexamethasone, 8 mg. After 2 h, she became agitated, restless and aggressive. IV midazolam, propofol and IV fentanyl were administered for sedation, but the patient remained agitated and confused. Over the next 3 h, IV fentanyl 100 μg, propofol 40 mg, midazolam 4 mg was administered after which the patient was relatively calm. Then, she became restless and delirious. Psychiatry consultation was sought. She was diagnosed with an acute psychotic episode possibly induced by steroids. IV midazolam 2 mg and intramuscular (IM) haloperidol 4 mg were given. An IV dexmedetomidine infusion at 0.4 microgm/kg/min tapered to 0.2 microgm/kg/min, provided sedation for 6 h, after which it was stopped. As the patient continued to be calm over the next 12 h, she was transferred to the ward. She continued to be stable and was discharged on the post-operative day 5.

[[18.0, 'year']]

F

{'7830185': 1, '15190136': 1, '7864702': 1, '19665383': 1, '14595285': 1, '8263640': 1, '30728709': 1, '7906026': 1, '23220857': 1, '21799397': 1, '12818945': 1, '19327637': 1, '24574603': 2}

{'3927303-2': 2, '3927303-3': 2}

3927303-2

noncomm/PMC003xxxxxx/PMC3927303.xml

Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery

A 58-year-old, female patient, presented for surgery for wide local excision of squamous cell carcinoma of maxilla and closure with split skin graft. Pre-operatively, as per protocol, she received IV dexamethasone 16 mg on the day of surgery at 6 am. Patient was pre-medicated with IV fentanyl 100 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 2 h. After extubation, she was awake and calm. On arriving at PACU, Another dose of 8 mg of dexamethasone was administered. After 6 h, she became restless and delirious. Psychiatry consultation was sought immediately. She too was diagnosed with an acute psychotic episode possibly induced by steroids. IV midazolam 2 mg and IM haloperidol 5 mg were administered. An IV dexmedetomedine infusion providing sedation was administered for 3 h at 0.4 μg/kg/h. She remained calm over the next 4 h after which she again became agitated. Midazolam 2 mg and haloperidol 2.5 mg were repeated. The dexmedetomidine infusion was restarted for next 6 h, initially at 0.4 μg/kg/h tapered to 0.2 μg/kg/h and then stopped. As the patient remained calm over the next 12 h, she was transferred to the ward. She continued to be psychologically stable and was discharged on the post-operative day 6.

[[58.0, 'year']]

F

{'7830185': 1, '15190136': 1, '7864702': 1, '19665383': 1, '14595285': 1, '8263640': 1, '30728709': 1, '7906026': 1, '23220857': 1, '21799397': 1, '12818945': 1, '19327637': 1, '24574603': 2}

{'3927303-1': 2, '3927303-3': 2}

3927303-3

noncomm/PMC003xxxxxx/PMC3927303.xml

Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery

An 80-year-old, female patient, weighing 35 kg presented with biopsy proven squamous cell carcinoma of the left side of the mandible. She had no other comorbidities. She was taken up for wide excision with segmental mandibulectomy, modified radical neck dissection and reconstruction with pectoralis major myocutaneous flap. Pre-operatively, as per protocol, she received IV dexamethasone 8 mg on the day of surgery at 6 am. Patient was pre-medicated with fentanyl 50 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 4 h. She was electively placed on endotracheal tube (ETT) with T-piece in the post-operative period in view of extensive surgery. In the PACU, another dose of 8 mg was administered. Fourteen hours after surgery, she became restless and she pulled out her ETT and Ryle's tube. She started bleeding from her suture site. She was wheeled into the operation theatre immediately for secondary suturing. After the surgery, she was placed on dexmedetomidine infusion for 12 h, initially at 0.3 μ/kg/h and then tapered to 0.1μ/kg/h (the infusion was stopped intermittently whenever the patient developed bradycardia or hypotension and whenever the patient remained calm). IV midazolam 1 mg and IM haloperidol 2.5 mg were continued 8 hourly for 2 days, after which the rest of post-operative period was uneventful. She was extubated 16 h after the surgery and then shifted back to the ward. She continued to be psychologically stable and was discharged on the post-operative day 8.

[[80.0, 'year']]

F

{'7830185': 1, '15190136': 1, '7864702': 1, '19665383': 1, '14595285': 1, '8263640': 1, '30728709': 1, '7906026': 1, '23220857': 1, '21799397': 1, '12818945': 1, '19327637': 1, '24574603': 2}

{'3927303-1': 2, '3927303-2': 2}

3927304-1

noncomm/PMC003xxxxxx/PMC3927304.xml

Esophageal polyp as a posterior mediastinal mass: Intraoperative dynamic airway obstruction requiring emergency tracheostomy

A 24-year-old 52 kg male was diagnosed with esophageal polyp and posted for elective polypectomy via transcervial approach. On preoperative evaluation, there was history of dysphagia, pressure sensation in throat and exertional breathlessness grade II for last 3 months. The symptoms were unrelated to change in position. No history of hoarseness of voice, congestion or puffiness of face, syncope, or palpitation was present. On examination, his pulse was 86/minute, blood pressure 110/70 mmHg and respiratory rate 20/minute. Airway examination was unremarkable.\nHematological and biochemical investigations were unremarkable. Chest X-Ray lateral view revealed a mass in the posterior mediastinum. Computed tomography (CT) scan of chest showed an intraluminal pedunculated polypoidal lesion of 10 × 4 cm size extending from upper end of esophagus to the junction of middle and lower third of esophagus with compression of lower end of trachea and both the bronchi. Tracheobroncheal compression ratio was less than 50%. Preoperative flow volume study and esophagography were not done.\nSedative premedication was avoided. In the operating room, intravenous access was obtained; a flexible fiber-optic bronchoscope, a rigid bronchoscope, and tracheostomy set were kept ready. After adequate preoxygenation, anesthesia was induced with gradually increasing concentration of sevoflurane. After confirming bag and mask ventilation, inj. Succinylcholine 100 mg was administered and fiberoptic bronchoscope guided tracheal intubation was performed with 8.0-mm polyvinylchloride (PVC) endotracheal tube (ETT). The tip of the ETT was kept in the compressed lower end of the trachea. However, both the main bronchi were found to be compressed as well. But ventilation was adequate and airway pressure was normal. Two wide bore intravenous access and left radial artery canula were taken. Anesthesia was maintained with oxygen, air, isoflurane, morphine, and intermittent dose of vecuronium.\nAfter an oblique cervical incision, esophagotomy was performed and the polyp was attempted to be pulled up. Initial 3-4 cm of the mass was exited smoothly but after that increasing resistance was encountered and the polyp could not be pulled up any further. Airway pressure increased from 18 to 42 cm H2O. Manual ventilation was started. Any ETT kinking/obstruction, distal migration into the bronchus and bronchospasm were ruled out. Manual ventilation became increasingly difficult, end-tidal CO2 reached 65-70 mm Hg and airway pressure 40-45 cm H2O. Increased external compression of the tracheobroncheal tree by the pulled up polyp was likely diagnosis. Attempts to push the mass back into the mediastinum with an expectation to relieve the obstruction also failed. Oxygen saturation decreased to 86%. Emergency tracheostomy was immediately performed which revealed a compressed ETT inside trachea; a gum-elastic bougie was introduced into the tracheostomy stoma and a reinforced flexometallic 8.0-mm ETT was advanced over the bougie forcibly to bypass the obstruction. Immediately airway pressure declined and SpO2 improved. Rest of intraoperative course remained uneventful. The mass was successfully retrieved transcervically and resected []. His tracheostomy tube was decannulatd after 2 weeks after ruling out any possible tracheomalacia.

[[24.0, 'year']]

M

{'21512393': 1, '11591553': 1, '12452402': 1, '22679546': 2, '19019249': 2, '19384235': 1, '16121086': 1, '15087617': 1, '16368421': 1, '17211158': 1, '25425803': 1, '20105150': 1, '10417460': 1, '12722093': 1, '18456215': 1, '11312487': 1, '24574604': 2}

{'3366316-1': 1, '2602996-1': 1}

3927345-1

noncomm/PMC003xxxxxx/PMC3927345.xml

Primary oral myeloid sarcoma: Report of a case

A 29-year-old woman appealed to the faculty of Dentistry, Department of Maxillofacial Surgery in August 2009. The patient complained about a painful buccal gingival swelling and bilateral submandibular lymphadenopathy []. She had the history of these complaints for 3 months. The patient was initially treated for periodontitis by a dentist. On clinical examination, of gray-brown keratinized, severly painful, sessile lesion at the anterior upper labial gingiva accompanied with submandibular lymphadenopathy was noted []. There was no gingival bleeding on probing. In detailed medical history, we found out the patient had weight loss, malaise, night sweats and fever for a while. Radiological examinations did not show any bone pathology. The patient's blood test results were as follows: hemoglobin, 10.8 g/dl; hematocrit, 36.5%; white blood cell count was 9.2 × 103/μL (52.9%monocytes, 23.2% neutrophils, 22.7% lymphocytes, 0.8% eosinophils, 0.4% basophils); platelets, 146 × 103/μL. A bone marrow aspirate showed 80-90% blastic cell infiltration.\nAn incisional biopsy was performed from the labial vestibular fornix under local anesthesia and sent to Department of Oral Pathology.\nOn gross examination, the excised material showed a central grayish-white non-specific soft tissue material. Histologic examination of the biopsy specimen showed monomorphous diffuse infiltrate with a population of immature blast-like cells beneath the intact oral epithelium on panoramic view. The tumor cells were intermediate in size and round to oval in shape with mild to moderate basophilic cytoplasm without granules []. The tumor was composed of two different cell types. Some of these cells had pale nuclei containing conspicuous nucleoli, while the others had large angular shaped hyperchromatic nuclei. The tumor cells exhibited loss of cohesion with each other at these areas []. Also the tumor cells had an increased nuclear-to-cytoplasmic ratio. Rare mitotic figures were observed whereas eosinophilic myelocytes were not seen. Immunohistochemical staining were performed on the paraffin-embedded sections. Tumor cells demonstrated pale positive reaction to CD117(c-Kit) [] and strong positive reaction to myeloperoxidase (MPO) [] monoclonal antibodies; whereas, negative reactions to S-100, Melan-A, HMB-45, pan-keratin, kappa, lambda, alpha smooth muscle actin, desmin, CD3, CD15, CD20, CD34, CD45 and CD68 monoclonal antibodies was observed. Histopathological examination demonstrated an extramedullary myeloblastic malignancy. Diagnosis was MS.\nThe patient's submandibular lymph node induration and gingival swelling increased during the time period between biopsy and final histopatological diagnosis was made. After the diagnosis, we consulted the Medical Oncology Department.\nIn PET/CT (Positron emission tomography/computed tomography) scans, tumor masses were apparent in mandible and on the floor of nasal cavity []. The patient received combination of idarubicin and ARA-C (cytosine arabinoside) chemotherapy regimen at first treatment phase. Because of the enlargement of the masses and development of AML, in second chemotherapy session 3-5-7 (daunorubicin, etoposide, ARA-C) regimen was performed. Bone marrow transplantation was planned after the fourth chemotherapy session but during this hold on period other aggressive tumor masses were found in left lacrimal gland and left breast []. Histopathological diagnoses of the new lesions were also MS. Unfortunately, the patient died waiting for the appropriate bone marrow transplant and after 15 months of first diagnosis of MS.

[[29.0, 'year']]

F

{'3473396': 1, '18155599': 1, '14692530': 1, '17428693': 1, '22937319': 1, '19215983': 1, '20561729': 1, '9497470': 1, '10964059': 1, '16504290': 1, '16019058': 1, '27721621': 2, '9623475': 1, '12137850': 1, '12110349': 1, '15735171': 1, '7023656': 1, '15721636': 1, '19138619': 1, '15380340': 1, '9822843': 1, '24574662': 2}

{'5051304-1': 1}

3927346-1

noncomm/PMC003xxxxxx/PMC3927346.xml

Plasma cell myeloma infiltrating the dental pulp: An interesting finding

A 55-year-old male patient reported to our department with complaints of pain and numbness on the right side of mandible of 3 months duration. His medical history revealed that he was under treatment for PCM, which was diagnosed a year back (M-band positive in protein immunoelectrophoresis). Radiographs showed multiple punched out radiolucencies on skull and spinal X-rays [Figure and ].\nOn examination there was a diffuse swelling on the right side of mandibular body seen in relation to 45, 46 and 47 regions. Mucosa over the swelling was normal. It was bony hard on palpation with slight buccal and lingual cortical expansion. The right molar (46) was caries exposed with grade III mobility []. Radiograph showed altered trabecular pattern in the periapical region of 46 []. The teeth was extracted and tissue from the adjoining socket area was reviewed for microscopic examination.\nHistopathologically, the tissue showed proliferating sheets of atypical plasma cells. Most of the cells had an abundant basophilic cytoplasm and an eccentrically placed nucleus. In between these cells were cells with centrally placed nuclei and basophilic cytoplasm, the plasmablasts. Prominent nucleoli were also seen [Figure and ].\nThe pulpal cavity of the extracted 46 after decalcification and hematoxylin and eosin (H and E) staining showed infiltration with atypical plasma cells with eccentrically situated nuclei and mild degree of nuclear pleomorphism [Figure –]. Immunohistochemical staining (IHC) for kappa and lambda light chains were done. The plasma cells showed strong cytoplasmic positivity for kappa-stain and were negative for lambda light chain which is consistent with clonal plasma cell dyscrasia [Figure and ].

[[55.0, 'year']]

M

{'12374918': 1, '9231172': 1, '17870425': 1, '17291793': 1, '9886299': 1, '6590771': 1, '26501029': 1, '1582971': 1, '19070692': 1, '1508895': 1, '24574663': 2}

{}

3927347-1

noncomm/PMC003xxxxxx/PMC3927347.xml

Granuloma with langhans giant cells: An overview

A 55-year-old male patient reported with a complaint of swelling in the left side of his face for the past 3 months. The patient noted a gradual increase of the swelling to the present size over a period of 3 months. The swelling was painless with no discharge. There was no history of fever or associated symptoms like cough and expectoration. He had no dental infection or history of trauma. He had no history of oral habits involving tobacco or other products. Radiograph of the chest did not reveal any significant findings.\nOn extraoral inspection, there was a single swelling of size 2 × 2 cm in the left submandibular region extending posteriorly from the angle of the mouth. Borders of the swelling were well-defined, and the overlying skin appeared normal. On palpation, the swelling was firm, non-tender, and not indurated. The overlying skin was pinchable, with no appreciable warmth. The patient was advised hematological and histopathologic investigations. He reported after 2 weeks when the swelling become fluctuant with development of a pointing abscess.\nHematologic investigations revealed a negative HIV status and normal hemogram values except for an elevated erythrocyte sedimentation rate (ESR) level. On aspiration, a purulent fluid was collected with the swelling remaining firm. A biopsy for histopathological examination was suggested. On surgical exploration, the swelling revealed lesional tissue with yellowish areas suggestive of degeneration. The specimen was sent for histopathological evaluation.\nHistologically, the lesional tissue was encapsulated and exhibited lymph node architecture with germinal centers []. The lesional tissue exhibited multiple granuloma formation and numerous giant cells. The granuloma was composed of central epitheloid and foamy macrophages bounded by lymphocytes and plasma cells []. Multinucleated giant cells were seen in different foci []. A few granulomas exhibited eosinophilic areas suggestive of central necrosis []. The giant cells were Langhans type displaying numerous nuclei arranged in horseshoe pattern and an eosinophilic cytoplasm [Figure and ]. Some of the giant cells exhibited arrangement of the nuclei at both poles []. Nuclei were uniform and appeared normal and vesicular. The giant cells were not associated with hemorrhagic foci, which were fairly observed. The histopathology was suggestive of a chronic granulomatous disease.\nBased on the histopathology, the differential diagnoses considered were:\nMycobacterial diseases Tuberculosis Leprosy Bacterial infections\nSyphilis Actinomycosis Cat scratch disease Fungal infections\nHistoplasmosis Blastomycosis Paracoccidioidomycosis Protozoal infections\nToxoplasmosis Miscellaneous diseases\nSarcoidosis Orofacial granulomatosis Crohn's disease Melkersson-Rosenthal syndrome Wegener's granulomatosis.\nThe patient was advised for further investigations to confirm the diagnosis but could not be followed-up as he was transferred. A list of hematological, microbiologic, and immunologic investigations was advised to be done at his work place.

[[55.0, 'year']]

M

{'18326339': 1, '32428826': 1, '10929057': 1, '15983898': 1, '31137506': 1, '9495146': 1, '27607191': 1, '32023676': 1, '30778526': 1, '34185152': 1, '8066361': 1, '17882899': 1, '10908370': 1, '33222688': 1, '17577332': 1, '24574664': 2}

{}

3927348-1

noncomm/PMC003xxxxxx/PMC3927348.xml

Ameloblastic fibrosarcoma: Report of a case

A 28-year-old asthmatic Nigerian female presented at the Oral Surgery Clinic of the University College Hospital with a 4-year history of a gradually enlarging right maxillary swelling which accelerated in growth following two pregnancies. Extraorally, the lesion extended anterioposteriorly from the right alar of the nose to the right tragus and superioinferiorly from below the infraorbital rim to the right commissure of the mouth, measuring approximately 14 × 10 cm in size [].\nIntraorally, there was no limitation of mouth opening. However, there was an intraoral extension of the tumor from 11 to 18, also involving the right side of the palate. The overlying mucosa was adherent to the lesion and had irregular areas of ulceration.\nComputerized tomography scan showed a well-defined, homogenous, isodense mass filling the right maxillary antrum with erosion of the lateral, posterior and anterior walls. The mass also extends to the floor of the right orbit, displacing it upwards without perforating it. The adjacent ethmoidal air cells and nasal cavity were invaded by the lesion [].\nThe incisional biopsy done was inconclusive, but was suggestive of a malignant lesion. The patient had right hemimaxillectomy; right external ethmoidectomy and sphenoidectomy performed by a combined team of maxillofacial surgeons and otorhinolaryngologists through a Weber-Ferguson incision with an infraorbital extension. The surgical specimen was then subjected to histopathological examination which revealed a low grade malignant neoplasm displaying mesenchymal and epithelial differentiation [Figure and ]. The mesenchymal component displayed storiform [] and herring bone pattern in a fibromyxoid stroma, while the epithelial component was composed of focal ameloblastic islands made up of columnar cells arranged in a palisaded pattern with a central area of stellate reticulum-like cells. Focal areas of necrosis and mitotic figures were seen. The features were those of AFS. Patient was rehabilitated with a feeding plate in the immediate postoperative period and later with an obturator. She has remained disease-free 29 months after surgical intervention [].

[[28.0, 'year']]

F

{'280833': 1, '7614208': 1, '19884826': 1, '286034': 1, '30948896': 1, '102609': 1, '3123623': 1, '18280269': 1, '26336021': 1, '11334469': 1, '17577546': 1, '24574665': 2}

{}

3927349-1

noncomm/PMC003xxxxxx/PMC3927349.xml

Myoepithelial carcinoma arising in recurrent pleomorphic adenoma in maxillary sinus

A 39-year-old lady presented with painless progressive swelling on the right cheek and right side of palate for 2 months. On examination there was a 2 × 2 cm firm, non-tender swelling. She had undergone a surgery elsewhere 2 years back for a palatal swelling, the details of which were not available. Computed tomography (CT) revealed a 29 × 28 mm enhancing mass in the right side of hard palate with large defect in the palatine process, extending into right maxillary sinus and nasal cavity, anteriorly up to the vestibule and inferiorly into the oral cavity. Right inferior partial maxillectomy was done with excision of the tumor which was sent for histopathological examination. Intraoperatively there was an encapsulated 6 × 4 × 3 cm size mucosa covered mass filling right maxillary sinus.\nTwo years later, she presented with recurrent swelling in right infraorbital region for 4 months associated with mild pain. On examination, the swelling was small, firm and non-tender. CT revealed a tumor over anterior wall of right maxillary sinus extending to soft tissues anterior to right maxilla. The tumor was excised via Caldwell-Luc approach and sent for histopathological evaluation.\nSubsequently, 1 year later, she presented with rapidly progressive swelling of bilateral cheeks and lateral surface of nose for a month, associated with breathing difficulty. On examination there was a 6 × 5 cm red tender swelling on the face with flattening contour of nose infraorbitally, extending to upper lip with obliteration of bilateral nasal cavities. On CT, there was an extensive heterogeneously enhancing soft tissue density lesion in both maxillary sinuses with destruction of the walls and extension into both ethmoid sinuses, nasal cavity, maxillary alveoli, soft tissue of upper lip, bilateral infratemporal region and both orbits. There was no intracranial extension. The mass was excised surgically. Intraoperatively, there was extensive friable tumor adherent to the skin, involving bilateral maxillary cavities with extension into the right orbit, right nasal cavity with erosion of septum and floor of mouth, both pterygopalatine fossa and bilateral pterygoid muscles. The tumor was sent for histopathological examination.\nThe initial excision specimen was partial right maxillectomy, with a tumor at the superior aspect. The tumor measured 4.5 × 3 × 2.5 cm on gross examination, with a grey white firm cut surface. Microscopy [] showed pleomorphic adenoma composed of sheets of myoepithelial cells and ductular structures lined by epithelial cells set in chondromyxoid stroma with extensive hyalinization, foci of myxoid change and osseous metaplasia. There was no evidence of malignancy.\nThe excised recurrent tumor grossly consisted of multiple soft tissue fragments, 0.5-1.8 cm in maximum dimension. Microscopy showed pleomorphic adenoma, without atypia or any evidence of malignancy.\nThe third specimen was initially sent to pathology intraoperatively for frozen section, wherein a provisional diagnosis of cellular neoplasm with atypical features suggestive of malignancy was given. Subsequently, the entire specimen was received for histopathological evaluation.\nTumor specimens from right and left maxillary sinuses were received separately. The specimen from right maxillary sinus was an irregular soft tissue measuring 5 × 2.5 × 2 cm, with a partly solid and partly cystic cut surface. Excised tumor from left maxillary sinus was received as multiple irregular fragments of soft tissue, largest measuring 6 × 5.5 × 2.5 cm, with greyish yellow cut surface containing hemorrhagic areas.\nMicroscopy [Figure –] showed a cellular tumor composed of lobules, nests, trabeculae and cords of polygonal cells with eccentrically placed hyperchromatic nuclei, mild to moderate pleomorphism, inconspicuous nuceoli, mitotic activity (up to 3/10 high power field (HPF)) and moderate amounts of clear cytoplasm, surrounded by fibromyxoid stoma with hyalinization. There were large areas of geographic necrosis, foci of cystic change and hemorrhage. Lymphovascular invasion was present. There was infiltration of the adjacent bone. Immunohistochemically, the neoplastic cells were positive for S100 [], pancytokeratin [] and focally [] for smooth muscle actin (SMA). A diagnosis of myoepithelial carcinoma arising in a recurrent pleomorphic adenoma was given.

[[39.0, 'year']]

F

{'8116228': 1, '26681866': 2, '9762928': 1, '12775221': 1, '6322732': 1, '9568509': 1, '20353573': 2, '11431714': 1, '20644067': 1, '8734420': 1, '27056196': 1, '32959208': 1, '20338616': 1, '33394378': 1, '31354359': 1, '10843278': 1, '15910594': 1, '24574666': 2}

{'4678559-1': 1, '2860350-1': 1}

3927351-1

noncomm/PMC003xxxxxx/PMC3927351.xml

Atypical case of primary intraosseous adenoid cystic carcinoma of mandible

A 64-year-old male patient reported to the outpatient department with the chief complaint of pain in the lower jaw. There was history of pain since five months, which was resistant to analgesics. Clinical examination revealed a slight, diffuse swelling throughout the buccal aspect of mandible. Gingiva appeared inflamed due to chronic generalized periodontitis with no other evident change in the mucosa. Submandibular lymph nodes were palpable but non-tender. Panoramic radiograph [] and intraoral periapical radiographs showed an irregular lytic lesion involving almost whole of the mandible. All teeth were vital.\nThe possibility of a malignant tumor was considered based on the clinical findings. On performing incisional biopsy, histopathological findings showed predominantly solid, tubular and cribriform pattern in very few areas. The tumor cells were basaloid in nature with scanty cytoplasm and oval to round nucleus. Peri-neural invasion was seen; and surrounding stroma was dense. Majority of the areas (>30%) showed solid pattern, hence the diagnosis of solid adenoid cystic carcinoma was made. To rule out the possibility of local and distant metastasis, subsequent examination including ultrasound scanning (USG), computed tomography (CT), chest radiograph and bone scan was advised. Distant metastasis was ruled out with no other lesions of the major or minor salivary glands.\nConsidering the size and bilateral extension of tumor, subtotal mandibulectomy (sparing the condylar stumps) along with bilateral suprahyoid neck dissection was planned as tumors >4 cm have been associated with an unfavorable outcome.[] Due to its peculiar clinical presentation, adequate soft tissue margin was removed prophylactically on both buccal and lingual aspect of the lesion. Sublingual and submandibular salivary glands were also removed bilaterally. Stabilization was done using 2.7 mm titanium reconstruction plate.\nHistopathology of the excised specimen showed intraosseous involvement of solid variant of adenoid cystic carcinoma [Figures and ], lymph nodes and excised salivary glands were negative. A final diagnosis of solid intraosseous ACC was given. Postoperative radiotherapy was given. Follow-up after 15 months since the initial diagnosis showed no sign of recurrence.

[[64.0, 'year']]

M

{'1059064': 1, '1311758': 1, '2197385': 1, '11149964': 1, '18403891': 1, '32959213': 1, '2172497': 1, '32189902': 2, '7677046': 1, '32189903': 2, '16504862': 1, '24015018': 2, '30484035': 1, '25709844': 2, '12796568': 1, '24574668': 2}

{'3757891-1': 1, '7069143-1': 1, '4325477-1': 1, '7069154-1': 1}

3927352-1

noncomm/PMC003xxxxxx/PMC3927352.xml

Congenital granular cell lesion: A rare tumor of new born

A 2-month-old female child was referred with the chief complaint of difficulty in feeding since a few days. On examination a 2 × 2 × 1 mm pedunculated growth was observed arising from the left side of maxilla in the canine region. The lesion was pink in color, similar to that of the surrounding mucosa, surface was smooth without any ulcerations and was firm in consistency. The patient was uncomfortable because of this small growth which was possibly hindering proper suction during breast feeding.[]. Surgical excision of the growth was performed under local anesthesia. There was minimal bleeding during the procedure and the infant was comfortable with breast feeding from the very next day. The gingival mass was fixed in formalin and sent for histopathological examination.\nHematoxylin and Eosin (H and E) stained section showed keratinized stratified squamous epithelium and underlying connective tissue stroma. High power view showed delicate Collagen fibers, numerous young fibroblasts and granular cells []. The granular cells were large oval cells with an eosinophillic and granular cytoplasm and single basophilic nucleus; these were seen to be scattered amidst the connective tissue []. Clinicopathological correlations were suggestive of CGCL.

[[2.0, 'month']]

F

{'16359158': 1, '27689516': 1, '11158496': 1, '17909507': 1, '6282735': 1, '9799384': 1, '4332322': 1, '15491088': 1, '19205730': 1, '8361733': 1, '17277473': 1, '34434082': 2, '16012311': 1, '24574669': 2}

{'8369402-1': 1}

3927353-1

noncomm/PMC003xxxxxx/PMC3927353.xml

Diagnosis and management of bilateral nasolabial cysts

A 69-year-old female reported to the Dental college with a chief complaint of an extraoral swelling on the right side of her upper lip and elevation of the alar base [] since 7-8 months. History of present illness revealed that the swelling had increased in size since its initiation but was not associated with any pain, drainage through oral/nasal cavity or difficulty in breathing through nasal obstruction. Furthermore, there was no history of dacryocystitis/watery eyes but there was a swelling intraorally corresponding to this extraoral swelling which was obliterating the labial vestibule on that side.\nIntraoral examination revealed bilateral smooth, soft, fluctuant masses lateral to the central incisor teeth in the maxillary labial vestibule. The right-sided mass was well-defined [] and measured approximately 2 × 3 cm and left-sided mass measured 1.5 × 1.5 cm when palpated bimanually. Aspiration biopsy from right-sided mass revealed straw-colored fluid [].\nOcclusal radiograph [] showed a large scooped-out radiolucent area with ‘cupping’ surrounding upper left central incisor (UL1) in the middle and coronal thirds of its root, but not in the periapical area. Radiograph was noncontributory on right side. Provisional diagnosis of bilateral nasolabial cysts was made on the basis of above findings. Patient's informed consent was availed for the surgical removal of these cysts. Medical history did not present any contraindication for the surgical procedure.\nThe cysts were enucleated [ and ] using intraoral approach under local anesthesia and adrenaline (1:80,000). A full-thickness incision was reflected along the crest of maxillary alveolar ridge in the canine to canine region and blunt dissection by periosteal elevator exposed two smooth, well-circumscribed cystic swellings just below the nasal floor. There had been scooping of the anterior maxilla on the left side due to expansion of the cyst. In contrast, morphology of alveolar bone on right side was not affected. In the same appointment, extractions of hopeless teeth were also done and the wound was closed with loop sutures using 3-0 non-absorbable black mersilk after debridement and irrigation with normal saline. Postoperative instructions were delivered. Tissue was sent for histopathological confirmation.\nHistopathology of the right-sided cyst revealed a cystic cavity lined by variable thickness of epithelium predominantly made up of many layered stratified squamous cells along with a few mucosal cells []. At few places, stratified squamous and pseudostratified columnar epithelia with many cilia and goblet cells were also evident [Figure and ]. Capsule showed loosely arranged fibrous tissue infiltrated with dense diffuse chronic inflammatory infiltrate. Left-sided cyst specimen showed two or more layered stratified squamous lining epithelium with thin capsule []. Diagnosis confirmed the presence of bilateral nasolabial cysts.

[[69.0, 'year']]

F

{'3108810': 1, '22523298': 1, '30150421': 1, '10748853': 1, '5260963': 1, '33732421': 1, '11868481': 1, '10401852': 1, '3859802': 1, '13041056': 1, '9347505': 1, '16467725': 1, '25795742': 1, '19517979': 1, '24574670': 2}

{}

3927354-1

noncomm/PMC003xxxxxx/PMC3927354.xml

Ancient neurilemmoma: A rare oral tumor

A 22-year-old male patient reported to the dental facility with a growth in the right back tooth region of his mouth, He had noticed the start of the growth 6 months ago. The lesion was stated to be painless and slow growing. On intraoral examination there was a nodular soft tissue mass in the mucobuccal fold region, in the right posterior maxillary quadrant above the molars. It was about 2 × 2 cm in size, smooth, sessile, non-tender and firm on palpation, with slight bleeding on manipulation. A provisional diagnosis of pyogenic granuloma was made []. The patient consented to surgical excision and the surgery was performed after general clinical and routine laboratory investigations. He is being followed-up regularly for the past 3 months and progress has been uneventful.\nThe cut-section of the excised tissue revealed a solid lesion with hemorrhagic areas []. On histopathological examination, the lesion presented as a circumscribed cellular mass []. The cells were mostly spindle shaped with oval/blunt elongated nuclei. They were arranged in two patterns. One pattern was a palisaded arrangement of cells encircling eosinophilic structures (suggestive of Verocay bodies) []; and the other pattern was an irregularly arranged configuration of spindle cells, sometimes in a loose myxoid background [Figure and ]. These patterns appeared consistent with descriptions of Antoni A and Antoni B patterns observed in schwannomas. There was significant vascularity throughout the lesion, with thick-walled blood vessels surrounded by hyalinization and inflammatory cells [Figure and ]. Extravasated red blood cells (RBCs), hemosiderin deposition and siderophages were occasionally encountered []. In some areas, the spindle cells revealed nuclear pleomorphism and increased nuclear cytoplasmic ratio [Figure and ]. Mitotic activity was insignificant, with mitotic index (MI) <1 per high power field (HPF). No abnormal or bizarre mitotic figures were observed.\nTaking into account the above features of schwannoma, along with extensive hemorrhage, hemosiderin deposition and cellular atypia, a histopathological diagnosis of ancient schwannoma was given.

[[22.0, 'year']]

M

{'26221545': 2, '11429745': 1, '19336874': 1, '23209358': 1, '28584531': 1, '6247681': 1, '29284981': 2, '27499782': 1, '2400975': 1, '22606860': 1, '34094841': 1, '29440792': 2, '12070601': 1, '32189912': 2, '19114949': 1, '24455054': 2, '24574671': 2}

{'5731032-1': 1, '3892226-1': 1, '4499617-1': 1, '5803881-1': 1, '7069146-1': 1}

3927355-1

noncomm/PMC003xxxxxx/PMC3927355.xml

Achondroplasia with oligodontia: Report of a rare case

A 16-year-old female reported to Department of Oral Medicine and Radiology with the chief complaint of multiple missing teeth. The patient had short stature and walked with an abnormal gait. The patient gave familial history of her mother and sister affected in similar manner. The patient was born to non-consanguineous parents, delivered normally at 8.5 months of gestation. The patient's father reported that she had large and dysmorphic head at the time of birth. The gross motor developmental milestones were delayed significantly, a finding often attributed to the large head of these patients, but fine motor developmental milestones, social and adaptive milestones and language milestones were reportedly normal according to her father.\nThe patient appeared to be well-adjusted, healthy and intelligent. General physical examination showed short stature, with normal trunk length and rhizomelic shortening of the arms and legs []. Lumbar lordosis; prominent buttocks; and short, stubby fingers with trident hand configuration were also evident. Anthropometry (at age 16 years) revealed a height of 124 cm (midparental target height 143.6 cm by Tanner's formula), weight of 42 kg, mesomelic dwarfism with upper limb to lower limb ratio of >1 and an arm span of 100 cm (expected to be 124 cm). The head circumference was 58 cm. Her vital signs were within the normal limits. Systemic examination did not reveal any other abnormality. Extraoral examination revealed facial features such as brachycephaly, midfacial hypoplasia, flat nasal bridge, frontal bossing and competent lips. A concave facial profile was also noticed; however, the mandible appeared normal and the chin was not prominent [].\nIntraoral examination revealed the presence of eight teeth (11, 15, 17, 21, 25, 27, 36 and 46). No abnormality was seen with intraoral soft tissues except for hypertonic lips [].\nOn radiographic examination, her orthopantomogram showed the presence of impacted maxillary canines (13 and 23) and the follicles of all third molars (18, 28, 38 and 48) []. The lateral cephalogram revealed an enlarged calvarium with increased transverse diameter, shortening of the skull base with frontal bossing and a retruded maxilla. The mandible appeared normal however []. The hand-wrist radiograph showed a trident hand configuration []. Based on the history, clinical examination and radiological investigations; a final diagnosis of achondroplasia was made.\nThe patient and her parents were provided with genetic counseling and the generally good prognosis of the condition was emphasized. The patient was then referred to Department of Prosthodontics for further treatment.

[[16.0, 'year']]

F

{'11731870': 1, '28893057': 1, '7847369': 1, '12870378': 1, '28679403': 1, '22628982': 2, '28702065': 1, '10360393': 1, '24151409': 1, '27298609': 1, '12357475': 1, '24574672': 2}

{'3357025-1': 1}

3927356-1

noncomm/PMC003xxxxxx/PMC3927356.xml

Kimura's disease - An unusual presentation involving subcutaneous tissue, parotid gland and lymph node

A 22-year-old male patient presented to our dental clinics with bilateral facial swelling. The swelling on the left was larger, painful and appeared consequent to trauma 7 years prior to presentation. Initially small and diffuse, it progressively increased over time to its present size. The mass on the right had been present for a year and was asymptomatic. The patient did not report any increase in the size of the swelling at mealtime, reduction in salivary flow or pus discharge. There was no history of weight loss, low grade fever or night sweating. The dental history did not include any incidence of tooth-related pain or space infection. Medical, surgical and family histories were noncontributory. There were no symptoms suggestive of facial nerve involvement.\nPhysical examination revealed a 4 × 5 cm firm, nontender, subcutaneous mass in the region of the left parotid gland, overlying the left masseter muscle and extending from the zygomatic arch to the lower border of the mandible. The overlying skin was normal with respect to both color and temperature and facial nerve function was unaffected. The swelling on the right side had similar clinical characteristics but was 2 × 2.5 cm in size, located 3 cm from the corner of the mouth and well ahead of the anterior border of the ramus []. Bilateral submandibular and upper cervical lymph nodes were palpable. There was no axillary or inguinal lymphadenopathy and the liver and spleen were not enlarged.\nLaboratory studies revealed hemoglobin concentration of 155 g/L, white cell count 8 × 109/L and an absolute eosinophil count of 1.5 × 109/L (reference range: 0.0-0.4 × 109/L). The IgE serum level was not determined.\nA computed tomography (CT) scan disclosed enlarged superficial and deep lobes of the left parotid gland, a well-defined lesion measuring 3.3 × 2.4 cm in the right buccal space and enlarged level IB, level III and level V lymph nodes [Figures and ]. Fine needle aspiration cytology (FNAC) from the left parotid swelling and lymph nodes, as well as from the right cheek gave the impression of chronic nonspecific lymphadenitis and myoepithelial sialadenitis. Based on the CT and FNAC findings, an incisional biopsy from the right cheek swelling and image guided biopsy from the left parotid lesion was advised.\nHistopathological study of the specimen demonstrated lymphoid tissue with reactive follicular hyperplasia. Within the germinal centers, deposits of eosinophilic proteinaceous material and areas of folliculolysis were seen. The interfollicular infiltrate was rich in eosinophils with admixed lymphocytes and plasma cells. Numerous thin-walled vessels were present, often grouped in small foci; their endothelial lining was flattened with no epithelioid or vacuolated cells [].\nSurgical excision of the right subcutaneous mass and superficial parotidectomy for the left parotid swelling with selective neck dissection was performed. Postoperative recovery was good with no signs of facial nerve injury. However, after the patient was discharged from the hospital, he was lost to follow-up; hence presence or absence of recurrence could not be assessed.

[[22.0, 'year']]

M

{'19618146': 1, '9865639': 1, '17174779': 1, '15087670': 1, '26889243': 1, '32957960': 2, '15888362': 1, '23120580': 1, '11167299': 1, '9866912': 1, '16715623': 1, '28764210': 1, '25928198': 1, '21897514': 2, '21103133': 1, '2919716': 1, '18457980': 1, '21206715': 2, '18246382': 1, '20421659': 1, '8672037': 1, '23120027': 1, '527967': 1, '1479100': 1, '23119706': 1, '9109334': 1, '18306548': 1, '23120099': 1, '16445506': 1, '19594570': 1, '31742081': 1, '24574673': 2}

{'3161468-1': 1, '7507290-1': 1, '3009441-1': 1}

3927357-1

noncomm/PMC003xxxxxx/PMC3927357.xml

Bisphosphonate-induced osteoradionecrosis

A 62-year-old, average built, male with average nutrition status of middle income group reported to Oral and Maxillofacial Surgery Clinic with complaint of swelling over left lower jaw since 4 months []. He suffered from orofacial pain and reduced oral opening. The symptoms were acute which subsequently became chronic with foul smelling discharge with a cutaneous fistula and numbness over left lower lip for last 3 months.\nHis past medical history was significant for multiple myeloma diagnosed 3 years back for which he underwent chemotherapy (26 cycles) and was on monthly doses of Zometa. He also underwent radiotherapy of knee and spine a year back. He was being treated for hypertension and diabetes which was being efficiently treated.\nPast dental history revealed that he underwent sequestrectomy on the left alveolus 1 year back.\nThe local examination revealed he was partially edentulous with dehiscence in the alveolar mucosa in left body of mandible and exposure of bone looking yellowish-white in the posterior mandibular region []. Sensory testing of the left lower lip revealed parasthesia of V3. There was mild purulent discharge from the intraoral wound and cutaneous fistula, which was sent for culture sensitivity test. The cultures revealed presence of Staphylococcus aureus, moderate growth of Streptococcus viridans, gram-negative rods and gram-positive cocci.\nOrthopantogram showed diffuse osteolytic lesions and erosion of left side body of mandible involving both buccal and lingual cortical plates []. The routine hemogram was not very significant except raised erythrocyte sedimentation rate (ESR) which was- 86 mm first hour. The scintigraphy which is a definite diagnostic tool for osteomyelitis could not be done because of nonavailability.\nFine needle aspiration (FNA) was performed and pieces of bone were sent for histopathology to rule out multiple myeloma lesions. The FNA revealed inflammatory cells-predominantly atypical lymphocytes and neutrophils-and also was positive for actinomyces. Histopathologically there was anastomizing lamellar bony trabeculae and inflammatory cell infiltration comprising of lymphocytes, plasma cells and histiocytes with congested blood vessels suggestive of chronic osteomyelitis [].\nCorrelating history, clinical evaluation and investigations, diagnosis of BRONJ was derived and sequestrectomy with aggressive debridement under antibiotic coverage was done. Six months follow-up showed no recurrence. Patient is currently under regular follow-up.

[[62.0, 'year']]

M

{'19254626': 1, '17663640': 1, '17912085': 1, '12528874': 1, '12202673': 1, '17664922': 1, '17049069': 1, '12966493': 1, '9494781': 1, '17307586': 1, '17307580': 1, '16243172': 1, '24574674': 2}

{}

3927358-1

noncomm/PMC003xxxxxx/PMC3927358.xml

Idiopathic huge pyogenic granuloma in young and old: An unusually large lesion in two cases

A 25-year-old male patient reported with a chief complaint of a mass on the gums in lower right posterior region of the jaw since 10 months. The lesion was painless and asymptomatic, except for the slight discomfort to the patient during mastication. The mass was gradually increasing in size. The patient had undergone surgical excision of the lesion 12 months back at a private clinic. No history of extraction was recalled by the patient and no history of any other systemic disease was present. On clinical examination, a localized, exophytic mass with pedunculated base measuring about 5 × 5 cm size was seen on buccal gingiva in relation to 46, 47 and 48 []. The surface of the lesion was smooth and the mass seemed to be originating from the interdental region. There was spontaneous bleeding on probing. General examination revealed no other abnormalities or cervical lymphadenopathy. No abnormality was detected on hard tissue examination. Teeth in relation to lesion were not mobile and were all vital. Preoperatively an orthopantomogram was taken [].

[[25.0, 'year']]

M

{'31743516': 1, '5220911': 1, '34471574': 2, '10213': 1, '3159762': 1, '17220613': 1, '16637811': 1, '18377654': 2, '22085075': 1, '22434943': 1, '23091574': 2, '31277111': 1, '24574675': 2}

{'3927358-2': 2, '8400606-1': 1, '3474946-1': 1, '3474946-2': 1, '2329656-1': 1}

3927358-2

noncomm/PMC003xxxxxx/PMC3927358.xml

Idiopathic huge pyogenic granuloma in young and old: An unusually large lesion in two cases

A 70-year-old female patient reported with a chief complaint of mass in the gums of lower left posterior region of the jaw since 36 months. The lesion was painless, but presented a significant discomfort in mastication due to its size. The mass was gradually increasing in size. No history of any other systemic disease was present. On clinical examination, localized exophytic mass with pedunculated base was observed on lingual gingiva measuring about 7 × 4 cm in size, extending from 34 to 38 region []. The surface was smooth. Physical examination revealed no other abnormalities or cervical lymphadenopathy. Teeth in relation to the lesion were mobile. Oral hygiene was poor and severe halitosis was noticed.\nOrthopantomogram was taken preoperatively [].\nSurgical excision was planned for both the cases under general anesthesia, due to their extensive nature. After placement of Ryle's tube and nasal intubation, lignocaine 2% with 1:200,000 adrenaline was infiltrated at margins of the lesion. Pedunculated stalk was excised with help of a 15 no. B.P. blade and electrocautery. The mass, in both the cases, were extending interdentally. Thus, in order to avoid leaving any remnants of the lesion interdentally, the teeth involved were extracted and alveolar process trimmed. Hemostasis was achieved using electrocautery and Surgical. Primary closure was achieved. Antibiotics and analgesics were prescribed for 1 week. The excised tissue was sent for histological examination [Figures and ]. Patient was instructed to feed through Ryle's tube for 4 days. Wound healed without any complications. Patient was followed-up for 6 months, no recurrence was observed till date.

[[70.0, 'year']]

F

{'31743516': 1, '5220911': 1, '34471574': 2, '10213': 1, '3159762': 1, '17220613': 1, '16637811': 1, '18377654': 2, '22085075': 1, '22434943': 1, '23091574': 2, '31277111': 1, '24574675': 2}

{'3927358-1': 2, '8400606-1': 1, '3474946-1': 1, '3474946-2': 1, '2329656-1': 1}

3927359-1

noncomm/PMC003xxxxxx/PMC3927359.xml

Anterior maxillary metastasis of gastric adenocarcinoma: A rare case

A 50-year-old male patient reported to our department with chief complaint of a proliferative swelling in upper labial gingiva since 3-4 months. About 6 months back the right maxillary central and lateral incisors exfoliated and 2 months later patient noticed a small swelling at the same region which attained the present size. It was not associated with pain or any other symptoms.\nIn his medical history, it was noticed that the patient had abdominal discomfort and vomiting on having food from 3 years which had increased since last 10 months. He had undergone endoscopy of upper gastrointestinal tract 3 years back which revealed chronic Helicobacter pylori associated gasritis for which he was on oral medication (proton pump inhibitors) till date. Patient was a chronic bidi smoker since 30 years.\nThere were no significant extraoral findings; also, no significant cervical lymphadenopathy was noticed. An intraoral examination revealed a single, oval proliferative lesion with well-defined borders on the anterior right maxillary labial aspect measuring about 4 × 5 cm extending anterioposteriorly in relation to right first premolar to left central incisor and superioinferiorly from the depth of the labial sulcus up to crest of the ridge []. The color of the lesion was pinkish white with a pebbly irregular surface. When palpated the lesion was soft, painless and pedunclated with a stalk of about 4 cm diameter.\nAt the initial visit patient had bouts of vomiting associated with abdominal pain, hence he was admitted and symptomatically treated. Incisional biopsies were performed from both mesial and distal aspects of the oral lesion and were sent for histopathologic examination which revealed dysplastic glandular epithelial cells arranged in the form of ductal and papillary pattern []. The cells were tall columnar exhibiting dysplastic features in the form of nuclear and cellular pleomorphism, nuclear hyperchromatism, prominent nucleoli and numerous mitotic figures [] suggestive of metastasis of adenocarcinoma of gastrointestinal tract.\nDue to history and current complaint of vomiting and abdominal discomfort, a repeat endoscopy was advised.\nResults of upper gastrointestinal endoscopy revealed a proliferative growth at cardia extending into lesser curvature []; multiple biopsies were taken from the lesion. Biopsy report revealed fragments of gastric mucosa showing intestinal metaplasia. Few other segments showed tumor cells arranged in glands, sheets and papillary projections []. The cells were round to oval with hyperchomatic and vesiculated nuclei, multiple nucleoli, moderate amount of amphophilic cytoplasm and exhibited numerous mitotic figures [] suggestive of moderately differentiated gastric adenocarcinoma.\nLater, on comparison of both reports, a similar origin that is the gastric adenocarcinoma was evident. Hence, it was concluded that the lesion seen in the oral cavity was a secondary metastasis from gastric adenocarcinoma. The case was discussed with tumor board and was decided for palliative chemotherapy.

[[50.0, 'year']]

M

{'18061527': 1, '21112790': 1, '8443744': 1, '29595701': 2, '26904182': 1, '19464643': 1, '29491603': 2, '7643282': 1, '9634377': 1, '24574676': 2}

{'5824515-1': 1, '5824515-2': 1, '5895424-1': 1}

3927360-1

noncomm/PMC003xxxxxx/PMC3927360.xml

Cheilitis granulomatosa

A 47-year-old female patient presented with a chief complaint of swelling in the upper lip since 2 months which had gradually increased in size. History revealed that the patient had visited a dentist 1 month ago with a complaint of broken upper left lateral incisor that was extracted, since it was considered to be the possible source of trauma. There was no subsequent change in swelling after extraction. There was no history of habits and medical history revealed that the patient was on antihistamines and prednisolone after which the lesion regressed for about a week and recurred again. There were no associated signs and symptoms.\nOn examination, a solitary, ovoid swelling was noted on upper labial mucosa, measuring approximately 3 × 2 cm, with diffuse borders. The skin and labial mucosa appeared dry and scaly. On palpation, the swelling was firm, non-tender and nodular. A single submandibular lymph node was palpable, mobile and tender.\nOn gross examination, the specimen was roughly wedge-shaped, creamish white in color, measured 1.1 × 0.7 cm in size, with a smooth surface and was firm to rubbery in consistency.\nA provisional diagnosis of Orofacial Granulomatosis was made.\nMicroscopically, the section showed stratified squamous epithelium exhibiting pseudoepitheliomatous hyperplasia with areas of para and orthokeratinization [Figures and ]. The underlying connective tissue showed organized non-caseating granulomas containing epithelioid cells, multinucleated giant cells of Langhans type with nine to thirteen nuclei arranged peripherally, surrounded by lymphocytes and plasma cells [Figures –]. These granulomas were surrounded by collagen fibers interspersed with fibroblasts and fibrocytes. The stroma was edematous and contained intense, perivascular chronic inflammatory cell infiltrate. Multiple peripheral nerve twigs were found and were suggestive of peripheral neuropathy [].\nBased on these features and by correlating with the clinical findings, a final diagnosis of cheilitis granulomatosa was made.\nCrohn's disease is a slowly progressive disease characterized by granulomatous superficial ulcerations of the gastrointestinal tract.[] Symptoms include abdominal cramps, colicky pain, alternating constipation and diarrhea.[] Microscopically isolated, loose, poorly formed non-caseating granulomas are found deeply situated with occasional giant cells, scanty inflammatory cells and fibrosis.[] We excluded this lesion as no gastrointestinal symptoms were present.\nIs a multisystem granulomatous disease, presents with hilar lymphadenopathy, pulmonary infiltration and skin and eye lesions. Microscopically, proliferative, non-caseating granulomas with epithelioid cells and multinucleated giant cells are seen.[] Often laminated basophilic calcifications known as Schaumann bodies, stellate inclusions known as asteroid bodies and Hamazaki-Wesenberg bodies are found. We excluded sarcoidosis as it lacked histological and clinical evidence.[]\nStructures that cannot be digested by tissue macrophages evoke a cascade of inflammatory reactions.[] They form foreign body granulomas with giant cells and which are often seen on routine hematoxylin and eosin (H and E) sections.[] This was excluded based on the history, clinical and histopathological features.\nMicroscopically, granulomas show circumscribed collections of epithelioid histiocytes, lymphocytes, multinucleated giant cells and central caseation necrosis. This was excluded as there were no other clinical symptoms or involvement of other sites.

[[47.0, 'year']]

F

{'17199771': 1, '24574677': 2}

{}

3927361-1

noncomm/PMC003xxxxxx/PMC3927361.xml

Dedifferentiation in adenoid cystic carcinoma

A 45-year-old female patient reported to the dental clinic with a complaint of swelling over the palate since 6 months. The patient had reported a couple of years back with a similar swelling at the same site which was diagnosed as minor salivary gland carcinoma 5 years back.\nIntra-oral examination revealed a large lobulated mass 4.5 × 3 cm in dimension. The swelling was covered by smooth stretched oral mucosa, appearing reddish at areas. Swelling extends from the midline of the palate to the gingiva of 22-27, mediolaterally and from 11-27 anteroposteriorly. The lobulated mass was soft to firm in consistency, causing discomfort but no pain.\nRadiograph revealed areas of bone erosion and destruction of the palate. Surgically, the lesion was quite vascular, was ill-circumscribed and soft to firm in consistency.\nMicroscopically, connective tissue stroma composing of lesional cells arranged in cords, nests, islands, cribriform pattern and in ductal structures with central eosinophilic coagulum was seen []. Classical areas of tumor cells arranged in epimyoepithelial islands were evident []. Areas of perineural and perivascular invasion were noted []. The neoplastic cells appeared uniform and basaloid with hyperchromatic nuclei. However other lesional areas showed solid transformation of the numerous cords, nests, islands and cribriform areas []. Some islands showed squamous metaplasia-like areas []. Areas were seen undergoing adenocarcinomatous change with basaloid tumor cells arranged in anastomosing cords with intervening thin fibrovascular connective tissue [].\nAreas of cribriform pattern [], cords, tubules, nests and islands along with solid areas showed evidence of dedifferentiation, composed of large anaplastic cells having more amount of cytoplasm. Both hyperchromatic and vesicular nuclei with prominent nucleoli could be easily cited[Figures and ]. Typical and atypical mitotic figures were evident []. Some solid tumor islands also exhibited central comedo necrosis [].

[[45.0, 'year']]

F

{'23821210': 1, '26895332': 1, '31898057': 1, '21876843': 1, '27605055': 1, '24574678': 2}

{}

3927362-1

noncomm/PMC003xxxxxx/PMC3927362.xml

Primary fibrosarcoma of maxilla in an 8-year-old child: A rare entity

An 8-year-old male child reported with the complaint of fast growing swelling over middle of face. The patient did not give any history of systemic illness or trauma to the head and neck region. There was no significant contributing family history. He gave a history of painless but rapidly growing swelling in the anterior maxilla since 20 days, which attained to the present size of 7×10 cm. There was no associated history of difficulty in speech and mastication with incomplete closure of mouth. The patient had also given the history of previous incisional biopsy, which was conducted by a general physician with histopathological report of benign fibrous lesion. Intraorally, a globular sessile mass with an area of ulceration due to previous biopsy procedure was present in the anterior hard palate extending from 55 to 65 []. The buccal and palatal cortical plates were completely destroyed. Missing regional teeth was also noticed, which had the history of spontaneous exfoliation. The labial vestibule was completely obliterated. The orthopantomograph (OPG) revealed a purely radiolucent destructive lesion in the anterior maxilla []. A chest radiograph was advised to rule out the metastasis, which was found to be clear without any significant and relevant finding. With a clinical provisional diagnosis of bone malignancy, the intraoral mass was subjected to incisional biopsy. The Hematoxylin and Eosin (H and E) stained section showed nonencapsulated tumor tissue made up of highly cellular stroma arranged in interlacing fascicles []. The tumor tissue showed the presence of spindle-shaped cells with large nuclei and scanty cytoplasm. Mitotic figures (6-7/10 HPF) were observed []. In few areas, Herring bone pattern characteristic of FS was also noticed. Immunohistochemically, vimentin positive cells were abundant [], whereas other immunomarkers like desmin, smooth muscle actin (SMA), S-100 were negative. A histopathological diagnosis of primary intraosseous FS (grade-II) was made. Patient had undergone surgical excision. The excisional biopsy was also consistent with the diagnosis of incisional biopsy. Finally the patient succumbed to the tumor within time period of 6 months of diagnosis.

[[8.0, 'year']]

M

{'6038738': 1, '1071090': 1, '974993': 1, '17695417': 1, '13458607': 1, '4464876': 1, '1053940': 1, '1624288': 1, '2810132': 1, '2449906': 1, '15281217': 1, '17296310': 1, '561651': 1, '18796134': 1, '11745814': 1, '16648761': 1, '1119646': 1, '4515257': 1, '31293956': 2, '4911477': 1, '6590714': 1, '26743922': 1, '8816102': 1, '9861345': 1, '1606539': 1, '2401777': 1, '16053882': 1, '1071089': 1, '3612464': 1, '3941916': 1, '26604519': 2, '27194883': 2, '5285189': 1, '4505736': 1, '3925099': 1, '8179091': 1, '24574679': 2}

{'4611951-1': 1, '4860923-1': 1, '6585220-1': 1}

3927363-1

noncomm/PMC003xxxxxx/PMC3927363.xml

Taurodontism: A dental rarity

A 25-year-old male patient was referred to Department of Conservative Dentistry and Endodontics, for the treatment of upper right and left first molar teeth. Intraoral examination revealed fracture of the palatal cusps with respect to 16 and buccal cusp fracture with respect to 26 []. At the time of examination, the teeth were asymptomatic. The teeth were not sensitive to percussion or palpation. Intraoral examination revealed a normal-shaped crown. Periodontal probing was within the normal range. Patient's medical history was noncontributory. Upon vitality testing, 26 showed positive response to thermal and electric pulp testing. The 16 showed no response to thermal and electric pulp testing indicating necrotic pulp. Intraoral periapical radiograph of 16 showed huge pulp chamber extending beyond the cervical area reaching the furcation in the apical third region []. Three short roots were seen at the furcation area in the apical third indicating hypertaurodontism. The intraoral periapical radiograph of contralateral 26 revealed similar findings []. The diagnosis of hypertaurodontism for the present case was made based on the radiographic finding and taurodont index as proposed by Shiffman and Chanannel [].\nThe tooth was anesthetized with lidocaine 2% with epinephrine 1:1, 00,000 (Lignox 2% A Warren India). Magnifying loupes (Carl Zeiss, India) were used throughout the procedure to facilitate visualization. The tooth was isolated and access cavity prepared. The pulp tissue which was voluminous was extirpated. A total of 2.5% of sodium hypochlorite was used as irrigating solution. The furcation area was situated in the apical third region and three canal orifices were located at the furcation area; palatal, mesiobuccal and distobuccal.\nWorking length determination was performed using electronic apex locator Propex II (Dentsply Maillefer, Switzerland, USA) and was confirmed with a radiograph []. After working length determination the instrumentation of the canals was done to size 40 for the palatal canal and up to size 30 for the mesial canals using RC prep (Premier, Ultradent, USA) as a lubricanting agent.\nA modified obturation technique was used because of complexity of inner root canal anatomy. This consisted of combined lateral condensation of the gutta percha in the apical part with vertical compaction of the remaining pulp chamber. AH-plus (Dentsply, Switzerland, USA) was used as a root canal sealer. The final radiograph confirmed well-obturated root canal system [].

[[25.0, 'year']]

M

{'18442747': 1, '28808451': 1, '34244468': 1, '6928171': 1, '278704': 1, '19776518': 1, '10556758': 1, '2307752': 1, '11039066': 1, '24574680': 2}

{}

3927364-1

noncomm/PMC003xxxxxx/PMC3927364.xml

Clear cell variant of calcifying epithelial odontogenic tumor of maxilla: Report of a rare case

A 36-year-old Indian woman reported to our department with painless, slow growing swelling of right upper jaw and loss of upper teeth due to mobility. Intra oral examination revealed solitary swelling in right posterior maxillary region with missing posteriors. The swelling was about 3 × 2 cm with normal color, intact mucosa and indentations of opposing tooth []. The mass was firm on palpation with slightly more expansion towards the palatal side. OPG showed 3 × 3.5 cm mixed radiolucent-radiopaque lesion in the posterior maxilla with impacted teeth. Radiographically “driven snow” appearance was appreciable []. Computed tomography (CT) revealed radiolucent-radiopaque mass in the right maxilla invading the cortex []. The lesion extended to posterior maxilla and obliterated the right nasal cavity.\nAn incisional biopsy was taken from the lesion. The specimen was subjected to histopathological examination. Hematoxylin and Eosin stained sections showed fibrous connective tissue stroma with islands of polyhedral epithelial cells containing nuclei of varying form and size. Extracellular eosinophilic amyloid like material was found containing concentric calcifications in the form of Liesegang rings []. Few scattered cells were found with clear vacuolated cytoplasm (clear cells). No cellular atypia or mitotic figures seen. The features were suggestive of CCEOT.\nConsidering the age of the patient, esthetic concern and benign nature of CEOT, curettage of the lesion along with the associated tooth was performed under general anesthesia (GA).\nPatient reported back after 10 months complaining of nasal obstruction and tearing. CT scan confirmed recurrence in the posterior maxilla []. Intranasal biopsy was performed, revealed clear cells in the stroma of CEOT confirming the diagnosis of clear cell CEOT []. Subtotal maxillectomy with Weber Fergusson approach was done. Six weeks postoperatively, an obturator was given. No recurrence was found on 2 years follow-up.

[[36.0, 'year']]

F

{'1069221': 1, '11175269': 1, '10960027': 1, '4419739': 1, '25654003': 1, '5343396': 1, '4817144': 1, '9159818': 1, '5228560': 1, '2269939': 1, '12627106': 1, '821872': 1, '28928785': 2, '412801': 1, '10889914': 1, '10235374': 1, '8283404': 1, '2004079': 1, '6936089': 1, '6815318': 1, '8026959': 1, '3861827': 1, '1569366': 1, '24574681': 2}

{'5553259-1': 1}

3927365-1

noncomm/PMC003xxxxxx/PMC3927365.xml

Three kinds of cysts in the same patient

An 18-year-old male presented with a history of asymptomatic swelling (3 × 5 cm) in the lateral region of the neck at the level of the mastoid, that was present since 2 months. It was fluctuant to palpation and freely mobile. A presumptive diagnosis established was of an epidermal cyst (EC); therefore, the lesion was extirpated. The content was caseous white-yellow material. From histopathological findings, it was reported as EC. After surgical intervention a hypertrophic scar developed as a complication.\nAfter 4 years and 10 months, there was a swelling that was increasing in size (4 × 2 cm) at the level of the hyoid bone. On physical exploration, the soft mass was at the level of the hyoid bone, which at the time of deglutition moved to the left side. An axial tomography was taken and a presumptive diagnosis of a TDC was established [Figure and ]. The surgical procedure was carried out 2 months later without apparent complications and the specimen was submitted for histopathological study, the results were in favor of a TDC []. Five days after surgery, the aponeurotic space was swollen and the patient complained of hypoesthesia, the patient presented a sensation of asphyxia that forced him to put the head in hyperextension in order to breath, after 3 days the sensation became worse and there was the need to debride. Draining yielded a thick yellow-liquid similar to lymph. A Penrose was placed and was kept for 4 days, the post operative condition was uneventful.\nAfter 2 months of the TDC surgery, the patient came again with a tumefaction on the right side of the neck close to mandible angle of approximately 3 cm, the presumptive diagnosis was an infected sebaceous cyst and medication was prescribed (10 mg Danzen®, Serratio Peptidase, Laboratory Hormona, Mexico) daily for a week. The cyst was enucleated on the same month without complications. The final histopathological report was of a branchial cyst [].

[[18.0, 'year']]

M

{'11054966': 1, '15037945': 1, '8577967': 1, '7970596': 1, '7169333': 1, '8289014': 1, '897966': 1, '7899590': 1, '9925396': 1, '8697325': 1, '24574682': 2}

{}

3927366-1

noncomm/PMC003xxxxxx/PMC3927366.xml

Orthokeratinizing odontogenic cyst of maxilla with complex odontoma

A 26-year-old male reported to the Dental Department, with the chief complaint of swelling and difficulty in breathing for about 5 months. The extraoral clinical examination revealed a diffuse swelling on the left side of the face obliterating the nasolabial fold. The swelling was associated with slight pain and continuous headache. Patient also complained of continuous tear discharge from the left eye. Computed tomography scan revealed a soft tissue lesion completely obliterating the left maxillary sinus and extending up to the nasal cavity; right maxillary sinus was normal. The swelling extended anteriorly up to external nasal orifices and posteriorly to the nasopharynx. The nasal septum showed deviation to the right side. Left ethmoid sinus was also found to be involved. The (orthopantomogram) showed similar radiolucency of the lesion which was interrupted by some flecks of radiopacitites [Figures and ]. Also, both the maxillary canines were impacted with the left maxillary permanent canine involved with the lesion and were closely associated with the small flecks of radioopacity.\nThe presence of keratin and cholesterol crystals in the fine needle aspiration cytology report directed toward the cystic lesion having keratin in the lumen. A provisional diagnosis of OKC was arrived upon. Complete enucleation of the lesion was carried out under general anesthesia, which was followed by extraction of all the left maxillary teeth. Along with the lesion frontoethmoid sinus was also excised as the lesion had involved the same. After completion of the surgical procedure the entire cavity was completely cleaned and was packed with Gel foam. Prosthesis (obturator) was made from the presurgical records and was delivered to the patient after surgery. Following the surgery, the healing of the surgical wound was uneventful and the patient was kept under observation to check for recurrence.\nThe histopathological examination revealed the cystic space which was lined by a continuous layer of stratified epithelium of 6-8 cell layer thickness with prominent basal cell layer and the absence of rete ridges. The stratified epithelium was orthokeratinized in nature with prominent stratum granulosum layer. Abundance of orthokeratin was present in the cystic lumen. The connective tissue showed minimal or no inflammatory response. One portion of the lesion was hard and solid which was processed by decalcification. The decalcified section showed presence of dentine and pulp like tissue arranged in an irregular pattern. Enamel spaces were seen in some areas. On the basis of thorough histopathological examination, the final diagnosis of orthokeratinizing odontogenic cyst associated with complex odontoma was given [Figures and ].

[[26.0, 'year']]

M

{'22090766': 2, '22442589': 2, '19159025': 1, '19615649': 1, '14996290': 1, '29491599': 2, '7775688': 1, '27688587': 1, '9568510': 1, '20121617': 1, '24818100': 2, '19622877': 1, '12076694': 1, '21062939': 1, '24574683': 2}

{'4015167-1': 1, '5824511-1': 1, '3304208-1': 1, '3304208-2': 1, '3304208-3': 1, '3304208-4': 1, '3304208-5': 1, '3214530-1': 1}

3927377-1

noncomm/PMC003xxxxxx/PMC3927377.xml

Use of Cemented Spacer with a Handmade Stem to Treat Acute Periprosthetic Tibial Fracture Infection: A Case Report

An 85-year-old woman with hypertension, dementia and dependent for normal life activities presented after an accidental fall with a left periprosthetic tibial fracture around total knee arthroplasty (Alpina®, Biomet-France) implanted 9 years ago (Fig. ). The fracture was classified as type IIB according to the Felix classification [] (adjacent to the stem and with an unstable tibial component). To treat this lesion, areplacement of the tibial component by one with a long stem was performed (Fig. ). Although the patient was discharged two weeks later without clinical complications, she was readmitted 4 weeks after the intervention due to wound drainage. Acute prosthetic joint infection was suspected and a surgical debridement was performed. The intraoperative cultures were positive for extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and ampicillin- and high\nlevel gentamicin-resistant Enterococcus faecium. Despite this surgical approach and parenteral antibiotherapy with vancomycin and imipenem, the clinical evolution was non-satisfactory, so after three days, all components were removed and a bone-cement spacer coated with clindamycin and gentamicin and a handmade stem with a metal core was implanted (Fig. ). The stem was made using the following\ntechnique: first, the cement was injected using a cement gun into a mold (although we used the tube used for cementing the femoral component of hip prosthesis, other molds, such as chest tubes, could be used) []. After this, a Kischner wire was inserted into the tube and buried in the cement leaving about an inch uncovered to allow for connecting it with the tibial plateau cement spacer. The limb was immobilized with knee extension with an orthosis for 4 weeks to control rotational forces at the level of the fracture focus. The wound evolution was correct except for a skin defect at the level of tibial tuberosity that required a neurocutaneous pedicled graft. Based on antibiogram, specific-parenteral antibiotherapy (imipenem 28 days + vancomycin 17 days followed by 11 days of linezolid) was prescribed. The patient was discharged with an articulated knee brace. Radiological signs of fracture consolidation were observed after 3 months of follow-up. Due to the previous health status of the patient and short life expectancy, it was decided to keep the spacer as definitive treatment. In the latest follow-up (24 months after surgery), the patient was able to sit without pain and to stand with help using a knee brace. There were no radiological (Fig. ), clinical (Fig. ), or blood analysis signs of infection.

[[85.0, 'year']]

F

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{}

3927488-1

noncomm/PMC003xxxxxx/PMC3927488.xml

A human de novo mutation in MYH10 phenocopies the loss of function mutation in mice

The proband is an 8 y old male from non-consanguineous family of mixed Ashkenazi Jewish and Caucasian ethnicity. He was born at 38 weeks of gestation via induced vaginal delivery. The prenatal history was significant for intrauterine growth restriction and unilateral multicystic dysplastic kidney. Decreased fetal movement was noted initially at the beginning of the third trimester. His birth weight was 5 pounds 12 ounces (< 5%), and his head circumference was 31 cm (< 5%). After birth he was noted to have bilateral dislocated hips due to an underlying developmental hip dysplasia. He was also noted to have foot abnormalities consistent with talipes cavus and bilateral undescended testicles. The immediate neonatal period was characterized by a prolonged hospitalization, hypotonia and feeding difficulties. MRI of the brain in the newborn period was abnormal demonstrating microcephaly and small thalami with increased intensities in bilateral basal ganglia and thalami. His growth continued to be poor, and he was severely hypotonic and microcephalic. MRI of the brain at the age of 4 y showed evidence of diffuse volume loss with decreased thickness of the white matter and increased ventricular size. The atrophy was also evident in the inferior cerebellar hemispheres and inferior cerebellar vermis. MRI demonstrated a left sided diaphragmatic hernia which has not been repaired with partial herniation of the stomach into the chest. At the age of 8 y he is severely developmentally delayed and microcephalic. He is non-ambulatory and non-verbal. He uses an assistive communication device. He is able to recognize objects and faces. All his feeds are via gastrostomy tube.

[[8.0, 'year']]

M

{'12893741': 1, '31615886': 1, '23033978': 1, '21910631': 1, '32734553': 1, '21480433': 1, '18096687': 1, '29084269': 1, '26334913': 1, '25098841': 1, '28768736': 1, '9356462': 1, '32545517': 1, '32012899': 1, '25356899': 1, '12909352': 1, '11283949': 1, '27513193': 1, '30879067': 1, '21076407': 1, '14699073': 1, '21908426': 1, '22368300': 1, '19851336': 1, '11590545': 1, '31443905': 1, '9858676': 1, '32033586': 1, '32825197': 1, '1860190': 1, '21920049': 1, '25447988': 1, '12792306': 1, '34453735': 1, '23123319': 1, '21572417': 1, '26960797': 1, '21712793': 1, '10973260': 1, '14594953': 1, '15339844': 1, '16481398': 1, '17429076': 1, '32858875': 1, '15015131': 1, '20679233': 1, '15034141': 1, '24825879': 1, '15292239': 1, '34573387': 1, '25003005': 2}

{}

3928060-1

noncomm/PMC003xxxxxx/PMC3928060.xml

Conventional mesh repair of a giant iatrogenic bilateral diaphragmatic hernia with an enterothorax

The reported patient is a 65-year-old male. During a vocal cord operation 10 years before, there was an accidental intralaryngeal gas explosion that required several subsequent tracheal reconstructions. Consequently, a huge bilateral diaphragmatic hernia developed over the years.\nAs the patient was suffering from progredient dyspnea, a computed tomography was performed, which showed a complete enterothorax (); therefore, an operative approach was indicated. The upper abdomen was incised by transverse laparotomy revealing a large package of small intestine ventrally disappearing on both sides of the chest (). The adhesions were divided and the parts of the colon and jejunum that were dislocated in the chest were repositioned into the abdomen. Some parts were partially strangulated but still in good shape. The stomach, however, was in the correct anatomical location. After repositioning and resection of the hernial sac, the hernial gap could hardly be adapted (). The diaphragm was very weak, which suggested that a direct closure would be too fragile. For this reason, a large flap of PERMACOL™ (original size: 18 cm ×28 cm ×1.5 cm; Covidien Ltd, Dublin, Ireland) was trimmed to fit so that it covered both sides of the dorsal diaphragm and the ventral part of the flap overlapped with the abdominal wall incision (). The flap was fixed all around with VICRYL™ 0 sutures (Johnson & Johnson, New Brunswick, NJ, USA; ). As a pneumothorax on the right side was provoked by the manipulation, thoracic drainage was applied. The abdominal wall was occluded involving the ventral edge of the PERMACOL™ flap to provide for more stability.\nThe postoperative course was uneventful apart from paroxysmal atrial fibrillation and the patient was released from hospital 16 days after operation.\nThe postoperative follow-up after 3 and 6 months including a computed tomography scan did not reveal any pathologies.

[[65.0, 'year']]

M

{'8852737': 1, '11217477': 1, '19620173': 1, '11116407': 1, '15916154': 1, '18629775': 1, '11443468': 1, '15851372': 1, '15098101': 1, '19710999': 1, '15351874': 1, '8145332': 1, '8694953': 1, '19750579': 1, '20064206': 2, '3664240': 1, '10742899': 1, '16925323': 1, '14799666': 1, '10803186': 1, '12269926': 1, '24600251': 2}

{'2817870-1': 1}

3928261-1

noncomm/PMC003xxxxxx/PMC3928261.xml

Surgical Management of Recurrent Leiomyosarcoma in Heart

A 63-year-old woman with an impression of a recurrent tumor was admitted with a chief complaint of shortness of breath 10 months after surgery for cardiac leiomyosarcoma. In her past medical history, she had undergone surgery for the removal of leiomyosarcoma in the main pulmonary artery at a different hospital, where she had been admitted with a chief complaint of dyspnea (New York Heart Association Functional Classification II-III). In addition, she did not have hypertension or diabetes mellitus, other than the previous cardiac surgery.\nUpon admission, her blood pressure was 130/90, and her heart rate was 90 beats/min showing a sinus rhythm. Her height, body weight, and body mass index were 160 cm, 60 kg, and 24.4 kg/m2, respectively. The blood test taken upon her admission showed creatine kinase-MB 2.5 and troponin-I <0.02, which were within normal levels. Arterial blood gas analysis revealed pH 7.48, PO2 61.3 mmHg, PCO2 27.2 mmHg, and O2 saturation 92.3%.\nIn her chest X-ray, no cardiomegaly was observed, but patchy haziness of the right middle lobe was seen. The cardiac computed tomography (CT) showed a massive amount of thromboembolism in the pulmonary trunk, right pulmonary artery, and left anteromedial basal segment artery (). Lung cancer, pulmonary infarction, myocardial infarction, and coronary artery disease were not observed. Because of a suspicion of recurrent leiomyosarcoma, a surgical resection was decided upon (preoperative echocardiogram was not carried out). There was no evidence of lung metastasis in CT; therefore, lobectomy of the lung was not considered.\nAfter carrying out median sternotomy, cardiopulmonary bypass was initiated. Transverse pulmonary arteriotomy was performed in the area straight above the pulmonary valve. Then, a mass with a volume of 4×4×3.5 cm hanging on the pulmonary valve with a stalk was observed. The mobile gelatinous mass was hanging loosely in the right ventricular outflow track (RVOT), infundibulum, and main pulmonary artery. The incision of the right pulmonary artery was made up to the superior vena cava. An incision of the left pulmonary artery was extended to the first bifurcation area. Then, the myxoid mass was resected (). The sufficient back flow from the distal pulmonary artery was verified in both the right and the left pulmonary arteries. The harvested greater saphenous vein graft was used for the reconstruction and widening of the main pulmonary artery and left pulmonary artery. Because the myxoid mass had a well-defined capsule and stalk, we thought that there was no invasion to the nearby apparatus; therefore, we decided upon a pulmonary valve preservation operation.\nThe duration of extracorporeal circulation was 235 minutes, while that of aortic cross clamping was 85 minutes. Extubation was carried out 12 hours after surgery, and the patient was transferred to a general ward on the fifth postoperative day. Cardiac CT performed on the seventh postoperative day confirmed that there was no remnant mass in the pulmonary trunk, RVOT, or in either of the pulmonary arteries (). The patient was discharged on the fourteenth postoperative day without any complications.\nThree months after hospital discharge, she again developed dizziness and palpitation, and an echocardiogram was carried out and showed a generally hypoechoic and heterogeneous mass. The CT images showed a 2.5×2.8 cm mass at the base of the interventricular septum of the RVOT, as well as redundant movements in the direction of the pulmonary artery (). As anticipated, the right ventricular systolic pressure increased to 70 to 75 mmHg. Upon the suspicion of recurrent cardiac leiomyosarcoma, we decided on a radical resection of the tumor.\nTransverse pulmonary arteriotomy under cardiopulmonary bypass was performed in the area directly above the pulmonary valve. A gelatinous capsular mass causing RVOT obstruction was removed in the pulmonary valve and subvalvar infundibulum. Then, the transvalvar RVOT reconstruction was performed using a Prima plus 25 mm valve, and the vascular graft after the pulmonary valve was removed. The duration of extracorporeal circulation was 117 minutes. The postoperative course was uneventful, and an echocardiogram performed on the sixth postoperative day did not show a mass in the RVOT and revealed a well-functioning pulmonic valve. The images of cardiac CT carried out on the eighth postoperative day showed no residual mass of the pulmonary trunk, RVOT, or in either of the pulmonary arteries (). The patient was discharged from the hospital on the tenth postoperative day.\nDuring the follow-up six months after hospital discharge, a chest CT disclosed findings that leiomyosarcoma metastasized to left upper lobe (lingular segment) and left lower lobe (). Lingular segmentectomy and lower lobectomy were decided upon and performed under thoracotomy. A tumor 3×3×3 cm in size, dwelling apart from the pulmonary artery, was observed in the lingular segment of the left upper lobe. Another tumor mass with a size of approximately 3.5×3×3 cm was found in the anterior basal segment of the left lower lobe, for which lingular segmentectomy and lower lobectomy were carried out. The patient was discharged from the hospital 10 days after surgery. She has been asymptomatic and free of recurrence for 36 months after the last operation.

[[63.0, 'year']]

F

{'20430913': 1, '9475541': 1, '5651258': 1, '15795839': 1, '12185227': 1, '17914083': 1, '25385248': 2, '11410579': 1, '24570864': 2}

{'4289262-1': 1}

3928262-1

noncomm/PMC003xxxxxx/PMC3928262.xml

Surgical Repair of Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair

A 75-year-old man visited our emergency department complaining of cough and sputum lasting one month. There was no definite mediastinal widening on a simple chest X-ray, but a prominent aortic arch was observed in comparison to the past two years. A three-dimensional computed tomography scan revealed multiple aneurysmal dilatations with pseudoaneurysm and thrombi in the aortic arch and proximal abdominal aorta. They were measured to be 2.7×1.1 cm (external diameter: 5.1 cm) and 1.5×3.6 cm, respectively, in size. Another focal aneurysmal dilatation was observed in the distal abdominal aorta just above the iliac bifurcation (). Upon admission, transthoracic echocardiography showed moderate aortic regurgitation and minimal mitral regurgitation without regional wall motion abnormalities. We planned a staged operation (thoracic endovascular aortic repair for aortic arch aneurysm first and aortic valve replacement later) as the patient was considerably old and had poor pulmonary function.\nThoracic endovascular aortic repair (36×100 mm, SEAL thoracic limb stent graft; S&G Biotech, Seongnam, Korea) was performed as previously described []. There was a 12-mm-long landing zone between the left subclavian artery and aortic arch aneurysm with an aortic diameter of 30 mm. Considering the possible type Ib endoleak caused by the mild aneurysmal dilatation of the descending thoracic aorta, we planned to position two overlapping stent grafts strategically (one just distal to the left subclavian artery, and the other covering the descending thoracic aorta). Balloon angioplasty was not performed. The patient was monitored in the intensive care unit postoperatively, transferred to the general ward on the first postoperative day, and discharged on the fifth day without any specific symptoms or signs. No endoleaks were found on the computed tomogram on the second day (). The patient follow-ups in the outpatient department revealed no symptoms except for the retrograde type A aortic dissection observed on the three-month computed tomogram performed as a routine follow-up study ().\nThe patient underwent aortic valve replacement and ascending aorta replacement under deep hypothermic circulatory arrest and selective unilateral antegrade cerebral perfusion. The aortic valve was replaced with a Carpentier-Edwards no 23. tissue valve (Edwards Lifesciences, Irvine, CA, USA). The intimal tear had originated from the bare metal structure in the anterior direction, which was in contact with the anterior wall of the ascending aorta. This bare metal structure was partially exposed after the excision of the dissected aorta. Distal aortic anastomosis was performed without the removal of the stent graft and reinforced circumferentially with pledgeted sutures. Distal aortic anastomosis sutures partly included the proximal bare metal structure of the stent graft. The pump time, aortic cross clamp time, circulatory arrest time, and selective antegrade cerebral perfusion time were 234, 144, 40, and 32 minutes, respectively.\nThe patient was extubated on the first postoperative day, transferred to the general ward on the third postoperative day, discharged on the eighteenth day, and followed up for 24 months without specific symptoms. Endoleaks were observed in the junction of the distal anastomosis site and the bare metal structure of the stent graft on the computed tomogram on the seventh day, but had no significant interval changes on the computed tomogram after 20 months ().

[[75.0, 'year']]

M

{'18424065': 1, '23535519': 1, '19171859': 1, '19752379': 1, '24570865': 2}

{}

3928263-1

noncomm/PMC003xxxxxx/PMC3928263.xml

Phlegmasia Cerulea Dolens after Coronary Artery Bypass Surgery: What Should We Know

A 67-year-old male with a history of diabetes (hemoglobin A1c, 9.4 mg/dL) and hypertension was admitted to the Cardiology Department after presenting with Canadian Cardiovascular Society class II angina. He had no symptoms or signs of claudication, deep vein thrombosis, or hypothyroidism. His cardiac function was unremarkable, with an ejection fraction of 65%. A coronary angiogram confirmed the presence of diffuse stenosis in the left anterior descending artery and right coronary artery branch vessels. Other laboratory findings were normal, including complete blood cell counts, electrolyte levels, chemistry results, coagulation factor assays, and the results of a urinalysis. He had no other comorbidities.\nThe patient underwent elective on-pump coronary artery bypass grafting (CABG) under systemic heparinization (400 U/kg). A senior resident harvested two great saphenous veins (GSVs) from the bilateral medial calves with the thigh abducted and rotated externally and with a small pillow kept under the knee. The harvested wound tissue was simply sutured and wrapped loosely with an elastic bandage. The left internal thoracic artery was anastomosed to the left anterior descending artery following posterolateral and posterior descending artery bypass using two GSV grafts. The anesthesia, cardiopulmonary bypass (CPB), and aortic cross-clamping times were 312, 131, and 106 minutes, respectively. No adverse events occurred during the operation. The blood pressure, acid-base balance, and other parameters were all unremarkable.\nOn the first postoperative day, the patient complained of severe left calf pain immediately after extubation. His left leg was markedly swollen, violet in color, tender, and warm up to the knee. Normal Doppler sounds were identified in the dorsalis pedis artery, lateral malleolar artery, and femoral vein. However, the venous flow below the popliteal vein was obscured in the color Doppler ultrasonography, and the patient's left foot was almost paralyzed. A decreased platelet count (85,000/µL) and an increased D-dimer level (355 µg/L) were noted. Because it was believed that anticoagulation therapy and infrapopliteal thrombectomy would be ineffective at that time, a prompt four-part fasciotomy was performed to prevent irreversible neurological and muscle damage. Unfortunately, despite all of our efforts, the patient's swollen muscles became infected with Acinetobacter baumannii after 1 week (, ). A delayed skin graft was required after repeated aggressive debridement. The foot drop did not recover, and the patient was discharged 5 months postoperatively with a disability.

[[67.0, 'year']]

M

{'19829914': 2, '22371444': 1, '16829838': 1, '16678609': 1, '11952578': 1, '8096598': 1, '22450114': 1, '24570866': 2}

{'2740129-1': 1}

3928264-1

noncomm/PMC003xxxxxx/PMC3928264.xml

Primary Ewing's Sarcoma of the Lung

A 41-year-old woman was admitted for hemoptysis of 4 days' duration. Her medical and family history was unremarkable. She visited a local clinic, where a chest radiograph revealed a radio-opaque mass in the right upper lung lobe. She was referred to Asan Medical Center. Computed tomography revealed several oval, smoothly marginated, and low attenuation lesions with ground-glass opacity in the right upper lung lobe (). Positron emission tomography with 18F-fluorodeoxyglucose (FDG) showed multiple round or oval lesions in the right upper lung lobe. The FDG uptake was increased in the lesions (maximal standard uptake value: 9.7) without any other abnormal uptake. She underwent bronchoscopy, and a transbronchial lung biopsy and wash with cytology were then performed. The pathological diagnosis of the specimen was a malignant small round cell tumor. Surgical resection was selected for definitive diagnosis and treatment.\nThe patient underwent right upper lobe lobectomy via posterolateral thoracotomy under one-lung ventilation. There were two relatively well-defined ovoid masses in the anterior and posterior segment of the right upper lobe (). These tumors were 5.5×5×3.5 cm and 4.5×4×3 cm in size, respectively. The cut surface was heterogeneously purplish, brown to yellowish, and pink in color. Focal hemorrhage and necrosis were evident. The tumors did not invade the visceral pleura. The surgical margins were not grossly involved. The small mass was approximately 3.3 cm from the bronchial resection margin, but the large mass abutted the bronchial margin. However, the remaining bronchus was too short to allow further resection, and the tumor was limited to the peribronchial soft tissue. Therefore, we decided to add radiation therapy.\nHistologically, the tumor was composed of uniform, small, round cells with indistinct borders. The tumor cells had scanty clear cytoplasm and round nuclei with fine chromatin. Immunohistochemical staining for CD 99 revealed diffuse membranous positivity in the tumor cells, which is a characteristic feature of Ewing's sarcoma (). Immunohistochemical staining for CD56, pancytokeratin, and leukocyte common antigen was negative for each.\nPostoperatively, the patient was transferred to the intensive care unit, and then, the next day, to the general ward. The chest tube was removed on postoperative day 2. She was discharged from the hospital on postoperative day 4, without any complications. At the outpatient clinic, the patient underwent 6 cycles of chemotherapy consisting of vincristine, doxorubicin, cyclophosphamide, ifosfamide, and etoposide. She also underwent radiation therapy. The patient received 50 Gy to the right hilum. She experienced no recurrence or distant metastasis for 4 years after the surgery.

[[41.0, 'year']]

F

{'22484982': 1, '6345338': 1, '18779607': 1, '17923745': 2, '3284809': 1, '33149376': 1, '1867320': 1, '34123607': 2, '33241208': 1, '9053479': 1, '20067987': 1, '27766786': 2, '24570867': 2}

{'2694395-1': 1, '5125323-1': 1, '8191847-1': 1}

3928265-1

noncomm/PMC003xxxxxx/PMC3928265.xml

Bronchioloalveolar Carcinoma in a Juvenile Rhadomyosarcoma Patient

An 11-year-old female was referred to our care for the treatment of a pathologic fracture of the lumbar spine. One month prior, she had fallen during exercise, causing persistent back pain. When symptoms failed to abate, computed tomography (CT) of the spine was performed, revealing a fracture at the L-2 level that was most likely pathologic. Given the circumstances, she was admitted to Seoul St. Mary's Hospital as a pediatric hematology patient. A chest X-ray () revealed a left lower lobe infiltrate with pleural effusion, and the chest CT revealed bilateral pleural effusions with multiple, diffuse nodules of both lungs. Positron emission tomography (PET)-CT further disclosed whole-body tumor involvement. Biopsies of the bone marrow and the sole of the right foot confirmed stage IV rhabdomyosarcoma. After 5 months of chemotherapy, a complete metabolic response was evident by PET-CT; and after 11 months of treatment, the lung lesions and pleural effusions had essentially resolved. However, two nodules persisted in the left lung-one in the upper lobe and the other in the superior segment of the lower lobe (). For diagnostic and curative purposes, wedge resection of these two nodules was performed via mini-thoracotomy. The patient's recovery was uneventful, and she was discharged on postoperative day 6.\nGrossly, the resected nodules were firm and ovoid, measuring 3 mm in diameter. In histologic sections, tumor proliferation was lepidic, marked by cuboidal to columnar cells with scanty cytoplasm following alveolar contours. Thus, bronchioloalveolar carcinoma (BAC), non-mucinous type () was diagnosed. The patient was tumor-free after 6 months, but a new mass developed on her left wrist 10 months postoperatively. Whole-body recurrence of rhabdomyosarcoma was subsequently verified by PET-CT.

[[11.0, 'year']]

F

{'14976453': 1, '21030925': 1, '18158138': 1, '19418544': 1, '9607481': 1, '17502169': 1, '24570868': 2}

{}

3928266-1

noncomm/PMC003xxxxxx/PMC3928266.xml

Mixed Squamous Cell and Glandular Papilloma of the Lung in a 64-Year-Old Woman

A 64-year-old-woman with no respiratory symptoms was referred to our hospital with a left lower lung mass detected in a chest X-ray during a routine health examination. She was a never-smoker and had no history of any medical conditions, except for pulmonary tuberculosis that had been cured by medication 15 years previously. The chest X-ray revealed a mass approximately 3 cm in size, which was located in the left lower lung field with a well-defined border (). The chest computed tomography (CT) revealed a 4×3-cm mass that was lobulated but not infiltrating the surrounding lung parenchyme in the left lower lobe mediobasal segment. The mass was homogenous with minimal necrotic findings in a small portion and was not enhanced upon contrast enhancement (). No abnormality was revealed by the bronchoscopic gross and cytological examination. The blood test and the tumor marker study were normal. The positron emission tomography (PET)/CT revealed that the maximal standardized uptake value (SUV) was 6.7 in the left lower lung mass without mediastinal lymph node uptake (). On the basis of the above examinations, we suspected lung malignancy that was in the operable stage; therefore, we planned surgical wedge resection biopsy and lobectomy if malignancy was confirmed. In the operation, the mass was resected by wedge resection with stapling and was diagnosed as adenocarcinoma upon a frozen section examination. Therefore, the patient underwent lobectomy, and the postoperative course was uneventful. Histopathologically, mixed squamous and mucin-secreting glandular epithelium covered the fibrovascular cores. In the focal area, mucin-secreting glandular epithelium showed a complex structure. Further, acantholytic squamous epithelial nests were mixed with mucin-filled epithelial cells with neutrophil and lymphoplasmacytic infiltrates (). Immunohistochemically, the tumor cells were positive for cytokeratin (CK5/6 and CK7) and p63 (). The Ki-67 proliferation index was less than 1%. These findings of the histopathological examination and immunohistochemical stain were compatible with mixed squamous and glandular papilloma. During the 18 months of follow-up, the patient has remained well and has not reported any medical problems.

[[64.0, 'year']]

F

{'19689808': 2, '21188658': 1, '22425912': 1, '21418399': 1, '20301213': 1, '31934202': 1, '24570869': 2}

{'2734747-1': 1}

3928267-1

noncomm/PMC003xxxxxx/PMC3928267.xml

Primary Epithelial Myoepithelial Lung Carcinoma

A 51-year-old female was admitted to the hospital with an abnormal chest radiographic finding on a periodic medical inspection. The patient was a non-smoker, and her past medical history was unremarkable. She did not have any respiratory symptoms, such as cough, hemoptysis, dyspnea, fever, or pneumonia. There were no palpable adenopathies, and cardiopulmonary auscultation and laboratory study results, including an electrocardiogram and blood analysis, were within reference limits. A chest radiograph showed a mass 3.2×2.8 cm in size in the left peripheral lung field. A chest computed tomography (CT) scan revealed a well-defined mass of 3×2.9 cm that bordered the visceral pleura at the lingular segment of the left upper lobe (LUL) (). A percutaneous needle biopsy was performed, and the diagnosis indicated that the mass was a salivary gland tumor. Positron emission tomography (PET)-CT revealed a LUL mass with a maximal standardized uptake value of 3.2 and uptake, which indicated distant metastasis. The patient was treated by a lobectomy of the left upper lung with lymph node dissection via video-assisted thoracic surgery. Grossly, the excised section of the left upper lung showed a well-circumscribed, gray-white to yellow tumor mass, measuring 3.3×2.4×1.9 cm (). A microscopic examination revealed that the cut section of the tumor was composed of two types of cells: tubular and glandular structures filled with eosinophilic material, mixed with solid spindle and polygonal cell areas (H&E, ×200). The inner tubular layer showed epithelial cell characteristics, whereas the outer layer exhibited myoepithelial cell characteristics. A few mitotic figures were also seen (H&E, ×400) (). Immunochemical staining for epithelial membrane antigen was positive in the inner tubular layers and epithelial components (EMA, ×200). Immunostaining for actin was positive in the outer tubular layer and solid areas (Actin, ×200). Immunostaining for S-100 showed a focal positive reaction in the outer tubular layer and solid areas (S-100, ×200) (). The postoperative tumor-node-metastasis (TNM) stage was T2aN0M0, and the pathologic stage was Ib. The patient did not receive any adjuvant treatment and was followed up for 16 months without any local recurrence or distant metastasis.

[[51.0, 'year']]

F

{'18973918': 1, '29987577': 2, '22934215': 2, '4340536': 1, '26622597': 1, '29196470': 1, '9726061': 1, '21798017': 1, '32093457': 1, '27583848': 2, '32832345': 2, '11353064': 1, '28653299': 1, '24570870': 2}

{'7438174-1': 1, '6037657-1': 1, '3423864-1': 1, '5008532-1': 1}

3928269-1

noncomm/PMC003xxxxxx/PMC3928269.xml

Metastatic Pulmonary Ameloblastoma Misdiagnosed as Primary Squamous Cell Carcinoma Preoperatively

A 50-year-old woman presenting with back pain was referred to our center with a 2.5-cm nodule in the right middle lung field on a chest X-ray. The patient had a past history of surgical excision of an odontogenic tumor at a local dental clinic 17 years previously. A chest computed tomography (CT) scan revealed a 2.6-cm lobulated, heterogeneous enhancing nodule and a 1.5-cm satellite nodule in the anterior segment of the right upper lobe (RUL) (). Therefore, we performed CT-guided percutaneous needle biopsy for the tissue diagnosis of the main nodule. The specimen showed a cohesive tumor island composed of squamoid cells, with central keratin pearl-like material. There was only one event of mitosis in the whole field (), and the patient was diagnosed with squamous cell carcinoma. Bronchoscopy, brain magnetic resonance imaging, and positron emission tomography scanning were performed for further evaluation and staging, based on the impression of primary lung cancer. Then, we performed a planned RUL lobectomy and mediastinal lymph node dissection through thoracotomy upon the diagnosis of clinical stage IA (T1bN0) or IIB (T3N0) lung cancer. The resected specimen showed two separate nodular lesions that shared the same histopathological features. However, the histopathological diagnosis after the operation was different from that of preoperative biopsy. Postoperative histopathological examination revealed densely packed tumor islands. These tumor islands showed peripheral palisading and loosely arranged central cells, which resembled stellate reticulum. The peripheral palisading cells were columnar and hyperchromatic. Little mitotic activity and cellular pleomorphism were observed (). The overall features suggested a follicular pattern of ameloblastoma. We contacted the patient's former dentist and requested her medical records, but we could not obtain any information related to the odontogenic tumor. Finally, the diagnosis of metastasizing ameloblastoma was made based on the patient's past history and histopathological studies. The postoperative course was uneventful. Although the patient had no associated symptoms, panoramic radiography and facial CT were performed after consulting a dentist to identify local recurrence at the oral cavity. There was fibrotic scar formation but no evidence of recurrence at previous odontogenic tumor site. No adjuvant therapy was performed. The patient was doing well without any evidence of recurrence or metastasis during regular follow-up.

[[50.0, 'year']]

F

{'20970910': 1, '2672358': 1, '10468461': 1, '27307800': 1, '32132332': 1, '33394372': 1, '19732391': 1, '21459020': 1, '22507293': 1, '24570871': 2}

{}

3928270-1

noncomm/PMC003xxxxxx/PMC3928270.xml

Treatment of Large Arteriovenous Malformation in Right Lower Limb

A 10-year-old boy (height, 120 cm; weight, 20 kg) presented with an 8-year history of arteriovenous malformation (AVM) involving the right lower limb. He had been started on sclerotherapy 4 years earlier because of leg length discrepancy causing gait disturbance. However, this treatment was stopped because there was no remarkable improvement. A year before presentation, the AVM had undergone rapid expansion causing significant pain and high-output cardiac failure. Therefore, an amputation of the affected lower limb was recommended at the other hospital.\nOn admission to Kyungpook National University Hospital, an examination revealed that AVM with soft tissue hypertrophy had spread all over the right leg (). A chest X-ray showed marked cardiomegaly with increased pulmonary vascularities (). Electrocardiography showed normal sinus rhythm with right ventricular hypertrophy. Two-dimensional echocardiography showed an enlarged right atrium, right ventricle, and left ventricle, but relatively good left ventricular contractility. The pulmonary artery was also enlarged, but there was no pulmonary edema. Computed tomographic (CT) angiography of the right lower extremity revealed extensive AVM with feeding arteries from the branches of the right profunda femoris and superficial femoral arteries. The venous drainage was through the superficial femoral and deep femoral veins, and there was a marked dilatation of the pelvic vein and inferior vena cava (). The blood investigations were found to be normal.\nOne week before surgery, the patient was scheduled to receive preoperative selective embolization to reduce the size of the AVM and minimize the risk of uncontrolled intraoperative bleeding. For embolization, the radiologist performed catheterization through the left common femoral artery and installed a tourniquet over the right proximal thigh. Soon after, remarkable bradycardia developed due to a baroreceptor reflex-induced abrupt increase in the systemic vascular resistance (SVR), and this procedure was cancelled. After a thorough discussion with the plastic surgeons, orthopedic surgeons, and vascular surgeons, right hip disarticulation was considered to be the best option for improving the patient's quality of life. It was anticipated that the large feeding vessel branches of the right profunda femoris artery, superficial femoral artery, and the large veins draining the limb would be difficult to control during a hip disarticulation. To minimize the chances of torrential hemorrhage, a disarticulation was planned under cardiopulmonary bypass.\nAfter anesthetic induction, an intra-arterial catheter 22G was inserted into the left radial artery to check the invasive arterial pressure and cardiac output by using an arterial pressure waveform-derived cardiac index sensor (FloTrac; Edward Lifesciences LLC, Irvine, CA, USA) and monitor (Vigileo, Edward Lifesciences LLC). Further, a central venous catheter was positioned into the left subclavian vein.\nAfter induction, the mean arterial pressure was maintained between 60 and 80 mmHg. The cardiac index (CI) and the central venous pressure (CVP) were recorded at 10 and 18, respectively, which were considered to be high.\nAfter heparinization, the right iliac artery was cannulated using an 18 French (Fr) cannula, and a 24 Fr venous cannula was placed through the right iliac vein. Partial cardiopulmonary bypass (CPB) was commenced at a flow rate of 1,200 mL/m2/min. The patient's body was maintained at a normal temperature, and the activated clotting time was greater than 400 seconds throughout the CPB. During a partial CPB, a continuous intravenous infusion of milrinone 0.5 µg/kg/min was used to improve the right ventricle function by decreasing the pulmonary vascular resistance. After the initiation of CPB, the CI and CVP were lowered to 2.5 and 3, respectively. The amputation was performed at the level of the proximal one-third of the right femur. The CPB time was 180 minutes. After heparin neutralization using protamine, the patient was weaned off of the bypass with 0.1 µg/kg/min of norepinephrine and 0.5 µg/kg/min of milrinone. Despite the use of CPB, the blood loss was extensive, and a transfusion of 8 units of packed red cells, 6 units of fresh frozen plasma, and 5 units of cryoprecipitate was required.\nHe was extubated on the following day. The postoperative period was uneventful, and he recovered fully with no neurologic deficit. A two-dimensional echocardiography, which was performed a week after surgery, showed a significantly smaller cardiac chamber. Two months after surgery, no residual lesion was observed in a CT angiography (), and a chest X-ray was unremarkable without cardiomegaly ().

[[10.0, 'year']]

M

{'31037191': 1, '15806424': 1, '15192580': 1, '17043419': 1, '32670448': 1, '14981454': 1, '19398189': 1, '11205678': 1, '15216065': 1, '3984901': 1, '24570872': 2}

{}

3928271-1

noncomm/PMC003xxxxxx/PMC3928271.xml

Successful Endovascular Management of Intraoperative Graft Limb Occlusion and Iliac Artery Rupture Occurred during Endovascular Abdominal Aortic Aneurysm Repair

A 75-year-old man visited the emergency room with anemia and dizziness. He was taking warfarin for deep vein thrombosis and had a hemoglobin level of 4.5 g/dL. The prothrombin time (international normalized ratio) was 6.28. He had undergone low anterior resection and partial bladder resection with adjuvant chemotherapy to treat sigmoid colon cancer 3 years earlier. He had also undergone incisional ventral hernia repair. He did not show hematochezia, melena, or abdominal tenderness/rebound tenderness. The anemia and the prolongation of the prothrombin time were easily corrected; thus, continuous bleeding was not suspected. Nevertheless, in order to rule out gastrointestinal bleeding as a cause of the severe anemia, abdominal computed tomography (CT) was performed. However, there was no evidence of intra-abdominal bleeding. Instead, a 55-mm abdominal aortic aneurysm with eccentric bulging combined with a right common iliac artery aneurysm (). The aneurysm size increased by 10 mm compared with the size 2 years previously. Because severe intra-abdominal adhesion and wound problems after laparotomy were expected, endovascular aortic aneurysm repair (EVAR) was recommended instead of open surgery. EVAR was started with the deployment of a bifurcated main body using an aortic stent graft of 30×30×40 mm and an inner bare stent 32×32×50 mm in size (S&G Biotech Inc., Seongnam, Korea). Subsequent extension of the right graft limb was performed uneventfully using two covered stents (12×12×80 mm and 12×12×60 mm) to exclude the right common iliac artery aneurysm. Dreadful complications occurred during the last procedure of the left graft limb extension. After the selection of the left graft limb and the guide wire exchange to a Lunderquist stiff wire (Cook Inc., Bloomington, IN, USA), a 16F introducer sheath was inserted for the delivery of a limb extension graft, but the tip of the sheath perforated the left proximal external iliac artery during the advancement of the sheath (). Sheath-pushing against the tortuous iliac artery caused the guide wire to slip back into the sheath, and the dilator tip punctured the arterial wall. Although the extension of the left graft limb was scheduled to end at the distal common iliac artery, the extension was promptly determined to be lengthened to the external iliac artery to cover the perforated site. The left graft limb of the main body was reselected, and a stent graft of 12×12×100 mm was deployed. A sheath angiography showed no further extravasation. However, subsequent aortography showed an occlusion of the left graft limb, and acute thrombosis was suspected (). A prompt balloon thrombectomy was attempted after the left superficial and deep femoral arteries were clamped to prevent distal embolization. A 6F balloon catheter was advanced through the occlusion and withdrawn carefully not to cause disjunction of the overlapped stent grafts. Fresh thrombus was successfully removed, and the graft flows became excellent without any endoleak upon the completion of angiography (). The patient was extubated and transferred to the general ward on the following day. He was discharged on the fifth postoperative day. Postoperative follow-up CT scan showed no endoleak (). At the 3-month follow-up, the patient was doing well without any symptoms like buttock claudication.

[[75.0, 'year']]

M

{'11122182': 1, '23399618': 1, '9052576': 1, '16897264': 1, '22263141': 1, '1837729': 1, '19703755': 1, '24570873': 2}

{}

3928345-1

noncomm/PMC003xxxxxx/PMC3928345.xml

Treatment for Giant Fusiform Aneurysm Located in the Cavernous Segment of the Internal Carotid Artery Using the Pipeline Embolization Device

A 40-year-old woman presented with a 5-year history of sharp left facial pain and discomfort of the left orbit when she moved her eye. Digital subtraction angiography (DSA) revealed a giant fusiform aneurysm involving the cavernous segment of the left internal carotid artery (ICA) (). The aneurysm was measured by 25×11 mm. The A1 segment of the anterior cerebral artery of the left ICA was nondominant. A cross filling test with manual compression of the left ICA showed a lack of blood supply from the anterior communicating and posterior communicating arteries. As a result, a balloon occlusion test was not indicated. Because of the size, fusiform shape and poor-collateral blood supply of the aneurysm, we decided to treat the patient with a PED. The patient received 100 mg of aspirin and 75 mg of clopidogrel per day for 1 week before the procedure.\nAfter starting general anesthesia, the patient was given a bolus of heparin and activated clotting time was maintained at 2 to 3 times baseline throughout the procedure. After accessing the right femoral artery, a 6 Fr Envoy guiding catheter (Cordis, Miami, FL, USA) was placed just proximal to the petrous segment of the left ICA using a coaxial technique. We gained control angiography to measure the size of the aneurysm and the parent arteries. The diameter of the inflow vessel at the petrous segment was 4.1 mm and the diameter of the outflow vessel at the cavernous segment was 3.2 mm. A Marksman microcatheter (EV3, Irvine, CA, USA) with a 0.027-inch diameter was introduced at the M1-M2 junction. A 4.0×20 mm PED was delivered via microcatheter. The PED was deployed across the targeted landing zone by repeated maneuvers of microcatheter unsheathing, delivery-wire stabilization and advancement, and microcatheter loading. Postprocedural angiography demonstrated that filling of the aneurysmal sac was slower than observed by preprocedural angiography. DynaCT and three-dimensional reconstructive angiography showed good stent position with no redundant portions between the PED and the wall of the parent vessel (). The periprocedural course was uneventful. The patient's facial pain was markedly improved the day after the procedure and the patient was discharged.\nThe patient returned for a 3-month follow-up angiography, having maintained antiplatelet medication of 100 mg aspirin and 75 mg clopidogrel per day. Symptoms had gradually reduced without neurological changes. DSA demonstrated anatomic reconstruction of the parent artery with complete occlusion of the aneurysm (). The distal portion of the PED covered the origin of the meningohypophyseal trunk; however, the meningohypophysial trunk was easily visualized by angiography. DynaCT and three-dimensional reconstruction angiography showed proper patency of the in-stent lumen without stenosis. The PED remained in the same position without migration or change in shape.

[[40.0, 'year']]

F

{'21071533': 1, '21979492': 1, '23190638': 1, '21257202': 1, '21148256': 1, '8103584': 1, '27651873': 2, '22300924': 1, '3883217': 1, '21839962': 1, '20150304': 1, '15509310': 1, '21881914': 2, '31295979': 1, '20150311': 1, '19349825': 1, '22948199': 1, '23424227': 1, '8747955': 1, '23321438': 1, '20616327': 1, '11523676': 1, '18580809': 1, '21436336': 1, '22403783': 1, '21071538': 1, '22821921': 1, '20339842': 1, '21719290': 1, '22710418': 1, '24570815': 2}

{'5028615-1': 1, '3304061-1': 1, '3304061-2': 1}

3928346-1

noncomm/PMC003xxxxxx/PMC3928346.xml

A Case of Endovascular Treatment for Followed by Side to Side Bypass for Vertebral Artery Dissecting Aneurysms Involved Posterior Inferior Cerebellar Artery

A 45-year-old woman was admitted to our hospital with a chief complaint headache and dizziness. On initial neurologic examinations, the patient had no neurologic signs. A 3-dimensional computed tomography angiography scan on admission showed left vertebral artery stenosis. On day 5, the patient underwent magnetic resonance angiography at a follow-up, showing no interval change of left vertebral artery stenosis (). On day 10, the patient underwent transfemoral cerebral angiography (TFCA) showing complex vertebral dissecting aneurysm of long segment arising from the PICA (). These findings were suggestive of a sign of impending rupture of left vertebral artery dissecting aneurysm because a short-term follow-up radiography revealed a change in the vessel contour. In this patient, we decided on the segmental occlusion using a coil with stent insertion of contralateral vertebral artery after PICA-to-PICA bypass surgery because of the proximity and parallel course of the distal segments of the PICA (). Because simple stenting method had still risk for rupture of aneurysm after intervention and parent artery occlusion had risk for ipsilateral PICA territory infarction, we decided that.\nAfter a midline suboccipital craniotomy, the cisterna magna was opened. After temporary clipping of proximal and distal PICA and perforating artery, a curved incision rather than a straight one along the PICA was done. To do this, the distal end of both PICA was stay-sutured. This was followed by the continuous suture from outside to inside of inner side of the vessel. Then, the final suture was done from inside to outside of the vessel. Following this, the proximal end was also stay-sutured on the external side and then tied with the final inner suture. Moreover, the continuous suture of outer side from outside to inside of the vessel was done in the same manner. After removal of temporary clips, a good patency was also seen on intraoperative indocyanine green angiography ().\nOn postoperative TFCA, a PICA to PICA anastomosis achieved a good patency of both PICA from the right vertebral artery (VA) (). Then, we performed left VA balloon occlusion test and the both PICA territories showed well. Then, the patient underwent segmental occlusion using a coil with stent insertion of contralateral vertebral artery. The patient finally, achieved a total occlusion of the dissecting aneurysms and a good patency of both PICA territories (). At a 2-year follow-up, the patient underwent uneventful course.

[[45.0, 'year']]

F

{'11453395': 1, '14210010': 1, '21990836': 1, '19721770': 1, '9848843': 1, '12405360': 1, '10549948': 1, '16157904': 1, '21856573': 1, '21211386': 1, '26539258': 2, '27429591': 1, '24570816': 2}

{'4630346-1': 1, '4630346-2': 1, '4630346-3': 1}

3928347-1

noncomm/PMC003xxxxxx/PMC3928347.xml

Two Cystic Cavernous Angiomas after Radiotherapy for Atypical Meningioma in Adult Woman : Case Report and Literature Review

A 49-year-old, Latin American, right handed, woman, at the age of 39 consulted for progressive swelling of the left frontal region. Magnetic Resonance (MR) scanning showed an intradiploic mass with dural attachment (). A Simpson I removal was achieved at the first operation; on histological examination () the diagnosis was atypical meningioma (World Health Organization II).\nThe patient received 6000 cGy of Fractionated Stereotactic Radiotherapy. Chemotherapy was not delivered. The patient was followed up neurologically and radiologically. Follow-up MR imaging did not reveal any recurrence of the tumour or other lesions.\nNine years later, at the age of 48, follow-up MR imaging showed two new well defined areas, with cystic and necrotic components, at the surface of each frontal pole. The lesions appeared isointense-hypointense on T1-weighted sequences, with heterogeneous gadolinium enhancement, and hyperintense on T2-weighted. Clinical examination was normal. The following year, at the age of 49, she presented to the emergency unit of our department with drug-resistant headache. MR imaging showed that both lesions had grown. The largest one (5.5×3.6 cm), in the left frontal lobe, was a large gliotic bordered lobulated lesion, with a big cystic component, that extended from the frontal pole to the frontal horn of lateral ventricle. The right lesion (3.7×2.4 cm), with a smaller cystic component, was entirely within the right pole (, ). Bilateral frontal craniotomy was performed to remove both the masses. The histopathological diagnosis was cavernous angioma (). The lesion was composed of hyalinized vascular channels, with different calibers. The vessels were thick and amuscular and the brain parenchyma interposed between the channels showed gliosis. The patient had not family history of cavernomas. After surgical removal, symptomatology completely remitted.

[[49.0, 'year']]

F

{'15891176': 1, '17566205': 1, '10371615': 1, '30937003': 2, '15662523': 1, '33218314': 1, '16021386': 1, '3393196': 1, '8161487': 1, '15662782': 1, '8052376': 1, '19534329': 1, '12115362': 1, '18555880': 1, '8727164': 1, '16859257': 1, '24570817': 2}

{'6417313-1': 1, '6417313-2': 1, '6417313-3': 1}

3928348-1

noncomm/PMC003xxxxxx/PMC3928348.xml

Spinal Cord Ependymoma Associated with Neurofibromatosis 1 : Case Report and Review of the Literature

A 49-year-old female patient was admitted to our department because of numbness in her fingers that progressed to her entire body above the bellybutton for half a year. In his past medical history there were expeditiously increscent cutaneous neurofibromas respectively on her back and left thigh for five years, and a total resection for tumors had been performed in a local hospital. Histological examination revealed both of them were neurofibromas with malignant features. On physical examination, widespread café-au-lait spots, axillary and groin frecklings, cutaneous neurofibromas, plexiform neurofibromas and operative scar on her back and left thigh were present, and a sensory deficit was present between the C4 level and bellybutton. No iris hamartomas had been found and mammary gland were normal. Among the family members her mother and maternal grandmother had similar manifestations of NF1, but her daughter and sons had no clinical evidence of NF1 ().\nMagnetic resonance imaging showed a relative-demarcated, heterogeneously enhanced mass lesion accompanied by perifocal edema in C5-7 level, a left-sided T11 spinous process heterogeneously enhanced mass in soft tissue, intervertebral disk hernia in L2-5 level and widespread punctum enhancing lesion in her scalp and in T11-L5 level. No evidences of optic pathway glioma and neurofibromatosis 2 (NF2) had been found in head MRI ().\nThe patient was positioned prone after placement of MEP and SEP monitoring devices, then a posterior laminectomy was performed from C5-7. After confirming the tumor location at the C5-7 level by ultrasonography, we incised the dura at the midline and slit the spinal cord, a yellowish mass with abundance blood supply in the spinal cord was observed. Under an operative microscope, the tumor was gross-totally resected safely, and a laminoplasty from C5-7 was performed at the end of the surgery ().\nHistological examination revealed it was a moderately cellular glial tumor characterized by round, irregular nucei and eosinophilic cytoplasm, and perivascular pseudorosettes formation was noted. Immunohistochemical analysis showed the tumor cells have immunoreactivity for glial fibrillary acidic protein, epithelial membrane antigen, neuron specific enolase and S-100, but were negative for reticulin. 1% of the cells were positive for monoclonal antibody to Ki-67 antigen. The findings were consistent with ependymoma, grade II in the World Health Organization classification. The biopsy of a scalp neurofibroma showed a typical cutaneous neurofibroma ().\nPostoperatively, no adjunctive therapy was given and the patient manifested normal physical development. One year after operation, the neurological disorders had recovered and no neurological deficits were examined. Follow-up magnetic resonance imaging revealed stable postsurgical changes in the C5-C7 level with no evidence of tumor recurrence and dissemination ().

[[49.0, 'year']]

F

{'21132433': 1, '11283797': 1, '12746402': 1, '11760389': 1, '20027112': 1, '19458954': 1, '19937438': 1, '10525761': 1, '19410195': 1, '19484253': 1, '12477702': 1, '29490631': 2, '10625171': 1, '11935243': 1, '20405509': 1, '16797490': 1, '18344915': 1, '11107159': 1, '21507563': 1, '17105749': 1, '20403699': 1, '19499166': 1, '9143927': 1, '21892408': 1, '18398287': 1, '20119838': 1, '24570818': 2}

{'5832195-1': 1, '5832195-2': 1, '5832195-3': 1, '5832195-4': 1, '5832195-5': 1}

3928349-1

noncomm/PMC003xxxxxx/PMC3928349.xml

Collapsed L4 Vertebral Body Caused by Brucellosis

A 50-year-old man working as an employee was admitted to neurosurgery clinic with severe low back, radicular right leg pain and hypoesthesia in right L4-5 dermatomes for 2 months. His past history revealed that he had weight loss, night sweats and chills, fatigue and severe malaise for 4 months, and he consumed unpaesteurized milk and dairy products. On neurological examination there was 3/5 motor strength of right ankle dorsiflexion and hypoesthesia in distribution of right leg L4-5 dermatomes. Brucellosis was common in the area where the patient was living and brucella tube agglutination (Wright) test was routinely studied in suspected patients coming from that area. Brucella tube agglutination (Wright) test was studied in serum sample of the patient and was positive with a titer of 1/640. Brucella melitensis was isolated from blood culture. X-ray of the lumber spine showed massive collapse of L4 vertebral body (). Magnetic resonance imaging (MRI) revealed fracture and collapse of the body of L4 vertebrae (). The spinal canal was narroved by posterior elements of the vertebrae, therefore neural tissue was compressed ().\nThe patient was taken to the operation emergently a posterior midline approach and bilateral hemilaminotomy were done. Grey-yellow colored pathologic specimen was obtained from vertebral body and epidural space. Neural tissue was decompressed and then posterior L3-5 short segment transpedicular screw fixation and stabilization was performed (). Tricortical iliac crest wedge obtained from the same patient (autograft) was used for fusion. Neurological signs and symtoms of the patient were recovered after the operation. Brucella melitensis was isolated from microbiologic culture of pathologic specimen. Antibiotic therapy was given for brucellar infection as doxycycline 200 mg/day and rifampicin 600 mg/day for 6 months.

[[50.0, 'year']]

M

{'17344084': 1, '16944052': 1, '9918255': 1, '10585793': 1, '19107498': 1, '18045560': 1, '11971204': 1, '15635968': 1, '11206346': 1, '2704806': 1, '17962938': 1, '24570819': 2}

{}

3928351-1

noncomm/PMC003xxxxxx/PMC3928351.xml

Patients on Anticoagulants after a Head Trauma : Is a Negative Initial CT Scan Enough? Report of a Case of Delayed Subdural Haematoma and Review of the Literature

A 66-year-old male presented to the emergency department after a fall and a mild head trauma. He had no history of loss of consciousness or posttraumatic amnesia. The patient had a history of atrial fibrillation and was on acenocoumarol (Sintrom®). His neurological examination was intact. Initial CT scan of the brain was without any sign of intracranial hemorrhage or cranial fracture (). The laboratory workup revealed an International Normalized Ratio (INR) of 2.5. After an 8-hour observation period, he was discharged home.\nForty-eight hours later the patient was transferred to the emergency room with a decreased level of consciousness and vomiting. On neurological examination he had a score of 9/15 on the Glasgow Coma Scale (E2V2M5) and a dilated left pupil unresponsive to light. A CT scan of the brain revealed a large left acute SDH with midline shift (). The patient underwent a craniotomy with evacuation of a large subdural clot. The point of the haemorrhage was some bridging veins to the transverse sinus, which were promptly coagulated. Postoperatively, the left pupil became small and reactive and a CT scan demonstrated complete removal of SDH. The patient progressively improved and one month after the operation he was discharged for further physiotherapy (). Six months later the patient has a Glasgow Outcome Score of 3.

[[66.0, 'year']]

M

{'32152956': 1, '28507998': 1, '3389997': 1, '20041055': 1, '16639305': 1, '22244878': 1, '18288015': 1, '27620896': 1, '24570820': 2}

{}

3928353-1

noncomm/PMC003xxxxxx/PMC3928353.xml

Malignant Rhabdoid Tumor of the Kidney and Spine in an Infant

An 8-month-old girl without specific past medical history was admitted to the hospital due to nausea and diarrhea. On physical examination, a firm mass was detected in the left upper quadrant of the abdomen. Abdominal computed tomography (CT) revealed a 6.8×5.8×5.3 cm sized left renal mass without lymph node enlargement (). There were no suspicious metastatic lesions in chest CT. Laboratory data showed leukocytosis. Radical nephrectomy with lymph nodes dissection was performed. Gross examination revealed a well circumscribed, ovoid, firm mass in the lower pole of the kidney (). The mass was abutted on the renal capsule, and the surface of the mass was whitish gray with multifocal hemorrhages. The remaining renal parenchyma was unremarkable. Microscopic findings revealed that the tumor was a highly cellular neoplasm composed of tumor cells of varying size with prominent nucleoli and abundant cytoplasm (). Histological examination was consistent with the diagnosis of malignant rhabdoid tumor. Immunohistochemistry showed loss of INI1 protein staining ().\nOne week after the operation, weakness of both lower extremities and voiding failure were noted. On neurological examination, she failed to respond to pain in both legs. Brain magnetic resonance imaging (MRI) did not show evidence of metastatic disease, but lumbar MRI revealed a 6.5×1 cm sized intradural extramedullary tubular mass with heterogeneous enhancement at L1-S1 level (). On the next day from onset of symptoms, laminoplastic laminotomy was performed by a neurosurgeon to remove the tumor and decompress spinal cord. Conus medullaris was displaced by the hypervascular tumor with yellowish color, however the upper margin of the tumor was clear (). The tumor was densely adhered to the left side of L5 nerve root. Near total removal of the tumor was performed using cavitron ultrasonic surgical aspirator, and there was no root injury during the surgery (). The pathologic findings were consistent with metastatic malignant rhabdoid tumor (). After the surgery, the motor power of lower extremity was returned. She received adjuvant radiotherapy for 2 weeks and 13 cycles of chemotherapy (vincristine, doxorubicin, and cyclophosphamide) for 3 months postoperatively. The patient showed general weakness, seizure and changes in mental status during the chemotherapy. Leptomeningeal metastasis with hydrocephalus was noted in brain MRI. A ventriculoperitoneal shunt was placed. However, she did not clinically improve and died 6 months after the surgery.

[[8.0, 'month']]

F

{'23532120': 1, '18288421': 1, '21370404': 1, '1851430': 1, '12029454': 1, '14631620': 1, '17454778': 1, '1631771': 1, '28058126': 1, '19965293': 1, '16234525': 1, '2543225': 1, '19521139': 1, '23511492': 1, '6310357': 1, '8523069': 1, '24570822': 2}

{}

3928354-1

noncomm/PMC003xxxxxx/PMC3928354.xml

Solitary Cavernous Sinus Neurosarcoidosis Mimicking Neurosyphilis

A 40-year-old man experienced the sudden onset of diplopia one month before admission. At that time, he was evaluated for his ophthalmoplegia in an outside hospital with brain magnetic resonance imaging (MRI), which demonstrated right sphenoid and left posterior ethmoid sinusitis. One month after the onset of diplopia, he still suffered from diplopia. He also developed a new onset of right facial pain and headache. The follow-up MRI revealed an enhancing mass lesion in the right cavernous sinus region. He was referred to our neurosurgical unit with the presumptive diagnosis of a cavernous sinus tumor.\nHe had a history of syphilis of unknown stage, which had been treated 20 years earlier. At admission, he was alert and fully oriented. He presented with diplopia, headache, right facial pain, and mild dysarthria. The neurological examination was notable for the complete palsy of abduction in his right eye, paresthesia in all divisions of the right trigeminal nerve and right facial palsy with mild dysarthria. There was no tinnitus, uvula deviation, or tongue deviation. In serum laboratory examination, his venereal disease research laboratory (VDRL) titer was 1 : 16. Treponema pallidum hemagglutination and fluorescent treponemal antibody absorption test were reactive. The serum angiotension-converting enzyme (ACE) level was 12.5 IU/L (normal range : 8.3-21.4 IU/L) and the HIV test was negative. The cerebrospinal fluid (CSF) examination revealed a normal opening pressure at lumbar puncture, 20 white blood cells (80% lymphocytes), no red blood cells, protein level of 41 mg%, and glucose level of 79 mg%. The CSF VDRL test was negative.\nBrain MRI demonstrated a lobulated mass predominantly involving the right cavernous sinus (). The mass extended toward the middle fossa laterally and to the sphenoid sinus anteriorly. This tumor also extended to the cerebellopontine angle posteriorly with a compression of the brain stem. The lesion appeared isointense on T1-weighted images and slightly hyperintense on the T2-weighted images. Moreover, the T2-weighted images revealed hyperintense signal changes in the pontine area. The mass showed strong enhancement after gadolinium administration. On the other hand, malignancy and inflammatory disorders were included in the differential diagnosis considering the rapid enlargement of mass and serological markers.\nA biopsy was performed via the transsphenoidal approach to make a precise diagnosis. The surgical approach was chosen based on the protrusion of pathology in the sphenoidal sinus and minimal invasive technique. A histopathological examination revealed a non-caseating granuloma with an asteroid body (). Special stains including periodic acid-Schiff, Ziehl-Neelsen stain for acid-fast bacilli and Gomori's methenamine silver stain for fungal organisms were negative. Chest and abdomen computed tomography were performed to exclude systemic sarcoidosis, but unremarkable.\nAfter administration of corticosteroid, the headache and facial paresthesia was improved but the diplopia has remained. The pathologic findings were consistent with a diagnosis of sarcoidosis, but the neurosyphilis could not be ruled out in the differential diagnosis due to the positive serologic result for syphilis. The patient received the treatment with intravenous penicillin G for 2 weeks and the steroid was tapered and discontinued. After 4 days of penicillin administration, the right side facial pain and paresthesia became aggravated. Therefore, we were confident in a diagnosis of neurosarcoidosis and resumed the steroid treatment. The facial pain disappeared again after steroid therapy. The steroid dose was tapered down and shifted to oral prednisolone in the third week. He was discharged with isolated right abducens nerve palsy. He received oral prednisolone at the outpatient department for one year and the abducens nerve palsy was improved. A follow-up MRI of the brain revealed resolution of the mass over the cavernous sinus region ().

[[40.0, 'year']]

M

{'22592831': 1, '15207796': 1, '22421696': 1, '5090748': 1, '3734178': 1, '10871259': 1, '20065791': 1, '1732690': 1, '4900707': 1, '17619108': 1, '10029426': 1, '15692958': 1, '21694502': 1, '7701433': 1, '34567398': 1, '204105': 1, '19249139': 1, '22075297': 1, '12383376': 1, '19276791': 1, '6488885': 1, '6093497': 1, '10209662': 1, '29284603': 1, '24570823': 2}

{}

3928376-1

noncomm/PMC003xxxxxx/PMC3928376.xml

Oral smoothened inhibitor for advanced basal cell carcinoma of the hand: a case report

A 43-year-old Caucasian man with a known history of genetic predisposition to BCC presented with multiple large ulcerated, biopsy proven BCCs on his head, trunk, arms, and legs []. In particular, he noted the inability to type on a keyboard, drive a car, or carry out activities of daily living due to the large BCCs studding his dorsal hands, including some that traversed the joints. He had a 2.5-cm multilobular BCC on the distal tip of the left small finger (Fig. ).\nAfter a discussion of his treatment options, the patient elected to begin therapy with oral vismodegib 150 mg daily, due to the size and extent of his tumors. After 1 month, shrinkage of all of the BCCs was apparent (Fig. ). After 6 months of treatment, the BCCs had regressed further, with the lesion on the distal fifth digit receding the slowest (Fig. ). Continued treatment led to further BCC shrinkage (Fig. ). Due to his vismodegib treatment, he regained the ability to carry out activities of daily living, with good functional and aesthetic results. While there are visible scars in areas of previous BCC, the patient reported no limitation in hand movement. In addition, several areas of erosion and erythema were persistent at 3 years and 4 months of follow-up, including the web space between the third and fourth digits, suggesting that a small amount of residual BCCs remained. However, the patient declined biopsy in the absence of lesion growth. He continues to be monitored with full body skin examinations every month for BCC chemoresistance.\nOver the course of treatment, the patient experienced commonly reported side effects, including hair loss and mild muscle cramping in the legs. He did not require treatment for his muscle cramping. Otherwise, the drug was well tolerated.

[[43.0, 'year']]

M

{'10845311': 1, '19726763': 1, '22670903': 1, '20885244': 1, '18813320': 1, '4038911': 1, '22670904': 1, '22474285': 1, '22670922': 1, '20026854': 1, '23446297': 1, '24570650': 2}

{}

3928480-1

noncomm/PMC003xxxxxx/PMC3928480.xml

A Case of Esophageal Fibrovascular Polyp That Induced Asphyxia during Sleep

A 51-year-old man visited our institution for routine endoscopy. He had a long history of snoring and obstructive sleep apnea. His wife frequently heard his labored breathing while he slept and would wake him up. However, the patient did not undergo a complete medical examination because he regarded his condition as simple snoring. Moreover, he did not have a history of regurgitation, pain during swallowing, weight loss, or signs and symptoms of upper gastrointestinal bleeding. His medical and surgical history was unremarkable, and the physical examination findings were normal. Laboratory results were also unremarkable.\nEndoscopy revealed a pedunculated polyp, >5 cm in length, that was detected immediately after inserting the endoscope into the patient's throat (). The polyp arose from just below the pyriform sinus and regurgitated into the oral cavity during endoscopy. Occasionally, the polyp passed through the vocal cords () and obstructed the airway (). We removed the polyp endoscopically using a polypectomy snare () because we believed that the polyp could induce asphyxia during sleep. Histopathological examination indicated that the polypoid lesion contained vascularized loose fibrous shafts covered by squamous epithelium with acanthosis, which were indicative of an FVP (). The patient was discharged on the next day without any complications. At the 3-month follow-up examination, the patient was found to be doing well without any further occurrence of snoring or sleep disturbances.

[[51.0, 'year']]

M

{'12452402': 1, '29416309': 1, '33026474': 1, '16368421': 1, '3039413': 1, '16683893': 1, '19653354': 1, '1130373': 1, '31620525': 1, '8610549': 1, '2178401': 1, '16121086': 1, '31964152': 1, '1948225': 1, '29349606': 1, '1731684': 1, '34459277': 2, '9477279': 1, '7077729': 1, '27148424': 2, '28984298': 1, '26593170': 2, '18957112': 2, '30300986': 2, '12683881': 1, '24570890': 2}

{'6453852-1': 1, '4846627-1': 1, '8408901-1': 1, '4673374-1': 1, '2585102-1': 1}

3928481-1

noncomm/PMC003xxxxxx/PMC3928481.xml

A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation

A 25-year-old female patient was referred from an outside hospital in November 2011 for the management of dysphagia. The patient initially presented to a different hospital in 2008 with a 4-year history of heartburn and acid regurgitation and was diagnosed with GERD. The patient did not complain of dysphagia or globus symptoms at the time, and the esophagogastroduodenoscopy (EGD) performed at the previous hospital showed grade B erosive esophagitis according to LA classification. A 24-hour intraesophageal pH study showed a DeMeester score of 33.1 (normal value, <14.2), a total fraction time of pH <4 of 9%, and abnormal acid regurgitation when the patient was upright (upright fraction time of pH <4, 24%). Preoperative esophageal manometry showed normal lower esophageal sphincter (LES) relaxation during swallowing (resting LES pressure 14 mm Hg to LES relaxation 2 mm Hg), and no peristalsis was observed in the esophageal body (). A favorable response to medical treatment (proton pump inhibitor) was not achieved, and subsequent laparoscopic Nissen fundoplication was performed in September 2009 in a previous hospital. Thereafter, the patient developed postoperative complications such as solid and liquid dysphagia, a sensation of inability to belch, and a sticking sensation in her lower to mid chest. Approximately 2 to 3 weeks after the operation, the patient's symptoms showed improvement. However, regurgitation recurred and was soon aggravated to dysphagia. Dysphagia was worse with solids than with liquids, and these symptoms occurred whenever the patient swallowed food. Medical therapy with proton pump inhibitors and prokinetics was attempted in the previous hospital but was ineffective. The patient was then referred to our hospital. EGD performed at our hospital showed postfundoplication status, and the endoscope could pass through the gastroesophageal junction without any resistance (). The previously observed erosive esophagitis was improved. Esophageal mucosal biopsies ruled out eosinophilic esophagitis. Abnormal barium stasis in the esophageal body was found on barium esophagography (). A paraesophageal hernia was observed on abdominopelvic computed tomography (), which was performed to evaluate the patient for postoperative organic causes of dysphagia. Esophageal manometry showed aperistalsis in the esophageal body, and the resting pressure and percent relaxation of LES were 5 mm Hg and 81%, respectively, which were within the normal range (). In our hospital, medical treatment (prokinetics, mosapride 15 mg; proton pump inhibitor, esomeprazole 40 mg; calcium channel blocker, nifedipine 5 mg) was initiated and continued for 2 months; however, a favorable outcome was not obtained. Pneumatic dilatation with a 30-mm balloon was used for symptom relief, but the symptoms did not improve. Therefore, additional pneumatic dilation with a 35-mm balloon was performed 2 weeks later. Barium esophagography performed after the second pneumatic dilatation showed improved barium passage through the esophagus, but the solid and liquid dysphagia, and globus sensation symptoms were not improved (). We considered esophageal motility disorder or paraesophageal hernia that developed after fundoplication as the most likely cause of the dysphagia. Therefore, we recommended a revision operation that would involve taking down the wrap or Toupet fundoplication. However, the patient refused to consent to a second operation and is currently undergoing medical treatment.

[[25.0, 'year']]

F

{'19172353': 1, '17177077': 1, '2239875': 1, '11818926': 1, '8931410': 1, '10594261': 1, '17306636': 1, '21424193': 1, '24570891': 2}

{}

3928482-1

noncomm/PMC003xxxxxx/PMC3928482.xml

Small Bowel Stent-in-Stent Placement for Malignant Small Bowel Obstruction Using a Balloon-Assisted Overtube Technique

An 80-year-old woman who underwent a pylorus-preserving Whipple procedure 6 years previous for pancreatic head cancer and recurrent disease with duodenal obstruction of the previous placement of two palliative SEMSs was referred to our institution for bowel obstruction distal to the ligament of Treitz. The stents had been placed 2 years and 11 months prior, respectively. Placement of a third stent using esophagogastroduodenoscopy and standard and pediatric colonoscopes had failed. We used a double-balloon enteroscope (DBE) to perform the procedure. The previously placed SEMS was obstructed owing to ingrowth with tissue and the small bowel kinking distally to the stent (). A large amount of impacted food was removed by flushing and suctioning. Using endoscopic and fluoroscopic visualization, the enteroscope was carefully advanced into the jejunum after dilating the stricture. After the scope was advanced, the overtube was gently pushed across the dilation. Deep enteroscopy was then performed, and no other obstructions were found in the afferent or efferent limbs. The Roux-en-Y anastomosis was located approximately 50 cm distal to the pylorus.\nA new SEMS (90-mm length, 10-mm diameter; Boston Scientific, Natick, MA, USA) was inserted across the previous two SEMS using the herein described balloon overtube technique using the following six steps. First, the enteroscope was kept across the stenosis in the upper jejunum (). Second, a Jagwire guidewire (Boston Scientific) was inserted in the jejunum (, ). Third, the scope was removed under fluoroscopic guidance and the wire was left in place (). Fourth, the overtube, which was looped and kinked in the J-shaped stomach, was straightened (). A trick was used to straighten the overtube without losing its position; that is, the balloon of the overtube was inflated distally to the stent. This maneuver allowed the overtube tip to get hooked to the distal part of the overtube while being pulled (i.e., straightened). The overtube straightening was essential to advance the stent through the wire inside the overtube and across the previous stents (; step 5). Sixth, the distal part of the stent was deployed under fluoroscopic guidance while the now deflated overtube was carefully brought back into the stomach through the old stent, thus permitting the new stent to deploy distal to the old stent and the overtube tip across the obstruction (, ). The patient is asymptomatic 3 months after the procedure.

[[80.0, 'year']]

F

{'27833393': 2, '21862005': 1, '25741156': 1, '19896664': 1, '29665632': 1, '22135731': 1, '22712706': 1, '28970734': 2, '21557717': 1, '22851867': 1, '21937243': 1, '22414138': 1, '17055891': 1, '32999905': 1, '11386268': 1, '26140008': 1, '24570892': 2}

{'5083807-1': 1, '5083807-2': 1, '5083807-3': 1, '5597510-1': 1, '5597510-2': 1}

3928483-1

noncomm/PMC003xxxxxx/PMC3928483.xml

A Case of Endoscopic Removal of a Giant Appendicolith Combined with Stump Appendicitis

A 48-year-old man was referred to our hospital for further evaluation of a 2-cm, large, protruding lesion in the cecum found on colonoscopy performed at a nearby hospital. He had been experiencing right lower quadrant discomfort for 1 month. He had undergone surgery for acute appendicitis 35 years earlier. During his recent hospital visit, his vital signs were measured, including blood pressure 120/70 mm Hg, pulse rate 72 beats per minute, respiration 20 beats per minute, and body temperature 36.0℃. Physical examination revealed light tenderness in the right lower quadrant of the abdomen, but there was no rebound tenderness, palpated mass, or muscle guarding. The results of the blood test were normal, with white blood cell count 8,900/mm3 (segmented neutrophil count, 76.7%), hemoglobin level 15.4 g/dL, platelet count 192,000/mm3, total bilirubin level 1.5 mg/dL, and aspartate aminotransferase/alanine aminotransferase level 21/31 U/L. An abdominal CT scan showed that the appendix was thickened owing to the presence of a 2-cm appendicolith; therefore, stump appendicitis was diagnosed (). We consulted the surgery department; they recommended biopsy and colonoscopy to identify the protruding lesion because the patient did not have typical signs of appendicitis, such as right lower quadrant pain, tenderness, and rebound tenderness. Therefore, we conducted a colonoscopy that revealed a 2×3-cm, large, protruding lesion covered by normal mucosa around the appendiceal orifice of the cecum. An embedded stone was visible through the appendiceal orifice. Because the orifice was too small for the stone to be removed, we made a 4-mm incision to widen the orifice by using an IT knife (KD-611L; Olympus, Tokyo, Japan). Next, with a snare, we grasped the lower part of the protruding lesion adjacent to the cecal wall. Then, as we strangulated the lower portion of the protruding lesion, a large stone (fecalith) with whitish pus gushed out of the orifice. During the procedure, complications such as perforation and bleeding were not noted (). An abdominal CT scan and a colonoscopy 2 months later did not show any sign of appendicolith recurrence. The patient has been under outpatient care and has had no symptoms for 2 years.

[[48.0, 'year']]

M

{'21922301': 1, '26598578': 2, '27073312': 2, '21487530': 1, '15657003': 1, '28878833': 1, '22767171': 1, '16536249': 1, '7552642': 1, '24570893': 2}

{'4810953-1': 1, '4655466-1': 1}

3928484-1

noncomm/PMC003xxxxxx/PMC3928484.xml

Extramedullary Plasmacytoma of the Pancreas Diagnosed Using Endoscopic Ultrasonography-Guided Fine Needle Aspiration

A 58-year-old woman was transferred to our hospital for further evaluation of pelvic pain that was aggravated by walking and began approximately 2 months before admission. The initial laboratory tests showed a hemoglobin level of 10.6 g/dL, and blood urea nitrogen was 12.0 mg/dL. The results of liver function tests were within normal limits. The level of total protein level was 9.7 g/dL and the albumin level was 3.3 g/dL. A peripheral blood cell smear revealed mild lymphopenia. Skeletal surveys detected a small osteolytic lesion without a sclerotic rim in the left parietal bone and a large bone destructive osteolytic lesion in the right inferior pelvic bone (). Incisional biopsy of the right pelvic bone suggested a malignant bone tumor. The lesion was diagnosed as a plasmacytoma. Further evaluation showed a serum free light chain lambda level of 3,475.3 mg/L and a β2-microglobulin level of 4.6 mg/L. Immunoelectrophoresis showed the presence of an abnormal band of immunoglobulin G and lambda lanes. Plasma cells were 14.2% on bone marrow biopsy. Contrast-enhanced abdominal computed tomography (CT) revealed a suspicious ill-defined marginated mass in the body of the pancreas (). To further characterize the lesion, magnetic resonance imaging (MRI) of the pancreas was performed. T2-weighted MRI indicated that the pancreatic proximal body contained a mass of subtle high signal intensity () with marked diffusion restriction (). For the histopathologic diagnosis, EUS-FNA was planned. Linear EUS (EU-ME1 Ultrasound System; Olympus, Tokyo, Japan) (GF-UCT 240; Olympus) revealed a 1.2×1.0-cm sized, hypoechoic, heterogeneous, well-defined round mass in the pancreatic body (); FNA was performed via a transgastric approach and five passages were made with a 22-gauge needle (EchoTip Ultra, ECHO-22; Cook Endoscopy, Winston-Salem, NC, USA) (). The cytopatholgy results showed a small cell neoplasm and the immunohistochemical profile was compatible with plasmacytoma (). The patient began combination therapy consisting of bortezomib, mephalan, and prednisolone with local radiation therapy for the right pelvic bone lesion. The patient was followed up carefully.

[[58.0, 'year']]

F

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{'5738755-1': 1, '6708728-1': 1, '4504588-1': 1, '5579914-1': 1}

3928747-1

noncomm/PMC003xxxxxx/PMC3928747.xml

Wandering Meckel's diverticulum on 99m technetium-pertechnetate scintigraphy: A diagnostic dilemma?

A 2-year-old male child admitted to the emergency room with 2 days history of 3 episodes of painless per rectal fresh bleeding. On examination, child was irritable, grossly anemic, afebrile with mild abdomen distention, but audible gut sounds. Per-rectal examination revealed only traces of fresh blood. His hemoglobin was 4.9 g/dl (normal 11-14 g/dl) while other biochemical and bleeding parameters were within the normal limits. Ultrasound abdomen was unremarkable and child had blood transfusions with and started on oral ranitidine (2 mg/kg 12 hourly). On the 3rd admission day, MD scintigraphy was performed with 3 mCi of 99m technetium-pertechnetate injected intravenously with 3 h fasting. Dynamic study for 60 min with a frame rate of 20s/frame was acquired in anterior projection under a dual head digital gamma camera (Ecam, Siemens, Germany) fitted with low energy high resolution collimators. Early images showed the appearance of focus of abnormal tracer deposition in hypogastric region concomitant with the appearance of gastric activity in left hypochondrium and better delineation in subsequent frames same as native gastric activity. Sequential images revealed gross shifting of abnormal focus to left iliac region, hypogastrium, right lumbar, umbilical and finally in epigastric region []. As this abnormal focus remained compact during its tortuous path with no sign of change in its morphology during its whole path, an intraluminal source of radiotracer like bleed (which keeps on changing its shape in lumen of small or large bowel) was ruled out and provisional diagnosis of a wandering MD with heterotopic gastric mucosa was made. The child underwent an exploratory laparotomy and MD was resected and histopathology revealed MD with heterotopic gastric and pancreatic mucosa.

[[2.0, 'year']]

M

{'11034511': 1, '20349056': 1, '15026601': 1, '2513119': 1, '7596666': 1, '19242720': 1, '7848082': 1, '25784978': 1, '16118164': 1, '17885366': 1, '18392223': 1, '24591779': 2}

{}

3928748-1

noncomm/PMC003xxxxxx/PMC3928748.xml

Primary neuroendocrine carcinoma of breast with liver and bone metastasis detected with fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography

Here we describe a case of a 45-year-old female patient who presented with jaundice and was evaluated to have multiple liver lesions and biopsy from liver showed metastatic neuroendocrine tumor. Her chromogranin level was 886 ng/ml (normal < 78 ng/ml). She was referred for the whole body PET/CT for detection of the primary site. PET/CT showed an intense uptake in the soft- tissue necrotic lesion in the inner quadrant of the left breast [Figure and ] with the same charecteristic feature of multiple hypodense liver lesions []. Furthermore uptake noted in a lytic lesion in the D4 vertebra [Figure and ]. Patient underwent fine-needle aspiration of the breast lesion, which confirmed neuroendocrine origin [Figure and ]. A diagnosis of primary NEC of the left breast with metastasis was made and she was treated with peptide receptor radionuclide therapy and is on follow-up now.

[[45.0, 'year']]

F

{'18064696': 1, '6091325': 1, '19020716': 1, '12664118': 1, '19352254': 1, '6303551': 1, '24591780': 2}

{}

3928749-1

noncomm/PMC003xxxxxx/PMC3928749.xml

Paradoxal metabolic flare detected by 18F-fluorodeoxyglucose positron emission tomography in a patient with metastatic breast cancer treated with aromatase inhibitor and biphosphonate

Here we report a case of a 53-year-old woman suffering from advanced breast cancer with bone pain, who came to our observation for the first time in July 2010 in Cracow branch of MSC Memorial Cancer Center. Routine radiological and scintigraphic bone examination confirmed multifocal bone spread with a mixed osteolytic-osteosclerotic pattern [].\nBiphosphonate (Aredia 90 mg/4 weeks) and endocrine treatments were immediately started (Zoladex 3.6 mg/month and Tamoxifen 20 mg/day) together with palliative radiotherapy of left hemipelvis.\nThe first FDG PET scan was ruled out in Gliwice branch of our institution on October 1, 2010 in order to exclude metastatic spread to soft-tissues. It was performed with the use of a Philips Gemini GXL device, 60 min after an injection of 333 MBq of radiotracer. Numerous skeletal lesions were detected, with no metastases outside bones [].\nA bone scan showed progression in April 2011. Due to clinical worsening of the patient's condition, with Zubrod score having increased from 2 to 3, Tamoxifen was substituted with an aromatase inhibitor (Femara 2.5 mg/day). The second palliative radiotherapy was performed on the thoracic spine from April to May 2011.\nA clinical improvement was observed successively in September 2011, with Zubrod score having returned to 2 and a stable bone scan.\nIn March 2012, Zubrod score shifted down further to 1 and Zoladex were stopped. The patient got only bifosphonate and aromatase inhibitor treatment.\nAnother FDG PET examination was performed on February 8, 2013 for a complexive evaluation of the regression degree, 22 and 31 months after the beginning of therapies with the aromatase inhibitor and biphosphonate respectively. The scan was ruled out with the use of a Siemens mCT device, 1 h after an injection of 240 MBq of FDG. Evident recalcification of bone lesions was seen on computed tomography (CT), while an increase of FDG uptake was clearly observable for almost all the bone lesions [Figures , and ]. A direct comparison between SUV scores was not possible, because of PET scans having been performed by different devices. However, tumor/background ratios between physiological liver uptake and pathologic FDG accumulation displayed on Figures (V right rib) and (sternum) confirmed the visual impression of increased radiofarmaceutical uptake [].

[[53.0, 'year']]

F

{'20737104': 1, '11387350': 1, '22317766': 1, '8229124': 1, '18626006': 1, '25829734': 2, '17309184': 1, '17647245': 1, '29748233': 1, '22731662': 1, '19857808': 1, '17060407': 1, '24591781': 2}

{'4379675-1': 1}

3928750-1

noncomm/PMC003xxxxxx/PMC3928750.xml

Solitary spinal epidural metastasis from lung carcinoma

A 78-year-old Indian lady was investigated for cough and weight loss. Initial baseline investigations suggested adenocarcinoma of right lung. Whole body F-18 FDG PET/CT was done for staging workup. The PET/CT scan showed right lung middle lobe mass with few ipsilateral mediastinal lymphnodes. An unusual tracer uptake in D12-L1 right neural foramina region was also noted []. On questioning, she reported lower backache and right hip region pain which was till that time being attributed to old age and degenerative changes. Due to persistent backache, regional MRI was advised after 15 days of PET/CT, which revealed enhancing focal epidural soft tissue thickening on right side at D12-L1 level []. Image-guided biopsy was not amenable and open biopsy was not performed in her clinical context. In view of clinical symptomatology and dual imaging findings, a diagnosis of solitary epidural metastasis was considered. Patient was given for D11-L2 radiotherapy which relieved her symptoms subsequently.

[[78.0, 'year']]

F

{'27413569': 2, '28302996': 1, '31804329': 2, '3067022': 1, '8197934': 1, '18420159': 1, '19634817': 1, '14960648': 1, '17152424': 1, '24591782': 2}

{'6919385-1': 1, '4927970-1': 1}

3928751-1

noncomm/PMC003xxxxxx/PMC3928751.xml

Report of two cases of fluorodeoxyglucose positron emission tomography/computed tomography appearance of hibernoma: A rare benign tumor

This was a case report of a 45-year-old lady, a case of the right breast carcinoma with ipsilateral axillary nodal and liver metastases; underwent a PET/CT scan post-six cycles of chemotherapy. The scan revealed hypermetabolic right breast mass, metastatic right supraclavicular and axillary lymphadenopathy and liver metastases [, maximum intensity projection (MIP)]. Apart from this a hypermetabolic (maxSUV 20.9), low-attenuating, well-defined mass lesion was noted in the left postero-lateral chest wall [Figure -]. This mass was relatively hyperdense to the surrounding subcutaneous fat. This mass had remained unchanged since the previous CT scan (pre-treatment), which was done 4 months ago. The imaging findings led to the diagnosis of a benign fat containing tumor – hibernoma. On a clinical follow-up, a year later after the PET/CT study this painless, soft swelling in the left postero-lateral chest wall remained unchanged confirming the benignity of this rare tumor.

[[45.0, 'year']]

F

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{'3928751-2': 2}

3928751-2

noncomm/PMC003xxxxxx/PMC3928751.xml

Report of two cases of fluorodeoxyglucose positron emission tomography/computed tomography appearance of hibernoma: A rare benign tumor

Here we describe a case of a 50-year-old male patient a diagnosed case of supraglottic cancer underwent a PET/CT scan to look for distant metastasis. He was clinically staged as T4N0M0. His PET/CT scan revealed a large hypermetabolic mass in the right supraglottis involving the right aryepiglottic fold, arytenoids, right true and false cord and eroding the thyroid cartilage. A hypermetabolic right retropharyngeal node was also noted. Apart from this, a hypermetabolic lesion was seen in the medial aspect of the right thigh [, MIP]. The axial images revealed a hypermetabolic (maxSUV 32.6), well-circumscribed ovoid mass with mild and heterogeneous enhancement in the right gracilis muscle, in the medial right thigh. The mass was predominantly of fat density (a little higher than subcutaneous fat) and showed prominent branching vessels within [Figure -]. On the clinical examination a painless, mobile mass was felt in the right medial thigh and the patient gave a history of this being present since many years (20 years). These findings and the history led to the diagnosis of a benign lipomatous tumor (hibernoma).

[[50.0, 'year']]

M

{'12902417': 1, '11395560': 1, '14602861': 1, '18356460': 1, '19188245': 1, '15371618': 1, '6390200': 1, '16971608': 1, '17545854': 1, '22613771': 1, '11953578': 1, '16333529': 1, '16628059': 1, '22914232': 1, '24591783': 2}

{'3928751-1': 2}

3928752-1

noncomm/PMC003xxxxxx/PMC3928752.xml

Asymmetrically increased rib cage uptake on bone scintigraphy: Incidental detection of pleural mesothelioma on single photon emission computed tomography/computed tomography

A 50-year-old female patient of carcinoma left breast underwent modified radical mastectomy, followed by radiotherapy 12 years back. She now presented with left-sided chest pain since 3 months. Suspecting the pain to be of musculoskeletal origin, the treating oncologist referred the patient for 99mTc-MDP BS to rule out skeletal metastases. BS was done 3 h, following intravenous injection of 20 mCi of 99mTc-MDP. It revealed diffusely increased radiotracer uptake involving all the left-sided ribs thus giving the appearance of asymmetrically increased left rib cage uptake [Figure and ; arrows]. The remaining skeleton showed normal radiotracer distribution. Because this pattern was atypical for rib metastasis, single photon emission computed tomography/computed tomography (SPECT/CT) of the thorax was done in the same setting. Transaxial SPECT and SPECT/CT images [Figure and ; arrows] revealed diffusely increased radiotracer uptake in all the left-sided ribs. Using bone window on CT [], all the left-sided ribs showed regular cortical outlines with no apparent abnormality. Transaxial CT in soft tissue window revealed circumferential nodular left-sided pleural thickening [; arrow, arrow head]. The increased uptake of tracer in the ribs was likely secondary to the increased vascularity in underlying pleural pathology and was interpreted as reactive in nature. Biopsy from the pleural-based nodular lesion was suggestive of pleural mesothelioma [Figure -]. Patient was referred to the oncology department for further work up.

[[50.0, 'year']]

F

{'21044553': 1, '15062612': 1, '22748483': 1, '8625125': 1, '19664483': 1, '15405683': 1, '2754488': 1, '4835032': 1, '34385805': 1, '24591784': 2}

{}

3928754-1

noncomm/PMC003xxxxxx/PMC3928754.xml

Bilateral trigeminal nerve recurrence of non-hodgkin lymphoma revealed with FDG PET/CT

A 63-year-old male patient treated for diffuse large B cell type NHL of left testis was in complete remission for 5 years. He presented with weakness, headache and trigeminal neuralgia to internal medicine. He was referred to Nuclear Medicine department for FDG PET/CT imaging to search for possible recurrence. For PET/CT examination, patient was intravenously injected 550 MBq of F18-FDG after 8 h of fasting period. After one hour of waiting period in a silent room, patient was imaged using an integrated PET/CT camera, which consisted of a 6-slices CT gantry integrated on a LSO based full ring PET scanner (Siemens Biograph 6). The injected dose, injection time and body weight were used to calculate the maximum standardized uptake values (SUVmax). PET and fusion images showed bilateral pathological intense FDG uptake in trigeminal nerves with a SUVmax of 16,6 [, arrows]. There were also increased FDG accumulation (SUVmax = 6,4) at the D1 spinal nerve root and slightly increased tracer uptake located at spinal cord between the level of D12 and cauda equina. Cranial MRI revealed thickening of bilateral 5th cranial nerve [Figure and ]. Spinal MRI demonstrated pathologic signal changes at the spinal cord between D12 level and cauda equina suspicious for lymphomatous involvement. Lumbar puncture was performed and cytopathology revealed lymphoma involvement. After administration of 6-cycles of intrathecal methotrexate, repeated CSF analysis was negative.

[[63.0, 'year']]

M

{'26634826': 1, '12672282': 1, '20368468': 1, '17957824': 1, '10653308': 1, '20150388': 1, '15613109': 1, '15925997': 1, '20528901': 1, '22130562': 1, '12075752': 1, '23006953': 1, '21502608': 1, '24591786': 2}

{}

3928782-1

noncomm/PMC003xxxxxx/PMC3928782.xml

Non-inflammatory destructive periodontal disease: a clinical,\nmicrobiological, immunological and genetic investigation

The patient, a healthy Caucasian 46-year-old lady, dental surgeon, presenting normal\nweight and regular physical activities, from the southeastern region of Brazil, promptly\nidentified the beginning of teeth mobility and gingival recession on her own mouth, and\nlooked for periodontal health care. First, she was unsuccessfully advised to intensify\ntoothbrushing procedures as an attempt to control the bone resorption. However, in spite\nof intense toothbrushing and relevant oral hygiene, the gingival recession and teeth\nmobility were continued and the patient came to evaluation by a periodontist from our\nresearch group. The history related by the patient, in this circumstance a dentist,\nsuggested an intriguing case of periodontal disease without visible signs of local\ninflammation. Then, we investigated this unique condition by performing a complete\nevaluation of the patient to provide the pathology's diagnosis, its mechanisms of\ndevelopment and to establish the most suitable treatment for this case.\nThe patient denied any pre-existing dental problems, neither was taking any medication\nfor at least 2 months prior to this study nor had a smoking history. Anamnesis was\nperformed, as well as clinical examination and a score for bleeding on probing, probing\ndepth, and clinical attachment loss at six sites per tooth, by the\nperiodontist, as described previously. Radiographic examination and occlusion movement data were also\nobtained and finally the patient was definitely diagnosed as presenting periodontal\ndisease. First, upon clinical examination, the patient did not present bleeding on\nprobing or probing depth ≥3 mm ();\nhowever, an extensive clinical attachment loss ranging from one third to two thirds of\nperiodontal support was verified in both arches, as well as in anterior and posterior\nteeth, which was confirmed by full-mouth radiographic survey (). The patient also showed gingival recession of 1-3 mm\naffecting mainly facial tooth surfaces ()\nand some teeth presented abnormal mobility. However, despite this broad attachment and\nbone loss, the patient presented satisfactory oral hygiene, with no apparent plaque\nformation or accumulation of gross calculus and the absence of gingivitis or other\ndetectable manifestations of gingival inflammation (). It is of note that this patient had never used tobacco products\nand reported vigorous and intensive toothbrushing, ranging from 5 up to 8 times a day.\nMoreover, regarding the dental occlusion conditions, no premature or abnormal dental or\nrestoration contact on occlusion contacts were verified, as well no laterality or\nprotrusion movements were found to be defective ().\nThe patient was questioned about the presence of systemic conditions that would require\nphysician consult, impact on the oral health or influence on periodontal status, but no\nsignificant findings were revealed and she reported to be generally in good health, as\nconfirmed by her physician. Nevertheless, complementary exams were still required for\ndeeper investigation, and the patient was submitted to standard protocols for evaluation\nof hematological, immunological and endocrine markers. Results from complete blood count\ndemonstrate a minor leukopenia (in special neutropenia) and lymphocytosis, both\nconsidered non significant by her physician (data not shown). Additionally, the levels\nof total hydroxyproline, ALP, calcium, calcitonin, urine calcium, PTH (parathyroid\nhormone), DHEA (dehydroepiandrosterone), FSH (follicle-stimulating hormone), LH\n(luteinizing hormone), glycemia, total cholesterol, HDL (high-density lipoprotein), LDL\n(low-density lipoprotein), triglycerides, type I urine, CRP (C reactive protein) and\nbone densitometry were completely normal.\nTo deeper explore the local modification of periodontal status, the biofilm samples\nobtained from the patient periodontal crevice/pocket were analyzed by Real-time PCR for\nperiodontopathogens detection. The gingival crevicular fluid and biofilm samples from\nthe periodontal crevice/pocket were collected with sterile paper point ISO #40\n(Dentsply, DeTrey, Konstanz, Germany) from at least 5 different bone\nloss sites in the inferior and superior arches, before treatment recommendations, as\ndescribed previously. Subgingival\nbiofilm samples were used for PCR assays for periodontopathogens detection. Bacterial or\nviruses DNA was extracted as previously described, and submitted to Real-time PCR analyses using SybrGreen\n(Invitrogen, Carlsbad, CA, USA) system, specific primers (the primer sequences are\ndepicted in ) and ng of DNA in each reaction. The positivity of bacteria or viruses\ndetection in each sample was determined based on the comparison with positive and\nnegative controls. As expected due to the oral hygiene condition of the patient, no\npositivity was observed for Aggregatibacter actinomycetemcomitans, Porphyromonas\ngingivalis, Fusobacterium nucleatum or Treponema\ndenticola, in any of the sites evaluated from both the inferior or superior\narches. Similarly, there was no DNA detection for viruses related to periodontal\ndiseases like Epstein-Barr virus type 1 (EBV-1), Herpes Simplex virus type 1 (HSV-1) or\nHuman Cytomegalovirus (HCMV) in the same sites ().\nGingival fluid was used for ELISA and enzymatic tests for quantification of the bone\nmetabolism markers acid phosphatase, alkaline phosphatase and RANKL, and inflammatory\ncytokines IL-1β and TNF-a, performed as previously described. These results were compared to 12 control and 12\nchronic periodontitis subjects who also had their gingival fluid collected from healthy\nor diseased sites respectively, as selected before. Although systemic bone metabolism markers were in the\nnormality levels, we observed elevated production of ACP, ALP and RANKL in the gingival\ncrevicular fluid (GCF) samples, in concentration similar to those found in chronic\nperiodontitis patients (-). Conversely, the levels of IL-1β and TNF-a were\nfound to be similar in the samples collected from the patient and the controls subjects,\nwhile higher levels of inflammatory mediators were detected in the chronic periodontitis\nsites (-). These results suggested that, although systemic features were not\naltered, the local bone metabolism was indeed modified, as observed when periodontal\nsites were evaluated.\nIn order to verify whether features like HLA or genetic polymorphisms could also\naccomplish for the extensive bone loss observed, the patient was typed for HLA molecules\nand single nucleotide polymorphisms (SNPs) in gene coding for cytokines associated to\nperiodontal disease susceptibility, as described previously. We also verified if the genetic status\nof the patient could account for the differential clinical condition observed. When the\nIL-1β 3954 SNP was analyzed, we observed the non-polymorphic CC genotype. The present\ndata also demonstrated that the patient carried the IL6-174 GC genotype (polymorphic\nheterozygous), the AA polymorphic genotype for TNFA-308 SNP, the MMP1-1607 - genotype\n1G/2G (polymorphic heterozygous), the non-polymorphic CC genotype of IL-10 592 SNP and\nTGFB1 -509 - genotype CT (polymorphic heterozygous) (). The genetic analysis also demonstrated that the patient was\npositive for HLA-DR4 (*0404) and HLA-B27 alleles, described to be associated with bone\nresorptive diseases like rheumatoid arthritis and periodontal diseases. Interestingly,\nthe patient reported a familial history of rheumatoid arthritis too.\nAltogether, the data obtained in the present case showed that the periodontal disease\npresented by the patient was not a direct consequence of the usual causes like\nmicrobiological factors. Instead, it could involve genetic findings and, in special,\nperiodontal trauma possibly due to excessive toothbrushing and oral hygiene, similar to\nsome gingival recession cases. In view of these results, a less vigorous and diminished\nfrequency of toothbrushing was recommended to the patient. At 2- and 6-month\nre-evaluations, the clinical periodontal condition, including bone loss was stabilized.\nFive years of follow-up revealed that the clinical scenario was stable without further\nevidence of disease progression, since no redness or bleeding on probing, increased\nprobing depth or attachment loss, or tooth mobility were observed. In fact, the clinical\nimages and the panoramic radiography (),\nafter 5 years of follow-up, showed no progression in the generalized horizontal alveolar\nbone loss when compared to the initial findings. Moreover, after controlling the\nexcessive toothbrushing, the levels of ALP, ACP and RANKL in gingival crevicular fluid\nin diseased sites were also greatly reduced, reaching nearby the control levels (-).

[[46.0, 'year']]

F

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{'4787315-1': 1}

3928783-1

noncomm/PMC003xxxxxx/PMC3928783.xml

Cleft lip and palate: recommendations for dental anesthetic procedure\nbased on anatomic evidences

A 20-year-old male patient with a complete unilateral CLP was seen at the\nOrthognathic Surgery Clinic of the Hospital for Rehabilitation of Craniofacial\nAnomalies, University of São Paulo, Brazil, for extraction of the pre-canine\nsupernumerary tooth adjacent to the cleft for prosthetic rehabilitation purposes\n( and ).\nAfter skin and oral antisepsis with 0.12% chlorhexidine (PerioGard®,\nColgate-Palmolive, São Bernardo do Campo, SP, Brazil), a topical anesthetic gel with\n20% benzocaine (Benzotop, DFL, Rio de Janeiro, RJ, Brazil) was applied at the bottom\nof the vestibule to reduce pain during the regional injectable anesthetic procedure\n(mepivacaine with epinephrine 1:100,000; Mepíadre, DFL).\nA first puncture was performed in the first premolar region (), away from the area to be handled in order to avoid a\npuncture near the nose as a direct infiltration in this area is usually very painful.\nThen, after approximately 5 min, when the area was partially anesthetized, a second\npuncture was made at the apex of the tooth to be extracted (), in a slow and gradual manner, with the needle\ninclined 45º to the apex of the pre-canine tooth. Injections throughout the marginal\nbuccal mucosa () and palate () were also performed. After the\nanesthetic procedure, the tooth was extracted following the steps: intra-sulcular\nincision (), dislocation and tooth\nextraction () and, finally, suture ().

[[20.0, 'year']]

M

{'11465251': 1, '11310139': 1, '18788864': 1, '16122652': 1, '19642773': 1, '3860013': 1, '14121954': 1, '13831636': 1, '16149833': 1, '18000905': 1, '11318002': 1, '22437689': 2}

{'3928783-2': 2}

3928783-2

noncomm/PMC003xxxxxx/PMC3928783.xml

Cleft lip and palate: recommendations for dental anesthetic procedure\nbased on anatomic evidences

A 13-year-old female patient with a complete bilateral CLP was seen at the Outpatient\nClinic of the Department of Oral and Maxillofacial Surgery, Prosthodontics and\nTraumatology of the Dental School, University of São Paulo, after referral from an\northodontist for extraction of residual roots located in the margins of the right\nalveolar cleft and premaxilla, and over-retained primary canine and supernumerary\ntooth located in the left maxillary segment. All teeth had poor bone insertion or\nroot malformation ().\nFor anesthesia of teeth located on the margin of the right cleft, topical anesthetic\ngel with 20% benzocaine (Benzotop, DFL) was applied at the bottom of the vestibule,\nin the right maxillary segment and premaxillary areas. The first puncture, using 2%\nlidocaine with epinephrine 1:100.000 (Alphacaine, DFL), was made in the premolar\nregion, avoiding the introduction of the needle in the area near the nose, which is\noften very painful (). A second\npuncture was made in the right maxillary segment close to the buccal aspect of the\ncleft and, in the third puncture, the tooth located on the right margin of the\npremaxilla was anesthetized, with the needle inserted at 45º toward the tooth apex\n(). Infiltrations along the mucosa\nin the buccal () and palatal aspects\n() of the right maxillary segment\nand premaxillary region ( and , respectively) were made to promote greater\nlocal anesthesia and hemostasia during the surgical procedure.\nOn the left side, the anesthetic technique was very similar to the procedure\nperformed on the right cleft, i.e., first infiltration away from the cleft site\n(), second and third infiltrations\nin the cleft area inclined 45º towards the tooth apex () and anesthesia of the buccal () and palatal mucosa\n(). After anesthesia, tooth\nextraction was conducted in a conventional manner (, and ).

[[13.0, 'year']]

F

{'11465251': 1, '11310139': 1, '18788864': 1, '16122652': 1, '19642773': 1, '3860013': 1, '14121954': 1, '13831636': 1, '16149833': 1, '18000905': 1, '11318002': 1, '22437689': 2}

{'3928783-1': 2}

3928834-1

noncomm/PMC003xxxxxx/PMC3928834.xml

Dilatation and curettage of urinary bladder: A rarity

Twenty-eight-year-old female, G4 P3 0 1 3, presented with a progressive decline in urine output for one month, fever, nausea and vomiting for two weeks. Detailed questionnaire revealed that she underwent medical termination of pregnancy by dilatation and curettage by quack, three months ago followed by profuse urethro-vaginal bleeding, urinary ascites and shock for which she was managed conservatively with parenteral fluid, blood component therapy, per cutaneous abdominal tube drainage in a local nursing home. After recovery from shock, the patient noticed a continuous leakage of urine per vaginam for two months followed by progressive decline in urine output for which she consulted various nursing homes with no relief and then she was referred to us. Since first surgery was done by untrained para-medical person, details of which was not available. Available records and frequent questionnaire from attendants could reveal that she had incurred massive vesico-urethral trauma during MTP.\nOn examination, the patient was pale, no pedal edema. Bilateral kidneys were palpable with mild tenderness and the bladder was not palpable. Locally, only vaginal opening with scarred area at the site of urethral orifice seen, anterior vaginal wall was lacerated. Cystoscopy, even with pediatric scope was not feasible.\nHer hemoglobin was 7.2 gm%, TLC-8800/cmm, P67%, L27%, M4% E2%, blood sugar-84 mg%, blood urea-108 mg%, serum creatine-3.9 mg%, serum Na-134 mEq/l and K-5.8 mEq/l. USG-abdomen showed bilateral kidneys enlarged with gross hydronephrosis and both ureters dilated till lower end and a small fibrotic bladder. Plain X-ray of KUB Kidney,Ureter,Bladder region and Electrocardiogram showed no abnormality. Bilateral Percutaneous nephrostomy (PCN were done under local anesthesia. Urine from bilateral PCN was cloudy, sent for culture sensitivity and the patient was put on antibiotic accordingly. When PCN urine culture report revealed no growth, 24 hour urine creatinine clearance from right kidney was 42 mg/ml/minute and from left kidney was 49 mg/ml/minute. After improving the general condition of the patient and when serum creatinine had returned to 1.2 mg%, bilateral antegrade pyelogram was done which showed the blind ending of ureters at lower end and no contrast in the bladder. Repeat sonography of KUB region showed that right kidney measures 10.2 × 4.5 cm in size and parenchymal thickness- 14 mm while left kidney measures 10.5 × 4.8 cm and parenchymal thickness- 15 mm. Both kidneys showed normal cortico-medullary differentiation. Moreover, there was good creatinine clearance from both kidneys, so intravenous urography IVU was omitted. Since there was no urethral opening, only scarring was present and further, bladder was a fibrotic remnant and non distensible on sonography, so voiding cysto-urethrography VCUG was not feasible. The patient was counselled for urinary diversion. She was neither willing to accept any kind of stoma, nor willing to perform clean intermittent catheterization CIC. She was planned for MAINZ II pouch. Pre-operatively, colonoscopy was done to exclude any bowel disease. She was given 300 cc saline enema to check for integrity of anal sphincter and one day prior to surgery, she received poly-ethylene glycol lavage. Under general anesthesia, she received single dose third generation cephalosporin just before induction and was explored through infraumbilical midline approach. Intra-operatively, both ureters were dilated and a fibrotic remnant of the bladder was present and anterior wall uterus was partially injured []. After identifying the rectosigmoid junction, colon was folded on itself, tagged with stay suture, detubularized by making inverted U-shaped incision (20 cm long) along antimesenteric border using cutting diathermy and posterior wall of the pouch was formed by closing in two layers. After making an incision in posterior peritoneum, right ureter was mobilized almost up to its midpoint. Left ureter was mobilized by incising along the line of toldt. Both ureters were reimplanted on posterior wall lateral to midline, via a 4 cm long submucosal tunnel using 5-0 Vicryl suture and were anchored on the posterior wall of the pouch. Both ureters were stented over 10F infant feeding tubes and brought out through anus by side of 30F flatus tube. After closing anterior walls of reservoir, pouch was fixed to periosteum of sacral promontory. Abdominal tube drain was inserted in pelvis. Flatus tube and infant feeding tubes were sutured to perianal skin. Post-op period remained uneventful. Abdominal tube drain and flatus tubes were removed on 4th post-op day. Infant feeding tubes were removed on 10th post-op day. Initially, she used to pass urine every 2-4 h, gradually day time frequency improved and she developed no nocturnal incontinence. At 3-year follow-up, serum electrolytes are normal and USG-KUB showed no dilatation of upper tract.

[[28.0, 'year']]

F

{'9823913': 1, '2179579': 1, '15142160': 1, '8426396': 1, '15210042': 1, '24592378': 2}

{}

3928835-1

noncomm/PMC003xxxxxx/PMC3928835.xml

Signet ring carcinoma of ampulla of vater

A 61-year-old woman was admitted to the Al Zahra hospital in Isfahan, Iran, in 2011 with occasional jaundice and generalized pruritic for 4 months; also, she complained of 7 kg weight loss during this period. She had no symptoms of nausea, vomiting, or abdominal pain. She had a past history of diabetes mellitus and blood hypertension. Physical examination was not contributory. In initial investigation, the laboratory test results demonstrated the rising level of glutamate-pyruvate transaminase, glutamic-oxaloacetic transaminase, alkaline phosphatase, γ-glutamyl transferase, and mild increase in total bilirubin and direct bilirubin. Ultrasonography indicted extra and intrahepatic biliary duct dilatation and increased common bile duct diameter. At endoscopic retrograde cholangiopancreatography (ERCP), the tumor of papilla of Vater was revealed and dilated intrahepatic and common bile duct with distal rat tailing was shown after dye injection []. Biopsies taken during ERCP were diagnosed as signet ring carcinoma. Subsequence CT scan indicated intra- and extrahepatic ducts dilation, there were no obstructive mass or adenopathy. Liver, spleen, stomach, and pancreas were normal. At last the patient underwent a Whipple resection. On macroscopic examination there was polypoid mass at ampulla of Vater measured about 0.8 × 1 × 1 cm. pancreas and duodenum were normal. On microscopic examination the, malignant epithelial cells had intracytoplasmic mucin and individually infiltrating pattern that invaded to duodenal wall []. Regional lymph nodes were not involved. The ampullary carcinoma was diagnosed as T2N0M0, Stage IB according to the International Union Against cancer TNM classification (UICC).[]

[[61.0, 'year']]

F

{'15490032': 1, '20200586': 1, '12397285': 1, '2171451': 1, '16536256': 1, '21376425': 1, '20950208': 1, '12768376': 1, '16437905': 1, '15536289': 1, '15648791': 1, '14509231': 1, '18030577': 1, '21386645': 1, '7876027': 1, '8049111': 1, '11995497': 1, '19230055': 1, '16361773': 1, '19890196': 1, '24592377': 2}

{}

3928840-1

noncomm/PMC003xxxxxx/PMC3928840.xml

Brain abscess as the first manifestation of pulmonary arteriovenous malformation: A case report

A 25-year-old male came to our hospital, had complains of headache, nausea, vomiting, and fever from five days ago. The general physical examination was unremarkable and neurological exam was also normal.\nPrimary hematologic and biochemistric laboratory data were unremarkable, except for mild polycythemia. Lumbar puncture (LP) was performed and cerebrospinal fluid (CSF) analysis revealed increased protein and white blood cells (mostly neutrophils), but CSF direct smear and also CSF and blood culture were negative.\nFor more evaluation, brain MRI was performed which showed hyposignal and round lesion (about 3.5 cm) in left occipital lobe in T1w image [], associated with high signal intensity capsule and obvious prelesional edema in T2w image [] and no signal loss in Fluid Attenuated Inversion Recovery sequence [], so brain abscess was the first differential diagnosis for patient.\nThen patient underwent craniotomy and occipital brain abscess was the first impression of surgeon during surgery.\nDirect smear of lesion's samples showed many gram positive cocci which was culture positive and identified as streptococcus viridians, so gram positive abscess was confirmed.\nPatient was not drug abuser and in cardiological consult and echocardiaographic exam, there was not any evidence of endocarditis, so, initial source of brain abscess remained undetermined.\nThree days post operation he suffered from right lower limb pain and swelling; he underwent a Doppler ultrasound exam and deep vein thrombosis of right superficial femoral vein was confirmed, then thoracic multislice CT scan was requested to rule out pulmonary thrombo embolism (PTE) because mild dyspnea of patient.\nPulmonary CT angiography was performed with special PTE protocol by 64 multislice CT, and we found partial filling defects in segmental branches of right lower lobe pulmonary artery which were compatible with segmental PTE [], but we were also surprised to see multiple obvious pulmonary arterio-venous malformations (AVM) as multiple masses or nodular densities with well defined and lobular margin containing feeding artery and draining vein [Figures –].\nAfter detecting multiple AVM, patient was reassessed and while reviewing his history and physical examination, we found history of recurrent epistaxis (with frequency of three to four times a week) and patient informed that episodes of epistaxis are usually after eating hot food stuff. So far, the patient did not yet have the need for nasal packing or blood transformation, conversely he had high hemoglobin (about 15.5) in the day of admission, indicating mild polycythemia. This polycythemia could be due to degrees of hypoxemia secondary to multiple arterivenous shunts, which is similar to other types of right to left shunts.\nAlso, his father and one of his sisters had recurrent epistaxis without any other complications.\nIn repeated physical exam, we noted telangiectatic lesions in his leg and ankle, so, four of four curacao criteria[] for HHT were fulfilled and Osler-Weber- Rendu syndrome was confirmed for the patient. There was no obvious clubbing or cyanosis. Also, abdominopelvic sonographic study was unremarkable and there was no any hepatic, splenic, or pancreatic lesion. Consultation with radiologist for interventional procedures and also with surgeon was requested for patient, but unfortunately patient left hospital on his own request and responsibility and refused further therapeutic options.

[[25.0, 'year']]

M

{'20466398': 1, '21177836': 1, '9509843': 1, '4834927': 1, '28603431': 1, '14768481': 1, '22093524': 1, '15827889': 1, '8027815': 1, '21959191': 1, '2244311': 1, '11553832': 1, '8184034': 1, '17170340': 1, '11804924': 1, '11930021': 1, '24592375': 2}

{}

3928844-1

noncomm/PMC003xxxxxx/PMC3928844.xml

Acute pulmonary emboli due to internal jugular vein thrombosis in papillary thyroid carcinoma, a case report and literature review

A 75-year-old woman with a three month history of dyspnea on exertion (DOE), weight loss and anorexia was referred to the clinic of pulmonary disease. There were no other symptoms. Her medical history had no problem. On admission temperature was 37°C, pulse rate was 85/min, respiratory rate 14/min and blood pressure was 140/90mm/Hg, jugular vein pressure (JVP) was normal and there was no neck and arm swelling. A right-sided cervical adenopathy with suspected thyroid nodule was detected. Other examinations were normal.\nChest X-ray was normal, erythrocyte sedimentation rate (ESR) was 70/hour, other routine laboratory tests were normal. Echocardiography was normal. Sonography revealed cervical adenopathy of the right side and thyroid nodule with the dimensions of 0.8 mm × 0. 6 mm.\nOne day after admission, sudden dyspnea was occurred with PR: 125/min, RR: 30/min, BP: 85/50mm/Hg and o2 saturation: 70%. A decreased sound was detected in both lungs. Chest X-ray showed a bilateral pleural effusion. Pleural tap was exudative, CT spiral showed bilateral pulmonary emboli with plural effusion and lung collapse []. She was treated with streptokinase. CT scan of the neck showed a right-sided cervical adenopathy, heterogeneous thyroid and internal jugular vein thrombosis concomitant with superior thyroid vein thrombosis []. Thyroid FNA revealed papillary thyroid carcinoma []. The day after thrombolytic therapy her respiratory distress became better that showed thrombotic nature of emboli.\nFinally total thyroidectomy was performed, histopathological examination revealed papillary thyroid carcinoma with lymph node involvement. Microscopic examination showed neoplastic proliferation of epithelial cell with papillary appearance, the cells include round to oval nuclei with ground glass foci. Doppler ultrasonographic examination of the subclavian, axillary and brachycephalic vein was normal. After total thyroidectomy, she was treated with the diagnosis of secondary IJVT due to PTC with enoxaparin and Warfarin, after 5 days warfarin continued.

[[75.0, 'year']]

F

{'12553740': 1, '15538664': 1, '22328450': 1, '12853582': 1, '21116671': 1, '3211826': 1, '20974769': 1, '24592374': 2}

{}

3928849-1

noncomm/PMC003xxxxxx/PMC3928849.xml

Streptomyces infection in Cushing syndrome: A case report and literature review

Patient was a 24-year-old man, admitted to hospital due to sudden dyspnea for 3 days with cough and yellowish sputum from almost 7 days before admission. He had fever for 5 days before admission. He was healthy until 50 days before admission and was sent to the tropical city for military service where he had an insect bite. After the bite, swelling and edema of upper limb occurred followed by edema on the face and body, acne and weakness of proximal muscles 2 days later. During 1 week, body edema decreased while muscle weakness, acne and facial edema remained. Acnes spread to the anterior chest and face.\nOn physical examination: He was ill and had a moon face appearance; a lot of papulopustular rashes were seen in the face and anterior of the chest. He was febrile with 39.3°C oral temperatures, respiratory rate: 30/min and pulse rate 115/min, blood pressure 145/95 mmHg. O2 saturation was 86%, White blood cells: 20500/cm, polymorphonuclear leukocyte: 90%, erythrocyte sedimentation rate: 72 mm at 1 h, k: 2.8 mEq/l, pH: 7.52 and he had a decreased sound in left lung with hyper resonance in upper and dullness in the lower portion of the chest, the force of proximal muscle was 3/5. Chest X-ray showed hydropneumothorax [].\nChest computed tomography scans showed pneumothorax, plural effusion in the left side accompanied by lung collapse. Also, there were several lung consolidations with pleural thickening [].\nThoracentesis was done and analysis for protein, lactate dehydrogenase, glucose, PH, cytology, culture and smear was sent. Blood culture was asked because of systemic inflammatory response syndrome.\nPleural fluid was indicative of empyema with glucose 30 mg/dl and pH: 7, so chest tube was inserted and a broad spectrum was administered until smear and culture of pleural fluid being ready. After chest tube insertion, chest X-ray was taken which showed decreased pleural effusion, but lung expansion did not occur. Bronchoscopy was normal. Thoracoscopy was done for decortication of pleural thickening [Figures and ].\nPleural biopsy showed fibrin deposition and chronic inflammatory cell infiltration, with chronic inflammation [].\nA smear of pleural fluid showed gram positive beaded basil and aerobic culture of pleural fluid confirmed Streptomyces with filamentous appearance. Pleural biopsy culture justified Streptomyces too. Culture was negative for acid fast bacilli. Bacteriogram reveal sensitivity to co-trimoxazole, meropenem, ciprofloxacin, cefotaxim, tetracycline and claritromycin and resistance to ampicillin, ceftazidim, cefotaxim and piperacillin-tazobactam. Blood culture was negative for specific organisms.\nDuring hospitalization polyuria occurred. In work-up, hypokalemia and hyperglycemia happened. Because of symptom, physical examination and laboratory test, a work-up for Cushing was done.\nUrinary free cortisol was 600 μg/24 h, over-night dexametason suppression test was positive justified Cushing syndrome. Adrenocorticotropic hormone (ACTH) was 180 μg/dl that showed ACTH dependent Cushing syndrome. High-dose dexametason suppression test was done and the suppression of cortisol did not occur, brain magnetic resonance imaging (MRI) did not show adenoma. Rapid progression of symptom and normal brain MRI confirm ectopic ACTH, but no origin was found in the work-up.\nBilateral adrenalectomy was done and histopathology confirmed adrenal hyperplasia without malignancy [].\nEmpirical treatment was converted to meropenem for 6 weeks. He was recommended to use claritromycin for 6 months at the time of discharge.

[[24.0, 'year']]

M

{'23092549': 1, '17369139': 1, '14875224': 1, '11702082': 1, '28341804': 1, '33414324': 1, '9675460': 1, '17928185': 1, '33414328': 1, '24592373': 2}

{}

3928915-1

noncomm/PMC003xxxxxx/PMC3928915.xml

Inflammatory pseudotumor of spleen

A 63-year-old woman was admitted in our clinic with abdominal discomfort. She complained of upper left quadrant abdominal pain from 2 years ago. She had past history of nephrolithiasis that was treated by extracorporeal shock wave about 2 years ago; she was a known case of uncontrolled diabetes mellitus and had several resorts to cardiologists for transient chest and abdominal pain. Her paraclinical findings were as follow: Fasting blood sugar was 269 mg/dl, HbA1c was 9.1, T3, T4, Thyroid stimulating hormone, Aspartate transaminase, Alanine aminotransferase, Alkaline phosphatase, Creatinine and Blood urea nitrogen was normal and Hb was 11.9 g/dl. There was no any contributory finding in initial physical examination, so she referred to radiologist for abdominal ultrasonography.\nUltrasonographic investigation revealed hypoechogenic solid mass at inferiomedial pole of spleen that measured 83 mm × 82 mm × 70 mm and cortical cyst of right kidney, thus furthermore abdominal computed tomography (CT) scan was done for her. On CT-scan examination the hypodense mass was shown at central portion of spleen that induced marginal bulging []. There was no calcification and remarkable enhancement. Liver density was low due to fatty change. Other organs were normal there was no lymphadenopathy. With such findings the different diagnosis was primary tumor of spleen, hamartoma and single metastasis, so splenectomy was advised.\nOn surgical operation the spleen with peripheral lymph nodes were removed and send to pathologist.\nOn macroscopic examination, spleen measured 13 × 9 × 7 cm and weighted 370 g. After sectioning a well circumscribed bulging brown colored mass, 8 cm in greatest diameter was identified with softer consistency than splenic tissue [].\nOn microscopic examination, the mass showed diffuse infiltration of fibroblasts and inflammatory cells mainly composed of lymphocytes, significant number of plasma cells, some histiocytes and neutrophils []. Lymph nodes showed follicular hyperplasia with some hemosiderin pigment deposition. This feature was consistent with IPT. For rule out the Hodgkin's lymphoma immunohistochemical study was recommended. The common panel for hodgkin's cells are cluster of differentiation 15 (CD 15) and CD30 positivity but in IPT the background CD3 and CD20 positive lymphocytes are only exist.\nIn immunohistochemical staining the CD15, CD30 and anaplastic lymphoma kinase (ALK1) were negative, CD3 and CD20 were positive in few background inflammatory cells thus Hodgkin's lymphoma was ruled out [].

[[63.0, 'year']]

F

{'16714624': 1, '25548610': 1, '19669195': 1, '31934000': 1, '1746682': 1, '26331003': 2, '26488026': 1, '19009664': 1, '10830990': 1, '11774173': 1, '15648289': 1, '21092210': 1, '12866373': 1, '18941088': 1, '7611533': 1, '18040148': 1, '20726354': 1, '11231487': 1, '22470813': 1, '26109554': 1, '10457425': 1, '11342774': 1, '24592376': 2}

{'4508554-1': 1}

3929008-1

noncomm/PMC003xxxxxx/PMC3929008.xml

A case report of Small Colony variant of Staphylococcus aureus isolated from a patient with chronic oesteomyelitis in a tertiary care hospital of eastern India

A 46 years old man had a closed proximal left humeral fracture following a road traffic accident one and half year back. After that he was referred to our hospital where fixation of fractured fragments was done by internal screw fixation followed by pre-emptive treatment with cefoperazone-sulbactum combination and ceftazidime for 10 days. The patients was initially fine for two weeks after that he suffered from persistent pain over affected region and six months later a sinus tract developed along with purulent discharge. [] The patient received various combinations of antimicrobials (mainly second and third generation cephalosporins) to control the disease. Conventional radiographs showed subperiosteal thickening in earlier stage. Bone scintigraphy showed increased uptake in the humeral diaphysis. Laboratory investigations revealed hemoglobin 12 mg/dl, leucocyte count 12 × 103/cmm, erythrocytic sedimentation rate 30 mm/1st hr, random plasma glucose level 130 mg/dl and CRP 180 ug/ml. The expressed pus from the sinus tract was aseptically collected. The direct gram stained smear of collected pus showed gram positive cocci (GPC) arranged in small clusters. The other part of collected sample seeded on blood agar (BA) and McConkey's agar (MA) plate and both the plates were incubated aerobically at 37°C for 48 hours. After 48 hours of incubation non-pigmented small 0.1 mm diameter non haemolytic colonies grew on BA plate. [] MA plate showed no growth. The colonies were further sub cultured on Nutrient Agar (NA) and grew as small non-pigmented colonies. Gram stained smear from colony of BA and NA revealed GPC arranged in small clusters. The colonies were catalase positive and oxidase negative. Slide coagulase test from the isolated colonies was negative and tube coagulase test was positive after 18 hours. Antibiotic susceptibility test result showed the isolated strain was only susceptible to vancomycin and resistant to oxacillin, azithromycin, co-trimoxazole, and cefpodoxime. [] A lawn culture was put on NA plate along with 20 ug and 40 ug menadione impregnated discs over it. The colonies around menadione discs grew as large colonies thereby confirming menadione auxotrophy. Subculture from this large colony revealed yellow pigmented normal Staphylococcal colony. [] These large colonies were catalase, coagulase (slide and tube) tests positive and oxidase negative.

[[46.0, 'year']]

M

{'16983605': 1, '19162480': 1, '31604449': 2, '26448688': 1, '9770133': 1, '7727677': 1, '701460': 1, '14609471': 1, '16541137': 1, '32443285': 1, '24600603': 2}

{'6788114-1': 1}

3929053-1

noncomm/PMC003xxxxxx/PMC3929053.xml

Diaphyseal osteosarcoma with varying histomorphologic patterns

A 29-year-old male presented with painful non-progressive swelling in the left lower leg since 3 years. He gave history of pain while walking. There was no history of trauma. Past and family history was not significant. On examination, 10 × 6 cm firm to hard swelling was noted at the middle one-third of left lower leg. The skin over the mass was unremarkable. Chest X-ray was normal []. X-ray of the affected lower limb revealed large lucent defect in the medullary cavity in the mid shaft, with extensive calcification/ossification in the soft tissue mass []. The possibility of adult Ewings sarcoma or osteosarcoma was considered. Magnetic resonance imaging (MRI) scan revealed a well defined lobulated mass with infiltration in the medullary cavity suggestive of a malignant neoplastic lesion, possibly osteosarcoma [ and ]. Three phase bone scan revealed pathology involving left tibial shaft without distant skeletal involvement. Fine needle aspiration cytology (FNAC) showed scattered small malignant cells suspicious for Osteosarcoma or Ewings sarcoma. Biopsy was advised. Tissue sections showed sheets of malignant cells. These cells were round to oval to spindle, they had a high N:C ratio, scanty cytoplasm with hyperchromatic nuclei. Foci of malignant spindle cell proliferations were seen, at places forming hemangiopericytomatous pattern. Osteoid formation with calcification was also observed. Other areas of the tumor showed telangiectatic features and atypical chondroid formation. Active mitosis was observed. Areas with islands of malignant round cells were also seen [Figures and ]. Based on these histopathological features, a diagnosis of high grade Osteogenic Sarcoma was offered. Patient was advised neoadjuvant chemotherapy followed by surgery of amputation of left lower limb. The patient went to oncology centre for treatment and has been lost for follow up.

[[29.0, 'year']]

M

{'16860938': 1, '9179055': 1, '25785071': 1, '7850721': 1, '16627266': 1, '28630843': 2, '1069603': 1, '23455825': 1, '24600604': 2}

{'5458701-1': 1}

3929265-1

noncomm/PMC003xxxxxx/PMC3929265.xml

Emphysema following vitrectomy with fluid–gas exchange: description of a rare complication

A 55-year-old man presented with bilateral eyelid and face edema, dysphagia, dysphonic voice, and mild dyspnea 30 minutes after a 23-gauge vitrectomy surgery with fluid–gas exchange. A slit-lamp examination presented with bilateral eyelid edema. A single X-ray image of the thorax and neck also confirmed the semiologic aspects ( and ). The air infiltration of the soft tissue demonstrated crepitating of the soft tissue to digital press on the face, extending to the neck and upper chest. The patient underwent an orbital computed tomography scan that revealed the presence of emphysema of the orbit and bilateral soft tissue on the face ().\nThe patient had a past history of face trauma for more than 20 years, with orbital fracture of the floor. This fracture was not previously correct by surgery and is considered as a scar nowadays ().\nThe patient was hospitalized for clinic observation, cardiac evaluation, blood testing, and prophylactic antibiotic therapy for one week. All signs of compressed anatomical structures by subcutaneous emphysema (dysphagia, dyspnea, and dysphonia) had ceased at the time of discharge, and the patient was in improved and stable condition. Postoperatively, at 3 months, the retina was flat with good intraocular pressure (IOP) control and no evidence of orbital infection.

[[55.0, 'year']]

M

{'10482105': 1, '26265649': 2, '15689813': 1, '18044691': 1, '21236459': 1, '19816241': 1, '17934167': 1, '27595884': 1, '15920190': 1, '1476983': 1, '29503885': 1, '8190488': 1, '24610998': 2}

{'4550992-1': 1}

3930962-1

noncomm/PMC003xxxxxx/PMC3930962.xml

Cryptococcal infection in non-HIV immunosuppressed patients – Three case reports in a nephrology setting

A 34 year-old male with chronic renal failure due to renal malformation, was admitted due to persistent headaches. Patient was diagnosed with bilateral renal atrophy at the age of 3. He was on hemodialysis since 1998 (day – 4783) and submitted to deceased-donor renal transplant in April 2001 (day – 3780). Immunosuppressive therapy consisted of cyclosporine A (CsA) and mycophenolate mofetil (MMF), with posterior conversion to sirolimus. High dose methylprednisolone (MP), plasmapheresis, monthly high-dose immunoglobulin infusions, and rituximab were administered due to acute humoral rejection in April 2010 (day – 548).\nOn November 2011 (day – 0) he was presented to the emergency department with a 5 day frontal headache, nausea and vomiting, photo- and phonophobia. No other symptoms were reported, namely fever. Physical examination was unremarkable. Hematologic and biochemical analysis demonstrated normal white blood cells count, no anemia nor thrombocytopenia, and a normal C-Reactive Protein (C-RP) level. Urinary sediment was bland. Chest X-ray, abdominal and graft ultrasounds were normal. Thoracic CT revealed condensation on the upper lobe of the left lung. Cerebral MRI presented asymmetric cortical lesions, with hyperintensity on T2-weighted and hipointensity on T1-weighted images.\nCerebral spinal fluid (CSF) analysis revealed 138 white blood cells (137 lymphocytes), glucose 0.69 g/L, and proteins 0.69 g/L. CSF was India-ink and culture positive for C. neoformans, and polymerase chain reaction (PCR)-positive for cytomegalovirus (CMV).\nA meningoencephalitis to C. neoformans concomitant with CMV infection was assumed. On day 2 treatment with liposomal amphotericin B associated to fluconazole was initiated, along with valganciclovir and anti-CMV immunoglobulins. Lumbar puncture repeated on day 15 revealed a CSF negative for both agents. Transition to fluconazole (400 mg per day, oral) for 12 months and valganciclovir (450 mg every other day) for 6 months was performed. Sustained clinical response was achieved.

[[34.0, 'year']]

M

{'16868977': 1, '17043051': 1, '11384512': 1, '15909263': 1, '24077953': 1, '33639642': 1, '8980772': 1, '21612758': 1, '27599471': 1, '20879857': 1, '20218876': 1, '20047480': 1, '33628263': 2, '16278598': 1, '15096556': 1, '31456952': 1, '24050410': 1, '22556106': 1, '12201357': 1, '24567894': 2}

{'3930962-2': 2, '3930962-3': 2, '7892246-1': 1}