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Emery Rodriguez

2001/1/5

(669)765-9245x489

37784 Ramirez Spurs Suite 713

A 17-year-old, nonparous girl presented with a one-month history of noticeable pelvic mass and was diagnosed to have a left ovarian tumour in 2007 with a raised serum CA-125 of 350 IU/L. Other tumour markers were not performed due to financial constraint. An intraoperative frozen section revealed immature teratoma and she underwent fertility sparing surgery. A staging laparotomy with left salpingo-oophorectomy, peritoneal cytology, pelvic lymph nodes sampling, and infracolic omentectomy was performed. Postoperative histology report revealed mature teratoma with focal area of immature teratoma of the left ovary. There was no malignant cell infiltration to the omentum or lymph nodes. Histology revealed immature teratoma grade I, FIGO stage 1a. Despite being advised for close surveillance, she defaulted followup after 6 months postoperative. One year later, she presented with lower abdominal discomfort and resought medical advice. She developed radiological recurrence of pelvic mass with a raised serum CA-125 of 180 IU/L following which she completed 6 courses of systemic chemotherapy (carboplatin-paclitaxel). After chemotherapy, the tumour marker normalised (<35 IU/L) but the pelvic mass progressively increased in size. CT scan of the abdomen and pelvis revealed presence of bilateral large adnexal masses with infiltration into uterus and also possibly to the sigmoid colon. Growing teratoma syndrome was suspected. She underwent staging laparotomy and complete excision of the tumour. Full bilateral pelvic lymphadenectomy was done. Postoperative CT scan of the abdomen and pelvis showed no residual disease. Histology of excised mass revealed mature teratoma with no presence of immature cells. The patient remained with no recurrence at the time of this report, which is 8 months after the second operation for GTS.

Henry King

1988/8/27

804.973.3503x9745

96232 Ashley Ways Suite 547

A 55-year-old Vietnamese male with no significant past medical history presents to a local community hospital emergency department because of abdominal pain and distention of two-week duration. The abdominal pain was generalized, described as cramping, present throughout the day, had no association with meals, and was getting progressively worse. The patient also reported nausea and vomiting clear material. He denied any recent fever, chills, night sweats, weight loss, change in bowel habits, sick contacts, and consumption of raw food. In addition, he denied any chest pain, shortness of breath, joint swelling, and skin rash. After immigration from Vietnam 11 years ago, his only travel outside the USA was back to his homeland one year prior to this illness. The patient was not taking any prescribed or over the counter medications or herbal compounds and denied any allergies. His physical examination showed no skin rash or jaundice, cardiopulmonary examination showed no abnormality, and the abdomen was moderately distended, with active bowel sounds, diffuse tenderness without rebound, and moderate ascites. There was no hepatomegaly or abdominal mass. In the emergency department, a complete blood count and comprehensive metabolic panel were significant for an elevated white blood count of 15.400 with 36% eosinophils. Abdominal and pelvis computer tomography (CT) showed moderate ascites with thickening of the gastric antrum and proximal small bowel (). The patient was admitted to the general medical service and placed on bowel rest and intravenous fluid hydration. Further he underwent esophagogastroduodenoscopy (EGD), which demonstrated mild duodenitis and biopsies demonstrated mild nonspecific acute inflammation predominantly lymphocytic. Stool tests were negative for ova and parasites. In addition, a screen for Cryptosporidium, Cyclospora, Isospora, and Sarcocystis did not reveal evidence of recent infection. Over several days, the patient's abdominal pain improved, diet was advanced, and he was discharged home with an empiric trial of albendazole for a presumptive diagnosis of parasitic infection. Two weeks after discharge, the patient was readmitted with worsening abdominal pain. Physical examination showed increased abdomen distention. Repeated blood counts and serum biochemical tests demonstrated an increase in white cell count of 17.100/mL with 71% eosinophils (absolute eosinophil count of 12.141/弮l with normal upper limit <450) (). Liver function tests continued to be within normal limits. Serum IgE level was elevated at 548 IU/mL (normal < 180). Repeat stool tests were negative for ova and parasites. Furthermore, immunologic studies for Toxocara, Trichinella, Strongyloides, Filiaria, Schistosoma, Echinococcus, and Cysticerus were negative. Repeated EGD was nondiagnostic. Flow cytometry of peripheral blood revealed no myelo- or lymphoproliferative findings. Serum 帣-2-microglobulin and LDH were 2.2 mg/dL (normal: 0.8??.0) and 170 U/L (normal: 80??00), respectively. Ultrasound guided abdominal paracentesis showed WBC count of 6600/mL, 95% of which were eosinophils (), LDH 284 mg/dL, albumin 3.2 g/dL (simultaneous serum albumin 4.1 g/dL). In order to exclude small bowel lymphoma, the patient underwent diagnostic laparoscopy with full-thickness biopsy of an inflamed portion of the jejunum. This revealed skipped areas of hyperemia and discoloration involving the small intestine and to a lesser degree the colon in addition to yellow-green ascites (). Histopathological evaluation showed marked eosinophilic infiltration of the muscularis propria and serosa with concomitant mild acute inflammatory reaction (). There was no evidence of malignancy, granuloma, TB, or parasites. The constellation of clinical presentation and histopathological findings were suggestive of eosinophilic gastroenteritis. Subsequently, the patient was started on oral prednisone (20 mg/day). Two weeks later and with noticeable symptomatic improvement, the prednisone was tapered over a two-week period. After completion of steroids, the patient's abdominal pain and physical finding of ascites completely resolved and a peripheral blood count revealed an absolute eosinophil count of 300/弮l (nL < 450). Furthermore, IgE level dropped to 105 IU/mL and CT imaging of the abdominal and pelvis showed complete resolution of the ascites and small bowel thickening. Four months have elapsed since treatment and the patient remains asymptomatic on no medications.

Victoria Daniels

1982/6/2

+1-856-413-4368x190

1117 Kaiser River Suite 673

The first case involved a 43-year-old man with a past medical history of hyperlipidemia and hypertension who presented to the hospital with chest pain. The chest pain was described as a pressure-like sensation in the center of his chest, 8/10 in severity, and radiated down his left arm. Upon presentation, vital signs were stable, cardiac biomarkers were within normal limits, and the electrocardiogram (EKG) showed no ST/T-waves changes. Transthoracic echocardiogram showed normal left ventricle function and no wall motion abnormalities. Of note, the patient had a similar presentation and ER course two weeks prior. Due to the fact that the patient continued to have 8/10 chest pain during his hospital stay, coronary angiogram was ultimately done. The angiogram showed normal coronary arteries without evidence of coronary vasospasm or an existing myocardial bridge. Slow flow, however, was noted in the left anterior descending artery (LAD). An intracoronary adenosine challenge was done and showed normalization of the TIMI (Thrombolysis in Myocardial Infarction) frame count (). The patient was given the diagnosis of coronary slow flow phenomenon and started on dipyridamole 50 mg three times a day and discharged home. On six-month followup, the patient reported that he had been chest-pain-free. Shortly after his six-month followup, the patient ran out of his medicine and again began to experience chest pain. Once the patient was placed back on his dipyridamole, he became chest-pain-free.

Xander Santana

2000/6/28

362.516.5576x16185

14752 Michael Path Suite 576

The second case involved a 70-year-old gentleman with a past medical history of squamous cell carcinoma of the base of tongue six years prior. The patient presented with a single episode of chest pain at rest described as pressure-like and associated with shortness of breath and diaphoresis. Admission EKG revealed T-wave inversion in the anterior leads and a prolonged QT interval (). Cardiac enzymes were also noted to be elevated (CKMB 8.3 IU/l and troponin I 1.14 ng/mL). Transthoracic echocardiogram showed normal left ventricular function with no wall motion abnormalities or left ventricular hypertrophy. A diagnosis of non-ST-elevation myocardial infarction (NSTEMI) was made, and the patient was started on the appropriate acute coronary syndrome medications. Left heart catheterization was done the following day and revealed normal coronary arteries with slow flow noted in LAD. An intracoronary adenosine challenge was done that showed normalization of the TIMI frame count (). The patient was given the diagnosis of coronary slow flow and started on amlodipine 2.5 mg daily. On 6-month followup, the patient reports that he has been chest-pain-free.

Myra Hunter

2003/12/11

-9773

459 Carmen Hill Apt. 378

An 18-year-old woman with a history of eczema during childhood presented with complaints of episodes of generalized urticaria, nasal congestion and secretion, conjunctivitis, and periorbital and labial oedema 6?? hours after coitus. There was no vaginal itching or burning. Total IgE was slightly elevated, 350 (0??50) KIU/L. The Phadia Immunocap and the Multiple Allergen Simultaneous Test-chemiluminescent Assay (MAST CLA) test panels were negative []. Histamine release tests for latex, the partners saliva, sweat and semen were performed. The histamine release test procedure includes histamine release from peripheral whole-blood basophils, in a glass fiber prepared microtiter plate, by challenging 25 弮L heparinised whole blood with 25 弮L buffered allergen dilutions in various concentrations for 60 minutes at 37簞C. The assay is calibrated by a two-point standard curve and a positive cell control (anti-IgE) []. The test results are given as negative or positive. Histamine release tests for latex and for the partners saliva and sweat were negative, whereas the test was positive for the partners semen. The partners sweat, saliva, and semen were also tested in blood from a healthy control person, and these tests were all negative. Furthermore, a skin prick test was performed in the patient finding a positive reaction with a diameter of 12 (positive control 5) mm for the partners semen. Skin prick tests with the partners semen were also performed in two healthy women finding negative results. During the first 6 months after a diagnosis of anaphylaxis to human seminal plasma was established, condom usage was not sufficient for prophylaxis. Even close body contact such as kissing and hugging would cause acute urticaria, sneezing, and conjunctivitis despite daily intake of oral antihistamines, however, life-threatening anaphylactic reactions did not occur. Sexual intercourse was only possible on prednisolone 25 mg/day; so, the couple opted for abstinence and slept in separate rooms during most of that period. Between 6 and 12 months after the diagnosis was established, gradually, body contact became possible, and some months later with the use of a condom and on premedication with oral antihistamines coitus was possible without associated symptoms. During the second and third years after diagnosis the patient would still use oral antihistamines prior to intercourse several times per week; however, the condition was challenged on a regular basis by the couple showing milder and milder symptoms. Five years after the diagnosis incidental episodes of provocation caused by condom defects and intended challenges without condom were not associated with significant symptoms. A skin prick test in the patient for the partners semen at that time found a positive reaction of a diameter of 10 (positive control 7) mm. The patient did not report any other sexual partners.

Archer Booth

2003/10/31

899.766.9407x82755

547 Kelly Groves Suite 740

A 17-year-old man, high school student, with no relevant medical history was admitted for 10 days of intense global headache accompanied by nausea and vomiting. He was hospitalized for 4 days before admission at another institution, where imaging studies were performed with simple brain scan reported as normal and then discarded central nervous system infection. The patient was managed with analgesics and was discharged. For persistence of the headache and sensory symptoms including hypoesthesia in right hemibody with slight loss of muscle strength, he was admitted again. He was evaluated by the Neurology Department with a physical examination which showed a blood pressure of 138/76, heart rate of 88 beats per minute, and respiratory rate of 17 per minute, temperature of 37 degrees, neurological exam with fluent speech, cranial nerves normal, fundus with absence of venous pulses bilaterally, muscle strength of 3 of 5 in right hemibody, tendon reflexes of +++ numbness in right hemibody. No nuchal rigidity or other signs of meningitis were identified. A new magnetic resonance imaging study with gadolinium and venography reported cerebral sinus thrombosis of the superior longitudinal sinus with venous infarction in subacute phase (Figures and ). Given the findings, it was decided to initiate anticoagulation with unfractionated heparin and warfarin. Further investigations ruled out infectious etiology. He was studied for primary thrombophilia identifying a mutation in the prothrombin gene with the following test: ?en F2 was analyzed using quantitative chain reaction (qPCR) with amplimers and subsequent extension of thermal dissociation curve. Platform Roche Light Cycler. It confirms the presence of G20210A mutation in the prothrombin gene. The mutation was found in heterozygous state, means that the patient has copy of the mutated gene.??The patient has a total resolution of symptoms and continues with oral anticoagulation with warfarin.

Zariyah Blanchard

1984/9/29

868.737.7002x36809

55908 Kirsten Orchard

A 47-year-old man presented at our attention for fever and abdominal pain in the right lumbar region without urinary symptoms. His medical history did not reveal any diseases. An abdominal ultrasonography detected an oval mass measuring 6 cm in diameter to the right para-aortic region. A CT confirmed the presence of a solid mass (53.3 ? 48 ? 60 mm3); the involvement of adjacent viscera was unclear, in particular the kidneys, renal vessels and right psoas muscle, while the cava vein appeared displaced in an anterior-medial direction (). The mass appeared well-encapsulated and defined. No signs of von Recklinghausen? disease were identified. Liver function tests were normal and preoperative tumour markers, including carcinoembryonic antigen (CEA) and carbohydrate antigen 19.9 (CA19.9), were not elevated. A CT-guided fine needle biopsy (FNB) showed a benign neoplasm of peripheral nerves tissue, characterized by the presence of elongated and wavy cells positive of S-100 protein. For these symptoms, the patient underwent a surgical resection that started with a subcostal incision after right ureteral stent placement. At the intra-abdominal exploration, the lesion appeared to constrict the cava vein and displace the right kidney, the renal vein () and the right ureter. These structures were identified and preserved after a sharp dissection. The specimen was extracted with en-bloc resection. Total operative time was 177 minutes with negligible intraoperative blood loss. The postoperative hospital course was uneventful, and the patient was discharged after 6 days. Pathology examination revealed a well-circumscribed lesion composed of loosely arranged tumour cells with the typical fascicular and wavy pattern of growth, plenty of collagen fibers and myxoid areas. We evaluated the expression of calretinin in our case, showing a weak stain in less than 25% of tumour cells, confirming the diagnosis of Neurofibroma (). During a multidisciplinary meeting, a clinical and instrumental follow-up was recommended. At the 8-month follow-up, the CT scan was completely negative.

Adler Mathis

1991/7/5

845-263-0963x320

6402 Nguyen Lodge Suite 172

A 52-year-old female with history of hypertension, smoking, alcohol dependence, and coronary vascular disease with recent myocardial infarction was admitted due to acute change in mental status. The patient had a spontaneous intraventricular hemorrhage, and an emergency bedside ventriculostomy was performed. Her hospital course was marked by persistent fevers in spite of multiple negative blood, cerebrospinal fluid (CSF), and urinary cultures. She received empiric levofloxacin intravenously 750 mg daily and vancomycin 1 gram intravenously every 12 hours until day 9 of hospitalization. Her neurologic function steadily improved, and the ventriculostomy was discontinued on day 11. However, her CSF cultures on that day yielded coagulase-negative staphylococcal (CoNS) species. Vancomycin 1 gram and rifampin 600 mg intravenously were administered every 12 hours. On day 15, computerized tomography (CT) of the head demonstrated increased intraventricular hemorrhage requiring reinsertion of an external ventriculostomy. Repeated CSF analysis demonstrated elevated WBC (57 cells/mm3 and protein 149 mg/dL) with decreased glucose (67 mg/dL). CSF cultures yielded CoNS again. Cultures of CSF continued to yield CoNS for the next three days despite the addition of daptomycin intravenously at 10 mg/kg (dosed at actual body weight) daily. As a result, intraventricular daptomycin was added on day 18, 10 mg daily for the first two days and then every other day. Culture of CSF became sterile on day 25 following 7 days of daptomycin intravenous and intraventricular therapy in addition to continued administration of intravenous vancomycin and rifampin. The second ventriculostomy was discontinued on day 38 (as was rifampin administration). Intravenous daptomycin and vancomycin were discontinued on day 55 after 37 days of dual treatment. Mental status progressively improved during this time. Daptomycin peak and trough levels in the CSF were measured on day 29, and day 30, respectively (correlating to day 10 following the start of intravenous and day 11 following the start of intraventricular daptomycin). The peak CSF level (following intravenous and intraventricular administration) was 6.30 mcg/mL on day 29 and the trough CSF level was 1.39 mcg/mL on day 30. The serum trough level on day 30 was 20.15 mcg/mL, and the minimum inhibitory concentration (MIC) of CoNS to daptomycin was <1 mcg/mL. The remaining hospital course was complicated with respiratory failure requiring tracheostomy and ventilation support, ventilator-associated pneumonia, sacral pressure ulcer, and Clostridium difficile colitis. The patient was successfully discharged on day 65 to a rehabilitation center.

Anne Glass

2000/5/2

001-733-202-7272x66215

8343 Sara Causeway Apt. 566

A 66-year-old male was seen in a USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership clinic in western Kenya, complaining of general body itchiness and skin patches on the chest for 3 months prior to contact. He had tested HIV positive three months prior to enrollment at the clinic. He complained of poor appetite and had lost 3 kg. He did not report any allergies to food or drugs, did not smoke, but reported that he takes alcohol (local brew) 2-3 times/week. On physical examination, he was in fair general condition with a BP of 100/60 mmHg, pulse rate of 92 beats per minute, temperature 36.1簞C, and arterial oxygen saturation of 93% while breathing ambient air. He weighed 65 kgs. His skin had 3 hypopigmented and hypoaesthetic patches on the right chest wall and right upper arm. The largest lesion measured 5 by 6 cm and the smallest 2 by 3 cm. Other systems were essentially normal. Baseline investigations revealed a CD4 cell count of 145/mL, CD4 percentage 10%, white blood cell count of 2800/uL, Hemoglobin 12.3 g/dL, and platelets count of 178,000/uL. SGPT and creatinine were within normal ranges. His chest X-ray was without evidence of pathology. An impression of Tinea corporis was made and the patient assigned WHO clinical stage 2 due to weight loss of <10%. He was given cotrimoxazole prophylactic therapy and clotrimazole cream. One month later, the patient was started on an ART regimen composed of stavudine, lamivudine, and nevirapine after adherence counseling. The patient's progress (CD4 counts, viral load and weight) is summarized in . The patient had poor adherence based upon missed clinic appointments and self report. There is documented history that the patient did not take his medications for a period of one month during the 3rd year of ART. He attributed this to social stressors. An outreach worker had to visit his home to remind him of clinic visits. After several adherence counseling sessions, his plasma viral load dropped from 1,084,798/mL at 29 months of treatment to 433,376/mL six months later. At this point, virological treatment failure was confirmed based on a plasma viral load of >5000 copies/mL. A decision was made to continue with first-line ART until perfect adherence is maintained for at least six months before initiating second-line ART. All this time the skin lesions persisted despite regular use of clotrimazole cream. After demonstrating good adherence, the patient was initiated on second-line ART regimen including abacavir, didanosine, and aluvia (Lopinavir/Ritonavir) 47 months after initiating first-line ART. The skin lesions persisted but did not increase in number or size. A decision to refer him to the regional center for leprosy was made where a skin smear was done and was positive for acid fast bacilli. According to Ridley-Jopling system, he was classified as having borderline tuberculoid leprosy based on having three lesions only that were well demarcated, asymmetrical, and unilateral. However, there was no enlargement of the nerve trunks and no neurological deficits other than the hypoaesthesia. According to the WHO classification, he was classified as having multibacillary leprosy based on having a positive skin smear on at least one site. Seven months after initiating second-line ART, he was put on rifampicin 600 mg monthly, clofazimine 300 mg once a month and 50 mg daily and dapsone 100 mg daily for 12 months which is the WHO recommended multidrug treatment (MDT) regimen for multibacillary leprosy. Six months later, the skin lesions had resolved, there was no neurological sequelea, and a check viral load was 188 copies/mL. Eighteen months since initiating MDT for leprosy, the patient remained stable without new lesions, nor neurological deficits. A follow-up skin biopsy showed mild chronic inflammation with noncaseating granulomas. Fite's Acid fast stain for leprosy was negative. Genotypic viral resistance testing performed revealed resistance mutations to nonnucleotide reverse transcriptase inhibitors (NNRTI's) and nucleoside reverse transcriptase inhibitors (NRTI's) but none to protease inhibitors (PI's).

Allan Martin

1978/2/23

453.361.7956x949

770 Frye Wall Suite 349

A 51-year-old man who lived in Trabzon, Turkey, was admitted to the hospital because of anorexia, dizziness, nausea, vomiting, diarrhea, and weight loss. During the previous few months, he had developed dark skin pigmentation noted by his family and lumbar back pain. He had knee surgery for a torn meniscus 5 months before admission; the past medical history otherwise was negative. Examination showed low blood pressure (90/50 mm Hg), severe orthostatic hypotension, and inguinal lymphadenopathy. Laboratory studies showed high erythrocyte sedimentation rate (50 mm/h), high C-reactive protein (14.5 mg/L), low-serum sodium (121 mmol/L), high-serum potassium (7.5 mmol/L), high-serum creatinine (2.2 mg/dL), and low-serum cortisol (5 弮g/dL). The diagnosis of acute adrenal crisis was made, and the patient was started on intravenous fluid replacement and methylprednisolone. Microscopic examination of the stool showed leukocytes and erythrocytes, and ciprofloxacin was started; however, stool cultures showed no pathologic microorganisms and the diarrhea resolved within 2 days. After 2 days of intravenous steroids, the serum sodium and creatinine levels became normal. Fludrocortisone was added because of resistant hyperkalemia. Further studies showed a low adrenocorticotropic hormone (ACTH) level (5.41 pg/mL) under treatment. Magnetic resonance imaging (MRI) of the upper abdomen showed asymmetrically enlarged adrenal glands (coronal diameter: right, 9 mm; left, 11 mm), consistent with bilateral adrenal hyperplasia (). Possible reasons that may cause adrenal insufficiency by infiltrating adrenal glands were sought throughly. Considering tuberculosis; the patient could not produce a sputum sample, and chest radiography was normal. Inguinal sonography showed multiple, enlarged (diameter, 1.5 to 2 cm), hypoechoic, nonreactive right inguinal lymph nodes with thickened cortex; excisional biopsy of an inguinal lymph node showed caseating granulomas, consistent with granulomatous lymphadenitis (). Lumbar MRI showed loss of vertebral body height and the presence of pathologic signal in L1 and L2, consistent with compression fracture, metastasis, or infection (); lumbar vertebral biopsy, performed by an open surgery, showed chronic, necrotic, caseating granulomas consistent with tuberculous osteomyelitis (). Polymerase chain reaction assays of homogenates of the lymph node and vertebral specimens were negative for Mycobacterium tuberculosis. Further evaluation was negative for other chronic diseases, diabetes mellitus, human immunodeficiency virus infection, and malignancy. The patient was treated with isoniazid, rifampicin, and pyrazinamide for 1 year, in addition to steroids (5 mg/day, fludrocortisone 0.1 mg/day). Two months after antituberculous therapy was completed, the glucocorticoid and mineralocorticoid drugs were stopped, and the patient was monitored closely as an inpatient. After 1 week of discontinuing steroid therapy, the morning serum cortisol was (7.3?? 弮g/dL), and ACTH was high (874??65 pg/mL). A Synacthen stimulation test was not performed as the level of ACTH was already very high. MRI of the adrenal glands showed bilateral asymmetric adrenal hyperplasia, similar to that observed 1 year earlier. The patient was begun again prednisolone (5 mg/d) and advised to increase the dosage during stressful conditions including fever, surgery, dental extraction, strenuous exercise with sweating, during extremely hot weather, and with gastrointestinal upsets such as diarrhea [].

Mila Huynh

1980/5/5

8446533368

358 Chandler Dam

A 20-year-old man referred to surgery department of Faghihi hospital, affiliated to Shiraz University of medical science, due to painless left axillary mass for 2 months duration. His past medical history was unremarkable. On physical examination he had stable vital signs. A firm mass was palpated at the left axillary area measuring about 8 ? 7 centimeter (cm). There was no evidence of hepatosplenomegaly and generalized lymphadenopathy. Left axillary ultrasound examination showed a well-defined superficial mass with area of punctate calcification with no evidence of hemorrhage and necrosis, suggestive of an enlarged lymph node (). The patient's lab data including complete blood count with differential and biochemical tests were within normal limits. Chest X-ray and abdominal ultrasound were normal. The left axillary mass was excised. On gross inspection, there was a firm creamy brown lymph node, measuring 8 ? 7 ? 5 cm with focal areas of white discoloration and hard consistency (). Histologic examination revealed follicular pattern with large nodules of mantle cells arranged concentrically around atrophic and vascularized germinal centers (Figures and ). There was also some benign-appearing bone trabeculae interspersed with lymphoid tissue (). The diagnosis based on histologic examination was Castleman's disease, hyaline-vascular type with osseous metaplasia.

Layton Cardenas

1984/8/7

(498)508-1250

6770 David Crossing Apt. 083

A 5-year-old boy presented to our hospital 2 days after being involved in a motor vehicle crash (MVC) with a velocity of 32 miles per hour. He was knocked down from the side while crossing the road as a pedestrian and was ejected about seven yards from the vehicle. On examination he had signs of torticollis to the right side, decreased reflexes and decreased power in his right arm (indicative of a brachial plexus injury), and decreased sensation below the clinical level of the second lumbar vertebra (L2). He also suffered decreased anal tone and lost bladder control. A Magnetic Resonance Image (MRI) demonstrated spinal cord oedema at the level of the second cervical vertebra (C2) () as well as spinal cord injury with oedema from the level of the 10th thoracic vertebra till the first lumbar vertebra (T10-L1) (). There were also facet joint fractures with disrupted ligamentum flavum and interspinous ligaments at the level of the second and third vertebrae (L2-L3). Prior to the surgical procedure the cervical spine radiographs were normal. After the MRI was performed, the patient underwent decompression of the spinal cord and fusion of the second and third vertebral bodies (L2-L3) (). Afterwards he was admitted to the postoperative ICU for five days, where he developed right-sided paralysis of the diaphragm and subsequent pulmonary complications as well as a urinary tract infection. Computed Tomography (CT) scanning performed postoperatively demonstrated no further abnormalities. The outcome of this boy was good; he returned to normal life.

Raven Hayden

1995/10/21

477.812.9844

2797 Hernandez Trail Suite 280

A 41-year-old Caucasian female patient with a past medical history significant for NF presented for open biopsy of her left tibia. The patient detailed a one and a half year progressive weakness and pain in her left ankle. Initial plain film radiographic examination in August 2010 showed a 3 ? 1.5 ? 2 cm destructive lesion of the cortical bone in the distal tibia. MRI analysis of the lesion in September 2010 showed a larger enhancing 5.7 ? 4.6 cm lesion. At that time the patient underwent Tru-Cut soft tissue biopsy of the mass with pathology confirming a nerve sheath tumor. However, there was insufficient tissue to determine malignancy and further tests were required. After a brief loss to follow up for insurance and financial difficulties, another MRI examination in January 2011 revealed an even larger 6.5 ? 5.1 cm T2 hyperintense lesion eroding through the tibia with a 2.4 cm proximal periosteal extension. The patient's condition had also deteriorated, and she now required crutch support for ambulation. She reported decreased sensation to cold, light touch, and pinprick over the left first and second toes. Concern for malignant degeneration of her NF disease in the left ankle warranted a more extensive open biopsy for definitive diagnoses. Preoperative anesthetic evaluation revealed no other significant medical problems, no known drug allergies, no prior general anesthetics, and a family history of pseudo-cholinesterase deficiency. She had several previous cutaneous nodule excisions for cosmesis completed under a combination of local anesthesia and sedation at outside institutions. The patient was prescribed temazepam (Restoril, Mallinckrodt Pharmaceuticals Group, MO) orally for insomnia as necessary, as well as hydrocodone-acetaminophen (Vicodin, Abbott Laboratories, IL) and ibuprofen (Motrin, McNeil Consumer Healthcare Division, PA) orally as required for ankle related pain. On general examination, she had multiple cutaneous neurofibromas diffusely distributed throughout her body. Her BMI was 29 and her airway examination was unremarkable. Prior to the nerve blockade, standard monitors (noninvasive blood pressure cuff, pulse oximeter, and 3-lead ECG) were applied. Supplemental oxygen (3 L/minute) was administered via nasal cannula. Adequate sedation was achieved with intravenous midazolam 2 mg (Versed, Roche, NY), and fentanyl 150 mcg after timeout was completed. The patient was placed in supine position with left foot elevation and left knee flexion, and the skin sterilized with ChloraPrep (Cardinal Health, OH). The US transducer (linear, 12-3 MHz, L12-3 Phillips) was placed transversely at the inferior aspect of the popliteal fossa. Cephalad and caudad orientation of the probe demonstrated relevant anatomy including the popliteal artery, vein, sciatic nerve, and its bifurcation into the common peroneal and tibial nerves. Of specific interest, sonographic ?arget signs??[] consistent with previous descriptions of intraneural fibromas [] were demonstrated in the sciatic, common peroneal, and tibial nerves []. The lesions appeared solitary, ovoid and contiguous with the nerve, had a hypoechoic echotexture with well-defined margins, and demonstrated subtle distal acoustic enhancement (). With popliteal artery in view, we were able to demonstrate true and faux (neurofibroma) arterial structures using doppler analysis (). Tracing the path of the sciatic nerve proximally, we identified a portion of the nerve with no neurofibromatous changes on ultrasound. We also carefully selected an area of the inferior thigh void of cutaneous neurofibromas for needle insertion. The skin was infiltrated with 2 mL 2% lidocaine, and a 10 cm 22-gauge Stimuplex needle (B. Braun, PA) was utilized. A real-time view of the Stimuplex needle tip, popliteal artery, and sciatic nerve was maintained at all times during the block. A total of 30 mL 0.5% ropivacaine (APP Pharmaceuticals, IL) with 1 : 400.000 epinephrine was injected with intermittent negative aspiration for blood. The local anesthetic spread circumferentially around the sciatic nerve as noted on ultrasound examination (). The patient reported no paresthesias or discomfort during the procedure. Within ten minutes, the patient reported subjective numbness, warmth, and heaviness of her left calf and foot. On examination she had complete sensation loss to sharp touch and cold in the sciatic distribution of her left lower extremity. Intraoperatively, sedation was provided with midazolam 2 mg IV followed by a propofol infusion (25??0 mcg/kg/min). She maintained spontaneous ventilation via laryngeal mask airway. The patient did not respond to the incision and remained hemodynamically stable for the duration of surgery. She received ondansetron 4 mg (Zofran, GlaxoSmithKline, NC) intravenously twenty minutes prior to the completion of surgery for nausea prophylaxis. The patient was alert, awake, and oriented in the postanesthesia care unit. She complained of no pain (verbal pain score 0/10) and had residual sensory loss and motor weakness of 1/5 in the left lower extremity. The patient denied symptoms of nausea and was discharged home later that afternoon. On post-operative day one, the patient was contacted at home via telephone for followup. The patient stated baseline motor and sensory functions returned approximately eight hours after the operation. Her pain was adequately addressed at home with hydrocodone-acetaminophen (Vicodin, Abbot Laboratories, IL) orally every six hours as needed. Her pain at rest was 1-2/10, and with activity increased to 3-4/10. She had no hematoma or tenderness at the site of the regional blockade. The patient reported an overall favorable anesthetic and postoperative pain experience.

Leroy Atkins

2002/3/16

434-989-8873x26209

1108 Ferguson Manors Suite 954

An 87-year-old lady who lives alone presented to the medical admissions unit with an inability to open her right eye. She has a past history of mild dementia and depression and was previous to this otherwise fit and well. She describes a 6-day history of blister formation surrounding the eye that extends to her right forehead and scalp. Her family noticed her eye was becoming increasingly droopy, red, and swollen culminating in it being permanently shut for twenty-four hours prior to admission. This visual impairment was most likely responsible for her falling before attending hospital, during which she sustained a left elbow laceration. Of note, she had been started two days previously on flucloxacillin and phenoxymethylpenicillin by her general practitioner. On examination she had a vesicular rash covering her right scalp, forehead, eye, and upper cheek. It was erythematous, swollen, and tender. She had a complete ophthalmoplegia, and her pupil was fixed and dilated. Her visual acuity in that eye was reduced to counting fingers. The remainder of her neurological and other systems examinations were normal. She was commenced on oral and topical acyclovir, dexamethasone, and cyclopentolate subsequent to ophthalmology review. There was no evidence of vasculitis on slit-lamp examination (see Figures and ). The vesicular rash resolved some two weeks later after admission, and she was discharged. She had regained some of her eye movements partially but the ptosis remained.

Mina Cox

1978/1/13

(207)714-9451x84988

2095 Mary Mount

The patient was a 42-year-old female who initially presented to the ED with left buttock and left-sided back pain that was described as ??2/10.??She had previously had a left gluteal abscess incised and drained at an outside hospital. She denied any history of fever. Her other past medical history included schizophrenia and prior Caesarian sections. She had a 6-pack-year smoking history. On physical examination, the patient was afebrile with stable vitals. She was awake and alert. Her abdomen was soft, obese, and nontender without masses. Rectal examination showed good sphincter tone without any purulent drainage. A boggy swelling was palpable in the left side of the rectum at the 3 or 4 o'clock position. The rest of the physical exam was benign. A CAT (computerized axial tomography) scan was performed, showing a large right-sided abscess () The patient was taken to the operating room for examination under anesthesia. Digital rectal exam showed an induration and boggy swelling 10 cm from the anal verge and at the 3 o'clock position. The examination was complemented with anoscopy, which revealed vague bulge into the lumen corresponding to the digital palpation site. Due to the difficult location of the abscess, surgical drainage was not feasible transrectally and the abscess was drained percutaneously under fluoroscopy by Interventional radiology. Multiple pictures were taken under fluoroscopy to characterize the abscess, shown in Figures and . The drainage catheter was left creating a fistula between the abscess and the skin. The drainage catheter had several dislodgements. Two tube-checks and adjustments were done by interventional radiology. However, two months after the initial procedure, the patient was again admitted with the similar symptoms. The patient was taken for surgical drainage through the previous transgluteal catheter insertion site, whereupon mucopurulent material was drained. The abscess was packed and the patient was once again discharged on trimethoprim/sulfamethoxazole and ciprofloxacin. One month after this, the patient was again admitted complaining of pain in her abdomen, groin, and vagina and drainage of purulent material from the left buttock at the surgical incision site. The patient was taken to the OR and an incision was made through her previous incision scar in the left buttock about 6 cm from the anal opening. Bimanual exam revealed a large boggy swelling. The abscess was dissected out and then opened. The serous and purulent fluid contents were drained and a size 28 Malecot and a 22 French Foley were both left in and sutured to the skin. The patient tolerated the procedure well and was sent home with daily wound and drain care as well as a 10 day course of ciprofloxacin and trimethoprim/sulfamethoxazole. She returned to the outpatient office for followup and had complete recovery of her abscess.

Connor Dyer

1980/12/11

981.358.5320

4653 Thomas Burg Suite 964

A 47-year-old man from Spain presented in University Hospital La Paz in Madrid, Spain, with a two-day history of intermittent fever, headache and fatigue. The patient had returned a week earlier from a four-week trip to Equatorial Guinea. He did not take anti-malarial chemoprophylaxis during the visit. He was a category A3 HIV-infected patient with a CD4 cell count of 650/弮L and HIV viral load of less than 20 copies/mL. He had been taking tenofovir, emtricitabine and efavirenz since 2008. On examination, he was febrile (38.7簞C) and had a heart rate of 120 beats/min, blood pressure of 93/64 mmHg, normal respiration rate and oxygen saturation 95% on room air. Laboratory investigations showed normal haemoglobin concentration (14.8 gr/dL), normal cell count and leukocyte formula (4.4 ? 109 cells/L, N 89.1%, L 6.9% M 1.6%), moderate thrombocytopaenia (36 ? 109 cells/L, reference range 125-350 ? 109 cells/L), normal glucose levels (110 mg/dL), bilirubin (28 弮mol/L, reference value < 20 弮mol/L), creatinine (176 弮mol/L, reference range 40-120 弮mol/L) and slightly increased aspartate transaminase (82 UI/L, normal < 37 UI/L) and an elevated C-reactive protein concentration of 157 mg/L (normal < 10 mg/L). Malaria parasites were seen on Giemsa-stained thick and thin blood films with Field's stain in 7% of erythrocytes. Parasite morphology identified P. falciparum. A rapid diagnostic test (RDT) result for histidine-rich protein 2 of P. falciparum (Now簧 Malaria Test, Binax INC, Maine, USA) was positive. Results of multiplex PCR assay, species-specific nested-PCR [] were positive for P. falciparum. The patient was admitted to the intensive care unit with several signs of severe malaria (parasitaemia of 7% of erythrocytes, haemodynamic instability, decreased level of consciousness, respiratory distress syndrome and mild renal insufficiency) for monitoring. Patient was treated with quinine and doxycycline intravenous for seven days at the recommended doses in adults. The anti-retroviral therapy with tenofovir, emtricitabine and efavirenz was not interrupted. On day 2 the parasitaemia was 1%. The parasites were cleared after six days without recrudescence. The hospital stay lasted 13 days.

Estrella Patel

1988/4/4

236.652.2654x831

3953 Austin Branch

A 38-year-old man from France presented to University Hospital La Paz, with a two-day history of fever, sweating, abdominal pain and vomiting after returning from a six-day visit to the Ivory Coast. He did not use personal vector avoidance measures (insect repellent, long-sleeved clothing, netting). He had not taken anti-malarial chemoprophylaxis. He had been diagnosed with HIV infection 10 years before. He was taking tenofovir, abacavir and darunavir/ritonavir with a CD4 cell count of 432/弮L and undetectable viral load (less than 20 copies/mL). He was admitted to the emergency department with a temperature of 39.9簞C but he was in good general condition with a normal respiratory rate, blood pressure of 147/88 mmHg, and normal oxygen saturation. The day of admission, laboratory investigations revealed: normal haemoglobin concentration (15,0 gr/dL), normal white cell count and leukocyte formula (6.3 ? 109 cells/L, N 78.3%, L 12.3%, M 8.5%), moderate thrombocytopaenia (91 ? 109 cells/L, reference range 125-350 ? 109 cells/L), normal glucose levels (104 mg/dL), bilirubin (1.6 弮mol/L, reference value < 20 弮mol/L), creatinine (135 弮mol/L, reference range 40-120 弮mol/L) and slightly increased aspartate transaminase (95 UI/L, normal < 37 UI/L) and ALT (92 UI/L, normal < 65 UI/L) and an elevated C-reactive protein concentration of 112 mg/L (normal < 10 mg/L). Malaria parasites were detected by microscopic examination in 0.5% of his erythrocytes. The RDT (Now簧 Malaria Test, Binax INC, Maine, USA) was positive for P. falciparum. The patient was treated with atovaquone/proguanil 250 mg/100 mg, every six hours for three days. On day 3, he was again febrile with P. falciparum parasitaemia nearly 8% of erytrocytes. His laboratory results showed a decreased haemoglobin concentration of 10.0 gr/dL and thrombocytopaenia more severe than 33 ? 109 cells/L. Anti-malarial treatment was changed to intravenous quinine and doxycycline for seven days and was monitored in the intensive care unit for the first 24 hours. The anti-retroviral therapy with tenofovir, abacavir and darunavir/ritonavir was stopped, after initiating the malarial treatment with quinine. On day 6 he was cleared of parasitaemia. He was discharged after 10 days. The multiplex PCR assays performed on the sample collected on the day of admission confirmed that the patient was only infected with P. falciparum. Analysis of point mutations in the cytochrome b gene, related to resistance to atovaquone, and in the dihydrofolate reductase (DHFR) gene, related to proguanil resistance, show a single mutation in the cytochrome b gene (L283I) and four point mutations for the DHFR gene (Table ).

Parker Boyle

1986/11/26

707-895-1979x703

053 Makayla Ridges Apt. 788

The patient, a 38 year old man, had started to drink alcohol at age 11. By the age of 18 he fulfilled the DSM-IV criteria for alcohol dependence. His first detoxification treatment was at age 15. Multiple detoxification and prolonged withdrawal therapies as well as anti-craving therapy with acamprosate had been unsuccessful. Before surgery the longest period of abstinence lasted 3 months. During these drug-free intervals the patient reported massive craving and high sensitivity to alcohol-related cues. Pre- and post-surgical assessment included Symptom Check list 90 (SCL), psychopathology, obsessive-compulsive drinking scale (OCDS), alcohol urge questionnaire (AUQ). The alcohol dependence scale (ADS) was only assessed before surgery. In addition, the patient had also been examined with a comprehensive neuropsychological test battery, which had revealed neither marked neuropsychological difficulties nor dementia. One week after implantation of the DBS electrodes (13 January, 2008) the stimulation was switched on. The patient experienced a short period of hypomania, which stopped upon changing stimulation parameters. Since then up to the submission of this report the patient has been alcohol abstinent and reports a virtually complete reduction of his sensitivity to alcohol related cues. Bilateral stereotactically guided implantation of quadripolar brain electrodes (model 3387, Medtronic, Minneapolis, MI, USA) was performed in general anesthesia as described by Heinze et al. . The electrode position was confirmed intraoperatively using stereotactic X-rays and finally by computed tomographic imaging (CT, see ). Postoperative CT-scans were retransferred into treatment planning MRI images. The most distal contact of the electrode was located 1?? mm rostral to the anterior commissure projecting onto the lateral border of the NAcc. This particular placement was necessary to save a prominent A1-segment of the anterior cerebral artery running through the intended target area. Settings of the impulse generator (Kinetra簧, Medtronic, Minneapolis) at time of testing were: monopolar cathodic using the most distal contact in each hemisphere (frequency: 130 Hz, pulse width: 90 繕s, amplitude: 3.5V ). The current (radius of approx. 3 mm around the active electrode contact ) affected dorsal parts of the NAcc, the BSTM and the VP (see ).

Aliya Alfaro

1998/12/18

795-927-8148

908 Donna Inlet

A 32-year-old woman with a history of psychological problems spent 1 year in an adolescent psychiatric unit and received psychotherapy for an eating disorder. Acts of DSH were carried for 7 years between the ages of 14 and 21 years, including cutting with objects such as glass, and blades and self-poisoning. All cuts were made to her left nondominant upper and lower arm alone, leaving her with numerous scars. Scar reconstruction was carried out on her left forearm.

Xzavier Roach

1987/6/12

958.652.8553

4218 Brown Trail Apt. 019

A 20-year-old woman presented with a history of moderate depressive disorder and personality difficulties. She was taking antidepressants and had a history of DSH for 5 years, between the ages of 12 and 17 years. She had multiple lacerations that were made with razor blades to bilateral forearms. Scar reconstruction was performed on her left forearm.

Lyanna Gordon

1979/9/27

001-976-405-5841x4237

18485 Webster Throughway Suite 120

A 32-year-old Afro-Caribbean female presented, on antidepressants for depression. With a 9-year history of DSH between the ages of 14 and 23 years, razor blades were used to both arms and she presented with linear scars to both forearms, one of which had become very stretched and unsightly. Scar reconstruction was performed on her right forearm.

Karter Parsons

1994/6/18

684-294-5751x624

908 Johnny Isle Apt. 234

A 28-year-old female presented who suffered from bipolar disorder and depression. She had a history of being in foster care as an adolescent with a number of psychosocial issues. She had a 9-year history of DSH between the ages of 13 and 22 years including overdose as well as self-cutting with razor blades and any other sharp objects found. Multiple linear scars were seen to bilateral arms with the left arm being more severe. Scar reconstruction was performed on her left forearm.

Maia Scott

2000/5/28

-2869

688 Townsend Curve Suite 621

A 37-year-old female patient presented with a large symptomatic panniculus after open gastric bypass surgery and massive weight loss (110 lb) (Fig ). Her initial BMI was 52.67; after her weight loss, her BMI was 32.55. Chronic skin problems were confined to the lower abdomen under the large panniculus. The patient also complained of difficulty in ambulation and interference with performing ADL associated with the large panniculus. She had a strong desire to preserve her navel. She underwent a functional horizontal panniculectomy with umbilical transposition, and a total of 10.10 lb of skin and subcutaneous fat was removed. Postoperative follow-up at 6 months showed no evidence of skin problems and improved ADL, based on her SF-36 score (Fig ).

Leo Jordan

2004/10/21

213.897.7399x922

44389 Stephen Manor Suite 268

A 34-year-old female patient complained of frequent infection and rashes in the skin around the navel and under the pannus along the suprapubic region and both groins after open gastric bypass surgery and massive weight loss (122 lb). Her BMI decreased from 44.38 to 24.60. Of note, she had a large incisional ventral hernia associated with her gastric bypass surgery (Fig ). She wanted to preserve her navel. She underwent a functional horizontal panniculectomy with umbilical transposition. Concomitant hernia repair was performed. A minimal vertical skin and subcutaneous excision overlying the supraumbilical hernia was also performed because of compromised perfusion. A total of 3.6 lb of skin and subcutaneous fat was removed. Twelve-month follow-up showed resolution of her skin problems and no evidence of hernia recurrence (Fig ).

Adalynn Hancock

1998/5/18

(431)652-2084

50166 Smith Ville Apt. 695

A 45-year-old female patient presented with a large panniculus and associated chronic skin problems in the lower abdomen after massive weight loss (140 lb) following open gastric bypass surgery. This resulted in a decrease of her BMI from 58.87 to 34.84. She complained of a significant difficulty in ambulating and carrying out her ADL associated with the large panniculus (Fig ). This was supported by her preoperative SF-36 score. She was indifferent to preservation of her navel. She underwent a horizontal panniculectomy with the sacrifice of her navel. A total of 11.0 lb of skin and subcutaneous fat was removed. There was no evidence of skin problems at 9 months postoperatively. Patient also reported improved ADL, as observed in her postoperative SF-36 score (Fig ).

Rex Curry

1978/9/2

-9002

8633 Gregory Track

A 37-year-old female patient presented with skin problems confined to her lower abdomen and around the navel after open gastric bypass surgery and massive weight loss (130 lb). There was also skin irritation in the vertical redundant folds around the navel (Fig ). Her BMI decreased from 46.67 to 23.99. She complained of interference with her ADL. She desired to preserve her navel and thus underwent a functional horizontal panniculectomy, minimal excision of vertical excess skin and subcutaneous fat from the supraumbilical region, and umbilical transposition. A total of 3.91 lb was removed during these procedures. Postoperative follow-up showed resolution of skin problems as early as 3 months after the surgery (Fig ).

Alison Matthews

1997/1/8

9073238048

285 Andrew Fort

A 55-year-old Caucasian man was admitted to the Nephrology Department at our institution for ARF diagnosed in the emergency room along with left-sided, community-acquired pneumonia. He was on oral anti-diabetic treatment for uncomplicated type 2 diabetes and was a cigarette smoker. He reported no recent use of non-steroidal anti-inflammatory drugs or antibiotics. Clinical examination revealed that his temperature was 38簞C and his blood pressure was 120/60 mmHg. His urinary output was diminished and concentrated. Pulmonary examination revealed diffuse crackles of the left lung accompanied by a dry, irritative cough and exertional dyspnea. The rest of the patient's examination was normal. Chest X-ray revealed alveolar opacities in the left lung. No sputum could be obtained for culture, but his test for Legionella antigenuria was positive. Antibiotic therapy with erythromycin and ofloxacin was initiated. Blood tests revealed elevated serum creatinine (614 弮mol/L; normal range, 62 to 106 弮mol/L), blood urea nitrogen (28 mmol/L; normal range, 2.14 to 7.14 mmol/L) and C-reactive protein (360 mg/L; normal range, 0 to 3 mg/L) with leukocytosis (13 g/L; normal range, 4 to 11 g/L). No anemia or thrombocytopenia was noted, and the patient's liver function tests were normal. The patient had elevated levels of lactate dehydrogenase (408 IU/L; normal range, 135 to 225 IU/L) and creatine phosphokinase (CPK) (2000 IU/L; normal range, 47 to 171 IU/L). At room air, his arterial blood gas was pH 7.44 (normal range, 7.35 to 7.45), partial pressure of carbon dioxide was 29 mmHg (normal range, 35 to 45 mmHg) and partial pressure of oxygen was 65 mmHg (normal range, 80 to 100 mmHg) with HCO3 of 22 mmol/L (normal range, 20 to 25 mmol/L). Analysis of the urinary sediment revealed aseptic leukocyturia (684/mm3; normal range, < 20/mm3) and hematuria (56/mm3; normal range, 0 to 10/mm3). The patient's urinary sodium was below 20 mmol/L, urinary urea was 13 g/L and proteinuria was 2.48 g/L (normal range, 0 to 0.3 g/L) with albuminuria of 0.4 g/L (normal range, < 0.03 g/L). His renal ultrasound was normal. Although our patient's respiratory signs and chest X-ray revealed improvement with antibiotics, his ARF worsened despite saline solute infusion, and he became anuric. His serum creatinine level at day 3 was 1000 弮mol/L. Hemodialysis was initiated with a central jugular catheter. Percutaneous renal biopsy was performed at day 4, which showed acute TIN (Figures and ) with interstitial edema and inflammatory peritubular infiltrate composed of lymphocytes and plasma cells. No proliferation or deposit was noted on the 21 glomeruli examined. Under immunofluorescence, only immunoglobulin-secreting plasma cells were visible. The patient's blood cultures were normal, his bacterial and viral serologies were negative (leptosirosis, human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus), the search for tuberculosis and autoimmunity was negative (normal complement level, negative anti-nuclear antibodies and anti-SSA/SSB) and his eye examination was normal. Therefore, we attributed his acute TIN to LD. Steroid treatment was initiated at 1 mg/kg/day. The patient's renal function rapidly improved, with appropriate diuresis allowing for withdrawal of hemodialysis after 2 days. There was no worsening of respiratory signs under steroid treatment. The patient was discharged at day 10, at which time his serum creatinine level was 110 弮mol/L. One month later, after cessation of steroids and antibiotics, his serum creatinine level was 77 弮mol/L. Investigation by Health Services did not find the source of Legionella contamination.

Preston Peters

1987/8/14

(953)768-6574x655

10835 John Vista Apt. 887

A 12-year-old Caucasian boy was referred with a presumed diagnosis of right ON glioma to our hospital. Four years earlier, his local ophthalmologist had diagnosed a 'yellow-whitish, well-demarcated papillary cyst with central retinal vessel displacement' in his right eye (oculus dexter, or OD) and documented a visual acuity of 20/30 in both eyes. He was examined twice a year, and his vision remained stable. Four years later, his ophthalmologist documented 'visual acuity of 20/80 and concentric visual field reduction to the central 10簞 isopter in OD'. Fundoscopic variation of the lesion was not noted. One month later, after a severe headache, visual loss progressed and no light perception with an absolute afferent pupillary defect was present in the OD. A computed tomography (CT) scan showed right ON thickening, and the boy was referred and admitted to our center. At admission, the described neuro-ophthalmologic findings were confirmed, and on CT, the optic disc appeared elevated and enhanced after intravenous contrast was administered. Fundoscopy revealed a well-defined whitish mass without macroscopic calcification at the ON head, dilated and tortuous retinal vessels, and small superficial retinal hemorrhages (Figure ). A complete general examination did not detect any other alterations. After informed consent was obtained from our patient's parents, a right transfrontal exploratory orbitotomy with canalicular unroofing was performed, and a normal chiasm, prechiasmatic and canalicular ON, and grayish infiltration in the proximal intraorbital portion were revealed. A frozen intraoperative biopsy of the tumor was diagnosed as an 'unrecognized tumoral process', and 0.8 cm of distal ON was resected. Because the eye had no light perception and the tumor was potentially malignant, the remaining ON and globe were enucleated with excision of the retrobulbar orbital fat. A gross examination of the eye revealed an ON with a width of 6 to 7 mm and a length of 6 mm. A sagittal section through the globe revealed a small, whitish, rounded tumor of 2 to 3 mm with a soft surface at the optic disc. No lesions of the cornea, iris, lens, or ciliary processes were detected. The tumor had areas composed of poorly differentiated neuroblastic cells with nuclear pleomorphism but no mesenchymal elements. Thus, the final histopathological diagnosis was malignant non-teratoid medulloepithelioma of the ON []. There was dense granulation tissue with giant cells, but no tumor was present in the adipose tissue surrounding the ON (Figure ). Systemic work-up was negative for any evidence of metastatic disease. In view of the significant mortality rate of this tumor, orbital exenteration was suggested, but our patient's parents declined [-]. Fifty gray of telegammatherapy (Co60) was applied in two fields. Our patient was closely followed with annual orbital CT and half-yearly echography for six years without evidence of recurrence. At present, he is 37 years old and has a disease-free survival of 25 years.

Leila Phan

1982/11/3

647.926.8184x38380

5570 Kevin Cliff Apt. 674

A 73 year-old man was admitted to our unit with severe aortic stenosis requiring aortic valve replacement. The patient had numerous risk factors for cardiovascular disease including obesity (BMI = 40; BSA = 2,46), hypercholesterolemia, hypertriglyceridemia, Type II Diabetes Mellitus and being a cigarette smoker. The procedure was performed through a J-shaped mini-sternotomy [] with routine ascending aorta and right atrial cannulation. After opening the aorta, we carefully removed all the debris on the valvular annulus that extended to the mitro-aortic junction. A tissue valve was then implanted. The operation was completed routinely and without incident. The patient was discharged from the Intensive Care Unit on post-operative day two. There were no major complications.

Maison Costa

1982/1/21

(258)480-8603x9549

104 Jennifer Trace Apt. 521

A 40-year-old Caucasian man with a body mass index (BMI) of 29 was admitted to our hospital with a 5-day history of fever. His physical examination revealed anorexia and fever (temperature > 39簞C). His white blood cell count was 11,350 cells/mm3 with 5800 lymphocytes/mm3. His C-reactive protein level was 51 mg/L. His liver function test results were alanine aminotransferase 68 IU/L and aspartate aminotransferase 75 IU/L. His prothrombin and partial thromboplastin times were within normal limits. Multiple blood cultures were negative. The results of serological tests for human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay (ELISA), hepatitis A immunoglobulin M (IgM), hepatitis B surface antigen, hepatitis C virus, Coxsackie B virus and toxoplasmosis were negative. Viral capsid antigen and Epstein-Barr nuclear antigen IgG antibodies were positive, suggesting a past infection with Epstein-Barr virus. The serological test for CMV ELISA was positive for IgM antibodies (CMV IgM > 50 U/ml). The result of a CMV pp65 antigenemia assay was also positive, suggesting acute CMV infection. On day 6 after admission, the patient complained of diffuse abdominal pain. An abdominal ultrasound revealed a small increase in the size of the spleen and the presence of free peritoneal fluid. During the next 24 hours, his abdominal pain worsened with the addition of rebound tenderness. Abdominal contrast-enhanced computed tomography revealed the presence of a thrombus about 7 mm in diameter located at the proximal superior mesenteric vein (Figure ). An emergency laparotomy was performed. The small bowel as far as the distal ileum and its associated mesentery had diffuse edema and ischemic lesions (Figure ). Furthermore, a segmental infarction of the proximal jejunum 50 cm long was present. An extensive enterectomy of about 100 cm of jejunum, including the necrotic segment, was performed, followed by an end-to-end anastomosis. Neither the patient nor his first-degree relatives had a history of vasculopathy or thrombosis. Anti-coagulation therapy was administered preoperatively when the diagnosis was established in the form of small-fractionated heparin (enoxaparin sodium 6000 IU twice daily) and continued for 1 month postoperatively. The patient had an uneventful recovery and was discharged on the 11th postoperative day. One month later the patient underwent a complete coagulation profile check, including anti-phospholipid antibody, factor VIII, protein C and protein S levels, as well as factor V Leiden and prothrombin 20210A mutations, that showed no deficiency. Six months later the patient was healthy and free of any symptoms.

Robin Lloyd

1984/5/18

291-713-0090x3138

174 Mejia Lakes Suite 010

A 62-year-old caucasian male known for dyslipidemia and scalp psoriasis was admitted to the emergency room for right renal colic. The patients had no history of constitutional symptoms, gross hematuria or abdominal pain. Laboratory findings were unremarkable. A computerized tomography (CT) was performed, which showed a 3.3 cm heterogeneous enhancing lesion in the upper pole of the right kidney consistent with a renal carcinoma (Figure ). Patient was then scheduled for a laparoscopic partial nephrectomy. The per- and post-operative periods were uneventful. Lymph nodes were explored during surgery and none were found. Nothing in the patient's clinical history or in the thoracic and abdominal CT scan performed suggested sarcoid granulomas involvement. No lymph node nor metastasis were present at the time of the surgery and at 30 months follow-up. Macroscopically, the tumor lesion revealed a 3.5 cm encapsulated yellowish mass with bosselated surface with small foci of hemorrhage and necrosis. Histological examination showed a conventional clear cell type renal carcinoma of Fuhrman nuclear grade III, without sarcomatoid features (Figure ). There was no perinephric, renal sinus fat, or renal vessel involvement. Surgical margins were negative. Neoplastic proliferation was delineated from normal renal parenchyma by a fibrous pseudocapsule where multiple non-necrotizing granulomas with multinucleated giant cells were found (Figure ). No granuloma was seen within the tumor. These granulomas did not contain centrally located malignant cells. These granulomas were associated with mild mononuclear, lymphocytic inflammatory infiltrate. No granuloma was seen in the adjacent renal parenchyma (Figure ). Ziehl-Neelsen and Grocott stains did not detect the presence of mycobacteria or fungi.

Zaire Lawson

1983/2/15

+1-533-463-1289x37939

28797 Cruz Summit

A 10-year old boy presented with a painful swelling in the dorsal aspect of the left distal thigh without history of trauma. Pain started 3 weeks before, increased with time and resulted in difficulties in walking at time of presentation. No fever, night sweats or weight loss was reported. Physical examination revealed a 9 ? 4 cm palpable firm mass in the biceps femoris muscle. Magnetic resonance imaging (MRI) demonstrated a 4 ? 3 ? 9 cm ill-defining tumor within the long head of the biceps femoris muscle with vivid uptake of contrast medium (Figure ). Also, enlarged lymph nodes up to a diameter of 2 cm were detected popliteal, inguinal and iliac. Radiologically, the most probable diagnosis was a malignant soft tissue tumor, most likely a rhabdomyosarcoma. Beside slightly enlarged inguinal and popliteal lymph nodes further staging did not reveal other organ or skin involvement. Laboratory HIV 1 + 2 screening tests showed no signs for HIV infection. Histological diagnosis was achieved by incisional biopsy. After being classified as Murphy stage II [], further treatment was conducted according to the international protocol for childhood ALCL (ALCL-99-NHL-BFM). ALK-1/NPM PCR was found positive in peripheral blood. After two cycles of chemotherapy the tumor was no longer detectable clinically or by ultrasound. The patient is currently receiving further chemotherapy without experiencing major toxicity.

Phoebe Hodge

1985/2/9

-10654

869 Cody Square

A 22-year-old Turkish man presented with a five-year history of intermittent daily headache centered on the left retro-orbital and orbital side. The pain was unilateral with a side shift only within the same bout. He experienced four to twenty attacks a week from the beginning of the bout, which resulted in severe social agitation. The attacks started abruptly and usually peaked within five minutes, without any aura or precipitating factors, and lasted 30 minutes to 120 minutes. He suffered from rhinorrhea, lacrimation and ptosis during the headaches, without any noted nausea, vomiting or photophobia. He had previously used several daily medications unsuccessfully, such as verapamil 160 mg thrice daily, naproxen 500 mg thrice daily, ibuprofen 600 mg thrice daily, dexketoprofen trometamol 25 mg twice daily, indomethacin 25 mg thrice daily, loratadine 5 mg daily and prednisolone 60 mg daily. Both general and neurological examinations between attacks and hematological-biochemical screenings were normal. He had neither significant past medical history nor family history of headache. On the day of a severe headache, an ophthalmological examination of our patient revealed lacrimation, conjunctival injection and ptosis without miosis. We measured both his pupils as 3.5 mm, with normal pupillary reactions to both light and near stimulation. As attacks occurred without significant periods of remission, we diagnosed our patient with chronic CH. We applied a cotton tip with 2 mL of lidocaine hydrochloride and epinephrine (Jetocaine, 20 mg lidocaine/0.025 mg epinephrine) into the left nostril for 10 minutes. The ptosis responded to the treatment and the intensity of his headache decreased. The magnetic resonance (MR) images of his brain and orbit and MR angiography of his brain and carotid artery were within normal limits. In 12 months of follow-up, he had six to ten attacks a week accompanied by autonomic symptoms, which resolved with intranasal lidocaine application.

Reign Carroll

1995/4/9

(698)911-6158x074

1274 Kelsey Shoals

A 29-year-old man with metastatic ONB presented to Virginia G. Piper Cancer Center Clinical Trials at Scottsdale Healthcare for participation in a pilot study to apply WGS on a fresh biopsy of one of his metastatic lesions to determine if identification of somatic perturbations might be useful for downstream therapy. The initial diagnosis of ONB was made after expert pathologic review at a major academic center. The tumor consisted of nests of closely packed cells with small to medium sized nuclei and scant cytoplasm. Within the nests, single cell and occasional necrosis was present. The tumor had features of epithelial differentiation confirmed by pankeratin staining, which highlights the clusters and single cells within the nests with strong cytoplasmic staining. The rest of the cells stain strongly for synaptophysin supporting the diagnosis of high grade ONB. The tumor was negative for chromogranin, neurofilament, CD45, CD20, S100, HMB45, and Melan A. Subsequently collected specimens also underwent confirmatory pathology review for the ONB diagnosis.

Zara Petersen

1979/2/11

001-504-462-8999x653

06632 Michael Parkway Apt. 029

Our case was a 15-year-old boy who had a motor vehicle accident. There was swelling, ecchymosis, severe pain, and valgus deformity, because of medial proximal fracture fragment, on the left knee. After evaluating the first radiograph (Figures and ), closed reduction and long leg splint were done, and control X-ray was taken (Figures and ). Correlation with computed tomography was performed in order to ascertain the fracture pattern (Figures and ). The patient had no neurovascular problems on his first physical examination. The fracture pattern was determined, and the patient underwent open reduction and internal fixation operation in emergency conditions. After a full anatomic reduction was achieved in our operation, the metaphyseal fragment was fixed to physis by two transverse cannulated screws. Fixation was also applied to the medial condyle with one cannulated screw (Figures and ). Since the patient's growth continues, we ensured that no screw passes through the physis. The patient was followed up for three weeks with long leg splint in the postoperative period. At the end of the three weeks, the splint was removed, a knee exercise program was implemented, and the patient was asked to walk on tiptoes for three weeks. At the end of the six weeks, knee extension was full, flexion was 150簞, and the patient started to walk with full weight. In his last control at the end of the one year, the knee regained full extension and 160簞 flexion.

Samson Wilkins

1987/10/10

372-992-3611x160

2552 Wheeler Corners

A 66-year-old man presented to the emergency department of University Hospital in Seoul, South Korea, complaining of severe, constant pain and bruising over the right flank for the previous 2 weeks. He had fallen, striking his right flank on the edge of the metal wastebasket approximately 4 weeks prior to presentation. At that time, he had a light abrasion on the right flank, but he did not receive any special treatment. He had a history of cardiovascular disease and poorly controlled type 2 diabetes mellitus over the past 40 years. On admission, the patient's mental status was alert. His vital signs were stable except for his temperature, which was 37.7簞C. Physical examination revealed intense pain on palpation, crepitus, swelling, and bruising over the right side of the abdominal wall, extending into the shoulder. No traces of the original wound remained. There were no other abnormal findings on physical examination. Laboratory tests revealed the following: white blood cell count, 8,000/mm3 with 74% neutrophils (normal, 4,500-11,000/mm3 with 40-75% neutrophils); hematocrit, 52.5% (normal, 38-52%); hemoglobin, 18.1 g/dL (normal, 13-17 g/dL); platelet count, 125,000/mm3 (normal, 150,000-400,000/mm3); and C-reactive protein, 256.43 mg/L (normal, 0-3 mg/L). Computed tomography scans of the chest and abdomen revealed soft tissue edema and stranding with gas in the chest and abdominal wall (Figure ). They did not show any abscesses in any other organs. After cultures of two blood draws and a sample obtained by direct needle aspiration were performed, treatment with cefazolin (2 g every 8 h, intravenously [i.v.]) and clindamycin (300 mg every 6 h, i.v.) was started. On hospital day 2, clindamycin was discontinued and cefazolin was changed to ceftriaxone (2 g every 24 h, i.v.) with the preliminary report of Gram-negative bacilli in the culture of the aspirated specimen. Because the patient did not show signs of systemic toxicity, elective operative drainage and debridement was performed on hospital day 3. Intraoperative findings included a foul-smelling brownish-gray exudate and subcutaneous emphysema tracking along the superficial and deep fascia from the right shoulder to the groin. On hospital day 5, the initial blood cultures were negative. The aerobic and anaerobic cultures of the needle-aspiration specimen and the necrotic tissue obtained during the operation were positive only for R. planticola, on hospital day 3 and 5 respectively, as determined biochemically by using the Vitek2 automated identification system (bioM矇rieux, Marcy l'Etoile, France; 95% probability). It demonstrated mucoid colony in both blood agar and MacConkey agar. The identity of the isolate was further confirmed using 16S rRNA sequencing []. Comparative sequence analysis showed a 100% identity with the sequence corresponding to the 16S rRNA gene of R. planticola ATCC 33531. Antibiotic susceptibility results were obtained using a Vitek2 AST-131 kit (bioM矇rieux) according to Clinical Laboratory Standards Institute methods. The isolate was found to be intermediate only to ampicillin and susceptible to the following antibiotics: amikacin, amoxicillin/clavulanic acid, aztreonam, cefepime, cefotaxime, cefoxitin, ceftazidime, cephalothin, gentamicin, imipenem, meropenem, piperacillin/tazobactam, tobramycin, levofloxacin, trimethoprim/sulfamethoxazole, and tigecycline. The isolates did not reveal extended-spectrum 帣-lactamase production. The patient required repetitive surgical debridements, and the wound was left open because of copious amounts of tissue fluid discharge (50-150 mL daily). Despite conversion to a negative culture on hospital day 16, ceftriaxone was changed to levofloxacin (500 mg every 24 h, i.v.) because the amount of discharge did not decrease. The patient's condition was complicated by Clostridium difficile-associated colitis on hospital day 28. Consequently, levofloxacin was discontinued, and the patient received tigecycline (initial loading dose of 100 mg, followed by 50 mg every 12 h, i.v.) for the coverage of both R. planticola and C. difficile. Over the course of 6 weeks of antibiotic therapy combined with five surgical debridements, the patient demonstrated obvious clinical improvement of both the colitis and the necrotizing fasciitis. Wound closure was performed on hospital day 37. After the 14-day administration of tigecycline, the patient had completed the treatment and was discharged without oral antibiotics. At outpatient follow-up, 4 weeks after discharge, the surgical wound was completely healed without any evidence of necrosis. The patient reported the resolution of symptoms related to the necrotizing fasciitis of the chest and abdominal wall.

Amalia Avila

1999/8/28

001-281-335-7155x242

6055 Jamie Ford

A 55-year-old man presented a lush conjunctival hyperaemia and chemosis of the inferior bulbar conjunctiva in the left eye accompanied with dry eye symptoms, on March 2011. This lesion has been described for the first time three months earlier, and it had been the reason for five emergency hospital visits. In this period the patient has been treated with different drops and ointments, including topical steroids, anti-inflammatory, antibiotics, and eye lubricants, but none has proven any efficacy. On March 2011, examination of the left eye disclosed an unilateral swollen and hyperemic inferior bulbar conjunctiva extending to both canthi; this was a light-pink-coloured lesion, painless, compressible and with an underlying transparent content (Figures and ); the inferior border of the mass was not identified. In the patient's medical history is important to highlight a kidney transplant in 1999 by the Alport syndrome that is currently being treated with corticosteroids, cyclosporine, and azathioprine. On ophthalmic examination, the best corrected visual acuity was 20/25 in both eyes. The biomicroscopy of the left eye revealed a punctate keratitis and the fundoscopy was normal. Intraocular pressure was 15 mmHg and pupils' reflexes were normal. The patient had no proptosis and no limitation on the eye movements. No signs of eye alterations associated with Alport's disease were found. No other systemic symptoms were pointed out by the patient. A computed tomography scan of the orbits and brain described a right and left maxillary and sphenoid sinuses, suggestive of sinus inflammation, with no involvement of the orbit (Figures and ). On May 2011, an incisional biopsy was performed under local anaesthesia which proved to be diagnostic and therapeutic. Histology showed a lymphatic proliferation and ectasia with a network of empty bloodless channels lined by flattened endothelium with the presence of some blood vessels and inflammatory infiltrate (haematoxylin and eosin stain, ?100; ), which is consistent with the diagnosis of conjunctival lymphangioma. The excision of the lesion led to the resolution of the case (Figures and ). Meanwhile the upper respiratory tract infection, which is likely to have exacerbated the size of the lymphangioma was resolved. Ten months later the patient remains asymptomatic with no signs of recurrence of the lesion.

Jaylen Atkins

1997/2/15

867.924.6689x07063

070 Mclaughlin Throughway

A 71-years-old female patient was presented to our burn clinic with the complaints of pain, rush, and burning in the left knee. Except of hypertension regulated with amlodipine besylate, the patient had not any systemic disease such as diabetes mellitus or asthma. The patient stated that she was on medical therapy for a long time due to osteoarthritis, but she had stopped it both because of epigastric burning and pains on her left knee not to resolve. The patient had referred to a person dealing with alternative medicine on the advice from her neighbour. That person had applied vaseline to the left knee and then scattered mustard seeds that were pulverized in a mortar on the creamed area followed by covering it with cotton and gauze. The patient stated that she had opened the dressing after 24 hours because of she felt burn in the left knee and that she had washed her knee which was slightly rushed using water and soap. However, complaints of rush, swelling, and itching in the left knee had started at the 36 hour after the application. On her physical examination, an erosion was found, surrounding the knee and compatible with second-degree burn, being more in the anterior side (). The treatment was planned as the patient to be hospitalized in the burn unit since she was elderly and the burn was surrounding the joint. First the burn area was cleansed with distilled water and debridement was made through a scalpel. Following application of the silver sulfadiazine cream, the burn area was wrapped with a gauze. This treatment was planned as once a day and the patient was discharged after one week. Topical silver sulfadiazine cream and daily dressing changes were applied over 14 days. The burn area was completely healed at the end of the first month (). No contracture developed during the 3-month follow-up period.

Mina Hunter

1980/12/17

5023985852

61602 Briggs Motorway Suite 011

A 40-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, HiTech Dental college and Hospitals, complaint of pain in the posterior right mandibular region for the past two weeks. He gave a history of intermittent pain in the same region for the past three months since the tooth was restored. His past medical history was found to be noncontributory. Clinical examination revealed a carious right mandibular first molar (47) with tenderness on percussion. The clinical findings, radiographic findings, and vitality tests led to a diagnosis of irreversible pulpitis with acute apical periodontitis of the right mandibular first molar, necessitating endodontic therapy. Radiographic evaluation of the involved that tooth did not reveal any unusual anatomy (). The tooth was anesthetized using 2% Lignocaine with 1 : 80,000 adrenaline (Lignox, Indoco Remedies Ltd., India) and isolated using rubber dam. Endodontic access cavity was established. The pulp chamber frequently flushed with 5% sodium hypochlorite to remove debris and bacteria. Inspection of the pulp chamber revealed five canal orifices (2 mesial and 3 distal, ). Canal patency was checked with number 10 K-file (Mani, Inc.; Tochigi, Japan). Working length radiograph was taken () and the presence of five canals was confirmed. Cleaning and shaping was performed using using a crown down technique with Protaper files (Maillefer, Dentsply, Ballaigues, Switzerland) under abundant irrigation with 5% sodium hypochlorite solution in a 5 mL syringe and EDTA (Glyde, Maillefer, Dentsply, Ballaigues, Switzerland). The tooth was then temporized. In order to ascertain the presence of middle distal canal, dental imaging using a multisliced computed tomography (SCT) was planned. After obtaining the informed consent from the patient, SCT of the mandible was performed using Dentascan, Dental Software (GE healthcare, USA). The spiral computed tomographic images revealed the presence of the three distal canals (Figures and ). Patient was then recalled after a week. The root canals were then dried with paper points (Maillefer, Dentsply, Ballaigues, Switzerland) and obturated with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland) and AH plus resin sealer (Maillefer, Dentsply, Ballaigues, Switzerland, ).

Archer Byrd

2002/7/31

001-858-827-5840

311 Jones Crest

A 23-year-old woman weighing 301 pounds and with a body mass index of 50.1 kg/m簡 presented to the bariatric surgery clinic for weight-loss surgery. She underwent a laparoscopic sleeve gastrectomy with no apparent postoperative complications. However, two weeks later, she presented with complaints of nausea, vomiting, epigastric pain and fever. She denied any hematemesis, changes in bowel movements, recent travel, or sick contacts. On examination she was febrile but had no peritoneal signs. CT abdomen revealed a 5.4 ? 3 cm fluid collection abuting the gastric body. Upper GI series revealed a leak near the GE junction (). Intravenous antibiotics and total parenteral nutrition were initiated. An upper endoscopy was done to assess the site and the size of the leak following which an 18 mm ? 125 mm fully covered wall flex stent was placed (). Gastrografin study during the procedure revealed no leak (). The patient was discharged home on total parenteral nutrition. Followup demonstrated clinical improvement, and repeat CT abdomen showed improvement in the fluid collection. The patient was started on a clear liquid diet 2 weeks after the procedure, to which protein shakes were later added. Patient was able to tolerate pureed food without any complaints at the end of the second month. Gastric sleeve stent was removed after 6 weeks. Follow-up upper GI series showed no gastric leak (). Proton pump inhibitor therapy was discontinued after 8 weeks. One year after the procedure the patient has lost 103 pounds and has been doing well.

Giselle Lang

1995/12/24

501.261.6151x293

309 Christian Grove Apt. 405

A 52-year-old man sought for treatment of a white plaque in the gingiva. The lesion was asymptomatic and had been noticed by the patient two years before the consultation. He reported daily tobacco and alcohol consumption. Oral examination revealed an 8 mm diameter and ill-defined white plaque on the edentulous alveolar ridge, region corresponding to the 38 tooth. Radiographs showed normal bone appearance (). The clinical diagnosis was leukoplakia. Under local anaesthesia, the white plaque was excised. Microscopically, the oral squamous epithelium was hyperplastic and hyperkeratotic but without dysplastic alterations (). A discrete chronic inflammatory infiltrate in the subjacent connective tissue was observed. In the deep portion of oral submucosa there were numerous islands of odontogenic epithelial cells scattered in a fibrous stroma (). Few nests were predominantly composed by polyhedric cells (). Other epithelial islands consisted of peripheral rows of palisaded hyperchromatic columnar cells and central polyhedric cells. The outer cells presented more basophilic staining than that inner ones (). In few larger islands, it was possible to see evident budding projections (). Semiserial section of the lesion exhibited epithelial islands with squamous metaplasia and incipient cystic formation (Figures and ). Another interesting microscopical feature was the presence of connective tissue surrounding the islands of odontogenic epithelial cells with looser arrangement than adjacent collagenous tissue not involved with the lesion (). The aggregate of odontogenic epithelial cells was confined to the connective tissue, without bone infiltration. The diagnosis established was early peripheral ameloblastoma subjacent to a nondysplastic leukoplakia. The patient was submitted to a long follow-up. In the nine-year follow-up, he was clinically and radiographically normal ().

Wells Brewer

1992/9/17

001-276-355-8571x4794

6429 Robertson Roads Suite 976

A 53-year-old woman presented with subjective sensation of retroorbital pulsation. Digital subtraction angiogram demonstrated a 10 mm left supraclinoid ophthalmic artery aneurysm with a 5.5 mm neck. She underwent elective stent-assisted coiling of this aneurysm. The procedure was performed under general anesthesia. Clopidogrel 600 mg and aspirin 325 mg was given through a nasogastric tube at the beginning of the case. Femoral artery access was established with a 7 F 11 cm sheath. Heparin was given intravenously to maintain activated coagulation time between 250 and 300 seconds throughout the case. A Neuroform-3 (4 ? 20 mm) stent (Boston Scientific, Natick, MA, USA) was deployed across the aneurysm neck. The aneurysm was then embolized using two HydroFrame coils (MicroVention, Aliso Viejo, CA, USA) through an Excelsior SL 10 microcatheter (Boston Scientific, Natick, MA, USA) positioned within the aneurysm dome (Figures and ). A Hydrosoft 10 helical 4 ? 6 mm coil (MicroVention, Aliso Viejo, CA, USA) was then chosen to continue the embolization. During delivery the coil detached from the delivery system without activation of the release mechanism. A long portion of the coil was left in the cavernous internal carotid artery (ICA) proximal to the aneurysm (Figures and ). Retrieval of the displaced coil was first attempted using the Alligator 4 mm Retrieval Device (ev3 Endovascular, Inc, Plymouth, MN, USA), but this was unsuccessful. An Amplatz 4 mm GooseNeck Microsnare (ev3 Endovascular, Inc, Plymouth, MN, USA) was then used for retrieval, but this resulted in further coils prolapse (Figures and ). At this point the ICA developed significant vasospasm. Nicardipine was infused intra-arterially with radiographic improvement. Abciximab (Reopro, Centocor, Malvern, PA, USA) 0.125 mcg/kg/min was also started to prevent thromboembolic complication. A Merci V 2.5 Soft retriever (Concentric Medical Inc, Mountain View, CA, USA) was advanced to the displaced coil and engaged the coil loops. Multiple fragments of the coil were retrieved. A remaining coil fragment was jailed to the vessel wall by placement of another Neuroform 3 stent (Figures and ). A 6 French Envoy guide catheter was used in the ICA, and this was removed simultaneously with the Merci device (Codman & Shurtleff Inc, Raynham, MA, USA). Post-operative angiogram shows near complete occlusion of the aneurysm. Flow in the ICA and its branches were normal (Figures and ). Abciximab was stopped 6 hours after the procedure. The patient had an uneventful postoperative course and was discharged to home neurologically intact. On three-month followup the patient remains neurologically normal (modified Rankin score = 0); and she has 20/20 vision bilaterally. She reported significant improvement in her subjective retroorbital pulsation. Magnetic resonance angiogram 1 year after procedure shows no evidence of aneurysm recurrence or coil compaction.

Thea Bennett

1986/12/18

384.237.5416

73849 Mark Forest Suite 764

A 75-year-old woman with atrial fibrillation presented with Hunt Hess grade four subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a 2.5 mm right posterior communicating artery (PCOM) aneurysm with irregular dome (Figures and ). She underwent emergent ventriculostomy and stent-assisted coiling of the ruptured aneurysm. Femoral artery access was established with a 7 F 11 cm sheath. Heparin was not given. A Prowler Select Plus microcatheter (Cordis Endovascular, Miami Lakes, Florida, USA) led by a Synchro 2 soft microwire (Boston Scientific, Natick, MA, USA) was advanced into the distal ICA. An Enterprise 4.5x22 mm stent (Cordis, Bridgewater Township, NJ, USA) was deployed across the neck of the aneurysm. Migration of the stent was noted during deployment, but it still covered the neck of the aneurysm. Tirofiban 0.1 microgram/kg/min was started intravenously. Two HydroCoil 10 coils (2 mm ? 4 cm) (MicroVention, Aliso Viejo, CA, USA) were initially deployed into the aneurysm through a SL-10 microcatheter (Boston Scientific). During coiling embolization several loops of the coil bulged into the parent artery (Figures and ). A decision was made to deploy an overlapping stent to hold the coil mass in the aneurysm. A Renegade Hi-Flo microcatheter (Boston Scientific, Natick, MA, USA) led by a Synchro 2 soft microwire was advanced into the vasculature. Significant migration of the previously placed stent was noted when the microcatheter and microwire passed through the Enterprise stent and the coil mass herniated out of the aneurysm (Figures and ). Attempts to engage the stent and coils using the Synchro 2 soft microwire were without success. A Merci V 3.0 firm Retriever was advanced into the ICA led by an 18 L Merci microcatheter (Concentric Medical Inc, Mountain View, CA, USA). We were able to engage the coils and stent and pulled them into the cavernous segment. A Merci V 2.5 soft Retriever was then advanced to the ICA. The Retriever engaged the coils and the stent again but attempts to pull them into the 6 F Envoy MPD guiding catheter (Codman & Shurtleff Inc, Raynham, MA, USA) were unsuccessful. At this point the coil/stent mass dislodged from the Merci device. The Merci Retriever, the 18 L Merci microcatheter, and the 6 F guiding catheter were then removed. A 7 F Envoy catheter led by a 0.038 glidewire was then used to select right carotid artery, and the tip of guiding catheter was placed at the distal cervical ICA near petrous bone. The 18 L Merci microcatheter led by a Synchro 2 soft microwire was again advanced into the distal ICA. The microwire was then removed, and a Merci V 2.0 Firm Retriever was advanced. The coils and the stent were pulled to the tip of the guiding catheter. The guiding catheter, the microcatheter, and the Retriever along with the coils and the stent were successfully removed out of the sheath. Examination of the objects on the field showed that the stent and the coils were intact without missing pieces. A postretrieval angiogram shows that the aneurysm was stable and the right ICA was patent without evidence of arterial dissection, pseudoaneurysm, or occlusion. A subsequent attempt at stent-assisted coiling of the aneurysm was successful using a Neuroform 4.0 mm ? 20 mm stent (Boston Scientific, Natick, MA, USA) and HydroCoils. A control angiogram after final coil deployment shows obliteration of the aneurysm (Figures and ). The stent was patent. An intracranial run showed that the distal ICA and its branches were normal in caliber without vasospasm or thromboembolism. Clopidogrel 600 mg and aspirin 325 mg was given at the end of the procedure. A repeat angiogram 3 days later showed moderate vasospasm and a secured PCOM aneurysm. Unfortunately the patient's clinical exam did not improve significantly, and the family decided on palliative care. She expired one month after the initial hemorrhage.

Leonardo Ali

1986/11/5

(427)362-9748x40393

4111 Webb Stream Apt. 524

A 68-year-old man presented in 2010 with recanalization of a previously treated anterior communicating artery (ACOM) aneurysm (). He had a history of Grade I SAH in 2004 from a ruptured 15 mm ACOM aneurysm. He was treated initially with endovascular coiling in 2004, and a repeated coil embolization was performed in 2008. A decision was made to treat this recurrent aneurysm with further coiling. Femoral artery access with a 7 F sheath was obtained. A 6 F Envoy guide catheter was introduced into the left ICA over a guidewire. Superselectively, the aneurysm was catheterized with a SL-10 microcatheter and a Synchro 10 microwire. A 3 ? 6 mm Orbit Galaxy coil (Codman & Shurtleff Inc, Raynham, MA, USA) was deployed in the aneurysm, but not detached since the coil was oversized and herniated in the parent vessel. Subsequently, a 2 ? 4 mm Galaxy Xtrasoft coil (Codman & Shurtleff Inc, Raynham, MA, USA) was deployed in the aneurysm. As soon as it was detached, the flow carried the coil from the aneurysm to the left A2 segment of the anterior cerebral artery (). A repeated injection demonstrates thrombosis of the left A2 without flow distal to the migrated coil (). At this point the SSEP signals were lost from the right leg. The decision was made to retrieve the coil with a Merci retriever, but the angle of the left A1/A2 junction was too acute to allow delivery of the Merci device from the left. An exchange maneuver was performed to replace the femoral access with an 8F sheath. An 8F Merci balloon guide catheter (Concentric Medical Inc, Mountain View, CA, USA) was also exchanged to replace the 6 F Envoy catheter and placed in the right ICA with the aim to diminish flow by inflating the balloon at the tip of the Merci guide while we are retrieving the coil. The left A2 was then catheterized through the right A1 with an 18 L Merci microcatheter. The microcatheter was advanced proximal to the migrated coil first, and 8 mg of tissue plasminogen activator was infused. The catheter was then taken distal to the coil, and a V2.0 soft Merci retriever was deployed and successfully ensnared the migrated coil (Figures and ). With the proximal balloon inflated, the coil was brought down to the tip of the guide catheter. At this point, we were unable to bring the coil inside the guide catheter, so the Merci retriever was removed, and an Alligator 2 mm Retrieval Device (ev3 Endovascular, Inc, Plymouth, MN, USA) was utilized to grab the coil and bring it inside the guide catheter. Postprocedure angiography demonstrates patency of the Left A2 (). At this point the SSEP signals returned to normal. Postoperatively the patient remains neurologically intact and was scheduled for a repeated coiling in the future.

Zelda Sparks

1980/3/24

+1-648-804-2570x87737

2704 Wolf Station Suite 760

A 76-year-old Caucasian female was referred to our department due to a 6-month history of constant aching pain over her left hip region. Imaging features were very typical of a primary bone tumor and thus, as tentative diagnosis chondrosarcoma was made by the reporting radiologist (). Subsequently performed tumor staging revealed the tumor as being a primary with an otherwise clear bone scan, CT chest, and abdomen. There was no evidence of metastatic disease. However, imaging of the kidneys suggested possible renal cell carcinoma involving the right kidney. Biopsy specimen of the proximal left femur revealed a biphasic tumor composed of a cartilaginous component with abrupt transition into a noncartilaginous malignant mesenchymal component (). The diagnosis of a dedifferentiated chondrosarcoma was made. The dedifferentiated part was consistent with an osteosarcoma. The patient underwent limb salvage surgery, performed according to standardized local protocol by surgeons specialized in oncologic surgery, followed by endoprosthetic replacement. Wide surgical margins were achieved. Although the patient was reasonably fit, adjuvant chemotherapy was not given due to the patient's age. During the further course of treatment, the suspicious condition in the right kidney, that had already been present during initial tumor staging prior to limb salvage surgery, was diagnosed as clear-cell renal cell carcinoma () and immediately subjected to nephrectomy. There was no evidence of metastatic disease. After more than 5 years of followup the patient is still free of disease. Besides the current complaints described above, the patient underwent hysterectomy and cholecystectomy years ago. She could not remember the reason and there is no documentation discussing why those operations were performed. However, her medical family history () revealed that her youngest brother started suffering from invasive medium- to-low differentiated urothelial carcinoma () of the bladder when he was 67-year-old. He died at age 69 of a fibroblastic osteosarcoma () located in his left femur. Their mother presented with renal cell carcinoma as well when she was 65-year-old (specimen not available). To assess the hypothesized diagnosis of LFS, DNA was isolated from blood samples of the female index patient, and we analyzed the tumor suppressor gene p53 using semiquantitative, multiplex ligation-dependent probe amplification (MLPA, MRC-Holland) to rule out alterations of the TP53 gene. Moreover, the entire coding (exons 2??1) region and flanking intron regions of TP53 were sequenced. Since both MLPA and sequenciation did not reveal pathologic changes of the TP53 gene, the GAG-banding pattern derived from cell division was analyzed as well. However, chromosomal aberrations were not detected in the cytogenetic analysis neither for structural or numerical reasons. Taking into account all the results obtained, the diagnosis of LFS could not be confirmed, but there is still uncertainty regarding a definitive diagnosis in terms of a possible new genetic syndrome.

Drake Gonzalez

2000/7/19

001-319-772-2952

227 Sarah Causeway Apt. 618

An 11-year-old male patient presented to our institution after sustaining trauma to his left lower extremity. On the day of presentation, there had been high winds in the vicinity resulting in the corrugated iron roof of a garage he had been walking nearby blowing off and landing on his left leg. The patient was trapped under the sheet of metal until freed by attending paramedics. In the emergency department, primary and secondary survey assessments of the patient revealed injuries to the knee and distal fibula only. A full formal examination of the knee was not possible due to pain and a tense haemarthrosis. Subsequent plain radiographs revealed an intra-articular avulsion fracture (), as well as fracture of the distal fibular diaphysis. A working diagnosis of displaced tibial spine avulsion fracture was made, and the patient was scheduled for surgery the following day to assess and fix the injury. Examination under anaesthesia revealed a ten-degree block to neutral extension of the knee and a positive Lachmann test with a soft end point. Arthroscopic examination of the knee revealed a lesion at odds with the preoperative diagnosis of tibial spine avulsion. A femoral end osteo-chondral avulsion fracture of the ACL was revealed (). Due to the unexpected findings and uncertainty about the optimal method of fixation in a skeletally immature patient, the fragment was reduced back into its normal position, the arthroscopic portals were closed, and the knee was splinted in extension in a plaster of Paris splint. With the benefit of hindsight, the treating team acknowledged that if a bone fragment this large had been avulsed from the tibial insertion of the ACL, this should have been reflected in the architecture of the tibial spine footprint on the preoperative X-ray. But as the appearances of this region appeared normal, this avulsion was unlikely to have occurred from the tibial end of the ACL, rather occurring from the less common femoral origin. A CT scan was subsequently obtained (), and the literature was scrutinised to aid preoperative planning of definitive fixation. Subsequent definitive fixation was perfomed nine days following the index procedure using a part arthroscopic and part open approach. Initial arthroscopic manoeuvres (including the use of a direct anterior portal in addition to the two standard portals) involved gentle curettage of the residual crater over the medial aspect of the lateral femoral condyle from where the ACL had been avulsed. Then two 2.4 mm Beath pins were passed in transosseous manner from the lateral supracondylar ridge into the centre of the defect (crossing the physis) using a posterior cruciate ligament targeting guide. 2 loops of 1 PDS suture were passed via these tunnels from the outside of the knee to the centre of the defect. Then a medial parapatellar approach to the knee joint was performed to formally expose the knee, two No. 2 Vicryl Bunnell sutures were passed across the femoral end of the ACL, and these sutures were placed into the PDS loops that had previously been passed into the knee. Pulling on the PDS sutures allowed the No. 2 Vicryl sutures to be passed through the tunnels previously drilled with the Beath pins and to be delivered to the lateral supracondylar ridge of the femur. The sutures were then tied to one another over a bone bridge thereby reducing the avulsed fragment back into its normal anatomical position (). Postoperatively, the patient was splinted in extension for the first four weeks. At this stage, the patient was placed into a range of motion knee brace (allowing up to sixty degrees of flexion) and allowed to partially weight bear with crutches. At six weeks following surgery, the patient's brace was slackened to allow a full range of motion. Radiographs performed nine weeks following definitive fixation showed union of his fracture (). He was allowed to ambulate free of his brace at this stage. At six-month follow up, the patient was able to ambulate without walking aids with a normal gait pattern and had a negative anterior drawer and Lachmann test and full restoration of knee flexion. No deformity or leg length discrepancy was noted at this follow up interval.

Abigail Larson

2003/10/31

001-682-547-7541x130

8924 Martin Locks

A 66-year-old African American woman with osteoporosis, osteoarthritis, and impaired glucose tolerance presented to the emergency department with a 5-day history of left groin pain, nausea, vomiting, and fatigue. Five days prior to admission, she had noted an abscess on her inner left thigh that progressively ruptured and drained purulent, bloody material. On evaluation, she was tachycardic (HR: 111??36) and febrile to 103.2簞F. The left thigh wound drained a thin serous and dishwater-type fluid. Labs revealed leukocytosis and hyperglycemia (WBCs = 23.8 ? 103: 86.4% neutrophils, 5.4% lymph, 8.1% monocyte; glucose: 239 g/dL; BUN 13 mg/dL, creatinine 0.6 mg/dL, chloride 92 mmol/L, total CO2 24 mmol/dL, total creatinine kinase = 67 mg/dL). CT scan showed a 4.6 ? 1.4 ? 5 cm fluid collection proximal to the left gracilis muscles with presence of gas bubbles, edema, and fat stranding in the subcutaneous tissues. The patient was taken emergently to the operating room to undergo radical debridement, washout, packing, and subsequently admitted for IV antibiotic therapy. Microscopic analysis of the debrided specimen revealed areas of necrosis and acute and chronic inflammation, consistent with a diagnosis of necrotizing fasciitis. Gram stain of the initial intraoperative specimen showed ?ew gram positive cocci in pairs and chains,??and final bacterial culture showed many GBS, moderate S. lugdunensis, and moderate Corynebacterium (see ). Subsequent additional debridement grew many GBS and many S. lugdunensis. Blood cultures were negative. Blood tests for HIV 1, HIV 2, hepatitis B, and hepatitis C were negative. QuantiFERON gold tuberculosis test was negative. During the course of hospitalization, the patient was empirically treated with IV antibiotics including vancomycin, clindamycin, and aztreonam. After multiple debridements, the patient underwent plastic surgery reconstruction of her left groin. She was discharged home in stable condition after a 67-day hospital course and is doing well at followup 18 months later.

Rafael Zimmerman

1984/3/13

640-466-8610x1618

97704 Katherine Point

A 47 year-old-man, human immunodeficiency virus negative, with a recent diagnosis of central nervous system lymphoma presented with perianal skin lesions and nonbloody diarrhea. The skin lesions began as nodules that progressed to a roughened plaque and in the minority, ulceration. The lesions began eight weeks prior to presentation, were multiple, scattered in the perianal area and upper thigh bilaterally, and three centimeters at the widest diameter (). A more distinct lesion with irregular border was present over the sacrum consistent with a decubitus ulcer. The patient had been diagnosed with a CNS lymphoma six weeks prior to admission when he presented to another hospital with lower extremity weakness, saddle anesthesia, and fecal incontinence, and was found to have a L1-L2 intramedullary spinal mass. He had emergent surgical resection of the mass and was treated with high-dose dexamethasone and further radiation therapy. He was additionally found to have a right temporal lobe mass that was resected and pathology was consistent with a B-cell lymphoma with T-cell infiltration. He had no other significant past medical history or immunocompromising condition. The lower extremity weakness persisted and primarily confined him to bed. For ongoing fecal incontinence and the nonhealing sacral decubitus ulcer, he ultimately had a diverting colostomy. Two weeks prior to presentation, his bowel movements became more liquid in consistency and increased in frequency. He denied abdominal pain. The perianal skin lesions were not painful, but the initial loss of sensation from the compressive spinal mass had not recovered. He remained on a dexamethasone taper and was transferred to this hospital for further evaluation for chemotherapy. His complete blood count was notable for a normocytic anemia, and his liver function tests for an elevated alkaline phosphatase. An excisional biopsy of one of the skin lesions from the upper thigh was obtained and sent for pathological examination. Sections of the pathological specimen revealed a dense neutrophilic crust with numerous bacteria distributed in varying sized aggregates, and the underlying epidermis was acanthotic with artefactual subepidermal clefting. However, the superficial dermis demonstrated a distinct perivascular lymphocytic infiltrate, and the endothelial cells were markedly enlarged (). Some endothelial cells contained magenta-colored nuclear inclusions consistent with cytomegalovirus (CMV) infection which was confirmed by a positive CMV immunostain (). Stains with periodic acid-Schiff and for acid-fast bacilli were negative. The patient was treated with intravenous ganciclovir at five mg/kg every twelve hours for 21 days followed by transition to valganciclovir. A serum CMV viral load was 16,400 copies/mL at treatment initiation and was undetectable after four weeks of treatment. The diarrhea resolved within two weeks, and the skin lesions had completely healed at the time of switch to valganciclovir. Based on pathological findings and response to treatment, the diagnosis of cutaneous CMV was made. The primary mode of pathogenesis was thought to be local inoculation from fecal shedding. The diarrhea appeared to be a manifestation of CMV colitis, but given the commitment to CMV treatment and the response to therapy, no further investigation was performed. Unfortunately, the patient later died secondary to complications of an intracranial hemorrhage at the site of the temporal lobe resection.

Ariyah McGee

1998/1/12

963-271-9815x25904

9952 Cervantes Islands

The second patient reported in this series was a 73-year-old female with a diagnosis of rectal adenocarcinoma 6 cm from the anal verge who underwent neoadjuvant therapy. In contrast to the first patient, this patient underwent a hybrid NOTES TME using a transanally inserted rigid, single port device. The single port access device has 3 channels for instrumentation, with 2 additional channels for CO2 insufflation. Using a 10 mm 45-degree laparoscopic camera, in lieu of a flexible colonoscope, the TME dissection was then carried out transanally with laparoscopic assistance as previously described. Operative time was 360 minutes. This patient also recovered uneventfully and was discharged home on postoperative day 6. Pathology revealed tumor-free margins and intact mesorectum with 2 of 11 lymph nodes positive for tumor (pT3N1).

Conner Weeks

1989/12/23

001-204-689-0781x40059

57640 Craig Throughway

The third case was reported by Tuech et al. in 2011 []. This report describes a 45-year-old woman with a reported T1sm3 rectal adenocarcinoma 3 cm above the dentate line. For this procedure a single port access device, endorec trocar (Aspide, France), was also used. This trocar consists of a rigid port with 40 mm outer diameter, three 5 mm, and one 10 mm access channel and an air inlet tube through which CO2 can be inflated. The extraperitoneal rectum was completely mobilized using this device. Once the lateral rectal attachments were divided, the rectovaginal peritoneal reflection was identified and perforated to gain access to the abdominal cavity. A second endorec trocar (Aspide, France) was then placed through the proposed ileostomy site and laparoscopic assistance with proximal colonic mobilization ensued. The procedure was performed successfully without complication. Operative time was 5 hours. The patient did well postoperatively without complication. Pathology revealed a pT1sm3N0 tumor. Fifteen lymph nodes were retrieved with the specimen. While the principles of NOTES transanal rectal cancer resection remain the same, the methodology, particularly with respect to transanal dissection, varies between clinical trials. The consensus is that the majority of the rectal and mesorectal dissection can be achieved transanally while laparoscopic assistance is needed for proximal colon mobilization and tissue retraction. It is the preference of our group at this time to use the rigid TEO platform for transanal endoscopic rectal dissection rather than a flexible single port device. The TEO platform comes in 2 lengths, provides rigid stabilization for instrument manipulation, and is an established cost effective, reusable platform readily available at our institution. Nonetheless, the published reports thus far demonstrate that adequate hybrid NOTES TME can be achieved using flexible or rigid platforms and highlight the importance of continued work and development in this field. As part of our effort to further this work, we are currently enrolling patients into an ongoing United States based Institutional Review Board (IRB) approved prospective clinical trial []. Patients selected for this approach include those with biopsy proven resectable adenocarcinoma of rectum located 4??2 cm from anal verge who are otherwise eligible to undergo standard open or laparoscopic low anterior resection with temporary diverting stoma. Tumors must be preoperatively staged as node negative, T1 (high risk features), T2 or T3 based on pelvic MRI with no evidence of metastasis on staging CT scans. For preoperatively staged T3N0 tumors, patients must have completed full-course neoadjuvant treatment. Procedures are performed following the same steps as described in cadavers, using an abdominal and perineal team working simultaneously. Transanal dissection is performed via the TEM platform with laparoscopic assistance through 1?? abdominal trocars. The right lower quadrant trocar is later used as the ileostomy site. Following transanal specimen retrieval, a handsewn coloanal anastomosis with diverting ileostomy is performed. For this protocol, a diverting ileostomy is standard given performance of a low-lying anastomosis in patients who likely will require either neoadjuvant or adjuvant chemoradiation.

Karen Hart

1979/8/3

(619)452-8104x100

326 Garcia Forest

A 30-year-old pregnant Caucasian female complaining of severe anal pain and an anal bump was referred to the Colorectal Surgery Office by her primary care physician. She was 8-week pregnant. Her pain started a few days earlier and she noticed a small amount of bright red blood on the toilet paper and coating the stools. She had been constipated. She stated the pain was worse during and after defecation. Her medical history was significant for irritable bowel syndrome, recurrent oral ulcers, and anal pruritis. She denied abdominal pain, nausea, or vomiting. Her family history was significant for inflammatory bowel disease in her maternal relatives. She denied any history of anal intercourse or instrumentation. Upon examination there were no significant physical findings with the exception of what appeared to be an atypical fissure with heaped up skin edges and ulceration in the center in the left posterior position. A local block was placed and a steroid injection was performed. Topical lidocaine mixed with diltiazem and high fiber supplementation were prescribed. Her pain transiently improved but upon repeat examination two weeks later she was having recurrent pain and there was no change in the appearance of the fissure. She was admitted for pain control, an examination under anesthesia, and a flexible sigmoidoscopy. The differential diagnosis upon admission was new onset Crohn's Disease or a severe anal fissure. Upon admission, her vitals were normal and anal inspection revealed two large skin tags. A digital rectal exam could not be done secondary to severe tenderness. Labs showed normal serum electrolytes, WBC 3900, platelets 133000, Hb 11 g/dL, Hct 31.5, and MCV 91. She was taken to the operating room and examination demonstrated a large deep anal canal ulcer in the left posterior-lateral position (). No obvious fistula or abscess was identified. A sigmoidoscopy was performed and revealed numerous aphthous erosions involving the mucosa of the rectum and sigmoid colon, which appeared consistent with inflammatory bowel disease. The proximal colon was not evaluated endoscopically. Biopsies were taken from the anal ulcer and rectosigmoid mucosa (). An additional steroid injection was given into the ulcer bed. She was discharged home that day and was to follow up the following week. In the following few days, the results of the peripheral blood smear and pathology returned. The smear contained 5% blasts. The biopsy from the anal ulcer depicted squamous mucosa with ulceration and submucosal atypical hematopoietic cell infiltrates suggestive of acute leukemia. Similar findings of discrete mucosal and submucosal aggregates of atypical large and medium-sized hematopoietic cells were noted on rectal biopsies. She was immediately readmitted and a bone biopsy was performed. Her results with flow cytometry showed hypercellularity with 53% blast cells. The abnormal cells were positive for CD13 (58%), CD33 (73%), CD15 (59%), CD45, CD34, CD64, CD4, HLA DR, and MPO markers consistent with acute monocytic leukemia (FAB M5b). Refer to Figures , , and . Subsequent cerebrospinal fluid analysis also showed 30% blasts on flow cytometry. Her cytogenetic evaluation revealed an abnormal female karyotype with Inv (16) (p13q22), and Trisomy 8 and 22. She was diagnosed with acute myeloid leukemia and started on high-dose Idarubicin and cytarabine for induction chemotherapy. Intrathecal methotrexate was also given as there was evidence of central nervous system disease. Her pregnancy was terminated therapeutically before the chemotherapy was started. A repeat bone marrow biopsy nine months later after completing chemotherapy did not show any atypical cells. She clinically has no evidence of disease at this time.

Joel Porter

2000/6/17

001-362-783-0235

62790 Gibson Point

A 61-year-old man was admitted to our hospital for a solid mass found in the right kidney during a routine checkup. Computed tomography showed that the mass was located in the superior pole. No remarkable symptoms such as flank pain or urinary irritation were reported by the patient. He also had no familial history or clinical evidences of VHL disease. Radical nephrectomy was carried out, showing a 5.3 ? 5.0 ? 5.0 cm mass. It was grey to yellowish in color and well-demarcated from the surrounding renal parenchyma. The patient had an uneventful postoperative recovery and was well at 12 months follow-up.

Ryleigh Munoz

1989/3/15

(922)859-1395

47541 Mark Springs Apt. 391

The patient was a boy, 4 years and 6 months old, who presented with a large intra abdominal mass. No risk factors such as prematurity, viral infection, or developmental disorders were present at the time of diagnosis. Radiological assessment suggested a multifocal epithelial tumor in both sides of the liver. Multiple bilateral lung metastases were also identified, classifying the tumor as stage Pretext IV. Serum 帢-fetoprotein (AFP) at diagnosis was 400.000 繕g/l. Treatment was initiated at this stage following the guidelines of the collaborative international center trial SIOPEL3. The high risk protocol consisted of 4? Cisplatin (CDDP, 80 mg/m2/24 h), 3? Carboplatin (CARBO, 500 mg/m2//1 h), and 3? Doxorubicin (DOXO, 60 mg/m2/48 h). After these courses, the tumor showed stable disease with slightly decreased AFP levels and tumor volume. However, lung metastases had completely disappeared. After completing chemotherapy, a local progress (tumor volume) occurred. Consecutively, the patient received high dose chemotherapy (CARBO/VP16 according to the GPOH protocol HB99) together with autologous stem cell transplantation and a transarterial chemoembolisation. This led to a partial response of tumor volume and AFP (50.000 繕g/l). With lung metastases still absent and the primary tumor being regarded as unresectable, the decision was taken to perform a living related liver transplantation (segments II and III) from the child's father. Immediately before operation, AFP rose again to a level of 153.000 繕g/l, still there were no lung metastases detectable. Hepatectomy and liver transplantation were carried out 6 months after initial diagnosis.

Justin Cherry

2000/3/6

001-744-398-1385x4772

890 Joshua Keys Suite 871

The patient is a 32-month-old male with a history of asthma who had been born at 36 weeks gestation via an unremarkable induced vaginal delivery secondary to oligohydramnios, with a birth weight of 5 pounds 12 ounces. The patient's asthma history is significant for multiple emergency room visits and one prior non-PICU admission for an asthma exacerbation. His maintenance medical regimen includes daily inhaled corticosteroids and albuterol as needed. The patient lives with his mother, father, an older sister who is healthy, a maternal grandmother who smokes in the house, and a cat. The patient presented to a nearby emergency room seven days prior to presentation with worsening respiratory distress in the context of two weeks of upper respiratory symptoms and diarrhea. On initial presentation at the nearby emergency room, he was diagnosed with bilateral pneumonia and treated as an outpatient with amoxicillin, azithromycin, oral steroids, and nebulized albuterol treatments. Four days after the initial emergency room visit, his respiratory symptoms progressed, necessitating emergency intubation and high frequency oscillatory ventilation at the outside hospital. The patient was positive for human metapneumovirus and had healthy appearing airways on bronchoscopy. After three days of progressive worsening on increased respiratory support, the patient was transferred to the JHH Pediatric Intensive Care Unit from an outside hospital and venovenous extracorporeal membrane oxygenation was initiated. Please refer to for the chest radiograph prior to ECMO initiation. The patient was initially treated with vancomycin, piperacillin/tazobactam, and fluconazole for presumed superinfection in addition to the HMPV pneumonia. After the blood cultures were negative for bacteria, fungi, and viruses for 48 hours, vancomycin and fluconazole were discontinued. However, due to the severity of his illness and concern for bacterial suprainfection, he completed an 11-day course of piperacillin/tazobactam for presumptive pneumonia. Due to decreasing urine output and concern for fluid overload compromising his respiratory status, the patient was started on continuous venovenous hemofiltration with a positive response, and he was subsequently transitioned to a furosemide infusion. He also required a nicardipine infusion for elevated blood pressures. Heparin anticoagulation and routine blood product transfusions were used during the ECMO run as per protocol. The patient progressed favorably from a respiratory perspective and was successfully decannulated on day 9 of ECMO, extubated 4 days following ECMO, and transitioned to room air 9 days following extubation. Given the unusual clinical course, an immunodeficiency workup to further investigate possible reasons for the development of respiratory failure in an otherwise healthy host was performed. T cell subsets were within normal limits. The remainder of his hospital course on the floor was notable for a successful diuretic wean, normalization of his work of breathing, cleared lung exam without coarseness, subglottic edema with intact vocal cords noted on bedside flexible laryngoscopy, and significant strides in physical and speech therapy.

Nyomi Cabrera

2005/8/29

676-998-4027x404

43243 Aguilar Club

A 77-year-old man presented to the urology outpatient clinic with a right scrotal swelling; the patient did not report any symptoms such as pain or discomfort from the site of the swelling. However, the patient did express his concerns about the slow and gradual growth of the mass in his scrotum for months. The patient had no history of asbestos exposure or any surgical procedures. On examination he had a tense swelling in the right hemiscrotum, the clinical features of which were consistent with a hydrocele. The scrotal ultrasound scan reported a large 7-8 cm multiloculated hydrocele (). Following a thorough review, the patient underwent surgery to excise the right scrotal mass. Surgery revealed a tense multicystic mass which was completely excised and sent for histopathological assessment. The histopathology review of the scrotal cyst did report a benign multicystic mesothelioma arising from the tunica vaginalis (). Four months later the patient presented for post-operative followup, and on examination the right testis was hard and fixed in the hemiscrotum but the right hemiscrotum, returned to the normal size. He was asymptomatic and free of recurrence.

Cade O’Neill

1986/8/4

+1-521-247-4203x2799

964 Burns Creek

A 6-month-old female infant had presented five times to medical services since birth with a history of discharge from the umbilicus. On days 2 and 4, she presented with bleeding from the umbilical stump, which was managed with a pressure dressing. At 2 weeks of age, she attended a general practitioner surgery with discharge of watery liquid from the umbilicus, and it was treated like an umbilical granuloma with silver nitrate application. She came to the paediatric assessment unit of the local district general hospital at 3 weeks of age because of ongoing discharge. The periumbilical skin area appeared raw with features of a chemical dermatitis. An umbilical swab was taken and treatment with oral flucloxacillin commenced. The child presented again with ongoing symptoms. This time, it was diagnosed as excoriated umbilical granuloma with possible tinea corporis infection and she was treated with miconazole and neomycin. The discharge was mainly serous fluid which occasionally turned serosanguinous but did not contain pus. At 6 months of age, she was rereferred by the general practitioner for persistent umbilical discharge with intermittent blood-stained fluid whilst she had been on her third course of antibiotics. On this occasion a consultant paediatrician reviewed the infant. An ultrasound was requested to investigate for remnants of an omphalomesenteric duct because of the persistence of symptoms. The ultrasound showed a cystic structure of 5 mm diameter with echogenic walls situated deep to the umbilicus (see ). There was no communication with the bowel. A fistula extended through the anterior abdominal wall to the umbilicus. She was referred to surgeons for further management. She had a surgical excision of the cyst and sinus tract at 7 months. On macroscopic analysis, it was found to be a hard cystic lesion below the umbilicus surrounded by thick chronic inflammatory tissue. A fistula extended through the abdominal wall with no obvious communication or tract to the peritoneal cavity except for its continuation into the ligamentum teres. Histology showed skin with exudates and ulceration overlying a cystic structure lined by gastric corpus type mucosa in keeping with an umbilical cyst lined by ectopic gastric mucosa (). Her postoperative recovery was uneventful, discharge and dermatitis resolved and she was discharged from hospital care.

Kenna Barr

1993/1/8

001-242-559-8814

3155 Ashley Ford Apt. 408

A 41-year-old-female had complained of headache and loss of olfactory function and underwent consultation at the Department of Otolaryngology of a general hospital. Endoscopic examination revealed a large mass involving the olfactory cleft of the left nasal cavity. Microscopic examination of a biopsy specimen indicated a diagnosis of neurogenic tumor. She was then referred to Kyoto University Hospital for further examination and treatment. Nasal endoscopy demonstrated a soft, whitish mass occupying the olfactory cleft and extending laterally to the middle meatus, with destruction of the middle turbinate in the left nostril. Computed tomography (CT) displayed a lesion at the olfactory cleft that extended superiorly to the olfactory groove, with a bone defect in the skull base (). The cribriform plate was elevated upward indicating that the tumor originated from the extracranial compartment. Magnetic resonance imaging (MRI) revealed a mass showing cystic changes (Figures ??, with solid portions demonstrating strong postgadolinium contrast enhancement. Our initial diagnosis based on radiographic findings was esthesioneuroblastoma. Partial resection of the tumor in the olfactory cleft was then performed using the endoscopic endonasal approach under local anesthesia, which suggested a histopathologic diagnosis of schwannoma. Based on this result, we planned subtotal resection of the tumor via an endoscopic endonasal approach. Under general anesthesia, the uncinate process in the left nostril was removed to expose the tumor in the middle meatus (). The tumor was attached but had not invaded the internal orbital wall. The anterior part of the middle turbinate was separated from the agger nasi and reserved into the choana as a pedicle flap. Resection of the agger nasi using a drill resulted in exposure of the entire anterior surface of the tumor. A tumor capsule was dissected from the nasal septum and then from the crista galli using a suction elevator and a 45-degree angled endoscope for visualization. During this procedure, the olfactory nerves were identified. After confirmation of their location, the anterior and lateral walls of the tumor were dissected from the posterior wall of the frontal sinus and nasofrontal duct. Afterward, the tumor capsule at the anterior surface was opened using an ultrasonic cutter (Harmonic scalpel, EthiconEndo-Surgery, Blue Ash, OH). The tumor contents were debulked with an ultrasonic surgical aspiration (CUSA, Tyco Healthcare Radionics, Burlington, MA) without bleeding. The tumor capsule was resected, except for the region connected to the dura matter. Following surgery, the region with the bone defect was covered with a mucoperiosteal pedicle flap that originated from the nasal septum and the middle turbinate. Pedicle flaps were fixed with fibrin glue, then covered with pieces of gelatin sponges. The operation lasted 3 h, and the volume of blood loss was less than 10 mL. Microscopic examination of the resected tumor demonstrated a neoplasm composed of spindle cells with eosinophilic cytoplasms and elongated or wavy nuclei with occasional symplastic changes (). The mitotic index was less than one per ten high-power fields, and there was no geographic tumor necrosis. All features were apparently compatible with schwannomas. Immunohistochemically, the spindle cells were diffusely positive for S-100 protein, neuron-specific enolase, and synaptophysin (Figures , , and ), and negative for epithelial membrane antigen (), which also supported the diagnosis of schwannoma, although Leu7 was completely negative (). The Ki-67 labeling index was 2%. These results were considered to best fit with a diagnosis of olfactory ensheathing cell tumor. No perioperative cerebrospinal leakage was identified. Postoperative imaging examinations confirmed subtotal extirpation of the tumor. The patient had an uneventful postoperative course, and no further recurrence was detected during the 2-year follow-up period (Figures ??.

Harley Rosas

1987/11/24

664-364-1994x47584

691 Alvarado Alley

A 50-year-old, nonsmoker woman was admitted to outpatient clinic for periodic examination. She was diagnosed with lung tuberculosis at the age of six and had history of several times of hospitalisation with the diagnosis of recurrent pulmonary infections. She had two term healthy deliveries. She had no complaints. At the physical examination, slight ipsilateral deviation of the trachea was found. There were fine crackles and decreased breath sounds on the left side. Findings on the rest of the physical examination were unremarkable. Routine hematologic and biochemical profiles were within the normal ranges. Plain radiograph showed a loss of volume of her left lung, cardiac and mediastinal displacement to the left, increased density in the left lower lung zone, and hyperinflation of the lung on the right side (). Hemidiaphragm elevation with volume loss of the left lung and absence of hilar shadow were remarkable. Echocardiogram showed no apparent structural abnormality of the heart, and no pulmonary hypertension (pressure gradient = 20 mmHg) was detected. Pulmonary function tests showed a ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) of 80%; FEV1 of 2.47 L (61% of predicted), FVC of 2.90 L (52% of predicted), total lung capacity of 67% of predicted, and a diffusion capacity for carbon monoxide of 72% of predicted. Contrast-enhanced 7 mm collimator computed tomographic (CT) of the chest showed an enlargement of the pulmonary artery trunk and demonstrated the absence of the left pulmonary artery with displacement of heart and mediastinum to the left and volume loss associated with increased interstitial markings involving her left lung (Figures and ). Cardiac arteriographic study revealed no other additional cardiac abnormalities. We decided to follow up the patient for respiratory symptoms, such as breathlessness, hemoptysis, and pulmonary hypertension. The risk factors regarding the absence of a pulmonary artery and travelling to high altitude were explained to our patient. Her clinical status remained stable, without any symptoms, during the follow-up period.

Joelle Hamilton

1989/7/23

3102354858

77216 Maurice Course Apt. 281

A 59-year-old Caucasian female with past medical history of hypertension, obesity, mild osteopenia, and >20 pack years smoking history presented to the primary care physician with a more than four-month history of generalized weakness, anorexia, weight loss of more than 30 pounds, a growing subcutaneous mass in the right lower back and back pain in the lumbar region. MRI of the spine revealed confluent bulky soft tissue mass measuring approximately 14 cm anteroposterior ? 13 cm transverse in size in the retroperitoneum region and pathological compression fracture of L1 vertebrae. Further, CT scan of chest/abdomen/pelvis confirmed bulky retroperitoneal mass/adenopathy with extensive liver metastases and multiple tiny pulmonary nodules (). The mass at lower back was excised and immunohistochemical staining of subcutaneous mass was positive for cytokeratin 7, cytokeratin 20, mucicarmine and villin but negative for ER, mammaglobin, TTF-1, napsin A, CDX2, p63, calretinin, and hepatocyte antigen. The villin positivity in conjunction with the cytokeratin 7 positive expression is suggestive of a noncolorectal gastrointestinal origin, including pancreaticobiliary/gallbladder source. The tissue of origin assay was unable to locate the primary source and subsequently, diagnosis of poorly differentiated adenocarcinoma of unknown primary was rendered. Ten days after the biopsy, while waiting for chemotherapy to begin, patient presented to her primary care physician with severe nausea and vomiting, altered mental status and decreased urine output. Basic metabolic panel (Chem-7) was consistent with dehydration with blood urea nitrogen (BUN) and creatinine of 31 mg/dL and 1.6 mg/dL, respectively, elevated from her baseline normal values about 10 days later. Patient was given a liter of intravenous fluid and was sent back home with antiemetics. Four days later, after nausea and vomiting persisted with lethargy, weakness and very poor appetite, patient presented to emergency room. Chem-7 revealed BUN of 117 mg/dL with a creatinine of 7.5 mg/dL. Other pertinent lab values with normal values in parentheses showed calcium 6.5 (8.9??0.3) mg/dL, phosphorus 8.8 (2.6??.6) mg/dL, uric acid 26.5 (2.8??.6) mg/dL, and lactate dehydrogenase 1265 IU/L with normal transaminases. Obstructive uropathy was excluded by retroperitoneal ultrasound. Patient went into oliguric acute renal failure (ARF) and was treated with intravenous fluids. However, renal function did not improve over the next two days, and hemodialysis was started along with rasburicase. Lab abnormalities were consistent with TLS. Due to poor prognosis, patient was not started on chemotherapy and discharged to hospice without chemotherapy, and she died three weeks later.

Jason McFarland

1991/6/25

+1-368-825-7097x9762

6374 Greene Rapid Apt. 063

The patient is a 57-year-old Hispanic man with a history of stage III moderately differentiated gastric adenocarcinoma intestinal type, diagnosed in late 2006. He was enrolled in a clinical trial for a new regimen of neoadjuvant chemotherapy consisting of oxaliplatin (85 mg/m簡 i.v. over 2 hours on days 1 and 15), docetaxel (25 mg/m簡 i.v. over 30 minutes on days 1, 8, 15), floxuridine (110 mg/kg i.v. over 24 hours on days 1, 8, 15), and leucovorin calcium (500 mg/m簡 i.v. over 24 hours on days 1, 8, 15) with treatment repeated every 4 weeks. After the second course (January 2007), he underwent resective therapy (partial gastrectomy) followed by 2 more cycles of the above-mentioned chemotherapy regimen as an adjuvant therapy. Five months later, recurrence of the primary tumor was found in the liver; therefore, the patient was started on a different regimen (paclitaxel 120 mg/m簡, floxuridine 150 mg/kg, leucovorin 500 mg/m簡, and cisplatin 100 mg/m簡), and liver segmentectomy was performed. Unfortunately, patient failed regular controls, and by 2011 a CT of the chest and abdomen revealed extensive metastatic liver nodules which ranged from 3.5 cm to sub-centimeter in size, and metastasis to the sternum were also found. Consequently, he was again included in the initial experimental chemotherapy regimen as a first line therapy for his metastatic disease (oxaliplatin, docetaxel, floxuridine, and leucovorin). Seven days after receiving the first chemotherapy cycle, he developed nausea, vomiting, oliguria, generalized weakness, and was referred to the emergency department by his oncologist due to abnormal laboratory data (). On arrival the patient was alert and appeared in poor general condition, pale, volume depleted with low blood pressure (102/63 mmHg), tachycardia (102/min), respiratory rate of 20/min, and body temperature of 36.6簞C. A firm, nontender, 2 cm below the costal margin of the right midclavicular line hepatomegaly was appreciated. There was no peripheral lymphadenopathy, and laboratory findings are shown on . Urinalysis determined urine pH of 5.0 (4.5??.5). The chest radiograph appeared to be normal. An EKG demonstrated atrial fibrillation with rapid ventricular response, left anterior fascicular block, and peaked T waves (). A renal ultrasound examination revealed an increased bilateral cortical echogenicity but no evidence of hydronephrosis. A diagnosis of chemotherapy-induced TLS with acute renal failure was made. The patient was given vigorous volume expansion, intravenous sodium bicarbonate, calcium gluconate, insulin given together with 50% dextrose, and allopurinol. His laboratory data did not improve and hemodialysis was started. The patient underwent a total of 6 hemodialysis over a course of two weeks and was discharged 18 days after with normal serum electrolyte and metabolic parameters. However, his renal function continued to be impaired with a serum creatinine of 3.86 mg/dL, blood urea nitrogen of 23 mg/dL, and eGFR of 16.

Annika Pineda

2001/12/8

-817

0057 Coleman Branch Suite 282

A 28-year-old man with no past medical history presented to the emergency department with a two-week history of severe ??0-out-of-10??colicky epigastric pain with profound nausea, 15??0 episodes of vomiting daily, and decreased oral intake for fear of triggering these symptoms. He denied alcohol and tobacco use, but reported he had smoked two marijuana cigars (each containing approximately 1.5 grams marijuana bud) every day for the last ten years. As his symptoms of nausea, vomiting, and abdominal pain intensified, he self-medicated himself with increasing amounts of marijuana and his symptoms became increasingly intense. The patient reported that he initially got symptomatic relief with a hot shower, though as his symptoms intensified, he required increasingly longer bathing times that eventually progressed to the patient soaking himself in hot baths for hours each day. He stated that he had never experienced any of these symptoms in the past. In the emergency department, the patient's vital signs were within normal limits and his physical exam was significant only for minor tenderness to palpation in the epigastric region. The patient had no focal neurological deficits. The patient was admitted for intravenous fluid support, antiemetic therapy, and further evaluation. The patient's medical evaluation revealed a complete blood count, basic metabolic profile, and hepatic profile that were within normal limits. An abdominal computerized tomography (CT) scan was negative for pathology, an EGD with biopsies showed only mild gastritis, and a gastric emptying study showed mildly delayed gastric emptying. In this patient, initial symptomatic treatment with ondansetron and morphine was unable to keep the patient from having breakthrough episodes of nausea, vomiting, and epigastric pain. The patient was unable to tolerate even a clear liquid diet, and was extremely anxious about trying to increase or advance his oral intake given the painful episodes that food had triggered in the past. After administering 1 mg IV lorazepam, the patient improved at a remarkable pace; within 10 minutes of administration he no longer experienced nausea, abdominal, or food aversion. Over the next 12 hours, he transitioned to a regular diet, oral lorazepam (1 mg tablets), and was able to discontinue all other analgesic and antiemetic medications. The time from marijuana cessation to complete resolution of symptoms was approximately three weeks. The patient was discharged with a seven-day prescription for lorazepam (1 mg PO, twice daily). The patient was contacted at 3 and 6 months after discharge and he reported that, with sustained abstinence from marijuana, he had no return of his symptoms.

Gerardo Hail

1986/7/25

808-378-9325x52825

0784 Torres Creek

A 77-year-old female with recurrent non-small-cell lung cancer presented to the outpatient lung clinic complaining of tremor, weakness, inability to coordinate motor movements, and confusion. Central nervous system metastases were suspected, and a CT scan of the head was ordered. The patient's medications were reported as oxycodone (slow release) 50 mg twice daily, oxycodone (immediate release) 5 mg when required, esomeprazole 40 mg twice daily, temazepam 10 mg at night, and docusate 100 mg with sennosides 16 mg twice daily. There was confusion as to whether this list was complete. A telephone conversation with the patient's community pharmacist revealed in addition to her reported medications that she had recently picked up a repeat prescription of citalopram 20 mg once a day, after not having it dispensed for several months. Diazepam had also recently been prescribed by her general practitioner for restless legs. The oxycodone had been started several months earlier (rotated from morphine) for cancer-related pain during the period that the patient was not taking her citalopram. Further discussion with the patient elucidated that the symptoms started shortly after recommencing the citalopram. The lung clinic pharmacist suspected a drug interaction between citalopram and oxycodone which had resulted in serotonin syndrome. Use of the Naranjo probability scale indicated a probable relationship between the combination of oxycodone and citalopram and the serotonin symptoms []. The symptoms satisfied the Sternbach diagnostic criteria for serotonin syndrome []. Oxycodone was changed back to morphine, and the esomeprazole was reduced to 40 mg daily (which in turn should improve citalopram clearance). The symptoms resolved within 48 hours, and the CT scan later came back clear.

Lainey Ford

1986/1/10

814-775-7833x708

0523 Alyssa Coves Apt. 703

A 78-year-old female presented with asymptomatic upper abdominal mass. Computed tomography (CT) was performed and demonstrated an encapsulated solid and cystic tumour involving the right lobe of the liver, measuring 16 cm in maximum diameter (). Positron emission tomography (PET) showed intense peripheral metabolic activity with a photopenic core, suspicious for a malignant tumour with central cystic, haemorrhagic or necrotic change. There was no evidence of underlying liver disease on blood tests, and tumour markers including carcinoembryonic antigen (CEA), carbohydrate antigen (CA-19.9), alpha feto protein (AFP), and chromogranin A were within normal limits. At the time of surgery a large, a well-circumscribed, partially haemorrhagic cystic lesion was noted (). This was adherent to the proximal colon and omentum, however, with no clear direct invasion. A 3 cm cystic nodule was also noted in the right pelvis. A partial right hepatectomy and en bloc extended right hemicolectomy were performed as well as removal of the pelvic nodule. The patient's post-operative course was unremarkable. Histology of the tumour revealed variable morphology. Prominent intratumoral necrosis was seen, and there was moderate mitotic activity. The morphological and immunohistochemical profile was consistent with undifferentiated embryonal sarcoma. The tumour was comprised of densely cellular areas of rounded and pleomorphic cells and myxoid more paucicellular areas with stellate and spindled cells (). Tumour cells stained positively for AE1/AE3, alpha1-antitrypsin, vimentin, and desmin. Variably sized eosinophilic, intracytoplasmic, PAS-positive, diastase resistant globules were also noted within occasional tumour cells (). In addition, nodules of malignant hepatoid tumour were admixed with the undifferentiated areas () and stained positively for HepPar-1, polyclonal carcinomembryonic antigen, and AE1/AE3. The patient declined adjuvant chemotherapy. Repeat CT imaging 6 months postoperatively showed no evidence of recurrent disease.

Luis Kerr

1990/2/12

704.438.5522

6601 Robert Fork Apt. 512

A 17-year-old primigravida, 31 weeks of pregnancy, was refereed to our hospital presenting a fetus with a large head circumference, one chest, and two vertebral columns. Two-dimensional (2D) ultrasound scan realized with a Voluson 730 Pro machine (General Electric, Medical System, Healthcare, Zipf, Austria) equipped with a volumetric convex probe (RAB 4?? L) showed a conjoined twin-cephalothoracopagus janiceps disymmetros, one placenta, and polyhydramnios. Twins were fused from head until upper abdomen at the level of the umbilical cord; they had a single chest, a common liver, two vertebral columns, and two hearts. There was one skull with two faces (), one of them well-formed with two eyeballs, brain, and duplicates and fused thalamus (). After preterm labor at 34 weeks, twins weighed 1, 660 g and were born by Cesarean section, surviving for twenty minutes. The X-ray and postmortem analysis confirmed the prenatal diagnosis (Figures and ).

Baylee Brennan

1996/12/26

(638)860-6034

026 Kelley Trail Apt. 878

A 62-year-old female patient presented to the Accident and Emergency Department with abdominal pain and nausea. She described a 3-week history of worsening right upper quadrant pain but denied any nausea, vomiting, or fevers. Her past medical history included coeliac disease, a hiatus hernia, and irritable bowel syndrome. Her regular medications were Mebeverine, Omeprazole, and Movicol with no known drug allergies. She worked as a cleaner, did not smoke, and drank minimal alcohol. Of note, she had not travelled recently, never had instrumentation of her abdomen, and did not have any recent antimicrobial treatments. Specifically, she denied any intentional or accidental ingestion of soil or aquatic material. On admission, she was apyrexial with normal observations. Significant examination findings were that of localised tenderness in the right upper abdominal quadrant, consistent with acute cholecystitis. Blood tests revealed raised inflammatory markers with mildly deranged liver function tests. (White Cell Count 24.0 ? 109/L, Erythrocyte Sedimentation Rate 98, C-Reactive protein 248, Bilirubin 12, Alkaline Phosphatase 189 U/L, Alanine aminotransferase 58 U/L, Gamma-glutamyl Transferase 141 U/L, Albumin 37 g/L). An ultrasound was performed which reported?€he gallbladder is distended, containing debris and calculi. It is thick walled, tender with some pericholecystic fluid around it. There is no drainable abscess or collections. The ultrasound appearances are consistent with an acute cholecystitis. The common bile duct is not dilated, and there are no dilated intrahepatic ducts. Normal appearances of the liver, spleen, and both kidneys.??She received 3 days of intravenous Co-amoxiclav, and her symptoms resolved. She was discharged with a 5-day course of oral Co-amoxiclav with arrangements to return for an elective laparoscopic cholecystectomy. Five months after her initial presentation, she reattended electively for a laparoscopic cholecystectomy. Due to adhesions throughout the epigastrium and right upper quadrant, this was converted to an open procedure. The gallbladder was buried in omentum, and there was a chronic abscess cavity due to a localised perforation of the gallbladder. Fluid from the gallbladder was sent for microbiological examination and a partial cholecystectomy performed. Postoperatively the patient was systemically well. Her observations were normal with no pyrexia, and she had minimal pain. The surgical team was contacted two days after the operation and informed that viable Raoultella planticola had been identified by VITEK 2 biochemical identification system with a very good probability of 99%. This was sensitive to Co-amoxiclav, Ciprofloxacin, Cefuroxime, and Tazocin. She was started on oral Co-amoxiclav following discussion with the microbiology team. She continued to make a good recovery and was discharged after a full 7-day course of Co-amoxiclav. She was reviewed 3 months after discharge with no new complaints.

Curtis Pugh

1990/7/13

-2953

2633 Romero Fork Suite 191

A 38-year-old woman with a 3-year history of cholecystolithiasis was examined at a local hospital and referred to our hospital for endoscopic gallstone removal without gallbladder excision. When she was hospitalized at our hospital, the acute right upper abdominal pain had persisted for two hours. On physical examination, no signs of jaundice were seen in the skin or sclera. The patient's abdomen was soft, with no sign of lumps, with tenderness other than rebound tenderness in the gallbladder area. Murphy's sign was positive. Ultrasonography revealed several movable masses of 7 ? 10 mm and 7 ? 9 mm in size, which were strongly echogenic, with acoustic shadowing in the body of the gallbladder; an immovable strongly echogenic mass of 7 ? 10 mm with acoustic shadowing in the neck of gallbladder and cystic duct; and poor sound penetration and a dense, low-light spot in the dark space of the bile. There was no thickening of the gallbladder wall. The gallbladder emptying index was 30%. No obvious abnormalities were seen in the liver, spleen or pancreas. The patient was diagnosed as having cholecystolithiasis complicating acute cholecystitis and incomplete biliary-tract obstruction. The patient had been given anti-inflammatory treatment after the examination for 2 weeks and the symptoms of acute cholecystitis had disappeared before the operation was schedule, and the patient was strongly in favor of preserving the gallbladder. Consequently, after approval by the medical ethics committee and provision of informed consent by the patient, the gallbladder was laparoscopically isolated and transected at the bottom (< 6 mm) under general anesthesia. First, the bile was drained with a sterile ventricular drainage tube to a sterile injector, and transferred to sterile tubes. Next, the gallbladder was explored with a three-channeled cholecystoscope (CHiAO; Chinese national patent number: ZL200810026985.X HAWK, China []), and the stones were collected with a stone extractor. We found only mild congestion in the gallbladder mucosa, which indicated only slight inflammation of gallbladder. Using endoscopy, we found many small, semitransparent stones (< 1 mm) adhered to the gallbladder wall (Figure ). These stones were removed with an endoscopic attachment (CHiAO absorbing box; Chinese national patent number: ZL 201110167069.X) designed to remove sludge-like gallstones combined with seven types of manipulation (pushing, squeezing, pressuring, tearing, bracing, flushing, and sucking) [], while several large stones (> 5 mm) were removed with a stone extractor (Figure ). The small stones were yellowish and semitransparent, and the large stones were polyhedron or globular in shape, and had a radial, layered arrangement in profile (Figure ). The bile was yellowish, opaque, turbid, and very viscous. After centrifugation at 1,450 g for 10 min, the bile supernatant was transferred to a clean tube, and about 0.5 mL of sediment was kept. The bile sediment was smeared onto labeled slides and viewed under a system microscope (BX51; Olympus, Tokyo, Japan). Colorless hexagonal plate crystals with high refractivity and limpid edges were seen, which were judged to be cystine crystals based on their morphology. Meanwhile, colorless, transparent crystals (in the shape of rectangles with missing corners or squares with missing corners, or glass flakes) were seen, which were judged to be cholesterol crystals from their morphology (Figure ). The gallbladder stones were analyzed with a Fourier transform infrared spectrometer (TENSOR27; Bruker Optics GmBH, Ettlingen, Germany) in the frequency range of 400 to 4,000 per cm at 4 per cm resolution. The results indicated that the small stones were cystine stones and that the large stones were cholesterol stones; (Figure ). Next, some of the small stones and a piece of a large stone were fixed onto the sample table and dried at 60簞C overnight, then sputter-coated with gold (ETD-2000, Beijing Elaborate Technology Development Ltd., China) and observed under a scanning electron microscope (EVO LS10; Carl Zeiss, Cambridge, England). The samples were photographed and analyzed with an energy spectrometer (X-Max; Oxford Instruments plc, Oxford, UK). Under scanning electron microscopy, the small stones were found to be composed of hexagonal cystine crystals (30-270 弮m), some with prominences on their edges. The energy spectrum indicated that the elemental composition was carbon, oxygen, nitrogen, and sulfur, along with gold from the coating. The large stones were composed of lamellar cholesterol crystals with a thickness of about 1 弮m. The energy spectrum indicated that the elemental composition was carbon and oxygen, with gold from the coating (Figure ).

Landry Person

1992/3/23

725-249-6446x264

8400 Martin Village

A 47-year-old Sri Lankan male presented in October 2006 with a 3-month history of bilateral red watery eyes with a foreign body sensation. He had RA, which was quiescent at presentation for which he was taking oral diclofenac, prednisolone (PDN), and methotrexate (MTX) with calcium and folic acid supplements. On examination, his best corrected visual acuity (BCVA) was 6/19 right eye (OD) and 6/9 left eye (OS). There was an inferonasal peripheral crescent-shaped area of corneal thinning (80%) forming a gutter from 3 to 6 o'clock, 1.4 mm wide in the right eye, while in the left eye there was a smaller inferonasal gutter with 20% thinning. His PDN and MTX were increased and hourly topical carmellose sodium 0.5% added. Initial reduction of ocular discomfort prompted reduction of his systemic medication, but on review within 9 days BCVA OD was reduced to 6/38 and the right anterior chamber was shallow with a small corneal perforation noted in the corneal gutter. This was plugged with iris and not actively leaking. The perforation was repaired with corneal cyanoacrylate glue and a bandage contact lens (BCL) was placed for comfort and exchanged at 6 weekly intervals thereafter. Slow tapering of his systemic medication was attempted again. On review 4 months later in February 2007, a small leak from the previous perforation was noted. After further cyanoacetate glue repair, he underwent multilayered amniotic membrane graft (AMG) to the right eye in March 2007. Initially his postoperative course was satisfactory but attendance at follow-up appointments was poor. In June 2009, he attended with marked discomfort and redness of both eyes and BCVA of 6/15 OD and 6/7 OS. He was systemically well with no signs of active RA. He was found to have marked bilateral inferior corneal stromal thinning with perforations in the inferotemporal mid-periphery and a small iris prolapse plugging the hole in both eyes (). Bilateral emergency tectonic penetrating keratoplasties (PKP) were performed, decentered infero-nasally in order to replace the thinned cornea (). Lamellar grafts were initially attempted but was converted to a PKP as a satisfactory lamellar plane was impossible to create due to a soft eye from the perforations. His systemic medications were again increased. One week postoperatively, BCVA was 6/38 OD and 6/19 OS but one month later he presented with recurrent, bilateral paracentral corneal melts. Glue repair was again performed and topical cyclosporine 0.5% twice daily was added to both eyes. He subsequently underwent a further triple-layered AMG and second PKP to both eyes in September 2009. Infliximab (5 mg/kg intravenously) was commenced on the first postoperative day and he continued to receive cycles at the same dose at weeks 2 and 6 and then every 8 weeks, while PDN and MTX were gradually reduced. Since he was from an area of high prevalence of tuberculosis, prophylactic isoniazid was commenced. He underwent uncomplicated phacoemulsification with posterior chamber intraocular implantation in both eyes in June 2010. Eighteen months following infliximab therapy both eyes remained quiet with no signs of further corneal melting. The BCVA was 6/48 in both eyes, limited by subepithelial haze and thinning of his corneal grafts ().

Moses Branch

1998/2/21

001-451-246-6978x01170

2069 Kelly Shores Apt. 020

A 46-years-old woman presented to our hospital with complaining of dysuria, frequency, and recurrent urinary tract infections from one year ago. She had no hematuria, suprapubic pain, or family history of such problems. She had history of hysterectomy three years before this admission due to uterine leiomyoma. Physical examination revealed a mobile, round mass in bimanual examination. Abdominal ultrasonography revealed a round mass measuring 4 ? 5 cm (). There was no hydronephrosis in both kidneys. There was a round hyperdense intravesical mass near bladder neck in CT scan (). The mass was intramural in MR imaging and showed intermediate signal intensity on T1-weighted images (). A well defined 3 ? 4 centimeter mass was seen in superolateral part of bladder neck during cystoscopy. There was no any involvement of ureteral orifices. Due to huge size of the mass and its proximity to ureteral orifice, trans-urethral bladder resection was not planned for patient. She underwent exploratory laparotomy with low midline incision. The mass was identified in the posterior aspect of the bladder wall so partial cystectomy was performed for her. The pathology of mass was epithelioid leiomyoma. The postoperative period was uneventful, and the patient was discharged from hospital after 4 days. The patient's followup with clinical examination, abdominopelvic CT scan, and cystoscopy was normal in period of 2 years.

Luisa Foley

1985/4/29

001-404-253-1063x454

818 Daniel Stream

A 45-year-old man, who suffered from pain in the left posterior maxilla and a bad smell from the nose, was referred to our department. A 4 ? 6 ? 3 cm cyst was found in the left maxillary molar region on radiological examination (). After treating the acute infection, the patient underwent cyst enucleation under general anaesthesia (). Six months postoperatively, the area had a severe bony defect extending to the zygomatic buttress superiorly and hamular notch posteriorly. After computed tomography (CT) and model analysis of the defect, we decided to reconstruct it using transport distraction. Under general anaesthesia, a vestibular incision was made and a mucoperiosteal flap was raised to expose the lateral wall of the maxilla. The bone between the number 23 and the number 25 maxillary teeth was cut vertically with a saw and then connected to a horizontal bone cut 5 mm above the apex of the second premolar running posteriorly on the buccal side. The bone on the palatinal side was cut horizontally with curved osteotomes, gently to avoid damaging the palatal mucosa. Before mobilising the transport segment including number 25, the distractor was adapted to its stabilising plates with screws, and then the segment was mobilised using osteotomes (). Before suturing the surgical site, the distractor was checked to ensure that the transport segment was being moved into the proper position. After a 7-day healing period, the distractor was activated by 1 mm once daily for 15 days. After full activation, the distractor was left in situ for the consolidation phase. Six weeks later, the distractor was removed and two dental implants were placed in the new bone. After 3 months for osseointegration, we realised that the implants were not aligned on the proper axis and position on CT (). To correct this situation, a subapical osteotomy including the implants was performed and a block autogenous graft was taken from the mandibular symphysis and adapted to the superior border of the osteotomy line. Permanent prosthetic rehabilitation was started 4 months after the subapical osteotomy. Metal-supported porcelain restorations were constructed using conventional methods. The patient was followed up 3, 6, 12 and 24 months after the prosthetic rehabilitation (Figures and ).

Mohammad Kramer

2002/12/25

890.907.2418x649

34649 John Creek

A 63-year-old woman with no past history of coagulation abnormality, recent trauma, or hormonal substitution experienced sudden onset of headache followed by installation of right hemiplegia and global aphasia. Computed tomography and subsequent brain MRI revealed massive left frontotemporal hemorrhagic infarction and thrombosis of the superior sagittal sinus, left sigmoid/transverse sinus, and cortical vein (Figures , , and ). Subsequently, chest tomography showed bilateral subsegmentary pulmonary embolism (). Doppler did not reveal any deep venous thrombosis of the lower limbs. The laboratory data showed severe hypochromic microcytic anemia with hemoglobin value of 3,4 g/L (normal range: 12??6). Serum iron concentration was 1 弮mol/L (N = 5??0), and ferritin concentration was 2 mg/dL (N = 11??37). No B12 vitamin or folate deficiency was found. Screening for coagulopathy was normal, including factor II, factor V (Leyden), activated protein C resistance, and antiphospholipid antibodies. Protein C, protein S, and antithrombin III were not interpretable because of early vitamin K antagonists therapy. Protein immunofixation electrophoresis demonstrated no gammopathy. Upper gastrointestinal and lower digestive endoscopies, mammography, endovaginal echography, thoracoabdominal and pelvic computed tomography were performed and failed to detect any malignant disease, source of active bleeding, or pelvic vein thrombosis. The patient was treated by blood transfusion and anticoagulation with intravenous heparin, followed by vitamin K antagonists (acenocoumarol) for a total duration of six months. The brain MRI performed one month after the onset showed an almost complete repermeabilisation of the cerebral venous sinuses. The patient's right hemiparesis gradually improved, as well as her global aphasia. The patient was discharged three months after the onset. The anemia gradually improved with a hemoglobin value of 13,0 g/L. Our assumption regarding the origin of the anemia was a vegetarian diet without a proper iron substitution.

Hanna Stein

1992/2/21

+1-463-207-6792x25661

132 Holland Port Apt. 676

A 43-year-old Caucasian female with a history of nonischemic dilated cardiomyopathy with left ventricular ejection fraction (LVEF) of 10??5% status following Thoratec Heart-Mate II left ventricular assist device (LVAD) (implanted 2 years prior as a Bridge to Transplant) was transferred to our tertiary care facility for management of unresolving pseudomonas driveline infection. The patient secondary to persistent pseudomonas bacteremia despite adequate treatment with intravenous antibiotics underwent LVAD removal with reimplantation with another VAD. The patient also underwent an AICD lead extraction with generator change secondary to questionable vegetation on the defibrillator lead on transesophageal echocardiogram. The patient did well following that and remained home for 4 months while awaiting a cardiac transplant. Her past history was significant for hypertension, dyslipidemia, recurrent pulmonary embolism, history of herpes zoster infection with postherpetic neuralgia, and intracerebral hemorrhage. Four months later the patient was electively admitted for transplant evaluation. Her panel reactive antibody (PRA) levels were found to be low at 4% as measured by flow cytometry using HLA class I Luminex-coated beads. The patient (CMV positive) finally underwent a CMV negative, Epstein-Barr virus (EBV) positive orthotopic heart transplant without the need for desensitization. The patient's immediate postoperative course was complicated by multiple failed attempts at extubation secondary to fluid overload that required tracheostomy and acute kidney injury requiring temporary hemodialysis (with complete eventual recovery of renal function). The patient after 4 weeks, on routine surveillance endomyocardial biopsy (EMB), was found to have ISHLT grade 2R acute cellular rejection which was successfully treated with intravenous pulsed steroids and mycophenolate mofetil. The patient was eventually discharged home 2 weeks later and was followed as an outpatient. Three months subsequent to transplant the patient started to develop signs and symptoms of upper respiratory tract infections manifesting as unremitting cough. The patient admitted was found to have viral infection with positive serologies for entero, rhino, and coronaviruses, and the EMB was negative for rejection. The patient was managed conservatively without any antiviral treatment except prophylactic ganciclovir for CMV prophylaxis and discharged home. The patient did present again with similar respiratory symptoms a month later at which time it was decided to treat the patient with a course of oseltamivir (Tamiflu) for a clinical suspicion of influenza. The patient was discharged only to be readmitted 2 months later (6 months after transplant) for symptoms of exertional dyspnea, nausea, and abdominal pain. The patient was found to have low cardiac index (1.59 L/min/m2) and elevated right sided pressures on right heart catheterization while the EMB remained negative for cellular or humoral rejection. An echocardiogram at the time revealed a mildly depressed left ventricular ejection fraction at 40% with mild right ventricular dysfunction. The patient's panel reactive antibodies were undetectable. lists the trends in the available viral titres and other laboratory data (glucose and lipids). The patient was treated with intravenous methylprednisolone and plasmapheresis to treat for possible graft dysfunction. The next day the patient had a sudden cardiorespiratory arrest and died despite prolonged attempts at resuscitation. A postmortem analysis revealed microscopic changes of concentric intimal proliferation and inflammation resulting in near-total luminal occlusion in the epicardial and the intramyocardial coronary vessels, suggestive of graft vasculopathy (Figures ??. There was no evidence of rejection seen.

Creed Summers

1998/7/10

001-302-693-2222x43904

227 Edward Lakes Suite 061

A 74-year-old female was referred to Emergency Unit (EU) of our hospital for an acute dyspnoea with 1-month history of progressive globus sensation; the patient was admitted to the Pneumology Department for evaluation of an important hypercapnic respiratory failure. Arterial blood gas analysis showed pH 7.35, pCO2 82.9 mmHg, pO2 52 mmHg; chest X-ray was negative for pulmonary disease. Family history was negative for remarkable diseases. Patient's past medical history included surgical excision of a cutaneous melanoma followed by chemotherapy (presently NED), carotid thromboendoarterectomy, a surgically treated CNS meningioma with implantation of ventriculo peritoneal shunt. Traumatic lesion of vocal cords, causing mild persistent dysphonia, was reported to have occurred during previous intubation for brain surgery. In the EU, the patient underwent a flexible endoscopic evaluation of the larynx that revealed a bulky mass on the left aryepiglottic fold with the involvement of the glottic space and consequent almost complete obstruction of the laryngeal respiratory space. No palpable lymph nodes were present. The patient was transferred to the Otolaryngology Department because of acute dyspnoea, and emergency tracheostomy was performed followed by incisional biopsy of the lesion. Intraoperatively, the mass was found to be smooth, pedunculated, and 3.5 cm in diameter. The histopathological examination of the incisional biopsy sample reported nonspecific fibrous submucosal tissue. CT scan demonstrated a round, heterogeneously enhancing mass, measuring 3.5 ? 3 ? 2.8 cm, which extended from the left aryepiglottic fold to the false vocal cord (). A second single-step surgical excision was then decided. The left false vocal cord was incised with a sickle knife, and a microflap was dissected; blunt dissection revealed an encapsulated, soft tissue mass. The tumor was completely excised. Macroscopically the surgical specimen consisted of a well encapsulated tan-coloured tumor mass, measuring 4 ? 2 cm. At microscopic examination, the tumor showed densely cellular areas with sheets of spindle cell palisading around amorphous matrix (Antoni A pattern) and less cellular areas with spindle cells in myxoid stroma and disorganized distribution (Antoni B pattern) (). Tumor cells were strongly immunoreactive for S100 protein. Cellular proliferation index evaluated with Ki67 antibody was <1%. Two weeks postoperatively, the patient reported that her globus sensation, chronic throat clearing, and shortness of breath had disappeared. The tracheostomy was closed. One month after surgery, she was reevaluated in the outpatient clinic by flexible fiberoptic laryngoscopy that revealed a complete healing of the vocal cord, minimal erythema, and no edema. At 18-month followup, the patient presented no endoscopic evidence of tumor recurrence and her voice had improved markedly ().

Frankie Stone

1998/8/9

515.426.0360

397 Charles Underpass

A 70-year-old, right-handed male developed simple motor seizures characterized by painful dystonic posturing of the right hand following left parietal meningeoma resection. Infrequently, the motor seizure spread to the right face and leg. At baseline the patient had a right hemiparesis with clasp knife rigidity of the arm, hyperreflexia, an extensor plantar response, and distal sensory loss in the right arm and leg predominantly involving proprioception. Gait was consistent with mild right-sided spastic hemiplegia. The patient's use of his right hand was limited to maintaining a grasp. During seizures, the strength and duration of muscle contraction appeared to be proportional to pain intensity. At the onset, sustained contraction of the right forearm and hand muscles with dystonic posturing were associated with severe pain in the right hand and wrist. The patient usually attempted to relieve pain by passively dorsiflexing the right wrist and fingers with the left hand. Pain intensity was reported as 10/10 and associated with grimacing, moaning, and tearfulness. Seizure involvement of the right face and right leg was not painful. Thirteen partial motor seizures were recorded during inpatient, continuous video/EEG monitoring. Most were not associated with epileptiform activity and either showed little change or irregular left central theta waves. Rarely, rhythmic low amplitude sharp waves appeared in the left central head region after the onset of arm jerking. MRI scanning indicated volume loss and increased T2 signal in the left parietal area. Initially, VNS plus levetiracetam resulted in a 70% reduction in seizure frequency. The VNS was turned off to allow MRI scanning, and its initial effectiveness was never reestablished. The patient received four BTX injections spaced 1 to 2 months apart using the following dosing schedule: (1) 200 units, right forearm, (2) 50 units, right deltoid; 50 units, right biceps brachii, (3) 100 units, right forearm flexor muscles, and (4) 50 units, right deltoid; 50 units, right biceps brachii; 50 units right forearm flexors; 50 units, right forearm extensors. The patient reported satisfactory pain relief during seizures and ictal facial grimacing and tearfulness resolved. Epilepsy surgery was then performed and resulted in seizure control so that further injections were not necessary. The patient reported less-painful seizures several hours after the first injection, suggesting an early onset of toxin-induced analgesia or placebo effect. However, he reported the same degree of sustained relief (80??0%) prior to injections two, three, and four as he did at one week after first injection. Thus, pain did not return to baseline levels between injections, so duration of effect following each injection was at least two months. Pain during seizures was easily tolerated by the patient but continued to vary directly with seizure duration and intensity. Definitive resective surgery occurred one month after the fourth injection.

Finn Wheeler

1988/10/30

707.650.4806x72284

9121 Sanford Expressway

A 30-year-old male presented with a 27-year history of partial motor seizures with painful muscle contractions beginning in the left foot and leg, sometimes spreading to the left thigh. The contractions occasionally extended rostrally to the thoracic paraspinal muscles. He also experienced complex partial, secondarily generalized seizures and simple partial status epilepticus. His neurological exam was normal. Pain Associated with Seizures. The patient reported a pain level of 10/10 during contractions of the left leg and foot at seizure onset. Muscle contractions in the left thigh, as well as in the paraspinal region, elicited a similar pain rating. Inpatient, continuous video/EEG monitoring recorded 10??0 partial motor seizures per day and an episode of simple partial focal motor status. Electrographic seizure onset appeared as rhythmic fast activity, C4 greater than Cz, and 2?? seconds after clinical seizure onset. The MRI did not reveal structural abnormalities. Ictal SPECT did not show perfusion abnormalities. Interictal PET revealed hypometabolism in the medial right posterior frontal and anterior parietal lobes. While under our care, VNS plus phenytoin, oxcarbazepine, clorazepate, and levetiracetam failed to control seizures. The patient received two BTX injections one month apart: (1) 40 units, left gastrocnemius; 30 units, left tibialis posterior; 30 units, left peroneus longus; 20 units, left peroneus brevis; 20 units, left flexor digitorum brevis; 40 units, left paraspinal muscles; 30 units, right paraspinal muscles, and (2) 300 units to the left thigh muscles, including the vastus medialis, vastus lateralis, rectus femoris, and thigh adductors. Injections were discontinued following successful palliative epilepsy surgery. Surgery included subpial transections of the superior and medial aspects of the right cerebral hemisphere and cortical resection of the medial aspect of the right cerebral hemisphere. Because some seizures persisted, the patient was subsequently enrolled by us (B. J. Fisch and M. E. Carey) in a Phase II clinical trial for the treatment of medically refractory partial seizures. The patient reported a 60??0% reduction in pain in his left lower leg and paraspinal muscles during seizures two to three days after his first injection. The focus of maximum pain shifted to the left foot and thigh but the highest ictal pain rating was 4/10. The second injection included left thigh muscles, and further pain relief was reported. Toxin-induced analgesia in the areas targeted by the first injection was sustained for at least two months. Epilepsy surgery occurred one month after the second injection.

Sydney Cross

1991/5/7

001-648-468-4008

908 Riggs Overpass

An 8-month-old girl was referred to the Department of Oral and Maxillofacial Surgery of the University Hospital San Vicente in Medell穩n, Colombia, for evaluation of multiple erythematous lesions on the tongue, cheek and floor of the mouth (). The lesions had been present for the previous four months. Physical examination revealed well-demarcated nodules measuring around 1 cm in diameter. The overlying mucosa appeared normal and nonulcerated. In order to complete a histological analysis, excisional biopsies were performed. The surgical samples were fixed in 10% buffer formalin for a minimum of 48 hours, embedded in paraffin, and cut at 5 弮m to be stained with Hematoxylin-Eosin technique. Microscopically, fusiform cell proliferation with elongated nuclei and eosinophilic cytoplasm was observed. Several blood vessels lined by a thin layer of endothelial cells were observed intercalated in the fascicules (). Immunohistochemical techniques were also applied, involving monoclonal antibodies against actin, vimentin, cytokeratin, and the S-100 protein (). The immunohistochemical study revealed the expression of vimentin, desmin, muscle specific actin (MSA), and smooth muscle actin (SMA) within the tumor cells. The other markers studied (cytokeratin, AE1/AE3, EMA, S100, and CD34) were negative. Diagnosis of vascular leiomyomas was confirmed. Computerized tomography ruled out bone association, corroborating the completely mucosal allocation of the leiomyomas. Finally, the lesions were removed under general anaesthesia (). The patient had a correct evolution without any postoperative incident. The patient returned after a 6-month period, at which time there was no evidence of recurrence.

Fabian Dodson

1994/8/3

+1-295-468-1808x722

6702 Harris Ferry Apt. 399

A healthy 37-year-old multiparous woman, gravida two para one, presented to the birthing unit in spontaneous labour at term. Three years prior, she had an emergency lower-segment caesarean section (LSCS) for failure to progress in labour, at 8 cm cervical dilatation. She had no other history of gynaecological surgery. On presentation, she was contacting every three minutes, with membranes intact and a reassuring cardiotocograph. An amniotomy was performed two hours later, at 8 cm cervical dilatation and station 2, producing copious clear liquor. No abnormalities were noted. Two minutes after the amniotomy, a ten-minute foetal bradycardia occurred (to 77 bpm), and the patient was transferred to theatres for an emergency LSCS. She was not in significant pain and had only scant vaginal bleeding. Due to the urgency of the situation, neither abdominal nor vaginal examinations were performed at that time. A live female infant was delivered 15 mins later, weighing 3285 g. The baby was dusky, with blood throughout her airways, and cord pHs of 6.97 (arterial) and 7.15 (venous). Despite this, the baby resuscitated well and had Apgars of eight (at one minute), eight (five), and nine (ten). Until this point the LSCS was routine, with no abnormalities noted. The uterus was closed in one layer, with persistent bleeding from an extension of the left uterine incision, near the left ureter. The ureter was thought to have been clamped during the repair, so assistance was sought from urology, who reflected the ureter and bladder off the uterus. This exposed an avulsion tear of the anterior vaginal wall, extending bilaterally to the uterosacral ligaments. The intact, dilated cervix was entirely visible through the tear. (see ). There was significant bleeding from the vaginal tear as well as from the (intact but friable) posterior bladder wall. Opinion was sought from a second Obstetrician, with consensus that the degree of damage and bleeding warranted a total hysterectomy. This was performed with the assistance of a specialist gynaecological oncologist. A left ureteric stent was also placed by the urology team once the bleeding was controlled. The patient had a total blood loss of 2500 mL, with her haemoglobin recorded as low as 67 g/L. During the operation she received 6 U of packed red blood cells, 2 U of fresh frozen plasma, 1 L of albumin and 8 L of crystalloid. She also required a metaraminol infusion to maintain her blood pressure above 90/60 mmHg. The total anaesthetic time was seven hours. Postoperatively, the patient was transferred to the intensive care unit, where she remained intubated and ventilated until the next morning. Despite this, she recovered well and was discharged home on day eight. Histopathology of the patients' uterus revealed that the previous LSCS scar was close to the site of the most recent LSCS incision, that is, 5 cm superior to the site of the rupture.

Etta Yang

1982/11/11

001-478-415-9677x1742

66140 Jones Valleys

A 17-month-old African-American girl was referred from her private dentist for evaluation of two papillomatous lesions in the anterior maxilla (). History revealed a healthy child, the product of a normal, uncomplicated full-term pregnancy. Dental history revealed that the growths first appeared 5 months ago and were slowly increasing in size. No history of dental and/or facial trauma was reported. The child was not in any pain, and no interference with feeding was reported by the mother. The lesion on the buccal mucosa was about 1 centimeter in size, pink in color, stippled and attached via a peduncle to the attached gingiva opposite tooth no. 51 and tooth no. 52. The lesion blanched slightly with digital pressure. The lesion of the palate was about 0.75 cm in size, circular, pink in color, stippled, sessile, and adjacent to the incisive papilla between tooth no. 51 and tooth no. 52. No blanching was noted with slight digital pressure. A radiograph of the area revealed no bony involvement (). Due to the age of the patient and the relative complexity of the procedure, it was decided to perform excisional biopsy of both lesions under general anesthesia. The lesions were excised utilizing a number 11 scalpel blade. The excised areas were then cauterized. On one-week followup both areas were healing well; no pain or discomfort and no difficulty in eating were reported by the mother (). includes most of the lesions that should be considered in the differential diagnosis of both lesions. An attempt is made to order the lesions ranging from the most likely to the least likely to occur in this specific patient. Buccal lesion?ense fibrous connective tissue surfaced by stratified squamous epithelium with a normal maturation pattern. No evidence of malignancy. Diagnosis of focal fibrous hyperplasia (). Palatal lesion?ense fibrous connective tissue surfaced by stratified squamous epithelium with a normal maturation pattern. Many stellate fibroblasts and long thin rete pegs are present. Diagnosis of giant cell fibroma (). The pathology report also suggested that since there were only subtle histological differences between the two lesions, they might have simply been in different stages of maturation. The report also advised that the child be assessed now and in the future for additional lesions and to consider and rule out fibromatosis syndrome.