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The recipient underwent an uncomplicated conventional LT without the use of a veno-venous bypass. There were no periods of hypoxia or severe hypotension during transplantation. The cold ischemic time of the graft was 8 hours while the warm ischemic time was 45 minutes. The graft reperfused well and no biopsies were taken. Intravenous methylprednisolone (500 mg) was administered intraoperatively, and postoperatively the patient received induction with Antithymocyte Globulin, which is the protocol followed at our institution. During transplantation the patient received a total of 4 units of packed red blood cells (PRBCs) and 6 units of fresh frozen plasma (FFP). | Transplantation surgery |
At the time of LT, the international normalization ratio (INR) was 1.53, while serum total bilirubin was 103 μmol/L . On postoperative day 2 the patient had a peak of his serum AST and at this point he had further biochemical evidence of primary graft dysfunction, with inability to normalize his INR , and with progressive elevation of his total serum bilirubin . Repeated ultrasonographic examination revealed a patent hepatic artery and portal vein, as well as patent hepatic veins. At this point, a liver biopsy demonstrated severe reperfusion injury with several apoptotic bodies, several dystrophic calcifications , and no evidence of acute cellular rejection. His clinical status deteriorated, he developed multiorgan system failure and died 12 days after his transplantation. No septic focus was identified. Both kidneys harvested from the same donor did not present any signs of delayed graft function after transplantation. | Hepatology |
A 55-year-old man of Greek origin underwent LT at our institution for ethanol and hepatitis B related cirrhosis, as well as a large hepatocellular carcinoma. The patient did not have a history suggestive of hyperparathyroidism or abnormal calcium metabolism, and upon listing his serum ionized calcium was 0.94 mmol/L. The donor was a previously healthy, 52 year-old male who suffered a closed head injury during a motor vehicle crash. The organ was procured by our transplant team. Prior to procurement the donor did not suffer any periods of hypoxia or hypotension. His liver function tests were normal prior to harvesting (AST 36 U/L, ALT 45 U/L). During procurement the liver was found to be well perfused, with no evidence of aberrant vascular anatomy and no evidence of trauma. Macroscopic examination of the liver did not show any evidence of steatosis. The recipient underwent a conventional LT without venovenous bypass and without intraoperative hypotension. The cold ischemic time was 10 hours while the warm ischemic time was 40 minutes. Following reperfusion, the graft appeared well perfused and again no biopsies were taken. Intraoperatively the patient received 500 mg of methylprednisolone, and postoperatively he was induced with Antithymocyte Globulin. During transplantation the recipient received 3 units of PRBCs and 6 units of FFP. In the early postoperative period the patient had to be explored once for retroperitoneal bleeding associated with hypotension (SBP< 90 mm Hg). | Transplantation hepatology |
In the present case report, we have shown that these events can take place in human subjects following liver transplantation. To our knowledge these are the first reported cases in the literature of liver calcification following liver transplantation, presumably secondary to I/R injury. Not only did both patients have biochemical evidence of severe graft I/R injury, they also had biopsy proven I/R induced injury associated with the development of calcifications. Furthermore, both succumbed to the sequelae of this injury. Both recipients received grafts from donors with normal serum biochemistries and no evidence of hepatic trauma or steatosis. Both donors had no evidence of crystal deposition or storage disease, and although we did not perform any donor liver biopsies, the grafts appeared macroscopically normal and perfused well with UW solution. Corroborating to this remains the fact that all four kidneys (from both donors) were transplanted without any problems. Neither recipient had any evidence of calcium metabolism problems, since both had normal serum calcium upon listing. Both recipients had an anticipated intraoperative course without periods of hypotension and without massive transfusion requirements. Finally, both grafts did not demonstrate any vascular problems in the postoperative period by Ultrasonography or CT scan examination or any evidence of intrahepatic thrombosis in postmortem or explant examination. | Hepatology |
In September 2000, a 35-year-old female without any history or clinical stigmata of NF-1 presented to her primary physician with complaints of a dull, localized left upper leg pain of several months' duration. An abdominal mass was palpated during a physical examination. Magnetic resonance imaging (MRI) as well as a computed tomographic (CT) scan of the abdomen and pelvis showed a large well-defined, near spherical mass in the left false pelvis which enhanced heterogeneously at a mean Hounsfield value of 44 units . The mass displaced the external iliac vein medially and psoas muscle laterally. It also abutted the upper surface of the left ovary without truly invading any of these or other surrounding structures. However, the mass was believed to be in the course of the left genitofemoral nerve and lumbar plexus. The decision was made to resect the mass. Intraoperatively, the tumor's capsule was found to be densely adhered medially to the external iliac vessels, with at least 10 external venous branches directly supplying the tumor. The tumor was carefully marsupialized out of the retroperitoneal area and the decision was made to leave the residual capsule, since an attempt at its removal would have entailed a highly morbid procedure that was not felt to be justified based on the histopathologic appearance of the tumor on frozen sections. Intraoperatively, a pigmented macular lesion with faintly irregular edges was noted in the left upper thigh, which was biopsied. Pathologic examination showed a malignant melanoma with spitzoid features. The precise circumstances regarding the duration of the lesion and whether there had been any increase in its size was unclear. She subsequently underwent a wide local excision (4 × 12 cm skin ellipse was removed) and sentinel lymph node biopsy, both of which showed no residual melanoma. The patient's postoperative course over the subsequent 2 years was remarkable for a relatively slow but progressive improvements in the neurologic symptoms related to her surgery. However, she showed no evidence of either tumor recurrence at last follow-up, 26 months postoperatively. | Oncology |
A 43-year-old woman with a history of schizophrenia since 1982, and a history of hospitalization to help the patient to acquire social communication abilities, at the age of 23 presented with slight pain on her left flank and back. In 1995, she was treated with ureterolysis and ureteroureterostomy because of left-sided ureteral obstruction. Histological evaluation of the biopsy revealed benign fibrous tissue proliferations; however, no further evaluation and surgical excision was planned as her mental state was deteriorating. She was put on regular follow-up with computed tomography (CT) scans. In May 2002, she was referred from the psychiatric hospital to our Department of Urology, as the tumor tended to grow. CT scan with contrast enhancement revealed a tumor located between iliocostalis and psoas muscles in retroperitoneal space. The peripheral part of the tumor was enhanced, while the central part did not. The left paravertebral muscles around the tumor showed atrophy. The medial margin of the tumor was deformed by a left transverse process of the second lumber spine, suggesting invasive behavior . Coronal magnetic resonance imaging (MRI) demonstrated the tumor to be located beneath the left kidney. The central part of the tumor was found to be of iso/low intensity in the T1-weighted phase and of heterogeneously high intensity in the T2-weighted phase. The marginal part showed very low intensity in both phases . In May 2002, needle biopsy was performed and revealed that the tumor consisted of well-proliferated spindle cells rich in collagen fibers, an observation that was inconsistent with the histological pictures made in 1995. In June 2002, resection was performed using a paraspinal approach. Although the tumor strongly adhered to adjacent tissues, including the urinary tract and peritoneum, it was marginally resected, including paravertebral muscles and part of the spine. As the kidney was less affected by the tumor, ablation posed no problem. On gross examination, the cut surface appeared homogeneously gray and glossy . Histologically, a uniform proliferation of spindle cells with a moderate amount of collagen fibers led to a diagnosis of extraabdominal fibromatosis in the retroperitoneal space . No adjuvant treatment was given and during the two years of follow-up, the patient has remained asymptomatic, with no restrictions of daily living. There were no clues as to recurrence of the tumor in computed tomography. | Urology |
The patient initially received glucocorticoid treatment to which she showed a temporary response until 6 months later when she relapsed. She was subsequently started on danazol without any clinical benefit. Intravenous immune globulin administration also proved ineffective after two 5-day cycles. As a result, the patient was subjected to splenectomy 9 months after the diagnosis with complete response, attaining platelet counts over 150 × 10 6 /L within 10 days after the operation. Five years later, she remains in clinical remission. | Hematology |
Herein, we describe a case of a man, who had an accident at work and 1 week later developed lymphocutaneous infection caused by N. brasiliensis . | Infectious diseases |
On admission, routine laboratory investigations showed only elevated white blood cell count (12,400/mm 3 ), while red blood cell count, haemoglobin, chemistry and urine analysis were within normal limits. Radiography of the bones of his left hand revealed fractures of the nail bones of the middle and the ring finger. Surgical debridement of the damaged soft tissue was undertaken with amputation of these two nail bones. The patient was hospitalized and intravenous therapy with ceforanide (1 g/12 h), ofloxacin (200 mg/12 h) and metronidazole (500 mg/8 h) was initiated. | Orthopedic surgery and infectious diseases |
Physical examination revealed multiple erythematous subcutaneous nodules along the lymphatics extending up the patient's left forearm. These nodules were tender and painful. There was no regional lymphadenopathy. Debridement of the lesions was performed and the tissue was submitted for bacterial and fungal cultures. The Gram-stained smear showed polymorphonuclear leucocytes and Gram-positive fine, branching filaments, partially acid-fast, with a tendency to fragment into coccoid and bacillary forms. | Dermatology/Infectious diseases |
After 5 days of incubation cultures of the pus and the tissue on Columbia blood agar grew white colonies adherent to the agar, rough with a velvety surface, having a characteristic mouldy odor . Colonial characteristics, physiological properties and biochemical tests performed identified the isolate as Nocardia brasiliensis (Table 1 ). Susceptibility to the antibiotics by the determination of the MICs using the E-test method (AB Biodisk, Solna, Sweden), showed that the isolate was sensitive to trimethoprim-sulfamethoxazole, amoxicillin-clavulanic acid, gentamicin, tobramycin, amikacin, and minocycline, intermediate to ciprofloxacin and resistant to ampicillin, second and third generation cephalosporins, erythromycin, clindamycin, ofloxacin and pefloxacin. The patient's antimicrobial therapy was changed to intravenous trimethoprim-sulfamethoxazole (160/800 mg b.i.d). The patient responded to therapy. Following 2 weeks of treatment the patient improved and all laboratory tests returned to normal. He was discharged 3 weeks after his admission on oral trimethoprim-sulfamethoxazole (160/800 mg b.i.d). The antibiotic therapy was continued for a total of 3 months. His hand and arm lesions were healing well and 6 months later revealed complete resolution of the infection without signs of recurrence. | Microbiology |
The present case is consistent with the classical presentation of lymphocutaneous infection with a primary lesion at the site of injury on the hand and an ascending lymphangitis involving the forearm. The inoculation probably occurred from the cotton that had been contaminated by Nocardia and entered the wound after the accident. | Infectious diseases |
A previously-healthy young woman developed behavioral changes followed by seizures and refractory status epilepticus. She was diagnosed with encephalitis and treated with antiviral and multiple antiepileptic agents. She required nasotracheal intubation and mechanical ventilation for respiratory support. She experienced persistent episodes of facial twitching resembling seizures. These episodes were not however associated with an ictal EEG pattern on continuous video/EEG monitoring. To clarify the nature of these episodes, 99mTc-HMPAO was injected during a period of frequent twitching. Brain SPECT showed a prominent focus of increased uptake interpreted by the radiologists and clinical team as arising in the upper brainstem A repeat study (using 99mTc-ECD) two weeks later, when twitching was no longer occurring, showed resolution of this increased uptake . These findings were considered to support a diagnosis of seizures/repetitive myoclonus originating from the brainstem. Although brainstem seizures in humans remain a controversial entity, there are reports in the medical literature of seizures and seizure-like movements related to brainstem lesions making this a plausible diagnosis in this case, based on clinical, EEG and SPECT findings. Antiepileptic and supportive treatment were continued, but the patient's disease proved fatal. No autopsy was performed. | Neurology |
The pancreas is an uncommon location for solitary metastasis from other primary cancers . Despite this, in large autopsy series the prevalence of pancreatic metastasis has been described to be as high as 6% to 11% . Whereas renal cell carcinoma appears to be the most common primary tumor to cause secondary pancreatic tumors, a variety of other cancers may spread to the pancreas, such as colon cancer, non-small cell lung cancer, and sarcomas . This article presents the case of a pancreatic metastasis presenting as first site of gastric cancer recurrence four years after primary diagnosis. | Oncology |
A 60-year-old woman presented with elevated blood levels of the tumor markers CEA (17.3 μg/L, normal <2.5 μg/L) and CA 19-9 (121 U/ml, normal <37 U/ml). Four years before being referred to our institution, the patient had undergone gastric resection (Billroth II gastrectomy) for an adenocarcinoma of the stomach. The tumor was located at the lesser curvature of the gastric antrum, measuring 3 cm in the largest diameter. Pathologic examination revealed a gastric carcinoma of low differentiation, which infiltrated the gastric wall into the subserosal layer without penetrating the serosa. Microscopically, the carcinoma was mainly composed of tubular formations of mitotically active, atypical epithelial cells . The tumor also displayed areas of marked desmoplastic stromal reaction, as well as areas of rather glandular differentiation. The latter two were mainly observed in paragastric lymph node metastases . The carcinoma at stage pT2 pN1 (6/15) M0 G2 was completely resected (R0 resection). No recurrence was detected during the regular follow-ups. | Oncology |
A 62-year-old woman was referred to the Plastic and Reconstructive Surgery Department for treatment of a bleeding exophytic tumor located on the right inner canthus. She had had the lesion for approximately 11 years. Initially, the patient was treated with excision and primary closure ten years ago. At this time the tumor had a diameter of 5 cm. The tumor was diagnosed as adenoid BCC microscopically and surgical margins were tumor-positive. The patient was operated on two years later when the diameter of the recurrent tumor was 15 mm. Histological examination of this second specimen revealed an "adenoid BCC" with clear surgical margins. | Oncology and Dermatology (more specifically, Surgical Oncology) |
Although the tumor recurred again after the second excision, the patient neglected medical advice and did not undertake any treatment . More recently, however, the tumor began growing rapidly and became hemorrhagic. On examination the lesion was located on the right inner canthus and involved 1/3 of the eyelid. The size of tumor was approximately 55 mm × 45 mm. Visual functions of the patient were normal. However, a fixed mass developed in the patient's periauricular area six months ago , although there were no palpable cervical nodes. We therefore investigated this region with computed tomography (CT), which revealed a tumor involving the right orbital structures extending to the ethmoidal cells. The tumor also involved the right parotid gland and multiple cervical lymph nodes. | Ophthalmology and Oncology |
A 66 year old male with history of rheumatic heart disease and aortic valve replacement (AVR) (twice for severe native and subsequent prosthetic valve regurgitation) presented with progressive worsening fatigue, exertional dyspnea and paroxysmal nocturnal dyspnea. His other medical problems included poorly controlled hypertension and hyperlipidemia. Following his second AVR 4 years prior to this presentation, a routine follow-up 2-dimensional echocardiogram (TTE) had shown preserved left ventricular and prosthetic valve function and a aorto-atrial fistula with color flow between the aorta-and the left atrium. Notably, only a soft and short ejection murmur across the mechanical prosthesis was appreciated and no continuous murmurs were heard. This was felt to be a possible postoperative complication currently not of clinical significance given his asymptomatic status and he was treated medically and did well for the last 3–4 years. | Cardiology |
Physical examination during this visit revealed an afebrile patient with a blood pressure of 138/84 mm Hg, regular pulse of 84/minute. An ejection systolic murmur (2/6 in intensity) was heard all over the precordium likely from the flow across his prosthesis. No continuous murmurs were heard. No evidence for clinical heart failure, anemia, jaundice or infection was noted. Laboratory tests revealed no leukocytosis and blood cultures were negative. Given prior echo documentation of fistula and new symptomatology suggestive of heart failure, a transesophageal echocardiography (TEE) was requested for more detailed assessment of prosthesis and AAF. TEE revealed normal left ventricular function, normal aortic prosthesis function with trivial aortic regurgitation. An echolucent area above the mechanical prosthesis, close to the left atrium near the orifice of the left coronary artery was noted. There appeared to be expansion of a portion of this lucency into the left atrium during systole suggesting communication with the aorta with turbulent color flow from the aorta into the left atrium (suggestive of AAF) throughout the cardiac cycle but mainly in systole as shown by color and continuous wave doppler . Compared to the prior 2-D echo there appeared to be mild left atrial dilation, mild left ventricular hypertrophy and significantly more prominent fistula flow suggesting either progressive shunting and enlargement of the fistula over time or underestimation by the prior 2-D echo. Although the echocardiographic findings mimicked changes which could also be related to endocarditis (abscess around prosthesis with pseudoaneurysm formation), the absence of any obvious vegetations or prosthetic malfunction combined with lack of clinical and laboratory evidence of endocarditis favoured a more slowly progressive postoperative complication rather than an infectious process . Based on his heart failure symptoms and progressive increase in AAF size and flow, surgical correction was recommended. He underwent uncomplicated surgical repair of the AAF which was found during surgery to be inferior to the left coronary ostium. No evidence of abscess or infection was found and the prosthesis appeared intact and healthy. The echo lucent area represented a postoperative weakening of the aortic wall adjacent to the left atrium, predisposing to the fistula formation and was also repaired. Intra-operative TEE showed no residual fistula by color flow at the site of repair. | Cardiology |
Recurrent dislocation of the patella can follow a violent initial dislocation, but occur more often in knees with one or more underlying anatomic abnormalities that predispose the patella to dislocation or subluxation. In these knees, less trauma is needed for dislocation to occur. The underlying pathologic condition causes an abnormal excursion of the extensor mechanism over the femoral condyles. High-riding patella (patella alta) and a damaged medial patellofemoral ligament at the time of first episode of dislocation leads to such an abnormality and leads to recurrent dislocation of the patella . Patella alta has been reported in patients with below knee amputation using patellar tendon bearing prosthesis. The usual treatment in these cases is surgical reconstruction. We present a case of bilateral recurrent dislocation of the patella with below knee amputation which was managed conservatively. | Orthopedic surgery |
A 25 years old bilateral below knee amputee presented with recurrent dislocation of the patella while walking on knees in emergent situations on uneven ground without the prosthesis. Amputation was performed at the age of 15 years as a result of train accident. Since then he has been using patellar tendon bearing (PTB) type below knee prosthesis on both sides. First episode of dislocation occurred after 5 years of amputation. The patient used to walk on his knees without using the prosthesis for in-house activities on uneven ground. His patella used to dislocate whenever there was an unnoticed pressure on the medial side of the knee. On clinical examination, patella alta and positive apprehension test were noted on both sides. The ratio of patellar length to patellar tendon length was 0.8 on both sides demonstrating relative elongation of the patellar tendon. The normal ratio is 1.0 . Modified shoes were given to the patient which were moulded in the inner surface around the patellar tendon and femoral condyles to provide uniform distribution of weight over a wider area. Another moulding was done on lateral side that prevented excessive movement of patella laterally [Fig. 1 ]. The patient was allowed to walk on knees after wearing these shoes [Fig. 2 ]. At 6 months follow up the patient is doing well with no recurrence. | Orthopedic surgery |
Osteoid osteoma is a rare benign osteoblastic lesion usually involving the long bones of the lower limbs. Cranial involvement has been mainly localised to the skull vault. Osteoid osteoma of the skull base is a rare entity . Surgical management of skull base osteoid osteoma may be challenging due to its proximity to vital structures, access and hard consistency. This report deals with a case of an ethmoidal osteoid osteoma invading the adjacent orbit and anterior cranial fossa and the team approach employed to achieve radical excision. The radiological findings and the surgical procedure employed are presented. | Neurosurgery |
A 33 year old male presented with decreased vision in the left eye and left sided headache of 3 months duration. Examination revealed left eye blindness with primary optic atrophy and no other neurological deficit. Imaging revealed a bony tumor in the left ethmoid sinus invading the left orbit and compressing the left optic nerve. Intracranial extension into the anterior cranial fossa on the left side was noted . Core biopsy of the mass showed an osteoid osteoma. | Neuro-ophthalmology |
A multispeciality team approach was devised to achieve radical excision of the tumor. Bicoronal scalp flap and pericranial flaps were raised separately. A single burr hole left fronto orbital bone flap was raised including the orbital roof and left zygomaticofrontal process . Dura was retracted and the bony hard whitish tumor visualised. This was excised using the high speed drill . Weber Ferguson incision was used to access the orbital portion of the tumor. Medially the tumor could be felt in the orbit but retraction of the globe was difficult. Hence inferior orbitotomy was done by removing the lower and lateral orbital margins. The intraorbital contents could now be retracted laterally and the tumor visualized . The tumor was then detached from the ethmoid sinus and the intraorbital extension excised. The ethmoidal portion was drilled and radical excision achieved . Dural tears were covered with temporalis fascia and glue. The ethmoidal sinus was packed with free temporalis muscle graft. Vascularised pericranial graft was used to cover the anterior skull base. The frontal sinus was exenterated and packed with gelfoam. The bone flap and orbital margins were replaced. | Neurosurgery |
An 18-year-old Caucasian male with type 1 diabetes presented to the emergency department complaining of severe left knee pain and swelling after sustaining a knee injury that occurred during a high school football match. Joint effusions were visible and palpable above the left knee, and there was significant loss of smooth motion of the knee, passively performed. Plain X rays showed no signs of fractures. The patient had had type 1 diabetes for six years, and his insulin regimen consisted of insulin glargine, 35 units at 8:00 p.m., and insulin lispro, 23 units at 8:00 a.m. and 16 units at 8:00 p.m. The patient had no apparent complications related to type 1 diabetes. | Orthopedics |
In the present case report we discuss the efficiency of the strategy of exposure minimization to allergens by the use of a milking robot, i.e., an automatic milking system (AMS) as an alternative measure to total elimination of allergens for the prevention of occupational asthma caused by cow hair allergy. | Allergology/Occupational medicine |
The female subject is the second child from consanguineous parents (second cousins) . The subject's mother and an uncle were affected with pseudoxanthoma elasticum, an inherited disorder of connective tissue. At birth, the subject had cutaneous xerosis and mild skin indurations of the lower limbs. At 1 month, she developed more severe skin stiffening on the lower limbs, trunk, and extensor areas on the forearms, accompanied by functional limitation in leg extension. Mild perioral cyanosis was also visible. A skin biopsy was performed at 2 years of age and histological analysis revealed fibrous thickening of the lower dermis, subcutaneous septa, and fascia, accompanied by a few mucinous deposits. Weigert staining showed pronounced rarefactions of elastic fibers. A dermal fibroblast culture was established from the biopsy sample. Physical examination of the subject at age 5 years revealed loss of subcutaneous tissue, especially on the face and limbs, and thickening of the skin that appeared shiny and taut in most areas. She also had a small face with a recessed chin, thin beaked nose, small ears, prominent eyes, prominent scalp veins, and alopecia. | Dermatology |
A 52 years old female attended the breast clinic with a cystic mass superior to the left nipple. Clinical FNAC of this mass was performed (using a 23 gauge needle and 10 cc syringe) yielding 5 cc of straw-coloured fluid. Subsequently the patient had digital mammography. Thereafter, she complained of a difficulty in breathing and a subsequent chest X ray confirmed the presence of left-sided pneumothorax which treated with per-cutaneous aspiration. The patient was admitted overnight for observation and a follow up chest X-ray showed resolution of the pneumothorax. The post-procedure mammogram showed an area of architectural distortion and irregularity in the medial aspect of the left breast which was regarded as suspicious. Three days later, this was subjected to an ultrasound guided core biopsy of the lesion and histology showed severe atypical hyperplasia. Ultrasound guided excision of the lesion was performed and the final histology showed radial scar, a 7 mm grade I infiltrating ductal carcinoma associated with ductal carcinoma in situ (DCIS). The surgical margins were clear. The patient subsequently had a sentinel node biopsy using the dual localization technique under local anaesthesia. | Oncology |
In our case, the patient has an absence of the costo-sternal portion of the pectoralis major muscle on the same side where the breast FNA was performed, therefore the thickness of the chest wall behind the breast was much smaller than the contra-lateral side, therefore increasing the risk of inadvertent pneumothorax. Our patient has no obvious deformities. However, subsequent mammogram and clinical examination showed an absence of the pectoralis major; a case which is related to a rare condition called Poland's syndrome. | Radiology |
Pneumothorax in patients with Poland's syndrome has been previously reported but not in association with breast FNAC. Luh et al described two patients with Poland's syndrome anomalies presented with spontaneous pneumothorax. To the best of our knowledge our case is the first report of pneumothorax after FNAC of a breast lump in a woman with Poland's syndrome. We have also diagnosed an incidental screen-detected breast cancer affecting the ipsilateral breast. | Oncology |
A 82-year old lady presented to the Department of General Surgery at the University of Heidelberg, Germany with recurrent attacks of hypoglycemia and a large abdominal mass. While diagnostic tests repeatedly documented glucose levels below 40 mg/dl (normal levels 80 – 120 mg/dl), a computed tomography (CT) scan of the abdomen revealed a large lesion of around 5 to 6 cm in relation to the pancreatic body and tail. There were also large masses of about 3–5 cm in the retroperitoneum and in the area of the celiac trunk and around the mesenteric artery. Furthermore, in the pancreatic body there was a hypervascularized area , that was suspicious for an insulinoma. Clinically this lady, who was not thriving, reported a weight loss of 12 kilograms over the previous 4 months. A somatostatin receptor scintigraphy showed an enhanced uptake in the region of the pancreatic body/tail as well as in the right axilla (a palpable mass was also noted there) and excluded the possibility of other involved areas. | Endocrinology |
She gave a past history of an operation done on the right eyebrow 2 years prior for a 0.8 × 0.8 cm lesion that was reported as a Merkel cell carcinoma. Histopathology showed rather uniform tumor cells in a trabecular growth pattern with monomorphous pale-stained nuclei and many mitoses . There was invasion of dermal lymphatics and blood vessels . Immunohistochemistry revealed strong positivity for cytokeratin 20 and neurofilament (not shown) in the characteristic dot-like pattern and a weak expression of chromogranin A . After excision, radiation therapy was also administered only at the site of the primary lesion, the draining lymphatic vessels and the first lymph node station. A year later, a large abdominal mass was noted of uncertain origin and an ultrasound guided biopsy showed an unspecified small cell cancer. In view of the large mass with additional suspicious areas being noted in the spleen, left adrenal gland and axilla, she had been subjected to palliative radiotherapy of 30 Gray over 2 months. However no definitive diagnosis of metastasis in these areas was established. With a working clinical diagnosis of symptomatic insulinoma not responding to medical measures, a decision for surgical resection of this large lesion was inevitable, the age of the patient and the previous history of palliative radiation just 6 months prior notwithstanding. | Oncology |
Surgical exploration revealed a large mass of about 5 cm in the tail of the pancreas, in close proximity to the spleen and the splenic flexure of the transverse colon. However there was no evidence of any metastatic disease to the liver, peritoneum and the adnexae. After a careful and meticulous mobilization, a distal pancreatectomy, splenectomy, and adrenalectomy along with resection of the splenic flexure of the colon were performed. | Surgery |
Our case adds some more information to the existing pool of knowledge about this tumor. It is well documented that treatment principles of this rare tumor revolve around adequate surgical resection and the addition of radiotherapy . In systemic disease, many combinations of chemotherapeutic agents have been used with poor results ; although in a recent study, Merkel cell carcinoma was chemosensitive but rarely chemocurable in patients with metastases or locally advanced tumors . While this elderly lady was possibly subjected to palliative radiotherapy given the extent of her abdominal mass, her unrelenting symptoms and the fact that age over 60 years is a poor prognostic factor in Merkel cell carcinoma prompted us to consider a surgical resection in spite of her advanced age. However, the symptoms (severe hypoglycemia) were not related to the metastatic Merkel cell carcinoma, but to the concomitant insulinoma. While her symptoms completely resolved due to excision of the insulinoma, the R0 excision of the Merkel cell carcinoma could also be expected to provide survival benefit; however this remains to be seen on longer follow-up. | Oncology |
A 73 year-old male patient, with a previous PTCA (percutaneous transluminal coronary angioplasty) of the left anterior descending artery and ramus intermedius, underwent a dipyridamole stress testing following a nondiagnostic exercise EKG (the exercise was terminated because of the occurrence of non sustained ventricular tachycardia). The baseline echo revealed an apical hypokinesis ( additional file 1 ) which did not change during the test, however ventricular tachycardia developed again during dipyridamole echo ( additional file 2 ). Lesson: it is useless to expose a patient with known coronary artery disease and a previously complicated test to another stressor. Indication must be appropriate. | Cardiology |
An 81 year-old female, with symptomatic and hemodynamically significant aortic stenosis and normal coronary angiogram underwent a high dose dipyridamole stress echo testing. The baseline wall motion was normal ( additional file 3 ). The patient fell in cardiogen shock and had a transient ischemic attack of the brain following a negative test ( additional file 4 ). Lesson: another dangerous experiment on a patient with already diagnosed normal coronary arteries. Indication must be always appropriate. | Cardiology |
A 57 year-old male patient with abdominal pain and claudicatio intermittens was studied with dobutamine echocardiography. Soon after the first (5 mcg/Kg/min) dose the patient had ventricular extrasystoles ( additional file 5 ) and during the 20 mcg/Kg/min dose of dobutamine, Torsade de points ventricular tachycardia evolved ( additional file 6 ). Lesson: in patients with arrhytmias in resting conditions, dobutamine can often provoke dangerous tachycardias. In this group of patients dipyridamole could be the first choice. | Cardiology |
A 55 year-old male patient with previous posterior myocardial infarction, quadruple by-pass, depressed left ventricular function and chest pain was sent to the echo lab for assessment of myocardial viability ( additional file 7 ). Low dose dobutamine echo was performed, however, following the 10 mcg/Kg/min dose a fatal ventricular fibrillation developed ( additional file 8 ). Lesson: there must always be an attending physician during pharmacological stress echo testing with all necessary equipment for reanimation. Dobutamine can provoke arrhytmias even in low doses. | Cardiology |
A 66 year-old male patient with a recent (12 days old) inferior infarction and inferior aneurysm underwent a high dose dobutamine stress test. A huge aneurysm of the inferior wall was present on the baseline echocardiogram ( additional file 9 ). The patient died following an acute cardiac rupture ( additional file 10 ). Lesson: indications for testing must always be first class, and in patients with recent infarction and aneurysm dipyridamole should be the first choice. | Cardiology |
It has been suggested that when patients suffer unexpected findings or develop multiple complications after any intervention, adverse outcomes might be expected if a strategy is not promptly implemented to identify the offending or triggering mechanism(s). In this case we present a patient who underwent surgical resection of filamentous aortic valve masses, closure of a patent foramen ovale, and performance of a modified Maze procedure for atrial fibrillation who then developed a series of unusual post operative events heralded by hemodynamic deterioration, dyspnea and rapidly progressive dilatation of superficial neck and facial veins, resembling a superior vena cava syndrome; two days post surgery. A careful retrospective examination of all clinical data is presented with a detailed review of all possible clinical entities. | Cardiology |
A 72-year-old woman with chronic atrial fibrillation, temporal arteritis, and avascular necrosis of the right hip requiring hemiarthroplasty that was complicated by deep venous thrombosis in the past, now presents with new onset left upper extremity clumsiness. A head computed tomography (CT) scan and subsequent magnetic resonance imaging study revealed a hemorrhage into the right parietal and occipital regions of the brain. In view of these findings, warfarin therapy was discontinued and as part of the workup a transesophageal echocardiogram (TEE) was performed and revealed a 4 × 6 mm mass on the aortic valve and a patent foramen ovale (PFO) with bidirectional shunting (right to left after the intravenous injection of agitated saline), mild bi-atrial enlargement, mildly dilated but normally functioning right ventricle, normal left ventricular systolic function and no significant valvular regurgitation. The patient was afebrile and blood cultures were negative. The patient was referred to our institution for surgical evaluation given the TEE findings and the patient clinical presentation. Surgical resection of the aortic valve mass and closure of the PFO were recommended. | Cardiology |
Upon examination of the aortic valve, a filamentous mass was identified on the leading edge of the noncoronary cusp midway between the ranula and the commisure. The mass was excised with sharp dissection. A second 2 × 3 mm mass was also observed on the underside of the leaflet and was excised in a similar fashion. Lesions were also observed at the commisure and on the left coronary cusp and were also excised. Pathologic examination subsequently revealed that these lesions were small fragments of myxoid tissue with hyalinization. A modified Maze procedure was also performed at the time of surgery and it required mobilization of the pulmonary veins bilaterally with application of radiofrequency lesions just proximal to the entrance of the left and right pulmonary veins. Another radiofrequency lesion was placed at the base of the left atrial appendage and this was then excised and then over sewn. Finally, the right atrium was then opened in a longitudinal fashion, the PFO was identified at the cephalad portion of the fossa ovalis and was then closed in a running fashion. | Cardiac Surgery |
The patient was weaned from bypass without incident and a TEE performed in the operating room revealed no residual masses on the aortic valve or right to left shunt. However, a mild degree of tricuspid regurgitation was now identified for the first time. Both right ventricular size and systolic function remained normal. The patient was taken to the intensive care unit in stable condition and the immediate post-operative course was unremarkable. There was no need for either vasopressor or ionotropic support and the patient was extubated on the first post-operative day and subsequently transferred to a step down unit. | Cardiology |
The patient did well until the night of the second post-operative day when she developed oliguria that progressively worsened followed by tachycardia and hypotension. At this time, a pronounced jugular venous distention was noted and a bedside transthoracic echo was immediately obtained to rule out the presence of pericardial tamponade. No pericardial effusion was noted; however, severe tricuspid regurgitation was now noted with dilatation and dysfunction of the right ventricle. In view of these findings, a spiral chest CT was requested but there was no evidence of pulmonary embolus; however, both superior as well as inferior vena cavae were dilated. The pericardium thickness was reported as normal. Because the clinical deterioration persisted, the patient was taken back to the operating room for mediastinal exploration; only a small amount of pericardial fluid was removed. Although the pericardial sac appeared to be under tension, no clot was found after extensive exploration. | Cardiology |
Despite a trial of medical management, the patient's cardiac index remained low and all facial and neck veins became progressively and markedly engorged. A repeated TEE demonstrated marked dilatation of the right-sided chambers with severe reduction in right ventricular systolic function and severe tricuspid regurgitation as a result of an incomplete coaptation of the tricuspid valve leaflets . During this TEE, normal left ventricular contractility was noted with no regional wall motion abnormalities, with the exception of a paradoxical septal wall motion as expected post recent surgery, and normal left ventricular systolic function. In addition, pulsed interrogation of all four pulmonary veins showed normal velocities in order to rule out post-surgical Maze procedure pulmonary vein stenosis. No visible alteration in either the main or secondary pulmonary arteries was seen by TEE or CT. Although a clear unifying mechanism that would encompass the hemodynamic deterioration as well as the disproportionate symptoms of dyspnea with the rapidly progressive dilatation of all superficial neck and facial veins could not be given, it was clearly evident that the incomplete coaptation of the tricuspid valve leaflets, as seen on TEE, would certainly continue to further deteriorate the current clinical condition. Therefore, the patient was taken to the operating room again and upon opening the right atrium, the dilatation of the tricuspid valve annulus was confirmed resulting in failure of coaptation of the otherwise normal appearing tricuspid leaflets. Tricuspid annuloplasty with a 34 mm Cosgrove band was performed with marked improvement in cardiac output not requiring further inotropic support. A postoperative TEE revealed no evidence of residual tricuspid regurgitation and the chest was closed. The remainder of the patient's post-operative course was uncomplicated. Unfractionated intravenous heparin was started once the surgeon felt it was safe to maintain a therapeutic activated partial thromboplastin time. The pronounced engorgement of her neck and face veins resolved and she remained hemodynamically stable. After the 5 th postoperative day, the patient was transferred to a rehabilitation facility. At one-month follow-up, the patient has remained in atrial fibrillation, but is otherwise doing well. | Cardiology |
This case demonstrates an unusual sequence of post operative events that occurred after surgical resection of filamentous aortic valve masses, closure of a patent foramen ovale, and performance of modified Maze procedure for atrial fibrillation in a patient presenting with transient neurologic findings. The inconclusive nature and contradictory results of diagnostic testing made it difficult to accurately identify the responsible mechanism(s) and reminds us that in order to clearly solve any clinical mystery we have to review all possibilities, and despite the unclear nature of objective evidence, whatever remains, though improbable, must in the end make sense and indeed might be the most simple explanation. | Cardiology |
This case demonstrates an unusual post operative course of events and physical findings in which a unifying diagnosis was difficult to identify given the conflicting nature of diagnostic testing. We present a careful retrospective examination of all clinical data and review possible clinical entities that could have been implicated in this particular case. In addition, we point out how TEE findings were most useful in identifying the best course of action. We postulate that in our case, resolution of the PE with anticoagulation and reestablishment of a normal right ventricular geometry with tricuspid valve repair worked in unison in restoring normal hemodynamics and resolving both dyspnea and venous dilatation. | Cardiology |
An 11-year-old female with a history of migraine headaches and exercise-induced asthma (EIA) was evaluated in the Allergy clinic two months after experiencing symptoms while holding a guinea pig at her hairdresser's home. This was the only episode of symptoms associated with guinea pig exposure; she had handled the pet previously without exhibiting symptoms. Within minutes of holding the guinea pig, she developed ocular itching, lacrimation, and periorbital angioedema. Symptoms rapidly progressed to facial urticaria and angioedema, rhinorrhea, throat tightness, and dyspnea. She had difficulty speaking, repeatedly attempted to clear her throat, and expressed feelings of impending doom. There was no coughing or audible wheezing. | Allergology |
A 24-year-old female smoker with allergic rhinitis, EIA, and known cat-induced rhinitis was evaluated for a several year history of perennial rhinitis and conjunctivitis. She also described an episode of severe allergic symptoms resulting from guinea pig exposure. Within minutes of cleaning her pet guinea pig's cage, she developed throat tightness, severe dyspnea, and anxious feelings. She denied coughing, wheezing, and urticaria. A feeling of "impending doom" was not specifically stated. Her symptoms resolved spontaneously one hour after departing outdoors. She did not take medication or seek medical attention. | Allergology |
A 59-year-old man was admitted to Coronary Care Unit because of suspected ST-segment-elevation myocardial infarction. The patient was complaining of typical coronary chest pain during the last twelve hours. He had a history of dyslipidemia, type 2 diabetes mellitus, smoking habit and a transient ischemic attack without any sensitive or motor squele one year ago. On admission, his blood pressure was 100/60 and heart rate was 110 beats per minute. Cardiac examination revealed jugular vein distension, and no significant heart murmurs. The ECG showed significant Q waves in II, III and aVf leads with mild ST-segment elevation in leads II, III, aVf and V4R. The chest radiograph revealed no cardiomegaly and clear lung fields. Transthoracic echocardiography was performed showing akinetic inferoseptal, inferior, and inferolateral segments with estimated left ventricular ejection fraction of 45%, right ventricle showed a global hipokinesia with severe systolic dysfunction and inferior vena cava plethora. The patient was initially treated with aspirin, low-molecular-weight heparin, dobutamine and saline infusions, and was scheduled for early catheterization. Coronary angiography showed total occlusion of right coronary artery proximal segment and two additional 70% stenoses in the first diagonal and obtuse marginal branches. Percutaneous revascularization was dismissed after a failed attempt of right coronary artery opening, then, the patient was treated using conservative medical therapy (aspirin 100 mg/day, clopidogrel 75 mg/day, simvastatin 20 mg/day and enalapril 10 mg/day), anticoagulation was maintained for 72 hours, and beta blocker therapy was not started because Mobitz I atrioventricular block phases were detected in continuous ECG monitoring. The later clinical outcome in the Coronary Care Unit was favourable, and the patient was discharged six days after to cardiology hospitalization unit. Nine days after hospital admission, the patient complained about sudden chest pain and rest dyspnea, his blood pressure was 80/40 and cardiac examination revealed a new harsh, holosystolic murmur along the left sternal border. Transthoracic echocardiography was immediately performed showing complex ventricular septal defect with a dissection tract that originated on left side of the basal inferoseptal akinetic segments, extended beyond the septum dissecting the right ventricular wall, and subsequently re-entered into the right ventricle chamber . No significant right ventricle outflow tract obstruction was present. The patient was scheduled for immediate surgical intervention, and hypothermic cardiopulmonary bypass with myocardial protection was established in the following two hours. The septal rupture was approached through the infarct, and prosthetic material (Gore-Tex ® patch) was used to reconstruct the septum, additionally, two bypasses using vein grafts were done in first diagonal and posterior descending arteries. Postoperative evolution was favourable with rapid resolution of cardiogenic shock situation. One month later transesophageal echocardiography was performed showing neither right ventricle dissecting tract or residual shunt. Left ventricular ejection fraction was 55%, and right ventricular systolic function was only mildly depressed. At six-month follow-up the patient remains stable and without any cardiac symptoms. | Cardiology |
In patient 13 with a favorable response to embolization of the right hepatic artery, embolization of the left hepatic artery was technically impossible because of a vascular anomaly. He was subsequently treated with multiple passes of RFA percutaneously for two large lesions (6 and 7 cm in diameter) in the let lobe under spinal anesthesia leading to a further reduction in 5-HIAA excretion. However, although CT scans after RFA showed no recurrence of tumor, duration of decreased 5-HIAA values lasted only 3 months and a relief of symptoms could not be obtained. | Oncology |
A 25 year old male patient was admitted with a diagnosis of Eales' disease and a non-resolving vitreous hemorrhage involving the left eye of 2 months duration. Ultrasound evaluation of the posterior segment revealed findings consistent with an organized vitreous hemorrhage and incomplete posterior vitreous detachment. Transconjuctival sutureless pars plana vitrectomy was planned using the Bausch and Lomb 25G vitrectomy system. Per-operatively, sleeve for the infusion line was first placed in the inferotemporal quadrant transconjunctivally using the 25 G trocar. After inserting the infusion line through the above sleeve, two more sleeves for the endo illuminator and vitreous cutter were made using the 25G trocar transconjunctivally. Vitrectomy was started using high cut rates and suction of 500 mm Hg. A fibrovascular frond was noted attached to the disc, which had to be diathermised. To accommodate a conventional unimanual bipolar diathermy probe a localized peritomy was made and the superonasal sclerotomy was enlarged using a 20 G MVR blade. The frond was diathermised, endolaser pan retinal photocoagulation was completed and the conventional sclerotomy was closed using 6-0 vicryl mattress suture placed at a depth of about 75% of the scleral lip. Vitreous was well cleared from this wound opening using the vitrectomy probe around the edges of the sclerotomy before closure. The sleeves of the remaining two 25 G sclerotomies were removed and the overlying conjunctiva was slightly massaged in that area. No wound leak was noted at the end of the procedure. Postoperatively intraocular pressure of 10 mm Hg was recorded. | Ophthalmology |
Mr BL, 31 years old, was a Congolese (DRC) male who was born in Kinshasa and who lived since 1998 in Muanda (Bas-Congo Province). On the 11 th of October, 2004, he was brought by his family to the General provincial Hospital of Kinshasa because he showed troubles of consciousness that had started on the previous day. Before mid-2004, the patient had no special medical history, except haemorrhoids. In July 2004, he complained of abdominal pains, which were more important in the pelvic region, and accompanied by diarrhoea. He treated himself with the traditional plants he took usually to treat his haemorrhoids. This was followed by an improvement in his diarrhoea but some time later the patient noticed the appearance of oedema of both lower limbs and he complained of a slight distending of abdomen. He treated the oedemas by local applications of a paste made of a mixture of plants. The oedemas diminished a little, but the patient then noticed the appearance of transient swellings of both upper limbs, accompanied with itching, that he treated with promethazine oral syrup during one week. The itching disappeared but the persistence of the oedema of the lower limbs one month after their appearance prompted the patient to go to Kinshasa so as to receive an appropriate treatment. On the 20 th of September, he went to a health centre and, in addition to the oedema, a fever was noticed by the nurse. A blood smear was prepared, which showed a light infection with Plasmodium (noted as + on the laboratory register), and a treatment with oral quinine and paracetamol was given. By the 8 th of October, the patient showed a fever in the evening during two days. This was then accompanied with an oliguria, the appearance of an oedema of the face on waking, and an asthenia. In the morning of the 11 th , the patient presented a functional impairment and troubles of consciousness which prompted his family to bring him to the General provincial Hospital of Kinshasa (GHK). | Tropical medicine |
At admission to the GHK, on the 11 th of October (Hospital Day 1, HD1), the patient presented with confusion, a swelling of the face, and a pitting oedema of the lower limbs. The temperature was not measured but the patient had a mild fever to the touch. The abdomen was soft, and no organomegaly was found. The blood pressure was 110/80 mmHg and the respiratory frequency, 20 breaths/min. There was no neck stiffness, the palpebral conjunctivae were normal, and bronchial breath sounds were found at auscultation. The rest of the examination was normal. The results of the laboratory tests performed the same day were as follows: low haematocrit, at 28% (normal value: 42–54%); leukocytosis at 12,000/mm 3 ; normal glycemia at 0.98 g/l; presence of Plasmodia in the thick blood smear (1 to 10 parasites per microscope field); albuminuria +++ on dipstick urine analysis; absence of glycosuria; and presence, in the urine, of red blood cells (10/field) and of leukocytes (10/field; normal value:< 5/field). A diagnosis of nephrotic syndrome associated with a severe malaria was proposed. An intravenous treatment with furosemide, cefotaxime, and quinine, was started. A permanent urine catheter was put in place, in order to measure diuresis. Additional biological examinations, and an abdominal echography were prescribed. | Nephrology |
On HD2 and HD3, the patient was in stage I coma, i.e. responded to pain by more or less comprehensible words. After an episode of agitation during the night of the HD2, he was calm, and still subfebrile to the touch. The rest of the condition was similar to the one recorded at admission. On HD3, the sedimentation rate was high, at 120 mm per hour; the leukocyte count had become normal at 4800/mm 3 ; and a new blood smear still showed the presence of Plasmodium , but at a very low density (1 parasite per 100 fields). On the HD4, an echography was performed, whose results were as follows: "kidneys of normal size and morphology, but with a marked loss of the cortico-medullar differentiation, making them almost white; liver increased in volume, but normal in its morphology and homogeneous in its structure; presence of an ascites, principally pelvic". It was concluded that the images were strongly suggestive of a bilateral glomerulopathy, associated with an hepatomegaly which was probably reactional to the renal disease. On HD5, the patient, whose clinical condition was stable, was transfered to the Cliniques Universitaires de Kinshasa (CUK) for more extensive investigations. | Nephrology |
On admission to the Emergency Unit of the CUK, the patient was in stage II coma (i.e. he responded to pain by no or incomprehensible sounds, but by an appropriate motor response), without neck stiffness. He still presented a swelling of the face, with an important oedema of the eyelids which obstructed completely his left eye. The oedema of the lower limbs was still present, the abdomen was slightly distended, and a moderate ascites was found. The temperature was 37.7°C, the blood pressure was 130/90 mmHg, and the respiratory frequency was 20/min. The results of the blood tests done on HD5 were as follows: marked anemia, with an haemoglobin concentration of 7.5 g/100 ml (normalvalues: 13–17); haematocrit still lower than at HD1, at 22%; normal leukocyte count, at 6800/mm 3 , with 79% neutrophils, 18% lymphocytes, and 3% eosinophils; urea: 1.05 g/l(normal: 0.10–0.42); creatinine: 29 mg/l(normal: 5–20); creatinine clearance: 27.6 ml/min(normal: > 60 ml/mn); glycemia: 1.13 g/l; sodium concentration: 138 mEq/l; potassium: 4.6 mEq/l. These results showed that the patient presented a marked chronic renal failure, with albuminuria and haematuria which, together with the echographic findings, suggested that it was due to a glomerulopathy. The hypothesis is raised that the renal failure might have been provoked by a possible nephrotoxicity of the traditional plants taken by the patient. Besides this, owing to the biological results, the degree of the troubles of consciousness and the clinical condition in general did not suggest an uraemic coma. The treatment implemented at the GHK, which included intravenous furosemide, cefotaxime and quinine was continued. A renal biopsy was prescribed, but later was not performed because of financial considerations. On HD6, the hypothesis was raised, that the neurological troubles would be due to a bacterial encephalitis or to a severe malaria. A new blood smear was prepared, in which no Plasmodium was found. On HD7, the calcemia was measured; it was at 4.6 mEq/l, i.e. close to the lower limit of normal (4.5–5.5); the bicarbonates were at 24 mmol/l (normal: 18 to 33). On HD8, a complete clinical examination was done again. Besides the troubles of consciousness, the oedema of the face and of the lower limbs, and the absence of renal bruit at auscultation, the examination showed several neurological signs which had not been noticed previously: a left facial paralysis, a convergent strabism of the right eye, an hypotonia of the right hemibody, a bilateral Babinski sign, and normal tendon reflexes. The hypothesis was raised that the neurological troubles might have been caused by an expansive intracranial process, including a cerebral abcess possibly related to an HIV infection. The patient was transfered to the Intensive Care Unit of the CUK. | Nephrology |
When he was admitted to the unit, on HD8, the patient was still in a stage II coma, without fever nor meningeal signs; the blood pressure was 120/80 mmHg, and the respiratory frequency, 24/min. The liver function tests performed the same day were normal (conjugated bilirubin: 9 mg/l; unconjugated bilirubin: 3 mg/l; ALAT: 3 UI/l; ASAT: 16 UI/l). A lumbar puncture was also performed and the cerebrospinal fluid (CSF) obtained was crystal clear, and showed no evidence of infection either at direct microcopic examination or after culture. A fundus examination showed narrowed retinal arteries, perivenous haemorrhages, several cotton-wool exudates, a slight macular oedema in the left eye, and well coloured and well limited papillae. On HD9, the neurological condition was stable, whereas the oedema of the lower limbs seemed to have regressed a little. New blood tests showed that the sedimentation rate was still high (150 mm per hour), an increase in the haemoglobin concentration (8.9 g/100 ml), a calcemia at 4.2 mEq/l and bicarbonates at 20 mmol/l. The results of the CSF tests were as follows: red blood cells: 79/mm 3 ; leukocytes: 2/mm 3 ; glucose: 0.68 g/l; proteins: 0.64 g/l (normal: 0.20–0.40); chloride: 126 mmol/l (normal: 120–130 mmol/l). The association of a high concentration of proteins with a low density of leukocytes was characteristic of an albumino-cytologic dissociation. A nasogastric tube was set up, in order to feed the patient with 400–600 ml of gruel and 300–400 ml of water per day, following the diuresis measured daily. | Neurology |
On HD10, the patient's clinical condition was similar with, in addition, a neck stiffness and an abolition of the tendon reflexes. The sedimentation rate was 124 mm per hour. As the possible intracranial process could be due to an abscess caused by pyrogens, the ongoing treatment with cefatoxime and quinine was completed by metronidazole. On HD11, the glycemia was at 1.47 g/l. On HD13, the hypothesis was raised that the neurological troubles might be due to a thrombo-embolic complication of the nephrotic syndrome. A cerebral CT scan was prescribed, but was not performed. Quinine treatment was stopped. On HD15, the patient who had remained apyretic until then, showed a fever at 38.6°C; the temperature became normal again two days after. On HD17, the leukocyte count was 7900/mm 3 , with 70% neutrophils, 20% lymphocytes and 10% eosinophils. On HD18, the treatment with metronidazole was interrupted, and though it was most unlikely that the condition would be related to stroke, a treatment by piracetam and multivitamins was started, whereas cefatoxime was continued. In spite of the continuing nursing care since the start of hospitalization, bedsores on the trochanters appeared on HD19. The patient was still in stage II coma. Bedsores on the coccyx apperared on HD23. On HD24, the urine protein excretion, quantified for the first time, was 1.30 g/24 h (normal: < 150 mg/24 h). On the same day, the blood pressure was found to be elevated on several instances, with diastolic values reaching or exceeding 100 mmHg. On HD25, the Glasgow coma score was 7/15 (eye opening: 4/4; motor response: 1/6; verbal response: 2/5). On the same day, a new lumbar puncture was performed, and the CSF was examined after double centrifugation to detect trypanosomes. No trypanosome was found, but three Loa loa microfilariae were counted. The other results concerning the CSF were as follows: glucose: 0.97 g/l; proteins: 0.98 g/l; chloride: 130 mEq/l; red blood cells: 2560/mm 3 ; leukocytes: 4/mm 3 ; absence of infection at direct examination and after culture; China ink stain to detect Cryptococcus neoformans capsules negative. Though the result on the red blood cells might mean that the CSF was contaminated with blood, and thus microfilariae, from a vessel injured during the tap, the presence of these Loa loa microfilariae suggested that the renal and neurological conditions of the patient might correspond to complications of a Loa loa infection. The same day, an HIV serology was done, which was found negative. | Infectious diseases and Nephrology |
The treatment by piracetam and vitamins was continued, and a treatment by enalapril maleate (Envas) and nadroparine calcium (Fraxiparine) was started to stabilize the blood pressure and prevent thromboembolic complications due to prolonged bed rest, respectively. Two options were considered to treat the Loa loa infection: diethylcarbamazine (DEC) associated with corticosteroids, and a treatment with Vofil – a speciality made of medicinal plants, manufactured and marketed in DRC – in association with astemisol, an antihistaminic. These treatments not being available, they were not administered to the patient. On HD27, the patient's clinical condition improved: he was in stage I coma. On HD28, the appearance of a productive cough prompted the medical team to start a treatment with carbocysteine syrup, which was replaced by acetylcysteine on HD30. On HD29, the haematocrit was 23% and the haemoglobin concentration was 8.2 g/100 ml. Treatment with nadroparine calcium was stopped, and replaced with aspirin at low dose. The clinical condition remained stable until HD34, when the patient was found lucid and coherent, to our great surprise. The nasogastric feeding tube was removed. During the following days, the patient was asthenic and appeared to be slightly out of touch with the reality, but he responded to verbal command and his level of consciousness improved progressively. He still showed mild pitting oedema of the lower limbs. A calibrated (50 μl) blood smear was prepared on HD35, and showed a high infection with Loa loa microfilariae (74,200 microfilariae per ml of blood). This result, and the favourable evolution of the condition, led to the project of treating the patient with DEC being abandoned. At that time, the patient was treated with piracetam per os, enalapril maleate, aspirin, multivitamins, and nursing care for his bedsores. We considered the possibility, as soon as the patient's condition would be satisfactory, of starting a long-term treatment with albendazole in order to decrease his Loa microfilaraemia progressively. On HD39, the patient left the Intensive Care Unit. His state of consciousness permitted questioning him in detail about the development of his troubles. He clearly stated that he was well aware that a mass ivermectin treatment had been organized in some areas of the Bas-Congo province in the first months of 2004, but that for his part he did not take this treatment nor any other antifilarial drug. On HD45, during nursing care for his bedsores, the patient presented convulsions, and died suddenly. | Parasitology |
During the first two months, the prevailing sign presented by the patient was the oedema of his lower limbs. The laboratory tests performed within the first days of hospitalization demontrated a significant decrease in the creatinine clearance, and thus showed that the troubles were related to a renal failure. In addition, the echographic findings, and the presence of an important albuminuria associated with a microscopic haematuria led rapidly to a diagnosis of glomerulopathy. As no renal biopsy could be performed, it is difficult to determine the exact type of renal lesions, or their aetiology. However, the clinical and biological examinations that were performed allow us to exclude several aetiologies: diabetic nephropathy, HIV-associated nephropathy, gout nephropathy. Besides this, a number of authors have reported cases of patients who presented, as ours, an infection with Loa loa and a renal disease with oedema of the lower limbs . | Nephrology |
In the present case, the troubles of consciousness appeared fairly rapidly, within only several hours, after a period of two days during which the patient had presented an evening fever and headaches. The presence of a Plasmodium infection could explain the fever and possibly the neurological symptoms; and this prompted us to start treatment with quinine. However, the absence of improvement during the following days strongly suggests that the troubles were not due to a severe malaria. The fact that the development of the coma was preceded by headaches, and the presence of mild signs of localization led us to consider the possibility of an intracranial expansive process. However, the absence of arterial hypertension, of any signs of intracranial hypertension in the fundus, or of any clinical improvement within the days following implementation of a wide-spectrum antibiotherapy, as well as the "spontaneous" subsequent improvement in his clinical condition, finally led us to consider this possibility as unlikely. The finding of Loa loa microfilariae in the CSF, as well as the very high Loa microfilaraemia, consitute arguments in favour of a diagnosis of Loa encephalopathy. In addition, the haemorrhages and cotton-wool exudates found in the retina of our patient were similar to those reported both in patients who developed a Loa encephalopathy after ivermectin treatment , and in individuals without history of antifilarial treatment but harbouring a very high Loa microfilaraemia . However, one should notice that the CSF contained also a fairly high number of red blood cells, and thus that it could have been contaminated by blood and microfilariae coming from a vessel injured during the puncture. | Parasitology |
In conclusion, we have described the case of a patient who presented a high infection with Loa loa and who developed, successively, two visceral manifestations which could be caused by this infection. The imputability of Loa loa in the clinical condition of our patient is questionable. This is due to the fact that the spontaneous visceral complications of loiasis are little known and that, in consequence, the presence of a Loa infection is rarely examined in patients presenting an encephalopathy or a glomerulopathy. In the present case, the diagnosis of loiasis was made only after three weeks of hospitalization. Besides this, once the diagnosis of Loa infection had been made, the investigations that would permit us to connect the clinical picture and the filariasis are rarely made. This is sometimes due to the cost of the required examinations but we do think that two of them should be made on patients who are infected with Loa loa and who present an encephalopathy: an examination of the fundus, to see whether there are typical retinal haemorrhages, and a direct examination of centrifuged sample of CSF. In patients with Loa infection and developing a glomerulopathy, it is desirable, if possible, to perform a renal biopsy. | Parasitology |
The patient is a 49 year-old lady, with a family history of HCM and no coronary risk factors, who in June 2005 was admitted to the coronary care unit due to an episode of oppressive and prolonged chest pain. Her ECG at admission showed sinus rhythm, left ventricular hypertrophy and ST segment elevation in leads V4 to V6, which later normalized, without developing Q waves . A fourth sound and a 4/6 systolic murmur along the mesocardium were noted in the physical exam. Twelve hours after the beginning of chest pain, creatin phosphokinase (CPK) 2.989 U/l and the CPK-MB fraction was 340 U/l. | Cardiology |
The ECG at hospital discharge showed sinus rhythm, right bundle branch block (RBBB) with no Q waves, right ventricular hypertrophy and/or posterior necrosis . The vectorcardiogram was consistent with apical necrosis . The chest X-ray showed a mild increase in cardiothoracic index and the lower left arch. The 24-hour Holter showed sinus rhythm, permanent RBBB and 234 monomorphic premature ventricular contractions (PVC's), without complex arrhythmias. | Cardiology |
Echocardiogram and left ventriculography of our patient showed an apical aneurysm (although the epicardial coronary arteries were angiographically normal), asymmetric septal and mid-ventricular hypertrophy, a moderate subaortic gradient and a mild mid-ventricular gradient. | Cardiology |
Several reports have shown the association between mid-ventricular and apical HCM and apical aneurysms, but this is the first case presenting a special phenotypic expression of HCM, characterized by a combination of asymmetric septal and mid-ventricular HCM that presents clinically as an infarction with normal coronary arteries and develops an apical aneurysm. | Cardiology |
Henneveld reported a case of an 8 months old girl affected by a rapid ventricular rate JET, who developed two years later a complete heart block with rapidly increasing left ventricular end diastolic diameter . The patient was not assuming therapy at the time of the onset of complete heart block. | Cardiology |
The term Malignant Fibrous Histiocytoma (MFH) was originally described by O'Brien and Stout in 1964 to cover a variety of pleomorphic soft tissue sarcomas derived from histiocytes capable of fibroblastic transformation. MFH is a common sarcoma of mesenchymal origin affecting soft tissues of the body, especially the extremities and retroperitoneum. Primary intra-abdominal MFH is a rare disease and few cases are reported in the English literature. Its presentation as high-grade pyrexia of unknown origin (PUO) is extremely unusual. We report a case of malignant fibrous histiocytoma affecting colon, spleen, left hemi diaphragm and distal pancreas in a 54 year old female, who presented with abdominal pain and pyrexia of unknown origin. | Oncology |
A 54 year old female presented to our surgical outpatient clinic with abdominal pain and pyrexia. Abdominal pain was of recent onset and mainly in the left upper abdomen but she had fever for at least 6 months. Her pyrexia was high grade (39.5–40 C 0 ), intermittent, and most common in the early morning. Clinical examination revealed a firm, vaguely defined, tender mass in the left upper quadrant of the abdomen. Blood results showed persistently high ESR (>100), high CRP (>240), leukocytosis, mildly raised Alkaline Phosphatase and anaemia (normochromic, normocytic). There was no overt source of infection that could account for the fever. Repeated blood cultures did not yield any bacterial growth. NM Leukocyte HMPAO scan showed no convincing abnormality to help localise an infective focus. There was no improvement in pyrexia after treating the patient with broad-spectrum antibiotics. | Gastroenterology |
CT scan of the abdomen was performed which showed three heterogeneous masses in left upper abdomen relating to splenic flexure of colon, pancreatic body and tail and left crus of the diaphragm . There was evidence of central necrosis in two of these masses. A trucut biopsy of the mass was performed and histology revealed spindle cell leiomyosarcoma. | Oncology |
The mode of presentation of MFH depends on the primary site of the body affected by the tumour, for example, dyspnoea and arrhythmias can be caused by cardiac lesions. In addition, symptoms of systemic illness caused by the tumour may also be the presenting complaint. Reporting our patient, intra-abdominal MFH presented as pyrexia of unknown origin, caused likely by tumour necrosis and release of inflammatory and pyrogenic factors. | Oncology |
In order to improve survival in patients with MFH, complete resection of the primary tumour as well as isolated peritoneal or hepatic metastases should be attempted where possible. An early multidisciplinary approach is important to improve clinical outcome. Our case report shows that primary intra-abdominal MFH can present in unusual ways including high-grade fever of unknown origin. Clinicians must remember this while establishing differential diagnosis for patients with PUO and abdominal pain. | Oncology |
Spontaneous perforation of the common bile duct is a rare event in adults, with only 40 cases having been reported earlier . Cholelithiasis, choledocholithiasis, and tumor obstruction of the ampulla have been reported as possible etiologies of perforation . We report two cases of spontaneous biliary tract perforations in pregnancy, which were managed successfully. The clinical presentations, radiological findings and management are discussed. | Gastroenterology |
A 28-year-old gravida 2, para 1, 30 weeks pregnant woman presented with sudden onset abdominal pain and distension for two days. There was previous history of right upper abdominal pain for six months, which got relieved on analgesics. The previous pregnancy had been uneventful. On physical examination, she was moderately dehydrated and her temperature was 39.6°C. Her pulse was 110/minute, blood pressure was 90/60 mmHg and there was no pallor or icterus. On abdominal examination, there was generalized tenderness, guarding, rigidity and rebound tenderness. Shifting dullness and fluid thrill was present. The uterine fundal height corresponded to 30 weeks gestation. Bowel sounds were absent. Routine laboratory tests revealed hemoglobin of 10.4 g/dL, total leukocyte count of 18850 cells per mL. The blood sugar, kidney and liver function tests were normal. The chest X ray was normal and there was no free air under the diaphragm. Abdominal sonography revealed bowel loops floating in large amount of free fluid. A Single live foetus of 30 weeks gestation was seen. Gall bladder with multiple calculi and wall thickness of 4 mm was also noted. Paracentesis yielded a free flow of purulent fluid admixed with bile. | Obstetrics |
A clinical diagnosis of peritonitis due to bowel perforation was made and the patient underwent an exploratory laparotomy, which revealed about 4 litres of purulent fluid inside the peritoneal cavity. A thorough exploration revealed normal bowel. A gall bladder with multiple stones and a perforation at the fundus was seen. A cholecystectomy with peritoneal lavage was performed. Postoperative course was uneventful and the patient was discharged one week later. Histopathology of the gall bladder was suggestive of acute cholecystitis. Her pregnancy continued and at 37 weeks' gestation she vaginally delivered a healthy baby. The patient is asymptomatic after a follow up of three years. | Gastroenterology and Obstetrics |
A 21-year-old primipara with 32 weeks pregnancy was referred to us from the gynecology department with upper abdominal pain and high-grade fever for 3 days associated with abdominal distension. On examination, the patient had a pulse of 124/minute and her blood pressure was 96/64 mmHg. Mild pallor was noted and there was no icterus, lymphadenopathy or pedal edema. On abdominal examination, the patient had generalized tenderness, guarding, rigidity and rebound tenderness. Bowel sounds were absent. The uterine fundal height corresponded to 32 weeks' gestation. Routine laboratory tests revealed hemoglobin of 12.1 g/dL, total leukocyte count of 14100 cells per mL. The blood sugar, kidney and liver function tests were normal. Abdominal sonography showed a viable fetus of 32 weeks gestation. There was a large collection of fluid in the right side of peritoneal cavity below the liver. Other viscera were normal. Ultrasound guided diagnostic aspiration of the collection revealed frank bile, the presence of which confirmed by biochemical analysis of the fluid. With the presumptive diagnosis of duodenal ulcer perforation peritonitis, the patient was taken up for an exploratory laparotomy. There was an 800 mL collection of bile in the subhepatic and right paracolic space. The stomach and intestines were normal. The gall bladder was distended and a 0.5 × 0.5 cm perforation in the lateral wall of the supraduodenal portion of the CBD was seen. There was no evidence of gall stones. The CBD perforation was closed over a T-tube. The midline incision was closed after inserting a drain in the subhepatic space. The patient went into spontaneous labor 48 hours later and a preterm baby was delivered. Subsequently, on 15 th postoperative day, after a normal T-tube cholangiogram , the T-tube was removed and the patient was discharged the next day. The mother and child are doing well after a follow up period of one year. | Gastroenterology and Obstetrics |
Pulmonary hamartomas, also known as mesenchymomas, can be parenchymal (80%) or endobronchial (10–20%) in location . Parenchymal lesions are usually an incidental finding and range in size from 1 cm to 8 cm in diameter in various series . The endobronchial tumours usually present with new onset respiratory symptoms most commonly recurrent chest infections or haemoptysis . We report a case of giant hamartoma which we believe is the largest reported case in literature yet, and this was successfully resected via a median sternotomy. | Pulmonology |
A previously healthy 61-year-old man was investigated for worsening breathlessness. Chest radiography demonstrated a mass in the right chest and a subsequent CT scan revealed a large anterior mediastinal mass extending mostly into the right hemithorax and compressing the right lung. The radiological appearances were consistent with a teratoma . The CT scan also revealed abdominal lymphadenopathy, which on biopsy proved to be non-Hodgkin's lymphoma. The lymphoma was successfully treated with chemotherapy, without any change in the lung mass. Nevertheless, surgical excision of this mass was indicated due to its large size. | Oncology |
The patient underwent a median sternotomy whereupon a giant fatty tumour was found arising superficially from the medial border of the right lung occupying most of the right chest and extending to the anterior mediastinum. The mass was compressing the right lung with no evidence of local invasion. The right phrenic nerve was identified and preserved, and the tumour was found to be adherent to the medial border of the lung and was easily dissected with sharp dissection and removed en bloc. The postoperative recovery was uneventful and the patient was discharged home on the seventh postoperative day. Six months postoperatively the patient remains well. The final histology of the tumour, measuring 25.5 × 17.5 × 6.5 cm, and weighing 1134 g , was a pulmonary hamartoma with predominantly adipose and leiomyomatous differentiation. | Thoracic surgery |
A 38-year-old woman with extensive abdominal GIST commenced imatinib mesylate (Glivec, Novartis) 400 mg/day in October 2003. Her adjusted serum calcium was 2.54 mmol/L (normal range 2.2–2.55). Imatinib was well tolerated, and her tumour mass slowly responded to treatment. She was active (performance status 1), had a normal diet and no evidence of malabsorption. During the fifth month of therapy, she complained of increasing muscle twitches and cramps, locked fingers, and spasm of the tongue. Her adjusted serum calcium was 2.28 and magnesium 0.75 (0.7–0.95) mmol/L, both at the lower limit of the normal ranges. | Oncology |
On stopping imatinib, the symptoms rapidly resolved, and the serum calcium and magnesium recovered to 2.37 and 1.0 mmol/L respectively . Imatinib was restarted after 3 weeks, with oral calcium and magnesium supplements, but the cramps recurred. She was then given quinine sulphate 300 mg/day, with complete resolution of the cramps. Fifteen months later, she continues on imatinib 400 mg/day with quinine sulphate 300 mg/day. The tumour mass continues to regress. Her serum calcium remains at the lower limit of the normal range, but her cramps are controlled with quinine sulphate. | Oncology |
Numb Chin Syndrome (NCS) is characterised by hypoesthesia, par aesthesia or pain over the chin in the region supplied by mental nerve and its branches . This is a pure sensory neuropathy because the inferior alveolar nerve has no motor fibres. The chin numbness is caused by malignant infiltration of the inferior alveolar nerve sheath or compression of the nerve by jaw metastases or local tumour . Intracranial involvement of the mandibular nerve by lesion at the level of base of skull is also reported . This syndrome is most often a forerunner to malignancy progression and relapse . We describes a case of NCS caused by high-grade lymphocytic lymphoma. We would like to highlight this rare and unusual condition as considering it as a differential diagnosis may help in early intervention and improve the prognosis. The clinical course and rapid deterioration since the initial presentation of this syndrome in a patient is discussed. | Neurology/Oncology |
Initial investigation showed an elevated C reactive protein (CRP)-139.2 mg/l and a slightly raised gamma glutamyl transferase-173 iu/l, normal full blood count, creatinine, urea and electrolytes, glucose, liver function test and chest X-ray at the time of initial presentation. The differential diagnosis at this stage was of a non-specific viral illness, atypical viral myositis or atypical Guillain-Barre syndrome. | Neurology |
In the next 2 weeks the liver function test became deranged. CRP and erythrocyte sedimentation rate (ESR) remained elevated. Slight weakness of left lower limb compared to right was noted together with new onset of right axillary lymphadenopathy (5 × 5 cm). The patient was managed by antibiotics, pain killers, vitamins and nutrition. In the meantime the renal function started to deteriorate and the patient became oliguric with signs of fluid overload, increasing potassium, urea and creatinine. The blood film done at this stage showed a leucoerythroblastic picture and lymphocytosis. The patient was hypercalcemic (3.0 mmol/l). Anaerobic blood culture showed growth of gram positive cocci for which Teicoplanin was started. The patient was admitted to ICU (Intensive care unit) at this stage for supporting renal and hepatic function. | Internal Medicine |
The patient was supported by continuous veno venous hemofiltraion (CVVH) because of worsening renal function via right femoral venous access. Arterial blood gas (ABG) showed worsening acidosis in spite of CVVH. pH-7.315, pO 2 -117.9 mmHg, PCo 2 -31.7 mm Hg, BE-9.4, HCO 3 -15.8 mmol/L. Filter was changed to a large size and predilution fluid volume increased. In spite of changes in CVVH acidosis improved a little and hence was started on NaHco 3 infusion of 100 ml/hour to a total of 300 ml. | Nephrology |
We present the case of a 37 year old male presenting with low grade fever, proptosis, pain and redness in the right eye, and a diffuse swelling in periorbital and temporal region. FNAC from the temporal region swelling showed features of plasmacytoma and further investigations revealed systemic involvement by the disease (multiple myeloma). | Hematology/Oncology |
Present case describes the extremely rare presentation of multiple myeloma with orbital involvement and highlights the utility of cytology in such lesions. Fine needle aspiration diagnosis of plasmacytoma at extramedullary sites offers an opportunity for non-invasive verification of systemic involvement and thus plays a major role in early diagnosis and management of these patients | Hematology |
The recombinant sample belonged to a 26-year old man who reported having had multiple male sexual partners, including one from Brazil, and who seroconverted between May and November of 2004. This patient reported a syndrome compatible with primary HIV-1 infection which included symptoms of fever, fatigue, myalgia, arthralgia, headaches, lymphadenopathy, nausea, vomiting, diarrhea, cough, anorexia, and weight loss of 5 kilograms (11 pounds) within 40 days of HIV diagnosis. The viral load was 64,050 copies per cubic milliliter (log 4.807) and the CD4 count was 391 cells per cubic milliliter. At that time the patient was negative for hepatitis B, hepatitis C and syphilis infections. | Virology |
A 77-year-old woman was admitted to our hospital with right upper abdominal pain in December 2004. Barium enema and colonoscopy revealed an ulcerative tumor in the ascending colon, which was diagnosed as moderately differentiated adenocarcinoma on biopsy. Physical examination showed no remarkable abnormalities. Neither hepatomegaly nor splenomegaly were apparent. Serum hepatitis B surface antigen and hepatitis C antibody were negative, and she had no history of alcohol intake or blood transfusion. Laboratory data on admission including liver function tests were unremarkable. Carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and α-fetoprotein (AFP) were within normal ranges. Abdominal ultrasonography showed a hypoechoic, 1.5-cm diameter mass in the left hepatic lobe (S3). Computed tomography (CT) revealed a low-density area in the same area, the interior of which enhanced equally. The outline of the mass was particularly enhanced in equilibrium phase . Magnetic resonance imaging (MRI) demonstrated a slightly low-intensity lesion on T1-weighted images; this was high-Intensity on T2-weighted images . Furthermore, superparamagnetic iron oxide (SPIO) uptake was not detected on T2-weighted images. Consequently, as metastatic liver tumor could not be definitively excluded, the patient underwent right hemicolectomy and S3 partial hepatectomy on 1 November 2004. | Gastroenterology and Oncology |
A 64-year-old woman who had a radical right hemicolectomy for stage II ascending colon cancer 10 years ago was admitted to our hospital with dysuria in July 2005. A hepatic tumor in the left lobe of her liver was concurrently revealed by CT scan. Serum hepatitis B surface antigen and hepatitis C antibody were negative, and she had no history of alcohol intake or blood transfusion. Laboratory data on admission including liver function tests were unremarkable. CEA, CA19-9, and AFP were within normal ranges. Abdominal ultrasonography showed a hypoechoic, 9 × 7 mm diameter mass in the left hepatic lobe (S2). Plain CT examination revealed a low-density area, the mass was enhanced by the contrast medium in early phase. At a late phase, the mass was showed as a low-density area. MRI demonstrated a slightly low-intensity lesion on T1-weighted images and a high-Intensity on T2-weighted images. SPIO uptake was not detected on T2-weighted images. At an early phase, Dynamic MRI revealed low-intensity mass in S2 . At a late phase, the mass was showed as a low-intensity area . Consequently, this nodular lesion was diagnosed hepatocellular carcinoma rather than liver metastasis, the patient was carried out left lateral segmentectomy on 7 September 2005. | Oncology |
Macroscopically, the resected liver had smooth surface and a normal appearance, cut section of the resected liver showed a well-circumscribed, not encapsulated, whitish mass in S2 of the liver . It measured 1.0 cm in diameter. Microscopically, this lesion revealed the almost same findings as Case 1 , so this nodular lesion was diagnosed as RLH of the liver, too. No recurrence has occurred during 10 months of postoperative follow up. | Hepatology |
A 77-year-old male with a history of diabetes mellitus reported to a private spine clinic for a problem with his right lower extremity. He had clinical signs of foot drop, with 0/5 muscle strength during plantar flexion, dorsiflexion, inversion, and eversion. His Achilles reflex was absent. Two-point discrimination was absent over the anterior and lateral calf and foot, with anesthesia present in the great toe, plantar fascia, heel, and calf. Anesthesia was also present in the plantar fascia of the left foot as well, with sensory Paresthesia present on the dorsum of the left foot and great toe. He was able to feel digital pressure in the superior portion of the anterior tibialis, but could not distinguish sharp and light touches. He was not being pharmacologically managed for his diabetes, and did not take any prescription medications. He reported taking only a tablespoon of red wine vinegar once daily. The patient had a mesomorphic build, and had no prior history of low back pain in the last year. In March of 2004, the patient claims that he fell in his front yard while gardening. Upon falling, he claims to have heard a loud "pop" in his lower back, but did not feel any back pain afterward. About one week after falling, he began feeling tingling and weakness in his right leg and foot. His primary care physician referred him for a lumbar spine MRI, needle electromyography, and nerve conduction velocity testing of the lower extremities. | Neurology |
After three months with no apparent improvement, the patient voluntarily discontinued care against medical advice and reported to the author's office. His initial self-rated disability was 43%, as measured by a Functional Rating Index, found to have an acceptable level of reliability and validity . He did not report any pain in his leg, and scored a 0/10 on a numeric pain rating scale. Visual inspection revealed significant atrophy of the right gastrocnemius and tibialis anterior; however, calf girth measurements were not obtained. | Physiotherapy |
After twice weekly visits for 90 days, the patient was referred for follow-up needle electromyography and nerve conduction velocity testing. His follow-up self-rated disability reduced from 43% to 25%, while his numeric pain scale remained at 0/10. At this time, the patient was able to move his right foot into dorsiflexion and plantarflexion. He discontinued wearing his ankle-foot orthosis. His follow-up EMG results are shown in Table 1 . The follow-up report concluded that only an L5 radiculopathy remained, and there was no evidence of a motor polyneuropathy or plexopathy. Muscle strength during dorsiflexion and plantar flexion improved to a 3/5, while eversion and inversion remained unchanged. The right Achilles reflex was graded as a 1+. Sensory deficits remained unchanged in both feet, but improved two-point discrimination was found in the anterior tibialis and lateral calf. | Neurology |
In the present report is described a case with bacteremia due to A.xylosoxidans post-ERCP in patient of pancreas cancer. | Gastroenterology |
A 70-year-old man was admitted to our hospital with a 10-day history of jaundice and abdominal pain. The patient is known to have suffered from pancreas cancer for three months and he was received second cycle of chemotherapy before one month. His vitality signs were: blood pressure was 110/70 mmHg, body temperature 36.3°C and pulse rate 68/min. His peripheral white blood cell count was 6.4 × 10 9 /L, erythrocyte sedimentation rate was 72 mm/h and C-reactive protein was 4.6 mg/dL. Four days later, the stent was placed into the biliary tract with ERCP. One day later, the patient was lethargic. His vitality signs were: blood pressure was 90/50 mmHg, body temperature 39.7°C and pulse rate 112/min. His peripheral white blood cell count was 14.1 × 10 9 /L with 86% neutrophils and 8% lymphocytes. His erythrocyte sedimentation rate was 80 mm/h and C-reactive protein was 11.2 mg/dL. Blood and urine specimens were taken for microbiologycal analysis. We started to administer empirical treatment with ceftriaxone to the patient. In blood culture , Gram negative bacillus was found to have reproduced. This microorganism identified with the help of Phoenix system (Becton Dickinson, Sparks, Md.) and biochemical tests. It was called as A.xylosoxidans . A.xylosoxidans was distinguished from other Alcaligenes species by acidification of oxidative-fermentative (OF) glucose and xylose. Key characteristics of A.xylosoxidans are shown in Table 1 . | Microbiology |
In summary, the post-ERCP bacteremia caused by A.xylosoxidans was presented in a 70-year-old man with pancreas cancer. The case report may help to redefine the role of A.xylosoxidans in post ERCP infections. The association of A.xylosoxidans with bacteremia further extends the clinical spectrum of this rare pathogen. This unusual case highlights that an effective antimicrobial therapy based on an immediate microbiologycal analysis may be life-saving in patients presenting a severe complication of ERCP. | Gastroenterology |
Investigations revealed hemoglobin of 7.6 g/dl platelet count of 529,000/mm 3 ; TLC of 16200/mm 3 with peripheral blood film revealing microcytes, micro-ovalocytes, macrocytes with hypochromia. Blood biochemistry revealed urea 310 mg/dl, S. creatinine of 9.2 mg/dl. Serum CPK and transaminases (AST & ALT) were within normal limits. He had normal urinalysis. There was no evidence of intravascular hemolysis as urine was negative for hemoglobin and plasma hemoglobin was less than 20 mg/dl. Ultrasound of abdomen revealed normal sized kidneys. | Nephrology |
His renal failure was managed by hemodialysis. However despite repeated hemodialysis, his urea and creatinine remained persistently high so kidney biopsy was undertaken after two weeks. It revealed 12 normal glomeruli, focal interstitial infiltration with eosinophils and lymphocytes with hyaline and pigmented granular casts in the tubules . These findings were consistent with tubulo-interstitial nephritis. In a focal area, the interstitial inflammationwas accompaniedbyinterstitial edema and few dilated tubules lined by flattened epithelium. This may besuggestive ofaccompanyingfocal/patchy acute tubular necrosis. | Nephrology |
Subsequently Chao et al reported a case with both acute interstitial nephritis and tubulopathy after wasp bites . The role of steroids in the setting of tubulointerstitial nephritis has also been discussed in these two reports. Our patient also had acute renal failure due to acute tubulointerstitial nephritis which responded to steroid therapy. The cause of acute tubulointerstitial nephritis is not clear. There was no history of any nephrotoxic drug intake so it could be due to hypersensitivity to the venom. This patient also had anemia at presentation but there was no evidence of hemolysis and the peripheral blood film was consistent with nutritional anemia which recovered on follow up with appropriate supplementation. | Nephrology |
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