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Name stringlengths 8 21	Age int64 18 45	Date_of_Birth stringlengths 8 10	Phone_Number stringlengths 4 22	Email stringlengths 16 30	Address stringlengths 13 36	Patient Progress Summary stringlengths 311 19.4k
Everleigh Brandt	28	2000/3/4	(457)893-3292x953	[email protected]	7748 Brown Highway	A six-year-old female presented for definitive procedure of persistent cloaca (Fig. ). She had colostomy on 5th day of life. Ultrasound of abdomen was reported as normal. Distal colostogram showed high recto-cloacal fistula (Fig. ). Endoscopic evaluation revealed an opening at bladder neck. At operation anal sphincter was identified by nerve stimulation and dissection started by making anterior sagittal incision. The sites for the future vagina and ano-rectum were made. Abdomen was then opened by mobilizing the stoma. Urinary bladder was opened and ureteric catheterization done to avoid their damage during surgery. The anomaly was identified as high confluence of rectum and vagina opening into the cloaca at the level of bladder neck (Fig. ). The opening of vagina was very minute that could not be identified on endoscopy as well as at operation. Distal loop of the colon was mobilized and detached from common cloaca. It was tailored distally, to be used as vaginal substitute and pulled down at the perineum, while its proximal end anastomosed with lower end of the vagina that was about 1/3rd in length. Similarly proximal loop of colon mobilized to bring it down as ano-rectum, through the already identified site for anus. Feminizing clitoroplasty was added. The common channel was left as urethra. Finally perineal body was constructed (Fig. ). Patient had uneventful recovery. Examination done after 02 weeks of surgery showed healed patent vaginal and anal passages. On 10th week post operative visit, the mother was satisfied the urinary continence. She observed occasional soiling (Kelly? continence score 3). She was on follow up and on vaginal dilatation program.
Damir Carr	42	2004/5/28	7209630230	[email protected]	427 Adam Lodge Apt. 077	A 6-month-old male infant presented in surgical emergency with history of bilious vomiting for 25 days and non passage of stool for a week. There was no history of abdominal distension. The patient on presentation could not tolerate feeds rather he was reluctant to take the feeds. The baby was investigated in another hospital where upper gastrointestinal contrast study showed obstruction in proximal jejunum (Fig. 1). CT scan of abdomen revealed a rounded intra-luminal mass obstructing the bowel lumen (Fig. 2). Patient had also developed jaundice Liver function tests showed, total bilirubin 3.2mg/dl, direct 1.2mg/dl, alkaline phosphatase 220IU/lit with SGPT and SGOT were within normal limits. Abdominal radiograph showed signs of sub acute intestinal obstruction. Surgery was planned for sub acute obstruction intestinal obstruction. On exploration, the proximal jejunum was distended, edematous and thickened, having putty like material on palpation, being stuck and could not be moved. Enterotomy was performed which showed edematous and swollen bowel mucosa. Jelly balls formed thick sludge and caused obstruction. The jelly like material was removed from the jejunum (Fig. 3). Enterotomy was closed transversely as after retrieval of jelly material the bowel was looking healthy and not compromised. Post operatively the parents were enquired about crystal jelly balls and mother admitted that the boy from neighbors gave the baby two jelly balls and he swallowed one of them. The patient developed burst abdomen on 6th postoperative day and was re-operated. At exploration anastomotic leak was found. The anastomosis was revised and abdomen closed by retention sutures. The patient developed septicemia, and succumbed after 2 days of second operation.
Rowan Montes	37	1983/7/6	764.817.9600	[email protected]	1130 Veronica Ford	A 14 year old male child had sudden onset of headache one and half month back which was associated with multiple episodes of vomiting. He was treated at local hospital and headache was reduced in intensity after oral analgesics. There was no history of fever, seizures or focal neurological deficits. His general and systemic examination was unremarkable. Higher mental functions were normal and there was no focal neurological deficit. Fundus showed bilateral early papilloedema. Blood investigations were normal. He was investigated with magnetic resonance imaging (MRI) which showed evidence of left basal ganglionic haematoma with mass effect and midline shift (Fig. 1,2). He underwent left frontal craniotomy and haematoma was approached through the middle frontal gyrus as it was approaching to the surface in that region. There was thin capsule containing altered blood which was removed completely. Histopathology showed organizing blood clot and there was no evidence of tumor cells or any abnormal vessels (Fig. 3). Child is doing well and there are no neurological deficits.
Darren Lynn	37	1998/1/1	729-654-0890x82211	[email protected]	294 Butler Haven Suite 442	A 7-year-old girl presented with abdominal mass that was noted at birth. She had abdominal pain and recurrent febrile episodes for the last 6 months that had worsened a week before presentation. On examination, she was febrile with generalized abdominal tenderness. A large well-defined, firm, fixed, tender mass, having bosselated surface and measuring 15 cms in diameter occupied entire left half of her abdomen. The fingers could be insinuated between the mass and left costal margin above and the mass and the pelvic brim below. Leukocyte count was 14,000/ mm3. Biochemical parameters were normal. Abdominal roentgenogram showed a soft tissue shadow occupying the left half of the abdomen displacing the stomach up and the bowel loops to the right. There were extensive areas of calcification (Fig. 1). Chest x ray was normal. Abdominal ultrasound revealed a large heterogeneous retroperitoneal mass pushing the left kidney and the ureter with mild to moderate left hydronephrosis. CT scan abdomen showed a well-defined retroperitoneal mass measuring 14cm x 10cm x 9cm in the left half of the abdomen having mixed density, septations, calcifications and teeth-like structures (Fig. 2,3). The mass displaced the left kidney posteriorly and cranially, the sigmoid colon anteriorly, and aorta and inferior vena cava to the right. The serum alpha fetoprotein levels were within normal range. The diagnosis of infected retroperitoneal benign teratoma was made. At operation a small amount of thick turbid came out. There were inter-loop pockets. The thick capsule of the tumor was found breached at 2 places. The overlying sigmoid colon was firmly adherent to the tumor capsule. The aorta, inferior vena cava and the mesenteric vessels were pushed to the right and did not pose any risk to the dissection. Both ovaries were normal. Excision of the large tumor necessitated resection and anastomosis of the sigmoid colon. Though the tumor could be removed in toto, there was gross spillage intra-operatively. Few para-aortic lymph nodes were sampled. The resected specimen had variegated appearance and there was evidence of cartilage, teeth, and hairs (Fig. 4). The patient did well post-operatively and was discharged on 15th postoperative day. The biopsy was reported as mature cystic teratoma (dermoid cyst) with evidence of extensive xanthogranulomatous reaction to keratin. The para-aortic lymph nodes had only reactive changes. She has been on close follow up since last 6 months and has been doing well.
Samira May	24	2001/11/22	001-980-966-1731x2902	[email protected]	437 Woodard Corner	A 6 year old girl, diagnosed case of popliteal pterygium syndrome, was admitted to our unit for pharyngoplasty. She had a series of surgeries for cleft lip and palate, lower lip sinus and bilateral popliteal pterygium (Fig. 1). Bilateral labioplasty was done at the age of 3 months, release of left and right knee flexion contracture at 7 months and 10 months of age, respectively (Doppler ultrasound showed no vessels in the band). Per-operatively, no nerve was found in the fibrous band. At 15 months of age mucous membrane adhesions were released (upper and lower buccal mucosa to the tongue). Palatoplasty was performed at the age of 1 翻 year. Left leg contracture was severe and had a repeat release at the age of 2 years. Soft tissue lengthening was done by releasing the fibrous band and lengthening of skin was made by doing Z-plasty. At the same time excision of lower lip pit was done. Her father had the same congenital anomalies for which he had multiple surgeries (Fig. 2). Her younger sister also manifested popliteal pterygium syndrome anomalies (cleft lip, cleft palate, lower lip sinus and bilateral popliteal pterygium) (Fig. 3). The index girl achieved all developmental milestones normally. She has learned to walk and run but she cannot put her heals fully plantigrade. Pharyngoplasty was performed at last admission and patient discharged. She is on regular follow up.
Finley Dougherty	29	1996/1/15	5777709358	[email protected]	279 White River Apt. 859	A 12-year-old boy presented in paediatric emergency room with complaints of severe paroxysmal colicky abdominal pain for the last 6-8 hours associated with non-bilious vomiting. Patient was apprehensive and looked pale. Patient had passed stool in the morning with no history of blood or mucous in the stool. On per abdominal examination no lump was palpable. There were no signs of peritonitis. His laboratory investigations were within normal limits. Abdominal radiograph showed air fluid levels indicative of a small-bowel obstruction. Ultrasonography revealed ileo-ileal intussusception. After resuscitation, patient underwent emergency laparotomy. At operation an ileo-ileal intussusception was found (Fig. 1). The invaginated segment was situated approximately 40 cm from the ileo-cecal valve. The reduction of intussusception was carried out gently. After reduction the adjacent small intestine had a normal color and peristalsis. A firm polypoid mass was palpable in the lumen of ileum about 20 cm from ileo-cecal valve (Fig. 2,3). An enterotomy confirmed the presence of a polypoid lesion arising from antimesenteric border. This segment of ileum was resected and an end-to-end anastomosis performed. Postoperative recovery was uneventful. Histopathological examination revealed that the mass was composed of mature pancreatic acini and ducts.
Alisson Melton	31	1978/8/25	409-541-9169x1212	[email protected]	5792 Sonya Land Apt. 351	A six-year-old female child was brought with the history of swelling of upper lip with discharge. The swelling was noted shortly after birth. It discharged thick material periodically. The parents had learned to decrease the size of the swollen lip by squeezing and letting the secretions out. On examination, the patient had a palpable lump over philtrum of upper lip about 8mm x 6 mm with two minute openings, one (cutaneous) on the midline of philtrum (Fig. 1A) and another (mucosal) towards the right of frenulum (Fig. 1B). On applying gentle pressure, thick creamy sebaceous material could be expressed from cutaneous opening. The patient was operated. After partial expression of sebaceous material, 0.2cc of 0.5% methylene blue was injected (Fig. 2A). The dissection was carried out from mucosal side (Fig. 2B) and the whole of the fistula was excised. On the philtrum, a small ellipse of skin around the cutaneous mouth of fistula was excised to ensure complete excision. Histopathological examination of the specimen showed features of fibrous fistulous tract with central cystic dilatation. The inner lining comprised of stratified squamous epithelial and contained dermal appendages including sebaceous and sweat glands. At one year of follow-up, there was an inconspicuous scar in the middle of philtrum (Fig. 3).
Lennon Flores	29	2003/11/27	775.476.8686	[email protected]	024 Keith Springs Apt. 094	An apparently healthy 11-year-old boy presented with acute pain in central abdomen of 5 hours duration. He gave history of a trivial blunt abdominal trauma while at play. Patient also complained of a bothersome itching all over his body especially over limbs and the trunk starting soon after the injury. At presentation, the patient was lying still in bed with pulse rate of 110/min and BP 110/60 mm Hg. There was no pallor. Lesions resembling utricaria were seen over thigh and trunk. Abdominal examination revealed generalized rebound tenderness. Baseline investigations were normal except for leukocytosis (13200/ mm3). Roentgenograms of the chest and the abdomen were essentially normal. Ultrasonography revealed that liver was enlarged and there were 2 cystic lesions [6.4X4.6 cm and 8.1X 6.9 cm] in right lobe of liver with hypoechoic contents and floating echogenic membranes and peripheral calcifications. Lot of free fluid was also present. Intravenous fluids were started with a bolus of Ringer lactate (20ml/Kg) followed by Dextrose 5% in normal saline (0.9%). Intravenous Hydrocortisone and Pheniramine maleate were adminstered along with antibiotic prophylaxis. The clinical picture with sudden generalized pain in abdomen with rashes, frank peritonitis and sonographic findings were suggestive of ruptured hepatic hydatid cyst. Patient was taken for exploratory laparotomy. The peritoneal cavity was filled with approximately 500 ml of bilious fluid which was drained out. Inspecting the liver surface showed extruded bile stained flaccid hydatid cyst (Fig. 1). Another intact hydatid cyst was palpable in segment VI which was removed by partial pericystectomy. The entire peritoneal cavity was lavaged with hypertonic (3%) and normal saline. The bed of the first cyst was inspected for any bile leak. As there was no evidence of large cysto-biliary communication, the cavity was packed with omentum. A tube drain was placed in right sub-hepatic space. Postoperative course was uneventful. The drain was removed on the on 7th post operative day. albendazole (15 mg/kg/day) was started and plan was to continue it for 6 months (3 weekly courses and drug free period of one week with a watch on the liver enzymes and counts). Four weeks later, the patient presented with upper abdominal fullness not associated with any other complaint. He was afebrile and hemodynamically stable. There was no icterus. On examination, there was distension of abdomen limited to the upper half of abdomen. There was no demonstrable free fluid and bowel sounds were normal. Laboratory values were: Hb-9.2 gms/dl, TLC-6900/mm3, serum bilirubin-0.8 mg%, ALT-17 U/ L, ALP 365 U/ L, AST-28 U/ L. Sonography revealed a large multiloculated cystic mass (15cmx13cmx18 cm) antero-superior to the liver. The intra-hepatic biliary radicals and the common bile duct were not dilated. There was no free fluid. CT scan was done to know further details. It showed 13cmx13cmx16 cm cystic lesion in the right lobe of liver with well defined septa of liver parenchyma within it (Fig. 2). Another cystic lesion was found in the left sub-hepatic space and lesser sac. Based on the findings it was diagnosed to be a ?alled off??bile collection. A pig tail catheter was inserted percutaneously into the bilioma under sonographic guidance which was both diagnostic and therapeutic. It drained about 500 ml of greenish brown fluid overnight and culminated with disappearance of abdominal distension. The catheter was removed after 4 days when the effluent was negligible. Patient was discharged and on follow up 3 weeks later, found to be doing well. Currently patient is on albendazole therapy.
Emilia Watts	34	1995/7/26	001-604-867-3804x4628	[email protected]	579 Kline Knolls Suite 319	A 4-month-old male baby presented to our hospital with the complaint of palpable mass in the right hemi-abdomen noted by the parents one day back. The patient was born at full term with uneventful birth history. The baby achieved milestones normally. Abdominal examination revealed a non-tender mass with vague margins in the right hemi-abdomen. Laboratory investigations including alpha-fetoprotein were within normal limits. X-ray abdomen showed mass impression pushing the gut shadows to one side. Bones and calcifications were also evident in the right hemi-abdomen. Ultrasound of the abdomen revealed a heterogeneous mass with calcifications suggestive of teratoma. Abdominal CT scan showed a 9.2cm ? 10.0cm heterogeneous mass containing fat, bones and soft tissues. The various bones were vertebrae, long bones like femur, tibia and fibula, and bones of hand/feet (Fig.1). Provisional diagnosis of FIF was made. At operation, a mass covered in whitish-gray membrane, pushing the gut loops to the opposite side in the upper retroperitoneum, was found (Fig.2). The membrane was incised to find a fetiform mass floating in clear fluid having a few well differentiated and other rudimentary organs. The fetiform mass was suspended in the amnion like cavity with an umbilical cord like stalk (Fig.3). The mass with sac was mobilized and excised completely. Post operative recovery was uneventful. Patient was allowed orally on 3rd and discharged on 7th post operative day. The patient is currently being followed with alpha-fetoprotein and ultrasound abdomen. At six months follow up patient is doing well. The FIF was of 13.75cm?12.5cm?6.25cm size with a weight of 500 grams. It was anencephalic having otic and nasal placodes and optic vesicles. The left upper limb was meromelic; lower limbs were sirenomelic. The umbilical cord had two vessels in it. The FIF had a scrotum like skin at the site of genitalia that lacked gonad in it. The FIF also lacked anus and genitalia (Fig.4). Plain radiography of the specimen revealed axial skeleton in the form of vertebrae, along with ribs, long bones of upper and lower limbs, and facial bones (Fig.5).
Dakota Ross	22	1986/12/18	001-309-648-1810x4857	[email protected]	675 Johnson Squares	A 12-year-old girl presented with gradual onset of continuous, low to high grade fever, and cough which was initially non-productive but later productive of yellow sputum over 20 days. She had anorexia and lost weight. She developed respiratory distress which gradually worsened. Family history was significant for tuberculosis in grandmother who lived with her. She was unvaccinated. Initially they took treatment from a family physician but later referred to other facility where she was admitted and worked up as no improvement was noted. Her x-ray chest showed bilateral pleural effusions (Fig.1) and ultrasound of the chest revealed large effusions on both sides with thick internal echoes. At thoracocentesis, pus was aspirated from both the sides. She was started on anti-tuberculous treatment (Inj. streptomycin, isoniazid, rifampicin and pyrizinamide). After the thoracocentesis, her condition worsened and x-ray chest revealed left pneumo-thorax, (Fig.2) and she was referred to our centre. At arrival, examination revealed a thin, emaciated, 21 kgs, tachypneic girl, with a respiratory rate of 52/min and heart rate of 118/min. BCG scar was not found. Chest movements were equal but air entry was reduced on both sides. Bilateral tube thoracostomies were offered. About 250 cc thin yellow pus was drained initially from the right side and 20 cc thick yellow pus drained from the left side along with air-leak. Post intubation x-ray chest showed partial lung expansion on the right side (Fig.3). Laboratory investigations showed Hemoglobin of 9 gm/dl and ESR of 40 mm/1st hour. She was started on ceftazidime and amikacin injectables, empirically along with anti-tuberculous drugs and supportive treatment. The initial pleural fluid examination revealed numerous WBCs, proteins 5.7 gm%, and gram negative rods. Pseudomonas aeruginosa was isolated from the pus and no AFB was seen on Ziehl Nelson (ZN) staining. Antibiotics were changed to tazobactam (according to culture report) and anti-tuberculous drugs continued. Her condition worsened despite optimal medical treatment. Respiratory distress increased together with persistent air leak and oxygen desaturation. She was shifted to intensive care unit and x-ray chest was repeated which showed bilaterally well expanded lungs with pneumonic patches. Both chest tubes were in place that drained pus though she required re-adjustments multiple times. She was also given nutritional supplementation. The pus culture were repeated that grew Morganilla morgani sensitive to tazobactam. Gradually her condition settled. Respiratory distress improved and fever subsided. Repeat x-ray chest showed bilaterally well expanded lungs except for a cavitatory lesion at the right lower zone. Ultrasound (US) chest showed collection with internal echoes measuring 5.4 cm ? 4.5 cm, and 10 cc pus was aspirated under US guidance and sent for culture. Proteus vulgaris was isolated with same sensitivity pattern. At 42nd and 48th day of intubation, left and right sided chest tubes were removed respectively after the x-rays when the patient was asymptomatic (Fig. 4). She was sent home on anti-tuberculous treatment and vitamin supplements after a total hospital stay of 66 days. On last telephonic conversation with family the patient was reported as thriving well, gained weight and was asymptomatic.
Peyton Rivera	39	1980/11/24	962.512.2458x38226	[email protected]	12857 Boyd Shore Apt. 258	A 20-year-old male, suffered from cough, rhinorrhea, wheezing and dyspnea after exposure to rainy environmental conditions. He was diagnosed with asthma in childhood. Positive family history of asthma included his mother and three elder sisters. Following treatment with inhaled corticosteroids, the symptoms abated over the next three days. Nine days after the onset of his asthma exacerbation, he developed an unsteady gait (day 1). The symptoms persisted, and on day 3 he developed blurred vision, dizziness, and nausea. On day 12, he became intermittently drowsy, however, he could be aroused by noxious stimulation. Six days later (day 18), he experienced an episode of tonic-clonic seizures. This episode brought him to the attention of the neurological team. On neurological examination he was fully conscious, had a wide-based gait, and was unable to stand on one foot. Limitations of lateral gaze in the left eye and vertical gaze in both eyes were observed. Motor and sensory functions were intact. Brain computed tomography (CT) and cerebrospinal fluid (CSF) examination showed no abnormalities. Electroencephalography (EEG) showed a 4?? cycle per second slow wave pattern diffusely, and a 22??6 cycle per second waveform predominantly over centroparietal area, bilaterally (Figure ). Brainstem encephalitis was tentatively diagnosed, and the patient was given intravenous dexamethasone (10 mg per day) for treatment. Despite the treatment, the patient? symptoms deteriorated, his level of consciousness varied from occasional drowsiness to lethargy, and on day 21, he developed quadriplegia. On the Medical Research Council (MRC) scale, his muscle strength was grade one for all limbs. Triceps brachii and biceps brachii reflexes were decreased bilaterally, and brachioradialis reflexes were absent bilaterally. Patellar and achilles reflexes were also absent bilaterally. Plantar reflexes were equivocal. CSF examination showed albuminocytologic dissociation with 64 mg/mL protein and 2/弮L cells. Serologic and CSF screenings for IgM antibodies against cytomegalovirus (CMV), Herpes Simplex Virus I (HSV-I), Coxsackie virus (CV), Measles virus (MV), Epstein-Barr virus (EBV), as well as EBV viral capsid antigen (VCA) IgA were all negative. Serologic analysis of antibodies against ganglioside complexes (anti-GDIa, anti-GDIb, anti-GM1, anti-GM2, anti-GM3, anti-GQIb and anti-GTIb antibodies) were negative. Serum and CSF examination, revealed significantly elevated IgE levels in both the serum (14.4 mg/L, normal range: 0.1-0.9 mg/L) and CSF (0.046 mg/L, normal range: undetectable), whereas, IgA, IgM and IgG were within the normal range. Nerve conduction study (NCS) revealed peripheral nerve abnormalities characterized by axonal damage (Figure ). Both motor conduction velocity and sensory conduction velocity were normal in the four limbs. Motor nerve conduction study showed variable decreased amplitude at the median, ulnar, tibial, and peroneal nerves on both sides. The right peroneal nerve showed slightly prolonged latency. Sensory nerve conduction study recorded decreased amplitude at the left tibial nerve, but the right sural nerve, right median nerve and left ulnar nerve were relatively spared. Left median F-wave could not be elicited, but H-wave was evoked normally. Overall, the NCS findings were consistent with a diagnosis of GBS with predominant axonal damage.
Charles Lopez	20	1997/12/16	446-529-5294x84610	[email protected]	58900 Jones Isle Apt. 829	A 68-year-old, right-handed Caucasian man was diagnosed with Gleason grade 4 + 3 adenocarcinoma of the prostate in March 2009. A partial prostatectomy and pelvic node dissection was completed, and our patient started androgen blockade with leuprolide (Lupron), dutasteride (Avodart) and bicalutamide (Casodex). His prostate specific antigen (PSA) levels decreased from an initial value of 41.6 to 0.07 ng/ml in April 2010. In May 2010, one month prior to admission, a transurethral debulking of his prostate was completed for difficulty in initiating a urine stream and an indwelling Foley catheter was left in place. In the 48 hours prior to admission, he developed a worsening saddle anesthesia. On the day of admission, June 10 2010, he described increasing headache as well as new-onset fecal incontinence but denied weakness. His past history, family history and a review of his systems were not significant. On admission, his mental status, cranial nerve and upper extremity examinations were unremarkable. A motor examination was intact in his legs but there was significant numbness below his ninth thoracic vertebra. Reflexes were absent in his lower extremities. Rectal sensation and tone were absent. Magnetic resonance imaging scans of his brain and thoracic and lumbar spine showed two irregularly enhancing lesions. The first, 2cm in diameter, was in the region of the fourth ventricle but was without secondary hydrocephalus. The second was a spindle-shaped intramedullary lesion of the conus medullaris (Figures , and ). The lesion was approximately 2cm in the vertical extent and appeared partially cystic. Our differential diagnosis included ependymoma, astrocytoma, a metastasis from the known prostate cancer or a metastasis from an undiscovered second primary tumor. Because of our patient? increasing neurological deficit, and given the uncertainty of the diagnosis, a decompression and an excisional biopsy were undertaken on the day of admission. With somatosensory and motor evoked potential monitoring, a twelfth thoracic to first lumbar vertebral laminectomy was completed. The level of the lesion was confirmed using intraoperative ultrasound. On opening the dura, abnormal appearing tissue was immediately identified involving the posterior surface of the conus. A small biopsy was consistent with malignant tissue. A more aggressive resection to the edges of the abnormal appearing tissue was completed and his cord appeared adequately decompressed. The closure was uneventful. On microscopy, the lesion showed sheets and nests of cells with abundant cytoplasm and prominent nucleoli. Mitoses were common. Intracytoplasmic and extracellular mucin was demonstrated. AEI/AE3 cytokeratin, CAM5.2, CK7, and CK20 were positive. PSA, Prostatic specific acid phosphatase (PSAP), thyroid transcription factor-1 (TTF-1), caudal type homeobox-1 (CDX-1), and S100 were negative. The pathology was consistent with metastatic adenocarcinoma of the prostate (Figure ). Following surgery, his sensory changes improved and the motor examination remained intact. His bowel and bladder function remained poor. The intracranial lesion and the resection cavity in the conus were both treated with CyberKnife簧 radiosurgery. The spinal resection cavity, contoured to the edge of the enhancing tumor on a postoperative scan, was treated to a marginal dose of 27Gy at the 85% isodose line in three sessions. Our patient remains neurologically stable three months after treatment, with no new neurological deficits and no new lesions.
Gianna Holmes	34	1978/12/23	297.575.3288	[email protected]	732 Clayton Lane Suite 760	An eight-year-old African boy, previously well, was referred to our unit on account of nephrotic syndrome. He had presented to our emergency department a day before with ascites, facial swelling and reduced urinary output in the preceding two weeks. After two days of hospitalization, he became deeply jaundiced with worsening of the generalized oedema. A day later, he had three brief episodes of generalized clonic seizures over a two-hour period and became increasingly drowsy. The seizures were aborted with diazepam and he remained seizure-free after a short course of phenobarbitone. A physical examination did not support a diagnosis of meningitis and other aspects of a neurological examination were normal. He had ascites and non-tender hepatomegaly; his spleen was not palpable. A review of his history did not reveal chronic or recent use of orthodox or non-orthodox medicines. In addition, there was no previous or current history of similar illness in his four siblings and close contacts. Both his parents were Africans, of the Igbo ethnic group from southeast Nigeria, but were not known to be blood relatives. In the second week of hospitalization, our patient developed tremors of his hands while at rest and when reaching for objects. He became clumsy when performing chores involving the use of his hands. Subsequently, he was observed to be stiff globally, with his trunk arched forward and fisting of the hands (left more than right). His gait was noticed to be shuffling with a tendency to fall forward when trying to walk. At the same time, his face retained a wry smile and his speech became slurred and dysarthric. He frequently complained of generalized body pain and derived some relief when his clenched fist was helped open. He was also noticed to be emotionally labile; he cried inconsolably when asking for food. He was reviewed by a paediatric neurologist who pointed out the possible presence of Kayser-Fleischer (KF) rings on both eyes. A slit-lamp examination by an ophthalmologist promptly revealed the presence of both KF rings (Figure ) and sunflower cataracts. Initial investigations showed proteinuria of grade 1+ and a spot urine protein to creatinine ratio of 1. Table shows the results for his liver function test during hospitalization. His serum electrolytes, urea and creatinine were within the normal reference range. An abdominal ultrasound scan revealed ascites and hepatomegaly with increased liver parenchymal echoes but no dilated intra- or extrahepatic ducts. However, his gall bladder was enlarged with a thickened wall and sludge within. Serology for human immunodeficiency virus, hepatitis B and hepatitis C viruses were negative. A serum sample for caeruloplasmin level was returned as having 5mg/dL of caeruloplasmin, using an immunoturbidimetric method (reference range: 25 to 45mg/dL). Using the scoring system proposed by the 8th International Meeting of Wilson Disease and Menkes Disease [], our patient achieved a score of 6 (compatible neuropsychiatric features = 2; K-F rings = 2 and caeruloplasmin level of 5mg/dL =2) and a diagnosis of WD was made. His diet was restricted to high calorie, low protein and low copper meals. Vitamins, including vitamin K, and lactulose and neomycin were commenced. Control of the generalized oedema was achieved with furosemide and spironolactone. Long-term zinc and pyridoxine therapy was started. The use of trihexyphenidyl helped achieved some control of the spasticity and rigidity, sufficient to allow resumption of basic activities such as walking and holding objects. His liver dysfunction also improved, with near resolution of the international normalized ratio (from 12 to 4).
King Reyes	44	2003/8/15	(941)613-0887	[email protected]	536 Wang Mall Suite 111	A 50-year-old Hindu man from northern India presented with pain in his neck and restriction of neck movements of two months duration. The pain was not radiating to any other part, was present throughout the day and was aggravated during the night and after activity. He had no history of any traumatic episode. Our patient was experiencing little relief with analgesics. The pain was not associated with fever; he had no weakness in any of his limbs, nor difficulty in speech or deglutition. On examination, he had tenderness over the spinous processes of the upper half of his cervical spine along with spasm of his neck muscles. There was no deformity or gibbus. Our patient had gross restriction of motion of his cervical spine in all directions. He had no palpable lymph nodes in his neck. On neurological examination, there was no deficit in any limb and his tendon reflexes were normal. He had no other systemic illness. Laboratory investigations showed little abnormality other than an increased erythrocyte sedimentation rate (54 mm in the first hour). A lateral view of plain radiographs showed a fracture of the body of his second cervical (C2) vertebra with mild displacement of the fractured anterior body fragment. The odontoid process appeared to be in normal alignment with his C1 vertebra. There was also a significantly increased prevertebral soft tissue shadow anterior to the C1, C2 and C3 vertebral region (Figure ), which indicates the presence of a retropharyngeal abscess. A computed tomography scan showed fragmentation of his C2 vertebral body and the anterior fragment lying separate from the parent bone. Posterior elements were found to be normal (Figure A, B). MRI clearly depicted the extent of vertebral involvement in T1-weighted, T2-weighted and fat suppression sequences. The destruction and expansion of the C2 vertebral body was seen along with significant pre- and paravertebral collection. This appeared hypointense in T1-weighted and hyperintense on T2-weighted images. The soft tissue mass was seen compressing the airway anteriorly and was causing slight indentation of the thecal sac posteriorly. However, the cord appeared normal on signal intensity. His C2 and C3 vertebral bodies appeared hyperintense on fat suppression images, suggesting extensive bone marrow edema. His cervical intervertebral discs appeared degenerated at various levels but otherwise appeared intact (Figure C, D). Transoral fine needle aspiration cytology of the lesion yielded caseous material on cytology but did not show any acid-fast bacilli. Our patient was given antitubercular treatment with a four-drug regimen (rifampicin, isoniazid, ethambutol, pyrazinamide) for two months followed by a two-drug regimen (rifampicin, isoniazid) for a period of four months. His cervical spine was protected by a Philadelphia collar. On follow-up radiographs, the fracture in his C2 vertebra was found to be united by the end of 16 weeks and the prevertebral soft tissue shadow returned to its normal limits (Figure ). The pain and stiffness in his neck also improved significantly following treatment, although some terminal restriction of motion remained even at the end of 25 months follow-up.
Audrey Pitts	24	1982/8/30	7942934080	[email protected]	6141 Peter Rapids	A 56-year-old Japanese woman had visited a local clinic, complaining of a two-month history of a painless cutaneous fistula in her anterior neck with pus discharge. She was diagnosed with a pyogenic granuloma [] by her previous doctor. The pus discharge temporarily subsided after antibiotic treatment, but the cutaneous fistula persisted. She was then referred to our department for further advice. On physical examination, a non-tender reddish lesion with a fistula and granulation was seen on her anterior cervical skin. Our patient reported that she had suffered from the sensation of a foreign body in her throat after eating fish approximately one year prior to the present onset, but the symptom had spontaneously improved after a few days. Taking her anamnesis into account, a fish bone foreign body was suspected. Endoscopic examinations of her laryngopharynx and esophagus showed no abnormality. However, computed tomography (CT) revealed a bone-density needle-shaped foreign body sticking out anteroinferior from the esophageal wall, penetrating through the superior pole of her left thyroid lobe, and extending nearly to the anterior cervical skin (Figure ). The foreign body was surrounded by a low density area, suggesting abscess formation (Figure ). The results of a blood examination were unremarkable, with normal thyroid and parathyroid functions. Our patient underwent the removal of the foreign body combined with left hemithyroidectomy under general anesthesia 20 days after her initial visit to our department. A horizontal cervical incision with the spindle-shaped excision of the orifice of the fistula was made, and the skin flap was elevated. Considerable cicatricial adhesion was seen around the fistula. The fistula passed through the infrahyoid muscles and was connected to her left thyroid gland. The tip of the fish bone was exposed by cutting her infrahyoid muscles open. As seen in the preoperative imaging, the fish bone penetrated through her thyroid gland, reaching the esophageal wall. The fish bone, fistula, left thyroid lobe and an abscess were totally removed with preservation of her recurrent laryngeal nerve. The injured esophageal mucosa was sutured and closed. Figure shows the removed fish bone, measuring 28mm in length. Our patient? postoperative course was uneventful. No esophageal leakage was observed during an esophagography, and she was allowed oral food intake seven days after the surgery. She was discharged nine days after surgery, and no evidence of recurrence was seen over the postoperative follow-up period of 42 weeks.
Trey Ventura	23	1982/11/13	298.866.9765x007	[email protected]	8092 Michael Pike Suite 013	Our patient was a 28-year-old Arab woman, gravida 3 para 2 with a history of nonconsanguinity, with two previous full-term normal spontaneous vaginal deliveries and an unremarkable past medical, surgical and family history. She was referred to our hospital at 22 weeks of gestation with severe hydramnios and a placental tumor, for investigations and management. Our patient presented to us complaining of shortness of breath, backache and abdominal pain. An ultrasound examination revealed normal fetal growth for gestational age. Her amniotic fluid index was 48 cm, with the deepest pocket of 13 cm and no signs of fetal hydrops. Ultrasound middle cerebral artery peak systolic velocity (MCA PSV) color Doppler was 48 cm/s, which was 1.71 Multiple of Median (MoM) for gestational age. The placenta was implanted anteriorly with a detectable vascularized tumor measuring 42 mm ? 56 mm ? 58 mm with a noticeable feeding vessel at the root (Figures and ). After extensive counseling, our patient agreed to undergo percutaneous embolization of the tumor. Employing a multidisciplinary approach involving interventional radiology, we performed an amnioreduction of 3 L for maternal relief of symptoms, followed by injection of 1.5 mL of enbucrilate (Histoacryl; n-butyl-2-cyanoacrylate liquid adhesive glue) diluted with Lipiodol Ultrafluide, at ratio of 1/5, into the feeding vessel of the tumor. After the procedure, ultrasound Doppler revealed a complete absence of flow through the tumor (Figure ). Cordocentesis was then performed and revealed a hemoglobin level of 10 g/L with hematocrit 28%. The fetus was transfused 50 mL of O-negative blood and the post transfusion hemoglobin level was 14 g/L with hematocrit 42%. Chromosomal analysis revealed a normal female karyotype. Ultrasound was repeated one and four days post procedure and showed a decrease in the amniotic fluid index, of 32.2 cm with a deepest pocket of 10 cm. The pregnancy was followed up weekly with ultrasound, which showed normal fetal growth, stable amniotic fluid index with no signs of hydrops, and no flow through the placental tumor (Figure ). At 29 weeks??gestation, ultrasound Doppler of the MCA PSV was 76.3 cm/s. This was 1.97 MoM for gestational age, with the development of mild pericardial effusion. The fetus was transfused with 50 mL of O-negative blood. Pre- and post-transfusion hemoglobin levels were 10.4 g/L and 14.9 g/L, with hematocrit 29% and 44% respectively. At 30 weeks and 2 days of gestation, an ultrasound detected poor fetal right ventricular contractility with enlarged thick ventricular walls and mild pericardial effusion. Ultrasound Doppler of the MCA PSV was 61.3 cm/s, which was 1.51 MoM for gestational age, and an amniotic fluid index of 19.9 cm. Two intramuscular injections of betamethasone 12 mg were given 24 hours apart and then an elective Cesarean section performed. The outcome was a live female baby weighing 1.6 kg, with Apgar score 5, 7 and 8. No skin lesions or dysmorphic features were seen. The baby was transferred to the neonatal intensive care unit (NICU). Gross examination of the placenta revealed a yellowish, well-circumscribed firm mass measuring 5 cm ? 5 cm connected by two vessels to the placenta. Histopathologic examination revealed a placental disc 15 cm ? 17 cm ? 13 cm, with a three-vessel umbilical cord that was attached peripherally and measured 9 cm ? 1.5 cm (Figure ). The weight of the placenta was 530 g. The tumor was confirmed to be a chorioangioma. Our patient? baby stayed in the NICU for 42 days. Ultrasound of her head and abdomen showed no abnormalities. Echocardiography confirmed right ventricular hypertrophy with a mildly dilated right ventricle and depressed systolic function. The baby was weaned from the ventilator. Oxygen and nitric oxide were tapered along with inotropic medications. The baby was eventually discharged from the NICU at 42 days old with a follow-up appointment with our cardiology team.
Zora Roth	41	1977/11/22	4362802185	[email protected]	79412 James Orchard Apt. 763	A healthy, engaged 28-year-old East Asian man presented at our hospital with a two-week history of right-side scrotal swelling and a three-month history of left-side scrotal enlargement. He had complained of temporary dull pain in his right scrotum, but the pain had disappeared within a day. He had no history of prior scrotal surgery, cryptorchidism or infections. On physical examination, his right scrotum was slightly swollen, whereas his left scrotum had marked swelling and a hard mass was detectable. A scrotal ultrasound showed heterogeneous bilateral scrotal masses that were hypoechoic on the right but hyperechoic on the left. Doppler ultrasonography indicated a diffuse hypovascular area in the right scrotal mass but iso- and hypervascular on the left. Pelvic contrast-enhanced computed tomography (CT) demonstrated that his right testis was normal in size with decreased enhancement, whereas his left testis was much larger with heterogeneous enhancement (Figure ). These findings seemed to suggest bilateral TGCTs as a differential diagnosis, but his right testis did not have typical features of a TGCT; therefore, we examined his bilateral testes with MRI. His right testis had a serpiginous vessel and the intratesticular lesion showed high intensity on the T2-weighted image (Figure A), but lack of contrast enhancement (Figure B). His left testis had a large multinodular tumor with high intensity on the T2-weighted image (Figure ). According to the MRI findings, his right and left testes were diagnosed with hemorrhagic infarction and a testicular tumor, respectively. Before further treatment, we performed a sperm test. Sperm were present (8 million/mL) and were cryopreserved for use in an assisted reproductive technique, although his levels of luteotropic hormone (15.6mIU/mL) and follicle-stimulating hormone (49.0mIU/mL) were high. Based on the preoperative diagnosis, a transverse scrotal incision was made to allow right scrotal exploration. Since inspection of his right testis revealed a necrotic testis with 270簞 intravaginal torsion of the spermatic cord, his right testis was removed. Left radical orchiectomy was then carried out. Pathological examination demonstrated hemorrhagic infarction and dilated vessels in his right testis (Figure A), and typical seminoma cells and atrophy of seminiferous tubules in his left testis (Figure B). Preoperative laboratory examination showed a high lactic dehydrogenase level of 580IU/L and normal alpha-fetoprotein and human chorionic gonadotropin levels in his serum. Because an abdominal CT showed para-aortic retroperitoneal lymphadenopathy, 9mm in size, we diagnosed seminoma stage IIA, which has a good prognosis according to the definition of the International Germ Cell Cancer Consensus Group. Therefore, our patient was promptly given chemotherapy in three cycles of bleomycin, etoposide and cisplatin []. At the end of the three cycles, a follow-up CT scan showed complete resolution of the previous retroperitoneal lymphadenopathy and the tumor marker level was undetectable. After bilateral castration his serum level of testosterone was markedly decreased, so we started supplemental therapy of testosterone for his erectile function.
Roy Bush	45	1994/11/18	228-977-7572	[email protected]	55713 Sanders Lodge Suite 925	A 37-year-old Chinese woman presented to our department four years and 11 months ago with bilateral lower limb crush injuries sustained in a traffic accident. The lower limb injuries were at different anatomic levels (Figure A-C). On the right side, her lower limb was crushed from her hip joint to 16cm below her knee joint, but the bones and soft tissues of the lower one-third of her leg were intact with only slight injury to the skin. On the left side, the distal portion of her leg was crushed. Our patient was in serious hypovolemic shock on arrival, with a heart rate of 150 beats per minute and blood pressure of 80/60mmHg. After rapid infusion of intravenous fluids, our patient rapidly recovered from shock and did not develop acute renal failure or acute respiratory distress syndrome. Emergency surgery was performed. Bilateral lower limb amputations were necessary. Her lower left leg was unsalvageable, but her lower right leg was suitable for replantation to the left leg stump after debridement. We decided to perform crossover replantation of her right lower leg to the left leg stump to provide our patient with a sensate weight-bearing extremity. Her amputated right lower leg was wrapped in sterile dressings, placed on a sterile tray and stored in the refrigerator at 4簞C during fixation of the left leg fracture. After amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia (Figure D). The fibula was not fixed. The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures. The anterior tibial artery and posterior tibial artery were anastomosed crosswise, and the ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover. The sural nerve and saphenous nerve were anastomosed crosswise, and the anterior and posterior tibial nerves were anastomosed without crossover. Heterotopic replantation of her right lower leg to the left leg stump was thus completed. A stump was created on the right side at her hip joint. Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively. In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap. The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days; aspirin (100mg) orally three times a day for three days; narceine (30mg) four times a day for seven days; and tolazoline (25mg) three times a day for seven days. Routine post-operative blood tests, including coagulation tests, were performed for seven days. The replantation was successful and our patient was discharged after two months (Figure A). She was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. One year post-operatively, X-ray examination showed perfect union of the tibia (Figure C). There was no ulceration of the replanted extremity or the right-sided amputation stump at 39 months post-operatively. The sole of her foot on the left side regained complete protective sensation (Figure B). Our patient described the functional result of the replantation as satisfying, and found that the prosthesis on the right side caused more problems than the replanted left lower limb. She had no complaints about the cosmetic result. In addition, she experienced restoration of perceived body height with the crossover replantation.
Everlee Hunter	28	1994/4/21	315-431-1186x15271	[email protected]	2624 Patrick Rapids	A 29-year-old woman Para 2 was admitted to the emergency department with increasing lower abdominal pain. The patient had no history of systemic disease or chronic abdominal tenderness. Her past obstetric history revealed a caesarean section performed at 38 weeks because of a breech presentation three years earlier. The patient had undergone an uncomplicated elective repeat caesarean section 7 days before being admitted to the emergency department. Indication for CS was breech presentation at term. The operation was without complications except some heavy bleeding occurred after the incision of the lower uterine segment; the bleeding was controlled by means of haemostatic stitches. The postoperative course was uneventful and the patient was discharged in good clinical conditions four days after CS. Three days after CS she reported a significant decrease of postpartum discharge (lochia) as well as a sudden complete stop of vaginal bleeding and discharge on day 4 after SC. On admission, patient was alert, conscious, and well-oriented. She complained of severe low abdominal pain. Blood pressure was 140/80 mm Hg, HR 105 b/min, and temp. 37.4. The pain started the day before the admission as an abdominal discomfort with a sudden increase during the following day. At the time of her admission the patient described a constant low abdominal/pelvic pain with colicky exacerbations. Examination at this stage found no vaginal bleeding. Palpation revealed a painful swelling on the right side just above the pelvis. There was no sign of peritoneal irritation or abdominal distension. The wound seemed to be healing well. Lab tests at admission: Hb 12,8 g/dL, Hct 35, PLT 280, and WBC 10,5 ? 109/L. Routine urine examination was normal. Ultrasound investigation showed a strongly involuted uterus (LD 7.5 cm, TD 4.2 cm, APD 3.7 cm) which was localized centrally in the pelvis and also an oval-shaped mass on the right side of the lower abdomen (25 cm ? 8 cm), showing thickened walls with complex internal echo patterns apparently suggesting a organized haematoma. In the pouch of Douglas, there were no signs of active bleeding or clots. Despite of the administration of meperidine hydrochloride 100 mg IM, a reassessment after two hours showed increased symptoms with additional signs of peritoneal irritation and restlessness whereupon an explorative laparotomy was decided. Access was gained through the previous Pfannenstiel incision. At the opening of the abdomen a large amount of coagulated, dark red blood was evident amongst the intestinal loops. A further exploration of the pelvis showed an involuted uterus without signs of recent hysterotomy. On the right side, at the level of right iliac fossa, there was an oval, reddish, soft structure with a maximum diameter 25 cm. Mobilisation and further inspection revealed an enlarged uterus situated on the right side in respect to the small one (uterus didelphys). This second uterus showed a torsion of 90簞 on its axis and had a congested appearance. The uterine cavity was filled with blood (lochia) coming out the tubae by squeezing of the uterus. There were no signs of uterine weakening. During the inspection before detorsion it was noted a transverse hysterotomy suture on the right side of the uterus which was not bleeding. The other smaller uterus appeared firmly fixed to the anterior pelvic fascia and the lower segment of the left anterolateral wall of the other uterus (). Both adnexa were normal at inspection. All adhesions needed to be removed before attempting a complete emptying and detorsion of the organ (). Postoperative recovery was uneventful and the patient could be discharged 5 days after the operation in good clinical condition. She got prescribed enoxaparin 20 mg per day for 6 weeks to prevent thromboembolism.
Archer Washington	38	1986/10/16	001-300-759-2990x6277	[email protected]	11744 Natalie Square Suite 649	The patient is a 12-year-old boy presented to our institution with intermittent gross painless haematuria, which lasted for the 11 months prior to his first under hospital observation. The haemoglobin value on presentation was 8.6 g/dL. He was initially submitted and managed with continuous saline bladder irrigation, not needing blood transfusion or any other treatment. He denied any other urological signs or symptoms, namely, dysuria or other low urinary tract symptoms (LUTS), flank pain, fever, asthenia, or fatigue. His physical examination was normal. The urine analysis confirmed gross haematuria and no other abnormalities namely, the presence of urinary casts. The immunological markers ANCa and ANA were negative. The ultrasonography showed normal kidney measurements and echogenicity, excluding hydronephrosis, renal masses or stones. The Doppler study revealed turbulent pattern of venous blood flow of the posterior LRV branch behind the aorta (). The abdominopelvic computer tomography (apCT) revealed LRV duplication with a dilated retroaortic branch, entrapped between the aorta and the vertebral column, promoting the renal nutcracker syndrome (Figures and ). The cystoscopy showed normal bladder and urethra mucosa, and a bloody ejaculate only from the left ureter meatus. Thereafter he was counseled to intense physical exercise restriction, oral iron supplements showing reduction of the haematuria episodes and substantial improvement of anaemia (actual Hg: 10.6 g/dL). The child is currently asymptomatic and proposed to clinical and analytical assessment.
Valerie Park	21	1980/1/27	750.570.4293x697	[email protected]	369 Frank Lake	A 50-year-old female presented to the ER of an inner city teaching hospital after experiencing a generalized seizure episode. She had a medical history significant for immune thrombocytopenia for 30 years and seizure disorder since experiencing a right occipitoparietal stroke at the age of 47 years, for which she took lacosamide and aspirin. She reported being allergic to sulpha drugs. She had smoked 1/2 packs per day for 30 years but quit 3 years before. She reported feeling out of breath after walking less than a block and a persistent cough without much expectoration for the past 8 to 10 months. Upon hospitalization, she received supplemental oxygen in addition to her home medications. A chest radiogram done on admission () showed bilateral patchy infiltrates; pulse oximetry done the day after showed oxygen saturation of around 94% on room air dropping to 90% after a 6-minute walk. A repeat chest radiogram done on the third hospital day () revealed significant clearance of the infiltrates with much improvement in her oxygen saturation values both at rest and with ambulation. Cardiac markers and 2D echocardiogram were normal. The patient did not experience any more seizures during hospitalization and was discharged on the fourth day to be followed up in the office. The diagnosis of NPE was made based on rapid resolution of the symptoms.
Daxton Simpson	28	2004/12/10	622-888-2855	[email protected]	5327 Salinas Views Apt. 377	A 63-year-old Mediterranean Caucasian woman presented with mild dyspnea on exertion and a progressive worsening of a dry cough of nine months??duration. Born in Turkey, she had a history of exposure to asbestos via building materials commonly used in eastern Turkey. She immigrated to the United States at the age of 37. Shortly after arrival in New York she was diagnosed with and treated for pulmonary tuberculosis. (The diagnosis and treatment records were confirmed by the New York City Department of Health.) She had no fever, night sweats, hemoptysis or weight loss. She had no history of allergies; she had never smoked or used illicit drugs. Other than her birth in Turkey and immigration to the US she had no other travel history. Initial examination included a chest X-ray, which showed fibrocalcific changes at the upper lung fields bilaterally as well as a right lower lobe mass density. A computed tomography (CT) scan of the chest revealed multifocal pleural scarring, appearing metastatic in nature, throughout both lung fields with early mediastinal invasion in the right infrahilar region (Figure ). Positron emission tomography (PET) scan revealed FDG (fluorodeoxyglucose (18 F))-PET positive multiple lung masses. A computed tomography (CT)-guided core biopsy of a dominant right lower lobe lung mass was obtained. The histopathological specimen findings included chronic granulomatous inflammation (multi-nucleated cells with central necrosis) with numerous budding yeast forms that were positive for Grocott's methenamine silver stain (GMS), Periodic acid-Schiff (PAS) and mucin stain, consistent with cryptococcosis. Ferruginous bodies were also present, consistent with asbestos bodies (Figure ). Cultures of the specimen examined for acid fast bacilli and fungi were negative, as were bacterial cultures. Serum cryptococcal antigen and HIV enzyme-linked immunosorbent assay (ELISA) were negative. A summary of the significant clinical data is illustrated in the table. She was treated with fluconazole (400mg (6mg/kg) per day orally) for four months. She reported a marked improvement in her symptoms and improvement in her general condition. At her four-month follow up, a chest radiograph showed a significant reduction of the basilar infiltrates bilaterally.
Anastasia Collier	42	1999/7/20	663.416.1987x3959	[email protected]	893 Eric Divide	Three years prior to her presentation with a fractured femoral neck, a 37-year-old Caucasian woman was admitted via our emergency service with a painless, swollen finger. We diagnosed a fracture of the third proximal phalanx of her right hand based on the findings on physical and radiological examination and performed percutaneous pinning under local anesthesia. At follow-up six weeks later, she complained of swelling of her right foot. We observed three metatarsal fractures on X-ray examination and treated them conservatively. Six months later, our patient presented with limping and edema of her left thigh. Radiographic evaluation resulted in the diagnosis of a Fielding type III subtrochanteric femur fracture with excessive callus formation; this was treated non-surgically, with bed rest []. Two weeks later, she again presented to our hospital, this time for right hip deformity and pathologic displacement after falling in the bathroom. Radiographs indicated a Fielding type I right subtrochanteric femur fracture without callus. We considered this a fresh fracture and performed intramedullary nailing under general anesthesia (Figure A). We observed a dropped foot at follow-up two months later due to excessive callus formation, which had entrapped the sciatic nerve. We resected the hypertrophic callus and freed the sciatic nerve. Our patient did not attend any follow-up appointments over the next eighteen months, but then presented to our hospital with similar symptoms, including a swollen thigh and limping. The neurologic deficit in her right foot had resolved. We detected a right femoral neck fracture; intramedullary nailing had previously been performed for a subtrochanteric fracture of the same femur (Figure B). We performed cementless total hip arthroplasty after removal of the nail under general anesthesia (Figure C). As was true for previous operations, she required no analgesia postoperatively. There were no anesthetic or infectious complications. We allowed mobilization with crutches two days after surgery. At her most recent follow-up, six months after the surgery, her active hip flexion was 100簞, abduction 40簞, and external and internal rotation 20簞 without any instability, and she could walk with full weight bearing. We made a thorough evaluation and established a definitive diagnosis of CIP on the basis of the characteristic findings of multiple perioral mucosal ulcers, shortening of her nails and acro-osteolysis, a prematurely aged facial appearance, an undersized skeletal structure and Charcot arthropathy of her right ankle. We also detected anosmia, insensitivity to temperature differences and mild intellectual disability (according to Cattell Culture Fair Intelligence Test and The Kent Inventory of Developmental Skills). She had no evidence of muscular weakness or sweating disorders. In an intradermal histamine test (histamine phosphate 0.05mg/mL or 1:1,000 dilution), the axon reflex response, pain, wheal and flare were all absent. Dermal biopsy specimens showed no pathologic changes. On neurologic examination, her cerebellar function, proprioception and muscle strength were normal, however both deep and superficial sensation was absent.
Edison Ho	41	1990/10/21	754.895.0196	[email protected]	949 Michael Pines	We report the case of a 48-year-old Sri Lankan man who was admitted to our facility with an intermittent fever associated with joint pains and a skin rash for three months. He had an inflammatory type symmetrical arthralgia confined to large joints with early morning stiffness for 30 minutes. Skin rash, which was non-itchy, non-scaly and non-photosensitive, appeared initially on the trunk but became generalized within a period of two weeks. He was overwhelmed with marked malaise, severe anorexia, weight loss of 19 kg over three months with significant hair loss and multiple painful oral ulcers. He had a watery diarrhea of three to four bowel movements a day of one month duration associated with occasional episodes of vomiting and a vague abdominal pain. His past medical history was unremarkable except for two uncomplicated episodes of malaria about twenty years previously. He denied either exposure to high risk sexual activities or intravenous drug use. He did not consume alcohol and was a non-smoker. On examination, the patient was ill looking, febrile (temperature of 38.4簞C), dyspneic and moderately pale. Jaundice, finger clubbing, cyanosis and lymphadenopathy were absent. He had a generalized erythematous maculopapular skin rash involving the palms and soles (Figure ), a non-scaring alopecia and multiple shallow ulcers in the oral mucosa. On admission, his pulse rate was 100/minute, his blood pressure was 100/70 mmHg and his respiratory rate was 46/minute. Breath sounds were reduced in the base of the right lung with occasional rhonchi heard over both lung fields. He had a tender, firm hepatomegaly of 14cm span with a smooth surface and a regular edge. There was no splenomegaly, abdominal masses or ascites. His rectal examination was unremarkable but several non-painful ulcers were present in his scrotum. Optic fundus showed cotton wool spots around the disc; otherwise his neurological examination was normal. Deformities or edema of the small or large joints were absent but joint line tenderness was demonstrable in his wrist, elbow, shoulder, knee, and ankle joints bilaterally. However, his spinal movements were preserved and movements of the pelvic and shoulder girdles were painful at full range. Laboratory tests revealed normochromic normocytic anemia (hemoglobin: 8.7g/dL, mean cell volume: 86.5fL) with a total leucocytes of 5.4 x 109/L (neutrophils: 75%, lymphocytes: 19%), and a platelet count of 64 x 109/L. Inflammatory markers were elevated (erythrocyte sedimentation rate: 140mm; C-reactive protein: 60mg/dL) and he had an extremely high serum ferritin level of 34,674ng/ml. Arterial blood gas analysis revealed moderate hypoxia (PaO2: 78.7mmHg). Chest X-ray did not show evidence of consolidation or cavitations but his right hemidiaphragm was elevated. His liver functions were abnormal (aspartate aminotransferase: 252IU/L [<35IU/L], alanine aminotransferase: 69IU/L [<35IU/L], alkaline phosphatase: 1857IU/L [<300IU/L], gamma glutamyl-transferase: 2089IU/L [<54IU/L]) with a reversed albumin/globulin ratio (albumin: 1.9g/dL, globulin: 4.6g/dL). Serum billirubin (11.9弮mol/L) was not elevated and serum creatinine (1mg/dL) was normal. Abdominal sonography revealed uniformly increased echogenicity of the enlarged liver but evidence of billiary obstruction or focal lesions was absent. A battery of serological investigations including enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV), a hepatitis panel, blood testing for malaria parasites, rickettsial antibody, sputum for acid fast bacilli acid-fast bacillus acid-fast bacillus (AFB) and tuberculin skin test were all negative. Repeated blood cultures did not yield any bacterial growth and a venereal disease research laboratory screen for syphilis (VDRL) was non-reactive. His rheumatoid factor was 128IU/mL(<8IU/mL) but autoantibody screen including anti-nuclear factor, U1 ribonucleoprotein (RNP) complex, anti-smooth muscle antibody (ASMA), antimitochondrial antibody (AMA) and anti-neutrophil cytoplasmic antibodies (ANCA) were negative. Biopsy of the skin rash was inconclusive (Figure ). Bone marrow examination revealed evolving marrow hypoplasia although evidence of marrow infiltration by metastatic deposits or granulomata was absent. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis in bone marrow aspirates was negative. His clotting profile was mildly abnormal with a prothrombin time of 15 seconds (INR: 1.3) and a partial thromboplastin time of 58 seconds (control 35 to 42 seconds). His dyspnea and tachypnea, attributable to bronchospasm associated with systemic inflammatory reaction (SIRS) was probably worsened by high fever, marked myalgia, right hypochondrial tenderness with enlarged liver and anemia. Considering the possibility of sepsis, broad spectrum antibiotic treatment with intravenous meropenem 1g daily and metronidazole 500mg every eight hourly was instituted from the day of admission. His symptomatology and respiratory distress was only slightly improved with bed rest in a propped up position, antipyretics, salbutamol nebulization, analgesics and blood transfusions to correct the anemia. He underwent liver biopsy on day two of admission after the correction of clotting abnormalities. A presumptive diagnosis of AOSD with granulomatous liver disease was made based on the clinical criteria of Yamaguchi (Table ) and extremely high serum ferritin levels [,]. He was started initially on indomethacin 25 mg every eight hourly followed by intravenous methylprednisolone 1g daily pulses for three days under broad spectrum antibiotic cover. These measures failed to improve his clinical picture. He died on the sixth day after admission due to sepsis and multi-organ dysfunction. The liver biopsy revealed noncaseating granulomas in the background of fatty liver, later found to be culture positive for M. tuberculosis (Figure ).
Calliope Blair	31	1980/9/21	789-849-8540x31224	[email protected]	82288 Schmidt Knoll	A 34-year-old Caucasian man was referred to our hospital with complaints of abdominal pain in the right upper quadrant and pain in his right shoulder. The pain was not associated with nausea or vomiting, and there was no history of fever or jaundice. His medical history included an open ductus venosus and an Abernethy malformation complicated by the development of pulmonary arterial hypertension (mean pulmonary artery pressure 48mmHg), which had been diagnosed three years before and treated successfully with the endothelin receptor antagonist bosentan. At the time of presentation, he was in New York Heart Association functional class I. Physical examination displayed no signs of icterus, and cardiac examination revealed a hyperkinetic cardiac impulse outside the midclavicular line and a loud second heart sound. He had a soft abdomen without organomegaly. His laboratory test showed a hemoglobin level of 9.2mmol/L, an elevated liver enzyme profile with aspartate aminotransferase 46U/L, alanine aminotransferase 50U/L and bilirubin 32弮mol/L. 帢-Fetoprotein (AFP) concentration was normal (3弮g/L) as was hepatic synthetic function. Computed tomography (CT) displayed the presence of a tumor, and magnetic resonance imaging (MRI) was performed for characterization of the lesion. The lesion was hypointense on T1-weighted images and hyperintense on T2-weighted images in the venous phase, and arterial enhancement and washout were demonstrated, as is typical for a HCC (Figure ). The presence of a shunt of 2 cm between the left extrahepatic portal vein and the inferior vena cava was confirmed (Figures and ). Preoperatively, workup included several tests, such as lung capacity (lung function test), cardiac function (electrocardiogram) and hepatic synthetic function (laboratory tests). If the results of these tests were normal, the patient would be eligible for surgery. In the preoperative workup, no biopsy of the tumor neither a biopsy of the normal liver parenchyma was found necessary. Because of his pulmonary hypertension, he was categorized as an American Society of Anesthesiologists (ASA) class 3 patient. There were no other contraindications for surgery, and the patient underwent a successful right hemihepatectomy and surgical discontinuation of the portocaval shunt. Postoperatively, his pulmonary hypertension increased, and he needed oxygen for five days, after which his condition recovered. Furthermore, a small biloma was diagnosed, which was treated by percutaneous drainage. Histological examination of the resected specimen revealed features of grade II fibrosis []. A tumor with a diameter of 16cm was characterized as HCC with the presence of microvascular invasion. A tumor-free surgical resection of 5mm was recorded. The follow-up of the patient consisted of a routine serum tumor marker AFP determination and contrast-enhanced CT or MRI at six months intervals starting three to six months after surgery. After nearly two years of follow-up, the patient is doing well and is free of HCC recurrence. His cardiac output is normalized, and his pulmonary hypertension is stable.
Troy O’Connor	30	1996/6/16	420-914-4987	[email protected]	25924 Anne Loaf	A 54-year-old Caucasian man presented to our facility with a left breast gynecomastia-like nodule. Clinically it was mobile, non-tender and not fixed to the skin or underlying muscles. The results of renal and liver function tests were normal. Ultrasonography showed a hypoechoic mass with irregular margins, measuring 4.0 ? 3.0cm in size. Doppler ultrasound did not show any significant vascularization. Since a breast carcinoma was suspected, a tru-cut biopsy was performed. From the biopsy results a diagnosis of FL was formulated. The fluorescence in situ hybridization (FISH) demonstration of t(14,18) suggested systemic disease. Two weeks later, the nodule was totally removed, as well as the axillary lymph nodes. The histomorphological features confirmed a diagnosis of lymphoma. Staging procedures showed positron emission tomography (PET)-positive mediastinal and abdominal lymphoadenomegaly and splenomegaly. A bone-marrow trephine did not show lymphoma infiltration. Six cycles of R-CHOP (rituximab-cyclophosphamide, hydroxydaunorubicin, Oncovin (vincristine), prednisone/prednisolone) chemotherapy for systemic lymphoma were administered. Two years later, a new nodule in the right breast was observed. The morphology and immunohistochemistry results of a new biopsy were superimposable to the previous samples. After another six cycles of R-CHOP chemotherapy our patient developed acute myeloid leukemia, from which he died some months later. All tumor samples from our patient were stained with EE (Ematossilin/Eosin) and then immunohistochemical studies were performed. The tru-cut biopsy showed proliferation of atypical lymphoid cells with a nodular pattern of growth, with small lymphoid cells (centrocyte type) and centroblast-like cells. The surgical specimen was represented by a wide excision of the central quadrant extending to the subareolar spaces. Macroscopically the tumor was poorly circumscribed with irregular margins, measuring 4.0 ? 3.0cm, with a solid, fleshy cut surface. Histologically the neoplastic proliferation showed similar features to the previous biopsy in in the adipose tissue. On immunohistochemical analysis the atypical cells were positive for CD20, B cell lymphoma 2 (Bcl2), CD10 and Bcl6 and negative for CD5, CD43 and melanoma associated antigen (mutated) 1 (MUM1) protein; the proliferative index evaluated by Ki67 immunostaining was higher than 50%. In the interfollicular areas there were sheets of CD20+/CD10+ atypical lymphoid cells. Centroblasts numbered more than 15. A final diagnosis of grade 3 FL was made (Figure ). Histology results of the right breast relapse sample showed similar features to previous breast samples. FISH analysis for the t(14;18)(q32;q21) translocation was performed on the tru-cut biopsy of the primary breast nodule using the Vysis LSI IGHSpectrumGreen/LSI BCL2 SpectrumOrange probe set (Vysis, Downers Grove, IL, USA). This probe set uses the dual-color, dual-fusion strategy and consists of a mixture of locus-specific fluorophore-labeled DNA probes containing sequences homologous to the IgH and Bcl2 genes. FISH analysis again showed the presence of t(14;18) translocation on the surgical sample from the left breast and the biopsy of the right relapse (Figure ). Then, after DNA extraction from a paraffin embedded sample, we performed multiplex polymerase chain reaction (PCR) for the identification of the rearrangement of heavy chain (IgH) CDR1-CDR3. DNA purified from the paraffin sample was of good quality as shown by the presence of discrete bands for both FR1, FR2 and FR3 rearrangements, indicative of a B monoclonal pattern (Figure ).
Charli Bruce	34	1996/3/28	566.954.4430x2200	[email protected]	67531 Wolf Plaza	A 30-year-old Indian man was brought to our Emergency Room after a road traffic accident, in which he was riding a motorcycle and was hit by a truck at a speed of approximately 50 miles per hour. Our patient complained of pain in his right arm and the inability to move it. An examination of his extremities revealed contusions over his right upper arm without any evidence of penetrating injury. There was marked swelling and tenderness in the middle part of his right arm associated with a closed injury. His cranial nerves were intact and no neurological deficits were present. No injures were found in his other limbs. In view of the above clinical findings, a radiograph of his right upper limb and a computed tomography (CT) scan of his head were suggested. While the CT scan did not reveal any abnormality, the radiograph of his right arm showed a unilateral displaced comminuted fracture of the mid shaft of his humerus (Figure ). Our patient was then given first aid in the form of a U-slab and immediately transferred to our orthopedic ward for further evaluation. His laboratory results were normal. Liver and kidney function test values were within their normal range. An electrocardiogram did not show any abnormal features. Our patient complained of tingling and numbness in his right little and ring fingers the following morning. On examination, there was hyperextension at the metacarpophalangeal joints and flexion at the proximal and distal interphalangeal joints with an inability to move his little and ring finger (Figure ). With the suspicion of an ulnar nerve injury due to the accident, a series of nerve conduction studies of his right upper arm nerves were suggested. The electrodiagnostic evaluation demonstrated a severe ulnar nerve conduction block along his arm with normal amplitudes of conduction along the median and the radial nerves. Correlating the clinical findings with the above radiological and nerve conduction findings, a diagnosis of ulnar nerve injury after the fracture of the shaft of the humerus was made. Our patient was taken to the Operating Room for surgery, during which a fragment of bone was found abutting the ulnar nerve after penetrating the triceps muscle (Figure A,B). This fragment of bone was replaced and the fracture was reduced by open reduction and internal fixation using a dynamic compression plate and screws. Postoperatively, the tingling and numbness of the little and ring finger gradually subsided and our patient received regular physiotherapy and was discharged two weeks after surgery. Our patient was advised to come regularly for follow-up every three months for a period of one year. Our patient first came for a follow-up appointment four months after discharge and told the attending surgeon about the recovery of the normal functioning of his right hand 14 weeks after surgery; confirming it to have been ulnar neuropraxia.
Uriah Quintana	23	1993/3/12	001-534-855-1924	[email protected]	1946 Traci Village	A 14 year old female complained of diffuse abdominal pain and distention with vomiting. These problems started suddenly three days before referring to our clinic, without any history of disease. The abdominal pain was not associated with meals. Nausea and vomiting were present too. She was referred to our clinic for further evaluation and was admitted at the Gastroenterology Ward. Past medical history was unremarkable. The family history showed that the parents were non-consanguineous and the mother had epilepsy. At physical examination, she had a puffy face and enlargement of the thyroid gland palpable in the neck. Vital signs were normal. Lungs were clear and heart sounds were normal too. The abdomen was distended with shifting dullness (due to ascites) without organomegalies. Extremities were normal without edema or deformities. Her pubertal development was appropriated for age; however (Stage II Public and III Tanner) bone age was 10 years, more retarded than the chronological age. Laboratory routine data including FSH and LH were within normal limits. Tumor markers tests showed strong elevation of serum CA-125 levels (105.4 u/ml) but CEA was normal. Thyroid function tests revealed very marked elevation of TSH -more than 100 mu/L, T4 and T3 depicted very low levels, 0.5 mu/L (with lower limit normal 8) for T3 and 25 mu/L (with lower limit normal 100) for T4 respectively. Abdomino-pelvic ultrasound and CT scan showed a cystic mass with a diameter of 40?45 mm located at the left lower quadrant (LLQ) which originated from the left ovary. The uterus was pubertal size (55?21 mm) with normal endometrial echo. Moderate free fluid was present in the peritoneal cavity. Liver, gallbladder, spleen, pancreas and kidneys were normal in structure and echo. Because of elevation of serum CA-125 levels, ovarian malignancy was included in differential diag-noses, but as Van Wyk and Grumbach syndrome was the main diagnosis, thyroxin (levothyroxin) replacement was started at a dose of 50 繕g per day and gradually increased weekly up to 150 繕g per day. After 4 weeks of treatment, the ovarian cyst was smaller and the ascites disappeared. In the laboratory examination not only TSH, T4 and T3 reached the normal range, but also CA-125 normalized too. The follow-up ultrasound after 5 months of initiation of therapy revealed complete regression of the ovarian cyst and the patient was well without any complications.
Kenia Hester	27	1991/1/16	001-534-705-1809x28958	[email protected]	677 Renee Village	A 22-year-old female presented to our centre with ten-day high fever of unknown origin. She was well and healthy until 6 months ago when she developed generalized arthralgia without obvious arthritis. She was seen by a local doctor and treated for symptomatic management. Her past medical history reveals a total mastoidectomy secondary to chronic otitis. Nonpurulent otorrhea already existed after surgery. On physical examination, she had generalized weakness, arthralgia, nonpurulent otorrhea, partial deafness of left ear, and tenderness at the costovertebral angles. The oral temperature was 39簞C. The rest of her physical exam was normal. The blood tests revealed anemia (Hb: 8.2 gr/L), elevated white cell count (WBC: 23700/mm3), elevated sedimentation rate (ESR: 136), and CRP. The urinalysis showed microscopic hematuria and proteinuria. The renal functions tests, serum electrolytes, and coagulation tests were in normal ranges for her age. The ultrasound study of her abdomen and pelvis showed a 6 cm heterogenic mass in the upper and lower pole of the left kidney. The patient underwent abdominopelvic spiral CT scanning with IV contrast which revealed a hypodense mass at the left kidney suggesting of a renal abscess, tumors or less likely infiltrative lesions like lymphomas (). The initial diagnosis was a renal abscess considering persistent fever and flank pain for 48 hours despite broad spectrum antibiotic therapy. Percutaneous ultrasound guided drainage of the presumed renal abscess was done, however, the aspirated fluid was clear without any pus or debris. She then underwent a core needle biopsy. The patient tolerated the procedure well and there was no immediate complication. Rheumatologic screening tests were also sent off. The ANCA test was positive and pathologic study of the tissue sample with H&E, Masson, and Jones revealed sclerosis, granulomatosis inflammation, multinucleated giant cells, vasculitis, and severe fibrinoid necrosis without any malignant cell suggestive of Wagener's granulomatosis (Figures , , and ). Unfortunately, a day after the biopsy, the patient died due to massive hemoptysis, and cardiopulmonary arrest.
Rene Person	45	2004/3/16	794.331.4257	[email protected]	47880 Cordova Pike	A 53-year-old woman was taken to the emergency room after an accidental fall. At the moment of the fall, the patient was holding a glass bottle that shattered with the impact. A sharp piece of glass caused a deep wound with a length of about 3 centimetres on the right cheeks. The patient showed no signs of facial nerve injury. The wound was then toileted and sutured. After 10 days from trauma the patient began to complain of the appearance of a continuous colourless and odourless fluid from the wound, which increased after food intake. Therefore the patient came under our observation on 20th day from trauma. A clinical examination revealed on the wound scar a 3 mm orifice discharging a clear serous secretion, suggesting the diagnose of posttraumatic parotid fistula. The patients were invited to limit oral intake for a week in order to reduce salivary output; steristrips were placed to close the fistula and a compressive dressing was applied for 7 days, with no results. Due to severe discomfort caused by a large amount of secretion, a device for transdermal delivery of scopolamine (Transcop Recordati OTC S.p.A. Milan, Italy) was applied on the right preauricular region (). This device is a patch of circular form containing a reservoir of 1.5 mg of drug scopolamine, which is released into the bloodstream. The daily release of scopolamine is about 0.5 mg with a duration of a pharmacological three days for each patch. In the following 3 days, the patient reported significant reduction in salivary discharge from the fistula. The patches were replaced and the successive examination after 3 days revealed that the fistula was completely healed. The treatment was well tolerated and the patient referred only to a mild dryness of the mouth in the last 2 days of treatment. No recurrence was observed during a 3-month followup.
Dylan Duncan	36	1983/5/7	813.701.8404x23042	[email protected]	4888 Amy Circle Apt. 106	A 57-year-old, otherwise healthy, female patient was admitted in the emergency room department complaining of midepigastric pain over the past twenty-four hours. The onset of pain was relatively gradual, two hours after a heavy meal. Nausea was present from the outset and two episodes of bile stained vomiting offered a temporal relief from the pain. The consistency of the pain as well as an increased body temperature (up to 37,8 degrees celsius) compelled the patient to seek medical assistance. On arrival, the patient had a body temperature of 37,5 degrees celsius, blood pressure of 120/75 mm Hg, pulse rate of 105/min, and respiratory rate of 17 breaths/min. On physical examination, the abdomen was relatively soft with however, notable tenderness elicited during the deep palpation of the midepigastrium. Signs of parietal peritoneum irritation such as rebound tenderness as well as pain during abdominal percussion were not observed. The patient had a blood gas ph. of 7.35, C-reactive protein levels of 11 mg/l while white blood cell (WBC) count were 14000/mm3. Serum amylase levels were elevated up to 500 U/dL, while liver enzyme serum levels were within normal range. The patient was submitted to an abdominal ultrasound that ruled out cholelithiasis as well as any gross pathology emanating from the extrahepatic bile ducts. With a suspected diagnosis of pancreatitis, despite the absence of obvious predisposing factors, the patient was admitted to the department's clinic for observational and supportive management. However, as the patient's condition did not ameliorate after two days of conservative treatment a computed tomography scan (CT) of the abdomen was decided. Surprisingly, a radiopaque foreign body in the pancreatic head, which the patient was not aware of ingesting, in continuity with the duodenum as well as the presence of air bubbles in the area of question suggestive of a probable intestinal perforation was revealed. See Figures and . An emergency operation was decided and a laparotomy via a midline vertical supraumbilical incision was undertaken. At laparotomy, peritoneal cavity appeared clear without evidences of gross contamination. After the mobilization of the right colonic flexure, the duodenum was clearly visualized. Then, a Kocher manoeuvre was performed to ensure the adequacy of duodenal inspection. An induration at the second portion of the duodenum and the adjacent area of the pancreatic head was observed during palpation without, however, any identifiable perforation. An oblique?n relation to the luminal axis of the duodenum?uodenotomy was performed and a sharp thin foreign body consistent with fish bone was subsequently identified. The bone was pinned at the medial-posterior wall of the 2nd portion of the duodenum just adjacent to the ampulla of Vater with an orientation towards pancreatic head. After the successful removal of the fish bone with gentle traction the duodenotomy was then closed in two layers with interrupted 3-0 absorbable suture material. The patient had an uneventful postoperative period and was discharged from the hospital on the 7th postoperative day. A scheduled followup at the outpatient clinic of our department thirty (30) days after the procedure confirmed the absence of any postoperative complication.
Avery Dalton	20	1995/6/1	9537943968	[email protected]	91618 Collier Trail	A 1-year-old boy presented with a mass localized to the right inferior aspect of genitalia in the perineal region, another small swelling was attached to the undersurface of the mass (). Both mass and swelling were present since birth. The mother's health throughout pregnancy had been uneventful, and there had been no recognized exposures to any teratogenic agents. The penis and the primary scrotum were completely normal, were contained testes within the scrotum. The mass just below the scrotum was soft in consistency and freely mobile. The swelling attached below the mass was soft, rugose, and contained no discernable testis-like structures. There was no other urological anomaly. The mass and swelling were surgically removed, and postoperative recovery was uneventful. The histological examination revealed the mass as being lipoma, and the other swelling had rugose epidermis with hair follicles and rudimentary dartos fibers, so histopathological examination confirmed the diagnosis of accessory scrotum ().
Lilian Warner	28	2002/8/24	(953)333-5850x396	[email protected]	666 Kemp Stravenue	A 24-year-old lady presented to our hospital one month after a Caesarean operation at another institute. This was her second Caesarean operation and was done as an emergency. Two days later the patient developed a pain in abdomen and fever; she was discharged on the eighth day. The symptoms exacerbated along with distension of abdomen, for which she consulted a private hospital and received cefotaxime and metronidazole. She was also referred back to the hospital where she was operated upon and she was treated symptomatically. However her condition worsened and she was referred to our hospital. She complained of fever, pain in abdomen, and vomiting. She also complained of loose stools and mucus discharge per rectum. On examination she was febrile and had tachycardia. Her abdomen was tender and lower abdomen had a vague tender mass. Her lab reports revealed neutrophilia and anaemia. A plain radiograph of abdomen was essentially normal. US of abdomen revealed a bulky subinvoluted uterus with a large collection within (pyometra), hypoperistaltic bowel loops, and mild hydroureteronephrosis on the right. However, the sonological impression of pyometra was not being correlated by gynaecological evaluation and hence a contrast-enhanced CT scan of abdomen was done (). It revealed a mesh-like structure in the lower abdomen with air trapped within. An oral dye was administered during the procedure which revealed a leak in the small bowel. A diagnosis of gossypiboma with bowel perforation was made. After due preparation, the patient was posted for an exploratory laparotomy. Abdomen was accessed through a midline vertical incision. On exploration a retained surgical sponge was found along with one litre of pus lying in a walled off cavity in the lower abdomen. The retained surgical sponge was removed (). The pus was sucked out. A pus sample was sent for culture and antibiotic sensitivity which was later reported to have grown Escherichia coli. There were multiple dense adhesions of the small bowel. On careful separation of the adhesions two ileal perforations were seen (). These perforations were half a centimetre in size and 40 cm apart. The intervening bowel was edematous. A resection of the perforation bearing bowel was done followed by anastomosis. The resected specimen was sent for histopathology which later revealed features of acute inflammation, and no granulomas were seen. The patient did well after the surgery. There was infection of the lower part of the abdominal wound, which was left open and a dressing was done regularly. A secondary suturing was done two weeks after the surgery and the patient was discharged. The hospital where the original surgery was done was informed to facilitate initiation of preventive steps. An inquiry into the details of the previous surgery revealed that the operation was done as an emergency and that it was difficult because of bowel adhesions due to previous Caesarean operation. The closure of abdomen was done by junior residents. A proper procedure for surgical counts was also found to be lacking.
Jaxton Johns	19	1988/8/24	+1-865-235-1941x7761	[email protected]	90579 Brian Hollow	A 48-year-old woman with a poorly controlled diabetes mellitus for 12 years, presented with acute severe right knee pain and fever for 7 days. Three weeks before the onset, she fell on the ground accidentally and developed right knee pain. However, she was able to walk after the event and there was no open wound nor knee swelling. A physician provided a short slab for right knee immobilization, but her knee pain was progressive and she was unable to mobilize or leave her bed for one week before admission. She also complained of perianal pain during this illness. At Siriraj Hospital, body temperature was 38.2簞C, pulse rate 102/minute, blood pressure and respiratory rate were normal. Her right knee was swollen, fluctuated on the lateral sides with diameter about 7 ? 15 centimeters (cm), and marked tenderness and warmth. Anal examination found a draining abscess on the left side of perianal area, sized about 3 ? 4 cm. Others were unremarkable. An aspiration of the right knee revealed frank pus. Plain radiography of the right knee was unremarkable. Blood sugar was 413 mg/dL, complete blood count showed hemoglobin of 7.5 g/dL, hematocrit 23.6%, white blood cell count of 23,180 cell/mm3 (neutrophil 88.2%, lymphocyte 4.3%, monocyte 4.4%), platelets count of 547,000 cell/mm3, ESR 102 mm/hr, and CRP 330 mg/L. Serum BUN and creatinine were within normal limits. She was admitted to the hospital and ceftriaxone 2 g/day with clindamycin 1,800 mg/day were empirically commenced. The surgeon performed incision and drainage (I&D) of the right knee abscess and perianal abscess on the first day of hospitalization. Operative findings showed 300 mL of subcutaneous pus around the right knee without connection to the joint cavity, and 20 mL of pus drained from perianal and intersphincteric abscesses. Gram stain of both specimens of pus showed moderate gram-negative diplococci as shown in and culture on chocolate agar grew Neisseria gonorrhoeae with positive beta lactamase testing. The organism was susceptible to ceftriaxone, ciprofloxacin, and tetracycline, but resistant to penicillin by disc diffusion method. Strain and serotype identification of Neisseria spp. were not tested in the hospital. Gram stain of pus from perianal abscess showed polymicrobial micro-organisms with gram-negative diplococci, gram-positive cocci in pairs, and rare gram-positive rods. The pus culture grew mixed microorganisms without N. gonorrhoeae. All blood cultures were negative. Disseminated gonococcal infection with polymicrobial perianal and intersphincteric abscesses were diagnosed. This patient denied previously multipartners sexual activity, receptive anal intercourse, and prior sexually transmitted diseases. She has been in menopausal period for two years and has been living with her healthy husband. Her last sexual intercourse was 2 months before admission. Atrophic vaginal mucosa and minimal mucus cervical discharge were identified from per vaginal examination and no microorganisms grew from cervical swab cultures. Nucleic acid amplification test (NAAT) of the vaginal discharge was negative for N. gonorrhoeae and Chlamydia trachomatis. The NAAT of rectal specimens was not approved to detect N. gonorrhoeae and C. trachomatis coinfection by our regulatory unit. The Anti-HIV antibody test and VDRL were also nonreactive. Serum C3 and C4 complements levels were 70.5 mg/dL (normal range; 87??77) and 23.8 mg/dL (normal range; 7??0), respectively. The initial antibiotics were continued and doxycycline 200 mg/day was added for 7 days for potential chlamydial coinfection. Insulin injection was used for control hyperglycemia. The anal abscesses resolved, however, fever was temporarily subsided. Besides there was persistent pus drainage from the incised wound of right knee and progressive swelling extended downward to calf area (). Ultrasonography of the right leg was done and discovered large multiloculated peri- and intramuscular abscesses of the right calf as shown in Figures and . Repeated surgical debridements were performed on day 8 and day 16 of hospitalization, there was foul-smell pus draining from muscles of posterior part of right lower thigh and right calf. Pus culture grew moderate amount of Escherichia coli, then intravenous meropenem was then substituted for treatment of complicated pyomyositis. Fever, swollen right leg, and pus drainage were resolved, then the wound was resutured. Meropenem was discontinued after 14 days of therapy. The patient was discharged from the hospital on day 34 of hospitalization. Two weeks later, the patient's condition almost returned to normal and anemia was improving from iron supplementation. Her husband was not available for investigation of gonococcal infection because he had been working in another province.
Giovanna Bean	35	1985/7/28	907.231.9392x737	[email protected]	979 Dillon Parks	A 58-year-old male patient was admitted with an acute attack of cholangitis due to HJ stricture. Three years earlier, he had undergone a pylorus preserving pancreaticoduodenectomy for a pancreatic mass. The diagnosis of the pancreatic mass was lymphoepithelial cyst. At admission, blood chemistry tests showed slightly increased liver enzymes. The ultrasound examination revealed mild dilatation of the intrahepatic biliary ducts, which did not allow a percutaneous transhepatic cholangiographic intervention for balloon dilatation of the structured segment or biliary stenting. The magnetic resonance cholangiopancreatography (MRCP) detected stricture at the HJ anastomosis and a gallstone in the common hepatic duct just above the bilioenteric anastomosis (). The patient underwent an endoscopic retrograde cholangiography using double-balloon enteroscope, which was unsuccessful due to the sharp angle between the jejunal limb and the biliary tree. Thus, it was decided to perform surgery. During exploration, the HJ anastomosis was found to be narrowed and covered with a scattered fibrotic tissue, with an outer diameter of less than 7 mm and 2 to 3 mm length. In addition, a stone was palpated in the common hepatic duct just above the HJ anastomosis. The length of the remnant common hepatic duct from the hilar region to the HJ anastomosis was approximately 1.5 cm. We decided to perform a Heineke-Mikulicz strictureplasty. A vertical incision of 2 cm was made to the anastomotic line. After the stone was extracted, the incision was resutured in a transverse fashion with simple suture technique using absorbable 4/0 polyglactin interrupted sutures, 2-3 mm apart. The strictureplasty provided an anastomotic patency of more than 1.5 cm (). The patient's postoperative course was uneventful, and he was discharged on the fourteenth postoperative day after the duration of the antibiotic treatment for cholangitis was completed. At the end of followup, for 18 months, patient's liver enzymes and bilirubin levels were within normal ranges, and the ultrasound examination showed a patent HJ anastomosis.
Mccoy Francis	25	2004/10/7	469-264-4200	[email protected]	2049 William Port Suite 954	A 57-year-old man, suffering from ALS since 2009 with concomitant marked lumbar lordosis and quadriplegia, was admitted for marked disease progression, respiratory distress, and complete dysphagia (for both liquids and solids). Tracheostomy was initially performed and the patient was placed on mechanical ventilation. Given the significant malnutrition, percutaneous endoscopic gastrostomy was attempted but failed due to technical reasons. Then a surgical jejunostomy with Witzel technique was performed. The post operative course was complicated by vomiting and gastric distension treated with nasogastric tube placement that drained approximately 700??500 mL of biliary secretions per day. Upper oral contrast series were then performed showing some contrast stagnation at the level of the third part of duodenum (). The patient did not have any pain or abdominal signs. Biochemical markers were in the normal range. The jejunostomy was functional. A prokinetic medical treatment with prostigmin and erythromycin was then started resulting in intermittent occlusion. We then decided to perform a CT scan in order to achieve better visualisation of the duodenal stop. It showed third part of duodenum completely clamped between the aorta and superior mesenteric artery, with a marked narrowing of the aortomesenteric angle to 8.7 degrees measuring 7 mm (Figures and ). These findings pointed towards diagnosis of SMAS and a conservative treatment was established with total enteral nutrition to 80 mL/h done in left lateral position. The nasogastric tube was withdrawn three days later and the patient was discharged from the hospital one week after with no occlusive symptoms. At followup of three weeks, he reported weight gain and could stand in supine position without presenting any abdominal symptoms.
Daniella Huff	29	2001/1/3	-9682	[email protected]	48544 Cuevas Shores Suite 951	A 10-year-old boy was admitted to The Children's Hospital of Alabama for medically intractable epilepsy as part of a presurgical evaluation for epilepsy surgery. His medical history was significant for herpes meningitis at age 4 months. At that time, he presented with fever for 3 days, with acyclovir treatment beginning on day 4 of his 40-day hospital course. There was no known family history of immunodeficiency, predisposition to viral infections, or epilepsy. While his developmental status had been normal at birth, he later experienced profound developmental delay beginning at about 6 months of age. He could walk but preferred to crawl, and his attention was poor. He had no language but was able to verbalize his needs in a manner interpretable by his mother. He lived at home and attended special education classes. He subsequently developed infantile spasms and ultimately a mixed seizure disorder characterized by absent, blank stares one to three times daily, sudden drop attacks about twice per month, and tonic/clonic seizures once or twice weekly. Recent video electroencephalogram showed a Lennox-Gastaut-type pattern with focal features of frequent runs of right frontotemporal spikes. His captured clinical seizure semiology demonstrated 2 types of seizures: dialeptic seizures and left arm fencing. Clinically, his seizure types also included frequent drop attacks with multiple episodes of status epilepticus. He had experienced several breakthroughs despite several drug changes and a current regimen of six antiepileptic medications. His regimen included levetiracetam 750 mg twice daily, lacosamide 200 mg twice daily, topiramate 100 mg twice daily, zonisamide 300 mg at bedtime, lorazepam 1 mg as needed, and rectal diazepam 12.5 mg as needed. In addition, a ketogenic diet had been tried without appreciable benefit. His MRI scan displayed an abnormality in the anterior portion of the right insula and right frontal operculum (). The cortex in this area was abnormally thin with increased T2 signal and a ribbon of low T2 signal around the periphery. There was some deficiency of subfrontal white matter in this region, but the abnormal area was fairly sharply demarcated. FLAIR images demonstrated some increased signal in the adjacent white matter. There was no evidence of hemorrhage or infarct. Based on these findings, the patient underwent a right frontal craniotomy for a partial frontal lobectomy. Recovery was complicated by a cerebrospinal fluid (CSF) leak requiring reoperation 1.5 weeks postsurgery. Upon reexploring the craniotomy, the previously normal-appearing dura had large, spontaneous fenestrations remote from the suture line. Postoperative herpes viral cultures and CSF herpes polymerase chain reaction (PCR) studies were negative. CSF and serum herpes antibody studies were not performed. Because of the postsurgical neuropathological findings, the patient also underwent a full, 21-day course of intravenous acyclovir therapy. This consisted of a 21-day course of intravenous acyclovir that began at 20 mg/kg but was reduced to 10 mg/kg after the surgical procedure to repair the CSF leak. This was followed by a return to neurological baseline and the patient was rendered seizure-free for approximately one month. However, this was followed by a return of seizure activity, up to several per day, in spite of the administration of multiple seizure medications. Immunological workup demonstrated a normal distribution and numbers of T, B, and NK lymphocytes, and normal functional studies for T-cell subsets and NK cells. Toll-like receptor (TLR) functional testing was normal for TLR-1?LR-8, including TLR-3, abnormalities of which have been associated with HSV-1 susceptibility. He is now one year postsurgery with no change in his preoperative electroencephalogram. He is being considered for placement of a vagus nerve stimulator.
Finnley Larsen	21	1993/3/4	-3098	[email protected]	254 Bethany Plaza	A 60-year-old woman, previously in good health and without a personal or family history of autoimmune disorders, presented to the Emergency Services with a 7-hour history of a right-sided hemiparesis and an expressive dysphasia. Physical examination confirmed signs of cerebellar dysfunction, a right-sided hemiparesis, and expressive dysphasia, and her physical examination was otherwise normal. CT head scan revealed a right-sided cerebellar infarct, and laboratory tests revealed a hemoglobin of 15.0 gr/dL (reference range 12??7 gr/dL), TTPK 39 s (range 22??0 s), prothrombin time 12 s (range 12??5 s), VHS 23 mm/hr, and C-reactive protein 0.7 mg/dL (range 0-1 mg/dL). Because of an allergy to aspirin she was started on ticlopidine 250 mg/day. One month later the patient developed purpura, equimosis, peripheral edema, arthralgia, and hypertension arterial of 180/110. The lesions were localized to the feet, legs, and thighs, with hemorrhagic blisters around the ankles, some in the process of healing and were associated with pruritus (). Further blood tests showed autoantibodies negative, crioglobulinemia negative, antihepatitis B and C negative, creatinine 1.06 mg/dL, hemoglobin 18.5 gr/dL, VHS 73 mm/hr, C-reactive protein 7.8 mg/dL, protrombina 13 s TTPK 56 s, and a diluted Russells Viper Venom test positive for a lupus-type inhibitor. Further questioning revealed three episodes of painless macroscopic hematuria during the previous month. The ticlopidine was discontinued and after skin biopsy, prednisone 60 mg/day was started for the vasculitis, as well as antihypertensive therapy. Because of the hematuria oral anticoagulation was not started. Skin biopsy revealed cutaneous detachment with necrosis of the epidermis; in the dermis there was a lymphocytic infiltration with leukocytoclasia, fibrinoid necrosis of the capillary walls, and extravasation of erythrocytes. Immunofluorescence showed deposits of C3繚 complement in the vascular endothelium of the middle and superficial dermis consistent with a leukocytoclastic vasculitis. A CT scan of thorax and abdomen revealed a 5 cm cystic tumor of the left kidney without evidence of metastasis (). She underwent left radical nephrectomy without complications for a clear cell renal carcinoma grade II. There was no evidence of a vasculitis in the surgical specimen. Bone marrow biopsy showed positivity for hypernephroma cells, detected using immunocytochemistry with a monoclonal antibody antihypernephroma (DAKO), consistent with micrometastases (). Two months later, there was no clinical evidence of the vasculitis, the TTPK was normal, and tests were negative for anticardiolipins; the diluted Russell's Viper venom test was normal, as was the VHS, C-reactive protein, and hemoglobin. One year later, repeated bone marrow biopsy failed to show the presence of hypernephroma cells. She is without active treatment and is 6 years without evidence of recurrence.
Xiomara Macias	23	1995/8/2	(389)674-5753x0381	[email protected]	0310 Joshua Plain	M. L. is a 44-year-old G0 Caucasian woman who presented for laparoscopic supracervical hysterectomy (LSH) for large fibroid uterus after counseling on all options including myomectomy and total laparoscopic hysterectomy. LSH of 1570 gm uterus was performed without difficulty with estimated blood loss of 100 cc. Bipolar cautery was applied to a depth of 5 mm in the remaining endocervix. She was discharged home the morning of postoperative day (POD) 1. Routine visit on POD 8 was unremarkable, and the patient had no complaints. She called on POD 14 after noting a self-limited episode of vaginal bleeding and a vaginal odor. Evaluation in the office on POD 15 revealed scant brown discharge. The cervix appeared closed and normal except for a 2 mm area of cautery effect at the 3-o'clock site in the transformation zone. There was no cervical motion tenderness. Clue cells were noted on wet mount, and she was started on metronidazole. The patient called later that same evening with a slow continuous flow of vaginal bleeding. Upon arrival to the emergency room (ER), she began having heavy vaginal bleeding. Evaluation revealed the cervix 1 cm dilated with brisk bright red bleeding. The top of the internal os was noted to be closed after gentle palpation with a Q-tip. The bleeding was thought to be coming from the left side of the endocervix. She was without any other complaints and had a completely benign abdominal exam. After 30 min of unsuccessful attempts in the ER to stabilize the bleeding with pressure, Monsel's solution, silver nitrate and suture, EBL was 1000 cc, and she was taken to the operating room for exam under anesthesia (EUA) and possible exploration. She had just eaten a full meal prior to arrival, had no abdominal tenderness, and was not felt to be bleeding intraperitoneally. She was given IV sedation for EUA. Deep figure eight sutures were placed vaginally in the cervix at the lateral aspects of the internal os. A running locking stitch was placed around the circumference of the open endocervix. Excellent hemostasis was noted. Intraoperative ultrasound revealed no intraperitoneal free fluid. The vagina was not packed, and the patient was observed overnight. Minimal spotting was noted overnight, and she was discharged on POD 1. Follow-up exam 4 days later revealed a slow, persistent, dark flow emerging from the endocervix. She kept a bleeding diary and ultimately stopped bleeding 7 days after the second surgery. She had normal clotting studies. Her recovery thereafter was uneventful.
Moshe Guerra	40	1984/11/26	001-430-676-4828x81105	[email protected]	47799 Ashley Crest Suite 922	A four-month-old male infant born out of a non-consanguineous marriage at 33 weeks of gestation with perinatal history of cephalhaematoma and hyperbilirubinemia in the neonatal period presented with history of partial seizures and altered sensorium since 4 days which improved with anticonvulsants after 24??8 hours. Electroencephalogram showed theta-delta range asymmetric background activity with intermittently sharp waves, sharp waves and slow waves seen over left hemisphere, and no further addition by photic stimulation. Metabolic workup done at the time was normal. Initial imaging workup with CT scan of brain revealed mild cerebellar atrophy with area of asymmetrical hypodensities in bilateral posterior parietal subcortical white matter (). Subsequent magnetic resonance imaging showed asymmetric T2WI hyperintensities in bilateral temporoparietal cortex and subcortical white matter regions with involvement of the insular cortex with prominence of cerebellar folia suggesting cerebellar atrophy (). At this point MRI diagnosis of urea cycle defects like citrullinemia and biotinidase deficiency were considered as differentials. Child was treated with biotin with no clinical improvement. Child continued to progress with convulsions and delayed milestones till 8 months of age at which time, on repeat examination, he had reduced tone, inguinal hernia, and poor hair growth (). Metabolic workup revealed increased lactate, decreased serum copper ??2 ugm% (N: 75??60), and copper oxidase levels ??.10 OD (N: 0.20??.55). MRI showed diffuse bilateral white matter hyperintensities on T2-weighted sequences. Symmetrical cerebral and cerebellar atrophy was seen, the latter being more prominent (). Extradural and subdural hemorrhages of various stages were identified, one showing fluid-fluid levels in high parietal region (). On MR angiography, tortuosity of internal carotid arteries, proximal middle cerebral arteries with distal narrowing were seen (). Trichoanalysis report suggested weak shape of anagen bulb, weak hair shaft with presence of sheath with anagen-telogen ratio of epilated hair: A-6 and T-4, and diagnosis showed pili torti hair which can be present in both Menkes kinky hair syndrome and twisting hair dystrophy ().
Edith Blake	37	1994/10/12	+1-687-840-3586x41701	[email protected]	6512 Valencia Lights	A 30-year-old male patient presented with a slow-growing, soft mass in the right upper posterior alveolar region, present since 2 years and which was associated with mild pain upon eating (). Patient had noticed a mobile tooth in the same region about a year and a half back and had got it extracted. The swelling had continued to grow slowly after the extraction. His medical history was noncontributory. Examination showed that the lesion was diffuse, reddish, slightly ulcerated, and measuring about 3 ? 3 cm in size. It was rubbery to firm in consistency and mildly tender, with slight bleeding on palpation. Radiographs were taken but no changes were observed. Incisional biopsy was performed. Microscopic examination revealed epithelium overlying loose myxoid stroma accompanied by a prominent vasculature (). Myxoid stroma showed a scattered spindle to stellate-shaped cells which had distinct borders and oval nuclei. There was no cellular or nuclear atypia or hyperchromasia and mitotic activity and necrosis were not present. Small, thin-walled curvilinear blood vessels were prominent throughout the stroma. A mild inflammatory infiltrate was present predominantly neutrophils (). An immunohistochemical staining was performed using vimentin and CD34 antigens. Most of the stromal tumor cells were immunopositive for vimentin () and the endothelial cells of the blood vessels displayed immunoreactivity for CD34 (). This confirmed the diagnosis of superficial angiomyxomas. Treatment was not done due to patient unwillingness.
Zyaire Sandoval	41	2003/10/1	(462)790-2028x843	[email protected]	21431 Beverly Ridges	A 16-year-old female presented with four months of recurrent right-sided epistaxis, nasal obstruction, and epiphora.The patient's past medical history included asthma and mild eczema.She denied oral contraceptive use and prior sexual activity. On nasal endoscopy, a pedunculated, grossly vascular tumor was visualized arising from the lateral surface of the middle turbinate.A noncontrast head CT demonstrated a soft tissue mass extending from the right maxillary and ethmoid sinuses to the right nasal choana ().There was no bony destruction evident on CT. Biopsy of the intranasal mass was performed in the office with no significant bleeding.The histopathology demonstrated a dense network of capillary-sized vessels consistent with LCH.The biopsy revealed acutely and dramatically inflamed granulation tissue.The presence of necrosis and squamous metaplasia was thought to suggest trauma with reactive changes. The patient was treated with image-guided endoscopic excision of the right nasal mass arising from the right middle meatus.Her surgery and recovery were uncomplicated and no recurrence has been noted six months postoperatively.The final pathology was read as lobular capillary hemangioma.
Elsie Lin	18	1994/3/11	729-293-4661	[email protected]	934 Rachel Locks Suite 631	A 12-year-old female presented with three months of recurrent, left-sided, epistaxis and nasal obstruction.On nasal endoscopy, the patient was noted to have a mass filling the left middle meatus.A head CT with contrast demonstrated a mass in the left nasal cavity ().The mass was biopsied in the office without significant bleeding after the procedure. Pathologic evaluation revealed proliferating small vessels and spindled cells in a myxoid stroma.These vessels assumed a lobular architecture in some foci.The pathology was read as polypoid capillary hemangioma. The patient underwent an image-guided transnasal endoscopic resection of this mass ().The mass was noted to arise from the left lateral nasal wall anterior to the middle turbinate.Her surgery and recovery were uncomplicated and no recurrence has been noted to date, more than three years after her surgery.The final pathology was capillary hemangioma.
Conor Donaldson	29	1984/3/30	252-927-5401	[email protected]	152 Henry Pass Apt. 769	This is a 66-year-old patient, with four pregnancies, three normal deliveries and one abortion. She smoked from the ages of 10 to 51 years and had no family history of breast carcinoma. She reported the presence of progressively growing nodules in both breasts in 2005. In 2006, she underwent a mammography (Figure ) with suspicious findings and was referred to the hospital. She did not visit the hospital for fear of a positive diagnosis. In December 2006, she underwent another mammography, and was examined again in February 2007. Mammography showed a regular 9-cm nodule in the right breast, without skin retraction, with elastic firm consistency, diffuse bulging breast and negative axillary lymph nodes. Mammography also noted a 6-cm nodule in the left breast with bulging and skin retraction located in inter-medial quadrants and retro areolar region, hardened, partially mobile and negative axillary lymph nodes. She was referred to preoperative assessment and surgery. Incisional biopsies of both breasts were performed. Biopsy of the left breast revealed the presence of invasive ductal carcinoma (pT3pn0, pMx), Nottingham grade II, nuclear grade III. Biopsy of the right breast showed a probable benign phyllodes tumor. No core needle biopsy was performed because the technology was not available in our clinic. Based on the diagnosis and the size and location of the lesions, we decided to perform a simple mastectomy in the right breast and modified Madden mastectomy in the left breast. The anatomopathological final result showed the presence of benign phyllodes tumor in the right breast (Figure ), which measured 9 cm in its longest axis, and invasive ductal carcinoma Nottingham grade II, nuclear grade III, which measured 7 ? 6 cm in the left breast. Further evaluation indicated negative axillary lymph nodes and absence of metastasis (Figure ). For histological assessment, fragments were dipped in Gender liquid at 4簞C for 24 h and were cut into small pieces of 1 mm3 and post-fixed in a 1% OsO4 solution for 2 h, dehydrated and embedded in araldite. Silver or gray thin sections (60 to 90 nm) were selected on a Porter-Blum MT-B ultramicrotome. The ultra-slices were mounted on copper silver grids with 200 patches and stained with uranyl acetate and lead citrate. The fragments were fixed in formaldehyde 10% at 4簞C. Approximately 24 h later the fragments were cut in cryostat. This protocol followed the routine procedures of our laboratory [-]. Figure shows the histological evaluation of the of phyllodes tumor. Figure shows the histological results of the carcinoma in the left breast focusing on steroid Her-2/neu-receptor. Preoperatively, history and physical exam were normal; bilateral mammography, abdominal and pelvic computed tomography (CT), usg total abdominal and pelvic, chest imaging, and biochemical tests (complete blood count, platelets, liver function tests, and alkaline phosphatase) were all normal. However, bone scan indicated a low probability metastases. The patient was given adjuvant therapy composed of radiotherapy and chemotherapy for phyllodes tumor and carcinoma, respectively. Chemotherapy included six cycles of the FAC regimen (5-fluorouacil, doxorubicin, dyclophosphamide). To date, the patient has not shown any clinical or laboratory alterations.
Natasha Dyer	23	1979/12/8	303-772-3204	[email protected]	480 Novak Mission Apt. 990	A 44-year-old male was admitted to our clinic with a history of left-side nasal obstruction, episodes of epistaxis, hyposmia, and postnasal discharge over the previous 2 months. The patient had undergone endoscopic sinus surgery 2 years earlier for bilateral sinusitis at another clinic. Otherwise, his medical history was unremarkable. General and neurological examinations and routine laboratory test results were unremarkable. Non-contrast-enhanced computed tomography (CT) sections revealed an extensive hypodense non-calcified lesion occupying the left nasal cavity and pushing against the lateral nasal wall (Figure A). The lesion showed heterogeneous iodinated contrast enhancement and demonstrated remodeling of the adjacent bony structure (Figure B). Magnetic resonance imaging (MRI) showed that the tumor mass was of slightly lower intensity than the brain parenchyma on T1-weighted images and heterogeneously isointense on T2-weighted images, with significant heterogeneous contrast enhancement on gadolinium administration (Figure A-D). The preoperative CT and MRI showed an endonasal soft tissue mass with no intracranial connection. During the operation, a friable mass originating from the bony-cartilage junction of the nasal septum and extending to the lateral nasal wall was resected completely with the attached septal cartilage and nasal mucosa via an endoscopic endonasal approach. The safety margins were free of disease. Microscopically, the tumor cells were arranged in sheet-like growths or were uninterrupted and patternless and showed nasal septum invasion (Figure A). No cellular whorl, psammoma body, or necrosis was observed. Individual tumor cells had round-to-oval nuclei, with prominent nucleoli and dense nuclear membranes. Mitosis was seen frequently (7/10 HFP, Figure B). The immunohistochemical profile was positive for epithelial membrane antigen (Figure C) and vimentin (Figure D), focal positive for S-100 protein, and negative for cytokeratin, p63, and smooth muscle actin. This histopathological investigation led to a diagnosis of an atypical meningioma (WHO Grade II) according to WHO criteria [,]. Two years later, the patient was readmitted to the Hematology and Oncology Department of our hospital with recurrent severe epistaxis and general weakness, which had developed over the previous month. He also described breathing difficulties. Paranasal sinus CT showed recurrence of the left nasal cavity tumor, with palate and maxilla region involvement. Histological investigation of this second tumor showed morphological characteristics similar to the primary tumor (Figure A). Positron emission tomography/computed tomography (PET/CT) was used to identify distant metastases. PET/CT showed no abnormal glucose metabolic activity, except in the nasal cavity and palate region. The patient received local external radiotherapy (6840 cGy in 38 fractions) for local recurrence of meningioma. Two months after local recurrence, subcutaneous tumors were found located on the left anterior chest wall (1.5 ? 1.2 cm) and left parietal region (0.5 ? 0.4 cm). The tumors were removed under local anesthesia. Histological examination showed morphological characteristics similar to the primary tumor (Figure B); however, the mitotic index (up to 40 mitoses within 10 HPF) and Ki-67 labeling index (40%) were higher than those of the primary counterpart. Foci of geographic necrosis were also found (Figure C). The tumor was classified as a malignant (WHO Grade III) meningioma. After radiation therapy, the nasal cavity tumor shrank markedly. However, 2 weeks after the radiation therapy, multiple small subcutaneous tumors occurred over the entire body. At that time, the patient was very debilitated and did not want any other intensive treatment. He was transferred to a palliative care facility and died 3 months later.
Atreus Stout	29	1997/10/18	+1-889-863-5643x2913	[email protected]	35678 Mclaughlin Parkways	A previously healthy 12 month old boy presented to hospital with a right 6th nerve palsy seven days after his routine 12 month immunizations: measles, mumps, rubella (MMR) (Priorix簧, GSK) and Haemophilus influenzae type b (Hib) ??Hepatitis B (Comvax簧, Merck). He had been well for the first four days post-immunization, but then noted by his grandparents to have a ?quint??and appear lethargic. He presented for medical attention on day seven post-vaccination because of persistent concerns about his unusual eye movements. Two months earlier he had received his second catch-up dose of 7-valent pneumococcal conjugate vaccination (Prevenar簧, Wyeth Vaccines) and meningococcal group C conjugate vaccine (Meningitec簧, Wyeth Vaccines). He had experienced no adverse events from any of his previous vaccinations, which were up to date for his age on the routine Australian National Immunization Program schedule []. He had a past history of emergency delivery at 36 weeks gestation by caesarean section for twin-twin transfusion following a twin pregnancy conceived by in-vitro fertilization. There were no significant neonatal problems and he was developmentally age appropriate. On admission he was afebrile, blood pressure 117/59, pulse rate 120/min, respiratory rate 30/min and oxygen saturation of 95%. There was no history of preceding viral illness or prodrome and no symptoms developed during admission. Further evaluation by a pediatric neurologist and ophthalmologist confirmed an isolated right 6th nerve palsy, with no evidence of facial asymmetry. There was mild plagiocephaly, with a head circumference of 46.5 cm (50th centile). No ptosis was evident, and fundoscopic examination bilaterally was normal. Initial blood investigations included normal full blood examination (Hb 128 g/L; Platelets 284 x109/L; leukocytes 11.1 x 109/L and normal baseline electrolytes, liver function tests, creatinine kinase (CK) and serum calcium levels. The erythrocyte sedimentation rate (ESR) was normal (3 mm/hr). Neuroimaging with magnetic resonance imaging (MRI) and angiography (MRA) of the brain demonstrated no intracranial abnormality. Cerebrospinal fluid (CSF) examination revealed no white cells, 89 red cells x106/L, protein of 0.19 g/L (0.20-0.40), glucose 2.8 mmol/L (2.8-4.0) and lactate of 1.2 mmol/L. A random blood glucose level was 6.0 mmol/l. There was no growth on CSF cultures. The CSF opening pressure was 31 cm CSF, but this was obtained at the third attempt at a lumbar puncture in a screaming child, and the pressure was therefore likely artefactually elevated. Acetylcholine receptor antibodies were negative (0.2 nmol/L). The differential diagnoses with this presentation included a post viral 6th nerve palsy, idiopathic cranial nerve palsy, myasthenia gravis and benign intracranial hypertension. He was initially trialed on Pyridostigmine (Mestinon簧 Valeant) 5 mg three times daily. This was subsequently increased to 10 mg three times daily, but with no change in clinical signs it was ceased. The 6th nerve palsy persisted at one-week post vaccination, but completely resolved spontaneously over the next six weeks, with resolution confirmed on ophthalmology follow-up. The child then re-presented aged 20 months with a recurrent episode of a right 6th nerve palsy. On this occasion it commenced followed a different live virus vaccination ??Varicella (Varivax簧 Merck) given four weeks earlier. Again, there was no viral prodrome and he had otherwise been alert and well. He presented with identical symptoms of a squint and was brought to hospital for evaluation five weeks after immunization. Repeat examination by an ophthalmologist and pediatric neurologist again confirmed an isolated 6th nerve palsy with no evidence of papilledema. He was afebrile and haemodynamically stable. The nerve palsy worsened over the subsequent two days, then significantly improved over the next 7??0 days and had entirely resolved by 5 weeks, now a total of 9 weeks post immunisation. On this presentation, he did not have any neuro-imaging, CSF analysis or repeat blood investigations. Over the next 12 months the child tolerated numerous viral infections with no recurrence of the squint or any neurological symptoms. He had ongoing ophthalmology review with no abnormalities noted. A follow-up with pediatric neurology at two years of age confirmed a normal examination, with all appropriate developmental milestones reached. Following detailed discussion with the family it was advised that further live attenuated vaccines not be administered, even though the routine Australian immunization schedule includes a MMR vaccine (2nd dose) at 4 years of age []. The main reason for this advice was that no previous recurrent cases had been reported in the scientific literature and therefore the safety of further live attenuated vaccines in this setting was unknown.
Chana Russell	23	2005/1/5	6506615499	[email protected]	72641 Kevin Cape Apt. 947	A 63-year-old nondiabetic, nonsmoker, hypertensive male patient, who presented with a 3-year history of severe paroxysmal and lancinating right facial pain in V2 and V3 trigeminal territories. The pain used to come in sudden bursts lasting 1?? minutes and recurs 10??0 times a day. The pain was not satisfactory controlled by oral opioids, tricyclic, or dual antidepressant. On physical examination, facial trigger points in the right maxilar region have been found without other neurological findings. Magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) of the brain demonstrated an elongated and tortuous vertebrobasilar artery causing mechanical compression at the right trigeminal nerve root (Figures and ). Surgical procedure (MVD) was then proposed due to refractoriness and images findings. A right retrosigmoid approach was performed with cerebellopontine angle exposure. Arachnoid dissection revealed a large vascular structure, identified as dolichoectasia of the basilar artery, dislocating and compressing the right ventrolateral region of brainstem and its respective trigeminal nerve root. As soon as the neurovascular conflicting area was identified, MVD technique placing pieces of Teflon between the trigeminal nerve and the basilar artery with displacement of dolichoectatic artery was performed. Care was taken not to injury of the artery during the vascular microdissection, because potentially fragile vessel walls in VBD. A very satisfactory surgical decompression result was achieved and pain attacks ceased immediately and completely after surgery. During the follow-up period (24 months), the patient has reported excellent relief of pain and currently does not need any more medications.
Weston Vo	26	1994/10/16	960-275-7301x93039	[email protected]	45075 Christine Island Apt. 694	A 26-year-old male patient was admitted to our hospital with a pulsatile mass in the right side of his neck that had been present for one week. He had no history of neck trauma. The patient had been diagnosed with Behcet's disease two years prior to admission to the hospital, suffered from deep vein thrombosis related to his Behcet's disease, and was being treated with sulfasalazine, warfarin, and prednisolone. Physical examination revealed an approximately 3 ? 3 cm sized painless, pulsatile mass on the right neck. The neurologic examination was normal, and his vital signs were stable. A computed tomography (CT) scan revealed a 3 ? 3 cm sized well-enhanced CCA pseudoaneurysm (). An angiogram showed a pseudoaneurysm just at the level of the bifurcation of the right CCA (). An intracranial angiogram showed collateral blood flow from the left carotid artery through the anterior communication artery during compression of the right CCA. We decided to treat the patient with a stent graft, which first involved placement of a 0.0035 inch Terumo guide wire (Terumo, Tokyo, Japan) via the femoral approach into the right internal carotid artery, passing the right CCA. A JOSTENT (length 28 mm; diameter 4?? mm; JOMED, Rangendingen, Germany) was then expanded in the CCA using an angioplasty balloon catheter (Ultra-Thin Diamond, 8 ? 4 mm, Medi-Tech, Watertown, MA, USA). Due to insufficient support of the guide wire, the CCA defect was not completely covered by the stent, and a subsequent angiogram revealed contrast material entering into the pseudoaneurysm sac. Reinsertion of a stent was planned; however, in order to completely occlude the defective area, the stent was placed over both the CCA and the internal carotid artery (ICA). Because this procedure could lead to backflow through the external carotid artery (ECA), a coil was first used to block the ECA. Next, a JOSTENT (length 17 mm; diameter 4?? mm; JOMED, Rangendingen, Germany) was placed into the ECA. After reinsertion of the stent, an angiogram showed that there was no longer contrast material within the pseudoaneurysm sac (). Several minutes after placing the stent graft, the patient complained of a sudden headache. An intracranial angiogram revealed thrombi in the middle cerebral artery. Immediately, an injection of nonpeptide Gp llb/llla antagonist was administered to the middle cerebral artery. After 15 minutes, an angiogram showed improved arterial flow and indicated that the thrombi had been resolved. The patient did not complain of subsequent headaches. Follow-up neurologic examination and a brain CT scan showed no further abnormal signs or findings. A total of seven months after placement of the stent graft the pseudoaneurysm was no longer visible on a CT scan, and blood flow of the stent area was patent.
Artemis Terry	30	1996/4/21	+1-626-313-2161x51931	[email protected]	2397 Gardner Ports Apt. 863	A 64-year-old female patient was admitted to our hospital with a suddenly enlarged pulsating mass of the right neck. The neck mass had developed two days prior to admission to the hospital. The patient had no history of neck trauma, surgery, or interventional procedure. She had been previously diagnosed with chronic obstructive pulmonary disease (COPD) and took regular medication to treat the disease. Physical examination revealed an approximately 3 ? 4 cm sized painless, pulsating mass on the right side of the patient's neck with no neurological symptoms. The patient's vital signs were stable. A CT scan revealed a 2.5 ? 3.4 cm sized well-enhanced CCA pseudoaneurysm (). The carotid artery angiogram showed a small defect in the proximal portion of the right CCA and a pseudoaneurysm, for which a stent graft was planned. A JOSTENT (length 28 mm, diameter 6 mm, JOMED, Rangendingen, Germany) was inserted and deployed over the CCA. After placement of the stent, a carotid artery angiogram showed no blood flow to the pseudoaneurysm (). After three months, a neck ultrasound revealed no blood flow to the pseudoaneurysm and indicated that the blood flow of the CCA was intact.
Armani Mack	21	1987/3/22	856-422-5764	[email protected]	820 John Plain	A 72-year-old man had a two-month history of a left-sided, slowly enlarging, painful mass of the cervical region. His medical history did not highlight any significant evidence. On examination, the mass was fixed to the deep plan, hard in consistency, measuring 4 cm in diameter with external signs of inflammation. The rest of examination revealed a skin ulcerated tumor of the forehead measuring 1.5 cm which appeared one month ago. The remaining systemic examination did not reveal any coexistent lesions. Cervical ultrasonography and computed tomography scan suggested enlarged cervical lymph nodes (). Random biopsies from the nasopharyngeal mucosa were normal. The patient underwent a cervical lymph node biopsy and an excision of the frontal lesion. The excised cutaneous specimen showed a dermal carcinomatous proliferation with features of LEL carcinoma, characterized by a nonneoplastic prominent lymphocytic infiltrate intermingled with a poorly differentiated epithelial proliferation with syncytial appearance (Figures and ). Cervical lymph node was massively infiltrated by a dense carcinomatous proliferation suggesting neuroendocrine differentiation, and it was made of monomorphous small basophilic cells with a very fine chromatin and minimal cytoplasm dispersed in a scanty stroma (). Frequent mitotic figures were found. Immunohistochemical stains of the cutaneous tumor and lymph node metastases showed immunoreactivity for neurofilament (), chromogranin, synaptophysin, and a characteristic dot-like perinuclear staining for cytokeratin 20 (). The tumor did not express TTF1. On the basis of these findings, the diagnosis of MCC with ipsilateral cervical lymph node metastasis was made. The patient was going to undergo radiotherapy and died 3 months after the diagnosis.
Nadia Francis	18	1982/6/25	-10014	[email protected]	09704 Kristy Crossroad Suite 076	A 57-year-old woman presented with a two-week history of short-term memory loss, headaches, subtle left-sided weakness, and unsteady gait. MR imaging of the brain with a T1-weighted fast spin echo (FSE) sequence showed an enhancing right temporoparietal mass adjacent to the atrium of the lateral ventricle (). The referring physician started treatment with 4 mg of dexamethasone given four times daily, which resulted in improvement of the patient's neurological symptoms. A surgical biopsy was initially planned; however, a routine stereotactic MR-imaging scan for intraoperative navigation using a spoiled gradient recalled (SPGR) sequence showed striking reduction in contrast enhancement within the mass (). Although there can be changes in the degree of enhancement when comparing a SPGR with an FSE sequence, the reduction in contrast enhancement observed is significantly more than would be expected due to differences in imaging techniques. Because the patient had improved functional status and the tumor demonstrated radiographic change, the clinical course suggested lymphoma, and surgery was not performed. A tapered steroid course was begun, but because of persistent neurological symptoms, the patient was continued on a dose of 2 mg of dexamethasone twice daily. Subsequent screening for extra-axial lymphoma was negative. Two weeks later, the patient developed worsening gait imbalance, and repeat T1-weighted FSE imaging () showed interval increase in size and enhancement of the right temporoparietal mass, a prominent focus of enhancement in the splenium of the corpus callosum, and further leptomeningeal spread. Furthermore, the areas with reduced enhancement on the SPGR image corresponded with areas of evolving necrosis on the follow-up T1-weighted FSE image. These findings suggested a possible diagnosis of malignant glioma. The patient underwent a stereotactic-guided craniotomy for excision of the right temporoparietal mass lesion. Gross examination of the lesion revealed yellow abnormal tissue of a firm consistency. Biopsy samples were sent as frozen sections to the surgical pathologist. Preliminary results were consistent with malignant glioma. An ultrasonic aspirating device was used to remove the dominant lesion. Tumor tracking from the splenium of the corpus callosum to the contralateral ventricle was not removed. Final histological diagnosis was glioblastoma multiforme, World Health Organization grade IV (). At 1-month followup, the patient reported better cognitive function, resolution of headaches, and improvements in left-sided weakness and gait imbalance. She continued to require 1 mg of dexamethasone daily for symptom management. Neurooncological treatment for glioblastoma continued with a combined regimen of temozolomide and whole-brain radiation therapy. At 2-month followup, she was tolerating her cancer therapy regimen well and remained clinically stable.
Harvey Moon	20	1995/4/29	689.412.7872x2980	[email protected]	7956 Cross Vista Suite 018	A 16-year-old man was referred with a 6-month history of worsening hyponasality and a seropurulent otorrhoea. He had an unremarkable past medical history. He denied weight loss, dyspnea, epistaxis, or fever. The clinical evaluation revealed significant thickening of the posterior wall of the nasopharynx. There was no lymphadenopathy present. A CT scan showed thickening of the left nasopharynx (). A biopsy was performed. The histopathology revealed chronic inflammation and the presence of actinomyces. Gram stains of the tissue revealed gram+ with filamentous organisms oriented radially around sulphur granules. The patient was diagnosed with actinomycosis and successfully treated with a prolonged course of penicillin (45 days). He subsequently improved and recovered after 34 months. The evaluation of the treatment outcome was made by nasopharyngoscopy. No further biopsy or CT scan was made.
Naya Dillon	40	1993/11/15	(514)390-3500x687	[email protected]	460 Fletcher Junction Suite 721	A 42-year-old woman without past medical history was referred for a right neck mass associated to leanness without rhinologic or otologic problems. Physical examination revealed a right subdigastric 3 cm ? 5 cm nontender and firm neck node. The remainder of the head and neck examination was unremarkable except for the finding of poor dental hygiene. The blood cell count was normal. The nasopharyngoscopy showed a nonulcerated mass of the right nasopharynx. Ultrasound imaging of the neck revealed right cervical lymphadenopathy with the largest node measuring 4 cm. The CT scan showed a thickening of the nasopharynx wall with multiple right lymphadenopathy. The histopathology revealed the presence of actinomyces (). She was diagnosed with actinomycosis and treated with high-dose penicillin, intravenously followed by oral penicillin during 2 months. She finally recovered after 10 months.
Alvin Fischer	25	1984/8/29	736-542-1926x52469	[email protected]	81250 Daniel Park Suite 323	A 42-year-old woman was referred for headache and epistaxis without nasal obstruction. Physical exam showed poor dental hygiene. The nasopharyngoscopy revealed a thickening of the right nasopharynx. The biopsy showed the presence of actinomyces. She was diagnosed with actinomycosis and treated with penicillin until recovery. (20 M/d during 45 days).
Maci Shepard	20	1981/2/6	206.261.6932x0197	[email protected]	7557 Lopez Prairie Apt. 092	Mary (Mary is the pseudonym of the client), a 62-year-old Chinese lady with 5 years of education, consulted me for depressed mood, panic attack, and numbing response triggered by conflict with her adult daughter. Her emotional functioning was unstable with chronic feelings of fear, confusion, nightmares (dreamed of baby crying), forgetfulness, mind going blank, freezing response, and flashbacks. She was experiencing moderate impairment in her daily functioning. There were times that she discovered herself crossing a road without knowing why she got there, or she found herself got injured without feeling any pain. Prior to this consultation, she consulted a family physician who prescribed antidepressants to her. Mary lived with her daughter and son-in-law. Her daily job was to take care of two school-aged grandchildren. She often had conflicts with her daughter over child discipline and daily household management. These conflicts set off her flashbacks of memories of traumatic situations (e.g., a ladder, an old village house, and blood on the floor). These intrusions caused her headache, stiffness of body, chest discomfort, ulcer pain, and nose bleeding. She fulfilled the criteria for complex PTSD [, , ]. Mary reported to have encountered a number of stressful life events since early childhood. At the age of 6, she witnessed the accidental death of her brother; at 12, she saw her aunt kill her baby by throwing him from heights; at 16, she experienced her sister running away from home; at 28, she underwent an abortion because of contracting venereal disease from her husband; in her thirties, she was deserted by her spouse. A detailed history taking revealed that the etiological event was the death of Mary's brother. This happened when Mary was 6 years old. At that time, her parents entrusted her brother (who was then 4 years old) to her while they were away to work in daytime. This was a common practice in traditional Chinese rural society. One day, the boy fell from a ladder and died. After that, Mary was believed to bring misfortune to her family and she was labeled by her kin as comets (comets symbolize an omen of death and misfortune in Chinese culture. In traditional Chinese community, if bad things happen, women of the family are often labeled as comets, meaning that they are the origin of the bad luck.) afterwards. Because of the stigma, she had encountered numerous situations that made her feel inferior and humiliated (e.g., not allowed to attend her father's funeral). In the interview, Mary could not recall a coherent narrative of this tragedy. She could only access rudimentary memories, including images of a wooden ladder, an old village house, a frightened girl hiding underneath the bed, a loud ?ang??sound, and people's noises. Mary had been assessed on the Trauma Symptom Inventory [] and Impact of Event Scale (IES; []) at different points of time. The Trauma Symptom Inventory (TSI) is a self-report questionnaire with good psychometric properties. It assesses posttraumatic stress symptoms and other trauma-related symptoms (e.g., self and other relations). In responding to the TSI, participants are asked to report how often various trauma symptoms have been experienced during the previous 6 months. Ten subscales are formed from the participants' responses. T scores are used to interpret the severity of the stress symptoms and a T score of 65 or above is considered clinically significant. The psychometric properties of the Chinese TSI were found to be satisfactory []. The reliability alphas of the subscales of the Chinese TSI in 57 Chinese adults who had come across critical events were as follows: anxious arousal (AA, 帢 = .84), depression (D, 帢 = .87), anger/irritability (AI, 帢 = .82), intrusive experience (IE, 帢 = .88), defensive avoidance (DA, 帢 = .87), dissociation (DIS, 帢 = .82), sexual concern (SC, 帢 = .80), dysfunctional sexual behavior (DSB, 帢 = .74), impaired self-reference (ISR, 帢 = .83), and tension reduction behavior (TRB, 帢 = .70). The Impact of Event Scale (IES; []) is another well validated self-report questionnaire designed to assess intrusive and avoidant symptoms in the respondents. A global score (intrusion plus avoidance scores) of 19 is considered to have high and severe impact, while a score below 9 is regarded as having low impact []. An unpublished local study on 323 Chinese adults who had encountered traumatic events in their life indicated that the Chinese IES possessed good psychometric properties []. Reliability alphas for the intrusion and avoidance subscales and Full scales for the Chinese IES were .92, .81 and .90, respectively. In relation to the target memory of the death of her brother, Mary's NC was ? am responsible for his death.??Given she had difficulty to formulate a PC, she was presented with a list of PC to choose, but the list did not fit her. She later came up with a PC ? can let go of my burden??with a Validity of Cognition Scale (VOC; []) of 3. The VOC is a 7-point Likert-type scale where 1 represents an adaptive cognition that is completely unbelievable and a 7 represents one that is totally believable. After several sessions of reprocessing, the VOC remained unchanged. We had a discussion to link up her narrative story line by placing everything came up from the bilateral stimulations (BLS) into perspective. In the course of the eye movements, she began to realize that her brother might be destined to die at an early age, just like it was written in fate that she had to face many hardships in life. This realization was further supported by a visualization of her brother smiling at her during the eye movements in one of the sessions. She interpreted the brother's smile as a kind of love and accepting without blaming. I discussed with her whether the originally specified PC still fit or something better could be used. She felt another PC ? just follow my destined path of life??more appropriate. The VOC of this new PC increased from 4 to 7 after several sessions of reprocessing. At the end of reprocessing, she came up with a thought that ?ccidents were inevitable when children are left at home unattended.??This reflected that she had accepted the death of her brother as a kind of accident resulting from the negligence of caretakers. The level of disturbance was measured by using the Subjective Unit of Distress (SUD) scale, where 10 is the highest level of disturbance and 0 is no disturbance. In general, Mary rated 8 to 9 on the SUD scale prior to reprocessing. The bodily sensations (e.g., chest pain, breathing difficulty, stiff shoulder, and hand tremor) associated with the disturbance were also noted. She had nose bleeding intermittently during the initial sessions of reprocessing. With the continuation of eye movements, the bleeding stopped itself. After reprocessing, the SUD dropped to 0 and near to 0. We concentrated on another traumatic event on her abortion experience after the primary event was fully processed. This took only 4 sessions to achieve a resolution. Her symptoms subsided after reprocessing these two events and she no longer met the criteria for PTSD. Given this, we decided to stop using EMDR to reprocess other memories. In sum, Mary received 21 sessions of EMDR (17 on the death of brother, and 4 on abortion) within a total of 65 therapy sessions over 4 years. Prior to reprocessing, her subscale scores on the Trauma Symptom Inventory (TSI; []) ranged from 45 to 78. After reprocessing, all the subscale scores fell below clinical level (see ). The scores of the Impact Event Scale (IES; []) were 29 and 38 (interpreted as having moderate to severe impacts) for her primary and secondary traumatic memories pre-processing, and dropped to 8 and 6 respectively after before exposure (see ). The decrease in the scores on the TSI and IES were consistent with the change in the ratings of the SUD (from 8/9 10 to 0) and VOC (from 4 to 7). These treatment gains were maintained at a 3-month followup. At the time of this writing, Mary was receiving training on self-assertion skills. She was also helped to make connection between the past events and her present experience. Bilateral eye movements were sometimes used to strengthen and reinforce the insights and discoveries surfaced during this period.
Damari Zuniga	26	1988/12/29	313.395.0340x66163	[email protected]	7203 Huff Crescent	A 69-year-old woman presented to the Rheumatology Clinic in January 2010 for evaluation of generalized morphea/localized scleroderma diagnosed 7 months after receiving local radiation to right breast for treatment of breast cancer. In September 2008, breast cancer was diagnosed by needle biopsy when an abnormal cluster of calcifications was identified by a screening mammography in September 2008. After consultation with her surgeon, oncologist, and radiation therapist, she underwent lumpectomy and sentinel lymph node biopsy. The cancer was estrogen receptor negative, and the sampled lymph nodes were negative. The tumor was estrogen and progesterone receptor positive. She opted not to take tamoxifen or other antiestrogen therapy. To prevent cancer recurrence, external beam radiation to right breast was completed (October 2008). She experienced local radiation side effects of erythema and superficial blister formation that resolved with local wound care. Approximately 7 months after completing radiation therapy, she developed two painful blisters in the inframammary fold of the right breast. On examination she was found to have generalized induration of the right breast and right axilla attributed to postradiation fibrosis. The breast and axilla were warm to touch and painful to palpation. That was with sparing of the areola. Additional lesions distant from the radiation field were also noted. These included hyperpigmentation of the skin at the waistline, induration of the skin in the left upper inner thigh and left groin, and a shiny patch of thickened skin on the anterior left shin. The lesions not involving the breast and axilla were not painful. In May 2009, a punch biopsy of the left groin lesion diagnosed localized scleroderma (morphea). On microscopy, the skin surface was thin with a slightly keratotic epidermis. The papillary dermis was edematous and homogenous. The reticular dermis had dense collagen in bundles with intervening mild lymphoid and plasma cellular inflammation present around the adnexal structures. Mild chronic inflammation in the subcutaneous fat was noted at the base of the biopsy. For treatment of the right breast and axillary lesions, topical calcipotriol and topical betamethasone dipropionate were prescribed without benefit. Painful ulcers developed in the area of application in the right axilla which healed slowly when the topical medications were discontinued. The area under the right breast remained painful with chronic superficial ulceration. Application of topical silver impregnated dressings was of no benefit. In addition to the skin lesions, she described fatigue and generalized arthralgias. She denied more specific symptoms of systemic connective tissue disease, that is, no history of Raynaud's, esophageal reflux, shortness of breath, cough, joint swelling, morning stiffness, sicca symptoms, pleuritis, or serositis. Prior to diagnosis of breast cancer, she had no significant past medical or psychiatric history and was on no prescribed medications. Family history was negative for connective tissue disease. Physical examination confirmed circumferential induration of the right breast with sparing of the areola. Induration extended into the right axilla. Superficial erosion of the epidermis was noted in the inframammary fold of the right breast. A band of hyperpigmented, thickened skin was noted along the anterior waistline. A hypopigmented indurated patch was noted in the left groin with a healed punch biopsy site. Thinning of the skin with hypopigmentation and superficial telangiectasias was noted in the upper left medial thigh. A 3 cm patch with central hypopigmentation was present on the left anterior mid tibia. She had no sclerodactyly. Nail fold examination for capillary changes was normal. Examination of the heart, lungs, and abdomen was normal. Laboratory testing was normal, including complete blood count, chemistry panel, thyroid function tests, and urine analysis. Sedimentation rate and C-reactive protein were normal. Lyme titer was negative. Thyroid autoantibody testing was negative. ANA was interpreted as borderline positive, with titer of 1 : 160 in a speckled pattern. Further testing for ANA subtypes was negative for anti-topoisomerase, anti-RNP, anti-Smith, anti-ds DNA, anti-SSA, and anti-SSB. She was prescribed minocycline 100 mg twice a day, and, after three days of therapy, she reported dramatic improvement in generalized pain and fatigue. The superficial erosions in the inframammary fold healed. However, despite the initial perceived benefit, the right breast remained warm and tender to palpation. New lesions occurred on the right lower extremity. In August 2010, methotrexate 7.5 mg weekly and titrated to 12.5 mg was prescribed. Folic acid 1 mg per day was prescribed to prevent methotrexate side effects. After the addition of methotrexate, no new lesions occurred. Signs of inflammation in the irradiated right breast resolved though skin thickening remained unchanged. The lesions on bilateral lower extremities softened. Minocycline was discontinued in March 2011 when abnormal pigmentation developed as a side effect. She remained without signs or symptoms of a systemic connective tissue disease.
Leslie Jenkins	32	1983/1/2	+1-496-611-7612x245	[email protected]	4196 Catherine Forest	A 77-year-old woman with hypertension and former tobacco use presented in March 2010 with a two-year history of progressive bilateral thigh Rutherford-Becker class 3 claudication despite medication optimization. Ankle-brachial indices were 0.65 for the right leg with monophasic wave forms and 0.86 for the left with biphasic wave forms. Angiography revealed no significant arterial calcification with a 60% stenosis of the mid-right common iliac artery with no pressure gradient and a 100% ostial right SFA stenosis with reconstitution of the distal right SFA via collateral blood flow from the deep femoral artery. The posterior tibial artery provided 1-vessel runoff to the right foot. The left lower extremity angiogram was significant for a 30??0% stenosis in the mid-SFA and an occluded mid-anterior tibial artery that reconstituted distally via collateral flow with 2-vessel runoff to the left foot. The patient was brought back a few weeks later for percutaneous revascularization. Retrograde access of the left common femoral artery was obtained and a 7 F 45 cm sheath was advanced over the aortic bifurcation into the right common femoral artery. The CrossBoss (Bridge-Point Medical, Plymouth, MN) catheter was advanced through the sheath to the SFA ostium, and the rotational tip was advanced through the SFA occlusion to the popliteal artery. As the tip of the catheter was subintimal, the catheter was exchanged out for the Stingray Re-Entry System catheter over a Miracle wire (Ashai Intec, Seto, Japan). The Stingray Re-Entry System balloon was dilated to 4 atmospheres to stabilize the catheter in the subintima of the popliteal artery. The dedicated Stingray Re-Entry System guide wire advanced through the catheter and exited the distal port of the balloon catheter as designed, penetrating the intima into the true lumen of the popliteal artery. Subsequently, the patient underwent angioplasty and atherectomy after placement of a distal protection device. Right iliac angiogram with runoff postintervention was performed with digital subtraction imaging revealing good angiographic results ().
Declan Bass	38	1990/12/16	526.400.8438x68376	[email protected]	196 Kelly Junctions	An 81-year-old male with a history of hypertension, diabetes mellitus, and chronic kidney disease stage 3, was referred by his primary care physician for worsening Rutherford-Becker class 3 claudication of both calves despite medication optimization. Ankle-brachial indices were 0.60 in both lower extremities with monophasic waveforms. Magnetic resonance angiography of his lower extremities showed severe ostial right SFA stenosis and diffuse moderate disease distally. The left SFA had a subtotal occlusion at its origin with reconstitution of mid-to distal segments. The left foot had one-vessel runoff by the peroneal artery. The patient was taken to the catheterization laboratory for possible percutaneous atherectomy of the left SFA. Arterial access was obtained at the contralateral femoral artery and a 7 F 45 cm sheath was used. Angiography showed 100% ostial stenosis of the left SFA with reconstitution of the distal third of the vessel via collaterals from the profunda femoris artery. A 6 F multipurpose A2 (MPA2) guide catheter was advanced in the sheath and positioned at the ostium of the left SFA. The CrossBoss (Bridge-Point Medical, Plymouth, MN) catheter was advanced through the MPA2, and the rotational tip was advanced through the SFA occlusion. A High-Torque Ironman Guidewire (Abbott Vascular, Redwood City, Calif), and later an Asahi Confianza Pro Guidewire (Abbott Vascular, Redwood City, CA) were used to steer and support the catheter. Multiple calcified areas along the course of the artery caused difficulty in advancing the catheter. With careful manipulation, the CrossBoss catheter tip successfully reached the distal third of the vessel after running a subintimal course. The catheter was exchanged out for the Stingray Re-Entry System catheter. The Stingray Re-Entry balloon was inflated to stabilize its position. Despite repeated efforts with the dedicated Stingray guidewire, and later a Runthrough NS 180 cm wire (Terumo Cardiovascular Systems, Ann Arbor, Mchi), access into the true lumen of the distal SFA could not be obtained. The procedure was then aborted ().
Zahra Dawson	45	1994/5/19	+1-413-431-7674x920	[email protected]	867 Wagner Walk	A 12-year-old girl with a history of fever, fatigue, and pancytopenia had been referred to Ali Asghar's Children Hospital from a clinic in Varamin (Tehran's suburb) on September 2003. She had been admitted in infectious disease ward for workup of fever, pancytopenia, hepatosplenomegaly, and inguinal and cervical lymphadenopathy. The results of first CBC taken in Ali Asghar's laboratory were as follows. WBC: 1??03/弮L, RBC: 3.33 mil/uL, Hemoglobin: 8.7 g/dL, Platelet count: 54??03/弮L, Hematocrit: 20.1%, M.C.V: 78.9 fL, M.C.H: 26.3 pg, M.C.H.C: 33.6 g/dL. She had been taking antibiotic, and the bacterial culture results were all negative at the time of admission. Upon consultation with hematology oncology ward, a Bone Marrow aspiration (BM) had been scheduled, and on microscopic evaluation a hypercellular BM with complete replacement by immature lymphocytes resembling L1-FAB subtype with negative myeloperoxidase cytochemistry were observed. Bone Marrow samples had been sent to cytogenetic laboratory for karyotyping and molecular diagnosis of BCR-ABL fusion gene, and the results had been normal karyotype and negative for BCR-ABL (p210) and (p190) fusion gene. A sample had also been sent to Iranian blood transfusion laboratory for Immunophenotyping and the results were as follows: CD10+, CD19+, CD20+, HLA DR+ CD13?? and CD33??and the interpretation were consistent with a pre-B-ALL. After diagnosis on April 2003, the patient had been treated according to the children ALL-BFM conventional protocol (without high dose methotrexate) with prophylactic cranial irradiation (1800 Rad). She had a good response to prednisolone and on day 28 BM aspiration had been consistent with hematological remission (<5% blasts), and the results of immunophenotyping had been normal. She had no serious complication during and in between chemotherapy cycles except for few leukopenic episodes that were corrected by G-CSF therapy. She had completed the whole protocol on January 2007 with BM at complete remission, normal CSF, normal Immunophenotyping, and normal uterus and ovaries sonographies. CBC results at completion of treatment were as follows. WBC: 5.7??03/弮L, RBC: 3.47 mil/uL, Hemoglobin: 11.6 g/dL, Platelet count: 4??03/弮L, Neutrophile: 67%, lymphocyte: 30%, Monocyte: 3%. She stayed 3 years out of treatment and at complete remission and had regular visits, and on August 2008 she came for regular checkups and the results of her CBC were as follows. WBC: 69.9??03/弮L, 3.79 mil/uL, Hemoglobin: 11.3 g/dL, Hematocrit: 33.6%, M.C.V: 88.7 fL, M.C.H: 29.8 Pg, M.C.H.C: 33.6 g/dL, Platelet count: 136??03/弮L, Neutrophile: 60%, Eosinophile: 3%, promyelocyte: 2%, Band: 20%. On physical examination a mild to moderate splenomegaly had been noticed, and she had been put on antibiotic in case of underlying infection, and bone marrow samples had been taken for cytogenetic, molecular and immunophenotyping evaluations and another CBC sample had been also taken on October 2008 and the results were as follows. WBC: 82.6??03/弮L, RBC: 366 mil/uL, Hemoglobin: 10.9 g/dL, Hematocrit: 32.4%, M.C.V: 88.5 fL, M.C.H: 29.8 Pg, M.C.H.C: 33.6 g/dL, Platelet count: 152??03/弮L, Neutrophile: 51%, Eosinophile: 2%, Lymphocyte: 16%, Band: 27%, Promyelocyte: 1%, Myelocyte: 2%. The results of molecular evaluation of BM aspirate had been reported negative for t (4, 11), t (1, 19), and t (12, 21) and negative for BCR-ABL (P190) fusion gene and positive for BCR-ABL (P210) fusion gene (TaqMan Technology), and cytogenetic results were positive for Ph-chromosome or t (9; 22). She had been put on imatinib mesylate (Gleevec formerly ST-1571), and there had been a good hematologic and molecular response, and white blood cell count decreased from 76700/uL on April 2008 to 2400/uL on October 2008, and the BCR-ABL fusion gene decreased from 11700 cpn on May 2008 to undetectable on July 2010. On her last visit on April 2011, she had been under good control no organomegaly, stable condition and still receiving Gleevec, and her CBC results were as follows. WBC: 4.9??03/弮L, RBC: 3.38 mil/uL, Hemoglobin: 10.4 g/dL, Hematocrit: 31.7%, M.C.V: 93.8 fL, M.C.H.C: 32.8 g/dL, Platelet count: 172??03/弮L, Neutrophile: 63%, Eosinophile 1%, lymphocyte: 33.2, Monocyte: 3%. According to the CBC results, the patient had been in complete hematologic remission and on molecular evaluation of BCR-ABL fusion gene; the patient had also been in complete molecular response (CMR) status ().
Iker Rollins	36	1997/3/1	365.614.5284x97845	[email protected]	58678 Donald Crossroad Apt. 416	A 24-year-old female presented to our outpatient department with complaints of foreign body sensation of the throat for the last 1 year. She also complained of change in voice for the past 4 months. She had no associated history of dysphagia or difficulty in breathing. On examination there was a 3 ? 3 cm smooth, grayish-white, firm, nontender swelling in the right side of base of tongue occupying the oropharynx (). No cervical lymph nodes were palpable in the neck. Rest of examination of the ear, nose, and neck, as well as general physical examination, was unremarkable. Contrast-enhanced computed tomography of the neck revealed a well-defined moderately enhancing soft tissue lesion involving the right side of base of tongue nearly 2.34 ? 2.29 cm in size which was compromising the oropharyngeal airway. The thyroid gland was normally located in the anterior neck (). Transoral fine needle aspiration cytology from the swelling was done which showed scattered cohesive clusters of epithelial cells surrounded by hyaline material. There was mild hyperchromasia and scattered squamous cells in background. Overall features suggested the possibility of pleomorphic adenoma. The patient was taken up for surgical excision. Tracheostomy was done prior to the procedure. A midline glossotomy was performed and deepened until the tumor was palpable. The lateral surface of the tumor was palpated and dissected using electrocautery. This approach provided an end on view to the lateral and inferior aspects of the tumor. The tumor was removed in toto with a cuff of normal tissue. The wound was sutured vertically in the midline from vallecula to tip of tongue (). Patient was started on oral feeding on the first postoperative day and was decannulated on the 5th day. Postoperative histopathology confirmed the diagnosis of pleomorphic adenoma with focal area of skeletal muscle involvement (). A postoperative computed tomography was done after 2 months of the operation which showed complete removal of the tumor. There has been neither functional disturbance nor any signs of recurrence to date ().
Araceli Montgomery	19	2002/5/18	659.617.8303	[email protected]	6408 Buchanan Ridges	A 6-year-old boy presented to our emergency room because of vomiting and abdominal pain. His parents reported that he had a 3-day history of low-grade fever together with abdominal pain, emesis, and constipation. There was no history of altered mental status, coryzal symptoms, or headaches. He was reported to have ?utism?? and four weeks earlier he had been placed on a ?pecific carbohydrate diet??including ?gg protein shakes.??Two days later, he developed ?ives?? and the egg protein shakes were discontinued. However, pruritus continued and he developed excoriated and dry lips over the next few days. These latter symptoms continued until his presentation to our emergency room. His past medical history was significant for premature birth at 30 weeks gestation, nocturnal enuresis for the past 8 months with some recent improvement using a bed alarm, and an inguinal hernia repair at the age of 3 years. He had been diagnosed with pervasive behavioral/developmental disorder attributed to autism. In an attempt to manage his behavior, he was started on a casein- and gluten-free ?pecific carbohydrate diet??(eggs, fruits, vegetables without complex carbohydrates) together with protein shakes. These had been discontinued two weeks prior to admission because of the development of a skin rash and pruritis. He had also been placed on multiple dietary and vitamin supplements as part of the management of his autism. These included 6 drops/day of vitamin A (equivalent to 30,000 IU per day) added to his diet for the past 4 months, Vitamin B12 shots twice per week, a custom-made multivitamin, Vitamin E Drops, Coenzyme Q and Omega-3 fatty acids. Family history revealed that his father had a history of kidney stones as a young adult, which had not been further evaluated and have not recurred. Maternal grandmother had thyroid surgery for an ?veractive thyroid.??There was no family history of hyperparathyroidism, thyroid neoplasms, pheochromocytomas, pituitary tumors, or islet cell tumors. On examination when he was initially seen in the emergency unit, his weight was 21.6 kg (50th percentile) and height 123.5 cm (80th percentile). He was sleepy and in discomfort complaining of abdominal pain. He was mildly dehydrated. He was noted to have cheilitis and a blanching erythematous rash on his face. He had symmetric hyperreflexia in all four limbs with normal muscle tone. Funduscopic examination was within normal limits. HEENT, abdominal, cardiovascular, and respiratory exam were all within normal limits. There was no evidence of thyromegaly, and thyroid gland was nontender. Sexual maturation was Tanner Stage 1. On initial presentation, he had a normal basic metabolic profile except that the total calcium was 13.7 mg/dL (normal range: 8.6??0.3). Serum creatinine was 0.6 mg/dL and BUN 26 mg/dL indicative of his mild dehydration. Intravenous hydration was initiated, and he was hospitalized for evaluation and treatment of hypercalcemia. He was initially treated with intravenous hydration using 0.9% saline at 3 L/m2/day. He also received a single dose of intravenous furosemide 1 mg/kg. His calcium stabilized with hydration and furosemide therapy within 48 hours and remained stable (though still near or slightly above the upper limits of normal) off IV fluids for 24 hours (see ). Supplemental vitamin A was discontinued on admission. During his initial hospitalization, serum phosphorus was 4.0 mg/dL (normal: 3.0??.0 mg/dL), intact PTH <3 pg/mL (normal: 14??2), 25-hydroxy-vitamin D 22.3 ng/mL (normal: 10??5), and 1,25 dihydroxy-vitamin D 16 pg/mL (normal: 22??7). TSH 2.29 mcIU/mL (normal: 0.35??.5), Free T4 0.95 ng/dL (normal: 0.9??.8 ng/dL), alkaline phosphatase 209 IU/L (normal: 140??20), AST 76 IU/L (normal: 10??0), and ALT 34 IU/L (normal: 10??5). EKG showed normal sinus rhythm. A urinary calcium/creatinine fractional excretion ratio was 0.03, and calcium/creatinine ratio was 0.9 at the time when serum calcium was 13.1 mg/dl. Both parents had normal serum calcium and phosphorous levels. Serum vitamin A level was 1738 mcg/L (normal: 360??200 mcg/L). He was discharged home on the fifth hospital day with instructions for oral fluid intake of at least 1.5 L/m2/day. His total serum calcium on the day of discharge was 10.9 mg/dL. Serum calcium was to be checked by his primary physician daily and was stable for two days. Three days after discharge, he presented again to the emergency unit with recurrence of abdominal pain, vomiting, and generally not feeling well. He had not been able to keep up with the recommended oral hydration plan of at least 1.5 L/m2/day. At this point in time, mother also gave a history of hair loss since discharge. He had lost 2 kg in weight. He had marked blanching erythema on the cheeks and rest of the body together with cheilosis. Total calcium at this time was 12.6 mg/dL. He had not received any vitamin A since the initial admission seven days earlier. He was hospitalized once again and started on 3.0 L/m2/day normal saline hydration, 2 mg/kg/day of prednisone, and furosemide 1 mg/kg BID. Despite these measures, his calcium rose to 14.7 mg/dL during the next 24 hours () at which point he was given a single dose of pamidronate 0.5 mg/kg IV. Calcium came down to 9.8 mg/dL over the next two days and to 8.4 mg/dL five days after pamidronate. He was changed to oral hydration, and serum calcium remained normal over the next few days. He was discharged home after six days to continue oral hydration and close followup. During this second admission, he had a skeletal survey that was remarkable only for a bilateral coxa valga deformity and mild generalized osteopenia. His serum vitamin A level was 2668 mcg/L. Tuberculin test was negative, and a chest X-ray and renal ultrasound were normal. Parathyroid hormone-related peptide (PTHrP) was 0.3 pmol/L (normal: <2 pmol/L). He also had a normal bone scan. After discharged home, he remained stable without additional hypercalcemia. His serum Vitamin A level 30 days after discontinuation of vitamin A was at 1201 mcg/L and serum calcium of 8.9 mg/dL.
Maximiliano Gutierrez	33	2003/1/21	772-652-9727	[email protected]	0999 Black Common Apt. 594	The patient was a 27-year-old male Staff Sergeant with 9 years of active-duty military service in the U.S. Air Force. He was an electronic warfare technician with an excellent service record who successfully supervised 20 military personnel prior to his deployment to an undisclosed location in Southwest Asia. In the six months prior to deployment, he received treatment by both military and civilian physicians for chronic low back pain associated with degenerative disc disease and secondary depression. He was prescribed a variety of medications including acetaminophen and codeine, hydrocodone and acetaminophen, acetaminophen and oxycodone, sertraline, mirtazapine, clonazepam, lorazepam, diazepam, and buspirone. He also participated in outpatient counseling with an Air Force social worker. Prior to his military deployment, he discontinued all medications except sertraline (200 mg per day) and diazepam (2 mg, as needed). When the patient was medically screened for deployment, he reported he was feeling well enough both physically and emotionally to be deployed. He was subsequently medically cleared for deployment, and shortly thereafter he received his first weekly dose of mefloquine for antimalarial prophylaxis. After arriving in the deployed location, approximately one week later, he took his second dose of mefloquine. Shortly after his second dose, he reported restlessness and sleep disturbances. The following week, after taking his third dose, the patient reported feeling moderately depressed. After taking his fourth weekly dose, he reported becoming very depressed and emotionally labile. His wife verified that he called home about this time and sounded very distraught and could not stop crying. Shortly after his fifth weekly dose, the patient began experiencing florid visual hallucinations, difficulty speaking, vivid nightmares, hypnopompic sleep paralysis, intense feelings of depression with uncontrollable crying, and strong suicidal ideations. He sought medical attention at a deployed medical clinic and was told to discontinue taking the mefloquine. He continued to take sertraline (200 mg per day), and his diazepam was increased from 2 mg as needed to 2?? mg twice daily to manage his acute emotional distress. He was later found wandering aimlessly on the other side of the deployed base, confused, and disoriented. Over the course of his deployment, the military service member was not exposed to any activity or stressor that might cause traumatic reactions and justify the symptoms recorded. The patient was subsequently aeromedically evacuated from his deployed location and arrived home a few days later, where his physical presentation and behavior alarmed his spouse. He was initially very quiet, nervous, and tense, displayed significant problems with word finding and speech enunciation, was afraid to go to sleep or be left alone, and was emotionally labile. The patient reported feeling overwhelmed by sensory stimuli and feeling ?ike a whole rush of stuff going into your brain at one time.??He perspired profusely and complained of being hot even on cold days. He continued to experience occasional visual hallucinations, violent nightmares, and ?lashbacks.??He reported that on one occasion, he became enraged and held a chair over his head, as if he was going to throw it at his wife when she did not respond quickly enough after he called her. All of these behaviors were reported to be very atypical for the patient. He was subsequently admitted to the inpatient psychiatric unit at Wilford Hall Medical Center in San Antonio, Texas, for further evaluation. His behavior on the inpatient psychiatric ward was very labile, ranging from agitated and confrontational, to tearful and shaky, to calm and cooperative. The patient participated in a neuropsychological evaluation over the course of two days, including an extended clinical interview and the administration of a comprehensive eight-hour battery of cognitive and personality tests. He was cooperative and appeared to put forth his best effort throughout the evaluation. His performance on ?ffort??tests and his scores on validity scales from the Minnesota Multiphasic Personality Inventory-2 were not consistent with symptom exaggeration, inadequate effort, or malingering. The patient's neuropsychological evaluation was considered valid. Although his full-scale intelligence quotient (IQ) was in the average range, he displayed significant deficits on certain neuropsychological tests, including moderate to severe impairments on measures of verbal learning, auditory and visual memory, verbal productivity, and upper extremity motor speed and dexterity. Milder impairments were noted on measures of sustained attention and concentration, information processing speed, visuomotor coordination and construction, and grip strength. Personality testing indicated that the patient was moderately depressed, anxious, tense, confused, and socially alienated. He reported a higher than average number of somatic complaints, reflecting his perception that his physical health was failing and his mind was not functioning properly.
Savannah Pratt	28	1988/3/13	737-592-8686	[email protected]	7805 Henderson Mill	A 31-year-old man presented with an asymptomatic, slowly enlarging, exophytic, brownish nodule of the abdominal wall with surface telangectasia (). His past medical and surgical history was significant for a resection of a lesion at the same localization 4 years earlier, which was histopathologically misdiagnosed as dermatofibrosarcoma protuberans. His general condition was good and the rest of systemic examination was normal. The recurrent nodule was totally excised. On macroscopic examination, tumor presented as a well-demarcated nodule of 22 mm in diameter, firm in consistency. On cut surface, it had dark-brown and yellow components. Histological findings demonstrated a well-defined unencapsulated dermal nodule with epidermal hyperplasia, an interposed grenz zone (defined as relatively normal collagen forming a boundary between normal epidermis and a dermal lesion) () and superficial involvement of the subcutis. At the periphery of the lesion, some hyaline large round collagen bundles were seen. The tumor was made of a dense proliferation of predominant histiocyte-like and fibroblast-like spindle cells arranged in interlacing fascicles or a storiform pattern. These cells were intermingled with atypical mononuclear and giant cells, sometimes with foamy cytoplasm, showing large, hyperchromatic, irregular nuclei; we found 4 mitotic figures per ten high-power fields (). No atypical mitoses were identified and no necrosis was detected. Prominent blood-filled spaces, numerous siderophages and hemosiderin deposits were noted. Immunohistochemical stains showed focal immunoreactivity for CD68 (), while cells were completely negative for S100 protein, HMB45, CD34 and alpha smooth muscle actin. These findings were consistent with the diagnosis of atypical cutaneous fibrous histiocytoma. The revision of the slides of the first tumor revealed the same morphological characteristics and immunohistochemical study was not performed. No recurrence has been detected 3 months after complete removal of the recurrent tumor.
Rowen Moran	20	1990/11/14	001-842-458-4204x99473	[email protected]	115 Cook Forest	A 34-year-old man who had previously undergone craniotomy a total of three times in 2005 and 2006 presented with a progressive gait disturbance and was referred to our institution for further treatment. He presented with paraplegia involving bilateral lower extremities and a memory disturbance. Computed tomography (CT) revealed a huge isodense mass, approximately 8 cm in diameter, with strong perifocal edema involving the falx and superior sagittal sinus (SSS). The tumor invaded the calvarium and scalp, with compression of bilateral frontal lobes. Magnetic resonance imaging (MRI) showed the mass as isointensity on T1-weighted imaging and heterogeneously intense on T2-weighted imaging, with heterogeneous enhancement with gadolinium (Figures and ). Intratumoral flow voids were diffusely distributed. Cerebral angiography demonstrated that the tumor was fed by the anterior falcian, precentral, central, and middle meningeal arteries, as well as a thick branch that originated from the tentorial artery (Figures , , and ). The SSS was not visible, and the cortical veins as draining veins were dilated and drained into the sphenoparietal sinus and the superior petrosal sinus. The fourth craniotomy was carried out in 2009. The tumor was highly vascular, composed of elastic-hard, fibrous, grayish-white tumor and soft reddish components that invaded the calvarium. The tumor adhered tightly to the cerebral cortex with involvement of the falx and SSS, and there was arterial bleeding from the falx. Dense vascular networks were cauterized, the SSS was completely obliterated, and the tumor was dissected from the edematous cortex and then totally removed. Blood loss was 6500 mL. Postoperatively, the patient had paraparesis and was transferred for extensive rehabilitation. Postoperative MR images showed complete removal of the tumor without recurrence (Figures and ). Two months after the last operation, X-rays and CT scans of the chest demonstrated well-circumscribed, multinodular tumors in bilateral lungs (Figures and ). The right basal posterior segment (S10) of the lung was partially resected thoracoscopically and initially diagnosed as ?eningioma.??Two months after biopsy, the posterior segment (S2) and the superior segment (S6) were resected. The specimen showed two nodules in the upper lung (one in each of S2 and S3) and five nodules in the lower lobe (S6). These seven nodules measured 1-2 cm. Macroscopically, the multiple nodules in the lung had well-defined borders, whitish color, and firm consistency (Figures and ). The patient's postoperative course was uneventful.
Celeste Lucero	35	1999/7/22	697-322-1351	[email protected]	76481 Kelli Forest	A 12-year-old girl was seen in the emergency room, with complaints of heavy bleeding per vaginum, since last 15 days, along with dysmenorrhea. She was referred to us from basic health unit. According to her mother, this was her first menstrual period. She had 7 siblings, 4 sisters, and 3 brothers. Her two elder sisters had normal, regular periods. Her past history was significant for bruises, epistaxis, and bleeding from gums from the age of three years. She was never transfused blood for these complaints, but did receive medical attention for the above complaints of epistaxis and bleeding from gums. One of her cousins had also died at the age of eight years, from uncontrollable hemorrhage from mouth and nose. Her maternal grandfather also died of intracranial hemorrhage, but there was no definitive diagnosis in both of the above deaths. At the onset of menarche, she suffered from heavy blood loss, with passage of blood clots. The amount of blood loss resulted in transfusion of one unit of blood. She was also kept on injectable tranexemic acid. The bleeding decreased initially for 48 hours, but was later followed by heavy bleeding per vaginum. At the onset of second episode of heavy vaginal bleeding, she was referred to Civil Hospital Karachi, for further management. General examination revealed extreme pallor, with blood pressure of 90/60 mm hg. Physical examination was unremarkable. Local examination revealed soiling of perineum, with blood and blood clots. Her hemoglobin concentration was 6 gm/dL, platelets count was 200,000, and prothrombin and partial thromboplastin time was normal. Her pelvic ultrasound was normal, with evidence of hematocolpos. She was started on injectable tranexemic acid 500 mg eight hourly, along with tab norethisterone 5 mg, three times daily. A single injection of depot medroxy progesterone 150 mg was also given. She was transfused four units of packed red blood cells. Her bleeding continued, despite the above measures. Her factor VIII level was assessed to rule out vWD and was found to be 150%. On the seventh day of her admission, her hemoglobin dropped to 3.8 gm/dL, with platelet count of 178,000. At this point we decided to perform platelet aggregation studies. Reports showed the following: ADP 18.1 (76.36??06.84%), collagen 20.4 (59??02%), epinephrine 24.1 (73.7??09.3%), ristocetin 59 (70.4??11.2%), and arachidonic acid 12.9 (55??27%). A diagnosis of Glanzmann's thromboasthenia was made. She was transfused with one mega unit (single-donor apheresis) of platelets then bleeding slowed for 6 hours and started again. She further received 4 more doses of platelets, but there was no improvement in bleeding. At this point, a decision was made for rFVIIa. She was given rFVIIa in a dose of 120 弮g/kg, dose repeated after 4 hours; bleeding slowed down a bit but continued. Subsequent two doses of 270 弮g/kg were given during next 24 hours. Bleeding decreased for 48 hours, but continued, and her hemoglobin again dropped. A decision for uterine tamponade was taken. Examination under anesthesia was done, and two Foleys catheters of size 10 F were passed in the uterine cavity and were inflated with 30 cc of normal saline to act as tamponade. They were left inside for 48 hours; then, bleeding stopped completely. She stayed in hospital for next few days and was discharged on oral contraceptive pills and ferrous sulphate.
Felipe Sweeney	34	1992/10/8	+1-824-708-6717x8552	[email protected]	3142 Day Lake	A 59-year-old-right handed man presented to the emergency department with a headache syndrome 6 months prior to admission. Head CT scan showed an enlarged sella and a suprasellar cystic mass (). His headache resolved so he sought no further treatment until one month later (5 months prior to admission) at which time he complained of a severe headache associated with a stiff neck. Examination during this episode was documented to have a headache with photophobia and nuchal rigidity. Visual fields were full to confrontation. Once again his headache improved with acetaminophen. An MRI showed an empty sella (). He re-presented to our office only three weeks later with a new MRI () that showed a large cystic lesion in the sella with suprasellar extension. During this visit, he appeared thin but not cachectic. There were no stigmata of Cushing's or acromegaly. His pupils were equal, round, and reactive to light and the extra-ocular movements were full and normal. Visual testing revealed a bitemporal upper quadrantanopia. Deep tendon reflexes were hypoactive throughout. The rest of the physical exam was within normal limits. Lab results were consistent with hypopituitary: TSH = 1.37 IUI/mL, Free T4 = 0.70 ng/dL, AM Cortisol = 5 ug/dL, FSH = 4.2 mIU/mL, IGF-1 = 43 ng/mL, and Prolactin = 4.12 ng/mL. He was started on thyroid replacement with levothyroxine and given the option of surgery. However, he was reluctant to agree to surgery and waited for 4 months. At this time he had developed a full bitemporal hemianopsia. Postoperatively, his visual complaints have been reversed and his fields are full to confrontation at 6 months. He remains on thyroid replacement.
Yara Hurley	24	1978/7/1	553-289-7396x9765	[email protected]	309 Thomas Ridge Apt. 710	A 51-year-old female presented with a 2-year history of swelling of the floor of the mouth. She was a deaf-mute since 2 years of age. Physical examination revealed deviation of the tongue to the upper side and swelling of the submandibular regions (). She was complaining of a swelling of the floor of the mouth but did not complain of dyspnea, swallowing difficulties, mastication, or phonation deficits. Blood tests were within normal limits, and a CT scan showed a low-density mass extending from the floor of the mouth to the mandible and protruding from the mylohyoid muscle (). MRI revealed that the mass measuring 50 ? 70 mm showed a homogenous, low signal intensity on a T1-weighted image and high signal intensity on a T2-weighted image (). The tumor was completely removed through a cervical approach under general anesthesia. The postoperative course was uncomplicated, and the patient was discharged. The position of the tongue returned to normal. The patient presented with neither taste disturbances nor sensitivity disturbances. Microscopy revealed that the circumscribed tumor consisted of interlacing bundles of spindle cells with hyperchromatic nuclei. Spindle cells were intermixed with foci comprising dense bundles of collagen fibers. Pathological diagnosis was a neurofibroma with no signs of malignancy (). Subsequent examination revealed no manifestations of VRD, and the patient's family history showed that no members of the family suffered from VRD. She had no caf矇 au lait spots and was followedup for 1 year with no signs of recurrence.
Van Lawson	44	1999/11/2	9504859370	[email protected]	451 Kelly Mission Apt. 062	The patient was a 44-year-old Venezuelan female which was referred to our center with asthenia, fatigue, fever, productive cough and respiratory difficulty. Previous past medical and chuirurgical antecedents were not significant. On examination, the patient had hepatosplenomegaly grade II. Laboratory findings revealed anaemia (Hb 5 g/dL), and hyperleucocytosis (total leukocyte count was 23, 1 ? 109/L) with the following differential count: 23% polymorphs, 20% lymphocytes, 9% monocytes, 2% eosinophils, 2% myelomonocytes, 4% metamyelocytes and 40% basophils; (platelets 120 ? 109/L). Bone marrow was infiltrated by 80% of cells with basophils granules in their cytoplasm and 20% of immature nuclei. Only a few blast cells were shown to be positive with Myeloperoxidase (MPO), the basophilic blast and the mature basophils were metachromatic in the toluidine blue stain, negative for the chloroacetate esterase, and, no reaction with acid phosphatase, Auer rods were absent. Immunophenotyping showed that the blasts were positive for CD34, CD33, and CD9 and negative for HLA-DR and CD14. Ultrastructural analysis reported the presence of azurophilic granules. Conventional cytogenetic studies using standard culture methods and GTG banding showed a trisomy of the chromosome 19 and translocation 9;22 on the 20 metaphases analyzed (). The presence of the BCR/ABL complex was detected by FISH analysis (Vysis, extrasignal) in 95% of the nuclei analyzed. Thus, myeloid chronic leukemia (CML) in blastic crisis was diagnostic. The patient was treated with oral hydroxyurea (2 g) with partial improvement, but she died two weeks later.
Phoebe Shelton	36	1993/1/31	253.355.3883x95138	[email protected]	974 Vargas Drive	A 53-year-old white man, suffered from type 2 diabetes diagnosed 20 years ago, was referred to our department for evaluation of recent discovery of incipient nephropathy and retinopathy. He was previously visiting another endocrinologist in the town but because of a change of job, he moved into the city. He brought a letter specifying that his glucose control had been acceptable since the diagnosis of diabetes (HbA1c lower than 7%). Recently, he was diagnosed of incipient nephropathy (microalbuminuria 200 mg/24 hours), high systolic blood pressure (140 mmHg), high LDL cholesterol (134 mg/dL), and retinal hard exudates close to the macula treated with laser photocoagulation. His current medication included metformin (2.550 mg/day), Detemir insulin (50 U/day), premeals Aspart insulin, simvastatin (20 mg/day), Candesartan (16 mg/day), and AAS (100 mg/d). Physical examination revealed the following: weight of 120 Kg, height of 174 cm, body index mass of 30,27 Kg/m2, blood pressure of 150/75 mmHg, and normal auscultation. The skin of the upper back and posterior neck was erythematous, indurated, and painless () with moderate restriction of range of motion of the shoulders and neck. Blood analysis revealed the following: leukocytes of 7500 弮L, haemoglobin of 16,3 g/dL, platelets of 281000 弮L, sedimentation glomerular rate of 10 mm, glucose of 135 mg/dL, creatinine of 0,3 mg/dL, cholesterol of 157 mg/dL, HDL-c of 58 mg/dL, LDL-c of 81 mg/dL, triglycerydes of 90 mg/dL, C peptide of 3,8 ng/mL, TSH of 1,78 弮UI/mL, negative antithyroid antibodies, microalbuminuria of 240 mg/24 h, and HbA1c of 6,7%. The serum protein electrophoresis was normal, excluding monoclonal gammopathy. When we noticed the lesion on the skin and asked about it, the patient explained that for the last 10 years he had noticed a progressive hardening of the skin of this area, that became less sensitive, and he also noticed a decrease in motility of his neck and shoulders. He did not remember if he was febrile 10 years ago when the lesion appeared on his back. He had never been studied for the skin disorder that he related with his obesity. The patient was sent to the dermatologist who suspected the diagnosis of scleredema and performed a skin biopsy. Histopathologic study demonstrated thick collagen bundles separated by spaces filled with mucin in the deep reticular dermis, consistent with scleredema adultorum of Buschke (). He recommended physiotherapy and UV-A1 therapy. The latter treatment was not made because of a lack of this modality of phototherapy in his town, then he started PUVA therapy. After two months of PUVA therapy (total cumulative UVA dose 120 J/cm2) and physical exercises, the patient has noticed amelioration of the mobility of the back and shoulders, and on exploration, the redness of the upper back has disappeared, and the skin was softer.
Leonel Watts	34	1999/2/14	673.937.4423x4678	[email protected]	4184 Dean Squares Apt. 509	Mr. B is a 59-year-old African American male with a long history of bipolar disorder, maintained on fluphenazine decanoate, and lithium carbonate for over 30 years without any incidence of toxicity. His past medical history is significant for hypertension, Type II diabetes, and morbid obesity. He presented with a 1-week history of increasing confusion and lethargy, slurred speech, urinary incontinence, worsening tremor, and gait difficulties. He was found lying on the floor beside his bed on the day of presentation. The family was unaware of how long the patient had been lying there but found him awake and alert, unable to lift himself off the floor. About 2 weeks before presentation, his antihypertensive regimen was modified with a doubling of the dose of Valsartan to 320 mg/day, in addition to his regular lisinopril 20 mg/day. His other medications were lithium carbonate 450 mg twice daily and fluphenazine decanoate 37.5 mg every 3 weeks (last administered 3 weeks before admission). His last recorded lithium level was 0.7 just prior to the above medication changes. Other relevant baseline laboratory results a few weeks before onset of symptoms included Na-134 mEq/L, K-4.1, BUN, 23, and Cr. 2.4 mg/dL. Collateral history from his outpatient psychiatrists revealed that patient had been stable on the above regimen of lithium and fluphenazine decanoate with no medication changes made within the past 6 months. On examination in the ER, the patient was in moderate distress, dehydrated asking for water to drink. His vital signs were fluctuating with temperature ranging from 99.3 to 100.1, heart rate from 75 to 102, and BP from 123/69 to 223/112 all over a period of 6 hours. Cardiovascular and respiratory exams were unremarkable. Neurological exam revealed slurred speech, hand tremors, and rigidity in the extremities with decreased motor strength in the upper extremities and lower extremities. Patient was oriented to place and person but not to time. Admission labs showed a leukocytosis of WBC-22.6, neutrophil count of 87.9%; sodium was 142 mEq/L; potassium was 3.5 mEq/L, bicarbonate 20.1 mmol/L; BUN 35 mg/dL; creatinine 4.1 mg/dL; blood glucose 145, troponin I 5.64; CPK 6008; CK (MB) isoenzyme 36.7 and a lithium level of 1.20 mEq/L. Blood, urine and sputum cultures yielded no growth. CT/MRI brain showed old frontoparietal infarct, and EEG was reported as within normal limits for drowsiness and briefly aroused state with no epileptiform discharges. CSF from spinal tap was unremarkable. Patient was commenced on IV fluid hydration and broad-spectrum antibiotics. Lithium was discontinued and fluphenazine decanoate was not administered. Repeated blood cultures yielded no growth, and thus antibiotics were discontinued. Patient showed gradual improvement in his mental status, he had no problems with articulation, and he was fully orientated within a week of admission. His lithium levels had decreased to 0.89 on day 5 and 0.55 on day 7, and his renal function was back to baseline. Patient's vital signs stabilized, and there was minimal rigidity at the time of discharge.
Melissa Carpenter	42	1978/10/3	-6647	[email protected]	947 Rachel Greens	A 63-year-old lady presented to her GP in February 2010 with dyspepsia. She was otherwise well, but her blood pressure was 150/90. She was prescribed omeprazole 20 mg od for dyspepsia and lisinopril 10 mg od for hypertension. Her haemoglobin was 13.9 g/dL, white cell count 7.37 ? 109/L (eosinophil count 0.07 ? 109/L), and platelets 303 ? 109/L prior to treatment. The lisinopril induced a dry cough, but the medication was continued. Over subsequent months, her gastrooesophageal reflux symptoms worsened and an endoscopy was performed in July 2010. Histology from an oesophageal biopsy showed marked mucosal thickening with prominent intraepithelial eosinophils seen throughout, occurring in aggregates with microabscess formation. There was no evidence of dysplasia or malignancy. A diagnosis of eosinophilic oesophagitis was made (see biopsy image, ). No specific treatment was given. By November 2010, she had become unwell with anorexia, weight loss of 7 kg, and generalised malaise. She continued to have dyspepsia. Since February 2010, blood test results revealed the development of a normocytic, normochromic anaemia, a modest eosinophilia and raised inflammatory markers including polyclonal hypergammaglobulinaemia and an increase in the ferritin concentration (). She was treated with ferrous sulphate with no response. She was referred to the haematology department in January 2011 for further investigation of the anaemia and weight loss. A detailed history and physical examination revealed no additional abnormal findings. A chest-abdomen-pelvis (CT) was performed and ruled out an occult malignancy, and there was no evidence of infection. Her liver, renal, thyroid function and bone profile were normal. Her tissue transglutaminase was negative. She reported that she had started to feel unwell after starting the treatment for hypertension, and it was considered whether lisinopril was the explanation for her symptoms and laboratory abnormalities. The drug was stopped at the end of February 2011. One week after stopping the lisinopril, her systemic and gastrointestinal symptoms resolved. By April 2011, her haemoglobin concentration had increased and the ESR, ferritin, and hypergammaglobulinaemia all started to resolve (); these continued to improve and she was well in June 2011, with her weight improving towards her initial baseline.
Jeremy Robinson	44	1984/3/13	883.561.1515x919	[email protected]	69293 Stout Throughway Apt. 757	A 33-year-old Hispanic female with no significant past medical history was referred to the rheumatology clinic in May 2010 by her primary care physician for having pain and swelling in multiple joints since November 2009. Patient received a seasonal flu shot in October and a week later, she noted some joint pain and aches in hands, wrists, and knees, which resolved within a few days and patient became asymptomatic. A month later, she received H1N1 (swine influenza) vaccine and a week after started experiencing joint pain, swelling, and stiffness in hand, wrist, elbow, shoulder, and knee joints. She also complained of significant morning stiffness that last for more than one hour. On physical examination she had bilateral synovitis in fourth and fifth metacarpophalangeal (MCP), second, and third proximal interphalangeal (PIP) joints, with prominent left ulnar styloid. She fulfilled most of the criteria for classification of RA based on American College of Rheumatology (ACR) guidelines. Laboratory findings initially included an erythrocyte sedimentation rate (ESR) of 24 mm/hr, rheumatoid factor (RF) of 26 IU/mL, C-reactive protein (CRP) of 1.3 mg/dL, cyclic citrullinated peptide (CCP) IgG of 212. Her basic chemistry, liver function tests, hemoglobin, and complement levels were essentially within normal limits. Serological tests were positive for antinuclear antibody (ANA), RF, anticyclic citrullinated peptide (anti-CCP) and negative for SSA, SSB, hepatitis C virus, parvovirus B19 and being immunized for hepatitis B. Her radiological findings were negative for any joint effusion or destruction. On initial presentation to her PCP, she was given a 10-day course of prednisone 40 mg daily, which partially helped with symptoms in the beginning with eventual relapse of symptoms. Later she was started on methotrexate 7.5 mg weekly along with a short duration (3 weeks) of low-dose prednisone with daily folic acid and calcium/vitamin D supplementation. During her follow-up visit about 2 months later, her disease activity score (DAS) were 4.83 and number of tender joints was 7 and number of swollen joints were 5, with significant improvement in morning stiffness which lasted for 5??0 minutes. However, her pain was controlled only while she was on steroid therapy for 3 weeks and had returned thereafter. Later she was switched to golimumab (TNF-帢 inhibitor) 50 mg once monthly subcutaneously. Her methotrexate dose was also increased to 12.5 mg weekly. At her third visit her symptoms were much improved and her ESR and CRP were also within normal limits.
Nora Bowen	18	1995/7/7	983.362.9111x33923	[email protected]	91513 Mario Oval Suite 191	A 75-year-old gentleman of Indian origin presented to a regional Ear, Nose, and Throat Department as a tertiary referral. The history of a painful lump over the left side of his upper neck was for approximately one year. The patient reported that the lump fluctuated in size and was initially painful but this improved with time. The accuracy of history was limited by the fact that the gentleman had a thick beard and may not have noticed the enlargement during shaving or from the external appearance. The pain was intermittent but worse after talking for long periods. He did not have any difficulty eating, shortness of breath, or alteration of hearing. There was no history of preceding trauma. Otherwise the patient was in good health, with no significant comorbidities. On examination the lump was located in the level 2 area of the neck extending into the preauricular area. The mass was firm and pulsatile. There was no facial nerve weakness or paralysis. All routine blood investigations, which included full blood count, renal function, clotting, C-reactive protein, liver function, fasting glucose, and lipids, were within normal limits. An ultrasound scan (US) of his left parotid region demonstrated a large aneurysm measuring 45 mm in maximum diameter, closely related to the left parotid gland. A subsequent computed tomographic (CT) angiogram was performed (Figure ()). This showed a thick walled aneurysm superficial to the mandible arising from the maxillary branch of the external carotid artery (Figure ()). Doppler US of his aorta and popliteal vessels excluded any further concurrent aneurysms. After discussions in the vascular surgical multidisciplinary meeting and with the patient it was decided to attempt endovascular embolisation. The external carotid artery was selectively catheterised with a 5 French vertebral catheter. Angiography during the procedure showed a very tortuous maxillary artery and the giant aneurysm arising from its midportion. The outflow branches appear to be arising from the sac itself and therefore we concluded that this was a true aneurysm. A microcatheter (Progreat-Terumo, Japan) was used to superselectively embolise the outflow vessel and the aneurysm inflow with (Vortex Coils-Cook Inc, USA) coils (Figure ()). Immediate angiography showed a successful procedure with no demonstrable flow in the aneurysm (Figure ()). Subsequently Doppler US of the aneurysm was performed which confirmed that there was thrombus and no flow in the aneurysm sac. There were no postprocedure complications and the patient was safely discharged home the following morning. At 6-month follow-up the mass has disappeared on clinical examination. Doppler ultrasound shows a tiny (<5 mm) area of residual flow at the aneurysm neck. No further treatment is planned.
Trevor Trejo	20	1980/4/21	-6500	[email protected]	78987 Thomas Plain Suite 966	A 71-year-old man developed progressive urinary obstruction symptoms and presented at our Hospital. Clinical examination suggested benign prostatic hyperplasia and a transurethral prostatic resection (TURP) was performed. Macroscopically, the excised tissue consist of many fragments of prostatic tissue weighing 30 grams. Microscopically, the histological specimens taken after TURP showed a diffuse proliferation of epithelioid and spindle cells, with a storiform and infiltrative growth pattern. There are not prostatic glands in the proliferation, no foci of necrosis, no vascular invasion. The neoplastic cells showed rare atypical mitotic figures in addition to moderate hypercellularity and moderate nuclear atypia with pleomorphism (). Immunohistochemically the neoplastic cells characteristically express diffusely CD34 and focally progesterone whereas no immunoreactivity was seen for cytocheratin (clone AE1?E3 and Cam 5.2), desmin, S-100, Bcl-2, chromogranin, CD117, and actin smooth muscle (). We evaluated additional immunohistochemical markers for their potential diagnostic and therapeutic utility. Although p53 and Ki-67 showed a very low expression. On the basis of the morphological and immunohistochemical features, a final diagnosis of LG-PS was made.
Rosalyn Fisher	36	1979/6/13	(288)576-1435x67958	[email protected]	89427 Mccarthy Forest	An 86-year-old female presented to the trauma bay following a fall from standing in which she struck her face. There was no loss of consciousness, and she was not amnestic to the event. She had intractable epistaxis from both nostrils and was intubated on arrival for airway protection. On physical examination, she had profuse bleeding from both nasal passages and blood accumulating in her oropharynx. The nasal passages were packed anteriorly and posteriorly, but she continued to have bright red blood accumulate in her oropharynx. The patient was taken urgently to the angiography suite for evaluation ().
Gael Ingram	28	1984/11/23	5343888506	[email protected]	784 Michael Avenue Apt. 451	A 25-year-old man presented with recurrent right epistaxis. Nasal endoscopy revealed a red, easily bleeding mass that filled the posterior part of the right nasal cavity. Enhanced computed tomography (CT) showed strongly enhanced tumor in the right nasal cavity with the extension to the PPF. The tumor also extended to the sphenoid sinus with bone erosion (). The tumor was considered as JNA, Radkowski stage IIA [], without performing preoperative biopsy due to the risk of bleeding. The angiography showed that the feeder into the tumor was internal maxillary artery (IMA) and the sphenopalatine artery (SPA). Endoscopic sinus surgery was performed under general anesthesia. Firstly, submucous inferior turbinoplasty (SIT) was performed. Vertical incision was made along the anterior margin of the inferior turbinate to expose the turbinate bone. The covering mucosa was elevated from the bone, and the inferior turbinate bone was removed with preserving the mucosa. Mucosal elevation was continued to expose the uncinate process. The inferior half of the uncinate process together with the horizontal portion of the inferior turbinate bone was then removed. SIT provided improved visualization and wide working space in the posterior part of the nasal cavity (Figures and ). The inferior turbinate mucosa was preserved throughout the surgery without swinging the lateral wall mucosa into the nasal cavity. Mucosal elevation was then continued posteriorly, and SPA, the feeder to the tumor was identified at the sphenopalatine foramen. Maxillary sinus was opened, and the mucosa was elevated from the posterior wall of the sinus. The posterior wall bone of maxillary sinus was then removed, and the PPF was widely exposed endoscopically (Figures and ). IMA was identified in the PPF and was ligated with a hemoclip, and IMA and SPA were cut with the Harmonic Scalpel (Figures and ). The tumor in the PPF was pushed into the nasal cavity. These procedures were all performed via submucous turbinate tunnel and were able to archive to manage the feeding artery safely without touching the easily bleeding tumor. Then, the tumor was resected transnasally without ethmoidectomy and was successfully removed in en bloc from the nasal cavity (Figures and ). No nasal packing was needed, and the postoperative course was uneventful. Postoperative histologic examination confirmed the diagnosis of JNA. No recurrences were observed at the 2-year follow-up examination. The anatomical structure of the nasal cavity and the physiological function of the nose could be preserved by this surgical technique.
Katie Haynes	28	2000/4/1	+1-626-847-6295x6363	[email protected]	8550 Wilson Cape Apt. 949	An 80 year-old healthy female presented to the emergency department following a two-day history of dysphagia. On initial examination, the patient was leaning forward with her head in a sniffing position, her tongue was protruding, and soft but audible stridor could be heard. She was afebrile and had a heart rate of 84, blood pressure of 170/70, respiratory rate of 18, and an oxygen saturation of 96% on room air. Examination revealed anterior neck fullness with a deep purplish discoloration of her skin. There was significant swelling, and induration in the submandibular and submental regions extending down towards the base of neck. No major cartilaginous landmarks could be palpated. Inferiorly, the sternal notch could be palpated. Intraoral exam demonstrated some mild trismus, swelling, and purplish discolouration of the base of the tongue, and a very firm and woody floor of mouth bilaterally. Bloodwork showed WBC (12.2), Na (141) and BUN (22.2), creatinine (226), and CK (787, reference is <170) values. She was administered intravenous antibiotics and supplemental oxygen. A flexible nasopharyngoscopy was performed and significant airway edema including the tongue base and epiglottis was noted. A CT scan was obtained which revealed significant gas in anterior cervical space suggestive of infection (Figures and ). Following transfer to the OR, surgical airway and debridement was attempted. When sitting upright, the patients anterior neck was infiltrated with xylazine and an awake tracheostomy was commenced. Immediately after the incision was made, a large amount of purulent and necrotic tissue was encountered. Blunt tissue dissection was carried out until the anterior wall of the trachea was palpated. At that point the patient began to desaturate. An urgent transverse linear incision was carried out to enter the trachea and an endotracheal tube inserted and inflated. End-tidal CO2 was immediately obtained and the patient was manually ventilated until her saturations which were as low as 30% for a brief period of time stabilized at 99%. She was then placed under general anaesthesia and an extensive debridement of her anterior neck, bilateral submandibular and sublingual spaces were carried out. Intraoperative pathology of the necrotic tissue confirmed the diagnosis of Ludwig's angina which then developed into necrotizing fasciitis of her neck. Postoperative CT scans demonstrate clear loss of anterior neck soft tissue (). While recovering in the ICU, the patient developed acute renal failure and hypotension, which ultimately stabilized. Further debridements were necessary to completely remove the necrotic tissue () and the impacted mandibular molar responsible for the infection was subsequently extracted by oral surgery. Three weeks after admittance, a pedicled deltopectoral flap was used to reconstruct her soft tissue defect. The tracheostomy was eventually decannulated and the patient was discharged home.
Kason Sweeney	21	1978/8/28	(501)394-8640	[email protected]	38299 Mitchell Underpass	Our patient is a 17-year-old male who was diagnosed with FA at 13 years of age when he presented with bruising, fatigue, and pancytopenia. Physical stigmata of FA included hypopigmented skin lesions, short stature (below 3rd percentile), micrognathia, and hearing loss. Diepoxybutane (DEB) testing revealed increased chromosomal breakage. FA complementation grouping was not performed. Two years later, at the age of 15, the patient experienced bruising, epistaxis, and fatigue and was diagnosed with T-cell ALL. T-cell ALL markers included CD1+, TdT+, CD2+, CD3+, CD4+, CD5+, CD7+ and CD 8+; however, cytogenetic markers were not available. He was treated with standard 4-drug induction therapy and received vincristine, prednisone, PEG-asparaginase, and 2/4 doses of daunorubicin at an outlying hospital as per Children's Oncology Group Protocol AALL0434. His clinical course was complicated by prolonged neutropenia (ANC < 500) lasting greater than 2 months and bacterial sepsis. He developed grade IV vincristine-related neuropathy by the Balis scale grading system. Within weeks of initiating vincristine dosed at 1.5 mg/m簡/dose, the patient became immobile and wheel-chair bound. He remained immobile for 12 months after vincristine therapy was terminated. He received cytarabine dosed at 125 mg/m簡/dose via continuous infusion for 3 consecutive days after which the patient developed fever and profound myelosuppression. Because of new onset respiratory symptoms, a chest X-ray was obtained that revealed a right middle lobe infiltrate. CT scan of the chest showed a cavitary lesion consistent with fungal infection and he was placed on voriconazole. Five months after the diagnosis of T-cell ALL, the patient was referred to our center for evaluation for bone marrow transplant. Pretransplant bone marrow aspiration and cerebral spinal fluid showed no evidence of malignant cells. MRI of the brain revealed a left parietooccipital abscess and CT scan of the chest showed enlargement of the right middle lobe cavitary lesion and small bilateral nodules consistent with fungal infection (Figures and ). CT scan of abdomen and pelvis showed multiple soft tissue abscesses of the upper thighs which were drained and found to be sterile. Antifungal therapy was initiated. The patient underwent complete surgical resection of the left parietooccipital lesion and partial resection of the lung lesion. Hyphae consistent with Aspergillus were identified on histopathologic studies from lung and brain lesions. Aspergillus species was cultured from brain tissue. Hematologic remission was sustained with modified dosing of cytarabine and intrathecal methotrexate. Our patient received an approximately 50% dose reduction of cytarabine (60 mg/m簡/dose) from the initial 125 mg/m簡/dose he had received previously. Cytarabine was administered over 15 minutes for 3 consecutive days instead of a 24 hour infusion in order to reduce cell exposure to chemotherapy. Reduced dose of intrathecal methotrexate (50% reduction of age-based dosing) was given followed by leucovorin rescue. Twenty-four hours after the completion of chemotherapy, filgrastim (5 mcg/kg) was started. The patient tolerated these agents well, neutrophils recovered within 12 days, and there was no progression of aspergillosis or leukemia. One month after partial pulmonary aspergilloma resection and 4 months after complete parietooccipital aspergilloma resection, the patient underwent a 10/10 matched unrelated donor bone marrow transplant using a modified reduced-intensity preparative regimen. The patient received voriconazole 200 mg orally daily and micafungin 100 mg IV daily for 4 months prior to BMT. Galactomanman levels remained negative, and radiographic studies of the brain and chest showed improvement and no new fungal foci. The BMT preparative regimen included fludarabine 140 mg/m2, cyclophosphamide 40 mg/kg, thymoglobulin 6 mg/kg (total doses), and 450 cGy TBI. 3 ? 106 CD34+ stems cells were obtained from the donor's bone marrow. T-cell depletion was achieved using rabbit ATG. GVHD prophylaxis included tacrolimus and mycophenolate. Neutrophils engrafted by day 14. There were no acute transplant-related complications. He received voriconazole for 6 months after BMT. At the time of this writing, 30 months after BMT the patient is without evidence of recurrent aspergillosis or leukemia, and continues to do well.
Yara Walters	40	1985/7/14	(708)751-1012x49320	[email protected]	99890 Regina Road Suite 979	Approximately one year ago, a 24-year-old Japanese man came for treatment with the complaint of intermittent left otalgia and blood-tinged otorrhea for 3 months. He noted a slight decrease in the hearing acuity of his left ear. He denied fever, vertigo, tinnitus, or facial weakness. He had no history of recurrent otitis media, trauma, or otologic surgery. Clinical examination revealed the presence of a mass that nearly occluded in the left external canal. The mass was smooth, elastic soft (). The tympanic membrane appeared normal in fiberscope. No other skin or mucosal lesions were noted. Computed tomography scan (CT scan) revealed the soft tissue mass without bony erosion or involvement of the middle ear and appeared to originate from the inferior external canal wall (). Magnetic resonance imaging (MRI) showed that the mass measuring 10 ? 10 mm showed a homogenous, iso signal intensity on a both T1- and T2-weighted image (). We performed cytological examination, and consequently it revealed no malignancy (data not shown). Blood test and the serum chemistry were within normal range. We considered it as a benign tumor which occurred from external canal wall. The patient underwent complete resection of the lesion through a transcanal approach, and we could easily extirpate it, because there was no adhesion between the mass and cartilage of ear canal. The histopathologic examination was that the predominant cell is the foamy histiocyte. The Touton giant cell is also commonly seen in this entity. This is a multinucleated cell with a peripheral ring of nuclei and a glassy, eosinophilic cytoplasm. This histopathologic examination is compatible with xanthogranuloma (). A half year passed, and there was no recurrence. His left hearing after surgery is normal.
Colson Sawyer	33	1984/12/20	001-286-284-7849x64302	[email protected]	874 Joseph Trafficway Suite 331	A 68-year-old Hindu male, who was a known case of hypertension since 10 years, reported to us with history of low-grade fever and intermittent headache since 10 days. Headache was generalized and relieved with medication. Meanwhile patient developed c/o of right-sided nasal obstruction and proptosis since seven days. There was no history of nasal discharge/bleeding or any ear/throat pain or any discharge. He was admitted in local hospital for the same for 3 days; here he was diagnosed as having pneumonia with right lower zone consolidation. Antibiotics and symptomatic treatment were given. There was no improvement in his condition so he was referred to our institution for confirmed diagnosis and management. Patient had a past history of CV stroke followed by facial palsy 5 years back. Patient was nondiabetic but was on regular antihypertensive drugs. He did not have any history of chronic illnesses or surgery in the past. Patient had an agricultural background. On examination patient was afebrile with normal pulse and heart rate. All other systems were normal. On ENT examination right maxillary sinus tenderness was present. Local examination of nose showed no local deformity, and vestibules were normal. Ophthalmological examination revealed right-sided proptosis with restricted ocular movements in all directions. Conjunctival congestion with pseudophakia was present. Pupil on right side was nonreactive to light. All findings suggested 3rd and 6th nerve palsy. Laboratory investigations showed leucocytosis with total count of 15,800/cumm. Peripheral smear did not reveal any abnormality. Patient was hyponatremic on admission. On routine macroscopic and microscopic examination, CSF was turbid with high protein count of 75 mg/dL, and total cells were 4 cells/uL, all being lymphocytes. Patient was negative for HIV. CT scan of brain and paranasal sinuses showed mucosal thickening of all sinuses with cellulitic changes in right orbit involving extraconal, intraconal, and preseptal compartment of orbit. MRI scan suggested changes of pansinusitis with possible fungal infection in right posterior ethmoid, sphenoid, and maxillary sinuses. There was inflammatory phlegmon with early developing abscess in right medial orbit with erosion of lamina papyracea and involvement of medial orbital content with extension of infection into infratemporal fossa and intracranial extension with focal meningitis in right frontotemporal region. Provisional diagnosis based on clinical and radiological findings was acute invasive rhinosinusitis with right eye proptosis and involvement of central nervous system. The patient underwent endoscopic surgery under general anaesthesia. Fungal debris was removed from both nasal cavity and paranasal sinuses. Intraoperatively blackish mass along with necrotic tissues was removed. Clinical specimens were collected and sent to the laboratory for microbiological and histological examination. On gross examination, tissue was brown to black in colour, necrotic, and hemorrhagic. The tissue, after mincing into small pieces, was subjected to 10% potassium hydroxide (KOH) mount which showed two different types of fungal elements. There were narrow, branched, septate hyphae along with globose vesicle containing phialides and conidia. Another type of hyphae was wide, aseptate, and ribbonlike with sporangium containing round sporangiospores. To our surprise, umbrella-shaped empty sporangia along with underdeveloped rhizoids and nodal sporangiophores were also visible in wet mount preparations (). Thin, septate hyphae with vesicle and conidia along with aseptate hyphae and sporangium in KOH preparation were seen in the same field (). The minced tissue specimen was inoculated on SDA plate with antibiotics for fungal culture in duplicate; one set was incubated at 25簞C and another at 37簞C. On SDA plate, and after 48 hrs 2 types of growth were observed. One was mat-like initially having rugose texture which changed to granular and powdery with yellowish-green surface pigment; another was cottony, woolly, and fluffy (). Subculture from both types of growth was performed for isolation of both fungi. Microscopic examination with lactophenol cotton blue staining also confirmed 2 different types of fungus. There were hyaline, branched, septate hyphae with large globose vesicle containing uniseriate phialides fully covering the vesicle with chains of yellowish-green round conidia with foot cells attached at the conidiophores. LCB preparation from mixed culture showing ruptured sporangium with developing vesicle in the same field in . All these findings favor diagnosis of Aspergillus flavus. Another finding was broad, aseptate, irregularly branched ribbonlike hyphae with sporangiophores arising from the hyphae and enlarging distally into hemispherical columellae with flattened base containing round sporangia. Sporangiospores were ovoid to elliptical and light brown in colour. At some places umbrella-shaped ruptured sporangia along with underdeveloped internodal rhizoids were seen confirming the diagnosis of Rhizopus arrhizus. The fungus was identified as coinfection of Aspergillus flavus and Rhizopus arrhizus. The histopathological report endorsed our findings showing broad and aseptate hyphae suggestive of Zygomycetes sp. and thin, septate hyphae with dichotomous branching suggestive of Aspergillus sp. ().
Marina French	42	1982/5/15	2519513295	[email protected]	15760 Michelle Branch	A 29-year-old nonsmoker lady presented to our department with complaints of fever and productive cough of three-week duration. Her chest radiograph showed bilateral infiltrates more so in upper zones (). She had normal haematological and biochemical parameters. There was no clinical evidence of any immunosupression. Acid fast bacilli were found in sputum smears and subsequently culture demonstrated Mycobacterium tuberculosis. She was advised of category 1 regimen of the Revised National Tuberculosis Control Programme of India which consists of isoniazid, rifampicin, ethambutol, and pyrazinamide three times weekly for 2 months followed by isoniazid and rifampicin three times weekly for 4 months, but she refused the same and was prescribed daily regimen consisting of isoniazid (300 mg), rifampicin (450 mg), ethambutol (600 mg), and pyrazinamide (1250 mg) for two months followed by isoniazid (300 mg) and rifampicin (450 mg) for four months. After three months of chemotherapy she was readmitted in our emergency department with complaints of left-sided pleuritic chest pain and exertional breathlessness. Her chest radiograph showed pneumothorax on left side () and corresponding computed tomography of thorax (CT) showed massive pneumothorax of left side with infiltrates and cystic spaces in right upper lobe (). The patient was advised of intercostal tube drainage but she refused. So she was managed conservatively with oxygen, cough suppressants, and bed rest. Since the patient was smear and culture positive for Mycobacterium tuberculosis, both were repeated and the results were negative. With supportive care, her condition improved and was discharged with the advice to continue antituberculosis drugs and to be on regular follow-up. Chest X-ray and CT at the completion of six months of chemotherapy regimen showed complete resolution of pneumothorax (Figures and ). The patient is under our regular follow-up without any complications.
Corey Hanson	33	1978/3/10	785-669-8355	[email protected]	46162 Steven Turnpike Suite 431	The patient was a 19-year-old male with a ten-year history of epilepsy, as well as transient episodes of severe morning headaches with nausea, vomiting, and dizziness. At age nine during a workup for severe headaches, he was found to have a presumed right insular vascular abnormality on imaging. A month later, the patient began having seizures. He was managed medically for ten years; however, during this time, his seizures progressed in frequency from occurring approximately once every six to nine months to almost daily simple or complex partial seizures and rare generalized tonic-clonic seizures despite maintenance on high-dose antiepileptic therapy. Given his refractory and progressive disease, he eventually presented to clinic for consultation about possible surgical management. The only finding on physical examination was distal left upper extremity weakness and hand muscle atrophy resulting from an injury in a motor vehicle accident sustained at the time of a seizure. A magnetic resonance imaging (MRI) scan performed one year prior to surgery showed a suspected single right posterior frontal flow void with adjacent cortical foci of susceptibility artifact compatible with calcification or hemosiderin from remote, small hemorrhages suggesting an atypical vascular lesion (Figures and ). The flow void itself had the appearance of a developmental venous anomaly (DVA), but the pattern of adjacent hemosiderin deposition was noted to be unusual for DVA or an associated cavernous malformation. There were no imaging features specific for parenchymal arterial venous malformation (AVM) or dural AV fistula. The vascular abnormality identified in the right frontal operculum was not demonstrated on MRA images. Imaging was repeated and showed the same lesion again felt to likely represent an atypical vascular malformation (Figures and ). The patient was elected to undergo intracranial seizure monitoring with subdural grid and depth electrode placement in order to determine the location of all epileptogenic foci. Postoperatively, the patient had some left-sided weakness, dysarthria, and left facial weakness. At one month postoperatively, he was almost completely back to his baseline with only minimal residual left facial weakness. The patient did not experience further complex partial seizures. In the immediate postoperative period, he had occasional auras every two to three days, but at one month postoperatively, this had decreased to once every four to six days. At his 20 month visit, he had no auras and his previously almost daily seizures had been eliminated. He was continued on his antiepileptic medications; however, a few days prior to his one year postoperative visit, he stopped taking his seizure medications for two days and suffered a generalized tonic-clonic seizure. A surveillance MRI performed at this visit showed encephalomalacia and no change in the size of the residual lesion (Figures and ). The patient's seizure medications were resumed, and he has not had any seizures or auras since on dual antiepileptic therapy.
Mariana Moon	42	1980/8/3	(258)788-2224	[email protected]	92024 Renee Ports	A 17-year-old male presented to University Medical Centre with persistent hiccups for 4 months and blurring of vision (both eyes) for 1 week. On examination he was found to be hypertensive with blood pressure of 180/110 mm/Hg in both upper limbs with heart rate of 94 beats/min. Fundus examination showed bilateral papilledema with grade 4 hypertensive changes and rest physical examination was within normal limits. He was then evaluated for renovascular hypertension. His routine investigations were as follows: Hb: 110 g/L, Creatinine: 55 micromol/L, Urea: 5 mmol/L, Na: 137 mmol/L, K: 3.8 mmol/L, Ca: 2.4 mmol/L, and Po4 : 1.1 mmol/L. His renal artery Color Doppler showed normal renal parenchyma and renal artery diameter but showed a bilateral suprarenal mass. Patient's CT abdomen was done that showed a relatively encapsulated, heterogeneously and moderately enhancing soft-tissue density mass (right??.9 ? 5.3 ? 6.9 cm and left??.8 ? 3.9 ? 4.6 cm) bilaterally in suprarenal area with internal necrotic and cystic areas (). 24 hr urinary metanephrines estimation was 450 mmol/mol creatinine (N??0??11 mmol/mol creatinine). Patient's 24 hr urinary vanillylmandelic acid estimation (VMA) was 137.86 micromol/day (N??.02??7.91 micromol/day). In the meanwhile, patient was started initially on prazosin 5 mg twice daily which was then followed by addition of propranolol (40 mg) once daily resulted in blood pressure of 134/86 mm/Hg (supine). Patient was reevaluated but neither gave any significant family history nor had any signs suggestive of MEN 2A/2B/1, VHL syndromes, or neurofibromatosis. Patient did not show cushingoid habitus or signs of virilisation. Patient's calcitonin estimation was 2.0 ng/L (N????6 ng/L). MRI Brain did not show cerebellar or retinal hemangioblastoma. CT chest was within normal limit. Patient was then shifted to the surgery department for surgical removal of the mass. Bilateral adrenlectomy was performed without any intraoperative complications. The mass was sent for histopathological examination. Postoperatively patient did not have complications, he got relieved off his hiccups, blood pressure was 130/70 mm/Hg off the antihypertensives, and he was supplemented with wysolone and fludrocortisone, awaiting histopathological examination. Histopathological examination of adrenal mass showed tumor cells arranged in mixed trabecular and nested pattern with marked nuclear pleomorphism and increased mitotic rate (). Areas of extensive necrosis and capsular invasion were noted. Immunohistochemistry of the tissue sample was positive for chromogranin. Post operative VMA was 35.3 micromol/day.
Nova Atkinson	23	1985/8/18	(718)878-7509	[email protected]	897 Mills Brooks Apt. 009	The patient is a 27-year-old male with no past medical history who was diagnosed with multiple myeloma and multiple osseous plasmacytomas in February 2008 on presentation with hip pain and a palpable rib mass. Laboratory studies at time of myeloma diagnosis are shown in . The patient was initially treated for his myeloma with radiation therapy to the right pelvis. He then received four cycles of bortezomib (1.3 mg/m2 on days 1, 4, 8, 11 of 3-week schedule), lenalidomide (15 mg daily for 14 days), and dexamethasone (40 mg po weekly) from April through June of 2008; platelet counts during this treatment ranged from 121,000 to 216,000 (). The patient received an autologous peripheral blood stem cell transplantation in July 2008 with a priming regimen consisting of cyclophosphamide (4 g/m2 on day-21) and melphalan (200 mg/m2 on day-1). His outpatient posttransplantation course was notable for severe thrombocytopenia that was unresponsive to platelet transfusions for approximately two weeks (). Platelet counts recovered to 135,000 by day +19 following transplant. From October through December of 2008, the patient received consolidation chemotherapy consisting of four additional cycles of bortezomib (1.3 mg/m2 on days 1, 4, 8, 11 of 3-week schedule), lenalidomide (15 mg daily for 14 days), and dexamethasone (40 mg po weekly). Following consolidation, he was maintained on single-agent lenalidomide (25 mg daily). In January 2009, the patient described new onset of alopecia involving his facial, leg, and chest hair. In early March 2009, the patient developed new leukopenia (WBC 3.1), but other cell counts including hemoglobin, hematocrit, and platelet counts remained stable (). Due to concern for progressive leukopenia, the patient's lenalidomide was discontinued on March 10th, 2009. Approximately 17 days after discontinuing lenalidomide, the patient developed new petechiae on his lower legs and was found to have a platelet count of 1,000. On presentation with acute thrombocytopenia, the patient reported no recent travel, no viral illnesses, and no new medications. Laboratory studies obtained at time of new thrombocytopenia are shown in . Peripheral blood film confirmed absence of platelets and no evidence of schistocytes or dysplasia ( and ). A bone marrow biopsy revealed normocellular bone marrow with trilineage hematopoiesis and adequate megakaryocytes ( and ). There was no increase in plasma cells. Drug-dependent antibodies to lenalidomide were negative. Restaging studies performed in March 2009, 10 days prior to presentation with ITP, included PET scan which revealed innumerable lytic lesions within the axial skeleton but no significant interval changes compared to scans from August 2008. The patient was diagnosed with acute ITP and was initially treated with high-dose dexamethasone and intravenous immunglobulins. As shown in , platelet counts steadily increased on tapering of steroid therapy.
Jazmin Gross	45	2004/12/30	001-961-975-1485	[email protected]	4607 Strong Crossroad	The patient, a 43-year-old nulliparous premenopausal Greek woman, presented to the Department of Obstetrics and Gynecology of the University of Patras Medical School with a complaint of abdominal pain and abnormal uterine bleeding. Her surgical history was unremarkable. She was suffering from SSc the last 21 years. She received methotrexate, D-penicillamine, and corticosteroids after initial diagnosis of SSc. Her family history revealed no evidence of cancer among the first-degree relatives. On gynecologic examination, there was a palpable pelvic mass. There were no palpable inguinal lymph nodes, and the rest of pelvic examination was normal. Preoperative computer tomography (CT) of the abdomen and pelvis and abdominal ultrasound (U/S) revealed an intra-abdominal mass 15 ? 15 ? 12 cm. Preoperative computer tomography (CT) of the chest, chest X-ray, intravenous pyelography (IVP), colonoscopy, and urethrocystoscopy were normal. Preoperative CA-125 was elevated as 426 U/mL. On exploratory laparotomy, the left ovary was markedly distended, measuring 20 ? 15 ? 10 cm. Frozen section showed malignancy, and the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy, and pelvic lymph node dissection. The histopathology revealed synchronous primary cancers of the endometrium and left ovary. The endometrial tumor invades less than one half of myometrium (). The ovarian tumor invades and ruptures the capsule of the left ovary, invades left fallopian tube, and extents to the omentum (). The right ovary was normal. The peritoneal washing smear was negative for malignant cells. Tumor cells in both primary cancers were positive for vimentin, cytokeratin, epithelial membrane antigen, estrogen receptor, progesterone receptor, CA-125, CA19-9, and B72.3 and negative for CEA. The final diagnosis was stage Ib endometrial cancer endometrioid type and stage IIIc ovarian cancer endometrioid type. The patient underwent postoperative adjuvant chemotherapy. She received six courses of carboplatinum (AUC 5) and paclitaxel (175 mg/m簡). Follow up 89 months after initial surgery, with CT of the chest, abdomen, and pelvis, abdominal U/S, chest X-ray, IVP, colonoscopy, and urethrocystoscopy, revealed no evidence of recurrence.
Quinn Austin	42	1998/12/18	632-803-5515x659	[email protected]	733 Mary Brook	A previously healthy 49-year-old female with complaints of sudden chest discomfort stretching down both arms was admitted to the hospital. Cardiac enzymes were elevated, and an EKG showed ST segment elevation with evidence of possible acute inferolateral myocardial infarction (Table ). However, cardiac catheterization found no hemodynamically significant coronary artery disease. The residual ejection fraction was 30% and showed profound left ventricular dysfunction, including akinesis of the mid anterior, apical anterior, apical, and inferoapical wall segments, with dyskinesis of the mid inferior, basal inferior, and anterobasal wall segments. No potentially causative physical or emotional stressors were identified. The patient was treated with nitrates and angiotensin converting enzyme (ACE) inhibitors.
Alivia Conner	20	2000/10/21	+1-789-995-6501x12502	[email protected]	665 Perez Vista Apt. 497	A 74- year-old female with a history of seizures and hypertension was admitted to the hospital after having been ?ound down??and obtunded from a fall that occurred two days prior. Cardiac enzymes examined, CK, CK-MB, and troponin I, were significantly more elevated in this case (Table ). We believe that there may have been some component of acute kidney injury secondary to the immobilization, which may have artificially inflated the creatine kinase and creatine kinase-MB beyond what is typically seen in Takotsubo cardiomyopathy. An EKG uncovered T-wave abnormalities and a suspected anterior infarct. Echocardiogram showed apical ballooning of the entire distal lateral septal, anterior, and inferior walls. After an imaging excluded intracranial pathologies, an emergency cardiac catheterization was performed which showed normal angiographic coronary arteries, but indicated severe left ventricular systolic dysfunction. We believe that this condition was triggered by the physical and emotional stress of her fall. The patient was treated with beta-blockers and ACE inhibitors.
Phillip Gomez	33	1992/5/18	(660)906-2644x795	[email protected]	32819 Rebecca Orchard	An 84-year-old female was admitted with complaints of worsening nausea, vomiting, diaphoresis, and non-radiating midscapula pain. The patient also has an extensive past medical history, which includes diagnoses of paroxysmal atrial fibrillation, cerebellar hemorrhage, subdural hematoma, orthostatic hypotension, hypothyroidism, cholecystectomy, and colon cancer. In addition, the patient reports significant family stressors. Upon examination, cardiac enzymes were elevated, and the EKG demonstrated ST elevation in the lateral leads (Table ). Cardiac catheterization showed luminal irregularities, with mild coronary artery disease, but was otherwise normal. The left ventricular ejection fraction was 20%. This event is believed to have been provoked by recent family stresses and was treated with beta-blockers, ACE inhibitors, and statins.
Natalie Camacho	21	1983/3/28	367.642.3194	[email protected]	54580 Johnson Plains Apt. 554	A 37-year-old female with a history of hypertension developed shortness of breath and chest pain immediately following a severe allergic reaction provoked by desensitization shots administered by an allergist. In addition, the patient had been taking unspecified 'fat burning pills' for the previous four days. Elevated cardiac enzymes and suspected inferior wall myocardial infarction prompted an emergency cardiac catheterization (Table ). This procedure did not identify any coronary artery disease, but did reveal severe mid inferior wall dyskinesis and moderate mid anterior wall dyskinesis. The echocardiogram was performed three days later, at which time no abnormalities in wall movement were identified. The allergic reaction is considered a contributing factor to the onset of these symptoms. The patient was initially treated with intravenous epinephrine and heparin followed by ACE inhibitors and beta-blockers.
Tatum Hicks	22	1979/3/27	001-463-464-2823	[email protected]	96127 Owens Mission Suite 342	A 63-year-old female with no known past medical history presented with shortness of breath. Cardiac enzymes, particularly troponin I, were only mildly elevated (Table ). The EKG showed poor R-wave progression and nonspecific ST changes. Cardiac catheterization showed only minor obstructive coronary artery disease. The LV was found to exhibit dyskinesis at the base of the anterior and posterior walls, akinesis of the mid and distal anterior wall and of the mid inferior wall, and dyskinesis of the apex. The history did not indicate any known stressors that contributed to this event. The patient was treated with ACE inhibitors and beta-blockers.
Alina Craig	42	1983/1/6	3324518940	[email protected]	898 Hayes Estates	A 34-year-old Caucasian female presented to the Emory Eye Center in March 2015 with complaints of blurry vision in both eyes for the past 1 week. The patient? past medical history is notable for multiple sclerosis (MS) diagnosed in 2011 after an episode of bilateral optic neuritis and gait instability. Her MS was initially managed with interferon beta-1a in 2011, but due to recurrent flares, she was transitioned to natalizumab in 2012. She had received monthly infusions of natalizumab with the last infusion 3 weeks prior to presentation. Visual acuity was 20/25 right and 20/50 eccentrically left eye. The pupils were equal and reactive without a relative afferent pupillary defect. Intraocular pressures were 14 in both eyes. Extraocular motility was full and non-painful in both eyes. Anterior segment exam was notable for trace cell in the right eye and 2 + cell in the left eye. Funduscopic examination showed areas of retinal whitening in the macula and periphery in both eyes with more confluent areas of necrosis in the left eye associated with retinal hemorrhage (Fig. a, b). The patient? clinical presentation was consistent with bilateral acute retinal necrosis, and she was admitted for further evaluation and management. A diagnostic anterior chamber (AC) paracentesis was performed, and the sample was tested for VZV, HSV, CMV, and toxoplasmosis PCR. The patient was given intravitreal injections of foscarnet 2.4 mg/0.1 cm3 and ganciclovir 2 mg/0.1 cm3 in both eyes and administered intravenous acyclovir. The diagnostic AC paracentesis was positive for VZV, and systemic work-up was unrevealing for HIV. Magnetic resonance angiography was negative for evidence of CNS vasculitis. After consultation with neurology, natalizumab was discontinued. Over the next several months, the patient was given multiple bilateral intravitreal injections and continued on systemic oral valacyclovir 1 g three times a day. The infection in the right eye resolved, and she maintained good vision at 20/30 at the last follow-up. However, despite aggressive therapy, the retinitis in the left eye rapidly spread throughout the macula and went on to involve the optic nerve with a drop in vision to hand motion. The patient later developed a macular-sparing combined tractional and rhegmatogenous retinal detachment in the left eye. Four months after presentation, the patient underwent scleral buckling and pars plana vitrectomy with silicon oil and successful reattachment of the retina. Visual acuity in the left eye at the last follow-up was hand motion, limited by macular and optic atrophy. The patient remains off natalizumab and is taking oral valacyclovir 1 g daily.
Odin Hardy	32	1989/5/7	-10742	[email protected]	09675 Raymond Row Apt. 988	A male patient aged 6 years reported to Department of Pedodontics and Preventive dentistry, VS Dental College and Hospital, Bengaluru. Patient? mother complained of severe bleeding from gums from past 1 week and inability of the child to eat. The child is known case of cerebral palsy with microcephaly and mental retardation with developmental age of only a few months (). Patient showed minimal response to verbal commands. On intraoral examination, erythematous gingival overgrowth was noted on labial and palatal aspects of 54 () and labial aspect of 64. On palpation, profuse bleeding was noted. A detailed case history was taken and it was noted that the patients teeth were cleaned once daily by mother by wiping with a wet cloth. No brushing or use of any dentifrice was done from the beginning. Depending on clinical examination and based on the oral hygiene status of the patient, a provisional diagnosis of inflammatory gingival hyperplasia due to poor oral hygiene was obtained. Pediatric opinion on general state of patient was obtained and after performing all the necessary blood investigations, excision of hyperplastic gingiva in relation to 54 was planned and done under local anesthesia (). The excisional biopsy specimen was sent for histopathological examination (). Meanwhile, mother was educated regarding the importance of oral hygiene, method of brushing and other oral hygiene practices. Chlorhexidine mouth rinse was also advised and the surgical excision of the tissue in relation to 64 was deferred till the final diagnosis was obtained. The histopathological examination confirmed the diagnosis of inflammatory gingival hyperplasia secondary to poor oral hygiene status. Patient was recalled after 1 week for excision on the other side, i.e in relation to 64 but it was observed that there was spontaneous healing of the gingival tissues probably due to the oral hygiene measures adopted ( and ). Therefore parents were advised to continue with oral hygiene measures and patient is being reviewed regularly.
Jessica Solis	35	1992/11/2	(571)651-6085	[email protected]	082 Williams Expressway	A 13-year-old boy reported to the Department of Pedo-dontics and Preventive Dentistry with the chief complaint of pain in upper right front tooth region. On examination there was an Ellis and Davey class 3 fracture with 11, tenderness positive with history of trauma 1 year back. Radiograph revealed incomplete root formation (). On the same day access opening, working length and biomechanical preparation was done and canal was dried with paper point and filled with calcium hydroxide for disinfection for 1 week (). After a week, Ca(OH)2 was removed and then with the help of carrier MTA was placed into apical region (). Material was then condensed into apical area and access opening was sealed with temporary filling material (). Placement of the material was confirmed with a radiograph and after a week, tooth was obturated with gutta-percha (). After 6 months follow-up radiograph revealed well sealed and healthy apical region ().
Ronin McDonald	31	1985/8/6	235.468.2622	[email protected]	08826 Gregory Turnpike Apt. 840	A 9-year-old girl reported to the Department of Pedodontics and Preventive Dentistry with the chief complaint of pain in upper right front tooth region (). On examination there was a Ellis and Davey class 3 fracture with 11. Radiograph revealed incomplete root formation. Access opening was done followed by amputation of the coronal pulp with sharp excavator, carefully to prevent further damage to the pulp and perforation of the pulpal floor ( and ). The coronal pulp tissue was removed, sterilized cotton pellets over each amputation site was once placed and pressure pack was applied for a few minutes. Once the homeostasis was achieved, 1 to 1.5 mm thick layer of freshly mixed mineral trioxide aggregate was placed directly on the pulp stump surface and then gently pressure applied with a moist cotton pellet. Damp cotton pellet was placed over the material, followed by temporary restoration with Zinc Oxide Eugenol Cement (). After a week intermediate restorative material was removed and final restoration over set mineral trioxide aggregate was done followed by composite build up ().
Daisy Atkinson	26	2003/6/11	001-673-926-2683	[email protected]	690 Timothy Street Apt. 653	A 4-year-old boy came to Department of Pedodontics with chief complaint of carious lower back teeth. On examination, his all 4 mandibular primary molars were carious (). Radiograph revealed deep caries approaching pulp with remaining dentin thickness of about 0.5 mm (). MTA pulpotomy was planned. Under rubber dam isolation all superficial caries was removed to minimize bacterial contamination before exposure. Then the roof of the pulp chamber was removed by joining the pulp horns with bur cuts followed by amputation of the coronal pulp with a sharp excavator (). Following, coronal pulp amputation sterilized cotton pellets over each amputation site was placed and pressure was applied for 5 minutes. Then 1 to 1.5 mm thick layer of freshly mixed mineral trioxide aggregate was placed directly on the pulp stump surface and then patted with a moist cotton pellet (). With a damp cotton pellet over the material, temporary restoration was done with zinc oxide eugenol cement (). After a week intermediate restorative material was removed and mineral trioxide aggregate was placed, tooth was then restored with Glass Ionomer Cement (GIC) followed by stainless steel crown ().
Duke Dalton	27	1981/5/10	315-366-8281x4441	[email protected]	379 Hanson Unions	A 13-year-old girl came to Department of Pedodontics with chief complaint of fractured left central incisor. On examination, there was Ellis class 3 fracture in 21 with history of trauma 1 year back and treatment was done somewhere outside the college. The tooth had root canal and labial perforation on crown. Radiograph revealed incomplete root formation ( and ). The working length was measured and biomechanical preparation was done. Then canal was dried with paper point and filled with MTA on perforation site for repair and at the apex for apexification. Placement of mineral trioxide aggregate was confirmed with a radiograph for adequate barrier to be created, with a wet cotton pellet. Excess moisture was removed from the pellet and placed in the canal (). Then temporary filling was removed at least after 3 to 4 hours and later a permanent filling material in the root and/or in the access cavity preparation was placed ( and ). The healing was assessed periodically using intraoral periapical radiograph.
Lilian Le	28	1996/2/18	976.283.2179x23012	[email protected]	249 Cassandra Corners	A 9-year-old boy presented to the clinics of Department of Pedodontics, Dr Ziauddin Ahmed Dental College and Hospital, Aligarh Muslim University, Aligarh, with his mother. The mother stated that none of his milk teeth had yet shed. The cause of her concern was that she herself had faced the same condition as a child and due to lack of awareness and funds, had not had a chance to rectify the situation. At present at the age of 32 she wore over dentures. Upon observation, the facies and the stance of both the mother and son were suggestive of the classical manifestations of cleidocranial dysplasia ( and ). The child () had a short stature, flat nasal bridge, widely spaced eyes, a malformed head and short and broad hands. He had broad neck, sloping and hypermobile shoulders. His physical development, intelligence, hearing, spine and rest of the systemic examination were normal. In the mother? case ( and ), the skeletal features well as the degree of apposition of the shoulders were more pronounced. Clinical examination of the 9-year-old male revealed a high arched palate and malar and maxillary hypoplasia as well as fused upper left primary central and lateral incisor. There was an absence of spacing in the lower jaw (). None of this child? teeth were mobile. The mother had partial anodontia with some erupted /malformed permanent teeth and mobile deciduous teeth present (). The head circumference was 50.5 cm (brachycephalic), with coronal suture ridging, depressed metopic suture (), just like in the mothers case (), hypertelorism and depressed nasal bridge. His ears were set low (). Upon palpation, the anterior fontanelle was judged to be not fully closed and clavicles were judged to be laterally deficient. The mother had more pronounced brachydactyly () than the son (). An OPG and X-ray chest were advised. The OPG showed that most of the permanent teeth had formed crowns but the root formation was lagging behind (). An OPG was also requested of the mother and it showed deciduous retained teeth, poorly formed permanent teeth and impacted permanent teeth with supernumerary teeth and dental age lagging behind chronological age (). The X- ray chest showed clavicles were deficient laterally (). The diagnosis of cleidocranial dysplasia was confirmed radiographically further by obtaining X-ray skull (AP and lateral) ( and ) and X-ray hand wrist ().
Damien Pham	24	1991/11/24	001-306-409-0886x1846	[email protected]	3696 Kristie Falls	A 19-year-old Japanese man developed left eyelid swelling around October 2, 2013. On October 9, 2013, he visited the ophthalmologic department of a local hospital because of subsequent gradually worsening ophthalmalgia and visual deterioration. The symptoms did not improve after the ocular administration of antibiotics. He was referred to Toho University Sakura Medical Center in Sakura, Japan (referred to hereafter as ?ur hospital?? on October 16, 2013, with a main complaint of left eyelid swelling. He had no medical, family medical, or allergy history. At the first visit, his right best-corrected visual acuity (BCVA) was 1.2; his left BCVA was 0.8 with visual deterioration. His right and left intraocular pressures (IOPs) were 17 mmHg and 36 mmHg, respectively. Prominent left eyelid swelling and exophthalmos were evident (Fig. ). A slit-lamp examination revealed prominent mucosal hyperemia, edema, and slight mucous discharge (Fig. ). Moderate mydriasis of the left pupil, direct light reflex attenuation, and positive relative afferent pupillary defect (RAPD) were present. No abnormality existed in the corneas, lenses, retinas, or optic nerve heads; however, ocular motility was omnidirectionally circumscribed. Dynamic campimetry showed neither central scotoma nor visual field deficiency. No laterality of central flicker values was revealed on central flicker examination. No systemic symptoms such as fever or infection were found on physical examination at the first visit. The blood examination exhibited a normal inflammatory response value. Orbital magnetic resonance imaging (MRI) showed soft tissue swelling in the left orbital muscle cone, and orbitographic MRI showed systematic trachychromatic images in the periorbital soft tissues (Fig. ). Clinical findings indicated suspected orbital cellulitis, although the blood examination exhibited no increase in the inflammatory response value. Intraorbital inflammatory pseudotumor was a differential diagnosis because of suspected orbital panniculitis on diagnostic MRI. He was hospitalized. An intravenous infusion of betamethasone (4 mg/day) was started on October 16, 2013. The following medications were started at the first visit because of the possibility of orbital cellulitis: ocular administration of levofloxacin four times daily and cefmenoxime four times daily, ofloxacin ophthalmic ointment once daily, and intravenous infusions of imipenem/cilastatin (0.5 g ? 3 times daily). Culture identification of the eye discharge was also performed on the same day. Oral administration of acetazolamide tablets (300 mg ? 3 ? 3 times daily) and potassium l-aspartate tablets (300 mg ? 3 ? 3 times daily) was also started because of left ocular hypertension. We supposed that there might be another possibility of an immunologic or inflammatory pseudo tumor besides orbital cellulitis because of the few inflammatory clinical findings; thus, we tried to use a sub-Tenon? injection of triamcinolone as a diagnostic therapy. A sub-Tenon? injection of triamcinolone (0.5 mg) in the left eye on the first day of hospitalization resulted in improvements in mucosal hyperemia and edema and the disappearance of eyelid swelling (Fig. ). The left BCVA improved to 1.2, there was a reduction in left IOP to 15 mmHg, and the left eyelid swelling nearly disappeared and did not recur. Mucosal hyperemia and edema were observed on the sixth day of hospitalization. Improvement of the left orbital panniculitis compared to the image acquired at the first visit was revealed by orbitographic MRI on the seventh day of hospitalization. He was discharged on the ninth day of hospitalization. Left and right IOPs gradually declined to approximately 15 mm Hg at discharged. Systemic and local administrations of antibiotics were discontinued on the seventh day of hospitalization because a culture of the eye discharge, which was performed at the first visit, had returned negative results. Oral prednisolone (30 mg/day) was started after hospital discharge. There was no recurrence of ocular symptoms and a favorable progression in vision to 1.2, despite a gradual reduction of prednisolone. Favorable progress in the left ocular tension to approximately 15 mmHg also occurred with the discontinuation of oral acetazolamide tablets and the initiation of the ocular administration of dorzolamide hydrochloride/timolol maleate (twice) and latanoprost (once). Symptoms had not recurred when he was examined at an ambulatory follow-up visit on January 8, 2014. On January 20, 2014, he visited the internal medicine department of a local hospital and was orally administered antibiotics because of a subsequent fever of 39 簞C and appendicular arthralgia. The symptoms did not improve, despite the oral antibiotic administration. A subsequent blood examination exhibited pancytopenia, hepatopathy, and an increased lactate dehydrogenase (LDH) level. He immediately revisited our department for an intensive examination and treatment on January 29, 2014 (the 15th week after the first visit) with a complaint of slight swelling of the right eyelid, whereas swelling of the left eyelid was observed at the first visit. Ophthalmological findings at the second visit revealed slight right eyelid swelling (Fig. ). The BCVA of both eyes was 1.2, but the intraocular pressure was 25 mmHg in the right eye and 27 mmHg in the left eye. Slight direct light reflex attenuation of both eyes was present, and positive RAPD of the right eye was also found. No abnormality was found in dynamic campimetry or a central flicker examination. However, orbitographic MRI showed right exophthalmos and orbital soft tissue inflammation. Left orbital panniculitis, which had improved (compared to the image acquired at the first visit), had recurred, compared to the image acquired during hospitalization on October 23, 2013 (Fig. ). Systemic findings included a high body temperature of 39.8 簞C and tachycardia of 103 beats per minute. A blood examination revealed leucocyte and thrombocyte cytopenia, hepatopathy, and increased coagulability: leucocytes, 3220/mm3; thrombocytes, 11.1 ? 104 mm3; aspartate transaminase/alanine transaminase (AST/ALT) level, 115/91 IU/L; LDH level, 1014 IU/L; creatinine kinase level, 362 IU/L; prothrombin time, 13.6 s; activated partial thromboplastin time (APTT), 37 s; and D-D dimer, 2.17 s. He visited the internal medicine department of our hospital for an intensive examination. Abdominal echography and abdominal/pelvic computed tomography (CT) showed moderate retention of abdominal fluid, dropsy, and an enlarged spleen. He was transferred to the hematology department at another hospital and was hospitalized for an intensive examination on the following day because of the possibility of hemodyscrasia, based on the increased LDH level in the blood examination results. Bone marrow aspiration examined after the hospital transfer revealed decreased numbers of nucleated cells and megakaryocytes and a small amount of corpuscular phagocytosis. A blood examination revealed leucocyte and thrombocyte cytopenia; increased levels of AST/ALT, LDH, and ferritin; and hepatopathy. Antibodies against herpes simplex virus, cytomegalovirus, and Epstein?arr virus were negative. Steroid administration (30 mg/day) was started with a diagnosis of HPS. After 1 week, he left the hospital because his symptoms improved. However, bubonalgia appeared immediately after hospital discharge and did not improve. He revisited the hospital on February 29, 2014. Abdominal CT exhibited suspected panniculitis in vesicular subcutaneous tissue. Cyclosporine was administered because of suspected Weber?hristian disease. The hepatopathy and increased levels of LDH and ferritin did not improve. Worsening HPS was diagnosed because of the appearance of a high fever (39.5 簞C) on the morning of March 20, 2014. A biopsy of the vesicular ventral subcutaneous adipose tissue by hypogastric transection was also performed in the anaplastic department of a local hospital on the same day. The histopathological diagnosis of the biopsy tissue revealed an aggregating tendency of nuclear irregularity-prominent atypical lymphocytes in the adipose tissue. SPTCL was diagnosed because of the surrounding arrangement (i.e., rimming pattern) of lipid droplets (Fig. ). On May 1, 2014, two aggregations of fluorodeoxyglucose in the right ilium were detected by positron emission tomography (PET) examination. Advanced malignant lymphoma was also suspected, based on the pelvic MRI findings. He was transferred to Suwa Red Cross Hospital (Suwa, Japan) on May 1, 2014 because of his requirements for intensive examination and treatment. After the hospital transfer, histopathological and immunohistological re-examinations of the vesicular adipose tissue exhibited poor infiltration of atypical lymphocytes into the dermis. Immunohistological findings exhibited positivity for CD3, CD8, granzyme B, T-cell intracellular antigen-1 (TIA-1), and beta F1; and negativity for C-gamma M1, CD30, CD56, and Epstein?arr virus-encoded small RNAs (EBERs), which led to a definitive diagnosis of 帢帣-type SPTCL. He was hospitalized for treatment on May 21, 2014. The standard treatment for malignant lymphomas?yclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy?as administered for 5 days, and presented no efficacy. Four courses of etoposide, methylprednisolone sodium succinate, high-dose cytarabine, and platinum chemotherapy were administered beginning on June 11, 2014. On September 26, 2014, he underwent autologous peripheral stem cell transplantation because his symptoms were controlled. Hospital treatment for 6 months resulted in remission of his symptoms. Remission has been maintained.
Raelyn Atkins	45	1994/10/6	(865)213-7162	[email protected]	7903 Ortiz Glens	A 59-year-old male was referred to the Department of Oral and Maxillofacial Surgery with a painless growth at retromolar trigone area. It had been present for 2 months and had increased in size during this period of time. Past medical history revealed a malignant mesothelioma which was diagnosed in September 2011 and treated with chemotherapy and radiotherapy until February 2014. The patient received 6 cycles of cisplatin (50 mg/100 ml, every 28 days) and premetrexed (500 mg, every 3 weeks) at the beginning. Since the lesion was inoperable, radiotherapy (50 Gy, in 25 fractions) was given after chemotherapy sessions. After radiotherapy sessions, starting from April 2012, the patient received 5 cycles of premetrexed (500 mg, every 3 weeks). A different regimen was given starting from January 2013. Cisplatin (50 mg/100 ml, every 28 days) and gemcitabine (1000 mg/m2) were prescribed. Gemcitabine was given on the 1st, 8th and 15th days. He was 71 kg when gemcitabine was started. After 4 months, the patient was 66 kg. Pemetrexed (500 mg, every 3 weeks) was prescribed instead of gemcitabine. The patient received 750 mg pemetrexed every 3 weeks until December 2013. In August 2013, positron emission tomography (PET CT) of the patient was evaluated. Figures and show the location of the tumor on the left lung and also possible metastasis on C7 vertebrae. He was 63 kg on that date. In January 2014, the patient was referred to our department because of the complaint in the oral region. Intraoral examination revealed a soft, haemorrhagic, ulcerated lesion at the right retromolar trigone area (Fig. ). Extraorally neither swelling nor lympadenopathy was observed. The innervation of N. trigeminus was balanced on both sides. There was no paresthesia on the lingual nerve. Radiologic examination revealed no destruction of the bony architecture (Fig. ). An incisional biopsy was performed under local anaesthesia. Haematoxylin and eosin staining showed invasive malignancy at subepithelial area (Fig. ). Syncytial aggregations composed of huge cells with pleomorphic nucleus, distinctive nucleolus and narrow cytoplasms were also detected (Fig. ). For immunohistochemical staining, the slides were stained with antibodies to calretinin (Ready to use, NeoMarkers, USA), secondary antibodies and DAB chromogen using standard procedures. Cytoplasmic/nuclear calretinin expression was considered positive. Intensity of staining was graded 3. The tumor cells were strongly positive for calretinin on immunohistochemical staining (Fig. ). Based on these histopathological and immunohistochemical findings, a final diagnosis of metastatic mesothelioma was made. The patient was informed about the possibility of multiple metastases within the body. He succumbed after 45 days following the deterioration of his medical condition. Malignant mesothelioma is a rare and aggressive tumor with a poor prognosis. The incidence of this disease is one or two cases per million per year []. The diagnosis of the primary malignant mesothelioma is established by clinical, histological, immunohistochemical, and radiological findings. In the present report, calretinin, a mesothelial marker turned out to be strongly positive in tumour cells on immunohistochemical staining, substantiating diagnosis of an epithelioid mesothelioma metastasis. Calretinin, a helix?oop?elix structural domain found in calcium-binding proteins and widely expressed in neural tissue, is expressed in most cases of epithelioid mesothelioma []. For radiological investigations, ESMO (European Society For Medical Oncology) recommends using CT scanning of the thorax for the localization of tumor sites and distant metastases or detecting early response to treatment. They recommend also MRI in special situations where tumor delineation is necessary []. But the diagnosis of the secondary malignant mesothelioma in the oral cavity, as in the present case, is based on the presence of known history of the tumor. Even with the presence of the primary tumor, it is necessary to make a definite diagnosis of an assumed oral metastases to allow for an appropriate management. Although the clinical behaviour and the view of the primary oral squamous cell carcinoma (OSCC) is unlikely to be misdiagnosed for a metastatic lesion by an experienced surgeon, OSCC is the most likely diagnosis of a persistent mass, without obvious traumatic or infectious origin. Wide surgical excision is often an acceptable treatment for the management of OSCC, whereas in a metastatic mesothelioma case, it will be inappropriate []. The current effective standard treatment for mesothelioma is the addition of bevacizumab to pemetrexed plus cisplatin which significantly improves the overall survival []. Unfortunately, there was no effective standard treatment for mesothelioma during the follow-up period of the present patient. Therefore, another different regimen of chemotherapy was prescribed. Although the cisplatin plus pemetrexed therapy of the present patient was the standard of care in the first-line treatment, the prognosis was poor and the patient succumbed to the disease. Malignant mesotheliomas frequently recurred locally in the chest and abdomen. Metastases occur at a relatively late stage of the disease. Kannerstein and Churg [] reported metastases in 18/50 autopsy cases. Distant metastases are very rare, especially in the oral region. Primary breast carcinomas are the most common types of tumour to metastasize to the jaw bones while primary lung carcinomas are the most common types of tumour to metastasize to the oral soft tissue []. These oral metastases represent about 1 % of oral malignances, and there are more cases reported arising in the jaw bones than in the oral soft tissues with a ratio of approximately 2:1 []. The case presented in this report is only the first report of a mesothelioma metastatic to the retromolar trigone. Although Kruse et al. [] and Hirshberg et al. [] reported that metastases of mesothelioma, although rare, tend to involve the oral soft tissues, especially the tongue. Sinon et al.[] reported that metastases to oral region are mostly seen in the tongue and the attached gingiva. One possible explanation for the tendency towards the tongue and the attached gingiva might be the rich capillary network, especially where chronically inflamed gingiva trap malignant cells and the fragmented basement membranes of proliferation capillaries allow easier penetration by malignant cells than in more mature blood cells [].
Cason Dickerson	18	1994/2/23	+1-535-459-5671x11511	[email protected]	915 Keller Prairie	A 54-year-old white man was referred with a 1-week history of bilateral pedal edema, worsening hypertension, and a rise in serum creatinine from 111 弮mol/L to 213 弮mol/L over 2 weeks. He had microscopic hematuria and proteinuria quantified at 24 grams/day (see Additional file ). His serum albumin was 24 g/L compared with 35 g/L 2 weeks earlier. Other relevant investigations included negative hepatitis B and C serology, weakly positive speckled antinuclear antibody (ANA) titer of 160 (normal <40) with double-stranded deoxyribonucleic acid (DNA) of 0 IU/mL (normal <7), normal ratio of serum free light chains, negative cryoglobulin screen, negative serum protein electrophoresis, and a normal C3 of 1.77 g/L and C4 of 0.38 g/L. He had a background history of hypertension, obstructive sleep apnea, and a 3-year history of colorectal carcinoma with hepatic metastasis. His initial treatment included neoadjuvant chemotherapy with capecitabine and bevacizumab, and 26 fractions of radiotherapy. He then underwent a right hemicolectomy and a partial right hemihepatectomy, followed by 6 months of capecitabine and bevacizumab. One year later, a new 74 mm metastatic lesion developed in his residual right liver lobe, and a 16 mm mucin-secreting adenocarcinoma occurred at the left vesicoureteric junction, which was managed by distal ureterectomy. He was recommenced on capecitabine, bevacizumab, and cetuximab, and continued on this treatment until presentation with nephrotic syndrome. A renal biopsy was diagnostic of MPGN type I. Functioning glomeruli showed mesangial hypercellularity, endocapillary proliferation, and double contours in capillary loops. No hyaline deposits were noted in the capillary loops and no segmental sclerosis was seen (Fig. ). There was interstitial fibrosis and tubular atrophy together with lymphocytes, plasma cells, and eosinophils in the scarred interstitium (Fig. ). Immunofluorescence showed moderate granular deposition of IgG and C3 in the mesangial areas and around the capillary loops. Electron microscopy showed deposits in the mesangial, paramesangial, and subendothelial regions. Focal duplication of the glomerular basement membrane was seen and there was mild expansion of mesangial matrix. Curative therapy for the malignancy was not possible, so treatment was commenced with prednisolone for the renal disease. Four months later, his proteinuria had reduced to 1.4 grams/day, creatinine had improved to 155 弮mol/L, and albumin returned to baseline of 31 g/L.

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