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a 70 year old black male presents with a lesion on his left lower extremity and one on his trunk that he has had since adolescence . the lesion on his lower extremity is a hyperpigmented scaly plaque extending along his left lateral thigh , knee , and leg ( figure 1a ) , biopsy of which demonstrates hyperkeratosis with acanthosis and increased pigmentation at the basal layer , consistent with an epidermal nevus ( figure 1b ) . the lesion on his trunk is a hyperpigmented patch with irregular borders and satellite macules extending bilaterally to his medial arms across his left shoulder and onto his lower neck ( figure 1c/1d ) . biopsy demonstrates acanthosis , hyperkeratosis with regular elongation of rete ridges , increased basal layer pigmentation with a normal number of melanocytes , and an increase in smooth muscle bundles in the dermis ( figure 1e/1f ) , consistent with a becker 's nevus . the patient is otherwise healthy with no clinically significant medical history , developmental anomalies , or family history of similar lesions . figure 1hyperpigmented scaly plaque on left lower extremity consistent with epidermal nevus ( a ) . biopsy of ( a ) showing increased basilar pigmentation , acanthosis , and hyper - keratosis(b , h&e 5x ) . large hyperpigmented patch with irregular borders and satellite macules ( c & d ) consistent with becker 's nevus . increased basilar pigmentation ( e , h&e 10x ) and smooth muscle proliferation ( f , h&e 20x ) in biopsies from lesion ( c ) . biopsy of ( a ) showing increased basilar pigmentation , acanthosis , and hyper - keratosis(b , h&e 5x ) . large hyperpigmented patch with irregular borders and satellite macules ( c & d ) consistent with becker 's nevus . increased basilar pigmentation ( e , h&e 10x ) and smooth muscle proliferation ( f , h&e 20x ) in biopsies from lesion ( c ) . this , along with the increased number of terminal hairs seen within many lesions , and reports of acne vulgaris confined to becker 's nevi , has raised the suspicion of androgenic stimulation as an underlying factor . hypertrichosis is present in approximately one - half of cases and there is often an associated smooth muscle hamartoma . epidermal nevi are congenital hamartomas that arise from pluripotential germinative cells of the basal layer of the embryonic epidermis . they appear as patches , plaques , or nodules that may be bilateral and most commonly affect the face , trunk , and proximal extremities . an estimated one third of affected individuals have involvement of other organs , which is called epidermal nevus syndrome . this sporadic neurocutaneous linkage of congenital ectodermal defects can affect the skin , brain , eyes , and/or skeleton . as some authors regard becker 's nevi as a subclass of epidermal nevi , patients with becker 's nevi should be examined for associated soft tissue , neurologic , ophthalmologic , and bony abnormalities . the becker 's nevus in our patient is remarkable due to its large size and co - existence with an epidermal nevus . a study of french men estimated the prevalence of becker 's nevi to be approximately 0.5% , while epidermal nevi have an incidence of approximately 0.1% of newborns . there is considerable debate in the literature regarding these two entities , some regarding both lesions as cutaneous hamartomas while others consider them each to be versions of epidermal nevi . regardless of the classification , the presence of both lesions in a single patient is very unusual , and to our knowledge , simultaneous expression of these two lesions has not been previously reported .

becker 's nevus is a cutaneous hamartoma that may be present at birth , but more commonly is noticed during puberty . it classically manifests unilaterally on the shoulder and upper trunk as a tan to brown patch or thin plaque . " it typically has an irregular margin , breaks up into islands at the periphery , and has an average size of 125 square centimeters . numerous skin , soft - tissue , and bony anomalies have been reported in association with becker 's nevus . we describe a patient with becker 's nevus of considerable size who has a concurrent epidermal nevus .

a 83-year - old woman was referred to our department , for a one year history of a large 15 cm diameter plaque lesion situated on the posterior side of the right leg , superficially ulcerated and necrotized , with tumorous borders ; two red or bluish - red nodular lesions , of about 45 cm of diameters , were also located in the inferior leg ( figure 1a , b ) . figure 1a ) eritematous nodular and partially ulcerated lesion , with a central escoriated zone and well defined edges ; b ) plaque lesion , partially necrotic in its central part , with eritematous and well defined edges . a ) eritematous nodular and partially ulcerated lesion , with a central escoriated zone and well defined edges ; b ) plaque lesion , partially necrotic in its central part , with eritematous and well defined edges . in the past she was treated for venous stasis ulceration with different topical and systemic therapies , without any improvement . the past medical history included systemic blood hypertension , chronic congestive heart failure and diabetes mellitus . the patient did not report any constitutional symptoms and haemato - chemical exams were all in the normal range . a skin biopsy from both nodular and plaque lesion showed a diffuse infiltrate of atypical large b cells cd20 and cd79a , spanning epidermis , dermis and subcutaneous tissue ; reactive t cells were also present ( figures 2a , b ) . a staging of the disease was done : no signs of extracutaneous lymphomas were found . so , the diagnosis of diffuse large b - cell lymphomas , leg type , was finally made . a therapeutic approach containing anti - cd20 monoclonal antibody ( rituximab ) was suggested to our patient , but she denied any kind of treatment . figure 2a ) the tumor cells have large and polymorphic vescicular nuclei and often show prominent nuclolei ; b ) the lymphocytes express cd20 . a ) the tumor cells have large and polymorphic vescicular nuclei and often show prominent nuclolei ; b ) the lymphocytes express cd20 . cutaneous b cell lymphomas constitute about 2025% of all primary cutaneous lymphomas . for long time there has been confusion and debate regarding the definition , terminology and treatment of different types of primary cutaneous b cell lymphomas . finally in 2009 , who - eortc classification for cutaneous lymphomas summarized two types of primary cutaneous diffuse large b - cell lymphomas ( dlbcl ) : dlbcl , leg type , and dlbcl , other . clinically dlbcl leg type is characterized by rapidly growing tumour masses of lower leg with a percentage of about 1015% of patients that could show skin lesions at sites other than the legs . histologically , characteristic findings include diffuse non - epidermotropic infiltrates predominantly made up of large non - cleaved b - cells , with variable proportions of centroblast- and immunoblast - like cells . there are few if any admixed small cells and inflammatory cells . more often , the majority of neoplastic cells have the morphology of large non - cleaved follicle center cells . these lymphomas generally strongly express the bcl-2 protein , but are not associated with the interchromosomal t(14;18 ) translocation . the prognosis is unfavourable for the frequent rate of metastasis located on lymph nodes and internal organs . other types of lymphomas can affect the lower legs : rare cases of intravascular b cell lymphomas can occur ; in addition , primary cutaneous immunocytomas preferentially involve arms or legs . concerning therapies , there are two favourite therapeutic options : generally , in patients with a single skin tumour , radiotherapy may be considered as first choice treatment , with the improvement of the local control and disease - free survival ; instead , in patients with multifocal skin lesions or relapses , cyclophosphamide , doxorubicin , vincristine , and prednisone ( chop ) chemotherapy is the standard systemic therapy for this disease with a cure rate of 40% to 50% . recently it has been demonstrated that the anti - cd20 monoclonal antibody ( rituximab ) is an effective treatment for pclbcl lt , because of the monoclonal antibody ability to eliminate b neoplastic cells by direct induction of apoptosis , activation of complement- and antibody - dependent cellular cytotoxicity . actually , rituximab in combination with chop has been accepted worldwide as the new standard therapeutic approach for the treatment of dlbcl . our case - report shows a very unusual initial clinical presentation ; in the literature only another case clinically similar has been described , therefore we want to underline the importance of considering a possible diagnosis of cutaneous lymphomas , in chronic ulcerations of the leg with an atypical clinical presentation a non - responsive behaviour to adequate therapies .

we report here a case of a woman with a cutaneous large b - cell lymphoma of the legs . she had a plaque lesion , superficially ulcerated and necrotized with tumorous borders situated on the posterior side of the right leg and two red or bluish - red nodular lesions . a skin biopsy from both nodular and plaque lesion showed a diffuse infiltrate of atypical large b cells cd20 + and cd79a+ , spanning epidermis , dermis and subcutaneous tissue . a therapeutic approach containing anti - cd20 monoclonal antibody ( rituximab ) was suggested .

different forms of squamous cell carcinoma ( scc ) exist , keratoacanthoma ( ka ) variously being regarded as a variant of scc or as a benign and self - limiting lesion . though invasion of adnexal , vascular or nervous structures usually precludes the presence of a benign tumour , a series of ka with perineural invasion has been published before , as has a case with venous invasion . in this report we present the case of a non - pigmented raised skin tumour , with clinical and histologic features of ka , showing venous invasion . a 79-year - old man with a past history of both non - melanoma skin cancer and melanoma presented with a new lesion on his left forehead . the lesion had not been noticed at a previous visit four weeks earlier , and he believed it had appeared and grown over the preceding three weeks . the lesion ( figure 1 ) was raised and symmetrical with central keratin surrounded by a white area , which merged to a pink area peripherally . dermatoscopy ( figure 2 ) revealed a non - pigmented lesion with a central structureless orange area ( consistent with keratin ) surrounded by a large structureless white area merging into a structureless pink area at the periphery . there was a pattern of branched serpentine vessels visible over most of the surface area outside of the keratin . on histologic examination of the excision specimen there was a well - differentiated squamoproliferative lesion with the characteristic pattern of keratinisation seen in a ka . in each of the two transverse sections taken there was a nest of keratinising squamous cells within the lumen of a vein in the deep dermis . the wall of the vein was highlighted using a verhoeff - van gieson stain ( vvg ) , immunoperoxidase stains for desmin , and a stain for smooth muscle actin ( figure 3 ) . findings and treatment options were discussed with the patient , and the decision was made to perform a deep and wide surgical excision with an additional 5 mm clinical margin . ka is variously regarded as a benign keratinising tumour and an scc variant characterised by benign ( non - metastasising ) behaviour . although invasion of peripheral nerves has been reported this has not been associated with an adverse prognosis . one of the authors ( dw , data not shown ) has now seen 122 cases of ka with perineural invasion without a single case of adverse outcome . we suggest that ka is not a variant of scc on the following grounds : they are each morphologically distinctive.the behaviour of ka with perineural and/or intravenous invasion is quite different to that of scc showing the same phenomenon.there are possible alternative interpretations for purported cases of ka that metastasised . the behaviour of ka with perineural and/or intravenous invasion is quite different to that of scc showing the same phenomenon . richard reed , a noted dermatopathologist , at the time of this controversy about ka being scc , went as far as to say : those of us who compliantly acquiesce to the authors dogmatic position will have relinquished both soul and conscience . while not all of the authors hold that extreme view , we do agree that over diagnosis is as culpable as under diagnosis . although the presence of venous invasion would be consistent with an scc , in the view of the authors , this lesion still represents a ka . this is also consistent with the clinical history of a new and rapidly growing lesion , though sccs can also occur rapidly . dermatoscopic central keratin with blood spots , white structureless areas and branched serpentine vessels are consistent with both diagnoses . histopathologically the present tumour was classified as a ka on the basis of a squamoproliferative lesion with the characteristic pattern of keratinization , unique to ka . the cells in a ka have a distinctive hue to their cytoplasm , which is paler than seen in a scc and this is best seen in the large central cells that may be up to double the size of peripheral cells . venous invasion of keratinocytes was confirmed by immunoperoxidase as well as verhoeff - van gieson stains ( figure 3 ) . ka is a commonly encountered lesion on sun - damaged skin and it is characterised by benign behaviour without metastasis and with ultimate complete regression expected . we have reported a case with venous invasion , a feature normally indicative of malignant behaviour and guarded prognosis .

keratoacanthomas are variously regarded as a self - limiting variant of squamous cell carcinoma or as a distinct benign lesion and they very seldom show attributes normally associated with malignant behaviour , such as perineural invasion . herein we report the case of a keratoacanthoma with venous invasion proven by immunoperoxidase and elastic tissue stains .

the minor salivary glands are important components of the oral cavity , present in most parts of the mouth , and their secretions directly bathe the tissues . individual glands are usually in the submucosa or between muscle fibers and consist of groups of secretory end pieces made up of mucous acinar cells and serous or seromucous demilune cells . we report a case of ulceration in the palatal salivary gland presented with intermittent heavy bleeding from the lesion . a 50-year - old male patient reported with the complaint of bleeding from the swelling in the palate for 4 months . the patient had consulted a doctor who had diagnosed it to be bleeding from a swelling in the palate . on intraoral examination , a small , well - defined , solitary papule measuring about 4 mm in diameter was present in the midpalatal region , on the left side of midpalatal raphe , along a line running from the right second premolar to the left second premolar . well defined , solitary papule with central ulceration in the palate on palpation , it was nontender and soft . the lesion showed some compressibility . upon compressing , serous discharge exudate from the central ulcerated area . on asking the patient to spit following gargling with water , heavy bleeding the case was provisionally diagnosed as ulcerative sialadenitis of minor salivary gland with considering minor salivary gland adenoma , adenomatoid hyperplasia , and nonhealing tuberculous ulcer as a differential diagnosis . histopathological examination showed hyperkeratotic stratified squamous epithelium and mucous acini collection in the underlying connective tissue . a minimal amount of chronic inflammatory cells and endothelial lined blood vessels with red blood cells were also seen . histopathological features were suggestive of a chronic nonspecific ulcer . based on the clinical features , histopathology report and other investigations , the final diagnosis was given as ulcerative sialadenitis of the palatal salivary gland . hyperkeratotic stratified squamous epithelium and mucous acini collection in the underlying connective tissue . minimal amount of chronic inflammatory cells and endothelial lined blood vessels with red blood cells were also seen ( h and e , 10 ) despite their name , minor salivary glands have an important role in the physiology and pathology of the oral cavity . they secrete more or less continuously , providing a steady flow of fluid , and organic substances to protect the oral tissues . because individual glands open directly onto the mucosal surface , their secretions create and regulate the local environment . the effect of smoking on the oral cavity has been well studied for quite a number of years . the glandular area of the hard palate mucosa shows papular elevations ( up to 23 mm in height ) with central umbilications with or without pigmentation of the surrounding mucosa . the central umbilication could be like a red spot in the center of a greyish or pale elevated papule . in mild stomatitis nicotina lesions red dots over blanched elevated areas can be seen , and in severe cases , papular lesions up to 05 cm . in diameter or more with umbilications up to 23 mm . in diameter . ulcerative sialadenitis of the minor salivary gland has not been mentioned in the literature so far . inflammation of the minor salivary gland openings due to smoking and some kind of traumatic irritation would have resulted in ulceration . the ulcerated friable mucosa would have developed the tendency to bleed on applying negative pressure . a further enlightenment on this condition could not be done as this is the first case to be reported on ulcerative sialadenitis of the minor salivary gland

minor salivary glands have an important role in the physiology and pathology of the oral cavity though they have been neglected at times . smoking has a direct effect on the palatal minor salivary glands , and their most common presentation is stomatitis nicotina . we report a case of ulceration in the palatal salivary gland presented with intermittent heavy bleeding from the lesion .

duodenal stenosis usually occurs in isolation , although it may be occasionally associated with annular pancreas . here , this case highlights the golden rule of ensuring distal patency per operatively for congenital anomalies . an 11-month - old cachexic baby weighing 4.3 kg presented with post - cibal recurrent non - bilious vomiting since day 5 of life . he had visited various hospitals over last 5 months with a suspected diagnosis of infantile hypertrophic pyloric stenosis . as ultrasound abdomen was normal ; malabsorption was the provisional diagnosis elsewhere before he was referred for further assessment . a dye study delineated a grossly dilated stomach and duodenum [ figure 1 ] . at laparotomy , a duodenal web with a hole admitting a 6 fr infant feeding tube was identified in the second part of the duodenum after kocherization [ figure 2 ] . a feeding tube , passed after excising the first web , could not be negotiated freely into jejunum . on releasing kinks around ligament of treitz and checking for distal patency , another web was suspected at duodenojejunal junction that was confirmed on second duodenotomy , with a small hole negotiating a 6 fr feeding tube . a barium meal follow throughout study , delineating a grossly dilated stomach and duodenum with definite duodenal obstruction ( first arrow ) and doubtful obstruction at duodenojejunal level ( second arrow ) ( a ) at laparotomy , an area of duodenal stenosis was identified . ( b ) a duodenotomy confirmed the first duodenal diaphragm with a hole of the size of infant feeding tube ( # 6 ) . ( c ) suspicious area of a second duodenal stenosis identified at the duodenojejunal junction . ( d ) second duodenotomy confirming the second duodenal diaphragm . ( e ) the second duodenal web with # 6 fr hole , through which a forceps prong has been passed . a trans anastomotic silastic foley catheter was put through the malecot catheter put as gastrostomy excision of the webs with heineke - mikulicz closure was done at both sites , separated at a distance of 8 cm . postoperatively , the child gained 2 kg weight within 2 months . at a follow - up of 24 months , most cases are congenital and idiopathic , although rarely there have been two reports of cases in siblings , which suggest to a familial predisposition . symptoms vary from recurrent episodes of vomiting , aspiration , or failure to thrive in the early childhood to gastroesophageal reflux , peptic ulceration , or duodenal obstruction proximal to stenosis by a bezoar in the adulthood . only anecdotal cases of double duodenal atresia or stenosis have been reported ; double duodenal atresia being more commonly reported including an antenatal case . while double duodenal atresia may present in newborn period , double duodenal webs usually present later , either in infancy or even in adulthood . obstruction at the duodenojejunal junction is extremely rare with only one case of a diaphragm web at this sitereported . the case described presented in an infant weighing 4.3 kg , much below the 5 percentile ( 7.5 kg ) for age . a diagnosis of duodenal stenosis was made on physical examination and confirmed by barium study . during operation , the second web could only be localized after a strong desire to ensure good distal patency . the duodenum distal to the web was also distended , while the jejunum was narrow . though successful , endoscopic treatment of a double duodenal web in an infant has recently been described , the authors feel that the kinks at the duodenojejunal junction in the case described could not have been released endoscopically . double duodenal atresia has been reported to present with neonatal intestinal obstruction , perforation , and presence of a duodenal cyst after the first duodenal obstruction has been treated . the diagnosis of congenital double duodenal diaphragms is one of suspicion and careful examination during operation , ensuring adequate distal patency . the second duodenal diaphragm , present at a rare site of duodenojejunal junction , could only be demonstrated after release of the kinks at the ligament of treitz . this case emphasizes the fact that the operative finding of one anomaly does not preclude the presence of a second anomaly , and , therefore , a thorough search for another may prove fruitful .

duodenal stenosis usually occurs in isolation and has a variable presentation in infancy due to partial obstruction . an unusual case of congenital double duodenal diaphragms in an infant presenting as failure to thrive has been described and pertinent literature has been reviewed herein . excision of webs with double heineke - mikulicz closure was performed .

endoscopic thyroidectomy has been in practice since the late 90s . the first endoscopic parathyroidectomy performed in 1996 minimally invasive neck surgeries can be classified into direct / cervical approach and indirect/ extra - cervical approach . the direct approach involves a small incision being made over the neck with thyroidectomy carried out in the conventional manner , albeit using endoscopic instruments . while endoscopic thyroidectomy might not be a novel technique , transoral endoscopic thyroidectomy ( tet ) is a recent advance . studies validating the feasibility of this procedure have been performed on cadavers and porcine models , but very few case reports of tet being performed on live patients are available . endoscopic thyroidectomy through other routes such as trans - axillary and through the chest wall leaves the patient with a minimal scar but involves a good amount of dissection , as the natural anatomical planes are not available . on the other hand , the transoral approach is truly scar free and involves minimal dissection , thus resulting in decreased post - operative complications . a 21-year - old female presented with complaints of a swelling over the left side of her neck for the past 1 year . examination revealed a 3 4 cm swelling over the left lobe of the thyroid gland that moved with deglutition . she requested a surgery that would leave her with a minimal or no scar . in view of the patient 's age and the small size of the swelling pre - operatively , the patient was asked to gargle with chlorhexidine mouth wash b.d . for 3 days . she was placed in supine position with her neck extended using a sand bag placed between her shoulder blades . the approach was through the inferior vestibule of the oral cavity where the ports were placed and included one midline 10 mm camera port and two lateral 5 mm working ports ( fig . the superior and inferior pedicles on the left side were identified and divided by ultra scission . the deep fascia was closed using absorbable sutures and the vestibular port sites were closed in layers using absorbable sutures ( fig . pre - operatively , the patient was asked to gargle with chlorhexidine mouth wash b.d . for 3 days . she was placed in supine position with her neck extended using a sand bag placed between her shoulder blades . the approach was through the inferior vestibule of the oral cavity where the ports were placed and included one midline 10 mm camera port and two lateral 5 mm working ports ( fig . the superior and inferior pedicles on the left side were identified and divided by ultra scission . the deep fascia was closed using absorbable sutures and the vestibular port sites were closed in layers using absorbable sutures ( fig . cosmesis today plays a pivotal role in choosing the type of surgery a patient undergoes . natural orifice translumenal surgery ( notes ) was introduced with the aim of providing patients with a scar - free surgery . while abdominal surgeries such as cholecystectomies have been successfully performed using the technique of notes , thyroid surgery remains a relatively unexplored field . the various approaches such as the trans - axillary or trans - areolar approach were successful in providing patients with minimal scars that could be hidden but they involved maximal dissection due to the absence of natural anatomic planes . in 2007 , witzel et al assessed the feasibility of performing thyroidectomy through the transoral approach . they conducted studies on cadavers and porcine models and found it to be a safe procedure that was easy to perform . in 2012 , nakajo et al published their results of trans - oral video - assisted neck surgery ( tovans ) performed successfully on live patients . they achieved a gasless transoral approach through the use of kirschner wires . in our patient , we chose to insufflate the field with carbon dioxide , thus eliminating the scar produced by the introduction of the kirschner wires . the following criteria were satisfied : ( 1 ) thyroid gland was approached using minimal dissection ; ( 2 ) patient was left with no visible scar . this surgical emphysema was due to insufflation of the surgical field with carbon dioxide and required no intervention . although the surgical field was clean , the port of entry , which was the inferior vestibule , is not sterile and hence she was started on oral antibiotics and antiseptic mouthwash to prevent wound infection . oral intake was started on post - op day 1 and she was discharged within a week ( fig . transoral endoscopic thyroidectomy is a feasible procedure that could be the final frontier in endoscopic thyroid surgery . while this surgery has been performed successfully in cases of thyroid carcinoma , we have found it to be effective in a case of solitary nodule of thyroid . the learning curve for this procedure is still in its initial stage but with more patients opting for scar - less surgeries , it has the potential to be performed with increasing frequency . written consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request .

highlightsendoscopic thyroidectomies aim to provide patients with minimal or no scars.transoral endoscopic thyroidectomy is based on the principles of natural orifice translumenal endoscopic surgery ( notes).involves minimal dissection and is truly scar-free.transoral endoscopic thyroidectomy has proven to be a feasible procedure.it provides easy access to the thyroid gland with aesthetically pleasing results .

they exhibit rapid postnatal growth followed by slow involution , often leading to complete regression . although most of these tumors are small and innocuous , associated structural congenital anomalies have been reported . a port wine stain is defined as a macular telangiectatic patch which is present at birth and remains throughout life . they may be localized or extensive , affecting a whole limb . they are often associated with an underlying disorder . these are best considered as low - flow vascular malformations which may occur on any part of the body but commonly affect the face in the distribution of the trigeminal nerve . initially , the lesions are pale pink patches , eventually they evolve into a violaceous color , remain static or even lighten . facial port wine stain typically evolve into thicker areas with vascular blebs , occasionally pyogenic granulomas and underlying tissue hypertrophy . a 40- year - old male reported to the dental clinic with complaints of stains on the teeth and bleeding gums . on examination a violaceous patch on the right side of the face was seen , extending about 2 cm below the hairline superiorly to the angle of the mouth inferiorly [ figure 1 ] laterally from the right tragus , medially to the midline . four papulo - nodular lesions were found overlying the lesion and distributed over the right malar area . intraorally bluish elevated lesions were observed on the mucosal aspect of lower lip [ figure 3 ] on the right side . based on the classical clinical features a provisional diagnosis of port wine stain with intraoral hemangioma was made . nevus of ota was considered as differential diagnoses , which were ruled out due to their characteristic color difference . showing unilateral distribution of port wine stain on the right side of the face reddish discoloration of right eye in comparison to the normal left eye showing intraoral hemangioma on the mucosal aspect of lower lip showing blanching of the intraoral hemangioma during diascopy test a classification system , first proposed by mulliken and glowacki was revised in 1996 by the international society for the study of vascular anomalies based on clinical , radiological and hemodynamic characteristics , into vascular malformations and vascular tumors . vascular malformations are errors of morphogenesis whereas hemangiomas and other vascular tumors grow by cellular proliferation . hemangiomas usually appear within the first month of life although they present as a precursor lesion in the immediate perinatal period . this can be very subtle , with a faint telangiectatic patch or even a patch of nevus anemicus - like pallor . . they may be superficial as in majority of the cases appearing reddish in color . . hemangiomas usually occur in the head and neck region but are less common in the oral cavity . majority of the hemangiomas involute with time but 10 - 20% of them fail to involute completely and may require post adolescent ablative treatment . hemangiomas are the most common tumors of infancy , occurring in as many as 2.6% of neonates and 12% of children aged 1 year . up to 30% of preterm infants with low birth weight ( 1000 gm ) may have hemangiomas . in the oral cavity , the bones and the muscles are affected as well as the mucosa and the skin . the most commonly affected facial bones are the mandible , the maxilla and the nasal bones . intraosseous lesions affect the mandible more often than the maxilla , with a ratio of 2:1 reported in one study . intramuscular hemangiomas in the oral region are most commonly seen in the masseter , compromising 5% of all intramuscular hemangiomas . a port wine stain is defined as a macular telangiectatic patch which is present at birth and remains throughout life . these are best considered as low - flow vascular malformations which may occur on any part of the body but commonly affect the face in the distribution of the trigeminal nerve . initially , the lesions are pale pink patches , but with time they may mature into a violaceous color , remain static or even lighten and may become nodular because of vascular ectasia . our patient presented with similar nodular swelling . port wine stains are associated with the following syndromes , sturge - weber - dimitri syndrome characterized by noninherited and nonfamilial , port wine stain , leptomeningeal angiomas and klippel - trenaunay syndrome characterized by port wine stain , angiomatosis of the extremities . a wide range of treatment options have been proposed for port wine stain which includes pulsed tuneable dye laser ( pdl ) which has become the treatment of choice . it is the only method that can destroy the tiny blood vessels in the skin without significantly damaging the skin . we ruled out possibility of any intracranial extension by imaging studies and referred for a laser ablasion . coexistence of port wine stain with intraoral cavernous hemangioma of the lip on the same side has been rarely reported in literature .

hemangiomas are neoplastic proliferations of endothelial cells , characterized by a period of growth after birth , and eventual spontaneous involution . the course can be uneventful with spontaneous resolution ; or it may be marked by complications such as infection , bleeding , ulceration , visual defects and feeding difficulties . apart from these , rare life - threatening complications such as congestive heart failure and consumption coagulopathy may also be seen . although hemangiomas commonly occur in the head and neck region , intraoral occurrence is relatively rare . a port wine stain is defined as a macular telangiectatic patch which is present at birth and remains throughout life . they may be localized or extensive , affecting a whole limb . this article reports a rare case of co - occurrence of port wine stain with intraoral hemangioma .

frontal fibrosing alopecia ( ffa ) is mainly a disease of postmenopausal women , and it is rarely seen in men . to the best of our knowledge and belief , only 23 cases of men with ffa have been reported in the literature . ffa in a male patient was first described in 2002 by stockmeier et al . in a 69-year - old man who presented with recession of the frontal hairline , and loss of eyebrows and sideburns . in women , ffa is typically characterized by progressive recession of frontotemporal hairline and usually associated with loss of eyebrow . in men , the beard area a 46-year - old man consulted for small patches of alopecia involving the sideburns and the beard area . patient stated the disease had developed 3 years before and was diagnosed as alopecia areata . clinical examination showed patchy alopecia of the beard and small atrophic patches of alopecia on sideburns [ figure 1a ] . a punch biopsy was obtained using the dermoscopy guided biopsy technique and was bisected as horizontal sections . it showed overall preserved follicular architecture with a focal area of follicular dropout and disappearance of the sebaceous glands . the follicular density was significantly reduced to five follicles ( three terminal follicles and two intermediate size follicles ) [ figure 2a ] . at the level of the isthmus , one follicle showed perifollicular fibrosis and a mild lichenoid infiltrate in perifollicular distribution [ figure 2b ] . these features were consistent with lichen planopilaris ( lpp ) . ( a ) small atrophic patches of alopecia on sideburns ( b ) dermoscopy showed loss of follicular openings and thin peripilar casts ( a ) significant decrease in follicular density with only five follicles ( three terminal follicles and two intermediate size follicles ) ( b ) at the level of the isthmus , one follicle showed perifollicular fibrosis and a mild lichenoid infiltrate in perifollicular distribution frontal fibrosing alopecia first described by kossard in 1994 in 6 postmenopausal women as a progressive scarring frontal alopecia . ffa mainly affects postmenopausal women , although it can be seen in premenupausal women and men . the exact pathogenesis is unknown although hormonal factors and an autoimmune process may play a role . other clinical features of ffa include hair loss involving eyelashes , axillae , pubic area and extremities , pruritus , burning sensation , trichodynia , and facial papules . on examination , perifollicular erythema , perifollicular hyperkeratosis , and lonely hairs may be seen . pathology of ffa shows lichenoid lymphocytic infiltrate , follicular fibrosis with destruction of hair follicles . treatment is challenging , and different modalities have been used including corticosteroids ( topical , intralesional and systemic ) , antimalarial ( hydroxychloroquine or chloroquine ) , finasteride or dutasteride , doxycycline , topical calcineurin inhibitor , and topical minoxidil . we describe in this report a male patient with ffa presenting only with the loss of sideburns and beard area . table 1 lists the reported cases of male patients of ffa with loss of sideburns . ramaswamy et al . described sideburn loss as a unique presentation of ffa in men and reported three patients with loss of sideburns and some other features of ffa as shown in table 1 . in contrast to our case , the patient we reported had only localized loss of sideburns with no other features of ffa . accordingly , loss of sideburns can be the only presenting feature in men with ffa . we recommend that all patients presenting the loss of sideburns should be examined thoroughly for the other clinical features of ffa , and a skin biopsy has to be done to confirm the diagnosis .

frontal fibrosing alopecia ( ffa ) is a cicatricial alopecia that affects mainly postmenopausal women . it is typically characterized by recession of frontotemporal hairline . hair loss of eyebrows , eyelashes , axillae , limbs , and pubic area may be observed . here , we describe a case of ffa in a male patient presenting with only localized loss of sideburns . skin biopsy findings were consistent with lichen planopilaris . to our knowledge , this is the only reported case of ffa patient with only localized loss of sideburns .

pseudoprogression , that is , initial tumor growth followed by subsequent tumor regression , has been well described for immunomodulation therapy in melanoma patients . nivolumab , an anti - pd-1 monoclonal antibody , was recently approved for nonsmall cell lung cancer ( nsclc ) as a second - line therapy . we present a patient with squamous nsclc , suffering from multiple bone and subcutaneous metastases . a subcutaneous lesion in her upper back grew substantially after the first cycle of nivolumab , and later regressed , with marked improvement in all cancer sites . nivolumab , an antiprogrammed death 1 ( pd-1 ) monoclonal antibody , was recently approved as second - line therapy for nonsmall cell lung cancer ( nsclc ) . pd-1 related therapies are an emerging field in cancer and currently , there are 3 approved therapies from this family ( pd-1 blockade ; nivolumab , pembrolizumab ; programmed death ligand 1 [ pdl-1 ] blockade ; atezolizumab ) . pdl-1 is a ligand released by the tumor which inhibits the lymphocytes in the microenvironment . by blocking the pd-1 receptor ( on the lymphocyte ) or by scavenging the pdl-1 , the immune system is enhanced and lymphocytes may interfere with the tumor tissue development . this process may cause local inflammation and physical growth . once the immune system overcomes the tumor this pseudoprogression may lead to misinterpretation of the patient 's status and wrong clinical decisions . we present here a case of pseudoprogression followed by dramatic regression of a subcutaneous metastatic lesion in a patient with squamous nsclc treated with nivolumab . pseudoprogression has been reported in 6.7% to 12% of patients with malignant melanoma treated by immunotherapy , while the manifestation of this phenomenon in lung cancer is still uncertain . a 68-year - old female smoker with a history of pulmonary embolism and diabetes mellitus was diagnosed with stage iiib ( t4n2m0 ) squamous nsclc . she was treated by definitive chemoradiotherapy with cisplatin and vinorelbine until september 2014 . in october 2014 , positron emission tomography computed tomography ( pet - ct ) scan demonstrated a good response in the primary lesion ; however , new metastases in the right adrenal gland and right femur developed and were irradiated in november 2014 . a month later the disease progressed with development of multiple bone and subcutaneous metastases . at that point she received one cycle of carboplatin and gemcitabine followed by severe pancytopenia , and treatment was switched to nivolumab 3 mg / kg q14 days in january 2015 . one week after the first cycle of nivolumab , a subcutaneous lesion in her upper back grew substantially , accompanied by severe pain and significant inflammatory reaction ( fig . after the second cycle of treatment marked symptomatic improvement was observed , including improvement in general appearance and dyspnea and reduction of the bone pain . the subcutaneous lesions started to regress too , with complete resolution by the 12th week as well as improvement in all bone lesions ( figs . 1 and 2 ) . ( a ) pet - ct demonstrating a subcutaneous metastatic lesion , 2 months after starting nivolumab treatment ( 03/2015 ) . ( b ) pet - ct demonstrating complete resolution of the lesion 5 months after starting nivolumab treatment ( 06/2015 ) . specifically , initial tumor growth followed by subsequent tumor regression ( pseudoprogression ) has been reported in metastatic melanoma . the underlying mechanism for the phenomenon is either continued tumor growth until a sufficient immune response occurs , or a transient immune - cell infiltrate . immune - related response criteria have been developed in order to address unconventional response patterns observed with immunotherapy . their use has revealed an additional 10% of favorable responses and survival in ipilimumab - treated melanoma patients . immune - related responses were also reported in melanoma patients treated with nivolumab , a fully human igg4 pd-1 immune check - point inhibitor . nivolumab received food and drug administration ( fda ) approval for second - line treatment of squamous nsclc based on superior survival rate over docetaxel in the checkmate 017 trial . the rate of pseudoprogression patterns in immunotherapy - treated lung cancer patients is still unclear . we describe a case of pseudoprogression of subcutaneous metastasis in a patient with lung squamous cell carcinoma treated with nivolumab .

abstractrationale : pseudoprogression , that is , initial tumor growth followed by subsequent tumor regression , has been well described for immunomodulation therapy in melanoma patients . this phenomenon is not well defined in lung cancer . nivolumab , an anti - pd-1 monoclonal antibody , was recently approved for nonsmall cell lung cancer ( nsclc ) as a second - line therapy.patient concerns and diagnosis : we present a patient with squamous nsclc , suffering from multiple bone and subcutaneous metastases.interventions:the patient was treated with nivolumab.outcomes:a subcutaneous lesion in her upper back grew substantially after the first cycle of nivolumab , and later regressed , with marked improvement in all cancer sites.lessons:such pseudoprogression may serve to predict subsequent clinical response .

an 80-year - old woman with a nodular lesion on her right breast was referred to our outpatient clinic in january 2010 after she had visited a local dermatology clinic . according to the patient , the lesion had existed since her early childhood , and its size had gradually been increasing . a dermatological examination revealed a well - demarcated blue / black colored nodule , measuring 10 7.0 cm in size , on her right breast ( figure 1 ) . a dermatoscopic examination showed a homogenous blue / black area in the center of the lesion with arborizing telangiectasia in the periphery to the surrounding region ( figure 2 ) . histopathological findings showed tumor masses mostly on the dermis with continuation from the epidermis in some parts . the tumor contained cystic spaces as well as palisading of the basaloid cells at the peripheral sites of the tumor masses and clefts between the stroma and tumor edge , which are often seen in typical basal cell carcinomas ( figure 3 ) . basal cell carcinoma is a slowly growing malignant epithelial skin tumor predominantly affecting middle - aged and fair - skinned individuals . histopathologically , bccs are composed of islands or nests of basaloid cells , with palisading of the cells at the periphery and a haphazard arrangement of those in the centers of the islands . these include solid , micronodular , cystic , multifocal superficial , pigmented , adenoid , infiltrating , sclerosing , keratotic , infundibulocystic , metatypical , basosquamous , and fibroepitheliomatous . criteria that may have value in distinguishing trichoblastomas from bcc include the following : the presence in the former of symmetry , circumscription with smooth margins and shelling out of the normal tissue , follicular and racemiform patterns of lesional cells , or the lack of a clefting artifact between stroma and epithelium that is characteristic of bcc . in the present case , the tumor masses are relatively asymmetrically distributed , and clefts between the stroma and tumor edge are observed . noninvasive procedures have been developed for the diagnosis of skin cancers [ 47 ] . among these , dermatoscopy is the most useful diagnostic procedure with the highest clinical impact in dermatologic practice to better differentiate benign from malignant skin lesions and to detect tumors in the early stage [ 6 , 7 ] . the model for the diagnosis of the pigmented variant of bcc is based on the absence of a pigmented network to differentiate it from melanoma and the presence of at least one positive feature including ( 1 ) ulceration ( not associated with a recent history of trauma ) , ( 2 ) multiple blue / gray globules , ( 3 ) leaf - like areas , ( 4 ) large blue / gray ovoid nests , ( 5 ) spoke - wheel areas , and ( 6 ) arborizing telangiectasia . however , bcc may exhibit a large variety of clinical and dermatoscopic characteristics because of its wide range of histopathological features . in the present case , the pigment network was absent and , among the six features , arborizing telangiectasia was present but the other features were not . instead , a homogenous blue / black area was seen in the center of the tumor , which could be distinguished from the large blue / gray ovoid nests . histologically , cystic areas overlay the tumor , which may have been the reason for the homogenous blue / black area . the mechanism of the cyst formation was assumed to be massive cell necrosis in the central part of the tumor , which was caused by the rapid tumor growth . we evaluated 102 cases of bcc diagnosed at our hospital between april 2005 and march 2010 . the cystic type was relatively rare ( 2.9% ) in the present study ( table 1 ) . among two other cases of the cystic type , in one , the patient did not undergo a dermatoscopic examination . in the other case , multiple blue / gray globules and arborizing telangiectasia were observed , but there were no homogenous blue / black areas ( figure 4 ) . this may be due to the fact that , unlike the present case , a cystic area existed under tumor masses ( figure 5 ) . in conclusion , we herein reported a cystic bcc showing a blue / black nodule on the right chest wall . dermatoscopy revealed a homogenous blue / black area with arborizing telangiectasia . this rare clinical appearance made it difficult to diagnose ; however , our findings suggest that bcc should be considered when a dermatoscopic examination reveals a cystic lesion with a homogenous blue / black area with arborizing telangiectasia .

basal cell carcinoma ( bcc ) is the most common skin tumor and contains several different histopathological types . here , we report a case of cystic basal cell carcinoma , which is relatively rare and might be clinically misdiagnosed . a dermatoscopic examination of the case revealed a homogenous blue / black area usually not seen in bcc . we reviewed 102 bcc cases resected and diagnosed at sapporo medical university hospital between april 2005 and march 2010 . among them , only three were the cystic type .

soil samples were collected from various parts of taebaek , gangwon - do , korea in 2013 . each soil sample was taken from approximately 15-cm depth , air dried , and stored in plastic bags at 4 until use . the fungi were isolated by conventional dilution technique and cultured on potato dextrose agar ( pda ; difco laboratories , detroit , mi , usa ) supplemented with 100 g chloramphenicol ( bacteriostatic agent)/ml pda for 5 to 7 days at 28 until growth of fungal colonies was observed . genomic dna of isolate knu13 - 5 was extracted using the dneasy plant mini kit ( qiagen , hilden , germany ) following the manufacturer 's instructions . the internal transcribed spacer ( its1 and its2 ) regions , including the 5.8s rrna gene were amplified with the primers its1 and its4 . the amplified pcr products were purified using the qiaquick pcr purification kit ( qiagen , valencia , ca , usa ) following the manufacturer 's instructions . the pcr products were sequenced using the abi prism 3730 dna analyzer ( applied biosystems , foster city , ca , usa ) . the sequences were compared with reference its1~its2 rdna sequences from ncbi 's genbank using the basic local alignment search tool ( blast ; http://www.ncbi.nlm.nih.gov/blast ) . the dna sequences were analyzed for phylogenetic relationships using molecular evolutionary genetic analysis ( mega 6 ) software . the sequence of isolate knu13 - 5 was compared with the sequences in genbank by using blast . the phylogeny of the tree was inferred using the maximum - likelihood heuristic search option with nearest - neighbor - interchange . the its regions of isolate knu13 - 5 were identical to those of m. alpina ( fig . 1 ) . the its sequence ( its1 and its2 ) of knu13 - 5 was 99% identical to that of m. alpina d27 ( accession no . morphological features of the fungus were observed on pda medium after three - point inoculations in 9-cm petri dishes and incubation in the dark at 28 for 7 days . the morphological characteristics were identified with the aid of differential interference contrast microscopy , as detailed by pitt and frisvad and samson . photomicrographs were taken with a kodak dcs 14n digital camera ( eastman kodak company , rochester , ny , usa ) attached to a compound microscope . 2 . colonies on pda are fast growing , attaining 35~45-mm diameter after 7 days when grown at 28 , producing a concentric pattern , sporulating well , and having mortierella - like odor and milky - white color ( fig . sporangiophores arising from the mycelial substrate are 60~110 m in size , erect , and unbranched ( sometimes dichotomously branched ) with terminal sporangia ( fig . 2d , 2e , 2f , and 2h ) . sporangia are hyaline , obovoid when young and spherical at maturity , 12~15 m in diameter , and multispored with a deliquescent wall ( fig . sporangiospores are cylindrical , 5~7 m in size , and sometimes curved to irregularly shaped ( fig . the phylogenetic analysis and morphological characteristics of strain knu13 - 5 indicated it to be m. alpina . knu13 - 5 , isolated from soil samples , taebaek , gangwon - do , korea . shin et al . described the morphological characteristics of the species m. alpina s49 , but the identification was tentative , and there have been limited studies on m. alpina in korea with respect to arachidonic acid production efficiency and its effect on the growth and learning ability in animals ; furthermore , the source of the isolates was not indicated [ 11 , 12 ] . in other cases , m. alpina dsa-12 was used for the production of arachidonic acid by using an organic nitrogen source and optimizing the culture conditions [ 13 , 14 ] . however , strain dsa-12 was obtained from doosan biotech , korea , and the mycological information on the strain has not been officially reported in any publication . furthermore , in a study on submerged and solid - state fermentations by the species for production of arachidonic acid , the isolate used was obtained from the american type culture collection ( atcc ) collection . therefore , to the best of our knowledge , this is the first authentic , official report of m. alpina in korea .

a new recorded species of mortierella was recovered during the investigation of fungal communities in soil samples collected from different locations of gangwon - do , korea . the species was identified and described as mortierella alpina on the basis of phylogenetic analysis of internal transcribed spacer sequences and morphological characteristics . this species has not been officially reported from korea thus far .

most patients do not recall swallowing foreign bodies , and the clinical diagnosis may be rather difficult due to nonspecific clinical presentations . we report a 60-year - old male patient who was admitted to our hospital for upper quadrant pain , diagnosed as coronary artery disease and peptic ulcer disease . computed tomography ( ct ) showed a round hypodense mass in the left lobe of liver , approximately 2.7 2.2 cm in size , and a fish bone was confirmed by surgery in the left lobe of the liver . the patient 's clinical symptoms alleviated completely after surgical removal of the fish bone and the liver abscess . a 60-year - old male patient presented with recurrent upper quadrant pain for 1 month . coronary angiography revealed 65% stenosis of the left anterior descending branch of the coronary artery . endoscopy revealed duodenal ulcer at the anterior wall of the bulb . on physical examination at admission , he had a temperature of 36.5c , a heart rate of 60 bpm , a respiratory rate of 20 per minute , and a blood pressure of 160/100 mm hg . laboratory examinations showed the following : white blood cells 16.6 10/l , serum c - reactive protein 40 g / ml , erythrocyte sedimentation rate 40 mm / h , ck - mb 13 u / l , ctni < 0.01 g / l , ck 582 u / l , serum bilirubin 28.1 mol / l ; aspartate aminotransferase and alanine aminotransferase were below normal level . an electrocardiogram revealed st segment elevation in leads v1v4 . on the second day after admission given his painful right ankle , his past history of gout and fluctuating temperature , he was prescribed nonsteroidal anti - inflammatory drugs as painkillers , omeprazole injection 40 mg i.v . gtt bid for alleviating abdominal pain due to past duodenal ulcer , and nitroglycerin tablets for dilating the coronary artery . ct showed a round hypodense mass in the left lobe of liver , approximately 2.7 2.2 cm in size , and a linear foreign body with hyperdensity lesion in the left lobe of the liver ( fig . 1 ) . nasal endoscopy ( fujinon eg-530wn , tokyo , japan ) showed an ulcer 0.9 1.0 cm in size at the lesser curve of the gastric antrum ( fig . the patient was transferred to the department of general surgery with a fish bone in the left lobe of the liver ( fig . 3 ) and a fistula between the stomach and the liver . the fish bone was removed , and the fistula lesion was cut successfully . meanwhile , a percutaneous drainage tube was implanted at the abscess lesion of left lobe of the liver . as a result , gastrointestinal perforation is commonly caused by foreign bodies , such as fish bones , chicken bones , needles and toothpicks . some patients present with high - grade fever , right upper quadrant pain and jaundice . however , other patients are not specific , so the diagnosis of liver abscess is rather difficult . when it comes to the etiology of liver abscess secondary to fish bone , a possible pathogenesis is penetration through the duodenum and migration from the posterior surface of the liver into the liver . our patient experienced recurrent abdominal pain and intermittent fever ; he could not remember whether he had a history of fish bone ingestion . ct showed a foreign body and a round hypodense mass located in the left lobe of the liver . the patient was cured completely after surgical removal of the fish bone and the liver abscess . our patient underwent coronary angiography due to upper quadrant pain and st segment elevation in leads v1v4 , and this revealed 65% stenosis of the left anterior descending branch of the coronary artery . however , the patient still suffered upper quadrant pain , and high - grade temperature was observed subsequently . upper quadrant pain accompanied by recurrent fever should be possibly considered as foreign body ingestion , and ct scan should be performed simultaneously . in conclusion , we report a patient with liver abscess presenting with upper quadrant pain and high - grade fever ; the liver abscess was secondary to fish bone ingestion . we should be aware of foreign body ingestion if patients present with abdominal pain and intermittent or persistent fever .

a 60-year - old male patient was admitted to our hospital for recurrent upper quadrant pain for 1 month . he had a past history of coronary artery disease . after admission , he repeatedly suffered from high - grade fever , chills and upper quadrant pain . computed tomography ( ct ) showed a round hypodense mass in the left lobe of the liver , approximately 2.7 2.2 cm in size , and a fish bone was confirmed by surgery in the left lobe of liver . the patient was cured completely after surgical removal of the fish bone and liver abscess . ct scan 1 month after discharge showed that the liver abscess had disappeared completely .

hajj is the fifth pillar of islam and though it should usually be performed once in one 's lifetime , many muslims perform the hajj several times . this season is the period from 15/11 to 15/12 of the lunar calendar with the peak period between 3 to 14/12 . health problems during hajj are due to the following reasons : 1 ) hajies are usually elderly , of different nationalities , social backgrounds , with diverse health problems . 2 ) the same rituals are performed by everyone over a short period of time , resulting in over - crowding and mass movement from one place to another . many patients , who normally come to the emergency room , do not have serious complaints . the hospital staffs get overworked as a result of the sheer weight of numbers , thus prolonging the waiting period for the patients . several health problems including heat stroke and exhaustion,13 medical,4 surgical,5 renal6 and epidemic problems79 have been studied during hajj period . however , very few studies if any have dealt with the problems of the emergency room . the aim of this study is to identify : 1 ) the major surgical and medical problems during hajj as a means towards the improvement of care and the reduction of the morbidity and mortality . 2 ) simple cases that could be dealt with at an outpatient clinic or primary health care center instead of the emergency department . the study was conducted prospectively during the 1413 ( 1993 ) hay pilgrimage from 20.11.1413 to 20.12.1413 . all saudi and non - saudi pilgrims presenting to al - noor specialist hospital 's emergency department were included . al - noor specialist hospital is 500-bed modern hospital with all sub - specialties and the main hospital in makkah . most emergency cases were brought to this hospital either by red crescent or medical hajj missions or by relatives and friends . the data were entered into a pc computer file of access program and the statistical analysis was done using statistical package for social sciences version 7 ( spss ) . the number of patients attending emergency department from 20.11 to 20.12.1413 was 7,676 patients , 55.1% ( 4228 ) of whom were males . out of those patients 1426 ( 18.6% ) were admitted . the age distribution was from newborns to 120 years old , with a mean age of 48 . there were 1230 patients ( saudi national and expatriates ) , 735 egyptians , 732 pakistanis and 368 indonesians . patients with abdominal pain and cuts were the commonest , 377 and 178 respectively and the lowest number of admissions . as shown in table 3 , there were many medical problems that could have been treated in the outpatient clinic or primary health care centers . the commonesst urgical problems attending emergency department the commonest medical problems attending emergency department the commonest medical problems attending emergency department with minimum admissions the emergency department is one of the most difficult departments run since it deals with different types of medical emergencies as well as cold cases . hajj creates a unique medical situation because of the huge number of patients presenting at the emergency department with different types of medical emergencies . hajies are usually elderly who participate in several strenuous physical activities . beside medical problems , other problems including the language barrier , different cultural backgrounds are evident . similar to a previous study done in al madinah al - munawara5 the commonest surgical cause for hospital admission in our study was trauma with or without fractures . though abdominal pain and cuts were the commonest surgical reasons for attending emergency room , they formed the smallest number of reasons for admission and they could have been dealt with at the outpatient clinic or primary health care centers . similar to previous study done in al madinah al - munawarah4 the commonest medical cause for admission was pneumonia . as shown in table 2 , asthma and gastroenteritis were the commonest cause for attendance at emergency room though they could have been treated in due outpatient clinic or primary health care centers and constituted the least important cause for admission . as these patients were in need of oxygen or intravenous fluid , they occupied emergency room beds for a few hours , which unnecessarily aggravated the problem of overcrowding . table 3 shows cases that should have gone to the primary health care centers instead of the emergency room since they were not serious enough for admission . in an overcrowded unit such as emergency room , a great deal of the work is urgent and any unnecessary overload affects the quality of care given to the sick patients . over 50% of patients in this study did not need to go to the emergency room and could have been managed in primary health care centers . in conclusion , the following are the observations of the researcher : 1 ) an important subject for further research is trauma , which was the commonest surgical problem requiring admission . 3 ) several medical and surgical problems could be dealt with in primary health care centers , leaving the staff to care for real emergency cases more effectively .

objective : hajj usually presents a unique medical crisis especially for the emergency department . this study will identify the surgical and medical cases that presented at the emergency department during hajj and percentage admitted.design:a prospective study of the pattern of surgical and medical cases that presented at the emergency department of the largest tertiary care hospital in makkah city and holy lands during hajj.methods:the study was conducted prospectively during the 1413 ( 1993 ) hajj pilgrimage from 20.11.1413 to 20.12.1413 . all saudi and non - saudi pilgrims presenting at the emergency department of al - noor specialist hospital were included.results:from the 7,676 patients who came to the emergency department , 1426 were admitted . the commonest cause for surgical admission was trauma , while the commonest cause for medical admission was pneumonia.conclusion:more than 50% of cases could have been dealt with in the outpatient department or primary health care centers .

sublingual hematoma secondary to anticoagulation therapy is a rare fatal condition and a medical emergency . a 45-year - old female patient reported with complaint of painful swelling in the floor of the mouth [ figure 1 ] . her medical history revealed mitral valve stenosis for which prosthetic mitral valve replacement was done 2 years ago . she was on warfarin 7.5 mg and aspirin 75 mg once daily since mitral valve replacement . past dental history revealed removal of left mandibular premolar tooth a year ago without any vascular complications . a 45-year - old female patient reported with complaint of painful swelling in the floor of the mouth on dental examination , intraorally a solitary swelling measuring about 3 cm 3.5 cm was present in the floor of the mouth extending anteroposteriorly from the alveololingual sulcus to the junction between the floor of the mouth and base of the tongue . the mucosa over the swelling was erythematous with few areas of smooth texture , and few areas showed pinpoint elevations . an ulcer measuring about 5 mm 5 mm was also present over the swelling in relation to left mandibular first molar tooth , which had a sharp cusp . the ulcer was tender with tissue tags in the margin and was not indurated [ figure 2 ] . based on the clinical findings , provisional diagnosis of the sublingual hematoma with traumatic ulcer was considered . intraoral swelling in the floor of the mouth with a sharp tooth induced ulcer over the swelling near left mandibular first molar tooth panoromic radiograph and mandibular occlusal radiographic examinations revealed no significant findings . diascopy , a technique for demonstrating blanching on compression using glass slide , revealed absence of blanching over the hematoma . blood investigations revealed elevated international normalized ratio ( inr ) of 7 , increased prothrombin time ( 65.9 s ) , and activated partial thromboplastin time ( 98 s ) . the patient was immediately referred to a physician for medical management where the patient was admitted in coronary care unit . the medical team temporarily stopped the warfarin for 4 days and transfused 2 units of fresh frozen plasma . the blood parameters at the time of sublingual hematoma formation and posttreatment are listed in table 1 . blood investigations showing pretreatment and posttreatment values anticoagulants are used for mechanical valve replacement in rheumatic heart disease , deep venous thrombosis , pulmonary embolism , and cerebral venous thrombosis . estimated annual incidences of bleeding rates are 0.6% for fatal bleeding , 3% for major bleeding , and 9.6% for minor bleeding . this particular case was unique in that the patient had mitral valve replacement and was on warfarin for the past 2 years but did not develop the sublingual hematoma . she also underwent removal of a tooth 1-year after mitral valve replacement but did not develop the sublingual hematoma . however , a trauma by a sharp cusp present in the mandibular first molar tooth triggered an episode of the sublingual hematoma in this patient . a minority of cases in the literature have indicated a causative factor for the sublingual hematoma arising from trauma alone without any anticoagulation significance , such as after oral surgical procedures . in addition to medical management , the sharp cusp of the mandibular first molar tooth was smoothened to prevent future trauma and ulcer development in the floor of the mouth . smoothening of sharp cusp is called enameloplasty , and it can be done in an outpatient basis with a cylindrical bur and airotor high - speed handpiece . the hematoma resolved completely , and no new hematoma formation was observed for a period of 6 months [ figure 3 ] . this article stresses the importance of the interdisciplinary approach and to consider dental examination for sharp cusps to all patients who will be administered anticoagulants and thereby reduce the risk of sublingual hematoma formation .

sublingual hematoma secondary to anticoagulation is a rare fatal condition . hemorrhagic complications of warfarin are well - known . this particular case is unique because the patient was on warfarin for the past 2 years but did not develop the sublingual hematoma . however , a trauma by an attrited sharp cusp triggered the episode of the sublingual hematoma in this patient . being a medical emergency , patient was promptly hospitalized in cardiac care unit and managed by medical team . the patient was transfused with 2 units of fresh frozen plasma and warfarin was temporarily stopped for 4 days . alternate day regimen of warfarin was started after 4 days , and international normalized ratio dropped to 3 . in dental management , enameloplasty of the mandibular first molar tooth was done to prevent trauma and ulcer development in the floor of the mouth . the hematoma resolved , and no new hematoma formation was observed for a period of 6 months .

foreign body ( fb ) impaction is seldom seen in adults , although a prevalence of 25% is reported in medical literature for paediatric population . this clinical record illustrates a rare case of impaction of coin in larynx in a healthy and conscious adult . the mode of entry , site of impaction and management were felt to be interesting , hitherto unreported in medical literature . a 45-year - old adult presented to the casualty department of vardhman mahavir medical college & safdarjung hospital , new delhi with the chief complaint of hoarseness . history revealed that the patient had accidently swallowed a two rupee coin while casually fiddling with it and rolling it in the mouth . indirect laryngoscopy ( il ) showed the said coin to be impacted at the laryngeal inlet . it would be prudent to note that patient had no signs and symptoms of airway compromise . x - rays confirmed the site of the coin ( figures 1 , 2 ) . the said coin was then removed in the operation theatre , with full anesthetic back - up under local anesthesia and sedation , by direct laryngoscopy and crocodile forceps ( figure 3 ) . the coin was found impacted obliquely at the laryngeal inlet with one smooth edge jagged at the anterior commissure ( figure 4 ) . post operative period was uneventful with no untoward incident to report and the patient was kept in regular follow - up . fb impaction in larynx in an adult is a rare phenomenon , as the sphinteric action of the larynx is well developed to protect the lower respiratory airway . hence , most of the foreign bodies are seen in the hypopharynx or they go past the glottis into the bronchus . impaction in adults is thus seen only in unconscious patients or those intoxicated with alcohol . moreover , fb lodges in the larynx if it is too large to pass through or if it is of an irregular shape with sharp edges that can catch on the laryngeal mucosa . contrary to these medical facts , it is interesting to note that a smooth and rounded coin got impacted in the larynx of our conscious patient . in addition , in the said case intubation , thereby general anaesthesia ( ga ) was avoided as there was risk of dislodgement of coin into the lower respiratory passages . as the patient was a healthy co - operative adult male with no respiratory distress whatsoever it is however , pertinent to note that such cases should always be operated with good anesthetic back - up , for obvious reasons in the best interest of patient care . in a literature search using medline services / pub med database using the medical subject function , authors could find no such case of coin impaction in the larynx as described here in . though some pointed , sharp and irregular objects find mention in literature , but impaction of any smooth edged , well defined foreign body has not been reported in literature . these sharp and irregular fb 's were either iatrogenic or traumatic in impaction , and were removed under general anaesthesia . the first author has also reported an alpin impaction in larynx resulting from casual fiddling , which was removed under local anesthesia . we would thus emphasize that casual fiddling with any small object , even a coin is best avoided , as it can get accidently impacted in larynx in a healthy conscious adult . in summary , the interesting mode of ingestion while fiddling , the unusual clinical presentation of impaction of the coin with no respiratory embarrassment in a conscious healthy adult and finally its endoscopic removal under local anesthesia make this clinical record unique , and prompted us to share our professional experience with the medical fraternity .

impaction of foreign body in larynx is reported exclusively in paediatric population only . moreover impaction of coin in larynx has never been reported previously . with this background , we report a rare case of coin impaction in larynx in a healthy adult .

cephalhematomas , in the neonate , occur due to bleeding in the subperiosteal layer of the scalp and are common in parietal area . they are frequently associated with traumatic labor such as assisted vaginal delivery using forceps or vacuum extraction although may be seen even after normal delivery . they are found in < 1% of newborns and usually resolve spontaneously within a month . rarely , they may persist and the periosteum undergoes ossification . this may result in either cosmetic deformity , inward compression of the soft calvarial bones , or rarely craniosynostosis . more importantly , the diagnosis per se may be missed unless one is aware of this rare phenomenon of ossification in cephalohematomas . furthermore , no consensus exists on the management protocol ( conservative vs. surgery ) and the surgical techniques used for ossified cephalhematoma ( oc ) . hence , surgical intervention may not be necessary in every child and is only selective . a 3-month - old , developmentally normal child presented with a hard swelling over the right parietal region . at birth , the parents had noticed a soft scalp swelling which was apparently overlooked . a computed tomography ( ct ) scan showed an additional layer of bone overlying the right parietal area and separated from calvarium by a hypodense area . the normal calvarium was not depressed [ figure 1 ] . in view of the relevant history and ct imaging , ( a and b ) computed tomography ( axial and coronal sections ) of skull showing type 1 ossified cephalhematoma ; the inner and outer tables are ossified with intervening organized hematoma ; the inner table is continuous with the normal contour of the skull . cephalohematomas do not cross suture lines due to periosteal attachments and thus differ from caput succedaneum and subgaleal hematoma . they are probably secondary to tearing of subperiosteal blood vessels due to sudden compression of skull with inward movement causing the bone to move away from periosteum . the shearing force between skull and periosteum may also cause stripping of periosteum from underlying bone . in general needle aspiration may be helpful when there is suspicion of infection or to prevent possible calcification in a long - standing swelling . although usually disappearing in a month 's time , occasionally cephalohematoma becomes organized and subperiosteal osteogenesis occurs resulting in calcification . of late , their formation is considered to be a phenomenon of ossification rather than simple calcification process as described in earlier reports . ocs are classified into two types : type 1 where there is no depression of the inner layer and hence no inward encroachment and type 2 where this is present . occasionally , they may undergo spontaneous remodeling which suggests that observation is an option in certain children with no major cosmetic concern . surgery is advocated in cases of significant deformity and/or secondary cranial complications as described earlier . propose an ostectomy of the outer layer while in type 2 , they have advocated a flip - over bull's - eye craniectomy or a cap radial craniectomy . for incompletely oc in children have advocated a passive cranial molding helmet therapy though others have expressed concerns that this might convert a type 1 into a type 2 variant . a differential diagnosis of oc is likely to be missed unless the physician is aware of this rare entity . further , considering the possibility of oc would lead the attending physician to seek appropriate imaging ( x - ray / ct scan ) and skip fine - needle aspiration which may be unwarranted in such lesions . supported by relevant history and classical ct imaging , the parents could be convinced of such benign condition which may require just follow - up in cases with no significant cosmetic or cranial effects . spontaneous regression of these lesions with growth of the cranium has been described by daglioglu et al . who advocate follow - up up to 2 years and likewise in our case too , we have reassured the parents and asked them to keep the child on regular follow - up . although rare , they should be considered as a differential . the management has to be tailored on case - to - case basis depending on cranial or cosmetic effects .

cephalhematomas occurring in newborn usually resolve within a month . rarely , they tend to ossify and present as hard scalp swelling . unless one is aware of this possibility , this condition may be misinterpreted as bony tumor and cause needless apprehension to parents as well as the treating physician . a suspicion that ossified cephalhematoma ( oc ) could present in such a manner supported by careful history taking and relevant imaging ( x - ray / computed tomography ) would help in appropriate evaluation of this benign condition . the management of oc is controversial . occasionally , they undergo spontaneous remodeling . those with secondary craniosynostosis and/or disfigurement are treated surgically . simple ossified lesions with no significant cosmetic issues may be conservatively tackled . we report such a case in a 3-month - old child . the other management options are briefly discussed .

comparison of multiple sequence alignments ( profiles ) with other profiles can identify subtle protein relationships beyond the resolution of sequence - to - sequence or sequence - to - profile comparisons ( 15,79 ) . the main advantages of using profiles instead of sequences are better characterization of the compared regions and the possibility for giving more weight to , or using only , conserved regions . using only conserved regions significantly reduces the search space and avoids possibly spurious hits by non - conserved and misaligned regions . blocks are local ungapped profiles of the most conserved regions of protein families and domains ( 2 ) . lama is a profile - to - profile alignment method , previously developed by us , for comparing blocks with each other and for searching databases of blocks with block queries ( 5 ) . it is a highly sensitive method for detecting sequence similarities that are often not found by other profile - to - profile and sequence - to - profile methods ( 6 ) . lama alignments do not use gaps , since the compared profiles are short and are themselves constructed from ungapped conserved regions . cyrca is a method for detecting weak protein sequence similarities by aligning multiple blocks ( 3 ) . the resulting multiple - block alignments are identified as block sets with consistent and transitive relationships , derived from pairwise block alignments previously found by lama . namely , if blocks a , b and c are aligned to each other in the same phase in overlapping regions , then these blocks are probably genuinely similar to each other , even if each pairwise alignment score is insignificant by itself ( figure 1 ) . the simplest transitive block relationship is a triangle graph ( a cycle of three blocks ) . cyrca first identifies consistent triangles , joins triangles with common edges and finally adds linear edges that have very high alignment scores . cyrca sets are , thus , identified from large - scale lama comparisons of many blocks with each other , typically using the whole blocks database . analysis of specific blocks has identified biologically significant and genuine relationships ( 10,11 ) , but it requires manual interventions . here we present a procedure and a web server for automatically adding new blocks to previously constructed or constructing new cyrca sets . in the first step of the algorithm , each of the query blocks is compared by lama with the database for which cyrca sets were previously computed ( the current version of the blocks database ) . next , all of the blocks found to be similar to the query or queries are compared by lama with each other . the resulting query hits ( graph edges ) , together with the edges found within the database , are then examined using the cyrca algorithm . this can identify new sets or join the block queries to existing cyrca sets ( figure 2 ) . the one - block cyrca procedure analyzes the relationship of one or a few block queries to a database , whereas the basic cyrca procedure inter - compares a whole database . we took advantage of this to use a more sensitive and time - consuming value for the cyrca cycle size parameter . one - block cyrca sets are identified by first locating consistent cycles of any size , not just triangular ones as in the basic method of kunin et al . input to the server ( ) is one or more blocks supplied by the user . the blocks can be in the blocks database format ( 2 ) ( ) or in another commonly used multiple sequence alignment format ( multiple fasta , clustal or msf ) . these latter formats can be found in many multiple alignments databases , such as pfam ( 12 ) , cdd ( 13 ) and smart ( 14 ) , and as the output of multiple alignment programs such as meme ( 15 ) , t - coffee ( 16 ) and dialign ( 17 ) . from these alignment types only ungapped regions wider than four columns will be used . the user can upload the input from a local file or can paste it into the query window . the default z - score threshold parameter of the lama alignment significance ( 5.6 ) corresponds to 1% significance level . the linear edge threshold score parameter default value ( 8.0 ) is more selective , since it is used for adding to cyrca sets linear edges whose consistency can not be checked ( 3 ) . these can be expanded pre - computed or new sets . if the queries were from the blocks database , it is possible that the sets will be unchanged pre - computed ones . the sets are shown with the description of their blocks , list of all the set edges ( pairwise alignments ) and phase alignment of all blocks . there are also links to the block entries in the blocks database and to interactive graph representations and superimposition of structures present in different blocks of each set ( figure 3 ) . hnh and giy - yig nuclease domains are often accompanied by regions with conserved sequence motifs . we have previously shown that these motifs are similar to known dna binding motifs and probably confer the substrate specificity to the nuclease catalytic regions ( 11 ) . our analysis was based on block - to - block alignments found by lama and cyrca . this required careful manual intervention since the nuclease - associated modular dna - binding domains ( numods ) blocks we found were not part of the blocks database . submitting the numod motifs to the one - block cyrca server returned the block sets we used to identify their function ( figure 3 ) . the high selectivity of one - block cyrca is derived from the transitive nature of its search . all hits found by the query are examined further if they are consistently similar to each other . this identifies a set of similar blocks that can form a multiple - block alignment . the one - block cyrca method has a novel combination of searching with short queries ( corresponding to local sites on proteins ) and using the powerful methodology of profile - to - profile methods . other servers and programs either use short queries to compare with sequences or compare long gapped profiles ( or hmms ) with other profiles . our approach allows the identification of weak and localized similarity between proteins embedded in otherwise different contexts . a graphical example of a consistent set of aligned blocks . ( a ) three consistently aligned pairs of blocks a , b and c are presented . ( b ) a consistent cyrca set obtained from the block alignments shown in ( a ) . such basic consistent graphs are then joined to form larger consistent sets ( 3 ) .

one - block cyrca is an automated procedure for identifying multiple - block alignments from single block queries ( ) . it is based on the lama and cyrca block - to - block alignment methods . the procedure identifies whether the query blocks can form new multiple - block alignments ( block sets ) with blocks from a database or join pre - existing database block sets . using pre - computed lama block alignments and cyrca sets from the blocks database reduces the computation time . lama and cyrca are highly sensitive and selective methods that can augment many other sequence analysis approaches .

glioblastoma multiforme ( gbm ) is a highly aggressive primary tumor in adults , composing of 12 - 20% of intracranial tumors and more than 50% of glial neoplasms . cerebrospinal seeding ( csf ) is present in approximately 15 - 25% of the cases of supratentorial gbm , while a higher incidence is seen in patients with infratentorial gbm . however , the exact incidence of csf seeding is unknown , as autopsy is not performed routinely . the rate of spinal metastasis from intracranial gbm has been variably reported to be 0.4 - 2% . according to a review by lawton et al . in 2012 , there were only 42 documented cases of primary intracranial gbm with spinal mestastasis . we present a unique case of late onset symptomatic whole spine metastasis of gbm in a patient approximately 36 months of detection of primary gbm . a 60-year - old male patient presented with slurring of speech and progressive weakness of the right side of the body since 1 month in june 2011 . magnetic resonance imaging ( mri ) of the brain was suggestive of a large left frontal irregular , heterogeneously enhancing lesion . the patient then underwent external beam radiotherapy ( ebrt ) in a dose of 59.4 gy in 33 fractions for 6 weeks with chemotherapy ( temozolamide capsule 100 mg daily ) with an uneventful course . he remained stable , and postoperative mris during follow - up were not suggestive of residual / recurrent disease . postoperative mri scan showing tumor excision after approximately 36 months , he presented with gradually progressive weakness of the left lower limb since 6 months , followed by weakness of the right lower limb along with numbness in both the lower limbs and bowel and bladder involvement for 10 days . on neurological examination , power in both the lower limbs was grade one - two with the sensory level at t - eight . pre and postcontrast mri of the spine showed a 24 mm 9 mm 11 mm ill - defined , enhancing , intramedullary lesion at d2 - 3 with cord expansion with extension into the extramedullary space with diffuse leptomeningeal involvement all along the cervical spine , along the filum and conus [ figures 2 and 3 ] . he underwent d2 - 6 laminectomy and tumor decompression , histopathology of which was suggestive of high grade astrocytoma compatible with recurrent metastatic glioblastoma ( who grade iv ) . the patient then underwent radiotherapy which he could not tolerate and eventually succumbed to his disease after a period of 6 months . sagittal view showing leptomeningeal , extramedullary , and intramedullary metastasis axial sections of the different levels of metastasis the most common sites are lower thoracic , upper lumbar , and lumbosacral regions , with nerve roots of the cauda equina , nerve root sleeves , and fundus of the thecal sac being the other sites of metastasis . intramedullary and entire spinal cord involvement is an extremely rare event with only six cases reported till 2008 . invasion of basement membrane structures and choroid plexuses with subependymal growth results in metatstatic spread along csf , while invasion into the cortical surface via subpial spread will lead to leptomeningeal dissemination . in a study of supratentorial gliomas in children , ventricular entry at operation , multiple resections , and male sex were associated with statistically significant increased incidence of csf dissemination . recraniotomy is additionally associated with greater csf dissemination , probably from repeated manipulation , a more aggressive tumor type and depression of the immune system because of radiotherapy and chemotherapy . common symptoms of spinal metastasis are radicular pain , sensory loss , gait disturbances , weakness and pain in the lower back , interscapular area , and the neck , followed by paraparesis , quadriparesis , paraplegia , bowel or bladder dysfunction , and sexual dysfunction . the treatment options are surgery for decompression , ebrt in total dosage of 25 - 40 gy , and intravenous or intrathecal chemotherapy . radiation is used most commonly ; because treatment is usually symptomatic , there is no obvious survival advantage of one therapy over the other . nevertheless , spinal metastasis of gbm have poor prognosis , with fatal outcome always occurring . the median time from diagnosis of the primary intracranial gbm to diagnosis of the csf tumor dissemination ranges from 8 - 14 months ( approximately 35 - 36 months in our case ) , median survival ranges from 11 - 17 months , and the average time interval between diagnosis of leptomeningeal metastasis and death is 2 - 3 months .

glioblastoma multiforme ( gbm ) is one of the most common and aggressive primary brain tumors , composing 12 - 20% of all the intracranial tumors in adults with a highly malignant course and average life expectancy of approximately 12 - 14 months following initial diagnosis . leptomeningeal or intramedullary metastasis from primary gbm is a rare phenomenon with a poor prognosis . we present a rare case of gbm with late onset intramedullary , extramedullary , as well as leptomeningeal spinal metastasis .

acute renal infarction is rarely detected in clinical practice . the diagnosis is often missed or delayed due to its non - specific clinical presentation . we are reporting the first case of acute renal infarction after varicella infection which presented as painless hematuria . a 20 year - old boy presented with fever for 2 days with centripetally distributed vesicular lesion that started from chest and progressed to extremities . fever subsided over 3 days and the lesions started to scab after 7 days . a week later he complained of left sided flank pain , which continued for 48 h followed by development of gross painless hematuria . investigations revealed hemoglobin ( hb ) 15.5 gm / dl , total leukocyte count 4600/mm , platelets 2.3 lacs / mm , erythrocyte sedimentation rate 18 mm fall in 1 hour , urine analysis revealed 2 + albumin with numerous red blood cells ( rbc)/hpf ; however there were no dysmorphic rbc 's , blood urea 38mg / dl , serum creatinine 0.9 mg / dl , prothrombin time ( test 13.0 sec / control 13.0 sec / international normalized ratio 1.0 ) . renal doppler revealed normal flow in right kidney ; however there was no flow in left segmental renal artery supplying lower pole . computed tomography ( ct ) renal angiography revealed a wedge shape defect in left kidney suggestive of infarct with no flow in segmental renal artery [ figure 1 ] . vasculitic workup was negative for any underlying autoimmune disease ( c reactive protein < 0.6 mg / dl , rheumatoid factor 11.5 u / ml , normal complement , negative anti nuclear antibody / double stranded dna and anti neutrophil cytoplasmic antibodies ) . serology for varicella confirmed recent infection with igm varicella with a value of 17.54 u / ml ( normal < 8 u / ml ) . limited workup for procoagulant state did not found anything significant ( negative rlupus anticoagulant test by dilute russel viper venom time and negative igm / igg anti phospholipid antibodie ) . the diagnosis of varicella vasculopathy leading to renal infarction was considered in view of serological diagnosis of recent varicella infection and temporal appearance of symptoms . he has been on regular follow - ups and has preserved renal function with no fresh hematuria . the diagnosis of acute renal infarction is often missed , mainly due to the entity 's non - specific clinical presentation and lack of physician awareness . renal infarction may present as subtle symptoms such as nausea , vomiting , fever , hypertension or overt symptoms abdominal pain or hematuria ; however it may remain asymptomatic . we present first documented a case of varicella zoster - associated vasculopathy , presenting as isolated renal infarction . most cases of renal infarction documented in literature have been usually associated with heart diseases , underlying hypercoagulable state or collagen vascular disease . series reported that the most common cause for renal infarction was underlying cardiac condition most likely atrial fibrillation and diagnosis of renal infarction was confirmed on ct renal angiography . in our case also although obstructed flow on segmental renal artery was picked by doppler , confirmation of renal infarct was made on ct angiography . though varicella vasculopathy is an infection related vasculitis , it usually affect medium and large vessels , mostly cerebral vasculature . it commonly presents with acute stroke , ataxia or blindness ; however involvement of peripheral vessels is infrequent . the diagnosis of varicella vasculopathy usually rest on the temporal occurrence of the symptoms following varicella infection . it is believed that it results from damage to the vessel wall media by direct viral invasion , immune - complex reactions , or a combination of both . this is the first such case in literature where primary varicella infection was associated with isolated renal vasculitis . in tropical countries such as ours where infection related vasculitic complications are common , patients presenting with hematuria following episode fever and rash possibility of varicella associated vasculopathy should also be considered .

renal infarction usually occurs against a background of heart disease or a thromboembolic tendency and rarely is associated with infections . here we present a case of a young boy who reported with painless gross hematuria following primary varicella infection and was found to have an isolated renal infarct .

rivaroxaban is an oral factor xa inhibitor used for stroke prevention in the setting of atrial fibrillation . there are currently no evidence - based guidelines for the treatment of hemorrhagic complications of factor xa inhibitors . we report the second case of an intracranial hemorrhage in a patient on rivaroxaban for treatment of atrial fibrillation . this is an 84 year - old right - handed female with a past medical history of atrial fibrillation on rivaroxaban 20 mg daily , alzheimer s dementia , hypertension , diabetes , and chronic obstructive pulmonary disease . the patient had fallen down 6 steps at home as witnessed by her husband . she became unresponsive 2 hours after the fall without tonic or clonic activity and was intubated in the field for airway protection . physical examination was significant for left forehead and right lower extremity ecchymoses . on computed tomography ( ct ) scan at time of presentation in the emergency room , she was found to have diffuse scattered acute subarachnoid hemorrhage and intraventricular hemorrhage ( figure 1 ) . repeat head ct less than 24 hours after initial event showed stable acute subarachnoid hemorrhage and intraventricular hemorrhage . laboratory evaluation at admission showed prothrombin time of 11.7 seconds , activated partial thromboplastin time of 24.7 seconds , and platelet count of 157,000 per mm . at 3 hours post event , she received four units of fresh frozen plasma and 10 mg of vitamin k slow intravenous push . the patient s hospitalization was complicated by intubation , pneumonia , and gastrostomy tube placement . warfarin anti - coagulation was started 2 - 3 weeks after onset of the hemorrhage . in this case we demonstrate an acute posttraumatic subarachnoid and intraventricular hemorrhage in the setting of use of rivaroxaban for the treatment of atrial fibrillation . clinical details of the current case as well as those of a previously reported case of hemorrhagic conversion of ischemic stroke while on rivaroxaban treatment for atrial fibrillation are presented in table 1 . in both cases , neurosurgical intervention was not necessary due to mild evolution which did not significantly increase mass effect . while fresh frozen plasma treatment was provided , reversal of rivaroxaban s effect was mostly likely achieved via clearance of rivaroxaban . in retrospect , the administration of vitamin k was not appropriate for this clinical setting . there was no elevation in prothrombin time and activated partial thromboplastin time to suggest accumulation of rivaroxaban . a limitation of this report is that laboratory testing of rivaroxaban concentration is not available at our facility . unfortunately , there is no clinically proven method of emergently reversing rixaroxaban s effect in the setting of acute hemorrhage . in a rabbit model , report that recombinant activated factor vii and prothrombin complex concentrate only partially improved the laboratory parameters , but did not reverse rivaroxaban induced - bleeding . the working group on perioperative hemostasis advises if possible waiting until clearance of rivaroxaban occurs , but this is not an option in in neurosurgical emergencies with possible herniation risk . the working group discusses using activated or non - activated prothrombin complex concentrates , which unfortunately have been associated with thrombotic complications , which becomes a concern especially in patients with existing atrial fibrillation . the lack of reliable reversal agents for rivaroxaban should be considered when initiating pharmacotherapy in patients with high fall risk .

rivaroxaban is an oral factor xa inhibitor used for stroke prevention in atrial fibrillation . there are currently no evidence - based guidelines for the treatment of hemorrhagic side effects of factor xa inhibitors . we report a case of a thalamic hemorrhage in an 84 year - old right - handed female on rivaroxaban for treatment of atrial fibrillation . the patient had fallen down steps and became unresponsive . she was found to have diffuse scattered acute subarachnoid hemorrhage as well as intraventricular hemorrhage . neurosurgical intervention was not required in this case , but controversy over decision making to pursue pro - coagulant therapy in the setting of worsening hemorrhage requiring emergent surgery is discussed .

human contact with mercury has been ongoing for centuries and has been previously considered a legitimate means of treating different cutaneous and systemic conditions . toxicity from this metal may occur from exposure to elemental , inorganic , and organic forms of mercury . a 23-year - old male patient presented to dermatology out - patient department with chief complaints of nodular , erythematous lesions over the left forearm , and anterior chest wall below the left nipple , of 4 months duration . there was a past history of injury to the chest wall and forearm 5 months back . injury was in the form of abrasions and ulceration over the chest wall and forearm . on local examination , there were irregular , nodular , erythematous lesions with induration , scarring and discoloration of the overlying skin on the left forearm and anterior chest wall region below the nipple [ figures 1 and 2 ] . gold - lysis test , blood , and urine mercury levels , energy - dispersive x - ray analysis and scanning electron microscopy were not carried out in our case . clinical photograph showing irregular , nodular , and discolored lesions on the forearm clinical photograph showing erythematous , nodular , irregular lesions on the anterior chest wall , below the left nipple routine hemogram and biochemical investigations were within normal limits . x - ray showed diffuse deposition of metallic material ( mercury ) in the soft - tissue upto subcutaneous plane in the left forearm and chest wall [ figures 3 and 4 ] . the patient underwent surgical excision of the areas of skin discoloration and soft - tissue induration . x - ray elbow ( anteroposterior and lateral view ) showing diffuse deposition of metal ( mercury ) in the subcutaneous plane x - ray chest posteroanterior view showing irregular diffuse deposition of mercury in the subcutaneous plane gross multiple , irregular , brownish tissue bits , total measuring 3.2 cm 2 cm 2 cm . after minute observation some shiny material was seen in the few tissue bits [ figure 5 ] . microscopy - hematoxylin and eosin stained sections revealed stratified squamous epithelium showing hyperkeratosis and epitheliomatous hyperplasia . subepithelial tissue showed multiple granulomas composed of central spherical dark , black colored opaque globules , surrounded by foreign - body type of multinucleate giant cells , histiocytes , and inflammatory infiltrate composed of lymphocytes , plasma cells , and few eosinophils [ figure 6 ] . for further confirmation of the shiny material seen on gross examination and spherical bodies seen on microscopy gross photograph showing tissue bits with some shiny material on cut surface photomicrograph showing multiple , dark black , opaque , spherical globules , surrounded by granulomatous reaction ( h and e , 100 ) the route of entry of mercury in the skin and subcutaneous tissue was unknown in our case . mercury could be one of the contents of the ointment that patient applied over the wounds . cutaneous mercury ( hg ) granuloma is a rare disorder caused by the introduction of elemental hg into skin or soft - tissue . altmeyer et al . reported a case of cutaneous mercury granuloma resulting in chronic painful local wounds and systemic toxicity in the form of abdominal pain , visual disturbances , and psychiatric abnormalities . metallic mercury in tissue sections appears as dark , opaque globules , usually spherical in shape and of varying sizes and numbers . a granulomatous foreign - body - giant cell reaction and a mixed inflammatory cellular infiltrate composed of neutrophils , lymphocytes , histiocytes , plasma cells , and occasional eosinophils are usually present . epidermal and dermal necrosis , with or without ulceration or pseudoepitheliomatous hyperplasia is also a common finding . vernon provided the clinical guidelines for surgical removal of tissues and proper disposal of mercury contaminated tissues in an environmentally sound manner . reported a case with a history of schizophrenia and inflammatory soft - tissue lesions after self - injection of elemental mercury presented to the emergency department . an incidental finding of oral mercury ingestion was followed clinically and did not result in complications . subcutaneous mercury injection should be managed with local wound debridement , whereas ingestions are rarely of clinical significance . in the reviewed literature , in almost all the cases similar granulomatous foreign - body reaction

cutaneous mercury granuloma is rarely encountered . clinically it may pose difficulty in diagnosis . here , we report a 23-year - old male presented with erythematous , nodular lesions over the forearm and anterior aspect of chest wall . metallic mercury in tissue sections appear as dark black , opaque , spherical globules of varying size and number . they are surrounded by granulomatous foreign - body reaction . it is composed of foreign body giant cells and mixed inflammatory infiltrate composed of histiocytes , lymphocytes , plasma cells , and few eosinophils .

it usually presents with a slowly progressive proptosis , displacement of the globe , ptosis and restriction of eye movements . spontaneous intraorbital hemorrhage may cause acute proptosis , compressive optic neuropathy and loss of vision . a 20-year - old girl presented with congenital , progressive unilateral proptosis . a 20-year - old girl presented to the out - patients department with unilateral proptosis since birth . there was also an ipsilateral facial deformity with fullness in the supraorbital space ( figure 1 ) . ultrasound examination showed multiple cystic intraconal spaces ( figure 2 ) with very low but turbulent flow . ct scan showed multiple hypodense nonenhancing intraconal lobulated lesions extending into the preseptal space ( figure 3 ) . mri showed an unencapsulated homogenous lobulated intraconal cystic masses with no extension into the orbital apex or superior orbital fissure ( figure 4 ) . enlargement of the orbital space however , was seen . in view of these findings , the diagnosis of orbital lymphangioma was considered . coronal post - contrast ct scan thin section shows the retrobulbar non - enhancing lesions with preseptal extension . t2-coronal mri section shows the intraconal cystic spaces with extraconal extension ( white arrows ) . hemangioma and venous lymphatic malformation are the two most common orbital vascular lesions seen in the pediatric patient . however , intrinsic hemorrhage can occur within these lesions , thereby acutely increasing the size of the mass and hence its are not encapsulated , do not respect anatomic boundaries , tend to penetrate into normal structures and can bleed profusely during surgery . orbital lymphangiomas are known to be associated with noncontiguous , intracranial venous angioma [ 1 , 2 ] and with vascular abnormalities of the retina and iris . hemangiomas should be considered in the differential diagnosis as lymphangiomas may rarely simulate cavernous hemangiomas . ultrasound is the first line of investigation and should always be performed in all such patients . ultrasonography of hemangiomas show high amplitude closely packed echoes from vessel walls adjacent to blood filled spaces . lymphangiomas have a similar ultrasound pattern , but with very wide separation of echoes due to larger fluid lakes . although ultrasound has a high sensitivity and simplicity to be the first choice diagnostic test , it suffers from lack of objectivity and extra - orbital delineation of the disease . ct scan plays an important role in diagnosis as well as depiction of extent of the disease due to its multiplanar reformation capability and high spatial resolution . graeb et al have shown that ct findings correlate well with the surgical and histological findings . on ct scan , orbital lymphangiomas are poorly defined lesions that cross anatomic boundaries such as the conal fascia and orbital septum . hemmer et al emphasized the role of thin - slice ct scanning with multiplanar reformations in preoperative assessment and surgical planning of the disease . in last decade , the role of mr imaging has been emphasized in the literature as it has the capability to precisely delineate and characterize these lesions . it is recommended to use surface coils for higher spatial resolution as this can differentiate between the typical vascular tumors . mri has been found to be particularly sensitive to the presence of cysts within the tumor and is also able to predict the contents of the cysts . tumor feeding vessels can also be detected on mri by the flow - void phenomenon unique to mri without the need for intravenous contrast . song gx in 1991 compared ultrasound , ct scan and mri in diagnosis of orbital disorders and concluded that mri was superior to the other imaging modalities in contrast resolution and spatial localization . however , the technique of mri is particularly important for this to be true . in our patient , as there was no history of sudden increase in proptosis , no hemorrhage was detected on mri . however , ct scan is important in detecting the vascular enhancing component within the tumor as it has a propensity for hemorrhage . therefore , ct scan enables the surgeon to resect this area to prevent postoperative hemorrhage . the diagnosis of orbital lymphangioma can be made on imaging and biopsy is usually not required . systemic corticosteroids have been used as an adjuvant treatment to surgery , although their role is controversial . the diffuse form of orbital lymphangioma is well known for its difficult surgical treatment and frequent recurrences . hsuan et al in 2004 suggested a surgical debulking with a carbon dioxide laser through a lateral orbitotomy combined with a 3-wall orbital decompression . they concluded that bony orbital decompression may be a useful alternative treatment in patients with severe proptosis , secondary to orbital lymphangioma . we conclude that high resolution ct is of great value in the diagnosis and preoperative treatment planning of orbital lymphangioma . mri is suitable in those patients who have a rapid increase in proptosis associated with pain .

we report a case of a 20-year - old girl who presented to the out - patients department with congenital , progressive unilateral proptosis and reduced vision . ultrasound , computed tomography ( ct ) scan and magnetic resonance imaging ( mri ) were performed . diagnosis of orbital lymphangioma was made on imaging . authors highlight the crucial role of imaging in diagnosis and to plan therapeutic approach . this case is reported because of its extreme rarity and unusual presentation .

hydatidosis of the bone occurs in 0.5 - 3% of all the cases reported in the literature . human beings contact to the infection is by means of contamination through the direct contact with the definitive host or its faeces or by ingesting food infected with parasite . oncospheres hatch in the duodenum , which penetrate the intestine and are carried through the bloodstream to various organs . the disease usually spreads over the spine by the direct extension from abdominal , pulmonary , or pelvic manifestation and most commonly affects the thoracic region of the spine . in this study , we report a case of intradural hydatid cyst of lumbosacral region in a child which is extremely rare . a 5-year - old boy presented with a history of gradually increasing backache , pain in both lower limbs , and difficulty in walking for 4 months . neurological examination revealed paraparesis of lower motor neuron type and diminished sensation below l4 on both sides with loss of perianal sensation . the magnetic resonance imaging ( mri ) of lumbosacaral spine revealed well - defined intradural cystic lesions from l4 to sacral region . there were cerebrospinal fluid ( csf ) like intensities on t1 - and t2 -weighted images . ultrasonography of abdomen , chest x - ray , and serological tests ( elisa - igg ) were negative for any systemic foci . an intradural cystic lesion was removed totally with capsule , and the cavity was irrigated with hypertonic saline [ figure 1 ] . although there was complete regain of sensation in 3 - 4 weeks , motor function and bladder control recovered only after 4 months . intra - operative photograph showing the detail of hydatid cyst histopathological examination confi rmed the presence of hydatid cyst ( h and e , 40 ) . hydatid disease is generally caused by an infection by echinococcus granulomsus and prevalent in most of sheep - raising regions of the world . the disease usually spreads over the spine by direct extension from abdominal , pulmonary , or pelvic infection , and most commonly affects the dorsal region of the spine . spinal hydatid cysts are located most commonly at the thoracic ( 52% ) , followed by the lumbar ( 37% ) , and then the sacral . primary spinal intradural hydatid cyst is extremely rare . in the most recent reviews by chakir et al . , 23 cases of intradural spinal hydatid cysts were reported in the literature . in another recent study , recently , kalkan et al . reported a case of intradural hydatid cyst in a child in dorsal region . to the best of our knowledge , the present study is the first case of primary intradural hydatid cyst in a child in lumbosacral region in the literature . clinically spinal echinococcus manifests by radicular pain associated with objective sensory and motor disturbances and local tenderness at the level of the involved vertebra . because of these features , it is often misdiagnosed initially as tuberculosis of the spine , spinal tumor , or disc prolapse . recurrence remains a major problem in spinal hydatidosis ; the literature cites rates of 30 - 100% . because of high recurrence rate , spinal hydatidosis has a poor prognosis . on mri examination , hydatid cysts appear as well - circumscribed , cystic lesions , with csf - like signal intensities . sagittal t1w mri showing cystic well - defi ned lesion from l4 to sacral region sagittal t1w mri showing hyperintense cystic lesion from l4 to sacral region . the choice of treatment in spinal hydatid disease is the laminectomy and total removal of the cysts without rupture . irrigating the wound with hypertonic saline or diluted betadine solution after the cyst removal helps destroy and disrupt the parasites . in the early postoperative period although primary intradural hydatid cyst was very rare , it was the documented cause of backache , leg pain , gait disturbance and urinary and faecal incontinence in this child . mri is the investigation of choice , and the best treatment is total surgical excision without rupture . high rate of recurrence is a major problem , and this can be reduced by total resection of the cyst with its capsule without rupture and the administration of antihelminthic drugs .

primary spinal hydatid cyst is very rare lesion affecting less than 1% of the total cases of the hydatid disease . in this study , we report a case of spinal hydatid in a 5-year old boy presented with a history of backache , leg pain , difficulty in walking , and bowel and bladder incontinence for 4 months . an intradural nonenhancing cystic lesion was detected using magnetic resonance imaging from l4 to sacral region , and histopathological findings were suggestive of hydatid cyst .

triplane fractures are those occurring in 3 separate planes at the end of an immature long bone . typically , they cross the epiphysis , physis and metaphysis , in the sagittal , transverse and coronal planes , respectively . by its nature radiographically , these fractures often resemble a salter - harris type iii injury on the anterior posterior view and a salter - harris type ii on the lateral view . in 1957 johnson and fall initially described the triplane fracture ; and a more detailed depiction followed in 1970 by marmor . lynn then conceived the term triplane fracture in 1972 and cooperman later reported 237 fractures involving the distal tibial physis , 15 of which were triplane injuries . the distal tibia is by far the most common site for a triplane fracture and it typically occurs between the ages 1215 . the distal tibial epiphysis begins to close with a centrally located epiphyseal hump and proceeds medially with posterior closure occurring before anterior closure . adolescents are susceptible to a triplane fracture following medial physeal closure and before lateral physeal closure . the anterolateral tibial growth plate is the last area to close ; therefore it is more prone to injury than any other area of the growth plate . in the distal radius fusion of the physis occurs centrally and progresses medially and laterally , though usually the medial ( ulna ) side fuses first . three cases involving triplanar fractures of the distal radius have been reported ; one by peterson and two by garcia mata et al . other upper limb triplane fractures have been reported in the distal humerus , the head of the proximal phalanx of the hand and proximal phalanx of the thumb . a 14-year and 1-month - old , right handed boy , was admitted to hospital having fallen out of a tree onto his left forearm . on examination , he had a swollen , painful and tender wrist that was minimally deformed . antero - posterior and lateral radiographs of the wrist showed a triplane fracture of the distal radius and a fracture of the ulna styloid ( figure 1 ) . satisfactory reduction was achieved by closed manipulation and a moulded below elbow cast used to maintain position . image intensifier confirmed reduction post application of cast.radiographs taken in clinic at 10 days post manipulation confirmed that the reduction had been maintained ( figure 2 ) . the cast was removed at 6 weeks post injury and the patient was allowed to mobilise as there was clinical and radiological union ( figure 3 ) . figure 2ten days post reduction antero - posterior and lateral radiographs of left wrist . figure 3six weeks post injury antero - posterior and lateral radiographs of left wrist showing radiological union . six weeks post injury antero - posterior and lateral radiographs of left wrist showing radiological union . at final follow up nine months after the original injury , the patient had been back to normal , full activities for over six months with no complaints whatsoever . radiographs , including comparison with the contra - lateral wrist were satisfactory , showing no growth abnormality ( figure 4 ) . management of triplane fractures in the more commonly involved distal tibia is well documented . for fractures with displacement of greater than 2 mm , surgical treatment triplane fractures of the distal tibia are reasonably common in adolescence due to the stress riser produced by the eccentric way in which the physis fuses and the high incidence of torsional forces on the ankle . in contrast , triplane fractures of the distal radius are extremely rare as the physis tends to fuse in a more uniform manner and injuries in this area usually result from an axial compression force rather than a torsional force . in the distal radius , there are only three documented cases from two investigators , of which only one involved significant fragment displacement . , those fractures with minimal displacement can be treated in the same way as fractures in a single plane and require immobilisation only whilst those with displacement can be treated by closed reduction and plaster immobilisation in a short arm cast for six weeks .

we report the case of a 14-year - old boy who sustained a displaced triplane fracture of the distal radius . this was treated with closed reduction and application of a cast with good clinical and radiological results . we discuss ( for the first time ) the reasons for the rarity of this fracture at the distal radius compared to the distal tibia .

the presence of morphological variations in anatomical structures is not an exception for the dentition , may it be primary or permanent teeth . supernumerary tooth is one of its types , which is an additional entity to the normal series and can be seen in all the quadrants of the jaw . hyperdontia , a synonym for the same ; is defined as a state in which there is any teeth or tooth substance in excess of the usual configuration of the normal number of deciduous or permanent teeth . the etiology of supernumerary teeth is still obscured and has been attributed to dichotomy of the tooth bud , the hyperactivity of the dental lamina or a genetic predisposition . supernumerary teeth may be classified on the basis of position or morphology as anterior , para - premolars , para - molars , disto - molars , supplemental and rudimentary types . it has a male predilection in the permanent dentition , while there is no significant sex prevalence in primary supernumerary teeth . thus , we report a very recherch form of supplementary incisor in mandibular anterior region in a female patient that presented a diagnostic dilemma . a 10-year - old girl reported to department of paedodontics and preventive dentistry of seema dental college and hospital for a routine dental checkup . clinical examination revealed a mixed dentition stage along with class i molar relationship . there was caries with 85 , mild crowding in mandibular anterior region and labial tipping of 21 . there was ectopic eruption of extra mandibular incisor in place of 44 [ figures 13 ] . the patient was advised an orthopantomogram that revealed tooth buds of 44 and 45 in the alveolar bone and incomplete root formation with the ectopic lateral incisor [ figure 4 ] . since the patient was not willing for any treatment for this condition so it was left untreated , and the patient was put on periodic recall after 6 months . intraoral view of mandibular arch ectopic eruption of extra mandibular incisor w.r.t 44 orthopantomogram revealed tooth buds of 44 and 45 in the alveolar bone and incomplete root formation with the ectopic lateral incisor the occurrence of supernumerary teeth in the mandibular arch is rare in indian population with a prevalence of 01.5% . very few cases of five mandibular incisors have been reported in the literature . in the present case , supernumerary mandibular incisor had a well formed crown and incomplete root formation ; it was separate and normal in all morphological patterns , both clinically and radiographically . in such conditions , their differentiation from their supernumerary counterparts assumes a difficult procedure thereby making it a diagnostic conundrum . distinguishing between a normal tooth and its supplemental doppelganger was difficult , in this case . earlier case reports suggested that the supplemental teeth may exhibit deep palatal pits and coronal invaginations , or that when no morphological abnormalities are noted ; the tooth with minimum measurement among other anterior teeth is regarded as supernumerary one . this condition was considered to be genetic which was not the situation in our case , where the siblings did not report with any supernumerary teeth . tooth transposition or ectopia being a differential diagnosis for this case was required to be ruled out . tooth transposition is an uncommon anomaly having an abstruse etiology wherein a permanent tooth develops and erupts in the position which is normally occupied by other permanent teeth . dental ectopia is characterized by the change in the normal pathway of tooth eruption , which may occur in any region of the alveolar and basal bone . mandibular tooth transposition account for about only 1530% of all tooth transpositions and the prevalence rate for mandibular incisor is 0.03% . thus transposition was ruled out as there are already four incisors present in the normal position in the mandibular arch . treatment for this condition is generally extraction of the supplemental tooth followed by orthodontic intervention if required . an incisor supplemental tooth in place of premolar in the mandibular arch is an unusual finding in the mixed dentition . this finding surely opens up a pandora 's box in terms of anomalies associated with supernumerary teeth .

abnormalities in tooth morphology and number are not uncommon . however , an exact clone of a normal tooth is a recondite clinical finding . presence of supplementary teeth is mostly noticed in maxillary anterior , molar or premolar region , followed by mandibular premolar region in descending order of its site of occurrence . supplemental tooth in mandibular anterior has a low prevalence of 0.01% . this paper reports one such rare case of nonsyndromic incisive jumeaux in mandibular anterior region during mixed dentition period .

we hereby report a case of severe bullous emphysema resulting in pneumothorax in a patient with a few years of marijuana abuse . we hereby report a case of a 25-year - old african american male who presented to the emergency room with sudden onset of shortness of breath and right - sided chest pain . his social history is significant for smoking two to four cigarettes and two to three joints of marijuana / day for the last 8 years . there is no history of significant occupational or animal exposure , intravenous drug use , or use of any medications . his past medical history is significant for sarcoidosis diagnosed 10 years back by bronchoscopy and biopsy . he was started on steroids for sarcoidosis , but was noncompliant to treatment . on physical examination , the chest exam revealed decreased breath sounds as well as hyper - resonance on percussion over the right lung field . a chest radiograph was performed , which showed a right - sided pneumothorax with no mediastinal lymphadenopathy [ figure 1 ] . subsequently , a chest computerized tomography ( ct ) was performed , which showed severe emphysematous bulla in the bilateral lungs with upper lobe predominance [ figure 2 ] . chest radiograph showing right - sided pneumothorax on presentation computerized tomographic scan showing severe bilateral upper lobe bullous lung disease the full - blood examination was normal , with no eosinophilia . an angiotensin - converting enzyme level was performed , which was normal ( 44 ; reference range : 1268 ) . alpha-1-antitrypsin was also within the normal range ( 151 ; reference range : 90200 ) . sputum microscopy and culture for bacteria , acid - fast bacilli , and fungi were negative . pulmonary function testing revealed a severe obstructive ventilatory defect , with a possible associated restrictive ventilator defect , and no response to the bronchodilator . gas transfer was significantly reduced . after excluding all the potential causes of cystic lung disease [ table 1 ] and taking into consideration his new - onset marijuana smoking in the last 8 years the patient was treated with a chest tube and subsequently discharged with advice to quit marijuana smoking and further referral to general surgery for bullous resection . main differential diagnoses of bullous lung disease in adults and features , from the current case , against these diagnoses the harmful effects of tobacco smoking , especially over a period of several years , leading to large emphysematous lung bulla have been well documented . however , the chronic pulmonary effects of marijuana smoking are less well described and there are very few reports demonstrating the association of marijuana smoking with large lung bulla . in 1972 , miller et al . reported a case of pneumomediastinum resulting from performing high - pressure valsalva maneuvers during marijuana smoking . in 2000 , johnson et al . described four cases of large lung bulla in young men with significant exposure to marijuana but low exposure to tobacco . according to the more recent data in 2008 , hii et al . conducted a prospective case series consisting of 10 patients who regularly used marijuana and who developed new respiratory symptoms . similarly , in 2008 , beshay et al . conducted a retrospective case series in which , among the 102 patients who presented with spontaneous pneumothorax at the emergency unit within a 2.5-year period , 17 patients who had relevant pulmonary emphysema and history of marijuana abuse were retrospectively evaluated systematically . the study concluded marijuana abuse as one of the important differentials in case of emphysema in young individuals . marijuana smoking frequently , known as pot , is of significant concern because of its frequent use among young adults . it may be a combination of direct pulmonary toxicity from components in marijuana in susceptible smokers and airway barotrauma related to the high inspiratory pressure and prolonged breath - hold generated during marijuana smoking . studies have shown that marijuana smoking involves a two - thirds larger puff volume , a one - third greater depth of inhalation , and four - times longer breath - holding time than tobacco smoking . this inhalation pattern can result in an increased risk of spontaneous pneumothorax , as seen in marijuana smokers . besides spontaneous pneumothorax , regular marijuana users also experience more cough , sputum , and wheezes than nonsmokers . three to four joints of marijuana per day have been reported to give as many symptoms as an average of 24 cigarettes . we affirm that in all cases of bullous emphysema in young individuals , marijuana abuse should be included in the differential diagnosis . the period of marijuana smoking plays an important role in the development of lung emphysema . video - assisted thoracoscopic surgery ( vats ) should be considered as one of the options for resection of bulla and prevention of recurrent pneumothoraces .

marijuana abuse has been on an increasing trend worldwide in the last decade . we hereby report a case of severe bullous emphysema resulting in pneumothorax in a patient with few years of marijuana abuse . we also review the major conditions in the differential diagnosis of bullous emphysema in adults .

prostate cancer is the most common malignancy in males , with an estimated incidence of more than 240,000 cases in 2013 . there are only a few cases reporting metastasis to the gastrointestinal system [ 36 ] . this is , to our knowledge , the first case report of a patient with histologically confirmed metastasis of prostate adenocarcinoma to the ileum . this report presents a very rare case of an ileum metastasis as the first symptom - presenting and diagnostic organ of prostate cancer . a 74-year - old caucasian male was referred to our department of urology after laparotomy with partial resection of the ileum caused by ileus in july 2013 . in the resected part of the ileum the histological diagnosis was described as metastasis of prostate cancer . in the history of the patient a resection of the rectum , pelvic lymphadenectomy and anus praeter in july 2012 is known . until september 2012 radio - chemo - therapy with 5-fu and radiotherapy up to 50.4 gy , because of adenocarcinoma of the rectum pt3 pn1(2/10 ) m0 l1 v1 g2 , were performed . after this surgical treatment , no other macroscopic abnormalities were reported . at the first presentation in our department in july 2013 , physical examination revealed a undernourished man ( height 1.68 m , weight 57 kg ) with an unsuspicious abdomen . digital rectal examination of the prostate was not possible , because the rectum had been resected . he denied any symptoms of nausea , vomiting , abdominal pain , melena , changes in bowel habit , or hematuria . at the first presentation in our department the value of psa was 36.02 ng / ml . a prostate biopsy via perineum was performed and the histology revealed adenocarcinoma of prostate , gleason 3 + 3 g1 . further diagnostics in july 2013 included a ct scan of thorax abdomen , with enlarged retroperitoneal lymph nodes ( maximum 1.5 cm ) and a disputable bone metastasis in the pelvis ; no other relevant visceral metastasis was identified . a bone scan showed only degenerative changes , not typical for metastases of prostate cancer . , and since august 2013 , leuprolide acetate ( lueinizing hormone - releasing hormone ( lhrh ) agonist ) . the psa decreased to normal levels within 3 months . since the ileum is a very unusual location for metastasis of prostate cancer , we compared the original paraffin blocks of the ileum with our prostate cancer material . surprisingly , we could demonstrate that this is a metastasis of adenocarcinoma of prostate cancer , and not of rectal cancer . figure 1 shows an overview of the resected ileum and in figure 2 , the broadened adventitia of the ileum with infiltration of prostate cancer tumour cells . as a sign of prostate cancer cells in subserous connective tissue , the paraffin blocks from the resected ileum have been supervised by two pathologists in different departments . for comparison prostate biopsy samples are visible in normal he in figure 5 and with positive p405s ( amacr ) in figure 6 . broadened adventitia of the ileum with infiltration by tumour cells ( h&e , scale 10x ) . muscularis propria with cribriform glands , prostate cancer cells in subserous connective tissue ( h&e , scale 10x ) . prostate biopsy sample in position tr ( p405s / amacr , 10x ) . in the ct scan from october 2013 , a partly response of retroperitonal lymph nodes could be described . the next ct scan in january 2014 showed a 5 cm measured structure presacrally ; in colposcopy a semicircular tumor 10 cm ab colostoma was confirmed . histologically , now adenocarcinoma of the colon with mutation of exon 2 in k - ras was described . in the oncological office , palliative chemotherapy treatment with 5-fu , folin and oxaliplatin to our knowledge this is the first case presentation of a metastasis of prostate cancer to the ileum . common sites of prostate carcinoma metastasis , in descending order of frequency , include regional lymph nodes , bone , distant lymph nodes , lung , and liver . prostate carcinoma with gastric metastasis is rare ; a literature review has revealed only six other cases diagnosed by histology premortem [ 35 , 79 ] . another four case reports describe metastatic disease to nongastric upper gastrointestinal tract sites ( 3 of the esophagus [ 6 , 10 , 11 ] and 1 of the duodenum ) . in postmortem studies , the incidence of gastric metastasis was reported as 1 - 4% [ 2 , 4 , 8 , 9 ] . on histopathology , prostatic adenocarcinoma classically demonstrates a relative lack of nuclear anaplasia , with nuclear informity , paucity of mitotic figures , and the absence of signet - ring cell forms . the diagnosis is confirmed by immunohistochemical staining with a positive psa stain as shown in the figures 16 . this case is the first report in the literature of a metastasis of prostate cancer to the ileum . although a very rare , it is imperative for oncologists , gastroenterologists , and urologists to consider the possibility of prostate cancer metastasis in the intestinal tract .

we present a case of a 74-year - old white male with a history of prostate cancer with unusual metastasis to the ileum , and with ileus as a very unusual first symptom of prostate cancer . this patient presented to us with histologically confirmed metastasis of the ileum after resection in the department of surgery .

a 31-year - old male presented with loss of consciousness of abrupt onset after several days of headache . initial pre - contrast ct showed swollen hypodense area , ichs and linear hyperdensity in the left frontal lobe ( fig . ct angiography with 3-dimensional post processing revealed dilated medullary veins with caput medusa appearance , but no venous drainage from the left frontal dva ) ( fig . multiplanar source images of ct angiography demonstrated the filling defect in the anterior superior sagittal venous sinus and suggested the thrombosis in the draining vein ( fig . ct angiograms ten days ( not shown in this report ) and two months later ( fig . 2b , c ) , thrombosed draining vein was progressively recanalized and detected were findings of venous infarction with multifocal parenchymal hemorrhages in the left frontal lobe . 2d ) clearly showed the presence of resolving venous thrombosis at a month ( fig . no underlying cause such as connective tissue disease , coagulopathy , history of steroid administration , dehydration and so on was identified for the spontaneous thrombosis in the venous drainage from dva . the patient was treated conservatively , became conscious five days later and eventually recovered without localized neurological deficit . he developed generalized seizure , but had been under control with anti - epileptic medications . in this case , interpretation of ct and ct angiography findings at the time of initial clinical presentation was complicated because spontaneous ichs abruptly occurred in a young , healthy male and there was no underlying vascular pathology found such as avm in the left frontal lobe or dural avm and the hemorrhages appeared not to be related to neoplasms . hypodense area in the left lobe involved both cortical gray matter and white matter as in the case of cerebral infarction , did not coincide with the territory of left anterior cerebral artery . source images from ct angiography showed multiple dilated linear enhancements with parenchymal staining in the left frontal lobe . possible venous infarction due to thrombosis in the venous drainage was suspected but dva with thrombosis was not included in the initial differential diagnosis because venous collector was not recognizable . early correct recognition of thrombosed typical dva as the underlying cause for the ich and venous infarction of sudden onset could lead to the proper anticoagulation treatment . cases of spontaneous ich related to dva were reported and associated with either high flow arteriovenous shunts or cavernous venous malformations [ 1 - 4 ] . however , very small number of typical dvas were reported , which presented ich as the initial manifestation [ 7 , 8 ] . analyzed previously reported 13 cases and their one case of typical dva complicated by thrombosis of the draining vein . among those 14 cases , they include one case of venous infarction without ich by mistake , thus four had ichs . eight cases of venous infarction including their own two were analyzed by masson et al . a case of childhood dva complicated by spontaneous thrombosis was reported elsewhere and should be included in the list of venous infarction . among those nine , two were categorized as " hemorrhagic " and we reviewed the case reports . authors of the two case reports related ichs to thrombosis in the draining veins , and their case figures did not show venous infarction initially [ 8 , 12 ] . among 21 cases of dvas with venous thrombosis in the previous literatures , one was reported in french and another one in spanish . 19 cases reported in english were reviewed [ 6 , 9 , 15 - 18 ] and we summarized their demographics , location of dva , presence of parenchymal hemorrhage at the initial diagnosis including our case ( table 1 ) . among those 20 , three had cerebellar dvas [ 14 , 18 , 19 ] , and one case presented with only with subarachnoid hemorrhage and no infarction . two cases had ich only [ 8 , 12 ] and f i ve cases [ 7 , 9 , 15 , 16 ] showed findings of ich and venous infarction on the initial brain images . most of them presented only ct , mri or angiographic images at the initial diagnosis or at certain time points . only four cases [ 7 , 10 , 12 , 20 ] had follow - up images of any sort , but they did not show sequential changes of the thrombosed vein and dva , neighboring brain tissue . as described elsewhere , thrombotic obstruction of dva and draining vein resulting venous congestion should be the pathologic mechanism for the initial parenchymal hemorrhages and venous infarction . in the present case , sequential ct , ct angiography and digital subtraction angiography demonstrated initial thrombotic obstruction of the venous drainage from dva , its recanalization and temporal changes occurring in the affected brain parenchyma .

we report a rare case of thrombosed developmental venous anomaly ( dva ) in a 31-year old male with hemorrhagic cerebral venous infarction at the initial clinical presentation . in this case , sequential ct , ct angiography and digital subtraction angiography demonstrated thrombotic obstruction of the venous drainage from dva , its progressive recanalization and temporal evolution of the affected brain parenchyma . the relevant previous literatures were reviewed and summarized .

the deep phenotype of gonads and sex ducts has not been addressed systematically . they permit the inspection and imaging of structures that are barely visible with noninvasive imaging procedures . informed decision making for genital surgery or gonadectomy critically depends on an understanding of how the individual 's anatomy deviates from what is defined as furthermore , there may be a scientific interest in unravelling genotype - phenotype relations . relating these new findings to a detailed examination of the deep phenotypic variations may foster insight of gene function during urogenital development . in spite of the highly variable anatomy , affected individuals and their families gonadectomy and genital surgery are controversial issues , and part of the controversy is about diagnostic uncertainty and lack of standardized procedures . this articles offers a concept for the standardized storage of images taken during endoscopy and laparoscopy . during 2002 through 2011 , 68 patients with dsd underwent diagnostic evaluation at our institution . our reports , images , and videos obtained during examinations of various disorders of sex development were reviewed . cystoscopies and genitoscopies were reexamined with a focus on urethral anatomy , in particular of the posterior urethra . laparoscopic images were reviewed with a focus on gonadal and sex duct variations within the same disorder . the review of our cystoscopies and genitoscopies showed that a different number of images were stored for each examination . comparing the images of the posterior urethra in patients with partial gonadal dysgenesis and hypospadias , many variations in the utricular region were found . , a similar variability was found at the entrance of the vagina to the urogenital sinus ( figure 2 ) . in patients affected by total gonadal dysgenesis , variations of gonadal development are of particular interest . size and shape of the gonad varied from true streaks to ovoid shape . examples of this variability and an example of a tumour arising in a gonad are depicted in figure 3 . while gonads in androgen insensitivity are very similar to normal testis , a marked variability in their localization and the paramesonephric ( wolffian ) structures and even mullerian structures was evident . these examples show convincingly that very different deep phenotypes may exist within a given disorder . these observations prompted us to recommend a standardized examination schedule with a precise proposal on what images to take . photographic views are referred to defined anatomic landmarks as shown in figures 5 and 6 . our own experience and a review of the literature showed a wide variability of diagnostic procedures and terminology that was used to describe the deep phenotype in dsd . we focussed on endoscopy and laparoscopy , because compared to the noninvasive investigations they allow the best visualisation . however , techniques and reporting of findings are also subject to variation and we concluded that a standardization of the surgical evaluation and defining what images to store would be most useful . based on the reevaluation of 66 patients with various dsd treated at our institution we propose the examination schedule shown above . all the views are clearly defined , refer to stable anatomic landmarks , and are easily applicable . storing of images is helpful for the interested individual and those who offer counselling or care . dsd requires a holistic approach , and the communication between team members is likely to be more efficient , when relevant anatomic details can be shared easily . both patients and doctors can obtain second opinions for rare or controversial clinical situations . documenting anatomical findings in detail and high quality size , shape , and surface anatomy of the gonads are highly variable , and these factors may be relevant for the individual tumour risk . the distance between bladder neck and vaginal confluens is important for vaginal reconstruction and continence . several noninvasive imaging procedures have been described , but the quality of endoscopy and laparoscopy for the visualisation of small mobile structures is unparalled . for most rare conditions , outcome research they can be analyzed applying checklists , and interobserver bias and observer bias can be addressed . this may facilitate clinical decision making , create a comparable data base for future investigations , and improve quality by eliminating ambivalent terminology . endoscopy and imaging techniques not only delineate pathologic findings , but also contribute a comprehensive definition of the normal phenotype and its variations .

this paper addresses the question , how the variations of the deep phenotype in disorders of sex development ( dsd ) are appropriately described . this is a relevant question , because extensive phenotypic variability occurs in gonads and sex ducts . with the advance of video endoscopy and laparoscopy , fresh insight in gonadal and sex duct anatomy is emerging . so far , an attempt to standardize the diagnostic approach and , in particular , how to document these findings has not been published . we propose a standardized examination schedule for these procedures . it consists of 5 pictures of relevant anatomic features . for laparoscopy , it includes two pictures each of gonads and sex ducts on either side and an image of the retrovesical space . for endoscopy , the examination of the ureteric orifices , the posterior urethra , and the urogenital sinus derivates is recommended . adherence of a standardized schedule and image storing enhances patient autonomy , because they can carry their examination for a second opinion without need for repeated examination . physicians and scientists create a structured image library that facilitates the comparison of clinical outcomes , research on genotype phenotype associations and may lead to better classifications .

cutaneous metastases from colorectal cancer are uncommon , accounting for 6.5% of all secondary skin lesions . we report the case of a 79-year - old patient who presented , two years after rectocolectomy for a rectal adenocarcinoma , obstructive renal failure secondary to a presacral recurrence , as well as symptomatic phimosis associated with papulonodules invading the penis , scrotum and pubis . after hemodialysis , percutaneous pyelostomy , and double - j catheter placement , the patient underwent circumcision and a pubic skin biopsy . on histology and immunohistochemistry , a cutaneous metastasis originating from the rectal adenocarcinoma was diagnosed . penile invasion by colorectal cancer revealed by phimosis is a rare occurrence but needs to be recognized and promptly diagnosed by biopsy in order to propose appropriate adjuvant therapy . colorectal cancer most often disseminates to the liver and lungs via the lymphatic or hematogenous routes and rarely to the skin [ 1 , 3 ] . colorectal cancer metastasizes to the skin in 6.5% of cases only , usually heralding generalized spread of disease . metastasis has been reported to abdominal surgical scars after colorectal tumor resection by laparotomy or laparoscopy , to the head and neck , extremities , and penis [ 4 , 5 ] . a 79-year - old man was referred to our department for obstructive acute renal failure secondary to bilateral ureterohydronephrosis . the patient had a history of lower rectal adenocarcinoma , diagnosed three years earlier and treated by surgery . chemoradiation treatment resulted in a favorable clinical course , with regression of the dilatation of the left pyelocalyceal cavities . during the 3 months prior to referral , the patient had suffered from extensive papulonodules ( fig . 1 ) of the pubis , penis and scrotum , with severe penile edema and painful sclero - atrophic phimosis . laboratory findings on admission signalled acute renal failure [ creatine , 81 mg / l ( normal = 8.412.5 mg / l ) ; potassium , 8 meq / l ( normal = 3.54.5 meq / l ) ] . a computerized tomography ( ct ) scan of the abdomen and pelvis revealed recurrence of bilateral dilatation of the pyelocalyceal cavities from the presacral masses . antegrade double - j catheters were placed . however , the patient experienced mounting voiding disorders affecting the skin lesions . the high post - voiding residue increased bladder pressure , causing a vesicoureteral reflux on the double - j catheters and leakage around the pyelostomy tubes . circumcision was performed to reduce pain and urinary disorders , and a biopsy of a pubic skin lesion was carried out ( fig . it was positive for cytokeratin 20 on immunohistochemistry , which is a specific marker of colorectal tissue ( fig . the overall incidence of cutaneous metastases , according to a meta - analysis , is 5.3% [ 2 , 13 ] . cutaneous metastases from colorectal cancer are rare in the absence of hepatic lesions and usually occur when disease spread has generalized [ 9 , 12 ] . our patient presented locoregional recurrence limited to the pelvis , without any signs of liver or lung metastases at the last radiographic assessment . on average , cutaneous metastases occur 4.9 years after colorectal cancer diagnosis but a 15-year interval was noted in one case . in our patient , they occurred after 36 months . several mechanisms may explain their occurrence : direct tumor extension , dissemination by the lymphatic and/or hematogenous routes , invasion of the ligaments of embryologic origin , or implantation of exfoliated tumor cells at surgical resection . invasion of the penis by colorectal cancer is rare and occurs on massive perineal extension of the tumor . invasion of the penis , scrotum and pubis from the foreskin as a result of atypical phimosis , as observed in our patient , seems to be extremely rare . diagnosis necessitates a skin biopsy in order to identify the nature of the metastasis and to select appropriate management ( radiotherapy , chemotherapy , hyperthermia , or penectomy ) . penectomy is a radical procedure , with a controversial survival benefit , to be reserved for penile metastases only . in view of the extensive lesions in our patient , not amenable to surgery , and his refusal of second - line chemotherapy this lesion must be recognized early and diagnosed by biopsy in order to be able to propose appropriate adjuvant therapy .

backgroundcutaneous metastases from colorectal cancer are uncommon , accounting for 6.5% of all secondary skin lesions . they occur in advanced disease . the most common site is the abdomen . the penis is a rare site.case reportwe report the case of a 79-year - old patient who presented , two years after rectocolectomy for a rectal adenocarcinoma , obstructive renal failure secondary to a presacral recurrence , as well as symptomatic phimosis associated with papulonodules invading the penis , scrotum and pubis . after hemodialysis , percutaneous pyelostomy , and double - j catheter placement , the patient underwent circumcision and a pubic skin biopsy . on histology and immunohistochemistry , a cutaneous metastasis originating from the rectal adenocarcinoma was diagnosed.conclusionspenile invasion by colorectal cancer revealed by phimosis is a rare occurrence but needs to be recognized and promptly diagnosed by biopsy in order to propose appropriate adjuvant therapy . these rare lesions can occur without any liver or lung involvement .

lipoid proteinosis , also known as hyalinosis cutis et mucosae ( urbach - wiethe disease ) , is a rare autosomal recessive disease usually presenting with mucocutaneous lesions starting since birth . it was first reported by erich urbach and camillo weith in 1929 . till date , around 300 cases have been reported in literature . rarely , two siblings are affected , particularly in consanguineous marriages . the presence of all characteristic clinical features of urbach - wiethe disease in both siblings in our case makes this a unique case report . an 11-year - old male patient , born to consanguineous parents , presented with hoarseness of voice since early childhood , multiple scars over the skin of face and dorsum of hands , and papules over elbows and buttocks . patient was normal at birth , but after 3 days of life developed weak cry and hoarseness of voice . at 2 months of age skin lesions began to appear . initially , only face was involved ; subsequently , lesions appeared over the buttocks , knees , and elbows . at presentation , both siblings had multiple brownish atrophic scars over the face [ figure 1 ] . hypertrophied and hyperkeratotic nodules were present over the elbows [ figure 2 ] . histopathology of a verrucous papule from the elbow revealed diffuse dermal deposition of a pale , homogenous , eosinophilic , hyaline - like material around blood vessels and adnexa ( sweat glands ) , which was congo - red - negative and periodic acid - schiff ( pas ) positive [ figure 5 ] . multiple scars over face warty nodules over elbow beaded papules along the margins of eyelids thick and immobile tongue pas - positive , homogenous , eosinophilic , hyaline - like material ( pas stain ; magnification 10 ) based on the typical clinical and histopathological features , the diagnosis of lipoid proteinosis was made . lipoid proteinosis is characterized by infiltration of hyaline material into the skin , oral cavity , larynx , and internal organs . the genetic abnormality lies in the loss - of - function mutation in chromosome 1 at 1q21 , the extracellular matrix protein 1 ( ecm1 ) gene . the presenting symptom may be hoarseness of voice during infancy as was in our case . skin lesions appear during childhood and consist of yellowish papules and nodules that may coalesce to form plaques on the face , forearms , neck , genitals , and dorsum of the fingers and scalp . similar lesions are also found on lips , undersurface of tongue , uvula , and larynx . translucent - beaded papules along the margins of the eyelids are the most characteristic clinical feature as seen in our case . the clinical triad of early onset hoarse voice , typical skin lesions , and beaded papules around eyelids confirms the diagnosis . immunohistochemical skin labelling for antibodies against the emc1 protein has been shown to be reduced in urbach - wiethe disease . staining with anti - type iii , anti - type iv , or anti - type vii collagen antibodies reveals bright , thick bands at the dermoepidermal junction . more than half of the patients have shown bilaterally symmetrical damage in the amygdaloid region on computed tomography scan studies . there is no definitive therapy at present , although dimethyl sulfoxide , oral retinoids , and dermabrasion have been shown to reduce skin lesions . surgical management consists of microlaryngeal surgery of the vocal cords using co2 laser to reduce their thickness and hence hoarseness . the urbach - weithe disease should be considered in the differential diagnosis whenever a child presents with a weak cry or a hoarse voice during early life .

lipoid proteinosis is a very rare autosomal recessive disorder characterized by deposition of hyaline material in the skin and the upper aerodigestive tract . hoarseness of voice occurs very early in life and airway obstruction may occur . characteristic skin lesions include multiple brown atrophic scars over face and distal extremities , beaded papules over the margins of the eyelids and verrucous nodules over the friction bearing areas ( elbows , knees ) . the overall prognosis is good . there is no definitive treatment .

dengue virus infection has varying clinical manifestation ranging from asymptomatic infection to life threatening hemorrhagic fever and dengue shock syndrome ( dss ) . the association of dengue infection with unusual neurological manifestation was first reported by sanguansermsri et al . dengue is known to cause neurological manifestation in 36% cases but presentation as a neurological sign or symptom is rare . we present five children who either presented as altered sensorium or seizures with fever of varied duration and were diagnosed as dengue infection . five children aged 5 months to 11 years presented with fever of 110 days duration . the clinical profile and laboratory investigation of these children can be seen in tables 1 and 2 . of five cases , four have low platelet count , but none required platelet transfusion . . clinical profile of cases laboratory profile of cases case one was a 5-month - old female who presented with fever of 10 days with multiple episodes of seizures and petechial spots over trunk and both limbs . the second case was a 11-year - old female who presented with altered sensorium and multiple episode of blood mixed vomiting with fever of 1-day duration . the association of dengue infection with unusual neurological manifestation was first reported by sanguansermsri et al . numerous neurological manifestation are reported such as encephalopathy , encephalitis , guillain barre syndrome , transeverse myelitis , acute disseminated encephalomyelitis and myositis . involvement of central nervous system ( cns ) has always been thought to be secondary to vasculitis with resultant fluid extravasation , cerebral edema , hypoperfusion , liver failure and/or renal failure . encephalitis or direct involvement of the brain by the virus was unlikely . however , recent evidence is in favor of dengue neurotropism because of dengue virus . dengue igm antibodies have been discovered in csf of encephalopathy patients , which suggest that dengue virus is capable of cns infection . most case series on dengue encephalitis suggest that patients with disease have a higher tendency to develop dengue hemorrhagic fever ( dhf)/dss . the neurological recovery was complete in most of these patients , although they had increased the incidence of dhf / dss . mortality in cases of dengue encephalitis is increased not due to the encephalitis per se which usually has a benign course , but due to increased incidence of dhf / dss . hence during an epidemic of dengue or in areas endemic to dengue infection dengue virus infection should be kept as a possibility in the differential diagnosis in children presenting with fever , altered sensorium and seizures .

neurological manifestation as the presenting feature of dengue infection is rare . this is a brief description of five children 5 months to 11 years with presenting features as seizures or altered sensorium . bleeding manifestations were seen in two . cerebrospinal fluid examination was normal in all . all were diagnosed as per who definition of dengue hemorrhagic fever and managed as per standard protocol . serology ( igm dengue ) or nonstructural protein 1 antigen was positive in all .

we experienced an unusual prostate - specific antigen ( psa ) decrease in a japanese patient with advanced castration - resistant prostate cancer ( crpc ) . the 63-year - old patient had a long history of prostate cancer with a gleason score of 9 ( 5 + 4 ) and t3an0m1b , and had already undergone treatment with combined androgen blockade , ethinylestradiol , prednisolone , estramustine phosphate , zoledronic acid , tranilast , tegafur uracil , docetaxel and strontium . at the maximum level of psa ( 1,235 ng / ml ) , 1 ) . initially , the bleeding seemed to not be severe , so conservative therapy was performed . however , the bleeding began to increase , so trepanation with drainage for cerebral hematoma was performed by neurosurgeons ( fig . two weeks after drainage , we replaced the luteinizing hormone - releasing hormone ( lh - rh ) agonist with the lh - rh antagonist , degarelix . surprisingly , the psa level began to decrease from 873 ng / ml at the time of the first degarelix injection , with a level of 540 ng / ml attained after 4 weeks . during hospitalization , the treatment for prostate cancer was not changed except for the lh - rh antagonist injection . unfortunately , the patient 's condition deteriorated again with intracerebral bleeding , mydriasis and loss of light reflex , and he died 58 days after hospitalization . to our knowledge , there have been no previous reports that cerebral bleeding or trepanation / drainage of hematoma cause a decrease in the level of psa . however , various acute insults induce a decrease of sex steroids and gonadotropins . low testosterone and luteinizing hormone similarly , 39% of hemorrhagic and ischemic stroke patients have been found to have hypogonadism with a low testosterone level . though it is likely that the intracerebral bleeding affected the psa level in our case , the decrease may also have been a fluctuation ; it is not clear if the testosterone level of this crpc patient treated with combined androgen blockade could have been reduced more by the intracerebral bleeding . the lh - rh antagonist may have contributed to the 56% decrease in psa , from 1,235 to 540 ng / ml . two previous studies indicated that switching from lh - rh agonist to lh - rh antagonist could decrease psa levels in crpc patients [ 5 , 6 ] . degarelix , which is a recently developed lh - rh antagonist , showed a significantly lower risk of psa progression or death in a certain population when compared with the lh - rh agonist . the difference in effect between lh - rh agonist and antagonist could be explained by ( 1 ) a loss of testosterone surge or a reduction of testosterone , ( 2 ) the suppression of follicle - stimulating hormone and ( 3 ) a direct effect of the lh - rh antagonist on the lh - rh receptors in the prostate cancer cells . a previous study indicated the possibility of a slight change in testosterone level being a cause of psa decrease . however , psa levels in these previous studies were 360 ng / ml upon commencement of lh - rh antagonist administration [ 5 , 6 ] . our case showed a psa level of 873 ng / ml when the lh - rh antagonist treatment was started , which is the highest level reported to date . the psa level decrease in this case may therefore have been caused not only by the testosterone level but other mechanisms as well . unfortunately , we did not measure either testosterone or follicle - stimulating hormone because we did not expect such a decrease in the level of the psa . our case demonstrated the therapeutic potential of lh - rh antagonist to decrease psa level in advanced crpc patients . however , a previous report indicated that switching from lh - rh agonist to antagonist decreased psa levels in only 3 of 17 prostate cancer patients . although it is necessary to still investigate the application of switching from lh - rh agonist to lh - rh antagonist because of not much evidence , patients who have already undergone all available treatments , as in this particular case , may be eligible candidates for this approach

an unusual prostate - specific antigen ( psa ) decrease in a japanese patient with advanced castration - resistant prostate cancer ( crpc ) treated with luteinizing hormone - releasing hormone ( lh - rh ) antagonist after cerebral bleeding was presented . there have been no previous reports that cerebral bleeding or trepanation / drainage of hematoma decreased psa level , which would make this the first . the lh - rh antagonist may be only one reason for the psa decrease . more cases need to be accumulated and and further investigation is needed to clarify if intracerebral bleeding or an lh - rh antagonist can decrease psa in such advanced crpc cases .

the primary tumour is usually easy to define on computed tomography ( ct ) and [ 2- f]fluorodeoxyglucose positron emission tomography ( fdg - pet ) . increased uptake on pet is also seen in tuberculosis , aspergillomas , rheumatoid nodules and amyloid . t3 tumours include tumours of any size with direct extension into the chest wall , diaphragm , mediastinal pleura or pericardium ( tables 1 and 2 ) . . chest wall and mediastinal invasion can be difficult to assess by either ct or magnetic resonance imaging ( mri ) both being inaccurate in differentiating contiguity from subtle invasion [ 25 ] with a reported sensitivity of 55% and specificity of 89% in predicting t3 or t4 disease . mri has superior soft tissue contrast to ct and is better at identifying chest wall invasion with a reported sensitivity of 90% and specificity of 86% , and it is better than ct for superior sulcus ( pancoast ) tumours and can identify involvement of the inferior branches of the brachial plexus ( c7 , t1 ) , vascular infiltration and invasion of the spinal canal or vertebral body . fdg - pet alone is worse than ct but the combination of pet / ct will improve things but is unlikely to make it any more accurate than ct alone . using ct and mri , size is the only criteria used to assess malignant infiltration and nodes that have a short axis diameter greater than 1 cm are considered abnormal . the accuracy for the detection of n1 disease is similar for ct ( 62%88% ) and mri ( 68%74% ) . in a meta - analysis of ct accuracy for assessment of mediastinal lymph nodes , dales et al . reported a sensitivity , specificity , and overall accuracy of 79% , 78% , and 80% , respectively , with similar results for mri . fdg - pet is more accurate than ct for staging mediastinal nodes as it is dependent not on size but on metabolic activity and will identify disease in nodes less than 1 cm in size , and although the sensitivity for small nodes is slightly less than that of nodes of 13 cm , the overall accuracy is the same . the initial reported sensitivity for fdg - pet in n2 or n3 disease compared to ct is 89%92% ( ct 25%57% ) , specificity 93%99% ( ct 94%98% ) with a npv for pet of 97% ( ct 87% ) . overall the correct stage is assessed by fdg - pet in 85%96% ( ct 58%59% ) [ 8 , 9 ] . combining fdg - pet and ct is better than ct alone with a very high negative predictive value ( npv ) for staging n2 and n3 disease ( 95% overall and 99% for individual nodes ) and therefore some authors would suggest a negative ct and negative fdg - pet would obviate the need for mediastinoscopy prior to surgery in patients with resectable tumours ( table 3 ) . however , recent studies have found the npv of pet decreases to 17% in patients with central tumours and mediastinoscopy should still be performed in those patients . however , many authors feel that all patients with a potentially resectable tumour should undergo pre - operative mediastinoscopy . de leyn performed mediastinoscopy on patients who were node negative on ct and found that 20% had n2 disease . endoscopic ultrasound ( eus ) with fine needle aspiration allows sampling of posterior mediastinal nodes and has produced some excellent results with reported sensitivity , specificity and npv of 92% , 100% and 94% . fine needle aspiration of scalene nodes may also be helpful in assessing occult n3 disease . the commonest sites for metastatic disease in nsclc in post mortem studies are brain , bone , liver and adrenals ( in decreasing order ) . the sensitivity of ct for detecting adrenal metastases is low ( 41% ) but the specificity is high ( 91% ) . however , small ( <3 cm ) , non - functioning adrenal adenomas are a common finding and both ct and mri can be helpful in evaluating these using either the ct on unenhanced scans or chemical shift imaging [ 14 , 15 ] . fdg - pet will identify unsuspected metastases and has higher sensitivity and specificity than ct for the detection of liver , bone and extra - thoracic lymph node deposits , with the detection of extra - thoracic metastases in 11%14% of patients selected for curative surgery . fdg - pet is used to stage the mediastinum , with nodes that are positive biopsied prior to thoracotomy , and for the assessment of distant metastases ( table 3 ) . clinician surveys have suggested that fdg - pet influences or changes management in 39%67% of patients [ 17 , 18 ] .

staging of non - small lung cancer ( nsclc ) uses the tnm classification and is undertaken to identify those patients who are surgical candidates , either initially or after chemo - radiotherapy , and to differentiate patients who will be treated radically from those requiring palliation and to plan radiotherapy fields . computed tomography and magnetic resonance imaging ( mri ) are used in staging and provide anatomical information but have well known limitations in differentiating reactive from malignant nodes , fibrosis from active disease and in defining the extent of invasion . mri , with its superior soft tissue contrast provides optimal information on brachial plexus and central nervous system involvement . functional imaging using [ 2- 18f]fluorodeoxyglucose positron emission tomography is increasingly being used to provide unique information and when combined with anatomic imaging will provide better staging information for both local disease and the extent of metastases .

in this issue of critical care , aliberti and colleagues examine the question of whether acidemia predicts outcome in patients admitted with acute cardiogenic pulmonary edema ( acpe ) and treated with continuous positive airway pressure ( cpap ) . the authors performed a retrospective observational study in a large cohort of patients admitted to the emergency department with acpe and treated with cpap . the authors compared treatment failure , defined as a switch to bi - level or invasive ventilation or in - hospital mortality , in two matched groups of patients with and without acidemia on admission . the main conclusion was that neither admission acidemia nor type was an adverse prognostic marker . acute heart failure syndromes ( ahfss ) are the most common reason for hospital admission in patients older than 65 years , over 50% of whom present with acpe , and up to 10% of patients with acpe will not survive their admission . a number of prognostic factors have been identified : age , systolic blood pressure ( sbp ) , brain natriuretic peptide or troponin rise , hyponatremia , renal dysfunction , previous ischemic heart disease , ejection fraction , and function at discharge . however , most of these variables have been used across the whole spectrum of ahfss and relate to longer - term outcome . focusing on acpe only , the 3cpo trialists identified patients at immediate risk of death and in need of intervention on presentation ; a simple score based on age , sbp , and the ability to obey commands predicted early mortality . in acute exacerbations of chronic obstructive pulmonary disease , acidosis is a strong predictor of adverse outcome . acidosis in hypercapnic respiratory failure is a direct reflection of organ dysfunction , in particular the failure of the lungs to ventilate the alveoli adequately . in contrast , in acpe , acidosis is only an indirect consequence of cardiac dysfunction caused by a combination of factors , including edema - impaired gas exchange and tissue hypoperfusion . more direct indicators of cardiac function , such as cardiac power output ( cpo ) , which is derived from the product of cardiac output and mean arterial blood pressure , have been shown to be powerful prognostic indicators in patients with ahfs , chronic heart failure ( chf ) , or cardiogenic shock [ 8 - 10 ] . clinical risk scores , a product of statistical modeling , are a popular tool to identify prognostic markers . however , most do not pass the acid test of clinical utility , and this is evidence that a change in risk score correlates with changes in patient outcome . differentiating the pathophysiological processes under - pinning the different ahfss to provide appropriate and rational treatment is an alternative approach to risk - stratify patients with acpe . cotter and colleagues suggested four major clinical ahfss : ( a ) pulmonary edema , ( b ) cardiogenic shock , ( c ) hypertensive ( htn ) crisis , and ( d ) exacerbated systolic chf . by plotting cpo as a marker of cardiac contractility against systemic vascular resistance ( svr ) , the authors demonstrated that 95% of patients could be categorized accurately into one of these syndromes . understanding the pathophysio - logical mechanisms is key to management ; for example , patients with cardiogenic shock and those with pulmonary edema demonstrate a similar presentation with pulmonary congestion , clammy extremities , low cardiac output , and high wedge pressure . however , the patho - physiologies are very different and the treatments are almost opposite . the former is characterized by low cpo and low svr that requires inotropic support and occasionally peripheral vasoconstrictors , and the latter is characterized by extreme neurohormonal activation with higher values of cpo and very high svr , necessitating aggressive peripheral vasodilation . according to this model , exacerbated systolic chf , htn crisis , and acpe may be viewed as a continuum of progressive neuro - hormonal activation leading to an increase in svr with progressive recruitment of cardiac power reserve . the objective of treatment is then to optimize the svr and thus the cardiac performance can be moved toward more optimal loading conditions to effect greater power output . the need for invasive hemodynamic monitoring is a limitation , but the advent of non - invasive tools could improve diagnosis , risk stratification , and management of patients with ahfs . the etiology of heart failure and the cardiac rhythm influence the acute cardiac response to cpap . in patients with dilated cardiomyopathy , cpaps lead to a reduction in cardiac volumes , whereas in ischemic cardiomyopathy , there were small increases . similarly , atrial fibrillation resulted in a fall in cardiac index but there was a small rise in sinus rhythm . cpap , with its unique combination of respiratory and hemodynamic effects , will remain a cornerstone of the symptomatic treatment of acpe . future management should look beyond clinical risk scores to an understanding of etiology and pathophysiology in each patient to provide optimal treatment for this deadly condition . acpe : acute cardiogenic pulmonary edema ; ahfs : acute heart failure syndrome ; chf : chronic heart failure ; cpap : continuous positive airway pressure ; cpo : cardiac power output ; htn : hypertensive ; sbp : systolic blood pressure ; svr : systemic vascular resistance .

several prognostic markers have been identified for patients admitted with acute cardiogenic pulmonary edema . most of the markers are based on clinical risk scores . unlike hypercapnic respiratory failure , acidosis is not an adverse predictor in these patients . hemodynamic variables that assess pathophysiological mechanisms may be more helpful to guide appropriate management .

cellulomonas sp . hzm is a gram positive , rod - shaped bacterium isolated from soil surface plant detritus in pekan tropical peat swamp in pahang , malaysia . the isolate was acquired by culture - plating on sizova 's cellulose minimal salt media preceded by a series of enrichment steps . genomic dna was extracted from 24 hour old cultures using the gf nucleic acid extraction kit ( vivantis , malaysia ) as per manufacturer 's instructions . the genome was sequenced using an illumina miseq sequencer ( 150-bp paired - end reads ) and the raw reads were trimmed and assembled de novo using clc genomics workbench 6 ( clc bio , denmark ) . a total of 78 contigs with an accumulated length of 3,559,280 bp ( 74-fold coverage , n50 = 99,115 bp ) and a g + c content of 73% were obtained . the genome contains 52 trna genes and 3 rrna genes ( 5s23s16s ) as predicted using trnascan 1.2 and rnammer 1.2 , respectively . a total of 3180 coding sequences in 352 subsystems were functionally annotated by rapid annotation using the subsystems technology ( rast ) server fig . a gene sequence putatively encoding endoglucanase ( ec 3.2.1.4 ) , as well as six copies of -glucosidase ( ec 3.2.1.21 ) gene sequences were identified in the starch and sucrose metabolism subsystem using the kyoto encyclopedia of genes and genomes ( kegg ) database available in rast . no sequences for exoglucanases ( ec 3.2.1.91 ) were identified , possibly indicating an incomplete cellulolytic system . of the hemicellulolytic enzymes , only a single copy of the sequence of alpha - l - arabinofuranosidase b ( ec 3.2.1.55 ) and acetyl xylan esterase ( ec 3.2.1.41 ) were identified . these enzymes remove side chains and thus have assistive roles as compared to endoxylanases ( ec 3.2.1.8 ) and -xylosidases ( ec 3.2.1.37 ) which cleave glycosidic bonds between xylose residues . however , no sequence for any xylan - degrading enzymes was annotated within the genome . other gene sequences for hydrolytic enzymes identified include those for -mannosidase ( ec 3.2.1.25 ) and chitinase ( ec 3.2.1.14 ) . both these enzymes may assist in providing nutrient availability for cellulomonas sp . . functional comparison of genome sequences in the rast server revealed the closest neighbors of cellulomonas sp . hzm as sanguibacter keddieii dsm 10,542 ( score 555 ) followed by cellulomonas flavigena dzm 20,109 ( score 336 ) , beutenbergia cavernae dsm 12,333 ( score 293 ) , actinomyces odontolyticus atcc 17,982 ( score 189 ) and xylanimonas cellulosilytica dsm 15,894 ( score 186 ) . analysis using the complete 16s rrna sequence ( performed using eztaxon at http://www.ezbiocloud.net/eztaxon ) is more specific by comparison , with the list of candidates being predominantly cellulomonas , whereby the closest match is cellulomonas uda ( pairwise similarity of 98.20% ) followed by cellulomonas chitinilytica ( 98.15% ) , cellulomonas gelida ( 98.06% ) and cellulomonas iranensis ( 97.89% ) . the whole genome shotgun project has been deposited at ddbj / embl / genbank under the accession no . jeoe00000000 . the authors declare that there is no conflict of interests with respect to the work published in this paper .

we report the draft genome sequence of cellulomonas sp . hzm , isolated from a tropical peat swamp forest . the draft genome size is 3,559,280 bp with a g + c content of 73% and contains 3 rrna sequences ( single copies of 5s , 16s and 23s rrna ) .

palmoplantar keratodermas ( ppks ) are a heterogeneous group of disorders characterized by abnormal hyperkeratosis affecting the palms and soles . inherited ppks can be further divided clinically into 3 distinct subgroups : diffuse ppk , focal ppk , and punctate ppk . a 27-year - old female thai patient presented to our outpatient department with unilateral asymptomatic linear thickening lesions on her right sole since childhood . the lesions first appeared as punctate small plaques that gradually increased in number and extended in linear fashion along the plantar surface . the patient had no history of a traumatic event prior to the appearance of the lesions . there were no similar lesions on any other parts of the body , and none of her family members had similar lesions . a review of systems did not reveal any symptoms of systemic involvement such as fever , chronic weight loss , or anorexia . the patient is a chinese - thai interpreter in china , and she denied any history or current use of drugs , alcohol , tobacco , or any other medication . a dermatologic examination revealed unilateral localized skin - colored - to - yellowish hyperkeratotic papules and plaques distributed in linear configuration on the right plantar surface ( fig . , we made the differential diagnoses of linear punctate ppk ( pppk ) , linear punctate porokeratosis , linear epidermal nevus , callus , and verruca vulgaris . we performed a 4-mm punch biopsy , and the specimen showed epidermal hyperplasia with hypermelanization and hyperkeratosis without columns of parakeratosis or cornoid lamella ( fig . based on the histopathologic findings combined with the clinical features , the final diagnosis of unilateral linear pppk was made . pppk typically presents as bilateral asymptomatic tiny hyperkeratotic punctate papules / plaques on the palmoplantar surface . among the pppk varieties , the linear presentation is much rarer , and its incidence remains unknown to date . although the exact etiology of pppk is not fully understood , both genetic and environmental factors are believed to play some roles in triggering the disease [ 1 , 2 ] . autosomal dominant , recessive , mitochondrial , x - linked , and acquired forms of ppks have all been described [ 2 , 3 ] . autosomal dominant pppk , which is known to be the main mode of inheritance , has recently been found to be linked with 2 loci on chromosomes 15q2215q24 and 8q24.138q24.21 . unilateral presentation of pppk is rare and may be explained by genetic mosaicism . until recently , there have been only 3 reports of unilateral linear pppk , and some cases have been associated with nail abnormalities such as longitudinal ridging , onychoschizia , onychorrhexis , trachyonychia , and notching . although associated systemic involvement is uncommon , patients with pppk may have an increased risk of developing some malignant conditions such as gastrointestinal , lung , and breast cancer as well as hodgkin 's lymphoma . topical keratolytics , systemic retinoids , liquid nitrogen , puva ( psoralen plus ultraviolet a ) , re - puva , and pairing have been used with variable success [ 1 , 2 ] . our patient was treated with topical 10% urea cream and 10% salicylic acid cream twice daily . after treatment , the lesions showed slight improvement ; however , the patient was lost to follow - up , as she had already gone back to china . in conclusion , we report a typical case of unilateral linear pppk . our patient presented with clinical findings and histopathologic features so far , this is the fourth case of unilateral linear pppk reported in the world , and the first one in thailand . after diagnosis , patients with pppk should be scheduled for long - term follow - up , because they may have an increased risk of developing some cancers . generally , no treatment is needed for pppk , but doctors may offer symptomatic treatment to alleviate the symptoms and improve disfigurement from pppk lesions . the authors confirm that the patient provided written informed consent to use her photos for publication .

punctate palmoplantar keratoderma ( pppk ) is a rare entity with an estimated prevalence rate of 1.17/100,000 . pppk usually presents with bilateral asymptomatic , tiny , hyperkeratotic punctate papules and plaques on the palmoplantar surface . among the pppk varieties , the linear presentation is much rarer , and so far there have been only 3 case reports . here , we report the case of a 27-year - old female thai patient who presented to our outpatient clinic with unilateral asymptomatic linear thickening lesions on her right sole since childhood . there were no similar lesions on other parts of the body . a histopathologic examination revealed epidermal hyperplasia and hyperkeratosis without columns of parakeratosis or cornoid lamella . the other examinations were normal . the clinical and histological contexts were consistent with a diagnosis of unilateral linear pppk . the patient was treated with topical 10% urea cream and 10% salicylic acid cream twice daily . to the best of our knowledge , this is the first reported case of unilateral linear pppk in thailand , and the fourth reported case worldwide .

hypodontia involves the absence of 1 to 6 teeth whereas oligodontia describes condition in which more than six teeth are missing ( 1 ) . in previous studies , it was seen that more than 80% of hypodontia present with one or two congenitally missing teeth and only less than 1% will present with six or more . it is a rare condition and the occurrence is common in girls in the ratio of 3:2 ( 2 ) . oligodontia can occur in association with various genetic syndromes , like ectodermal dysplasia , van der woude syndrome , down syndrome and reiger syndrome or as a nonsyndromic isolated familial trait , or as an infrequent finding . oligodontia is often related with conical shaped teeth , microdontia , delayed eruption of permanent teeth , an increased freeway space and retention of deciduous teeth . syndromic and non syndromic form of oligodontia can be differentiated by conducting thorough physical examination of hairs , nails , sweat glands , eyes and to check for any congenital disorders . a 13 year old boy reported to the department for a routine dental check - up . his past medical history was non - contributory and family history revealed that he was born to non - consanguineous marriage with normal delivery and no one in his family have congenitally missing teeth . extra oral examination revealed a face with normal facial profile and normal skeletal dental base relations ( fig 1 ) . during clinical examination , maxillary central incisors were conical in shape along with bilateral peg shaped maxillary lateral incisors . the deciduous right mandibular central incisor and maxillary canines , first and second molars were retained and permanent mandibular incisors were missing . radiographically , in orthopentomogram ( opg ) all four permanent second molars and permanent mandibular central and lateral incisors were missing ( fig 2 ) . clinical photograph of the subject close up view of permanent dentition of patient showing conical permanent maxillary incisors ; and panoramic radiograph showing pattern of hypodontia : missing all four permanent second molars and mandibular incisors ; retained primary mandibular central incisor is seen a provisional diagnosis of non syndromic oligodontia was given with differential diagnosis of ectodermal dysplasia ; rieger syndrome and van der woude syndrome . complete set of investigations were done which included routine examination of blood including serum calcium , alkaline phosphate , tsh , t3 , t4 . the findings of these investigations were normal . during physical examination , hairs were not thin and sparse , nails were not brittle and no difficulty in perspiration was seen which ruled out ectodemal dysplsia ; on occular examination , no signs of glaucoma was seen ruling out rieger syndrome and lastly van der woude syndrome was left out as there was cleft palate or any mucosal cysts in lower lip . the treatment plan considered for the patient included reshaping conical maxillary teeth , followed by the extraction of all the retained deciduous teeth present in both maxillary and mandibular arches . after healing of extraction sites , removable partial denture will be considered for aesthetic and functional rehabilitation of the patient . oligodontia is the term used most commonly in describing the phenomenon of congenitally missing teeth . oligodontia has been classified as isolated or non - syndromic and syndromic hypodontia ( 3 ) . although oligodontia can occur over with 60 different syndromes , these anomalies can occur without any syndrome or systemic disease . however , oligodontia is seen more common in non - syndromic or familial form than syndromic form ( 4 ) . the biologic basis for the congenital absence of permanent teeth is partially explained by the failure of the lingual or distal proliferation of the tooth bud cells from the dental lamina . the causes of hypodontia are attributed to environmental factors such as irradiation , tumours , trauma , hormonal influences , rubella , and thalidomide or to hereditary genetic dominant factors , or to both ( 5 ) . all mutations of pax9 identified to date have been associated with nonsyndromic form of tooth agenesis ( 6 ) . oligodontia condition should not be neglected as it may result in various disturbances like abnormal occlusion , altered facial appearance which may cause psychological distress , difficulty in mastication and speech . case of tooth agenesis should be recorded with complete clinical history including medical and radiological investigations to rule out any syndrome ( 7 ) . in conclusion , even though oligodontia is mostly considered to be associated with several syndromes but non syndromic aspect of oligodontia should also be taken into consideration . taking this fact to account , the dental fraternity should aim at treating the condition as early as possible and achieve both prosthetic and aesthetic functionality of teeth .

oligodontia is a rare genetic disorder which represents the congenital absence of more than six teeth in primary , permanent or both dentitions . it is usually a part of a syndrome and seldom occurs as an isolated entity . genes responsible for non syndromic oligodontia are found to be msx1 and pax9 genes . in this case report a 13 year old boy is presented who had absence of all four second permanent molars and permanent mandibular incisors . the maxillary central incisors presented with conical shape . during physical examination , there was no abnormality in either hairs or nails , perspiration was normal and no congenital clefts of lip or palate was seen . hence in this case , oligodontia is not associated with any syndrome which is a rare finding .

lateral meningocele is a rare presentation of spinal dysraphism characterized by extensions of the dura and arachnoid through an enlarged neural foramen.[110 ] in the present report , we discuss a case of a 23-year - old female who had bilateral multiple level lateral meningocoele with no neurological deficits and without any associated craniofacial anomalies , neurofibromatosis , or marfan 's syndrome . a 23-year - old female patient presented with 6-month history of low back pain and associated spine deformity . on neurological examination higher mental functions , cranial nerves , motor , and sensory systems were normal . routine laboratory investigations including hemoglobin ( 10.6 g% ) and routine urine microscopy were within normal limits . a whole spine magnetic resonance imaging ( mri ) showed well - defined multiple cystic masses involving dorsal , lumbar , and sacral spinal levels . these multiple cystic lesions are hypointense on t1-weighted images and hyperintense on t2-weighted images , which is similar to cerebrospinal fluid ( csf ) signals . in addition , there was dural ectasia and neural foraminal widening [ figures 1 and 2 ] . the patient was managed with analgesics and regular physiotherapy and is under regular follow - up and observation . ( b ) sagittal section and ( c ) left parasagittal section show multiple level and extensive lateral meningocoele with neural foraminal widening ( arrow ) and dural ectasia ( arrow ) . serial coronal magnetic resonance imaging stir images ( a , b , c ) of dorso - lumbo - sacral spine show multiple level and extensive lateral meningocoele with neural foraminal widening ( arrow ) , dural ectasia ( arrow ) and scoliosis deformity . lateral or anterior spinal meningocoeles are relatively rare congenital anomalies where protrusion of dura mater and arachnoid extending laterally through an enlarged intervertebral foramen into the paraspinal , intrathoracic , or retroperitoneal region . lateral meningocoeles may be unilateral or bilateral ( as in the present case ) or may be solitary or multiple . an anterior defect can form in the vertebral column as a result of faulty embryogenesis . such faulty development can also result in coexisting abnormalities in the skin , subcutaneous tissues , spine , and internal organs . another important factor that can influence the development of anterior and lateral spinal meningoceles is the balance between both the hydrostatic pressure and the pulsations of the csf , and the resistance of the arachnoid and dura mater to deformation by such pressure , especially at the intervertebral foramina . if there is a developmental bony defect , the dura and arachnoid may bulge out through it . lateral meningocele syndrome or lehman syndrome , is characterized by multiple lateral meningoceles in the absence of neurofibromatosis or marfan 's syndrome , commonly present during the fourth and the fifth decades of life ( in contrast to this , our patient was 23-years old ) and overall , female patients are more often affected than male patients . lateral meningoceles commonly occur in thoracic and lumbar regions followed by the cervical area,[58 ] and rarely in the sacral region . because of this unique finding , gripp suggested the term lateral meningocoele syndrome . it is suggested that lateral menigocoele syndrome is an autosomal dominant disorder affecting primarily the connective tissue with many associated skeletal findings kypho - scoliotic deformities , joint hypermobility , pectus deformities , craniofacial abnormalities , and vertebral defects such as hemivertebrae , scoliosis , absence of neural arches on the affected side , widening of the spinal canal , and intervertebral foramina . in our patient kypho - scoliosis the clinical manifestations of meningocoele closely relate with its size and its relationship with surrounding structures in contrast , in the setting of a small meningocoele , no symptoms can be recorded , and the lesion may be incidentally diagnosed on a routine chest radiograph . it is widely accepted that excision of the lesion is indicated in the presence of progressive neurologic deficit , respiratory distress , or rapid progress in the size of the meningocoele . on conventional radiographs , meningocoele appear as sharply defined round , smooth , or lobulated paraspinal masses . on computed tomography ( ct ) scan , these lesions appear as well - defined , homogeneous , low - attenuation paravertebral masses . mri findings are often diagnostic and better delineate the details of multiple lesions including paravertebral expansion and dural ectasias with scalloping of the pedicles , laminae , vertebral bodies , and an enlarged spinal canal . surgical excision is recommended for symptomatic lesions , particularly when there are neurological deficits or bowel and bladder involvement . however , as our patient was not symptomatic for any of the lesions , she is being monitored during regular follow - ups . bilateral multiple level menigocoele without association with neurofibromatosis or marfan 's syndrome is a rare entity .

lateral meningocoele is a very rare disorder characterized by extensions of the dura and arachnoid through an enlarged neural foramen . we report a case of a 23-year - old female with deformity of spine who presented with low back pain and no neurological deficits . a whole spine magnetic resonance imaging showed multiple well - defined cystic masses involving dorsal , lumbar , and sacral spinal levels bilaterally , with dural ectasia and neural foraminal widening suggestive of bilateral multiple level lateral meningocoele . the patient is being managed conservatively and is on regular follow - up .

brooke - spiegler syndrome ( bss ) known as familial autosomal dominant cylindromatosis is a rare disorder characterized by various adnexal tumors including cylindromas , trichoepitheliomas , and spiradenomas . other associated tumors are trichoblastomas , basal - cell carcinomas , follicular cysts , and organoid nevi . a 35-year - old female presented with multiple asymptomatic nodules which started over face and gradually increased in size and number since age of 5 years [ figure 1a ] . few nodules appeared over scalp 5 years back and gradually increased in size [ figure 1b ] . her son , younger and elder sister , father , father 's sister , and grandmother had history of similar lesions [ figure 1c & d and 2 ] . on examination , multiple , asymptomatic , skin - colored , firm , papulonodular lesions measuring from 2 to 8 mm with smooth surface were present on central part of face [ figure 1a ] . scalp showed pinkish , firm , dome - shaped nodules with smooth surface measuring about 1 to 3 cm [ figure 1b ] . histopathological examination of punch biopsy sample from lesion over face showed basaloid inclusions with multiple immature hair follicles and abundant stroma , thus confirming the diagnosis of trichoepithelioma [ figure 3a ] . the lesions over scalp showed well - circumscribed epithelial neoplasm in mid and deep dermis comprising of basaloid cells arranged in closely crowded reticulated pattern giving a jigsaw puzzle appearance . within these nodules , several scattered ductal structures lined by eosinophilic cuticle and pink colloidal intracytoplasmic bodies were present . these findings were consistent with the diagnosis of cylindroma [ figure 3b ] . based on clinical and histopathological features , diagnosis of bss as the only concern of patient was regarding cosmetic appearance , she was referred to plastic surgeon for excision of nodular lesions . ( a ) multiple skin - colored papulonodular lesions affecting forehead , upper lip , nasolabial folds ( arrow ) . ( b ) single , smooth surfaced , skin colored dome shaped nodule over scalp ( arrow ) . ( d ) similar lesions in her son ( arrow ) family pedigree showing seven members in four successive generations affected with the disease ( a ) basaloid inclusions with immature hair follicles and abundant stroma which is consistent with trichoepithelioma ( hematoxylin and eosin , original magnification 100 ) . ( b ) wellcircumscribed epithelial neoplasm in mid to deep dermis with basaloid inclusions , giving a jigsaw puzzle appearance which is diagnostic of cylindromas ( hematoxylin and eosin , original magnification 100 ) bss is an autosomal dominant disease characterized by multiple adnexal neoplasia particularly cylindromas , trichoepitheliomas , spiradenomas located on head and neck . they are occasionally present in association with basal cell adenomas of the parotid glands , milia , organoid nevi , and basal cell carcinomas . a defect in the differentiation of folliculo - sebaceous - apocrine unit the susceptibility locus has been mapped to chromosome 16q12-q13 and mutations in the cylindromatosis tumor - suppressor gene have been implicated in the phenotype diversity . cylindromas occur as numerous papules , nodules , or tumors distributed over scalp and sometimes on face and trunk . trichoepitheliomas are skin - colored papules distributed on face with a predilection for nasolabial folds , forehead , chin , and preauricular area . cylindromas show a well - circumscribed lesion composed of tumor islands and cords of basaloid cells arranged in a jigsaw puzzle like pattern . histopathologically , trichoepithelioma is aggregations of relatively monomorphic basaloid ( germinative ) cells in dermis surrounded by fibrous stroma . treatment modalities for cylindromas include excision , dermabrasion , electrodessication , carbon dioxide ( co2 ) laser , cryotherapy , and radiotherapy . considering the high recurrence and risk of malignant transformation , wide local excision is the preferred treatment . medical treatments like sodium salicylate and prostaglandin a1 , which restore growth control by inhibiting nf - kb activity , are being tried in few cases .

brooke - spiegler syndrome ( bss ) is a rare autosomal dominant disorder characterized by the presence of various adnexal tumors including multiple cylindromas , trichoepitheliomas and spiradenomas . a 35-year - old female presented with multiple asymptomatic nodular lesions over face and scalp since the age of 5 years . there were no complaints suggestive of systemic involvement . her son , elder sister , younger sister , father , father 's sister , and grandmother had history of similar lesions . on examination , there were multiple asymptomatic skin - colored firm papulonodular lesions measuring from 2 to 8 mm in diameter , with smooth surface mainly affecting central part of face . scalp showed pinkish , firm , smooth - surfaced , dome - shaped nodules measuring about 1 to 3 cm in size . histopathological examination was consistent with trichoepitheliomas for the facial lesions and cylindromas for the scalp lesions . the diagnosis of bss was thus confirmed .

minor salivary gland tumors constitute less than 20% of all salivary gland neoplasms . over 50% of intraoral salivary gland tumors it accounts for 5377% of parotid tumors , 4468% of submandibular tumors , 6.4% occur in the minor salivary glands . pleomorphic adenoma arising from minor salivary glands in the nasopharynx and parapharyngeal space have also been reported although in rare instances . it appears as a unilateral painless , slowly growing , firm mass typically in adults from the 3 to 5 decades and 60% of the cases are reported in females . the other intraoral sites are lips , buccal mucosa , tongue , floor of the mouth , and retromolar trigone ( 0.7% ) . a 58-year - old south indian male patient came to the department of oral medicine and radiology , with the complaint of a small mass in the left lower retromolar region of the mouth . it was present from the past 6 months and has grown slowly to the present size . the patient also gave a history of occasionally biting on the mass causing an ulcer . on intraoral examination , there was a 22 cm dome - shaped mass on the left retromolar region . the surface was smooth and the covering mucosa showed an ulcer in the anterior part of the lump . on palpation , the lesion was firm , nontender , and mobile over the underlying tissues . the overlying mucosa color was normal except on the traumatized area [ figure 1 ] . note the traumatized area on the surface of the swelling based on the history and clinical findings , differential diagnosis consisting of fibroma , minor salivary gland tumor , and mucocele were considered . the cells were arranged in ductal pattern [ figure 2 ] . there were areas where the epithelial cells showed proliferation in sheets , cords , and strands . minor salivary gland tissue was observed and the lesion showed the presence of a capsule . a diagnosis of pleomorphic adenoma of minor salivary glands ( retromolar area ) was rendered . the patient was followed up for a period of 6 months during which satisfactory healing of the surgical site was observed and no evidence of recurrence was noticed . the minor salivary glands are small , independent , predominantly mucous glands that are found in every part of the upper respiratory tract . the majority of the minor salivary glands are located in the palate , while the others are found in the submucosa of the uvula , inner surface of the lips , around the opening of the parotid duct , in the mucous membrane of the cheek , floor of the mouth , palatoglossal folds , superior pole of the tonsils ( weber 's glands ) , on the inferior surface of the tongue , near the frenulum of tongue , and within the palatine tonsil . this tumor of the salivary glands is also known as a benign mixed tumor . in most cases , when they occur in the minor salivary glands , the most common site is the palate , followed by the lip , buccal mucosa , floor of mouth , tongue , tonsil , pharynx , retromolar area , and nasal cavity . the palate has the highest concentration of minor salivary glands in the upper aerodigestive tract , and it is the most common site for benign and malignant minor salivary gland tumors . intraoral pleomorphic adenoma usually presents as a mobile slowly growing , painless firm swelling that does not cause ulceration of the overlying mucosa . an ulcer was noticed on the surface of the mass due to trauma from the opposing tooth . a study conducted on a mexican sample , showed that it was 64.2% of benign neoplasms and only 35.8% were malignant . usual location was palate and cases reported in the retromolar area are malignant and submandibular tumor were benign with a slight female predominance . variants of pleomorphic adenoma include pleomorphic adenoma with lipomatous change , myxolipomatous pleomorphic adenoma , pleomorphic adenoma with squamous differentiation , and benign metastasizing mixed tumor . there are three histologic subtypes , myxoid ( 80% stroma ) , cellular ( myoepithelial cells predominant ) , and mixed ( classic ) . pleomorphic adenoma is known to produce recurrence either due to spillage , inadequate removal or enucleation at the time of operation , but is not known to produce distant metastasis . the ideal treatment of choice for pleomorphic adenoma is wide local excision with the removal of periosteum or bone if they are involved . rarely , a malignant tumor may arise within this tumor , a phenomenon known as carcinoma ex - pleomorphic adenoma . the malignant transformation in the pleomorphic adenoma has been linked to recurrence and multiple excisions . the most reliable features to determine malignancy include an infiltrative growth pattern , vascular permeation , perineural invasion , and marked cytologic atypia with abnormal mitotic figures . there is a second class of tumors , which are called metastasizing benign mixed tumors .

we describe a case of pleomorphic adenoma of minor salivary glands occurring in the retromolar area . a 58-year - old male patient reported with complaint of a small mass in the left lower retromolar region of the mouth . it has grown slowly to the present size . based on the history and clinical findings , differential diagnosis of fibroma , minor salivary gland tumor , and mucocele were considered . the microscopic findings revealed the presence of minor salivary gland tissue and the lesions showed the presence of myoepithelial and epithelial cell proliferation . the cells were arranged in ductal pattern . there were areas where the epithelial cells showed proliferation in sheets , cords , and strands . the patient was followed up for a period of 6 months and there was no evidence of recurrence . the retromolar area being affected as in the case presented is rare for this condition . surgical excision along with surrounding normal tissue is the treatment of choice .

the national cancer registry programme of the indian council of medical research , which collected data from six different parts of the country , showed lung cancer as a leading cause of cancer in india . malignant pleural effusion due to its recurrent nature poses a unique problem of increased morbidity of patients . medical thoracoscopy , a major modality for its treatment is not easily available and also a number of patients are not medically fit to undergo thoracoscopy . using an indigenous way of deploying indwelling pleural intercostal drainage ( icd ) without permanent bag attachment will decrease morbidity associated with external icd in situ and avert the learning curve , expertise and cost required for indwelling pleural catheter , thereby providing the benefits of both methods . a 60-year - old female , laborer by occupation , a diagnosed case of carcinoma lung with metastasis presented with chief complaints of dyspnea . the patient was offered thoracoscopy and talc poudrage which the patient refused so an indwelling intercostal tube insertion was planned . in order not to hamper the motility a newer economical technique was employed on the lines of indwelling pleural catheter , which not only is very expensive but also not easily available in india . chest radiograph pa view depicting massive pleural effusion after detailed informed consent , the site of icd insertion site was marked by ultrasonography in the mid axillary line . a second point was marked 5 cm behind and above the first point and lignocaine 2% was given liberally at the point of icd insertion and subcutaneously in the line between these two points . two subcutaneous nicks were given , the first 0.5 cm behind the point of icd insertion and the second at the second point behind and a subcutaneous tunnel was created by straight artery forceps between the two points . an 18 fr rhemsons icd tube was taken and passed through the subcutaneous tunnel and pulled out with the artery forceps . a nick was given and the front end was inserted in the chest wall as a normal icd insertion . the rear end of the tube was cut and used as an air tight cap after reversing it [ figure 2 ] . one stitch was placed at icd site and the other at the second point [ figure 3 ] . the icd was bent and dressing applied in two layers with the upper layer in two parts so that whenever drainage was to be done [ figure 4 ] , the patient removed the distal part of dressing above and connected to a bag [ figure 5 ] and sealed the tube with the cap after drainage of fluid . the patient was mobile without any need for carrying the icd bag with icd in situ [ figure 6 ] continuously and remained comfortable with the tube for 4 months till the end of life . during this period the patient was called for follow up every 15 days and sterile dressing was done . no complication was encountered during the above said period . intercostals drainage tube rear end being used as an airtight cap after reversing intercostal drain ( icd ) bag being filled for drainage of fluid site of stitches to hold icd tube one at icd site and other 5 cm behind second point dressing for indwelling drain pleurodesis has been the mainstay for management of malignant pleural effusions for decades , but it is associated with a number of problems . the largest randomized trial in pleural disease ( n = 486 ) , 5 talc ( poudrage or slurry ) pleurodesis indicated that only about 75% of malignant pleural effusions patients at 1 month and around 50% by 6 months had significant fluid control . also , in a subset of patients with conditions like trapped lung in which the lung does not expand and hence pleural approximation can not occur , pleurodesis is useless . few trials have also shown that talc induces lung and systemic inflammation and killed 2.3% of patients in a cancer and leukemia group b study through talc - induced respiratory failure . this acute lung injury can be decreased by using large particle size talc preparations , such products are imported in india and one small vial costs around 5000 rupees and is not available in all the states . the shortcomings of pleurodesis in a selected set of patients can be overcome by introduction of indwelling pleural catheters which allow fluid evacuation from a single minimally invasive procedure . it is associated with minimal complication as pain ; however , a systematic review including 1370 patients has confirmed that serious complications were uncommon ( 3% ) . various other studies have demonstrated safety records in patients undergoing chemotherapy and local radiotherapy with indwelling pleural catheters in situ and found them to be quite safe . indwelling pleural catheters is generally accepted for treatment of malignant pleural effusions patients in whom pleurodesis has failed or is contraindicated ( especially trapped lungs ) . however , its use in india is limited by the fact of decreased availability and cost . the priority for most malignant pleural effusions patients are alleviation of dyspnea and optimization of quality of life ( the principle end points for aforementioned european multicenter trials ) while avoiding hospital admissions . therefore , in an indian context the primary aim of malignant pleural effusions management is to improve dyspnea and quality of life , with minimal intervention and hospitalization at a less cost without compromising on the safety . using a normal portex intercostals drainage tube which is easily available , highly economical , with pulmonologists already well versed with its use ( and hence eliminates the need for learning curve for indwelling pleural catheter ) and equally efficacious is the answer of choice to selected patients of malignant pleural effusions who are not fit for pleurodesis , want to remain mobile and social , want to decrease morbidity and cost and prefer home management instead of hospital admissions . indwelling portex icd offers a low cost , easily available and successful alternative to thoracoscopy and indwelling pleural catheter for persistent malignant pleural effusions in a selected subset of patients .

malignant pleural effusion is a leading cause of morbidity in lung cancer patients requiring repeated pleural aspirations or persistent intercostal drainage tube . using an indigenous method of putting icd tube of smaller size with subcutaneous tunneling would allow draining fluid from lungs easily and painlessly when needed and avoid the need for repeated injections and chest tube insertion every time the fluid is to be drained .

cerebral microbleeds are frequently detected on magnetic resonance imaging ( mri ) in patients with small - vessel diseases such as cerebral amyloid angiopathy and lipohyalinosis . they are frequently observed in brains of patients suffering from alzheimer dementia ( ad ) and are mainly related to cerebral amyloid angiopathy . the clinical significance of microbleeds in ad is poorly understood . we present the clinical history and the post - mortem t2-weighted gradient - echo ( gre ) 7.0-t mri findings with the neuropathological correlates of a suspected hippocampal microbleed in a patient with ad . this female patient died at the age of 88 years from a neurodegenerative disease of unknown etiology . the prior clinical history included thrombophlebitis , complicated by lung embolism , gout , knee arthrosis , cholecystectomy and dyslipidemia . she had a cognitive evaluation at the age of 86 years . on the mattis dementia scale an mri of the brain showed bilateral hippocampal atrophy and symmetrical hypersignals in the brainstem on a t2 sequence . walking became impossible due to the development of a parkinsonian syndrome with extreme axial rigidity . the patient had to enter a nursing home at the age of 87 years , due to rapid physical deterioration . post - mortem brain examination was obtained by written informed consent from the nearest family . the brain tissue samples were first used for diagnosis and afterward integrated in the lille neuro - bank , dependant from the lille university and co - federated by the on histological examination the diagnosis of ad , stage vi , was made according to the braak and braak criteria . the bleeding load in the brain was quantified according to a method previously described : only a few widespread small bleeds were observed . three coronal sections of a cerebral hemisphere were submitted to a t2-weighted gre 7.0-t mri , and afterwards compared to the corresponding histological sections for the detection of microbleeds , according to a previously described method . a moderate number of hyposignals were observed , predominantly in the deep cortical layers of the central and occipital sections on the t2 sequence . however , the corresponding histological slide showed only amorphous iron deposits around the granular cellular layer and inside the layer of pyramidal neurons ( fig . 2a , b ) . moreover , iron deposits were present in the walls of small vessels ( fig . the present study shows a false - positive microbleed signal in the hippocampus on a t2 weighted gre 7.0-t mri sequence , due to iron deposition . overall , cerebral microbleeds are rarely observed in the hippocampus , compared to other brain regions , in patients with suspected cerebrovascular disease . brain iron deposits are mainly observed in the basal ganglia and were recently found to be associated with general cognitive ability and cognitive ageing . increased iron accumulation has been demonstrated in the hippocampus of ad brains [ 10 , 11 ] . this case report shows that one has to be careful in the interpretation of hyposignals as microbleeds on t2 sequence mri .

the present post - mortem study of a brain from an alzheimer patient showed on a t2-weighted gradient - echo 7.0-t mri of a coronal brain section a hyposignal in the hippocampus , suggesting a microbleed . on the corresponding histological examination , only iron deposits around the granular cellular layer and in blood vessel walls of the hippocampus were observed without evidence of a bleeding . this case report illustrates that the detection of microbleeds on mri has to be interpreted with caution .

idiopathic muscular hypertrophy of the gastrointestinal tract is a very rare condition of unknown aetiology with no predisposing factors . it mainly involves the oesophagus and there are few cases reported affecting the small bowel . there have been 25 cases reported in the english literature with this condition , and none in the last 20 years . the present case is unique on account ; entailing an adult woman with an isolated segment of idiopathic muscular hypertrophy of the second part of the duodenum causing gastric outlet obstruction . a 69 year old female , presented with a 6 week history of upper abdominal discomfort , nausea and vomiting symptoms . she has a past medical history of sarcoidosis and steroid dependent asthma for the past 2 years . on physical examination of the abdomen , bowel sounds were present and there was no distension , palpable mass , or tenderness noted . an upper endoscopy showed distal tertiary esophageal contractions , small sliding hiatal hernia with mild gastroesophageal reflux , and an intestinal obstruction at the level of the second portion of the duodenum . an ugi study showed severe stenosis of the second portion of the duodenum . upon preparation for surgery an exploratory laparotomy demonstrated an olive type mass in the second portion of the duodenum involving a 5 cm segment of the second portion of the duodenum with thickening of the duodenal wall measuring up to 1.3 cm . a longitudinal duodenotomy showed a diverticulum at the ampulla and two biopsies of the wall were taken . ten days after the surgery , the duodenostomy dehisced and a roux - en - y duodenojejunostomy was performed . four hours later , abdominal compartment syndrome was diagnosed , and the patient was taken to the operating room where an abdominal wound vac for open abdomen was placed . a few patients have described some mild abdominal discomfort ( 1 - 3 ) , which was also present with our patient . the most common location of muscular hypertrophy of the gastrointestinal tract in adults is in a short segment of the oesophagus ; usually occurring in elderly white men(1 ) . the first documented record was in 1885 by reher ( 1 ) , and the last one in 1988 by yamagiwa ( 3 ) . of which , 18 were adult men between 27 and 74 years old , 2 women of 27 and 68 years , respectively , and 5 children between 9 days and 11 years old . involvement of the small bowel is even more unusual with only 5 cases published up to date . all cases involved marked hypertrophy of the muscularis propia ( 1 - 4 ) along with normal mucosa . however , spencer and hudson ( 1 ) report diverge on a thicker mucosa , and yamagiwa ( 3 ) describes atrophic villi and an extra sheet below the longitudinal layer . our patient , besides the expected findings , had a focal mild increase in eosinophils . we conclude that because this is a rare and usually asymptomatic condition , it is very difficult to know what should be the ideal diagnostic test . nevertheless , if the patient is symptomatic , he / she can be diagnosed with a ct scan and an ugi study or a small bowel series . depending on the extent of the hypertrophy , the proper treatment may vary . in our opinion , the best possible treatment in this case would have been a fredet - ramstedt type myotomy .

there have not been any cases published of idiopathic muscular hypertrophy of the gastrointestinal tract in the past 20 years , mainly because it is a very rare condition of unknown aetiology . it is usually asymptomatic and presents mostly in the oesophagus of adult men.our case involves a 69 year old female that presented with a 6 week history of abdominal discomfort and weight loss . an upper endoscopy showed a blockage at the second portion of the duodenum and the upper gastrointestinal series demonstrated stenosis in the same location . an exploratory laparotomy discovered a mass involving 5 cm of the second portion of the duodenum with wall thickening measuring up to 1.3 cm in thickness . the histological report was muscular hypertrophy with mild eosinophils.this is the first case reported with such a distinctive isolated involvement of the second part of the duodenum .

neutropenic patients are at high risk of developing invasive fungal infections . in this patient population , however , surgical resection is indicated in hemoptysis or progressive radiological findings.1 video - assisted thoracic surgery ( vats ) and anatomic lobectomy were initially described in 1993 mainly for the treatment of lung cancer . by the mid-1990s , vats became an important approach for the treatment of lung and mediastinal lesions in adults and some specific cases in children . vats surgery is usually performed using three incisions ; however , some surgeons employ just two ports or even only one in a superior surgical approach.2 a computed tomography ( ct ) scan of the lungs showed new right interstitial infiltrates . antifungal prophylaxis was given , but because of the patient 's persistent fever , the treatment was changed to broad - spectrum antibiotics . five days from the beginning of the new treatment , a second ct scan showed a right hydropneumothorax . two weeks later , the fever persisted and the ct scan of the lungs showed a new localized lesion in the middle pulmonary lobe in direct contact with the lower right lobe fissure and the parietal pleura ( fig . 1 ) . these findings suggested the diagnosis of pulmonary aspergilloma and antifungal treatment with voriconazole was added to medical treatment . as part of the treatment for the hematologic disease , the patient was waiting for stem cell transplantation ; however , it is well known that these therapies increase the risk of mortality for invasive aspergillosis . therefore , a multidisciplinary team ( a hematologist , a pneumologist , pediatricians , and thoracic surgeons ) decided a therapeutic approach by combining the most conservative pulmonary resection using the less aggressive approach and systemic antifungal treatment . accordingly , the patient underwent a surgical resection of the pulmonary lesion with a minimal approach for vats single port . a middle lobectomy and wedge right lower lobe resection were performed . after 2 days of operation , the chest drain was removed and pain was managed just with acetaminophen . the unilateral lung ventilation was achieved with a double - lumen robertshaw 26 endotracheal left tube ( p3 medical ltd . ) . multiple pulmonary adhesions were found and they were isolated by blunt dissection using endopath ( ethicon ) and ligasure ( covidien ) devices . the lesion was visualized in the middle lobe , across the major fissure affecting the lower and middle lobes . then , the lung was rotated to expose the superior and middle pulmonary vein ( fig . the middle branch was divided and ligated with a vascular stapler ; afterward the middle bronchus was carefully identified , dissected , and sectioned with a bronchial stapler ( fig . once the middle bronchus was transected , the middle lobe artery was exposed and clipped proximally and thermo - sealed distally . the middle lobectomy was completed including a wedge resection of the lower lobe by stapling this lobe from the dissected inferior vein to the stapled line of the minor fissure ( fig . ( a ) surgical piece consisting of the middle and lower lobe right pulmonary segments . the chest drain was extracted after 3 days from surgery , and the pain was controlled with oral acetaminophen for 6 days . the unilateral lung ventilation was achieved with a double - lumen robertshaw 26 endotracheal left tube ( p3 medical ltd . ) . multiple pulmonary adhesions were found and they were isolated by blunt dissection using endopath ( ethicon ) and ligasure ( covidien ) devices . the lesion was visualized in the middle lobe , across the major fissure affecting the lower and middle lobes . then , the lung was rotated to expose the superior and middle pulmonary vein ( fig . the middle branch was divided and ligated with a vascular stapler ; afterward the middle bronchus was carefully identified , dissected , and sectioned with a bronchial stapler ( fig . once the middle bronchus was transected , the middle lobe artery was exposed and clipped proximally and thermo - sealed distally . the middle lobectomy was completed including a wedge resection of the lower lobe by stapling this lobe from the dissected inferior vein to the stapled line of the minor fissure ( fig . ( a ) surgical piece consisting of the middle and lower lobe right pulmonary segments . the chest drain was extracted after 3 days from surgery , and the pain was controlled with oral acetaminophen for 6 days . standard treatment , combining early surgery and antifungal therapy , has the best prognosis in these cases . surgical resection can be curative in certain patients after antifungal treatment . furthermore , in patients who would need immunosuppressive treatment , aggressive surgical management has been suggested.3 the surgery for pulmonary aspergilloma can be technically challenging because multiple adhesions can be usually found between the main lesion and adjacent normal anatomical structures . despite the potential benefits of a minimally invasive procedure in immunosuppressed patients , the vats approach to perform lobectomy for pulmonary aspergilloma we have not found studies of pulmonary aspergilloma treated by vats single port in adults , and no significant experience with thoracoscopic lobectomy in children has been previously reported .

we present the case of an 11-year - old girl with pulmonary aspergilloma secondary to a hematologic disease successfully treated with a single port video - assisted thoracoscopic lobectomy . this surgical procedure was not previously reported . we consider this approach to be a safe and appropriate procedure for lung resection , in children or adults requiring minimal intervention and early recovery .

infection with penicillium marneffei , an emerging facultative intracellular dimorphic fungus , is an important disease among human immunodeficiency virus ( hiv ) infected persons in south east asia . in south east asian countries such as thailand , penicilliosis marneffei ( pm ) ranks as the third most common opportunistic infection , after extra - pulmonary tuberculosis and cryptococcus , in people with acquired immunodeficiency syndrome ( aids ) . although p. marneffei has been reported in varied clinical manifestations , it has rarely been isolated from the oral cavity . we report a patient with hiv who presented with oral lesions wherein a diagnosis of p. marneffei was made after microscopic examination and culture tests . a 32-year - male reported with the chief complaint of nonhealing painful ulcer from past two months on the left border of the tongue . the ulcer was small , superficial with clinical resemblance to recurrent apthous ulcer [ figure 1 ] . careful history revealed that patient was a chronic smoker and he had chest pain and chronic productive cough from past 23 months . the patient was on some medication which he used to take off and on depending on cough and diarrhea . ( an ingredient of paan ) on ulcer . when no sign of ulcer healing was seen and pain increased , then the patient reported to dental college . clinical picture showing ulcer on left lateral border of tongue examination of oral cavity revealed that the patient had a very poor oral hygiene with generalized gingival recession . the blood investigations revealed that the patient was anemic with hemoglobin level of 8.5 g / dl . the patient was found to be seropositive with a cd4 + count of 110 cells / ml . patient 's saliva samples and scrapping from ulcers were inoculated separately on sabroud 's dextrose agar ( sda ) . slight growth was also seen on sda on 5 day in both samples but nothing conclusive could be drawn . on 10 day of inoculation , it showed typical brush border appearance with the presence of conidiophores and stergimata which confirmed the diagnosis[figure 3 ] . greenish black colonies of p. marneffei with red pigment on sda lactophenol cotton blue preparation of p. marneffei with typical brush border appearance with the presence of conidiophores and stergimata the patient was treated with amphotericin b followed by itraconazole maintenance therapy and he was also referred to department of general medicine for antiretroviral therapy and other medical problems such as cough and diarrhea . the infection is most commonly seen in southeast asia , southern china , hong kong , and taiwan . it is one of the commonest opportunistic infections among aids patients in areas of endemicity and is considered an indicator disease for aids . p. marneffei has been isolated from bamboo rat furrows and the current consensus would favor soil as the most probable reservoir , with transmission to humans via the respiratory root . therefore , there seems to be no role for the rats on the natural occurrence of the disease . similar to other pathogenic fungi , the conidia are inhaled and internalized by alveolar macrophages and transported to the reticuloendothelial system . the organisms then proliferate as soon as host immunodeficiency takes place , leading to systemic infection . the first cases in english literature from india were published by singh np et al . in four hiv positive patients from manipur . in 2009 , baradkar et al . reported a case of p. marneffei infection in hiv positive individual from mumbai , which is a non endemic area . history of travel to endemic area was a major clue to diagnosis in case from vellore , india . a report of a patient who lived in an nonendemic area but developed penicilliosis 11 years after visiting hong kong has suggested the possibility of a long latency with subsequent reactivation . there is also evidence that primary infection might occur as p. marneffei infection can present early in young children who had acquired hiv perinatally . maniar et al . reported a case of p. marneffei infection in an hiv - infected individual from manipur . multiple erythematous , discrete papules , and nodules with umblication were situated over the face , chest , back , and proximal parts of extremities . nittayananta suggested that oral p. marneffei lesions usually occurs in patients with disseminated infections , presented as erosions or shallow ulcers covered with whitish yellow , necrotic slough which may be found on palate , gingival , labial mucosa , tongue and oropharynx . the mortality rate in patients with acute disseminated penicillinosis is high if the infection is not diagnosed early enough and a timely and effective antifungal therapy is not used . in a correctly diagnosed case of infection with p. marneffei , amphotericin b followed by itraconazole maintenance therapy is generally curative or effective in preventing a relapse of disease . thus , an early diagnosis is a prerequisite for lowering the mortality rate in patients with acute disseminated p. marneffei . this case aims to emphasize the fact that p. marneffei can be isolated from oral cavity and also from the nonendemic areas . the isolation of p. marneffei from nonendemic areas suggests the changing scenario of infections , which may result in greater morbidity and mortality . further research work is required in the field of infections with p. marneffei , with respect to its global distribution , natural history , pathogenesis , and impact of antiretroviral therapy .

penicillium marneffei is a dimorphic fungus , which can cause fatal infection in hiv - infected patients . the aim of this article is to report a rare case of penicillinosis in an hiv - positive patient from a nonendemic area such as paonta sahib , himachal pradesh . the patient presented with nonhealing painful ulcer on tongue , chest pain , cough , and chronic diarrhea . diagnosis was made possible through blood investigations and culture reports of saliva and blood samples .

trilateral retinoblastoma ( trb ) is a rare disease associating intraocular retinoblastoma with intracranial primitive neuroectodermal tumor . trb can occur with both familial and sporadic forms of retinoblastoma . to the best of our knowledge , this is the first case report of positron emission tomography / computed tomography ( pet / ct ) imaging features in trb with suprasellar mass and drop metastasis . he underwent magnetic resonance imaging ( mri ) which showed right orbital mass lesion infiltrating optic nerve , and diagnosis of retinoblastoma was made . he was referred for fluorodeoxyglucose ( fdg ) pet / ct to find out the extent of the disease . whole body contrast enhanced pet / ct [ figure 1a ] showed abnormal fdg - uptake within right orbital mass lesion [ figure 1b ] and suprasellar region [ figure 1c ] , sagittal fused - pet / ct showing enhancing lesion in the cervical spinal canal level [ figure 1d , arrows ] . whole body contrast enhanced fluorodeoxyglucose - positron emission tomography / computed tomography ( fdg pet / ct ) maximum intensity projection image ( a ) axial fused - pet / ct showed intense uptake in the soft tissue lesion in the right orbit ( b ) suprasellar mass lesion and ( c ) sagittal fused - pet / ct showing drop metastasis in cervical spinal canal level ( d , arrows ) . also , physiological brown fat uptake noted in bilateral cervical , supraclavicular , and paravetrbral locations trb is a disease associating unilateral or bilateral rb with an intracranial midline primitive neuroectodermal tumor , which usually arises in the pineal gland ( 77% ) . the risk of developing trb in rb patients is less than 0.5% for sporadic unilateral disease , 5 - 13% in sporadic bilateral disease , and 5 - 15% in familial bilateral rb . the unusual presence of leptomeningeal dissemination at diagnosis raises the question whether the suprasellar tumor could be a metastasis . its strict midline location , the absence of continuity and intraorbital extension on mri , the absence of diffuse intracerebral nodules , are strong factors against metastasis as well as the close relationship to rb . marcus et al . , who described in their pathologic review on 80 cases of trb , 9 suprasellar and parasellar masses with hypointense images on mri and significant enhancement of gadolinium . in 36 cases , intracranial tumor spread was documented at autopsy and comprised seeding along the spinal cord and canal , diffuse meningeal , ependymal and subependymal involvement , invasion into brain parenchyma , and optic nerve invasion . ct or mri of the orbit and brain are the standard imaging modalities used for diagnosing and evaluating disease extent in retinoblastoma . to the best of our knowledge , the role of 18f - fdg pet / ct in trb has not been reported in the published literature . there has been previous report on the use of 18f - fdg pet alone without ct in 4 patients with retinoblastoma and radhakrishnan et al . , described the role of pet / ct in staging and evaluation of treatment response after three cycles of chemotherapy in locally advanced retinoblastoma . this is the first case of identifying trb with drop metastasis in pet / ct . treatment of these patients is very difficult and prognosis is poor despite a multimodality approach , as most of them die of leptomeningeal dissemination .

trilateral retinoblastoma ( trb ) is a rare syndrome associating hereditary bilateral or unilateral retinoblastoma ( rb ) with an intracranial neuroblastic tumor . the latter arises in the midline , most often in the pineal gland , less frequently in the suprasellar or parasellar region . the outcome is usually fatal because of secondary spinal dissemination . we report 10-year - old boy presented with a right eye proptosis and leukocoria , and the magnetic resonance imaging ( mri ) showed right orbital mass lesion infiltrating optic nerve and diagnosis of retinoblastoma was made . he was referred for fluorodeoxyglucose - positron emission tomography / computed tomography ( fdg pet / ct ) to find out the extent of the disease . pet / ct showed abnormal fdg - uptake within right orbital mass lesion , suprasellar enhancing lesion and drop metastasis in the cervical spinal canal level . he was diagnosed as a case of trb with spinal canal drop metastasis . he underwent chemotherapy and craniospinal irradiation .

tufted angioma ( ta ) is a rare vascular neoplasm localised to the skin and subcutaneous tissues , occurring primarily on the trunk and extremities of children . these tumours pursue a benign course of slow angiomatous proliferation , without any evidence of aggressive behaviour or metastases . the lesions are usually asymptomatic but , rarely , paroxysmal painful episodes may also be associated with it . the occurrence of eruptive ta is still rarer , and has been described almost exclusively in association with immunocompromised states . we report here a case of acquired painful multifocal tufted angiomas on the face and neck in a young adult . a 19-year - old man presented with multiple , reddish , elevated , and painful skin lesions on the left side of his face and neck for the duration of three months . there was no history of trauma , bleeding from the lesions or from other parts of the body , or increased sweating or discharge from the lesion . in addition , multiple small erythematous nodules ( measuring 1 1 cm ) were present on his upper neck [ figure 2 ] for the same duration . the lesions were tender , firm in consistency with a slight rise in local temperature . punch biopsy specimens of the skin from a facial plaque and a nodule on the neck showed multiple , discrete , circumscribed dermal foci of closely set vascular channels . the lobules consisted of multiple capillaries with bloodless lumen , surrounded by dilated crescent - shaped vascular channels [ figure 3 ] . in addition , there was increased sebaceous gland proliferation in the dermis . complete hemogram , prothrombin time , partial thromboplastin time , bleeding time , clotting time and other routine biochemical panels showed normal results . based on the clinical and histopathological features , a diagnosis of tufted angioma was made . the patient was treated with fluticasone propionate ointment , which reduced the painful episodes to some extent , but the lesions were persistent . multiple erythematous plaques and papules on left cheek multiple erythematous plaques and papules and small erythematous nodules on upper neck ( a ) multiple , discrete , circumscribed dermal foci of closely set vascular channels ( h and e staining , 100 ) . ( b ) multiple capillaries with bloodless lumen , surrounded by dilated crescent - shaped vascular channels resembling a " cannonball " ( h and e staining , 400 ) most cases ( 60 - 70% ) of ta develop before the age of five years and fewer than 10% of cases with ta had occurred after the age of 50 years . the lesion of ta enlarges slowly over 5 months to 10 years , after which no further growth occurs . clinically , ta appears as a deep red or purple patch or plaque with superimposed angiomatous papules that predominantly appear on the upper thorax , neck , and shoulders . face , scalp , and proximal extremities the diameter of the patch or plaque generally ranges from a few millimeters to several centimeters . on palpation , the lesions often have a rubbery consistency , and may be tender . peripheral extension occurs occasionally , and lesions of ta are rarely described as having a thick indurated border and a central depression ( annular ta ) . occasionally , ta may be associated with the kasabach - merritt syndrome ( kms ) . in this setting , the presence of petechial and ecchymotic patches should alert the physician to the development of kms . no specific laboratory study is helpful in the diagnosis or treatment of ta . on suspecting the coexistence of kms , a complete haemogram ( including a platelet count ) , prothrombin time and/or activated partial thromboplastin time , and full screening for disseminated intravascular coagulation is indicated . magnetic resonance imaging ( mri ) studies have proven useful in the evaluation of the depth of invasion and extent of growth of ta . they are characterised by the vascular tufts of densely packed capillaries , randomly scattered throughout the dermis in a so - called cannonball distribution . there are crescentic spaces surrounding the vascular tufts and lymphatic - like spaces within the tumour stroma . two previous reports of acquired eruptive ta exist in the pubmed database . in one patient , eruptive ta occurred after liver allograft transplant and , in the other , it appeared in a patient with crohn 's disease , who was receiving immunosuppressants . in these cases , immunosuppression or influence of drugs on angiogenesis might have played a role in the development of ta . ta should be differentiated from kaposiform haemangioendothelioma , juvenile capillary , or strawberry angioma , haemangiopericytoma , glomeruloid haemangioma , lobular capillary haemangioma , or pyogenic granuloma . these include complete surgical excision , cryosurgery , and radiotherapy . pulsed dye laser has also been reported as an effective option for treatment of ta . high doses of interferon 2 and systemic steroids may be tried before proceeding to excision , particularly in cases with extensive lesions . the case is reported here for the combination of rare clinical features and to emphasise the importance of considering ta in the differential diagnoses of any acquired vascular tumour .

tufted angioma ( ta ) is a rare benign vascular neoplasm , localized to the skin and subcutaneous tissues , occurring primarily on the trunk and extremities of children . the lesions are usually asymptomatic but , rarely , paroxysmal painful episodes may be associated . the occurrence of eruptive ta is still rarer and had been described almost exclusively in association with immunocompromised states . we report here a case of acquired painful multifocal tufted angiomas on the face and neck in an immunocompetent young adult .

rats are used as animal models of many human diseases , such as cancer and hypertension . because of its significance in biomedical analyses , the genome sequence of the brown norway rat strain was determined as the third complete mammalian genome . the national bioresource project rat ( nbrp - rat ) at kyoto university is one of the largest repositories for rat strains , and currently , > 700 strains have been collected and preserved as live animals , embryos , or sperm . determination of genome sequences for these strains is important not only for understanding genetic causes for various phenotypes but also to augment their value as biological resources . whole exome sequencing is an efficient approach to characterize only the exonic portions of a genome , which typically comprise 1%2% of complete mammalian genomes , and has been successfully used in the identification of relevant genes and their causative mutations in many diseases in humans . although some non - human exome capture kits exist , there had previously been no such capture probe set for rats . therefore , we established a target capture kit specifically designed for this rodent species , employing the seqcap ez developer library ( roche nimblegen , madison , wi , usa ; design name 140929_rn5_ms_ez_hx1 ) . in designing our target capture probe set , we included highly conserved non - coding sequences ( cnss ) as target regions as well as all annotated exons , covering a total 146.8 mb of the genome . by applying this target capture method targetec ( target capture for exons and conserved non - coding sequences ) to four rat strains ( wtc / kyo , wtc - swh / kyo , pvg / seac , and kfrs4/kyo ) , we confirmed that targetec performs efficiently in the identification of causative mutations , including those present in the non - coding regions . in this study , we further applied targetec to 20 additional inbred strains preserved in nbrp - rat to identify additional variants observed in multiple rat strains . these 20 strains were selected according to the following three categories : disease models derived from selective breeding ( bdix / nemoda , bdix.cg-tal/nemoda , buf / mna , htx / kyo , hwy / slc , kfrs3b / kyo , rcs / kyo , zf , and zfdm ) , those originated from wild populations ( bn / ssnslc , dob / oda , is / kyo , is - tlk / kyo , le / stm , lec / tj , and nig - iii / hok ) , and representative inbred strains ( f344/ducrlcrlj , f344/jcl , f344/nslc , and f344/stm ) . all animal experimentation protocols were approved by the institutional animal care and use committees of kyoto university and were conducted according to the regulation on animal experimentation at kyoto university . target capture was performed using the standard seqcap ez system protocol ( roche nimblegen ) . dna sequencing libraries were prepared using the kapa hyperplus library preparation kit ( kapa biosystems , london , uk ) according to the manufacturer 's protocol . sequencing was performed on an illumina nextseq 500 platform ( illumina , san diego , ca , usa ) using the high output kit ( 2 150 cycles ) . sequence reads were mapped to the rat genome assembly rn5 ( rgsc 5.0 , march 2012 ) using bwa ( v0.7.4 ) with the default parameters . samtools ( v0.1.12a ) , picard tools ( v1.87 ) ( http://broadinstitute.github.io/picard/ ) , and the genome analysis toolkit ( gatk ; v2.5.2 ) were used for post - processing of mapped reads . we identified 154,330 snvs and 24,368 indels in the target regions , on an average ( table 1 ) . the number of unique snvs and indels among the 20 strains was 470,037 and 68,652 , respectively . sequence data and variants identified for these strains represent valuable resources for further genetic studies in the rat .

we report sequence data obtained by our recently devised target capture method targetec applied to 20 inbred rat strains . this method encompasses not only all annotated exons but also highly conserved non - coding sequences shared among vertebrates . the total length of the target regions covers 146.8 mb . on an average , we obtained 31.7 depth of target coverage and identified 154,330 snvs and 24,368 indels for each strain . this corresponds to 470,037 unique snvs and 68,652 unique indels among the 20 strains . the sequence data can be accessed at ddbj / embl / genbank under accession number prjdb4648 , and the identified variants have been deposited at http://bioinfo.sls.kyushu-u.ac.jp/rat_target_capture/20_strains.vcf.gz .

warfarin therapy in patients with intracardiac thrombus is effective in reducing the size of a thrombus by inducing a relative predominance of plasma fibrinolytic activity over anticoagulation - inhibited thrombin activity . however , the effect of novel oral anticoagulants on intracardiac thrombi has not been fully elucidated , and it is controversial whether or not dabigatran therapy is effective in decreasing the size of an intracardiac thrombus . here , we report a patient with atrial fibrillation in whom a mobile thrombus in the left atrial appendage increased in size after dabigatran therapy ( 110 mg b.i.d . ) a 74-year - old japanese man with hypertension , type 2 diabetes mellitus , ischemic heart failure , and nonvalvular atrial fibrillation ( nvaf ) presented at our hospital after the sudden onset of right hemiplasia and dysarthria . on admission , the plasma level of the thrombin - antithrombin complex was 21.7 ng / ml ( normal range : 0 - 3.0 ng / ml ) . axial diffusion - weighted magnetic resonance images and magnetic resonance angiography images showed hyperintense signals in the left front - parietal cerebral cortex without any intracranial stenotic lesions , and acute cardioembolic stroke associated with nvaf was diagnosed . transesophageal echocardiography ( tee ) performed on day 3 after admission revealed a mobile thrombus ( 1.0 2.2 cm ) in the left atrial appendage ( fig . 1a ) , and dabigatran therapy ( 110 mg b.i.d . ) was initiated to prevent stroke recurrence . activated partial thromboplastin time ( aptt ) was 31 s before dabigatran and 33 s 3 h after 110 mg dabigatran . tee performed on day 9 after admission revealed that the size of the thrombus had increased to 1.5 3.0 cm ( fig . medication was changed from dabigatran to warfarin with a target prothrombin time / international normalized ratio of between 2.0 and 3.0 . tee performed on day 23 after admission revealed that the size of the thrombus had decreased ( fig . 1c ) , and tee performed on day 42 after admission revealed that the thrombus had disappeared ( fig . the patient did not have a recurrent stroke and was discharged from hospital on day 43 with an nihss score of zero and a modified rankin scale grade of zero . an intracardiac thrombus is detected by tee in 12 - 14% of patients with nvaf . the decrease in the size of a thrombus that occurs after warfarin therapy may be due to the relative predominance of plasma fibrinolytic activity over anticoagulation - inhibited thrombin activity . although warfarin is known to reduce the size of a thrombus , the effect of novel oral anticoagulants on intracardiac thrombi has not been fully elucidated . according to the present case , dabigatran therapy ( 110 mg b.i.d . ) this may be because dabigatran has a peak and a trough in its concentration curve that warfarin does not have , and the predominance of fibrinolytic activity that occurs in the trough phase may be too small to cause a reduction in the size of the thrombus . on the other hand , vidal et al . reported that in a 59-year - old woman with a clot in the left atrial appendage , the size of the thrombus decreased after dabigatran ( 150 mg b.i.d . ) was used for 6 - 7 weeks . therefore , in the present case , dabigatran 150 mg b.i.d . or warfarin may have been more effective than dabigatran 110 mg b.i.d . at reducing the size of the thrombus . low bioavailability of dabigatran might be another explanation why intracranial thrombus reduction failed in this case . low availability , absorption , and serum concentration of dabigatran are reflected by the low aptt that was observed 3 h after dabigatran administration . therefore , for dabigatran treatment of intracardiac thrombus , it is important to ensure that aptt is prolonged in the first hours after administration .

we report a case of atrial fibrillation in a patient in whom a mobile thrombus in the left atrial appendage increased in size after low - dose dabigatran therapy . a 74-year - old man was admitted to our hospital because of sudden onset of right hemiplasia and dysarthria . on admission , his national institutes of health stroke scale score was three . axial diffusion - weighted magnetic resonance images and magnetic resonance angiography images showed hyperintense signals in the left front - parietal cerebral cortex without any intracranial stenotic lesions , and acute cardioembolic stroke associated with nonvalvular atrial fibrillation was diagnosed . transesophageal echocardiography revealed a mobile thrombosis ( 1.0 2.2 cm ) in the left atrial appendage , and dabigatran therapy ( 110 mg b.i.d . ) was initiated to prevent stroke recurrence . transesophageal echocardiography performed 6 days later revealed that the size of the thrombus had increased to 1.5 3.0 cm . medication was changed to warfarin , and the thrombosis subsequently decreased in size . the patient did not have a recurrent stroke and was discharged with a national institutes of health stroke scale score of zero . this case demonstrates that low - dose dabigatran may not be effective in reducing the size of a thrombus .

in the previous issue of critical care , lucidarme and colleagues describe the impact of nicotine abstinence on the clinical course of critically ill patients receiving mechanical ventilation for at least 48 hours . the smokers were more likely to be younger and male , have a history of alcoholism , and be admitted for septic shock compared to non - smokers . the results of the study showed active smoking history to be an independent risk factor for agitation . there are 1.2 billion smokers in the world , half of whom will die from diseases caused by smoking . tobacco products are highly addictive and abstinence from their use in active smokers can lead to withdrawal symptoms . these symptoms are often non - life threatening and are not well described in the critically ill . mayer and collaborators reported five cases of agitated delirium in smokers hospitalized for brain injury . they attributed the delirium to nicotine withdrawal because of its improvement following nicotine replacement therapy ( nrt ) . tran - van and colleagues reported a case with difficulty to wean from mechanical ventilation , and restlessness attributed to nicotine withdrawal . the patient 's condition improved following nrt . because of several confounding factors , it is difficult to determine the exact incidence of nicotine withdrawal in critically ill smokers . critical illness , mechanical ventilation , and sepsis can be associated with various levels of encephalopathy . . the manifestations of abstinence from such addictive substances may not be easily distinguishable from the manifestations of nicotine withdrawal . although compromised by the small sample size , lucidarme and colleagues have done their best to minimize the impact of confounding factors by matching cases and controls . there is a scarcity of data addressing the presence and extent of clinically important nicotine withdrawal symptoms in critically ill active smokers . the study by lucidarme and colleagues is one step towards this . since the symptoms and signs of nicotine withdrawal lack specificity in the critically ill , effective therapy aimed specifically at preventing and treating nicotine withdrawal , with no effect on other conditions with similar manifestations , may help to define the clinical course of nicotine withdrawal in the critically ill . the major currently available treatment options for nicotine addiction include nrt , bupropion , and varenicline . several studies performed mostly in the outpatient setting have shown that nrt is safe and effective in ameliorating symptoms of nicotine withdrawal . although data justifying the use of nrt in the critically ill are non - existent , some icus have developed protocols offering it to all active smokers . we recognize that hospitalization provides an excellent opportunity to intervene on nicotine addiction ; however , nrt may not be a harmless intervention . although the study was compromised by several limitations , our groups have shown that nrt may be associated with increased mortality in the critically ill . we have recently completed a prospective , cohort study of active smokers admitted to a medical icu . however , nrt did not reduce the development of delirium . since nicotine addiction is a global health problem , some healthcare providers treat critically ill active smokers with nrt . theoretically , this approach may be beneficial to critically ill smokers whose clinical course may be complicated by nicotine withdrawal . however , the clinical impact of nicotine withdrawal in the critically ill has not been well described . although there are case reports suggesting that prevention and treatment of nicotine withdrawal may be beneficial , retrospective studies have shown nicotine replacement therapy may increase mortality in the critically ill . moreover , interventions aimed at the prevention and treatment of nicotine withdrawal in the critically ill should be subjected to clinical trials before applying them to patients .

over 500 million of the current world population will die from diseases caused by smoking cigarettes . the symptoms and signs of nicotine withdrawal are not well described in the critically ill . since the various conditions of critical illness may lead to clinical manifestations mimicking nicotine withdrawal , describing its specific manifestations may not be easy . a few case reports suggest that nicotine replacement therapy may ameliorate nicotine withdrawal in the critically ill . however , retrospective studies have found that it may increase mortality . despite the abundance of active smokers , there is a paucity of data describing nicotine withdrawal , and its prevention and treatment options in the critically ill . future studies are warranted to address these issues .

coronary artery fistula ( caf ) was first described in 1865 , and is not an uncommon anomaly.1 ) coronary artery aneurysms , defined as coronary arterial dilatation that exceeds the diameter of normal adjacent segments or the diameter of the patient 's largest coronary vessel by 150% , are respectively noted in 0.15% to 4.9% of patients undergoing coronary angiography . we experienced a female patient who developed double fistulas detected by transthoracic echocardiography ( tte ) and confirmed by coronary angiography . to the best of our knowledge , this is the first case report on concurrent , dual fistulas of ascending aorta and coronary artery to pulmonary artery . a 64-year - old female was admitted with exertional chest tightness and shortness of breath for several weeks . the chest tightness radiated to the left scapular area occasionally , and lasted more than half an hour . there was no family history of aortic , collagen , vascular or congenital heart disease . her vital signs were as follows : blood pressure of 140/90 mmhg , pulse of 70 beats / min , respiration of 20 breaths / min , and body temperature of 36.5. on examination , cardiac auscultation revealed 2 to 4 grade diastolic murmurs and her electrocardiography demonstrated no apparent st segment and t wave abnormalities . blood chemistries , including coagulation studies and complete blood cell count , as well as cardiac enzymes and lipid profiles , were within the normal limits . the size of left ventricle was normal with an ejection fraction of 64% and there were no abnormalities in the regional wall motion , cardiac valves . exercise treadmill test showed 10 met positive finding ( 2 mm st depression in v5 , v6 ) . 2b and c ) , and another from the proximal portion of the left anterior descending coronary artery ( fig . multi - detector - row computed tomography was performed in order to further evaluate the fistulas associated with aneurysm , which showed that the fistulas were comprised of two source vessels and a single draining vessel ( fig . there was separate ostium of the left main coronary artery and fistula tract ( fig . caf is a congenital abnormality with an estimated frequency of 0.27% to 0.4% of all congenital cardiac lesions,1)2 ) and usually discovered incidentally at coronary angiography . in addition , caf can be diagnosed during evaluation of continuous murmur at the precordium , and rarely found during investigation for the etiology of bacterial endocarditis.3)4 ) the fistula may be single or multiple , isolated or associated with accompanying congenital defects . the hemodynamic effect of caf depends on the site of drainage and resistance within the fistula . the most frequent complaints of patients with caf are angina pectoris , atypical chest pain and lethargy . the pathophysiologic mechanisms of the symptoms are volume overload as a result of the shunt , coronary steal that causes decreased myocardial oxygen supply and lack of capillary formation.5 ) tte is an important non - invasive tool for identifying the anomalous origin of coronary arteries , and continuous turbulent systolic and diastolic flow pattern characterizes the shunt entry site.6)7 ) however , coronary angiography still remains the gold standard for diagnosing coronary anomalies . selective coronary angiography can be used to reliably identify the size and anatomic features of the fistulous tract , which can be diagnostic and therapeutic.8 ) current treatment options include careful observation , surgical ligation with or without cardiopulmonary bypass , ligation with bypass of the involved coronary artery , and transcatheter embolization . treatment for asymptomatic fistulas without significant shunting remains controversial.9)10 ) small fistulas are usually asymptomatic and managed conservatively . surgical ligation of fistula is limited to larger symptomatic fistula with large branch vessels that may be compromised by occlusion devices . there is general agreement that symptomatic patients , such as our patient , should be treated , and it is well accepted that all symptomatic patients should be treated with surgical ligation or closure . this is the first report of dual fistulas associated with a large aneurysm originating from the ascending aorta and proximal left anterior descending coronary artery , which were connected to pulmonary trunk . the patient was successfully treated with fistula ligation operation . because the patient was transferred to a surgical hospital to investigate chest pain and dyspnea , early evaluation with tte is useful and remains very important to predict and diagnose the exact disease cause .

coronary artery fistula to pulmonary artery is common . however , to the best of our knowledge , a case of coronary artery fistula to pulmonary artery associated with aortopulmonary fistula remains unreported . we herein report a 64-year - old female with a left anterior descending coronary artery and ascending aorta to pulmonary artery fistulas , and conduct a brief review of the literature .

hepatic artery aneurysms ( haa ) are rare but clinically significant entities , owing to the high rates of spontaneous rupture and subsequent high mortality . asymptomatic in up to a third of cases , haa are increasingly diagnosed incidentally during radiological investigations for other pathology.(2)early diagnosis and repair before rupture occurs is clearly preferable , and morbidity and mortality of elective surgical or radiological intervention appears to be low.(3)here we present an incidental finding of an asymptomatic giant haa and successful elective surgical repair . a 74 year - old female with a background of diverticular disease , hypertension , and type 2 diabetes mellitus was admitted with a three - day history of rectal bleeding . on admission the patient was haemodynamically stable with a pulsatile , non - tender mass palpable in the epigastrium and tenderness in the left iliac fossa . she underwent a ct scan , which revealed an incidental finding of a large saccular aneurysm involving the common hepatic artery and the hepatic artery proper , measuring 6.2 x 7.1 x 7.5 cm in maximum dimensions ( figure 1 ) . in addition , multiple focal dilatations of medium - sized visceral arteries ( including the splenic artery and left renal artery ) were identified . axial computerised tomography scan after administration of intravenous contrast showing a giant hepatic artery aneurysm owing to the proximity of the aneurysm neck to the bifurcation of the hepatic artery and lack of landing zone for the stent , the aneurysm was not felt to be suitable for endovascular repair . open surgery was therefore performed , with exposure of the aneurysm through a midline incision ( figure 2 ) and repair using an interpostion long saphenous vein inlay graft to exclude the aneurysm sac . intraoperative image showing the aneurysm arising from the common hepatic artery ( white sling ) and its relationship to the left and right hepatic arteries ( red and blue slings ) post - operatively the patient was transferred to the intensive care unit for ongoing monitoring . she made a good recovery with no immediate or early complications , and was discharged home after one week . she remains asymptomatic 6 months post - operatively , with graft patency confirmed on duplex ultrasonography . true hepatic artery aneurysms , particularly those of the dimensions described in this case , are rare vascular lesions . frequently atherosclerotic in origin , they may also be due to vasculitides such as polyarteritis nodosa and inherited connective tissue disorders.(4 ) clinical presentation ranges from incidental detection of asymptomatic aneurysms on ultrasound or computerised tomography , to acute abdominal pain and cardiovascular collapse in the event of rupture , which carries a mortality in the region of 40%.(1 ) haa are thus an important , if rare , diagnosis to consider in the patient presenting with right upper quadrant pain and haemodynamic instability . symptoms such as obstructive jaundice and gastrointestinal bleeding can also occur,(5 ) and may be mistakenly attributed to more common conditions . there are few reports of management strategies for giant haa in the literature , and as such the optimal treatment remains controversial . several studies have demonstrated the efficacy and safety of endovascular management of visceral artery aneurysms including giant haa.(6 ) elective open surgical repair of haas has also been shown to be associated with high success rates and low complication rates in both the short and long - term.(7 ) as this case demonstrates , surgery may be the most appropriate option in cases where the anatomical characteristics of the aneurysm preclude against endovascular repair . in either case , expedient repair before rupture occurs is essential once the diagnosis has been made .

hepatic artery aneurysms ( haa ) are rare vascular lesions which are associated with significant morbidity and mortality in the event of rupture . early diagnosis and expedient management are therefore important to optimise outcome . here we report a case of a giant hepatic artery aneurysms ( haa ) found incidentally on computerised tomography , successfully managed without complication by elective surgical repair .

morganella sp . a motile gram - negative rod belonging to the family enterobacteriaceae , has low pathogenicity , but compromised patients can develop diarrhoea , wound infections , urinary tract infections , bacteraemia , and sepsis due to morganella morganii , . genomic dna was extracted from pure culture of bacterial strain and subsequently sequenced using roche 454 gs ( flx titanium ) pyrosequencing . all of the reads were assembled using gs de novo assembler version 2.8 ( 454 life science ) , which generated 1355 contigs with n50 2419 bp . the genome contains 34 trna genes and 6 rrna genes ( 5s-23s-16s ) predicted by the ncbi prokaryotic genome annotation pipeline ( pgap ) . a total of 3229 protein coding sequences in 322 subsystems were functionally annotated by rapid annotation using the subsystems technology ( rast ) server ( fig . the draft genome was annotated using an automated annotation pipeline based on the prodigal gene prediction algorithm , which predicted 2552 candidate protein - encoding gene models for strain sa36 . the predicted cdss were used to search the ncbi non - redundant database using blast tools . sa36 contains various gene clusters encoding putative virulence genes and heavy metal resistance proteins ( cobalt , molybdenum , manganese and copper ) . functional comparison of genome sequences in the rast server revealed the closest neighbours of providencia rustigianii dsm 4541 ( score 549 ) followed by providencia stuartii atcc 25827 ( score 276 ) , providencia alcalifaciens dsm 30120 ( score 251 ) , providencia stuartii mrsn 2154 ( score 245 ) and m. morganii subsp . on the other hand , analysis of the complete 1355 contig sequence in ncbi ( https://blast.ncbi.nlm.nih.gov/blast.cgi?page_type=blastsearch ) under default settings ( with matches only against cultured strains ) m. morganii subsp . overall the various in silico results confirmed that the present environmental isolate is a member of the genus morganella , though further characterization work is required to determine its species . sa36 whole genome shotgun project has been deposited in ddbj / embl / genbank under the accession no ldnq00000000 . the authors declare that there is no conflict of interests on the work published in this paper .

we report draft genome sequence of morganella sp . strain sa36 , isolated from water spring in aljouf region , saudi arabia . the draft genome size is 2,564,439 bp with a g + c content of 51.1% and contains 6 rrna sequence ( single copies of 5s , 16s & 23s rrna ) . the genome sequence can be accessed at ddbj / embl / genbank under the accession no . ldnq00000000 .

gastric carcinoma is the 7 most common tumour in the uk , with an incidence of 13 per 100,000 population . we present here the unusual case of deafness in a 61 year old man caused by the presence of metastatic gastric adenocarcinoma . a sixty - one year old man presented with a history of progressive dysphagia , vomiting , weight loss and new onset of back pain . upper gastrointestinal endoscopy revealed a lesion at the gastro - oesophageal junction ( figure 1 ) and biopsies confirmed the presence of adenocarcinoma with signet ring differentiation . despite the absence of metastatic disease on computed tomography , positron emission tomography demonstrated multiple vertebral and sternal deposits . the deafness was accompanied by dizziness , but there was no other detectable focal neurology . magnetic resonance imaging identified bilateral lesions , each approximately 2 centimetres in diameter , at the internal auditory meatus ( figure 2 ) , consistent with a radiological diagnosis of bilateral acoustic neuromas . magnetic resonance imaging at the level of the internal auditory meatus , showing bilateral mass lesions ( highlighted by arrows ) the patient subsequently died of carcinomatosis and a limited post - mortem examination unexpectedly revealed bilateral metastatic adenocarcinoma infiltrating the internal auditory meatus and the acoustic nerves ( figure 3 ) . low power ( 40x ) magnification showing the acoustic nerve within the auditory canal ( a ) , but extensive infiltration with metastatic gastric adenocarcinoma demonstrated on high power ( 200x ) magnification ( b ) . gastric carcinoma is the 7 most common tumour in the uk , with an incidence of 13 per 100,000 population . in addition to local invasion and regional lymph node metastases , other unusual sites of metastasis include the breast ( 1 ) , spleen ( 2 ) , skin ( 3 ) and meninges ( 4 ) . temporal bone metastases have been reported throughout the literature from numerous different tumours , including renal and bronchogenic carcinomas ( 5 ) , although it has been suggested that these metastases are often asymptomatic ( 6 ) . in contradiction to this , a report by suzuki et al documented four cases of bilateral hearing loss due to metastatic gastric carcinoma , although in three of the four cases the deafness was due to a process different to direct infiltration with metastatic tumour ( 7 ) . in this presented case , the limited post - mortem was carried out because of the radiological appearance of acoustic neuromas , which could have had a major significance for the patients family , given the hereditary nature of type ii neurofibromatosis . although an unusual cause of deafness , reported only once previously to the authors knowledge , this case report highlights the unpredictable nature of malignant disease and should serve as a reminder that patients with gastric adenocarcinoma may present with bilateral hearing loss .

a sixty - one year old man was referred with a history of progressive dysphagia , vomiting and weight loss with some back pain . upper gastrointestinal endoscopy and biopsies revealed a gastro - oesophageal junction adenocarcinoma . despite the absence of metastatic disease on computed tomography , positron emission tomography demonstrated multiple vertebral and sternal deposits . he was reviewed in an ent clinic with a sudden onset of hearing loss accompanied by dizziness , but no focal neurology . magnetic resonance imaging identified bilateral 2 cm lesions at the internal auditory meatus , consistent with a diagnosis of bilateral acoustic neuromas . the patient subsequently died of carcinomatosis and , because of the potential familial significance of bilateral acoustic neuromas , a limited post - mortem examination was carried out . unexpectedly , this revealed bilateral adenocarcinoma metastases infiltrating the internal auditory meatus affecting the acoustic nerves . the authors believe this a very rare presentation of metastatic gastric disease .

although the radiological diagnosis is straight forward in most cases , leiomyomas can occur in unusual locations or present with unusual growth patterns that make the diagnosis more challenging . intravenous leiomyomatosis ( ivl ) is a rare tumour characterized by intraluminal growth of benign smooth muscle into either venous or lymphatic vessels outside the limits of myoma . a 32-year - old woman was admitted with complaints of abdominal swelling and pain since 6 months . she also had feeling of incomplete voiding of urine with overflow and stress incontinence since 3 months . pelvic ultrasound showed bulky uterus measuring 96.84.3 cm , with multiple hypoechoic lesions in anterior and posterior myometrium , the largest one measuring 118.87 cm . computed tomography ( ct ) scan was not done due to unavailability of the facility in the rural set - up as well as the unaffordability of the patient . as the mass was very big and the patient was symptomatic and abdomen was opened by midline vertical incision . during surgery , multiple large subserosal , intramural , and submucosal fibroids ranging from 54 cm to 2030 cm were seen . during surgical removal , the tumor showed worm - like projections into the pelvic veins [ figure 1 ] . bilateral hypogastric artery ligation was done which reduced uterine blood supply and enabled easy removal of the uterus . the postoperative course was uneventful and she has been in good health for 16 months after the operation . microscopic examination demonstrated the tumor cells invaginating the vascular tree with no evidence of atypia . intravenous leiomyomatosis was first described by birch - hirschfeld in 1896 and defined by norris and parmlyin in 1975 . the neoplasm may result from the invasion of myometrial sinuses by either leiomyomatosis cells or proliferating smooth muscle cells , arising directly from the venous wall of the uterine or pelvic veins . female gonadal steroids play a major role in the pathogenesis as the condition is associated with high estrogen levels . early diagnosis may be difficult because patients may be asymptomatic despite extensive intravenous extension . although there may be some difficulties in distinguishing such lesions from low - grade sarcomas , they are different histologically from sarcomatosis uteri because the intravenous plug is mainly smooth muscle in origin . the tumor behaves like a benign tumor , and the mitotic index is low with most active lesions showing only one mitosis per 15 high - power fields . conservative surgery is usually adequate as the intravenous extensions are probably incapable of independent parasitic existence and remain dormant after removing the uterus . several cases requiring open heart surgery to remove the intracardiac thrombosis have been successful without recurrence . knowledge about this condition and its recognition is important to provide the best treatment for the patients . prophylactic hypogastric artery ligation is safe and effective to reduce uterine blood supply before attempting hysterectomy for vascular uterine tumors . though intravenous leiomyomatosis imitates malignant neoplasm regarding its pattern of growth and extension , it must be differentiated histologically from malignant tumors to avoid overtreatment . since intravenous leiomyomatosis has a tendency for recurrence , long - term follow - up of patients

leiomyomas are benign tumors arising from smooth muscle of the uterus . intravenous leiomyomatosis is characterized by intraluminal growth of benign smooth muscle into either venous or lymphatic vessels outside the limits of myoma . it commonly extends into the pelvic veins and manifests as worm - like protrusions of tumor emanating from veins at the parametrial margins of hysterectomy specimen . the tumor can cause life - threatening symptoms if it involves inferior vena cava or right atrium . we report a case of intravenous leiomyomatosis of the uterus managed at our institution .

localized renal cystic disease ( lrcd ) is a rare non - hereditary , non - progressive benign condition where multiple cysts involve part or whole of one kidney with no cysts in the contralateral kidney or other organs . the main significance of this condition is that it must be differentiated from other cystic diseases of kidney like autosomal dominant polycystic kidney disease , multicystic dysplastic kidney and multilocular cystic nephroma , which may need surgical intervention ; whereas lrcd maybe followed up under imaging . a 40-year - old male patient presented with pain in the left loin . a screening ultrasound revealed a complex cystic mass in the lower pole of the left kidney . contrast - enhanced computed tomography ( cect ) showed a cluster of variable - sized simple renal cysts involving the lower pole of the left kidney , separated by normally enhancing intervening renal parenchyma and no definitive capsule . one of the cysts appeared hyperdense on plain study [ figure 2a ] , suggesting hemorrhage within . no cysts were seen in the contralateral kidney and in the other solid organs in the abdomen . axial ( a ) and coronal ( b ) contrast - enhanced computed tomography showing a cluster of variable - sized simple renal cysts ( white arrow ) , separated by normally enhancing intervening renal parenchyma ( black asterisk ) involving the lower pole of the left kidney with no definite capsule axial plain computed tomography ( a ) showing a solitary hyperdense cyst ( white arrow ) among the cluster , suggesting hemorrhage . axial contrast - enhanced computed tomography ( b ) in the delayed phase showing the normally opacified pelvicalyceal system on both sides based on these characteristic imaging findings and clinical history , the diagnosis of localized renal cystic disease ( lrcd ) with a solitary hemorrhagic cyst was made . a follow - up using cect at 6 months was suggested to confirm the non - progressive nature of the condition . it is a rare , non - hereditary benign condition , characterized by with multiple cysts in part or whole of one kidney with no cysts in the contralateral kidney or other organs . follow - up imaging is suggested at 36 months and then annually to document its non - progressive nature . computed tomographic findings of this condition are characteristic , demonstrating multiple simple cysts of varying sizes forming a conglomerate mass with no definitive capsule and normally enhancing intervening renal parenchyma . on imaging , the differentials to be considered are the autosomal dominant polycystic kidney disease , in which cysts are often bilateral and may be seen in other organs , multicystic dysplastic kidney that is characterized by an atretic pelvicalyceal system and ureter and multilocular cystic nephroma where the cystic mass shows discrete encapsulation .

localized renal cystic disease ( lrcd ) is a rare benign non - hereditary , non - progressive condition which must be differentiated from other renal cystic diseases . familiarity with this condition and its characteristic imaging features avoids unnecessary surgical intervention . we report a case of lrcd in a 40-year - old male who presented with left loin pain . computed tomography demonstrated a cluster of simple cysts in the lower pole of the left kidney with normal right kidney and other organs . diagnosis of lrcd was made on typical imaging characteristics and absence of family history of cystic renal disease .

a 32-year - old man presented with a lump on the right side of his scrotum without any predisposing factors . early on , there were 45 soybean - shaped , gray and black , flat wart bands with clustered distribution without exudation and desquamation ; however , there was paroxysmal itching or the sensation of ants crawling on the skin . the patient often felt his skin was burning and tingling when the itching was very severe . he self - medicated with compound dexa - methasone acetate cream , xuanshi solution , and other medications for external use . after drinking or using hot water to clean the areas , the urticant ache became worse each time . after the patient took cephalosporin antibiotics , the wound healed and the warts became flat , but the primary sense still remained . to confirm the diagnosis , he visited the hospital . a more in - depth examination revealed an approximately 3 5-cm , pink , ill - defined , hyperplastic plaque with an uneven surface , basal infiltration , sheet depigmentation in the center ( fig . the nucleus was round at both ends , a perinuclear halo could be seen , and staining was positive for actin and negative for s100 . the combination of he morphology , immunohistochemistry , and pathology was in line with a diagnosis of scrotal leiomyoma ( fig . , the skin leiomyoma came from the hair erector muscles of the skin , dartos , and blood vessel walls of smooth muscle . this type of cancer is generally divided into 3 subtypes : vascular , genital , and hair leiomyoma . genital leiomyoma involves the smooth muscle network from the deep dermis such as the scrotal dartos muscle . cutaneous leiomyomas account for approximately 5% of all leiomyomas , and genital smooth muscle tumors , such as scrotal leiomyoma , have an even lower clinical incidence rate . europe , the united states , japan , and some southeast asian countries have reported a few cases in recent years [ 2 , 3 ] . the pathogenesis of the disease is not yet clear , though some scholars have proposed the disease may be related to the male hormone androgen , and experiments have confirmed that the lesions demonstrate androgen receptor expression . leiomyoma is known to occur in the uterus ; however , levels of the female hormones estrogen and progesterone are closely related to scrotal leiomyoma in male endocrine and metabolic disorders , genetic mutation , or immune abnormalities . to confirm this , usually , there are no early symptoms ; however , over the course of time , the paroxysmal pain increases . our patient , who had local lesions , experienced paroxysmal severe itching with burning , tingling , and , as mentioned in the previous literature reports , no pain or bursts of pain . the pain is thought to be due to the smooth muscle contraction , but the itching is difficult to explain . the clinical manifestations of scrotal leiomyoma may not be characteristic of the disease , and in order to identify it , a variety of differential diagnoses are needed including dermatofibroma , schwannoma , neurofibroma , adnexal tumors , and metastases ( table 1 ) . the most important thing is to rely on the pathology - based and differential diagnoses . the histopathological features of the disease are the proliferation of tumor cells with characteristics of smooth muscles cells and actin - positive immunohistochemistry . most leiomyoma lesions are benign and complete resection of the tumor , such as with mohs micrographic surgical technique , rather than with radiotherapy treatment , is advised because radiotherapy treatment may induce malignant transformation .

scrotal leiomyoma is a benign tumor derived from the scrotal dartos muscle ; it is rare in clinical findings . the cause of the disease is not yet clear . here , we present the case of a patient with no typical clinical features , but with some typical pathological changes . a middle - aged male patient saw a doctor for paroxysmal itching and burning of the scrotum . the physical examination revealed 3 5-cm2 , ill - defined , pink plaques , an uneven surface , and basal infiltration with pigmentation defects in the center . pathology results showed dermal spindle cells in nodular hyperplasia . the nucleus was round at both ends , a perinuclear halo could be seen , and staining was positive for actin and negative for s100 . therefore , the diagnosis of scrotal myoma was made .

coronary - subclavian steal syndrome occurs when blood is diverted away from the coronary territory through the internal mammary artery to the upper limb as a result of a significant stenosis or an occlusion of the proximal subclavian artery . in the case we observed , the coronary - subclavian steal syndrome was masked due to a malfunctioning hemodialysis access vessel and recurred after a successful peripheral balloon angioplasty . a 61-year - old man presented with angina pectoris , which was newly developed after a percutaneous transluminal angioplasty of the arteriovenous fistula ( avf ) in his left arm 1 week ago . four years prior to this , the avf was formed in his left arm for hemodialysis . seven years ago , the patient had been diagnosed with three - vessel coronary artery disease and underwent coronary artery bypass grafting , during which his left internal mammary artery was sequentially anastomosed to the mid portion of the left anterior descending artery , ramus intermedius , and the posterior descending branch of the right coronary artery . six years after surgery , he had been asymptomatic but began experiencing a progressively worsening angina pectoris starting a year ago . the selective coronary angiography at the onset of angina pectoris showed no significant interval changes of the three - vessel coronary artery disease . however , to - and - fro flow was noted in the lima ( fig . the selective left internal mammary angiography showed no stenosis in the anastmotic sites or in the left internal mammary artery itself ( fig . coronary - subclavian steal syndrome was suspected , and a balloon angioplasty ( aviator plus , 5.020 mm , cordis , warren , nj , usa ) followed by stenting ( genesis 7.024 mm , cordis , warren , nj , usa ) , which was performed successfully ( fig . 1d ) . since the stenting of his left subclavian artery , the patient had been asymptomatic for one year he was referred for a malfunctioning avf in his left arm one week prior to his latest arrival in our clinic . the arteriovenous fistulogram showed three tight stenosed lesions of the venous outflow tract ( fig . 2a and b ) . a balloon angioplasty with a plain balloon ( reef hp , 740 mm , invatec , roncadelle , italy ) and subsequently a cutting balloon ( peripheral cutting balloon , 720 mm , boston scientific , natick , ma , usa ) was performed successfully ( fig . 2c and d ) . however , the patient reported chest discomfort during activity requiring effort and during the hemodialysis . the coronary angiography showed no significant changes compared to what was reported a year ago . aortography revealed that the left subclavian artery was restenosed at its stented position ( fig . coronary - subclavian steal syndrome was suspected again , and a balloon angioplasty with peripheral cutting balloon ( peripheral cutting balloon , 820 mm , boston scientific , natick , ma , usa ) was performed successfully ( fig . 3d ) . after the balloon angioplasty and instant restenosis of the left subclavian artery , for patients with a previous coronary artery bypass graft operation , during which the left internal mammary artery conduit is used , a great vessel disease , in particular subclavian artery stenosis , should be suspected.1 ) in the presence of a hemodynamically significant subclavian artery stenosis proximal to the origin of the lima , flow through the left internal mammary artery may reverse , and the patient can develop symptoms of angina.2 ) subclavian artery stenosis or occlusions , avfs , and coronary - pulmonary or graft - pulmonary fistulas may cause coronary steal.3 - 5 ) although the incidence of subclavian stenosis in coronary patients is less than 1% it is of utmost importance to rule out this entity before coronary surgery.6 ) coronary - subclavian steal syndrome should be considered before a coronary artery bypass graft operation using the internal mammary artery conduit , especially when hemodialysis using the left arm vessels is expected to prevent additional coronary - subclavian steal syndrome . in the present case , we suspected that the coronary - subclavian steal syndrome had been masked by the stenoses of the hemodialysis access vessel in the patient 's left arm and re - appeared after a successful angioplasty , presented as chest discomfort on effort and also during hemodialysis . we related the recurrence of chest pain during hemodialysis to the increase of blood flow to the hemodialysis access vessel due to the resolution of avf stenoses in the left arm .

we report a case of coronary - subclavian steal syndrome , which had been masked by a malfunctioning hemodialysis access vessel and then reappeared after a successful angioplasty of multiple stenoses in the arteriovenous fistula of the left arm in a 61-year - old man . this case suggests that coronary - subclavian steal syndrome should be considered before a coronary artery bypass grafting surgery using internal mammary artery conduit is done , especially when hemodialysis using the left arm vessels is expected .

quorum sensing ( qs , e.g. , ahl molecules ) , a common form of cell signaling , is gaining significant interest in marine ecology . quorum sensing is a form of intercellular communication within microbial populations that occurs in a density - dependent manner . qs substance can result in downstream changes in gene regulation and modulation of bioluminescence , virulence , biofilm formation , and secondary metabolite production . chemical mediators of ahl and molecular crosstalk between bacteria and eukaryotes have been described for a wide range of symbiotic organisms . in algal bacterial microenvironments , previous works have investigated the crosstalk signaling between algae and bacteria , which can broaden understanding of the complex multi - species interactions , , . in this work , we found the citrobacter freundii strain st2 , which was isolated from the dinoflagellate ( scrippsiella trochoidea ) and possessed ahl activities to produce n - acylhomoserine lactones . the genome sequence of c. freundii strain st2 may provide insights on the regulation of quorum sensing mechanisms , and will help us understand the ecological behavior of this specie in algae bacteria symbiosis . for the above - mentioned reasons , the draft genome sequence of c. freundii strain st2 was determined . genomic dna of this bacterium was isolated using a dna kit ( mo bio , ca , usa ) according the instructions of the manufacturer . the quality of dna was examined using a nanodrop spectrophotometer ( thermo scientific , usa ) and gel electrophoresis ( bio - rad , usa ) . the whole - genome sequencing of c. freundii st2 was performed using the illumina hiseq 2000 platform after the construction of the sequencing library using a truseq dna sample preparation kit , v2 ( illumina inc . after filtering the low - quality data , we assembled the short reads into a genome sequence using soap denovo v1.05 , and the scaffolds were manually connected based on paired - end relationships . the filtered reads were de novo assembled with the clc genomic workstation v5.1 , generating 21 contigs , containing 4,896,351 bp . gene prediction was performed using prodigal ( v260 ) , and 4626 open reading frames were predicted . homologous comparisons by blast showed 3647 cds involving the 21 functional cog groups and a part of the cds involving the 34 metabolic pathway kegg groups ( fig . one complete rrna operon and one copy each of nine 5 s - rrna gene , seven 16 s - rrna gene , and six 23 s - rrna gene were identified using rnammer . in addition , 57 minisatellite dnas and 3 microsatellite dnas were determined based on the repbase transposable elements library . the genome features of c. freundii strain st2 were summarized in table 1 . based on blast2go analysis , the luxr gene of c. freundii strain st2 was found in contig 4 , and the gene length was 1541 bp . it has a highly identity of the luxr gene of another enterobacteriaceae family member ( c. freundii uci 31 , genbank : ejf23932.1 ) . furthermore , a putative ai-2 ( autoinducer-2 ) synthase gene with a metallo - beta - lactamase domain was also found in silico contig 4 . the complete genome of c. freundii strain st2 provides novel insights into the quorum - sensing and signaling confusion genomic features of strain st2 . further work needs to be conducted to study the roles of this bacterium in the phycosphere environment under ahl molecular regulation . the authors declare that there is no conflict of interests on work published in this paper .

citrobacter freundii strain st2 , isolated from the algae bloom sample , possesses an n - acylhomoserine lactone ( ahl ) production activity that secretes short - chain ahl molecules . in this study , we sequenced the complete genome of c. freundii strain st2 to understand the molecular regulation of the ahl system and to search for the ahl gene in this bacterium . the results show that the genome size is 4.89 mb with a g + c content of 51.96% . 4626 function proteins were predicted and 3647 proteins were assigned to cog functional categories . a predicted ahl - coding gene luxr was found at contig 4 and the length was 1541 bp . the strain temporary deposited at shenzhen public platform of screening & application of marine microbial resources ( shenzhen , china ) , and the genome sequence can be accessed at genbank under the accession no . ljsq00000000 .

a 59-year - old woman presented to the emergency room with sudden visual loss in the right eye , which had started 15 hours prior . her intraocular pressures were 13 mmhg od and 12 mmhg os by goldmann applanation tonometry . anterior segment examination was normal , and fundus examination demonstrated a pale retina with typical " cherry red spot " in the right eye . her blood pressure , glucose , lipid , and coagulation profiles , as well as her erythrocyte sedimentation rate and c - reactive protein were within normal limits . under the diagnosis of acute non - arteritic crao , she was urgently transferred to the neuro - intervention team for intra - arterial thrombolysis . although there is some debate regarding the efficacy of intra - arterial thrombolysis for treatment of crao , her acute onset of symptoms within 15 hours without any systemic risk factors , and her insistence for further intervention encouraged consideration for thrombolysis therapy . transfemoral cerebral angiography demonstrated normal choroidal blush with a patent right ophthalmic artery which was stemming from a 3.7 4.5 5.2 mm sized aneurysm located at the origin of the ophthalmic artery ( fig . external cerebral artery angiography revealed visualization of distal parts of the ophthalmic artery via the middle meningeal artery . due to the fear of aneurysm rupture , and as the middle meningeal artery collateral communication was confirmed , the right middle meningeal artery was selected for target vessel instead of ophthalmic artery and 200,000 units of urokinase and 100 grams of tirofiban were hand injected . the next day , her visual acuity improved to finger count and the right fundus showed macular edema with improved vascularity . spectral - domain optical coherence tomography ( sd - oct ; spectralis oct , heidelberg engineering , germany ) showed increased thickness and reflectivity of the inner retina ( fig . 2c ) . goldmann visual field test demonstrated typical temporal islands , and electroretinography revealed decreased amplitude of the b - wave in the affected eye . to evaluate other possible systemic causes of the crao , ancillary studies including brain magnetic resonance imaging , transcranial doppler , holter monitoring , carotid doppler , and echocardiography were performed and no further abnormalities were found aside from an asymptomatic patent foramen ovale . definite treatment of the ophthalmic artery aneurysm was not recommended considering the risk of the procedure . after four months , her visual acuities were stationary ( hand motion ) , but sd - oct showed atrophy of the inner retina ( fig . peripheral ophthalmic artery aneurysms , which are confined to aneurysms stemming from ophthalmic artery branches distal to the internal carotid artery ( ica ) , make up a very small portion of intracranial aneurysms , so that only 35 cases have been reported . among them , 15 cases presented with visual loss , which were mostly due to the compressing effect of the aneurysm itself on the optic nerve , and among those cases , only five had visual improvement after neurosurgery . however , compared to previous cases , our patient was unique in that her visual loss was acute in onset and her fundus findings were typical for crao , which made a compressing effect on optic nerve unlikely . the possibility of the aneurysm itself compressing the ophthalmic artery or the ica causing visual loss could be excluded as the ophthalmic artery was shown to be patent during cerebral angiography . qureshi et al . reported that embolization can occur from aneurysms even in the absence of angiographically demonstrated clots within the aneurymal sac . the prevalence of ischemic events secondary to embolization from unruptured intracranial aneurysms was shown to be 3.3% . reported a case of crao associated with an aneurysm of the ica , and highlighted the importance of differentiating intracranial aneurysm as the cause of crao in young patients without risk factors for vascular occlusive disease . since our patient had no known risk factors for crao except an ophthalmic artery aneurysm in the involved eye , emboli derived from the aneurysm might be the most probable explanation . opting to treat the ophthalmic artery aneurysm requires prudent consideration as an aneurysm carries the risk of spontaneous rupture . since the aneurysm was small in size , and was asymptomatic , observation was deemed more beneficial to the patient rather than invasive surgical intervention . endovascular coil embolization may aggravate embolic risk with increased thrombogenicity , which was another reason to bypass treatment . in conclusion embolism from ophthalmic artery aneurysm can be a cause of crao and it is meaningful to include ophthalmic artery aneurysm in the differential diagnosis of crao without other systemic risk factors .

central retinal artery occlusion ( crao ) is one of the most devastating ophthalmic emergencies , causing acute painless visual loss in the affected eye . we describe the first case of acute non - arteritic crao associated with peripheral ophthalmic artery aneurysm and its clinical course after intra - arterial thrombolysis therapy . this case suggests that ophthalmic artery aneurysm can be the cause of crao and should be included in the differential diagnosis of crao .

pseudoxanthoma elasticum ( pxe ) or grnblad - strandberg syndrome is a multisystem disorder characterized by progressive calcification and degeneration of the elastic fibers throughout the body . perforating pxe is a rare variant that occurs either in association with hereditary pxe or as a localized acquired cutaneous form . we report a case of pxe with periumbilical perforation in a nulliparous woman without any systemic involvement . a 21-year - old nullipara presented with asymptomatic pigmented skin lesions over the sides of her neck and abdomen of 1 year duration . the onset was insidious , beginning over the sides of neck as a slight alteration in texture , and was not preceded by trauma or any general symptom such as fever . dermatologic examination revealed multiple brownish - black papules symmetrically distributed over the front and sides of the neck [ figure 1 ] and periumbilical area [ figure 2 ] . the skin over the area was soft , lax , and wrinkled . a few of the papules above the umbilicus were relatively keratotic . the mucosa over the hard palate showed small , firm , yellowish - white plaques . multiple brownish - black papules on the sides of the neck , with soft , lax , and wrinkled overlying skin multiple brownish - black papules with soft , lax , and wrinkled skin in the periumbilical area ocular examination did not reveal any abnormality . the routine hemogram and biochemical parameters , including renal function tests and serum calcium , were within normal limits ; chest x - ray and ekg were also normal . histology of the biopsy specimen showed fragmented , irregularly clumped , basophilic material throughout the mid - dermis [ figure 3 ] . the section from the periumbilical plaque showed discontinuity of the epidermis through which the elastic fibers were being extruded through this break in the epithelium [ figure 4 ] . fragmented irregularly clumped basophilic material throughout the mid - dermis ( h and e stain 100 ) elimination of the altered elastic fiber through the epidermis ( verhoeff - van gieson stain 100 ) the patient is being followed up and has been specifically instructed to report if she becomes pregnant . rigal first described the cutaneous lesions of pxe in 1881 and darier was the first to demonstrate the typical histological changes in the elastic fibers . recent studies show that pxe is caused by mutations in the atp - binding cassette transporter c6 ( abcc6 ) gene , which is also known as multidrug resistance - associated protein 6 ( mrp6 ) gene . the localized lesion usually occurs in a periumbilical location in obese multiparous black women , with or without accompanying systemic manifestations . juvenile cases of pxe have been seen , with reports of the condition in a 2-year - old boy with microlithiasis of the testicle and in an 8-year - old girl with ocular findings . the cutaneous manifestations of pxe are highly characteristic and are generally the first physical signs of the developing disorder . the characteristic cutaneous findings are small yellowish papules coalescing into plaques , presenting classically along the sides of the neck and giving rise to a other sites of predilection are the axillae , periumbilical area , groin , perineum , and thigh . these skin lesions are usually noted in the second or third decades of life . in older individuals other clinical presentations reported in literature include acneiform lesions , brown reticulate macules , and chronic granulomatous nodules . elastosis perforans serpiginosa may coexist with pxe . of the systemic involvement , ocular manifestation as angioid streaks is the most frequent association . periumbilical pxe has been reported to be associated with chronic renal failure and bilateral angioid streaks . recently it has been reported that mild chronic oxidative stress affects pxe fibroblasts , which suggests that reactive oxygen scavengers might improve this disorder . oxidative stress has also been reported to play an important role in the mechanism of the calcifications and hence in the pathogenesis of pxe . the prognosis in pxe largely depends on the extent of extracutaneous organ involvement , and life expectancy depends on the system involvement and the complications if any . pregnancy is not contraindicated in pxe patients , though the risk of miscarriage is increased in the first trimester . patients typically have a normal life span , but complications such as acute gastrointestinal hemorrhage , myocardial infarction , or cerebral hemorrhage can be fatal . it is known that damaged tissue is susceptible to calcium deposition in patients with hypercalcemia , which suggests that the elastic fiber alteration caused by high levels of reactive oxygen species leads to the calcification in pxe . to the best of our knowledge , pxe with periumbilical perforation without any systemic involvement has so far not been reported in a nulliparous woman . in addition to periodic screening to exclude abnormal phosphate calcium metabolism or renal abnormalities , women with pxe should be thoroughly examined for any involvement of the periumbilical area and their pregnancy must be closely and carefully followed up .

pseudoxanthoma elasticum ( pxe ) is an inherited multisystem disorder that primarily affects the skin and is characterized by progressive calcification and degeneration of the elastic fibers . pxe has recently been found to be caused by mutations in the atp - binding cassette transporter c6 ( abcc6 ) or the multidrug resistance associated protein 6 ( mrp6 ) genes . perforating pxe is a rare presentation that is usually seen in the periumbilical area in obese multiparous black women ; it has distinct clinical and histopathological features and there may or may not be systemic manifestations . we report an unusual case of pxe in a nulliparous woman , with perforation in the periumbilical area and without any systemic involvement .

in a very interesting study performed on 77 severe traumatic brain injury patients , legrand and colleagues found that the optic nerve sheath diameter ( onsd ) measured on the initial brain computed tomography(ct ) scan ( performed within the first 3 hours of injury ) was a very good predictor of icu mortality . in the multivariate analysis , onsd > 7.3 mm was independently associated with icu mortality , and performed better than age > 32 years , anisocoria at admission , and basal cistern compression on initial ct scan . the optic nerve is surrounded by a dural sheath that can inflate in cases of raised pressure in the cerebrospinal fluid . an enlarged onsd , measured using ocular sonography , has been found in patients with raised intracranial pressure ( icp ) . even if in legrand and colleagues ' study the icp was measured in only 9% of the patients , we can assume that the strong association between onsd enlargement of initial ct and mortality was related to raised icp occurring very early after trauma , as suggested by the fact that onsd enlargement was also associated with other signs of raised icp in the first ct scan as basal cistern effacement and midline shift . this is probably the major interest of this study : onsd measurement on initial ct scan could offer the possibility to detect patients with raised icp needing urgent therapeutic interventions and/or invasive intracranial monitoring to guide the treatment . our enthusiasm must be tempered , however , as the method to measure onsd using ct scan needs clarification and confirmation . onsd has been measured 3 mm behind the globe - where the dural sheath is distensible , as has previously been determined using sonography [ 2 - 4 ] and magnetic resonance imaging . in legrand and colleagues ' study , onsd has been measured on a millimetric slice brain ct scan but only in one plane . as suggested by unsold and colleagues , since the optic nerve has a sinuous course in the horizontal and the vertical plane , a section of the nerve in a single plane can conduce one to overestimate onsd . actually , the values of onsd in legrand and colleagues ' study are larger than values obtained with ultrasound or magnetic resonance imaging or even with ct . moreover , the precise limits of the sheath and the orbital fat surrounding the sheath can be very difficult to determine . this study probably needs further confirmation of the reliability of the onsd measurement , after realignment in the optic nerve plane and measurement in several axes . ct : computed tomography ; icp : intracranial pressure ; onsd : optic nerve sheath diameter .

optic nerve sheath diameter ( onsd ) enlargement on initial computed tomography ( ct ) scan has been found to be associated with increased mortality after severe traumatic brain injury . this could offer the possibility to detect patients with raised intracranial pressure requiring urgent therapeutic interventions and/or invasive intracranial monitoring to guide the treatment . the method to measure onsd using ct scan , however , needs further confirmation . moreover , the link between onsd enlargement on initial ct scan and raised intracranial pressure also needs to be confirmed by further studies .

image 1organismmameliella albastrainumtat08sequencerillumina hiseq 2000data formatassembledexperimental factorsbacterial strain isolated from paralytic shellfish toxins producing dinoflagellateexperimental featuresde novo genome sequencing followed by assembly and annotationconsentn / asample source locationclonal culture of dinoflagellate alexandrium tamiyavanichii from straits of malacca , malaysia dinoflagellates are phytoplanktons that play an important role in the primary productivity of the world 's oceans . however , several species of this microalgae are known to produce a wide variety of toxins that can cause seafood poisoning via transfer through the food chain . moreover , many countries are affected by harmful algal blooms ( habs ) and related shellfish toxicity and fish mortality events . a clonal culture of toxic dinoflagellate alexandrium tamiyavanichii was established during an investigation of habs and shellfish poisoning reported after consumption of green mussels originated from a mussels culture farm in malacca , malaysia . the bacteria can be free living in the phycosphere , can be attached to the surface of the algal cells or can occur as intracellular algal symbionts . they may play an important role in growth , physiology and modulating the biosynthesis of psp toxins in dinoflagellates . in order to understand the dinoflagellate - bacteria interactions , a study was carried out to investigate the culturable bacterial diversity associated with toxic dinoflagellate a. tamiyavanichii . during this study , members of the roseobacter clade are abundant in the marine environments suggesting that they play important roles in marine ecosystems , such as the degradation of aromatic compounds and the biogeochemical cycles of carbon and sulfur . the genome of strain umtat08 was sequenced in order to gain genetic insights into the role of mameliella alba in the phycosphere of dinoflagellate . genomic dna was then extracted using the gf-1 nucleic acid extraction kit ( vivantis , malaysia ) . sequencing was performed on the illumina hiseq2000 generating 31,195,648 raw fastq paired - end reads . two million reads were sub - sampled for error correction and de novo assembly using spades v.3.1.0 . resulting contigs were used for scaffolding then gap - closing using sspace 2.0 and gapfiller v1.11 , . sixty - two gap filled contigs with an n50 of 10 sequences longer than 226 , 111 bp were produced and the total sequence length was 5,837,382 bp with a 62 coverage . prokka v1.8 annotation pipeline comprising of prodigal ( v2.60 ) , rnammer ( v1.2 ) and aragorn ( v1.2.36 ) was used to annotate the genome predicting 5717 open reading frames , 5 rrnas and 49 trnas , , , . the predicted 16s rrna was analyzed to identify its phylogenetic affiliation using the eztaxon server ( http://www.ezbiocloud.net/eztaxon ) . results showed that strain umtat08 was most closely related to ponticoccus litoralis ( 96.73% similarity ) and mameliella alba ( 95.62% similarity ) . however , average nucleotide identity ( ani ) was then calculated and strain umtat08 was confirmed as mameliella alba . furthermore , antismash was used to identify the presence of secondary metabolite biosynthesis gene clusters in the genome . analysis of the genome revealed genes associated with nutrients uptake and environmental adaptation , including osmotic and oxidative stress as well as quorum sensing . the genome is predicted to have genes involved in the degradation of aromatic compounds and metabolism of nitrogenous and sulfur compounds , potentially enabling strain umtat08 to utilize the dinoflagellate exudates as an immediate source of energy . interestingly , several gene clusters for the biosynthesis of type 1 polyketide synthase , bacteriocin , microcin , terpene and ectoine have been identified ( contig 1 , 2 , 7 , 12 , 14 & 23 ) . this suggests that strain umtat08 possess better ability to compete with other bacteria to colonize the host dinoflagellate as survival mechanism . the draft genome sequence of mameliella alba strain umtat08 has been deposited at ddbj / embl / genbank under the bioproject number prjna265019 , biosample number samn03145050 and accession number jsuq00000000 .

mameliella alba strain umtat08 was isolated from clonal culture of paralytic shellfish toxin producing dinoflagellate , alexandrium tamiyavanichii . genome of the strain umtat08 was sequenced in order to gain insights into the dinoflagellate - bacteria interactions . the draft genome sequence of strain umtat08 contains 5.84mbp with an estimated g + c content of 65% , 5717 open reading frames , 5 rrnas and 49 trnas . it contains genes related to nutrients uptake , quorum sensing and environmental tolerance related genes . gene clusters for the biosynthesis of type 1 polyketide synthase , bacteriocin , microcin , terpene and ectoine were also identified . this is suggesting that the bacterium possesses diverse adaptation strategy to survive within the dinoflagellate phycosphere . the draft genome sequence and annotation have been deposited at ddbj / embl / genbank under the accession number jsuq00000000 .

massive free - floating thrombi in the right heart ( fftrh ) are uncommon and incidentally diagnosed when image studies are performed in patients with suspected or proven pulmonary thromboembolism ( pte ) , and they increase the risk of mortality compared to the presence of pte alone.1)2 ) a massive fftrh is relatively unstable , and migration toward the pulmonary trunk is often fatal.3)4 ) however , there is no clear consensus regarding the optimal management of fftrh . we herein present the case of a patient with the echocardiographic disappearance of a fftrh after thrombolysis . however , the fftrh migrated , resulting in massive pte , and was successfully removed surgically . a 74-year - old woman presented at our emergency room with sudden - onset dyspnea . her blood pressure was 70/50 mmhg , and her heart rate was 140 beats / min at that time . the electrocardiogram showed sinus tachycardia and st - t wave depression in leads v1 to v3 . chest computed tomography showed filling defects in the right ventricle ( rv ) and both pulmonary arteries ( fig . echocardiography was then performed immediately and showed a d - shaped left ventricular cavity with enlargement of the right atrium ( ra ) and rv . in addition , a free - floating and thread - like echogenic material attached to the tricuspid valve was observed ( fig . 2a , supplementary movie 1 ) . laboratory data showed normal white blood cell and platelet counts , the aspartate aminotransferase level was elevated to 210 iu / l ( normal values : 13 - 33 iu / l ) , and the lactate dehydrogenase level was increased to 469 iu / l ( normal values : 119 - 229 in addition , both d - dimer ( 56 g / ml , normal values : less than 0.5 g / ml ) and b - type natriuretic peptide ( 230 pg / ml , normal values : less than 99 pg / ml ) were also elevated . immediately , the recombinant tissue plasminogen activator ( actylase , boehringer ingelheim , ingelheim , germany ) 100 mg was intravenously received and followed by 18000 u per day unfractionated heparin infusion . after the administration of thrombolytic agents , no free - floating , rod - shaped materials were observed within the ra and rv , and only the thread - like echogenic material attached to the tricuspid valve was found to be improved ( fig . however , the patient 's blood pressure was not restored with inotropic agents , and cardiac arrest occurred . an emergency cardiopulmonary bypass was performed , including a right atriotomy ; no fftrh was identified in the ra or rv cavity , including the tricuspid valve ( fig . however , the massive thrombus and fftrh were extracted from the bilateral pulmonary arteries under direct vision using forceps inserted through a longitudinal incision in the main pulmonary artery ( fig . the optimal management of life - threatening fftrh remains uncertain despite the availability of several different treatment modalities.1)5)6 ) previous reports have demonstrated that thrombolytic therapy can be administered quickly and results in a good prognosis , and it is therefore advocated as an initial treatment.7)8 ) however , thrombolytic therapy may lead to thrombus fragmentation.9 ) in addition , a small , single - center , nonrandomized trial did not show any advantage of thrombolysis over surgical embolectomy.6 ) we report a case of migrated pte with a large , entrapped fftrh . based on the follow - up echocardiography after thrombolysis , the fftrh was considered to be resolved . however , thrombolysed thrombi that were not observed had migrated , and a fragmented thromboembolism was detected in the pulmonary arteries in the surgical field . when compared to conservative treatment including the thrombolysis of a massive fftrh , particularly in the past few decades , surgical embolectomy was rarely reported to have lower mortality rates , a lower number of hemorrhagic events or recurrent thrombosis.10 ) recently , surgical embolectomy was also strictly recommended to those in whom thrombolytic treatment has not improved hemodynamic status.11 ) in our case , we successfully performed surgical embolectomy in a patient with a fftrh and an acute massive migrated pte with hemodynamic collapse and rv dysfunction . however , surgical embolectomy may be the more preferred therapeutic option for fftrh due to the potential of massive thrombus fragmentation and migration .

the optimal treatment for free - floating massive right heart thrombi remains uncertain . however , they appear to increase the risk of mortality compared to the existence of a solitary pulmonary thromboembolism . thrombolytic therapy has been shown to be effective in most patients , resulting in complete resolution of the massive thrombus and clinical improvement . we report the echocardiographic disappearance of a free - floating right heart thrombus after thrombolysis , however , the thrombus migrated and resulted in pulmonary thromboembolism . it was successfully removed with surgery .

a 63 year old caucasian high school graduated man , who has been a known case of alzheimer 's disease according to dsm - iv - tr and criteria of national institute of neurological and communicative disorders and stroke and alzheimer 's disease and related disorders association ( nincds / adrda ) ( 1 ) since 3 years ago , was visited in february 2012 . at the time of diagnosis , his past medical history was otherwise unremarkable . with worsening of his cognitive functional state , the patient was treated with 10 mg / day donepezil . on the next day , the patient appeared delirious and was referred to our center due to agitation and confusion . based on reports by family members , following the dosage increase of the medication , the patient was unable to recognize family members consistently , showed difficulty in awareness of time , acted aimlessly , and became emotionally irritable and violent with the family member attempts to assist him . at the time of referral , his mmse score was 8/30 . upon general and neurologic examination , routine laboratory examinations , serum creatinine and ammonia as well as liver and thyroid function tests were in normal limits . after withdrawing donepezil , patient 's symptoms improved gradually in course of one day . patient became alert and returned to his baseline cognitive functional state although he was unaware of his previous delirious behaviors . at 6 months follow - up , the patient demonstrated no delirious behavior and his mild cognitive impairments have not progressed substantially . to the best of our knowledge , this is the second reported case of delirium in a patient upon treatment with donepezil . in 2003 , kawashima and yamada reported a patient with alzheimer 's disease who was presented with delirium three days after increasing the dosage of donepezil from 3 mg / day to 5 mg / day ( 2 ) . this patient also recovered in two days following withdrawal of the medication and his recovery was maintained at 5 months follow - up . two months subsequent to donepezil discontinuation based on a decision by family members , patient 's aggressive behaviors disappeared and no similar event was repeated . along the same line , emergence of violent actions during treatment with donepezil and disappearance of symptoms with medication withdrawal is reported by bouman and pinner in a patient with dementia in 1998 ( 3 ) . similarly , in 2003 , bianchetti and trabucchi presented a patient suffering from alzheimer 's with mild cognitive impairments that demonstrated aggressive and agitated behaviors toward relatives and attempted self - harm following increase in starting dose of 10 mg / day donepezil from 5 mg / day ( 4 ) . in line with these cases , lo coco and cannizzaro described a patient who showed inappropriate sexual behaviors during treatment with donepezil ( 5 ) . notably , in 1996 , traepacz et al . reported a patient with alzheimer 's disease who showed signs of neurotoxicity and cholinergic delirium following dosage increase of tacrine , another member of acetylcholinesterase inhibitors which is not currently widely used due to its associated adverse events , to 160 mg / day ( 6 ) . this patient also recovered to a great extent although he did not return to his baseline function after 5 months of tacrine withdrawal . although this case does not prove donepezil as a cause of delirium , incidence of delirium following treatment with this medication and spontaneous recovery of the patient subsequent to its withdrawal , suggest physicians should be cautious in prescribing acetylcholinesterase inhibitors .

donepezil , a member of the acetylcholinesterase inhibitor family , is approved for management of cognitive impairments as well as behavioral complications in patients with neurodegenerative alzheimer 's disease . generally , donepezil is regarded as a safe medication in patients with alzheimer 's disease although there have been reports of several minor adverse events including gastrointestinal disturbances . herein we describe a patient with alzheimer 's disease who demonstrated delirious behavior upon treatment with donepezil .

in model systems , identifying and generating mutations is the usual genetic approach to understanding the function of individual genes . in humans , natural mutations , such as chromosome aberrations , are a comparable resource for genetic research , since dna breakage and reciprocal recombination often lead to the fusion or deregulation of genes ( 13 ) . indeed , most human cancers ( both leukaemias and solid tumours ) and congenital disorders ( including dysmorphology syndromes ) display recurrent chromosome abnormalities . so far , the mitelman database ( http://cgap.nci.nih.gov/chromosomes/mitelman ) constitutes the main effort to collect clinical and morphological data on cancer related chromosome aberrations ( 4 ) . however , the mitelman database contains relatively little molecular information and depends completely on manual curation . we employ automatic text mining methods on pubmed abstracts to gather molecular and clinical facts for all recurrent and non - recurrent breakpoints described in human disorders . the complete and automatic identification of relevant abstracts from 10 million publications is possible , since aberration codes , for instance t(9;22)(q34;q11.2 ) , are unambiguous . to facilitate the literature exploration of specific breakpoints , relevant information is compiled into textual and comprehensive overviews ( the database is updated every 13 months ) . for every breakpoint , we calculated statistically significant genes ( 5,6 ) and biomedical terms ( e.g. disease names ) that were mapped back onto their source sentences . in the web - based interface these genes and keywords serve as hyperlinks between information - rich sentences ( see figure 1 ) . in this manner , the information for breakpoints becomes accessible as a navigable network that is intuitive and exhibits all the advantages of the internet ( 7 ) . as researchers can move between sentences taken directly from source abstracts diseases and associative verbs are also highlighted and hyperlinked within the text to further facilitate the perception of associations with human pathologies . additional molecular information on breakpoints is accessible through links to external databases , such as genbank , locuslink and omim . the complete system , called hcad ( human chromosome aberration database ) , contains 737 breakpoints and 861 literature associated genes from 2082 cytogenetically different translocations and inversions ( see figure 2 ) . this is a difficult task even though the complete human genome is now known , because of the sheer number of genes per cytoband ( 8) . the premise behind hcad is that genes directly affected by recurrent breakage events will be quoted more often in abstracts about the corresponding breakpoint , even if a direct proof for this association has not yet been described ( see figure 3 ) . the statistical analysis in hcad thus provides probabilities for genes to be relevant for a certain breakpoint ( literature evidence ) . false positive associations of these predicted genes are eliminated by crosschecking their localization with genomic data ( 9 ) . indeed , for one - third of these there are already clear experimental evidences that they are involved in fusion events . we believe that the hcad information system provides a reliable basis for uncovering the role ( 10 ) of the remaining human genes in the context of chromosomal aberrations . we are grateful to the us national library of medicine for making medline publicly available . this work was supported in part by the oriel ( ist-2001 - 32688 ) and temblor ( qlrt-2001 - 00015 ) ec projects , mcyt projects bio2001 - 0068 and saf2001 - 0056 , and the fundacion ramon areces grant .

recurrent chromosome aberrations are an important resource when associating human pathologies to specific genes . however , for technical reasons a large number of chromosome breakpoints are defined only at the level of cytobands and many of the genes involved remain unidentified . we developed a web - based information system that mines the scientific literature and generates textual and comprehensive information on all human breakpoints . we show that the statistical analysis of this textual information and its combination with genomic data can identify genes directly involved in dna rearrangements . the human chromosome aberration database ( hcad ) is publicly accessible at http://www.pdg.cnb.uam.es / unipub / hcad/.

schistosomiasis is one of the most prevalent parasitic diseases and infects over 200 million people worldwide . it is endemic to many developing countries in the world , and 80% of those affected are in sub - saharan africa ( 1 ) . we present a case of acute appendicitis caused by schistosomiasis , a rare effect of the parasitic infection . a 31 year - old male from zimbabwe presented with sudden onset severe abdominal pain of twelve hours ' duration , beginning centrally then moving to the right iliac fossa and associated with several episodes of vomiting . he was tachycardic , apyrexial and abdominal examination revealed tenderness in the right iliac fossa . the white cell count was raised at 12.8 109/l and neutrophils raised at 11.2 109/l . a diagnosis of acute appendicitis was made and the patient taken straight to theatre for open appendicectomy . the appendix was found to have perforated and there were copious amounts of pus in the pelvis . pathological examination described the macroscopic appearance of a swollen , congested appendix measuring 7.5 1.5 cm with faeces in the lumen , and microscopic findings of active inflammation in transmural sections , and schistosomal colonisation of the mucosal and serosal surfaces . a detailed history revealed that the patient had lived in both rural and urban zimbabwe where he had swum in lakes , and had experienced episodes of abdominal pain 10 years earlier . an abdominal ultrasound was performed to assess for complications of chronic infection including hepatosplenic disease and urinary obstruction , which was normal . schistosomal serology was weakly positive and there was no evidence of schistosomiasis in the faeces or urine . the patient was prescribed praziquantel , an antihelmintic drug used in the treatment of schistosomiasis . histology - high power view of the appendix histology - low power view of the appendix appendicitis is the commonest abdominal surgical emergency in the uk ; the lifetime risk of appendicectomy in the us has been reported at 12.0% for males and 23.1% for females ( 2 ) . the exact aetiology is uncertain , although the most common hypothesis is of obstruction to the appendiceal lumen with secondary infection . the obstruction leads to the accumulation of mucosal secretions and multiplying resident bacteria , thus raising intra - luminal and intra - mural pressure . eventually the pressure causes venous obstruction and thrombosis of the appendicular vasculature , resulting in ischaemia . ultimately , infarction and perforation occur which can lead to peritonitis , septicaemia and death . some of the common causes of the obstruction are thought to be a faecolith , lymphoid hyperplasia and adhesions . in older patients , schistosomiasis itself does not frequently cause appendicitis thus the condition is uncommon even in endemic regions . one study reported an incidence of 6.2% in nigeria , an endemic country ( 3 ) . in a non - endemic region a recent study reported 6 cases in 5,100 patients , an incidence of 0.001% ( 4 ) . schistosomiasis is contracted by exposure to contaminated freshwater ; schistosome eggs in the water enter a snail intermediate host where they mature then are released back into water . here they penetrate through the skin of a human host and enter the systemic circulation through the pulmonary capillaries . in the portal vein they multiply and travel to veins draining the intestine or bladder where they lay eggs that either stay in the circulation or are shed in the faeces or urine . the pathological manifestations depend on the location of this inflammatory response , for example colonic polyposis due to inflammation in the bowel wall , liver fibrosis causing portal hypertension and haematuria or obstructive uropathy caused by bladder involvement . the acute infection is often asymptomatic , although there may be fever , nausea and bloody diarrhoea , or urticaria in response to the parasite penetrating the skin . there are five species of the family schistosomatoidae that infect humans , which are endemic to different countries . the species s. haematobium is most commonly associated with appendicitis and is most prevalent in africa , the eastern mediterranean and the middle east . the most common hypothesis is that eggs in the appendix wall stimulate inflammation and thus fibrosis and narrowing of the appendiceal lumen ( 5 ) . other hypotheses include schistosomal egg emboli causing ischaemia , and granulomatous inflammation of the peri - appendicular intestine , causing fibrosis and disruption of the intestinal wall leading to obstruction of the appendix and acute appendicitis . there are no clinical or laboratory features that can point to the diagnosis pre - operatively . schistosomiasis is confirmed by egg detection in urine and faeces , and serology can be used to detect mild infections . chronic schistosomiasis can lead to life - limiting complications , yet a simple treatment can eradicate the parasite and prevent the sequelae . schistosomal - appendicitis may be the only presentation of the infection , and diagnosis allows investigation of long - term effects and treatment . this highlights the importance of awareness of unusual causes of common surgical presentations particularly in view of increased immigration of people from endemic areas and increased travel to these areas . it also reminds us of the importance of a thorough history including foreign travel and other risk factors .

schistosomiasis is a parasitic infection in humans , which is prevalent in developing countries . the infection manifests itself as a variety of different pathologies , depending on the location of the parasite and its eggs . a rare manifestation is that of a common surgical presentation , acute appendicitis . we present a case of a young male who underwent appendicectomy for acute appendicitis caused by a schistosomiasis infection , proven on pathological examination of the resected appendix .

methylmethacrylate was the first reported in 1941 as a cause of contact dermatitis . since then , occupational contact allergies to acrylates in dentistry , orthopedic surgery , printing industry and industry have been reported in the literature . polymerization of acrylate occurs when the polymer and the monomer are mixed together in the presence of an organic peroxide catalyst and accelerator . however with photobonded sculptured acrylate nails , polymerization requires exposure to uv radiation . in this study , we describe 3 patients with distinct clinical presentations of contact allergy to acrylates present in artificial nails . epicutaneous tests were applied on the upper back using finn chambers , and a positive patch test reaction was defined according to the international contact dermatitis research group guidelines . all patients were tested with the european baseline series ( with additions recommended by the portuguese contact dermatitis study group ) and personal products . we observed three female patients aged 3550 years old ( mean 41.5 ) with allergic contact dermatitis from sculptured acrylic nails . two patients ( one customer and the other both customer and professional nail beautician ) developed periungual eczema two and four months respectively after the first application of acrylic gel ( figure 1 ) ; one of them had clinically an airborne pattern . the third patient only presented with dermatitis localized to the face and eyelid that was noted four months after the first contact with sculptured acrylic nails . this patient had no hand / periungual or any other cutaneous lesions at distant sites . the tests showed positive reactions to 2-hydroxyethylmethacrylate ( 2-hema ) and 2-hydroxypropylmethacrylate ( 2-hpma ) in three patients . positive reactions to other acrylates were also found : in all our patients 2-hydroxypropyl methacrylate and triethylene glycol diacrylate ; two of our patients tested positive for 2-hydroxyethyl methacrylate , ethylacrylate and hydroxyethyl acrylate , showing how allergic sensitization induced by one acrylic compound extends to one or more other acrylic compounds . one patient tested also positive to nickel with probable relevance to jewelry and to metallic pigment nail polisher . dermatitis resolved in all patients after having their acrylic gel nails removed and in those with occupational setting , after they stop working with as manicurists . nowadays are available three distinct types of sculptured acrylic nails : acrylate monomers and polymers that polymerize at room temperature in the presence of an organic peroxide and accelerator ; photobonded sculptured acrylate nails in which polymerization of the acrylate requires exposure to uv radiation ; and , cyanoacrylates nail preparations . initial formulations contained methyl methacrylate monomer , which caused severe contact dermatitis , paronychia and nail dystrophy . since 1974 , the food and drug administration banned the use of this monomer in artificial nails . currently marketed artificial nails contain various methacrylate ester monomers such as ethyl , butyl and isobutyl methacrylate monomers ; dimethacrylates and trimethacrylates . the reported cases demonstrate the heterogeneous clinical presentation of allergic contact dermatitis from sculptured acrylic nails . clinical manifestation in sensitized patients includes : contact dermatitis at contact areas and at sites distant to the contact ; transient or permanent nail dystrophies and paronychia . eyelid and face dermatitis can be caused by airborne dusts of completely polymerized resins that have become depolymerized by the filing process or by exposure to organic vapors and polymethacrylate dusts . the particular clinical presentation with an airborne pattern following exposure to methacrylate ester monomers has been reported in the english literature in dentistry , orthopedic surgery and printing industry but never in patients with sculptured artificial acrylic nails thus far as we know .

methylmethacrylate was first reported in 1941 as a cause of contact dermatitis . since then , occupational contact allergies to acrylates in dentistry , orthopedic surgery , printing industry and industry have been reported , but few reports are found in the literature as a consequence of the contact with sculptured artificial acrylic nails which are increasingly popular . we describe here 3 patients with contact allergy to acrylates in artificial sculptured nails . patch tests were performed with the portuguese baseline series of contact allergens and an extended series of acrylates were applied . in particular , we tested three female patients with allergic contact dermatitis from sculptured acrylic nails . two of these patients were both customers and also technical nail beauticians . two patients developed periungual eczema ; one presented only with face and eyelid dermatitis had no other lesions . the tests showed positive reaction to 2-hydroxyethylmethacrylate ( 2-hema ) and 2-hydroxypropylmethacrylate ( 2-hpma ) in all the three patients . our cases demonstrate the variety of clinical presentations of allergic contact dermatitis from acrylic sculptured nails . they show the need to warn patients of persistent and sometimes permanent side effects of these products . they also emphasize the importance of cosmetic ingredient labeling .

to emphasize the importance of histological step sections in the pursuit of the correct diagnosis when microscopic findings do not correspond to clinical hypothesis . 21-year - old female with a superficial basal cell carcinoma in pubic region diagnosed after histological step sections and treated with topical imiquimod . although very rare , basal cell carcinomas do occur in young patients and , at times , on areas of the body where they are not conventionally seen . step sections are an important tool that dermatopathologists should use on a regular basis to enhance diagnostic accuracy . basal cell carcinomas are usually found in sun exposed areas of older individuals , especially the head and neck [ 1 , 2 , 3 ] . the incidence of basal cell carcinoma in patients younger than 50 years old , was 5% in one brazilian study , and these were mainly in regions exposed to sunlight . although several cases of basal cell carcinoma in the vulva can be found in the literature [ 58 ] , only one case reported it to occur in the pubic region . we describe a young female patient with an enlarging erythematous macule on the pubic region that was diagnosed as superficial basal cell carcinoma . there was no clinical suspicion of malignant neoplasia , however , that diagnosis was possible by performing histological step sections . a 21-year - old female presented a 2 cm erythematous macule on the pubis that had been slowly enlarging over a period of 18 months ( figure 1 ) . her main complain , actually , was diffuse hair thinning and scalp scaling , which was interpreted as androgenetic alopecia associated with seborrheic dermatitis . mycologic tests ( direct examination with potassium hydroxide and culture ) done on the pubic lesion were negative . no improvement was seen after topical corticosteroid for 10 days . a skin biopsy ( 3 mm punch ) was performed with the following clinical hypothesis : seborrheic dermatitis , eczema , psoriasis , tinea incognita . histological sections ( figures 2a , 2b , 2c ) showed a well - demarcated area of ulceration with crust . adjacent epidermis depicted irregular acanthosis and prominent spongiosis with inflammatory cells in exocytosis ; superficial and mid - dermis presented a dense inflammatory infiltrate composed mainly of lymphocytes . step sections were ordered because skin ulceration is unusual in those clinical differential diagnoses listed . new sections ( figures 3a , 3b and 3c ) surprisingly showed neoplastic blocks attached to the epidermis demonstrating slit - like retraction of the palisaded basaloid cells from the adjacent stroma . the diagnosis of superficial basal cell carcinoma was yielded . the patient started topical imiquimod cream ( figure 4a ) , five days a week for six weeks . severe inflammation was noticed in week three ( figure 4b ) , followed by crusting in week six ( figure 4c ) , and complete healing . no signs of recurrence was seen at a six - month follow - up ( figure 4d ) . to the best of our knowledge , this is the first case report of superficial basal cell carcinoma in the pubic region of a young adult female . the only case we found in the literature occurring in the pubic region was a polypoid basal cell carcinoma ( fibroepithelioma of pinkus ) measuring 7.1 5.0 2.2 cm in a 61-year - old woman a totally different clinical and histological setting from the case reported herein . another feature that contributes to the peculiarity of this case is that the diagnosis of basal cell carcinoma was possible because step sections were ordered . the order was based on the odd aspect of the first hematoxylin and eosin slide where an area of ulceration could be seen . a pas stain with diastase was already performed and had not given any enlightenment on the matter . the intention of ordering deeper sections was to find the explanation for that ulceration and to rule out the remote possibility of a bullous disease or of herpes simplex virus infection . actually , in the author s ( bw ) own experience , herpes simplex virus infection is the champion among the diagnoses made by deeper / step sections , especially when follicular herpes infection is present . resnik and dileonardo reported three such cases , a setting they called herpes incognito . some studies have approached the matter of step sectioning in dermatopathology [ 1114 ] and its usefulness in enhancing diagnostic accuracy and cost - benefit issues are the major concerns . these authors were all convinced that 3037% of their cases benefitted from that practice [ 1114 ] . the higher rate of ordering step sections was obtained in a retrospective study by maingi and helm , where the dermatopathologist felt compelled to order deeper sections based on histological aspects . 63% of the step sectioned cases could be signed out without ordering them , with no change in diagnosis . on the other hand , if no step sectioning were performed , 37% of the patients would not benefit maximally from the diagnostic power of skin biopsy . step sectioning can be crucial to diagnosis , like what happened in the case reported by us .

background : basal cell carcinoma usually occurs in sun exposed areas of older male individuals.objectives:to emphasize the importance of histological step sections in the pursuit of the correct diagnosis when microscopic findings do not correspond to clinical hypothesis.patient:21-year-old female with a superficial basal cell carcinoma in pubic region diagnosed after histological step sections and treated with topical imiquimod.conclusions:although very rare , basal cell carcinomas do occur in young patients and , at times , on areas of the body where they are not conventionally seen . step sections are an important tool that dermatopathologists should use on a regular basis to enhance diagnostic accuracy .

the study of mitochondrial function as and in networks implies considering unique traits such as interdependence , multiplicative effects , collective dynamics spanning several temporal scales , and communication . together , these traits are necessary and sufficient to define the confines , conceptually and in tools , of a new paradigm . several attempts , whose approach qualifies for the network paradigm , are to a certain extent already underway in the brain ( nicholls , 2008 ) and in the heart ( aon et al . , 2008a , b ; arsac et al . , 2008 ; beraud et al . , 2009 ; zhou et al . , 2009 , 2010 ; yang et al . , 2010 ) . applying this integrative approach to cells is the most immediate use of the new paradigm , which includes but transcends by far the mere analysis of differences between isolated and in vivo mitochondrial physiology . simulating complex physiological responses with computational models , at several simultaneous temporal and spatial scales ( cortassa et al . , 2006 ; 2009 ) , in conjunction with high throughput technologies , has a great future for its potential ability to produce unprecedented insights into the inner working of organ physiological mechanisms , under health and disease . the combined experimental - computational strategy represents the edge of the future for mitochondrial networks . the computational approach provides the ability to calculate basic control and regulatory properties of extended networks , comprising processes of different nature , i.e. , metabolic , transport , electro - mechanical , like in the heart . due to the interdependence factor that characterizes network behavior , affecting them with pharmacological agents , triggers diffuse control loops with consequences that go beyond intuition and the expected targets , i.e. , so - called secondary or collateral effects ( see cortassa et al . , 2009 , and glossary ) . the emerging science of networks represents a new chapter within systemic approaches to biology and medicine in health and disease . the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest . network : the collective organization of an ensemble of objects , or groups of them , in space ( structural and topological ) and time ( dynamics ) . emergent behavior : novel and sometimes surprising macroscopic properties arising from the self - organizing capacity of biological systems internal structure and dynamics . self - organization appears in non - linear open systems like cells , organisms , and ecosystems , away from thermodynamic equilibrium , i.e. , constantly driven by exchange of matter and energy or information with the environment . fractal : an object of geometric , statistical , or dynamical nature that obeys power laws of the form m(l ) l , with d as the non - integer fractal dimension ( means is proportional to ) . mandelbrot introduced fractal geometry and defined a fractal as a shape made of parts similar to the whole in some way . this last property is called self - similarity , and represents one of the most distinctive features of fractals . dynamic fractals : self - similar statistical objects described in time series , i.e. , the time - dependent behavior of an observable ( e.g. , mitochondrial membrane potential , nadh ) . these statistical fractals exhibit scale - free dynamics , i.e. , they span a wide range of temporal scales simultaneously ( e.g. , from milliseconds to several minutes ) , in such a way that the short - term fluctuations are related to longer - term trends in the dynamic behavior . as a result , what affects one time scale affects them all : a fundamental property of dynamic fractals . the long - term correlation in mitochondrial dynamic behavior can be interpreted as memory since their status in the present is dependent on their condition in the past , a fact underscored by their non - random statistical behavior . control by diffuse loops : it is defined as the control that a process a exerts over process c or d without an apparent direct mechanistic link among them . this is a new conceptual tool uncovered from calculating control and regulatory properties of the overall network of energetic and electro - mechanical processes involved in cardiomyocyte function . for example , inhibition of the na / k atpase controls mitochondrial respiration through an extensive diffuse loop involving the sarcoplasmic reticulum ca atpase ( serca ) , the sarcolemmal na / ca exchanger , and the levels of cytoplasmic na , ca , and atp .

a new paradigm of mitochondrial function in networks is emerging which includes , without undermining , the glorious and still useful paradigm of the isolated mitochondrion . the mitochondrial network paradigm introduces new concepts , tools , and analytical techniques . among them is that mitochondrial function in networks exhibits interdependence and multiplicative effects based on synchronization mechanisms , which involve communication between mitochondrial neighbors . the collective dynamics of these networks become advantageous for coordinating function spanning from the cell , to the tissue , and the organ . however , under severely stressful conditions the network behavior of mitochondria may become life threatening .

we report a man with septic olecranon bursitis who had an early development of meningitis . a 74-year - old man presented to the emergency room with malaise , headache , mental confusion , a fever unsuccessfully treated with oral nsaids and ice , and with a 10-day history of pain and swelling in his right elbow . clinical and laboratory evaluation excluded other causes and microbiological evaluation documented a s. agalactiae infection . this is the first report on olecranon bursitis and concomitant meningitis related to s. agalactiae infection . the most common offending organism is staphylococcus aureus and only 5% of cases of septic bursitis are caused by streptococcus agalactiae or group b streptococcus ( gbs ) . in adults , gbs behaves as an opportunistic pathogen against a background of such diseases as diabetes mellitus , chronic renal failure , or tumors , or following long - term corticosteroid administration . here , we describe the case of an adult with olecranon bursitis and concomitant meningitis caused by s. agalactiae . a 74-year - old man , with a history of type 2 diabetes and depression , presented to the emergency room with malaise , headache , mental confusion , and a fever ( 38.5c ) that was unresponsive to nsaids . he complained of a 10-day history of pain and swelling in his right elbow , unsuccessfully treated with oral nsaids and ice . examination of the right elbow revealed the presence of spontaneous pain , soft - tissue swelling , and tenderness of the olecranon prominence . range of motion at the elbow was unpainful , 0 to > 120. the skin appeared locally warm and hyperemic . radiographs of the right elbow showed soft - tissue swelling without any foreign body or free air . blood chemical evaluation documented an increase in c reactive protein plasma levels ( 46.65 mg / dl ; normal range : < 0.5 mg / dl ) . his leukocyte count was 13.38 103/ul , with 85% neutrophils ; the hemoglobin and hematocrit levels were 14.7 g / dl and 42% , respectively . cerebrospinal fluid ( csf ) examination revealed a xantochromic color with a limpid aspect and with high levels of white cells ( 960/mmc ) and proteins ( 747 mg / dl ; normal values : 10 - 45 mg / dl ) and low levels of glucose ( 1 md / dl ; normal values : 40 - 76 md / dl ) . both gram - stained and methylene blue smears of the csf were negative , while csf antigen evaluation ( directigen meninigitis combo test , bd inc . csf microbiological examination on triple sugar iron broth , agar - blood , agar - chocolate and mcconkey , mannitol salt agar , and sabouraud agar plates showed smooth translucent colonies with a zone of beta - hemolysis . a latex agglutination test ( prolex streptococcal grouping latex kit , prolabinc , ontario , canada ) and identification ( vitek 2 , biomrieux inc . , mo , usa ) confirmed the presence of s. agalactiae . the aspiration of the olecranon bursa revealed a murky , yellow fluid with a leukocyte count of 18,000/mm ( 85 neutrophils , 15 lymphocytes , and 0 monocytes ) . the s. agalactiae was confirmed through pcr analysis of the dna extraction obtained from the csf and bursal fluid ( extracell kit , nanogen advanced diagnostics , turin , italy ) . nucleic acid amplification tests ( pcr assay ) of both the csf and bursal fluid documented the presence of bacterial dna from the same strain of s. agalactiae . an antibiotic susceptibility test , performed with vitek 2 and an agar disk diffusion method according to the clinical and laboratory standard institute ( clsi ) , revealed a high susceptibility to penicillin , ampicillin , vancomycin , cephalosporins , macrolides , quinolones , but resistance to tetracyclines . the patient was treated with 1 g of intravenous ceftriaxone every 12 hours and ampicillin 1 g intravenous every 8 hours for 2 weeks . after antibiotic therapy , the patient showed steady clinical improvement and normal laboratory indices were found . no side effects to the pharmacological treatment were noted . at 1 year after discharge , the patient has had no further episodes of bursitis or infection . this case suggests the advisability of early aspiration of bursal fluid for gram 's stain and culture in cases of bursitis in patients with medical conditions predisposing to infection . septic bursitis represents a common clinical condition that , if correctly diagnosed , is successfully managed with non - surgical treatment and it uncommonly causes serious , potentially life - threatening complications . this case report also suggests physician that patients can have other systemic complications or infections ongoing at the time of the septic bursitis .

background : we report a man with septic olecranon bursitis who had an early development of meningitis.case summary : a 74-year - old man presented to the emergency room with malaise , headache , mental confusion , a fever unsuccessfully treated with oral nsaids and ice , and with a 10-day history of pain and swelling in his right elbow . clinical and laboratory evaluation excluded other causes and microbiological evaluation documented a s. agalactiae infection . antibiotic treatment induced a rapid improvement , without the development of side effects.conclusion:this is the first report on olecranon bursitis and concomitant meningitis related to s. agalactiae infection .

afl is a common arrhythmia , and when it is generally treated like atrial fibrillation ( af ) , it has different features . rheumatic heart disease , myocardial infarction , pericardial diseases , cardiac tumors , hypertrophic cardiomyopathy , congenital heart disease , cardiac surgery , thyrotoxicosis and alcohol intoxication are known etiological factors . herein we describe a patient with afl developed in the early post - myocardial infarction period causing hemodynamic instability who was successfully treated with rf catheter ablation . a 61 year old male patient complaining of sudden onset chest pain of one hour was admitted to our emergency department . electrocardiography ( ecg ) showed st segment elevation in anterior precordial leads with reciprocal depressions in inferior leads consistent with acute anterior myocardial infarction . primary percutaneous coronary intervention was performed and left anterior descending artery was stented with 3.0x 22 mm sirolimus eluting stent . prior to discharge transthoracic echocardiography showed hypokinesia in anterior wall with an ejection fraction of 40% . the patient was discharged uneventfully with medical therapy including clopidogrel 75 mg , acetyl salicylic acid 300 mg , metoprolol 50 mg , ramipril 5 mg , sprinolactone 25 mg and atorvastatin 80 mg . he was admitted to our clinic 10 days due to discharge with dyspnea and palpitation . ecg showed supraventricular tachycardia at a rate of 160 beats / min . despite intravenous diuretics , amiodarone and oral beta blocker therapy , the patient condition deteriorated therefore electrical cardioversion was performed with biphasic shocks at 50 jules , 75 jules , 100 jules and 150 jules but sinus rhythm did not restore . as the normal sinus rhythm and hemodynamic could not be restored therefore electrophysiological study was performed to the patient . typical clockwise afl line was revealed and cavo - tricuspid isthmus radiofrequency ablation was performed and sinus rhythm was successfully restored ( figs . 1 and 2 ) . patient was found to be asymptomatic and at sinus rhythm during follow up visits of 1 , 3 , 6 months . to our knowledge , there is no similar case reported in the literature as yet , in which the rf ablation of afl was performed in the early post myocardial infarction period in a hemodynamically decompensated patient . afl is characterized with fast and regular atrial depolarization . it may decrease cardiac output and may cause systemic embolization . it was classified by wells as type-1 ( typical ) having 240 - 340 atrial depolarization / minute and type-2 ( atypical ) having 340 - 440 atrial depolarization/ minute [ 2 , 3 ] . lately , it was classified according to anatomical and electrophysiological properties into two classes as macro - entrant ( type-1 ) and idiopathic ( type-2 ) . type-1 atrial flutter is further divided into two subgroups according to the direction of depolarization current in the macroentry circle as clockwise and counterclockwise . restoration and continuity of sinus rhythm , rate control and prevention of systemic embolization constitute its management . restoration of sinus rhythm may be achieved via dc cardioversion , medical cardioversion and rf catheter ablation . rf catheter ablation is the first line treatment option for long - term accomplishment of sinus rhythm . sinus rhythm is restored through the linear rf ablation of cavotricuspid annulus in patients with isthmus dependent type-1 atrial flutter . the frequency of afl was reported 3.2% in post myocardial infarction period . because afl was evaluated and managed with atrial fibrillation in post myocardial infarction period studies , , there is no similar case reported in the literature yet , which successfully treated with rf catheter ablation in the early post myocardial infarction period . in conclusion , catheter ablation of afl may be an important therapeutic option for patients resistance to conventional measures to restore sinus rhythm in early postmyocardial infarction period .

atrial flutter ( afl ) is a common arrhythmia which may decrease cardiac output and may cause embolic events . direct current ( dc ) cardioversion , medical cardioversion and radiofrequency ( rf ) ablation are therapeutic options , but over all rf ablation therapy has the longest event free period . although development of afl after myocardial infarction is quite common it may spontaneously recover or results in atrial fibrillation . herein we report a patient with medical and electrical cardioversion resistant afl which developed in the early post - myocardial infarction period causing hemodynamic instability , who was successfully treated with rf catheter ablation .

in this ecologic study , distribution of tb prevalence rates ( all forms , per 100,000 population per year , 2006 ) ( 10 ) for each eu member state was plotted against 2 measures of income distribution to examine the most descriptive indicator of how socioeconomic setting relates to tb prevalence in europe : 1 ) the gini coefficient , a common measure of inequality of income distribution within a country ( 11 ) ; and 2 ) eurostat s inequality of income distribution ratio , which measures the ratio of total income received by the 20% of the population with the highest income ( top quintile ) to that received by the 20% of the population with the lowest income ( lowest quintile ) . the gini coefficient was not strongly associated with tb prevalence in europe ( r = 0.22 ) , nor was eurostat s inequality of income distribution ratio ( r = 0.34 ) . hypothesizing that the quantification of a country s wealth ( i.e. , gdp ) , along with its distribution , would correlate better than either indicator separately , we computed an indicator called the public wealth index ( pwi ) . this index divides a nation s economic wealth ( using eurostat data on gdp in pps per capita ) by its level of social cohesion ( using the eurostat inequality of income distribution ratio ) . effectively , this metric takes the relative high level of wealth in europe into account while also controlling for its distribution . it favors wealthy countries with low ratios of income inequality : the top 5 scores on the public wealth index were generated by luxembourg , norway , denmark , sweden , and the netherlands . using the pwi , we then developed a simple regression model to explain tb prevalence rates . because of the structure of the data , we used a log - log transformation in r version 2.8 ( 12 ) . the explanatory variable ( pwi ) and the dependent variable ( tb prevalence rates ) , were log - transformed . the model yielded a strong inverse relationship between pwi and tb rates with a correlation coefficient of r = 0.69 . the differences when using the estimator for the intercept parameter in the model ( 14.36 , p<0.001 ) and when using the estimated regression parameter for the logarithmic pwi ( 1.39 , p<0.001 ) were both significant . the observed values and the regression line with no log transformation are shown in the figure . public wealth index and tuberculosis ( tb ) prevalence rates in the 27 european union member states plus norway and iceland , 2006 . finally , to demonstrate the differences in the composition of tb populations between countries , we plotted the percentage of foreign - born tb case - patients within a country ( a surveillance proxy for immigrant populations , which is typically defined as place of birth , except in austria , belgium , bulgaria , malta , and poland , where it is defined as place of citizenship as reported in 2006 ) ( 10 ) . as countries rank higher on the pwi , the proportion of tb case - patients that are foreign - born generally increased ( figure ) . with increasing pwi status , tb rates dropped , but the proportion of foreign - born tb case - patients increased . the data presented here are , however , subject to important limitations . first , aggregation bias is inherent in all ecologic studies , which are not able to disaggregate individual level risk factors important in tb transmission . one of the indicators , foreign born , is perhaps an unfortunate proxy term for migrant populations , but it is the only one available . the term is further limiting because definitions of foreign born vary between countries , as discussed earlier . third , inconsistencies in tb reporting likely occur across the european union , although this would in any case bias the results away from the null hypothesis . nevertheless , given the strong correlation between the pwi and tb rates across europe , as well as the strong trend linking high pwi with higher rates of tb among foreign - born populations , our data lend support to the notion of ensuring equality , both within and between nations , as an important building block for effective tb control . yet , as the figure suggests , especially for countries with higher scores on the pwi , emphasis must also be placed on directly engaging specific vulnerable groups for public health action , whether these groups consist of foreign - born persons , hiv - positive persons , roma people ( http://web.worldbank.org/wbsite/external/countries/ecaext/extroma/0,,contentmdk:20341647~menupk:648308~pagepk:64168445~pipk:64168309~thesitepk:615987,00.html ) , or others . the current financial crisis could exacerbate the conditions of existing vulnerable groups as well as create new ones . for example , the eu directorate for employment , social affairs and equal opportunities estimates that 16% of europe s population currently lives below the poverty line ( 13 ) . rising unemployment rates could push this rate even higher , with implications for factors that drive tb spread such as the quality of housing and sanitation . returning jobless migrants might also be particularly vulnerable if they are no longer able to access their country s social insurance systems . thus , particularly for countries with high incidences of tb , advancing social equalities is fully compatible with the aim of lowering tb prevalence rates . indeed , addressing social and environmental determinants ( such as social inclusion , education and training , crowding , and indoor air pollution ) could pay dividends in the fight against tb during difficult economic times . data related to the financial crisis and its effects on public health will need to be carefully scrutinized as they become available . in the meantime , the public health community must continue to both defend and act upon the insights from the world health organization commission on the social determinants of health , which has so eloquently inserted discussion of social inequalities into public health discourse ( 3 ) . addressing tb among vulnerable populations and tailoring services to these groups ( 14 ) will also be an essential component of any strategy aiming at progressing towards tb elimination , as the action plan by the european centre for disease prevention and control suggests ( 15 ) .

in europe , wealth inequality is directly related to tuberculosis ( tb ) notification ( r2 = 0.69 ) , while in countries with lower tb rates , higher proportions of tb cases occur in foreign - born persons . particularly during times of financial upheaval , efforts to eliminate tb must address social inequality .

contrast - induced nephropathy ( cin ) is a known complication of intravenous , iodinated contrast and is a common cause of acute kidney injury ( aki ) in the inpatient setting . the reported incidence of cin varies among studies , due to differences in definition , type and dose of contrast medium , study population , imaging procedure and the frequency of other potential causes of aki . the widely used definition for cin is as an acute rise of 0.5 mg / dl in serum creatinine or a relative increase of more than 25% from the baseline value . cin is usually transient , with serum creatinine beginning to rise within 24 to 48 hours after exposure , reaching a peak within 3 to 5 days after the administration of the contrast medium , and returning to baseline within 7 to 10 days after administration . the pathogenesis of cin is not completely defined , and suggests a combination of toxic injury to the renal tubules and ischemic injury , partly mediated by reactive oxygen species . the cin incidence can range from 2% to more than 40% in high - risk patients [ 4 - 9 ] . although the reported need for acute hemodialysis is low , patients developing cin have longer hospital stays , more complicated clinical courses and higher mortality rates . only a small number of studies report kidney function beyond a few days after exposure to the contrast medium . in one study , the rate of long - term adverse events was higher in individuals with cin after adjustment for baseline comorbidities and risk factors . although these data signal a worse long term in patients with contrast nephropathy , there is still insufficient evidence to reach a definitive conclusion . pre - existing chronic kidney disease is the greatest risk factor in the development of cin . other factors include diabetes , age over 75 years , heart failure , cirrhosis , hypertension , anemia , intra - arterial injection , hypotension , intra - aortic balloon pump and volume of contrast . most of these risk factors are often found in patients who have been admitted to the icu . additionally , computerized tomography with intravenous administration of iodinated radiographic contrast media is a frequent and necessary procedure for the management of critically ill patients in a variety of situations . however , the risk for cni from radio - contrast exposure has not been well evaluated in this population . in the previous issue of critical care , cely and colleagues performed a single - center prospective matched cohort study of icu patients requiring ct scanning with or without radio contrast to determine the incidence of cin . they matched patients based on pre - scan measured creatinine clearance , diabetes and mechanical ventilation . the primary end point was a decrease in measured creatinine clearance by 33% within 3 days following scanning . the decline in renal function was equally frequent in groups scanned with and without radiographic contrast material ( rcm ) . without a control group who were not exposed to contrast , , a similar rate of decline in renal function experienced by patients scanned without rcm leads to the conclusion that the loss of glomerular filtration rate in this scenario can not be attributed solely to the rcm exposure . a frequent decline in renal function and substantial daily variation in serum creatinine is known to occur in critically ill patients , whether or not they have been exposed to contrast - media injections . depending on the criteria in use , these fluctuations in serum creatinine can determine different incidences of cin - associated aki . the impact of the fluctuations of renal function in critically ill patients on the diagnosis of cin has also been discussed by bruce and colleagues . considering these findings and the results of the present study by quartin and colleagues , it becomes clear that aki after the administration of rcm may be reflective of other processes occurring simultaneously in the critically ill patient . in this context , the diagnosis of cin is challenging . instead of ruling out cin , other possible causes of aki therefore , patients suspected of cin must also be evaluated for other possible causes of aki . before we accept a low incidence of cin in critically ill patients , other important factors should be mentioned . the majority of patients in the study by quartin and colleagues received cin prophylaxis . the average fluid administration exceeded 3 l on the day of scanning among both contrast patients and noncontrast patients . cin is a preventable cause of aki and , even if the incidence in icu patients may be low , prophylaxis should always be carried out . furthermore , cin has unfavorable outcomes and the long - term outcomes in patients with cin are uncertain . whether cin can increase the severity of aki and the time to recover renal function is still unknown . identification of earlier and etiologic - specific bio - markers for cin will probably allow determination of the real incidence of cin and the development of targeted therapies . currently , the use of delta creatinine in a 12-hour period after contrast exposure could be an alternative with good sensitivity and specificity for early detection . while waiting for a more sensitive and specific biomarker for cin , clinicians should weigh the benefit of scanning with contrast media against the short - term and long - term risks of cin - associated aki . aki : acute kidney injury ; cin : contrast - induced nephropathy ; rcm : radiographic contrast material .

contrast - induced nephropathy is a common form of hospital - acquired acute kidney injury . incidence is low in patients with normal renal function but increases in high - risk patients . patients with contrast - induced nephropathy have higher in - hospital complication rates and mortality . critically ill patients have been assumed to be a high - risk group for contrast - induced nephropathy . in the previous issue of critical care , cely and colleagues showed an unexpectedly low incidence of contrast - induced nephropathy in critically ill patients receiving radiographic contrast material for computerized tomography . we should note that it is difficult to establish the true frequency and impact of the contrast nephrotoxicity because of many other causes for acute kidney injury in this population . moreover , the impact on long - term kidney function and the possible effect of this insult on the recovery of renal function when associated with other causes of acute kidney injury are unknown .

we genotyped the rils of the dspr by requiring that each putative variant be supported by a minimum of five reads . we confirmed that the ril panels were free of cryptic population structure by performing principal component analysis ( extended data figure 2 ) . we next excluded sites wherein fewer than 150 individuals have a supported genotype , where the minor allele was present in fewer than 10 individuals , or where more than 15% percent of individuals with data had heterozygous genotypes . following this , we assessed statistical significance for non - independence between pairwise combinations of alleles using a test , and applied a 5% false discovery rate to correct for multiple testing . to reduce type 1 error , we restricted our search to inter - chromosomal comparisons and required that each putative instance of grd be consistent with signal from adjacent variants ( see supplemental methods ) . to confirm the predictions of the grd scan , we first crossed the two dspr founder strains that contributed the predicted interacting alleles . virgin f2 females were then individually and randomly mated to a single f2 male . after mating for 4 days , the f2 pairs were individually genotyped at known variable sites near the interacting alleles . we used taqman kits to perform qpcr on the f2 parents , and performed numerous statistical analyses to quantify epistatic effects as a product of genotypes at the two sites ( see supplemental methods ) . a. geographic distribution of the dspr founding strains ( in orange panel a and in red panel b ) . each founder strains were crossed in a round - robin design ( line 1 line 2 , line 2 line 3 , , line 8 line 1 ) to produce f1s , the f1 were then allowed to mate free to produce an f2 population . in each panel a and b , these f2 population were split into two independent population to create panels a1 , a2 and b1 , b2 . after 50 generation , for each replicate panel , about 400 isofemale lines were inbred for 25 generations to create the 4 panels of ril used in this study . c. crossing scheme used to validate epistatic effects . a pair of founder segregating incompatible allele was selected and crossed to produce f1s , we then intercrossed the f1 progeny to produce a large f2 population , segregating all possible allelic combinations between alleles at loci 1 and 2 . we then counted the progeny each pair produced by intercrossing a large number of f2 s which were later genotyped at sites near to the predicted interacting loci . in green panel a-2 , blue panel b-1 and red panel b-2 . showing no evidence of population structure . a. grd between chromosomes 2r and 3r ( tagged by snps 2r:4806926 , on the x axis and 3r:5870973 , colored lines ) shows strong negative epistasis due to the low fitness of the aa;bb genotype . the additive - by - additive genetic effect is equal to 13.75 ( sensu phillips et al and cheverud ) . b. grd between chromosomes 3l and x ( tagged by snps 3l : 11510853 , on the x axis and x : 16483812 , colored lines ) also shows negative epistasis . here approximate divergence times of commonly studied drosophila species are indicated by blue stars , and the red star indicates a reasonable expectation for divergence times of stocks used to found the dspr ( ~10,000 years ) . the red - line indicates a very approximate speciation threshold , and indicates that many species pairs that are commonly studied exceed this threshold significantly .

the importance of epistasis non - additive interactions between alleles in shaping population fitness has long been a controversial topic , hampered in part by lack of empirical evidence1,2,3,4 . traditionally , epistasis is inferred based on non - independence of genotypic values between loci for a given trait . however epistasis for fitness should also have a genomic footprint5,6,7 . to capture this signal , we have developed a simple approach that relies on detecting genotype ratio distortion ( grd ) as a signal for epistasis , and we confirm experimentally that instances of grd represent loci with epistatic fitness effects . in applying this method to a large panel of drosophila melanogaster recombinant inbred lines8 , 9 , we conservatively estimate that any two haploid genomes in this study are expected to harbor 1.15 pairs of incompatible alleles . this observation has important implications for speciation genetics , as it indicates that the raw material to drive reproductive isolation is segregating contemporaneously within species and does not necessarily require , as proposed by the dobzhansky muller model , the emergence of incompatible mutations independently derived and fixed in allopatry . the relevance of our result extends beyond speciation , as it demonstrates that epistasis is widespread but that it may often go undetected due to lack of statistical power or lack of genome - wide scope of the experiments .

when a patient presents with symptoms of hemoptysis and has a hilar opacity on chest radiograph , the likely diagnosis is bronchogenic carcinoma or less commonly tuberculosis in indian context . we report a rare case of such a presentation where cause of hemoptysis was behcet 's disease . a 38-year - old man , nonsmoker presented with the history of multiple episodes of hemoptysis of 18 months duration . with each episode of hemoptysis he had no symptoms of fever , breathlessness , chest pain / discomfort , hoarseness of voice , difficulty in swallowing or weight loss . he had been previously treated with antitubercular treatment on one occasion in the past 18 months with an empirical diagnosis of pulmonary koch 's . since he did not have any clinical or symptomatic benefit with the antitubercular treatment , his anti - koch 's drugs were stopped after a period of 4 months . on examination , he was afebrile , had no lymphadenopathy and had no signs of pulmonary disease . he was found to have multiple oral ulcers on the lower lip and a healed ulcer on the tongue . he had a scrotal ulcer measuring 2 2 cm [ figure 1 ] . on investigation , he was found to be severely anemic ( hematocrit 18 ) with total wbc count of 8500/cumm . his serum ana , anca , ra factor , vdrl , and tpha were reported negative . his chest x - ray pa view showed right hilar mass [ figure 2 ] . biopsy of the oral ulcer was done which showed spongiosis and features of acute inflammation . bronchoscopy revealed extrinsic compression of right intermediate bronchus however no focus of bleed was found . contrast ct scan of the chest was done which showed marked thickening of the right pulmonary artery along with aneurysmal dilatation with thrombus in situ extending along the descending branch of the left main pulmonary artery proximally [ figure 3 ] . ophthalmic examination excluded eye involvement . since our patient had oral and genital ulceration with features of systemic vasculitis , a diagnosis of behcet 's disease was made . he has been clinically stable with no further episodes of hemoptysis after 6 months of treatment . behcet 's syndrome is a rare multisystem disorder of unknown etiology presenting with recurrent oral and/or genital ulcerations , chronic relapsing uveitis which may cause blindness and/or neurological impairments.[13 ] the prevalence ranges from two to thirty per 100 000 populations in asian countries . it generally begins in the third decade of life , but could present at any age . bd presents with varied systemic features and pulmonary involvement is one of the features of the disease , which could present as hemorrhage , vasculitis , thrombosis , aneurysm , arterio - venous shunting , etc . in world literature only about 1% of patients have pulmonary artery aneurysmal involvement . reports of behcet 's disease in india commonly have noted predominantly mucocutaneous and arthritic involvement . our patient had oral and genital ulcers , but had negative pathergy test and had no eye or skin involvement . this is not unusual in a patient with pulmonary involvement due to behcet 's disease . in a case patients with behcet 's disease , who also had pulmonary manifestation did not fulfill all four criteria required for the diagnosis ( isg criteria are quoted in table 1 ) . international study group criteria for the diagnosis of behcet 's disease ( 1990 ) ( in the absence of other clinical explanations , patients must fulfill the following criteria ) the pulmonary problems associated with bd are multiple , and these can be classified into three groups:[810 ] pulmonary artery aneurysm ( paa).pulmonary parenchymal changes including pulmonary artery occlusion , pleural effusion.pulmonary obstructive airway disease . pulmonary artery aneurysm ( paa ) . pulmonary parenchymal changes including pulmonary artery occlusion , pleural effusion . pulmonary obstructive airway disease . among all these manifestations of bd , the cause of hemoptysis is either rupture of aneurysm or erosion into a bronchus . in our patient , another probable cause of hemoptysis is development of the in situ thrombus from active vasculitis . thrombotic aneurysms are the most frequent type of aneurysm in behcets patients as stated in the literature in our patient , the ct images appearance showed thrombus in situ with features of vasculitis . empirical anti - inflammatory and/or immunosuppressive drugs tailored to the severity of the disease remain the mainstay of treatment . a combination of cyclophosphamide and methyl - prednisolone is used most frequently for patients with pulmonary artery aneurysms . paa has a very poor prognosis and is one of the leading causes of death in behcet 's disease . mean survival after the onset of hemoptysis in a patient with behcet 's disease with paa was about 10 months in a case series by ben taarit et al . our patient continued follow - up with us for 6 months following which he had to move away on account of his job and has not reported for follow up thereafter . in conclusion , in the indian / asian context , when a well preserved , young male patient presents with hilar opacity and hemoptysis , apart from the history - taking and evaluation for infective and malignant etiology , it is important to consider the rarer possibility of behcet 's disease if they have other features of the disease such as oro - genital ulcerations .

common differential diagnosis of lung and hilar opacity includes infectious pathology or a mitotic lesion . behcet 's disease ( bd ) is a rarely diagnosed disease in indian subcontinent . bd is a multisystem inflammatory disorder that presents with recurrent orogenital ulceration , uveitis , and erythema nodosum . we present here the case of a patient who presented with recurrent hemoptysis with radiological picture of hilar mass , during the evaluation of which the diagnosis of bd was established .

small bowel obstruction is one of the most common causes of an emergency admission with pain abdomen often requiring surgical intervention . appendiceal knotting is a rare complication of acute appendicitis , which may give rise to small bowel obstruction . , we report a case of 26-year - old male who presented to us with features of small bowel obstruction and on exploration there was the presence of the terminal ileum due to appendiceal knotting . a 26-year - old male patient presented to the emergency department of medical college and hospital , kolkata , india in the year of 2013 with complaints of generalized abdominal pain , obstipation and bilious vomiting for last 3 days . he also gave a history of vague pain in the lower abdomen 2 weeks ago , which subsided with over the counter medication . there was no past history of any abdominal surgery . on physical examination , patient 's vitals were stable though he had a persistent tachycardia ( 122/min ) with fever . a straight x - ray of the abdomen in erect posture showed multiple air fluid levels with distended small gut loops . a provisional diagnosis of small intestinal obstruction was made and an exploratory laparotomy was planned after proper resuscitation . on exploration through midline laparotomy , ~1 l of hemorrhagic fluid was found within the peritoneal cavity . the tip of the inflamed appendix was adherent to the terminal part of ileum forming a ring like structure with herniation of terminal 60 cm of ileum through the ring [ figure 2 ] . segmental ileocolic resection including the gangrenous ileal segment and ileocolic ( end - to - end ) anastomosis was done . the post - operative period was uneventful and the patient was discharged on the 10 post - operative day . dilated small bowel found on exploratory laparotomy appendiceal knot formed by adherence of appendix with part of terminal ileum small bowel obstruction as a complication of acute appendicitis may be a dynamic or mechanical . paralytic ileus caused by appendicular inflammation is the most common cause of intestinal obstruction in acute appendicitis occurring in 1 - 5% cases of appendicitis . mechanical obstruction with or without strangulation may result from wrapping of appendix around a bowel loop or adhesion of the appendicular tip with small bowel , cecum or posterior peritoneum forming a ring like structure known as an appendices knot . a portion of small bowel usually herniates through that ring or knot forming a closed loop obstruction with or without strangulation . in the view of mobility and variable position of the tip of appendix , it is possible that the appendix may get adhered to adjacent structures during the phase of inflammation giving rise to pathology mentioned above . in our case , there was a similar appendiceal knot through which a portion of ileum was herniated and resulted in closed loop obstruction with strangulation . as the formation of appendiceal knot is a resultant of acute appendicitis , mechanical small bowel obstruction caused by appendiceal knot usually presents a certain period after the episode of acute appendicitis . the straight x - ray abdomen may be helpful in diagnosis of small bowel obstruction but it often fails to identify the etiology . though computed tomography scan of the abdomen is diagnostic of acute appendicitis , but its role in the diagnosis of intestinal obstruction due to appendicitis is questionable . release of the appendiceal band and appendectomy is adequate when the herniated bowel is viable . resection of the non - viable intestine and anastomosis or stoma creation is necessary in the presence of nonviable gut , as in our case . a high index of clinical suspicion is of utmost importance in identifying and correctly managing this rare condition . all authors have assisted in preparation of the first draft of the manuscript or revising it critically for important intellectual content . all authors have read and approved the content of the manuscript and confirmed the accuracy or integrity of any part of the work .

small bowel obstruction is a common cause of an emergency admission in the surgical wards . acute appendicitis presenting with small bowel obstruction due to appendiceal knotting is a very rare and unsuspected condition in an emergency scenario . we report a case of acute small bowel obstruction in a 26-year - old male who , on exploration was found to have small bowel strangulation due to appendiceal knotting . though rare , the possibilities of such a diagnosis should be kept in mind in patients with small bowel obstruction with no known identifiable etiology .

the zld and zld alleles were generated by imprecise excision of the p{rs3}24 element um-8171 - 3 ( flybase , szeged stock center ) . the ovod frt stock was generated by transposition of p{mini w+ , ovo}25 onto y w sn frt , hsflp122 . germ - line clones were induced in zld frt 19a / ovo flp122 frt19a by the flp - frt technique26 . virgin females were collected and mated to yw , fm7 , or fm7c - ftz - lacz males . the yeast one - hybrid screen was performed following the matchmaker one - hybrid system ( clontech ) protocol with the 91 bp zen - promoter and a 0 - 6 hours drosophila embryonic cdna library fused to the gal4 activation domain27 ( gift from l. pick ) . dna binding assays9 and drosophila s2 cell transient transfection assays28 were performed as previously described . the fold activation was calculated as a ratio of the normalized ( for transfection efficiency ) lacz activity in cells treated with 0.5 mm cuso4 and untreated cells . various rna probes , antibodies and molecular probes were used to detect gene expression or to visualize the cytoskeleton and nuclei ( further described in the online methods ) . embryos were viewed by fluorescence microscopy using a nikon fx - a microscope for whole embryo views , or an improvision yokogawa csu-10 spinning disk confocal system for grazing and sectional views , and by nomarski optics using a zeiss axiophot microscope . total rna was extracted from three independent collections of 1 - 2 hr yw and m zld embryos by trizol ( invitrogen ) . cdna was prepared using the genechip ht one - cycle cdna synthesis kit ( invitrogen ) , labeled with the bioarray highyield rna transcript labeling kit ( enzo ) , and hybridized to affymetrix drosophila genome 2 arrays and processed by a genechip fluidics station 400 . the zld and zld alleles were generated by imprecise excision of the p{rs3}24 element um-8171 - 3 ( flybase , szeged stock center ) . the ovod frt stock was generated by transposition of p{mini w+ , ovo}25 onto y w sn frt , hsflp122 . germ - line clones were induced in zld frt 19a / ovo flp122 frt19a by the flp - frt technique26 . virgin females were collected and mated to yw , fm7 , or fm7c - ftz - lacz males . the yeast one - hybrid screen was performed following the matchmaker one - hybrid system ( clontech ) protocol with the 91 bp zen - promoter and a 0 - 6 hours drosophila embryonic cdna library fused to the gal4 activation domain27 ( gift from l. pick ) . dna binding assays9 and drosophila s2 cell transient transfection assays28 were performed as previously described . the fold activation was calculated as a ratio of the normalized ( for transfection efficiency ) lacz activity in cells treated with 0.5 mm cuso4 and untreated cells . various rna probes , antibodies and molecular probes were used to detect gene expression or to visualize the cytoskeleton and nuclei ( further described in the online methods ) . embryos were viewed by fluorescence microscopy using a nikon fx - a microscope for whole embryo views , or an improvision yokogawa csu-10 spinning disk confocal system for grazing and sectional views , and by nomarski optics using a zeiss axiophot microscope . total rna was extracted from three independent collections of 1 - 2 hr yw and m zld embryos by trizol ( invitrogen ) . cdna was prepared using the genechip ht one - cycle cdna synthesis kit ( invitrogen ) , labeled with the bioarray highyield rna transcript labeling kit ( enzo ) , and hybridized to affymetrix drosophila genome 2 arrays and processed by a genechip fluidics station 400 .

in all animals , the initial events of embryogenesis are controlled by maternal gene products that are deposited into the developing oocyte . at some point after fertilization , control of embryogenesis is transferred to the zygotic genome in a process called the maternal to zygotic transition ( mzt ) . during this time many maternal rnas are degraded and transcription of zygotic rnas ensues1 . a longstanding question has been , what factors regulate these events ? the recent findings that micrornas2,3 and smaugs4 mediate maternal transcript degradation have shed new light on this aspect of the problem . however , the transcription factor(s ) that activate the zygotic genome remain elusive . the discovery that many of the early transcribed genes in drosophila share a cis - regulatory heptamer motif , caggtag and related sequences5,6 , collectively referred to as tagteam sites5 brought up the possibility that a dedicated transcription factor could interact with these sites to activate transcription . here we report that the zinc - finger protein , zelda ( zld ; zinc - finger early drosophila activator ) , binds specifically to these sites , and is capable of activating transcription in transient transfection assays . mutant embryos lacking zld are defective in cellular blastoderm formation , and fail to activate many genes essential for cellularization , sex determination , and pattern formation . global expression profiling confirmed that zld plays a key role in the activation of the early zygotic genome , and suggests that zld may also regulate maternal rna degradation during the mzt .

viral rna was extracted as described ( 6 ) from brain tissue of 67 rabid raccoons . samples came from raccoons in ohio ( 1996 [ n = 9 ] and 2004 [ n = 10 ] outbreaks ) and the neighboring states of pennsylvania ( 20032004 [ n = 21 ] and west virginia ( 19872004 [ n = 27 ] ) ( appendix table ) . we amplified a 1,345-nt portion of the glycoprotein gene ( g ) and , for a smaller subset of samples ( n = 20 ) , the complete nucleoprotein gene ( n ) ( 1,416 nt , ) ( see for primers and conditions ) . sequences from a florida raccoon ( g , u27216 ; n , u27220 ) were included as an outgroup . after alignment , appropriate evolutionary models ( 7 ) were found for phylogenetic estimation by using maximum - likelihood and bayesian approaches ( 8,9 ) . maximum - likelihood trees were constructed by using heuristic searches , and node support was assessed with 1,000 bootstrap replicates under the distance criterion with maximum - likelihood model settings . bayesian estimation was performed with 2 runs of 6 million samples each and a sampling frequency of 1,000 ; the first 1,000 samples were discarded as burn - in . a bayesian molecular clock based method ( 10 ) was used to estimate when the 2004 rrv lineage had started to diversify . to estimate evolutionary rates , we included 3 raccoon rabies sequences isolated during the larger atlantic coast epizootic of 19821984 . analyses were run for 10 million steps after a burn - in period of 1 million under an exponential growth model ; alternative demographic models produced equivalent results ( data not shown ) . according to the combined g and n data , the phylogenetic analyses showed that the 2004 ohio outbreak was caused by a distinct rrv lineage that had limited diversity ( figure 2 , panel b , red ) , which suggests a single - source introduction into ohio . the 2004 lineage was not a direct descendent of any previously sampled lineages , but it shared a common ancestor with another lineage ( figure 2 , panel b , yellow ) that contained the viruses responsible for the 1996 ohio outbreak along with contemporary viruses from western pennsylvania . no members of either of these lineages had been found east of the orv barrier ( figure 2 , panel a ) , an area dominated by a different group of viruses ( figure 2 , panel b , blue ) . the same result was obtained when the larger dataset based on g data only was analyzed ( appendix figure ) and when we included rrv sequences from throughout eastern north america ( data not shown ) . this finding suggests that the virus associated with the 2004 outbreak in ohio most likely originated within the orv zone . temporal estimates further indicated that all viruses sampled in the recent ohio outbreak had started to diversify at least 3 years before 2004 . the estimated dates associated with the most recent common ancestor were 1998 ( highest posterior density interval 19932001 ) for the concatenated g and n data and 1995 ( highest posterior density interval 19902000 ) for g data only . our findings imply that rrv had been circulating undetected among raccoons in the orv zone , and possibly beyond it , for several years before its detection in 2004 . these findings have important implications for the control of wildlife rabies in raccoons through orv . first , the genetic analyses do not point to a long - distance transmission event to ohio but rather suggest that the virus was indigenous to the region . in view of potential continued transmission events within the current orv zone , second , the findings suggest that rrv may be able to persist within the orv zone for several years and thus provide continued risk for eventual spread into unvaccinated raccoon populations however , spatial variation in the level of immunization or random fluctuations in the number of infected animals may also enable the virus to persist in parts of the orv zone . third , the level of surveillance needed to detect rrv when transmission frequency is low is unclear . our results indicate that the virus had been present within ohio for several years when surveillance efforts were relatively low ; from january 2000 through june 2004 , an average of 71 raccoons were tested each month compared with an average of 139 per month during 19971999 ( figure 1 ) . therefore , the critical question is : at what point would the marginal cost of increased surveillance leading to earlier detection have outweighed the cost associated with controlling the 2004 outbreak ? to develop the most cost - effective strategy for containment and ultimate elimination of rabies among raccoons , further analyses should aim at quantifying this trade - off . maximum - likelihood tree of 67 partial g gene sequences of raccoon rabies virus sampled in or near ohio , 19872004 . bootstrap values and corresponding bayesian posterior values ( both as percentages ) are shown for key nodes . tree was rooted using a raccoon rabies virus sequence from a florida raccoon ( not shown ) . numbers following taxa names indicate the time of sampling , which is expressed relative to the year 1900 ( i.e. , ' 102.6 ' represents june 10 of the year 2002 ) . see figure 2 for further details .

in 2004 , the raccoon rabies virus variant emerged in ohio beyond an area where oral rabies vaccine had been distributed to prevent westward spread of this variant . our genetic investigation indicates that this outbreak may have begun several years before 2004 and may have originated within the vaccination zone .

normal urine is clear and amber colored due to the presence of urochrome , an amorphous pigment1 ) . variations in color saturation are due largely to differences in urine concentration , but may also be caused by changes in ph , ingested substances and metabolic abnormalities2 ) . it is unusual for urine to develop green discoloration without the addition of either exogenous substances such as medications and food dyes or endogenous pigments such as biliverdin . here we report a case of green urine hue that developed after the ingestion of herbicides . a 76-year - old woman was admitted to the hospital following the ingestion of approximately 150 cc of inorganic herbicide ( proprietary name : magma ; mefenacet , imazosulfuron ) . she wan initially admitted to the local hospital 1 day before being transferred to our hospital . the patient presented to her local hospital with cyanosis of the lips and hands and her urine was noted to be a very distinctive green color ( figure 1 ) . the patient was referred to our hospital because methemoglobinemia was suspected due to the symptoms of cyanosis and green urine . she was treated in the intensive care unit . on examination , her vital signs were blood pressure 140/70 mmhg ; heart rate , 98 beats / min ; a respiratory rate , 18 breaths / min ; body temperature 36.6 clinical examination confirmed cyanotic discoloration of her lips , tongue , fingers , and toes and that her urine was a green color . laboratory results were as follows : hemoglobin , 12.6 g / dl ; total bilirubin 0.8 mg / dl ; blood urea nitrogen , 6.4 mg / dl , and creatinine 0.7 mg / dl . urinalysis revealed a green colored urine with a ph of 7.0 , a specific gravity of 1.011 , negative for bilirubin and protein and 5 - 9 red blood cells per high power field . meq / l , po2 of 132 mmhg and an oxygen saturation of 98.8% ; the pulse oxymeter was 98% with oxygen supplied via a nasal canula . because the patient had cyanotic lips and hands , she was treated with methylene blue because methemoglobinemia was suspected . however , her methemoglobin level was normal and further hypoxia was not observed ; therefore administration of methylene blue was stopped . after conservative treatment only , the cyanosis of the fingers and toes improved and the urine color returned to normal by the seventh day of admission . a red colored urine is observed with hemoglobinuria , myoglobinuria or porphyria , as well as drugs including metronidazole , phenytoin and rifampicin3 ) . green colored urine is an uncommon clinical finding that may have several possible causes including medications , dyes or infections ( table 1 ) . ehrig et al.4 ) reported that blue dyes such as food dye and color blue number 1 , used for enteral feeding , are possible sources of green colored urine in patients with ulcerative colitis . in addition , there have been many reports on the association of greencolored urine with the administration of propofol after surgery5 - 7 ) . green urine may be due to the application of methylene blue or indigo blue4 , 5 ) , but our patient did not have any history to suggest an explanation for the green colored urine . bilirubin has also been associated with green urine ; however , our patient had a normal serum bilirubin level and the urinalysis was negative for bilirubin and urobilinogen . in addition , there were also no signs of urinary tract infection and the urine culture was negative . we considered the possibility that mefenacet and imazosulfuron ( magma ) were the cause of the green discolored urine . mefenacet and imazosulfuron are the main ingredients of magma ; these structures are shown in figure 2 . however , we do not know whether these two compoounds caused the green urine or alternatively whether metabolites of the main ingredients in the herbicides , or other components , were responsible for this change . a sample of the patient 's urine was sent to a reference laboratory for spectrophotometric analysis , which showed an absorption peak at 630 nm . in the green color in conclusion , green urine in the setting of a patient admitted to the intensive care unit may reflect a serious condition such as methemoglobulinemia . however , the green urine that was observed after ingesting the herbicide magma was clinically benign area of the wavelength spectrum ( figure 3 ) .

the development of discolored urine may have many possible causes . here we present the case of a 76-year - old woman who was admitted after ingesting the inorganic herbicides , mefenacet and imazosulfuron . her urine color changed to green almost immediately . since the patient had no specific medication or medical history we considered that the most likely cause of the change in urine color was the ingestion of the herbicides . spectrophotometric analysis of the urine was conducted and a peak was observed in the green area of the wavelength spectrum . these findings show that mefenacet and imazosulfuron should be considered in the differential diagnosis of green discolored urine .

renal lymphangiectasia is a rare disorder of the lymphatic system that might be confused with various other renal cystic diseases and urinoma . clinical presentation is non - specific and characteristic findings in radiologic imaging are the mainstay of diagnosis . we reported a case of bilateral lymphangiectasia in a 32-year - old woman who presented with flank pain and hypertension . surgery is rarely required , except in cases such as those with persistent pain refractory to medication . renal lymphangiectasia is a rare renal condition characterized by dilatation of perirenal , per pelvic , and intrarenal lymphatic vessels ( 1 , 2 ) . this condition can be found in children and adults of both sexes and can be unilateral or bilateral ( 3 - 5 ) . clinical signs and symptoms are non - specific and characteristic findings on ultrasonography ( usg ) , computerized tomography ( ct ) , and magnetic resonance imaging ( mri ) arethe mainstay of diagnosis . a 32-year - old womanpresented with recent history of intermittent low - grade bilateral flank pain . ultrasonography revealed bilateral perirenal and parapelvic septate collections with increased echo texture and enlarged kidneys . subsequent ct scan of abdomen showed per pelvic collections of various densities with indentationon renal capsule . excretory phase had normal excretion of contrast without any extravasation , ruling out any communication with pelvicalyceal system . analysis of usg - guided aspirated fluid showed few lymphocytes with abundant protein and high levels of renin . patient was treated with angiotensin - converting enzyme ( ace ) inhibitors , 50 mg of diclofenac sos , and salt restriction . on follow - up , renal lymphangiectasia is an uncommon benign condition associated with disturbances in lymphatic drainage of perirenal and hilar areas causing cystic dilatation of perirenal and peripelvic lymphatics ( 6 , 7 ) . although the exact pathophysiology is unclear , both developmental malformation and acquired obstructive inflammatory causes has been suggested . patients might present with flank pain , abdominal mass , lower extremity edema , gross hematuria , ascites , or hypertension ( 7 ) . the cause of hypertension is presumed to be compression of renal parenchyma by the subcapsular collection resulting in excessive renin release . differential diagnosis of this condition includes polycystic kidney disease , multicystic dysplastic kidneys , multilocular cystic nephroma , and urinoma depending upon clinical presentation . diagnosis can be made on the basis of characteristic findings on usg , ct - scan , and mri . percutaneous aspiration of perinephric collection has been done to relieve pain not responding to analgesics ( 8) . marsupialization has been also reported to make communication with peritoneal cavity to drain fluid ( 9 ) . rarely , renal lymphangiectasia is associated with renal vein thrombosis and needs nephrectomy ( 10 ) .

introduction : renal lymphangiectasia is a rare disorder of the lymphatic system that might be confused with various other renal cystic diseases and urinoma . clinical presentation is non - specific and characteristic findings in radiologic imaging are the mainstay of diagnosis.case presentation : we reported a case of bilateral lymphangiectasia in a 32-year - old woman who presented with flank pain and hypertension.discussion:renal lymphangiectasia is an uncommon benign condition . most of the cases improve with conservative treatment . surgery is rarely required , except in cases such as those with persistent pain refractory to medication .

we have combined bcmn with mtfm to simultaneously control ligand spacing with sub-5 nm resolution while also recording integrin tension with pn force sensitively and high temporal resolution in living cells . we found that integrin receptors placed 100 nm apart displayed significantly reduced tension as well as diminished capacity for fa formation compared to receptors with 50 nm spacing . on the basis of our data , we propose that integrin ligand sensing occurs by the following steps : ( 1 ) f - actin polymerization drives an increase in the mean integrin ligand tension to 13 pn during nascent adhesion formation ; 2 ) critical ligand spacing ( < 6070 nm ) allows bound integrins to harness actomyosin - driven tension to increase their average tension to 68 pn , thus stabilizing fa and facilitating its maturation process . with larger ligand spacings ( > 100 nm ) , integrin clusters may be destabilized by the increase of tension , as indicated by the small fa size and high turnover rate of fa proteins . this physical model of fa maturation complements structural models of integrin clustering that relate the dimensions of -actinin and talin1 to the minimal ligand spacing required for nascent adhesion maturation . this model may also shed light on how cells exert specific mechanical forces upon recognizing the nanoscale organization of cell binding sites of the ecm in tissues , such as the 66 nm band periodicity of collagen fibers and the nanometer - spaced epitope in fibronectin fibers . we also show that the mechanism of increasing cell traction force occurs through the recruitment of a greater number of integrins under tension rather than maintaining a constant number of integrin receptors and ramping the tension per receptor . note that the reported values of tension represent an average for each ligand , and this does not preclude that some ligand - receptor complexes will experience greater or lower values of force . for example , each pixel of an image collected from cells on the 50 nm spacing reports on the average force for 9 mtfm probes , and it is unlikely that all of these probes are engaged by integrin receptors . therefore , the values of tension reporter here represent the lower bound estimate of force , and this is not inconsistent with our recent finding of integrin force - driven biotin streptavidin dissociation and the recent report of 40 pn universal peak tension for integrin activation . it would be of interest to compare forces exerted onto more physiological integrin ligands such as fibronectin and collagen that can engage different classes of adhesion receptors and thus may display important differences in force magnitude and dynamics . combining mtfm with bcmn - based patterning is highly modular and adaptable , and thus this technique can be applied to study the complex relationships between receptor clustering and mechanical tension in many other receptor signaling pathways , such as t cell receptor activation and the egfr pathway . our approach is certainly more facile than the most commonly used approaches to measure receptor tension , such as traction force microscopy ( tfm ) and pdms micropost arrays , both of which employ elastomeric substrates that deform under mechanical stress . therefore , we expect that this strategy will likely become a workhorse tool in studying the molecular biophysics of cell receptor signaling .

herein we aimed to understand how nanoscale clustering of rgd ligands alters the mechano - regulation of their integrin receptors . we combined molecular tension fluorescence microscopy with block copolymer micelle nanolithography to fabricate substrates with arrays of precisely spaced probes that can generate a 10-fold fluorescence response to pn - forces . we found that the mechanism of sensing ligand spacing is force - mediated . this strategy is broadly applicable to investigating receptor clustering and its role in mechanotransduction pathways .

a 41-year - old woman with a 2-month history of shock - like pain radiating down the spine to the lower limbs with a radicular pattern was admitted into our department . neurologically , muscle strength was normal , deep tendon reflexes were diminished without pathologic reflexes , and there were no sensory abnormalities . magnetic resonance imaging ( mri ) revealed a circumscribed intramedullary lesion at the level of t11t12 that appeared isointense compared with the cerebrospinal fluid ( csf ) on both t1-weighted and t2-weighted mri ( fig . a laminoplasty of t11t12 was performed , which revealed an expanded spinal cord at this level ( fig . we proceeded with a splitting cord approach through the midline , which allowed us to enter the cyst right at its lower portion where we could see the nerve roots split by the lesion . we avoided going around the cyst , and we do not recommend this approach as the risk of neurologic deficits increases . the cyst was opened and clear csf - like fluid was obtained , resulting in immediate collapse of the cyst ( fig . the cyst wall was partially removed to obtain a diagnosis , and adequate communication between the cyst and the subarachnoid space was ensured ( fig . 4 ) . pathology showed cuboidal epithelium without a basement membrane , resting on fibrous tissue ( fig . postoperatively , the patient noted immediate improvement with absence of the shocking pain and resolution of the perineal hypoesthesia . she has been followed for almost 2 years and sagittal magnetic resonance imaging ( mri ) revealing a circumscribed intramedullary lesion at the level of t11t12 that appears isointense compared with the cerebrospinal fluid on t2-weighted mri . cerebrospinal fluid like substance was obtained , resulting in collapse of the cyst . pathology showing a cuboidal epithelium without a basement membrane , resting on fibrous tissue . an intramedullary ependymal cyst is a rare lesion of dysembryoplastic origin , and only a few cases have been documented in the conus medullaris . including this case , there are eight cases of ependymal cyst of the thoracolumbar region ( table 1 ) . there have been only 22 reports of an intramedullary ependymal cyst since the first in 1938 . ependymal cysts occur more commonly in the conocaudal segment ( 56% ) than in the cervical ( 22% ) or thoracic ( 22% ) spine . however , only seven ependymal cysts have been reported in the conus medullaris.1 2 3 intradural spinal cysts are uncommon benign formations histologically classified as arachnoid , enterogenous , and ependymal cysts . arachnoid cysts are the most common intradural spinal cysts and usually occur in the subarachnoid space but not in the intramedullary compartment . enterogenous cysts generally occur in the anterior portion of the third ventricle and have an epidermal lining of intestinal origin . ependymal cysts originate from evaginated cell resting on the floor plate of the neuroectoderm , which are cut off from the main mass of the neural tube in the developing embryo . the intramedullary variety might originate from islets of ependymal cells , which are frequently found near the ependymal canal.1 2 3 there is a female preference for the cysts in the conus medullaris ( only one case has been reported in a male patient ) . the pathogenesis indicates that the floor plate of the neural tube is evaginated on the ventral side and then a cyst forms later . pathologically , ependymal cysts are lined with columnar or cuboidal epithelium with or without cilia that lack a basement membrane and rest on fibrous tissue . the cyst does not communicate with the central canal and must be differentiated from syringomyelia and terminal ventricle . ventriculus terminalis cysts are congenital midline conus cysts that could be related to spinal dysraphism and are more common in children.1 2 3 magnetic resonance is the best imaging method for evaluation of spinal cord cysts . the cyst is also isointense with csf on t1- and t2-weighted images without contrast enhancement.1 2 3 anticytokeratin antibodies cam5.2 and ae1/ae3 are useful markers of ependymal tumors of neuroepithelial origin . ependymal cysts are also positive for glial fibrillary acidic protein and s-100 , both of which are glial markers expressed by normal ependymal epithelium , whereas enterogenous cysts express epithelial markers but no glial cell markers.1 2 3 various techniques have been reported for ependymal cysts , including total resection , partial resection , biopsy , marsupialization of the cyst , and cystosubarachnoid shunt . recurrence of this type of cyst is rare , and neurologic signs and symptoms are usually relieved by surgical decompression.1 2 3 nevertheless most authors recommend a surgical procedure that provides adequate decompression and communication between the cyst cavity and subarachnoid space .

study design case report and review of the literature . objective to present an unusual case of conus medullaris ependymal cyst . methods this is a case of a 41-year - old woman with a diagnosis of ependymal cyst who presented with a history of shock - like pain to the lower limbs . results the patient underwent a successful cyst decompression . conclusion a few cases have been reported in the literature . including this case , there are a total of eight cases of ependymal cyst in the conocaudal segment reported .

an alert citizen in 1975 notified the connecticut health department about her children ( as well as others in the community ) being diagnosed with juvenile rheumatoid arthritis . this was in a geographic region bounded by the broad connecticut river in a rural wooded area that included the towns of lyme and e. haddam . although more cases were diagnosed in other towns , lyme disease stuck ( not unlike the illogical methods one finds in the naming of some eponyms ( 2 ) ) . allen steer , a rheumatology trainee at nearby yale , with a background in the epidemiologic intelligence service at the center for disease control ( cdc ) was notified and began to investigate . eventually , more than 50 individuals were identified ; many of whom complained of an additional skin rash . the rash seemed similar to previous outbreaks of tick - borne diseases in europe ( 3 , 4 ) . organisms were not identifiable in afflicted patients , but serodiagnostic testing through western blot technology developed from previously infected patients worked to diagnose the disease . diffuse clinical manifestations including cardiac and neurological were appreciated as was further epidemiological spread to the united states beyond connecticut . in the town , in central connecticut ( west of the connecticut river ) where i lived at the time , lyme became a big business in an effort to rid the community of ticks , even though it was thought that the east side of the connecticut river was considered the problem area because that is where the infected deer population lived . in 1981 , borrelia burgdorferi , a spirochete , was identified as the causative agent , via deer tick transmission . the 1976 annual convention of military veterans was held at the bellevue - stratford hotel in philadelphia for 3 days and was attended by more than 2,000 american legionnaires . the convention ended uneventfully . however , within a few days , 10 of those attending died suddenly with symptoms of tiredness , chest congestion , and chest pain . a primary care physician who had been the doctor for some of these victims , contacted the pennsylvania health department . within a week , 25 had died . lay press headlines in philadelphia and around the country were alarmist ( 5 , 6 ) . the source of the organism was found to be the cooling tower of the hotel 's air conditioning system . beginning in 1979 , there were reports from los angeles and new york city of outbreaks of pneumocystis carinii pneumonia and/or kaposi 's sarcoma among previously healthy men ( 7 , 8) . however , this changed rapidly , with the inclusion of injecting drug users followed by hemophiliacs and others receiving blood product transfusions , and men from haiti . subsequently , it appeared to be spreading heterosexually , male to female and transplacentally in pregnant women . incidence of kaposi 's sarcoma ( ks ) , pneumocystis carinii pneumonia ( pcp ) , and other opportunistic infections in the united states , 19791981 . since the observation that group sexual behavior was a very high - risk activity for gay men , drastic public health measures were taken in new york and california to reduce risk ( 10 ) . in 1982 , the cdc used the term aids . in 1983 , the french discovered a retrovirus labeled lymphadenopathy - associated virus as the likely cause of aids . the national cancer institute in 1984 identified the htlv-3 virus as the cause for aids and that it was identical to the french discovery . the cdc licensed the first commercial assay for hiv screening and blood banks started screening . were there reasons why these three important infectious diseases occurred when they did in relatively rapid succession ? global considerations take time to be understood . in the case of aids , we need to look back at possible behavioral changes that occurred years before as we now know the natural history of hiv infection including the typical 10 + years needed after initial infection to develop a sufficiently low cd4 count to be at risk . during the 1970s , there were opportunities to learn life lessons . observing unexplained cases with a balanced approach invariably , good detective work and follow - up are needed when chasing a menace . a new bacterium , growing in a cooling tower , was not initially at the top of many lists . and , in the case of aids , a personal contact of mine at the time , who saw many of these patients at his greenwich village office , was certain that the epidemic of immunosuppression was recreational drug related . were there reasons why these three important infectious diseases occurred when they did in relatively rapid succession ? global considerations take time to be understood . in the case of aids , we need to look back at possible behavioral changes that occurred years before as we now know the natural history of hiv infection including the typical 10 + years needed after initial infection to develop a sufficiently low cd4 count to be at risk . during the 1970s observing unexplained cases with a balanced approach should be guided by the principles of good medicine . invariably , good detective work and follow - up are needed when chasing a menace . expert epidemiologic work solved the riddle . in philadelphia , a new bacterium , growing in a cooling tower , was not initially at the top of many lists . and , in the case of aids , a personal contact of mine at the time , who saw many of these patients at his greenwich village office , was certain that the epidemic of immunosuppression was recreational drug related . the author has not received any funding or benefits from industry or elsewhere to conduct this study .

forty years ago is not ancient history in the medical field . however , being an eye witness to the emergence of three new infectious diseases in the northeastern united states in the 1970s left a deep impression on this author . i will relate a small portion of the amazing events that caught the attention of the medical establishment and the general public in a roughly 5-year period of medical discovery .

coronary anomalies are defined in terms of the number , origin , course , and termination of the arteries and are rarely encountered in the general population . these anomalies may be detected incidentally in 0.3% to 1% of all patients undergoing coronary arteriography , depending on the anatomical variant.1 , 2 accordingly , coronary artery anomalies are divided into those that cause and those that do not cause myocardial ischemia.2 a coronary anomaly may be compatible with a normal life expectancy ; nevertheless , its sufferers , especially younger individuals , are at an increased risk for sudden death during or shortly after exercise.1 , 2 we report a case with a rare congenital anomaly of the left anterior descending coronary artery ( lad ) and the left circumflex coronary artery ( lcx ) , with stenosis in the mid - portion of the lad and the distal portion of the lcx . a 47-year - old man referred to the cardiac center of boushehr university hospital with atypical chest pain of one - week duration . one year previously , he had developed chronic stable angina , as is defined by the canadian classification ii.2 the patient s atherosclerotic risk factors included untreated hypertension and smoking . serial electrocardiograms ( ecg ) did not show significant changes , while cardiac troponin i test was positive . transthoracic echocardiography revealed normal chamber sizes , mild mitral regurgitation , and slightly decreased left ventricular function ( ejection fraction = 50% ) . moreover , lad and lcx arteries were in normal position , and there was significant stenosis in the mid - portion of the lad and the distal portion of the lcx ( figure 1 ) . a large branch originated from the distal portion of the lcx and tapered toward its proximal portion . aortic root contrast injection showed a single coronary artery , which took off from the left coronary sinus , and the right coronary artery ( rca ) originated from the distal portion of the lcx . angioplasty and stenting of the lad and lcx was done . before discharge , medical therapy ( clopidogrel , aspirin , atorvastatin , and metoprolol ) was prescribed for the patient . coronary artery anomalies are classified based on the anomalies of the origin , course , and termination . they may also be classified as hemodynamic according to a modified version of a classification system.35 isolated coronary artery anomalies are rare . indeed , the incident of a single coronary artery , occurring without associated congenital heart disease , detected during routine coronary angiography reports is extremely infrequent ( 0.020.04%).6 canbay et al.7 reported 3 cases with a single left coronary artery from the left valsalva sinus giving off branches to the lad , lcx , and rca . considerably , significant anomalies of the coronary arteries are characterized by abnormalities that influence myocardial perfusion and thus lead to an increased risk of myocardial ischemia or sudden death.5 myocardial ischemia or sudden cardiac death is usually associated with its route between the aorta and main pulmonary artery.7 another case with a single coronary artery originating from the distal portion of the lcx was reported by asha et al.,8 who observed an atherosclerotic lesion during coronary angiography . in an extremely rare condition , a case similar to the one presented herein was reported in 2010 , in which the rca originated from the distal portion of the lcx.9 the treatment modality of patients with a single coronary artery has yet to be clearly defined . however , the course of the clinical symptoms and the extent of the atherosclerosis of the coronary artery should determine the therapy . the importance lies in the recognition of this anomaly at cardiac catheterization as these patients may present symptoms of coronary ischemic disease .

congenital anomalies of coronary arteries , albeit rare , may be significant contributors to angina pectoris , hemodynamic abnormalities , and sudden cardiac death . a 47-year - old man referred to us with atypical chest pain . electrocardiography demonstrated no significant ischemic changes , but cardiac troponin i test was positive . the patient underwent coronary angiography , which revealed a single coronary artery from the left valsalva sinus . in addition , the left anterior descending ( lad ) and the left circumflex ( lcx ) arteries were in normal position with significant stenosis in the mid - portion of the lad and the distal portion of the lcx . a large branch originated from the distal portion of the lcx and tapered toward the proximal portion as the right coronary artery ( rca ) . this is a rare coronary anomaly that has no ischemic result . coronary lesions were the cause of the patient s angina pectoris . angioplasty and stenting of the lad and lcx was done , and medical therapy ( clopidogrel , aspirin , atorvastatin , and metoprolol ) was continued . the patient was asymptomatic at 8 months follow - up .

there have been great emphasis and wide improvements in the surgical management of the patient following the world health organisation surgical safety checklist . prior to closure of the surgical wound , numerous steps and checks are implemented to ensure that the correct number of swabs and instruments are present with the scrub nurse to prevent any catastrophes , which to this day still occasionally occur . when the instrument count is complete this report highlights the importance of scrutiny of each individual instrument especially when used in spinal surgery as complications can often lead to devastating complications . a 68-year - old male presented with back pain and left - sided sciatica associated with ipsilateral foot drop . an mri scan revealed severe lumbar degeneration at the level of l3/4 and l4/5 with significant central canal stenosis . day 1 postoperatively , the patient complained of reduced sensation in the l4 and l5 dermatomes on the right side . on examination , he had a right foot drop . day 2 postoperatively , scrotal sensation and anal tone were both found to be reduced . postoperative anterior - posterior and lateral ( figs 1 and 2 ) radiographs of the lumbo - sacral spine revealed a radio - opaque foreign body on the right side of the spinal canal . the foreign body was found to be lying in the spinal canal on the right side with an associated small dural tear . the object was identified as a broken metal tip and traced to an osteotome used in the primary procedure . the most plausible explanation for this complication is that during the release of the hypertrophied facet joint , the osteotome tip broke . what is particularly concerning is the fact that although the approach was on the left side , the broken tip was able to traverse the midline and settle adjacent to the spinal canal on the right , tearing the dura in the process . with an uneventful procedure at the time and routine intraoperative counts being correct assessed the use of routine radiographs during 670 visits in 202 patients who underwent posterior instrumented lumbar spine fusions . they concluded that routine radiographs had limited use in the early postoperative period after instrumented lumbar spine fusion . likewise , grimm et al . did not find any use for routine postoperative radiographs after cervical spine fusions . postoperatively , no radiographic imaging of the spine was undertaken until the patient presented with abnormal signs and symptoms . within our centre , as a result , routine postoperative spinal radiographs are only done following implantation of devices for spinal stabilization . swab and instrument counts form an important and integral part of the final operative checklist . however , given our experience , we propose whether the need for scrutiny of instrument integrity should make up part of this final checklist . in addition , this case also raises the question of whether routine postoperative radiographs following spinal surgery are necessary to detect these unforeseen but potentially catastrophic complications .

complications following spinal surgery can range from simple wound infection to complete paralysis . intraoperative checks have been introduced to account for all the instruments and materials used and help minimize surgeon - related complications . we report a case of a broken osteotome tip within the spinal canal following a routine posterior decompression of the lumbar spine .

a 15-year - old girl presented with sudden pain and sense of giving way of the right knee for 1 week . she underwent total meniscectomy for the lateral meniscus at another hospital 8 years ago . physical examination showed mild effusion , no joint line tenderness , and negative mcmurray test . radiographs and mri showed a displaced , large osteochondritis dissecans in the lateral femoral condyle . autogenous osteochondral grafting using multiple plugs was performed immediately , and lateral meniscal transplantation was undertaken 5 years after the osteochondral grafting . for meniscal transplantation , the patient was positioned supine on the operating table and the right knee was placed in the figure - of-4 position . the size of the meniscal allograft was measured using the radiographic method proposed by pollard et al.7 ) after thawing the lateral meniscal allograft , redundant soft tissues of the allograft were excised carefully and a 9-mm bony bridge connecting the anterior and posterior horns of the lateral meniscal allograft was prepared . a 1-mm wire was bent along the medial border of the bony bridge and the periphery of the lateral meniscal allograft ( fig . the prepared wire was introduced through the lateral mini - arthrotomy while the patellar tendon was retracted medially . the straight part of the wire was placed along the lateral tibial spine ( fig . however , some portion of the round part of the wire was extruded from the anterolateral margin of the lateral tibial plateau . the round part of the wire was placed accurately along the anterolateral margin of the lateral tibial plateau ( fig . 2b ) . after removal of the wire , a bony trough was made along the marked line using a u - shaped chisel . the rest of the transplantation procedure of the lateral meniscal allograft was done in the usual manner . at 1 year after surgery , she had no pain or effusion or pain during mcmurray test on the right knee . follow - up mri showed low - signal intensity of the midbody of the allograft that was positioned adequately without extrusion ( fig . the anterior horn of the lateral meniscus always blends with the anterolateral bundle of the anterior cruciate ligament.8 ) the posterior horn inserts more centrally than the posterior aspect of the lateral tibial spine . the anterior aspect of the lateral tibial spine can be visualized with a mini - arthrotomy . however , the posterior aspect of the lateral tibial spine can be barely seen , because it is mostly obscured by the anterior cruciate ligament.9 ) anatomic complexity of the insertions of the horns of the lateral meniscus can lead to a relatively lateralized transplantation of the meniscal allograft . it is also impossible to know the exact rotation of the allograft during transplantation even under the fluoroscopic control . a recent study demonstrated that an externally rotated keyhole of the graft is a factor responsible for midbody extrusion.6 ) the technique descried in this report using a wire that is shaped to conform to the contour of the lateral meniscal allograft will help surgeons to place the graft more accurately and anatomically . for this technique , however , the use of a thin wire should be avoided to prevention distortion during insertion via a mini - arthrotomy .

recently , studies have emphasized the importance of anatomical placement of the lateral meniscal allograft to decrease postoperative extrusion . however , it is infeasible to identify the exact rotation of the allograft during transplantation . we present a patient who underwent a lateral meniscal transplantation using a wire for correct positioning of the allograft . the use of a wire intraoperatively shaped to resemble the contour of the lateral meniscal allograft will aid in more accurate and anatomical graft placement .

the work of boomer and colleagues in the previous issue of critical care provides further insights into the concept of sepsis - induced immunosuppression . clinical observations have shown that many patients with severe sepsis survive the first critical hours of the syndrome but eventually die in a state of immunosuppression . this immune failure is illustrated by patients ' difficulty in fighting the primary bacterial infection , decreased resistance to secondary nosocomial infections , and reactivation of viral infections that normally are solely pathogenic in immunocompromised hosts . both innate and adaptive immune responses are affected after sepsis . however , in the last five to 10 years , much attention has been given to the study of the innate side of the immune response , in particular via monitoring of the decreased expression of monocyte hla - dr ( a monocyte anergy biomarker whose decreased levels are associated with mortality and nosocomial infections in critically ill patients ) . sepsis - induced lymphocyte alterations include severe lymphopenia due to increased apoptosis , decreased t - cell proliferation and cytokine production after stimulation , and increased percentage of circulating regulatory t ( treg ) cells . very recently , the loss of t - cell receptor repertoire diversity ( assessed at the molecular level ) was shown to be associated with increased mortality and risk for nosocomial infections in patients with septic shock , independently of lymphopenia . the study by boomer and colleagues reinforces these observations and complements the outstanding work on post - term biopsies recently published by the same group . importantly , the latter study showed that sepsis - induced immunosuppression is a severe and profound mechanism occurring not only systematically but also locally in organs . indeed , the authors demonstrated that , in deceased patients with septic shock , both lung and spleen lymphocytes were markedly immunodepressed ( decreased cell counts , altered functional response to stimulation , and increased co - inhibitory receptor expressions ) . here , the investigators extended these observations by prospectively monitoring circulating lymphocytes in patients with sepsis . more specifically , a panel of co - inhibitory receptor expressions ( pd-1 , btla , ctla-4 , tim-3 , and lag-3 ) along with cd127 ( receptor for interleukin 7 ( il-7 ) , a key cytokine in lymphocyte function ) were determined in parallel with treg cell percentage and lymphocyte functional response . in regard to co - inhibitory receptor expressions , the main result of the present study is to show that , although only low levels of expressions were observed at the onset of sepsis , these expressions over the first week were progressively upregulated on lymphocytes of patients with sepsis . along with the decreased cd127 expression ( a feature of exhausted lymphocytes ) and the increased percentage of circulating treg cells ( the major immunosuppressive cells in the body ) , this upregulation suggests that a full picture of lymphocyte exhaustion occurs within a few days in patients with sepsis . interestingly , this observation is very similar to clinical observations made in patients with chronic viral infections such as hiv . importantly , these results support the concept of ' delayed immuno - suppression ' after sepsis . another interesting observation is that these increased co - inhibitory receptor expressions were associated with altered functional responses ( that is , decreased interferon - gamma production after stimulation ) . most importantly , the authors suggest that impaired lymphocyte functions after sepsis could be reversible . here , ex vivo incubation of patients ' cells with fresh media improved responses . this is improvement likely indicates that it remains possible to rejuvenate lymphocytes after sepsis and thus this opens novel therapeutic strategies in battling sepsis - induced immunosuppression . this is of the utmost importance since sepsis - induced immune alterations are known to be associated with increased mortality and nosocomial infection rates in patients . given the central role of lymphocytes ( mainly , cd4 t cells ) in orchestrating immune responses , one may expect that restoring their function can generate a positive global effect , mediated by both lymphocytes and innate immune cells , on the overall immune response . two therapeutic strategies are conceivable : blocking negative / co - inhibitory pathways ( for example , with anti - pd-1 antibodies ) or boosting lymphocyte functions . in the latter case , recombinant human il-7 would represent a major candidate . of note , these two approaches are already used and assessed in cancer and chronic viral infections , which are clinical conditions that share many similarities with lymphocyte dysfunctions described in sepsis . however although a large battery of co - inhibitory receptor phenotyping was performed , the low number of patients included precludes any robust conclusion , especially in regard to correlations with clinical outcomes . despite this limitation , this study reinforces the idea that , after severe sepsis , patients develop a phenotype of lymphocyte exhaustion . this agrees with previous results postulating that immunostimulating therapies aimed at battling lymphocyte anergy and exhaustion could restore immune function in immunodepressed patients and thus help in decreasing mortality after sepsis .

septic syndromes induce immune alterations that have long been considered solely an overwhelming pro - inflammatory response . increasing evidence now suggests that , after the first pro - inflammatory hours , sepsis is accompanied by the occurrence of a systemic immune failure . here , novel perspectives regarding sepsis - induced lymphocyte alterations will be discussed in the context of a recently published study investigating overtime evolution of co - inhibitory lymphocyte receptor expressions in patients with severe sepsis .

daylight saving time ( dst ) is used to better match the activity peaks of a population with the daylight hours . the original purpose of dst was energy conservation . however , recent research indicates that dst does not substantially reduce energy consumption and may even increase it . the research has also shown that transitions into and out of dst cause minor jet lag symptoms such as sleep disruption , fragmentation of the circadian rhythm , and fatigue [ 13 ] . since dst does not serve its original purpose and also causes a variety of disruptive symptoms , it is debatable whether there is any reason to maintain the practice . transitions into and out of dst change our social timing quickly , but affect the timing of body changes more slowly . according to our earlier results , it takes several days to adjust to new time schedules resulting from dst transitions [ 13 ] . since sleep deprivation and circadian rhythm disruptions are known to decrease attention and alertness , dst transitions may lead to higher accident rates . only a few studies have explored the impact of dst transitions on accident rates [ 48 ] , and the results are inconsistent . some reports suggest that dst transitions increase accident rates , while others suggest that dst transitions decrease them [ 47 ] . our study showed that transitions into and out of dst did not increase the number of accidents requiring hospitalization . however , dst transitions may increase the number of less severe incidents which do not necessiate hospital treatment . herein , our aim was to assess whether dst transitions increase the number of traffic accidents during the first week after transitions . we hypothesized that if sleep disruption caused by dst transitions increases accident rates , this increase will be seen during the first week after the transitions . this assumption is based on our earlier studies which indicated that dst transitions cause only minor and short - term symptoms : the healthy subjects recovered from the mild rhythm disruption caused by dst within one week . we studied the number of accidents one week before and one week after dst transitions from 1981 to 2006 . the data used in this paper was based on nation - wide register of finnish motor insurers ' centre . finnish motor insurers ' centre collects harm reports from both police and insurers ' and thus the finnish motor insurers ' centre 's data accuracy is higher than any other sources of accident data in finland . finnish motor insurers ' centre 's data has information for each day separately , and also the causes of accidents are known . the methods for data collection and reporting have not been changed since 1973 and thus the data can be accurately compared from year to year . the number of accidents was analysed using a poisson regression model with a log - link function which is the standard method for analysing frequency data . the proportion of personal injuries in all traffic accidents was modeled with logistic regression . in both models , the year ( from 1981 to 2006 ) was used as a continuous explanatory variable , and the season ( spring or autumn ) and period of time shift ( before or after dst transitions ) as categorical explanatory variables . splines are a good choice for smoothing because of the simplicity of their construction , ease of use , and accuracy of evaluation , as well as their capacity to approximate complex shapes through curve fitting . all interactions between explanatory variables were found to be significant when the number of traffic accidents was modeled ( table 1 ) . season did not essentially modify the very weak association between dst and number of accidents . however , both season and dst did modify how accident rates were associated with calendar year . for proportion of personal injuries we found two significant interactions : between season and dst , and season and year ( table 2 ) . according to our results , transitions into and out of dst did not significantly increase the amount of traffic accidents . however , those who are especially sensitive to circadian rhythm disruptions , such as patients suffering from seasonal affective disorder or bipolar disorder , may be more vulnerable to sudden changes in timing . in addition , those who already suffer from chronic sleep loss may suffer more from the additional sleep deprivation caused by dst transitions . during the study period from 1981 to 2006 , the proportion of personal injuries increased in spring but remained at the same level in autumn . according to our statistics , the amount of road traffic has increased from 1981 to 2006 and similarly the total number of traffic accidents . this is probably the result of improved education and better traffic culture reducing the number of severe accidents .

circadian rhythm disruptions may have harmful impacts on health . circadian rhythm disruptions caused by jet lag compromise the quality and amount of sleep and may lead to a variety of symptoms such as fatigue , headache , and loss of attention and alertness . even a minor change in time schedule may cause considerable stress for the body . transitions into and out of daylight saving time alter the social and environmental timing twice a year . according to earlier studies , this change in time - schedule leads to sleep disruption and fragmentation of the circadian rhythm . since sleep deprivation decreases motivation , attention , and alertness , transitions into and out of daylight saving time may increase the amount of accidents during the following days after the transition . we studied the amount of road traffic accidents one week before and one week after transitions into and out of daylight saving time during years from 1981 to 2006 . our results demonstrated that transitions into and out of daylight saving time did not increase the number of traffic road accidents .

this is the gold standard for their measurement , however it is invasive , time consuming and uncomfortable , therefore is not considered suitable for routine clinical practice.1 to overcome these shortcomings , drink tests were developed as a noninvasive methods to assess gastric sensation and accommodation . it is still unclear whether drink tests estimate gastric sensation and accommodation exactly.1 - 3 although drink tests have not been used in clinical practice , they are often performed in clinical researches evaluating patients with functional dyspepsia or gastroparesis.4 nutrient drink tests seem to be performed more often than water load tests in clinical research despite no comparative studies among them . nutrient drink tests should be performed in the morning after an overnight fast . any medications which can alter gastrointestinal sensation , accommodation or gastric emptying different nutrient drink tests based on various nutrient containing solutions , are performed with various drinking rates.1 - 3 nutrient drink test developed by mayo clinic presents the simplest method among other tests.4 subjects consume 120 ml of ensure ( abbott laboratories , abbott park , il , usa ) , which contains 1.06 kcal / ml with 65% of carbohydrate , 20% of fat and 15% of protein , every 4 minutes until full.5 ensure is administered in a paper cup that is refilled every 4 minutes . at 5 minute intervals , subjects score fullness using a rating scale that combines verbal descriptors on a scale graded 0 - 5 ( 0 : no symptoms , 1 : first sensation of fullness [ threshold ] , 2 : mild , 3 : moderate , 4 : severe and 5 : maximum or unbearable fullness ) . postprandial symptoms were measured 30 minutes after completing the test with participants scoring each symptoms of bloating , fullness , nausea and pain on a visual analogue scale with 100 mm lines and the words " unnoticeable " and " unbearable " as anchors . the sum of the four 100 mm visual analogue scales for each symptom provides an aggregate symptom score . nutricia , zoetermeer , netherlands ) , which contains 1.5 kcal / ml with 39% of fat , administered at 100 ml / min . males significantly consumed more nutridrink ( 1,405 81 ml vs 946 74 ml , p = 0.002 ) than females in this rapid caloric drinking test . using the 10th percentile as the lower limit of the normal range , nutridrink volumes of < 800 ml for men and < 600 ml for women were considered abnormal . in a nutridrink drink test administered at a rate of 15 ml / min to healthy volunteers , tack et al2 reported that maximum satiation occurred after ingestion of 1,005 35 ml ( mean se ) with a lower limit of normal as 653 ml . in the ensure drink test done by chial et al,5 where 30 healthy adolescents and 40 adults ingested ensure at a rate of 30 ml / min , an average maximum tolerated volume ( mean se ) was 1,181 50 ml ( table ) . there was a weak but significant correlation ( r = 0.29 , p = 0.02 ) between the volume to fullness and body mass index . nutrient drink test results are reported as the maximum tolerated volume , 4 individual and aggregate symptom scores . if emesis occurs , the volume of emesis should be recorded and subtracted from the total ingested volume . an extremely low maximum tolerated volume may suggest that extra - gastric or central factors are playing an important role in symptom generation , while low maximum tolerated volume may predict impaired gastric accommodation . since several physiologic factors including gastric sensation , accommodation and gastric emptying may influence the maximum tolerated volume of nutrient drink , the results of maximum tolerated volume can not be used to guide therapy . four individual and aggregate symptom scores are more likely to be higher in patients with functional dyspepsia than controls . various nutrient drink tests are used in clinical researches evaluating patients with unexplained upper gastrointestinal symptoms . standardization of nutrient drink tests is required to be widely performed in patients with functional dyspepsia . the maximum tolerated volume , individual and cumulative symptom scores can be reported as results of nutrient drink tests .

nutrient drink test is one of the drink test techniques to assess gastric accommodation and to quantify meal - induced symptoms . it uses nutrient - containing solution instead of water and has been proposed as a surrogate method for estimating gastric volumes and validated for assessing satiation , sensation of bothersome symptoms after meal ingestion . various nutrient - containing solution and drinking rates have been used and there were no widely accepted reference values for nutrient drink test until now . however , tests results are usually reported as the maximum tolerated volume , individual and cumulative symptom scores . the accommodation response , gastric sensation and gastric emptying may influence the maximum tolerated volume of nutrient drink . although drink test is a useful tool for assessing gastric accommodation and sensation , it remains unclear exactly what physiologic processes are assessed by nutrient drink tests .

a 27-year - old female patient visited a pain clinic for right - sided cervical tenderness that had continued for 5 days , and painful cervical rotation . she had no history of operations or other diseases or conditions with the exception of emotional stress . the tenderness and a taut band were present on the right side of the sternocleidomastoid ( scm ) muscle , and continuous stiffness with cervical motion pain was observed . the continuous pain was rated 2 on the visual analog scale ( vas ) , motion - related pain was rated 4 , and sleep disturbance was not present . during the physical examination , there was no sensory disturbance , allodynia , skin erythema , mass , or limited range of motion . a tender point injection was performed on the tender point of the right scm under a diagnosis of myofacial pain syndrome ( mps ) . however , there was no symptomatic improvement at follow - up 3 days after the initial visit . the lesion then started to swell with more severe tenderness , general weakness , and fatigue . on the seventh day , the patient developed febrile sensations , cold sweats , and chills . on the eighth day , her right neck swelling was grossly confirmed , and she visited the emergency department and consulted the otolaryngology department . laboratory examination results showed a white blood cell count of 3,150/mm , erythrocyte sedimentation rate of 62 mm / h , c - reactive protein level of 33.2 mg / dl , negative perinuclear antineutrophil cytoplasmic antibodies , negative tb interferon - gamma , and an antinuclear antibody ratio of 1:40 . cervical computed tomography ( ct ) showed several lymph nodes ( < 1.8 cm ) with internal necrosis at the right level ii to iv ( fig . she was diagnosed with kd at the level iv lymph node based on aspiration cytology , which revealed several reactive lymphocytes . after 5 days of supportive care , the symptoms began to subside , so she was discharged without any complications . at the 1-month follow - up , kd is associated with fever , myalgia , and leukocytopenia with elevated esr , and is usually accompanied by cervical lymphadenopathy . about half of patients with cervical lymphadenitis have cervical tenderness , and other organs such as lymph nodes , liver , spleen , and skin can also be involved . almost every patient 's symptoms resolve in 2 months , and the recurrence rate is 2 - 3% . atypical symptoms are panuveitis with impairment of visual acuity , arthritis , aseptic meningitis , amygdalitis , cryptogenic organizing pneumonia , and renal failure . although rare , there have been five cases of death associated with heart failure , transplantation , febrile syndrome and sle complicated with hemophagocytic syndrome . ct images are similar to those of lymphoma , but the size of the lymph nodes is not as large as that in lymphoma . however , no specific assay is available to confirm the radiologic diagnosis of kd . most patients visit clinicians because of lymph node masses , tenderness , or fever , and there is no report of a patient with mps without any other symptoms . the patient in this case underwent tender point injection because the neck pain was diagnosed as mps . however , the pain and swelling of the neck worsened after 4 days ; thus , the initial mps of scm can be regarded as the initial symptom of kd . the patient showed fever , leukocytopenia with elevated esr , and cervical lymph node enlargement and tenderness without any other accompanying symptoms . thus , she was discharged later with no complications . among publications referenced by pain clinicians this report implies a disconcerting situation if clinicians do not consider kd in the care of patients with similar signs and symptoms . therefore , the possibility of kd in young patients with mps should be considered and explained to the patients . kd is rare but can be accompanied by severe complications ; thus , examinations for diagnosis and consultation might be performed when kd is suspected .

kikuchi 's disease ( kd ) is an idiopathic and self - limiting necrotizing lymphadenitis that predominantly occurs in young females . it is common in asia , and the cervical lymph nodes are commonly involved . generally , kd has symptoms and signs of lymph node tenderness , fever , and leukocytopenia , but there are no reports on treatment for the associated myofacial pain . we herein report a young female patient who visited a pain clinic and received a trigger point injection 2 weeks before the diagnosis of kd . when young female patients with myofascial pain visit a pain clinic , doctors should be concerned about the possibility of kd , which is rare but can cause severe complications .

90yearold female patient with medical history of stroke referred to our endoscopic unit in the context of failure removing the feeding nasogastric tube at the emergency department of our hospital after several attempts . the ngt which was placed 2 months ago could not be pulled out or pushed inside . the patient was in a confusional state while the physical examination ( her abdomen was soft , nontender , and nondistended ) , and laboratory tests were unremarkable with stable vital signs . a plain abdominal xray revealed a loop in the epigastric region with no signs of gi tract perforation or any other abnormality ( fig . esophagogastroduodenoscopy was performed , and the distal part of ngt , forming a loop , was recognized inside a large hiatal hernia , 5 cm in length ( fig . the loop was released after untangling the tube with great difficulty via rattooth forcep ( fig . the nasogastric tube was withdrawn about half an hour later . when we reviewed the esophagogastroscopy procedure , there was no active bleeding in the stomach or esophagus . ( b ) image taken of the loopforming tube immediately after removal , showing the stiffness and bending of its lumen . although an uncommon entity 1 , 2 , ngt coiling or knotting remains one of the numerous complications that emerge after or during tube placement 3 , 4.there are some causes that predispose nasogastric tubes to loop formation . one of them is the thin lumen and malleability as well as the excessive inserted tube length . moreover , the presence of a hiatal hernia especially a large one ( as happens in our case ) may predispose to ngt coiling and loop formation . furthermore the simultaneous use of multiple tubes crossing through the same enteric section may induce loops too 5 . coiling emerges more frequent in patients with altered gastric anatomy ( i.e. , after gastrectomy ) or after the softening of the tube at body temperature . finally , in order to avoid such a complication , changing ngt to peg if long use of the former needed is considered as an appropriate followup treatment . esophagogastroduodenoscopy was performed , and the distal part of ngt , forming a loop , was recognized inside a large hiatal hernia , 5 cm in length ( fig . the loop was released after untangling the tube with great difficulty via rattooth forcep ( fig . the nasogastric tube was withdrawn about half an hour later . when we reviewed the esophagogastroscopy procedure , there was no active bleeding in the stomach or esophagus . ( b ) image taken of the loopforming tube immediately after removal , showing the stiffness and bending of its lumen . although an uncommon entity 1 , 2 , ngt coiling or knotting remains one of the numerous complications that emerge after or during tube placement 3 , 4.there are some causes that predispose nasogastric tubes to loop formation . one of them is the thin lumen and malleability as well as the excessive inserted tube length . moreover , the presence of a hiatal hernia especially a large one ( as happens in our case ) may predispose to ngt coiling and loop formation . furthermore the simultaneous use of multiple tubes crossing through the same enteric section may induce loops too 5 . coiling emerges more frequent in patients with altered gastric anatomy ( i.e. , after gastrectomy ) or after the softening of the tube at body temperature . finally , in order to avoid such a complication , changing ngt to peg if long use of the former needed is considered as an appropriate followup treatment . all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards . this article does not contain any studies with human and animals performed by any of the authors . mg : involved in conception and design . at , lv , and ap : involved in analysis and interpretation of the data .

key clinical messagenasogastric tubes ( ngt ) are extensively used and generally harmless , yet loop formation and malpositioning are often reported especially when using thin ngt for enteral feeding which placed blindly ; therefore , diligent followup of ngt is required with confirmation of right placement , changing it to peg if long use of ngt needed .

fortunately , the robust vascular supply of the face allows for many reconstructive options using localized flaps . the rhomboid flap is commonly used for facial skin defects because of its simple design . however , a severe transposition may result in the development of a standing cone deformity , making closure of the flap difficult as a result of the tension on the tissue . if the raised flap region is closed , severe tension will also lead to the development of other deformities that affect facial symmetry . to solve this problem , to create the modified rhombic bilobed flap design , an abcd rhombus , with angles of 60 and 120 degrees , is drawn around the defect . the first lobe of the bilobed flap is formed by constructing a standard dufourmentel type of rhombic flap and the bad angle is the same as the def angle , which makes the first lobe of the bilobed flap equal to the size of the defect . the second lobe of the flap is created from half to two - thirds of the first lobe . the angle of fgh is also equal to the angles of bac [ figure 1 ] . design of the bilobed rhombic flap a representative case of a 68-year - old man with a 9 mm , benign nevus on the side of his nose is described . one - year post - operatively , the ectropion of the inferior eyelid and the nasal deformities were no longer apparent ; the patient was satisfied with the result [ figure 2 ] . ( a ) nevus cell nevus on the side of the nose and the planning of the flap ( b ) immediately after the operation and the ( c ) 1-year post - operative result the original rhombic bilobed flap concept required that the lengths of the sides of the flaps be the same but that the angles at the tips of the flaps be small . when using this approach , necrosis was noted at the tips of the second lobe because of its greater distance from the base of the flap . therefore , we changed the design so that the angles at the vertices of the flaps were the same . this allowed the sides of the first lobe , around the defect , to be the same but the lengths of the sides of the second lobe to be shorter . using this design , we did not note any skin necrosis . the bilobed flap design has advantages over the single flap design in that the tension and stress on the skin can be dispersed across two flaps rather than across the single flap . a standard bilobed flap has the disadvantage of pin - cushioning that often develops as a result of the curvilinear flaps ; the incidence of pin - cushioning is reported to be 5% . the precise geometric design of the revised rhombic bilobed flap decreases the incidence of pin - cushioning by producing angular corners . in conclusion , the revised rhombic bilobed flap is very simple to use and is associated with fewer complications , including pin - cushioning and standing cone deformities , while minimizing the risk of skin necrosis and tension on the flap .

we describe a combination of the common rhomboid flap and bilobed flap and provide an example of its use . the rhombic bilobed flap is simple to use and is associated with fewer complications , such as pin - cushioning and standing cone deformities , while minimizing the risk of skin necrosis and tension on the flap .

a 24-year - old female patient reported with a chief complaint of fractured upper right lateral incisor ( # 12 ) . patient revealed an alleged history of fall from two - wheeler on the previous day . , there was a horizontal fracture at the cervical third of crown with the fracture line extending 2 mm subgingivally on palatal aspect . on radiographic examination , it was found that the fractured tooth was root canal treated and obturation was satisfactory with the intact lamina dura [ figure 1 ] . a definitive treatment of orthodontic extrusion followed by a crown with a dowel and core was planned and explained to the patient . intraoral periapical radiograph showing obturation in 12 with intact lamina dura full mouth prophylaxis cleaning was done prior to orthodontic extrusion . obliging to patient 's request , orthodontic extrusion was designed with the invisible approach ( lingual orthodontics ) so that the brackets are not exposed . the lingual brackets ( combi brackets ) were placed on the upper cast , and a transfer tray made from glue gun was fabricated [ figure 2 ] . brackets were bonded onto the lingual surface of the teeth whereby the bracket was positioned more gingivally ( 2 mm ) on the tooth to be extruded [ figure 3 ] . the 0.012 ni ti was loosely knotted to the bracket of 12 in the 1 month , and then placed in the bracket slot in the 2 month . a slow extrusive force of 0.20.3 n was used . the patient was recalled once weekly to assess the amount of extrusion . the desired extrusion ( 3 mm ) to regain the lost biologic width had been attained in a period of 3 months which was very evident on the radiograph [ figure 4 ] . transfer tray made with glue gun intraoral picture showing lingually placed brackets from 16 to 26 intraoral periapical showing extrusion of 12 by lingually placed brackets about 2 mm of the crown was exposed in relation to 12 using crown lengthening procedure without encroaching the biologic width [ figure 5 ] . esthetics was taken care of by carrying out gingival depigmentation in the upper anterior region on the labial side using a soft tissue laser [ figure 6 ] . crown lengthening of 12 labial depigmentation the orthodontic appliance was left passive for 2 months for stabilization of achieved extrusion . a direct wax pattern was made for a post and core and was transferred to the laboratory for construction . fabricated cast post and core were cemented with resin cement . a provisional porcelain fused to the metal crown it is estimated that majority of population sustain traumatic injuries to anterior teeth because of its forward position and proclination which could result in esthetic and psychiatric problems . reports have shown that the incidence of complicated crown fractures was 1820% of all tooth injuries in a permanent dentition in which oblique fractures contribute to 85% of traumatized incisor fractures from labial to palatal aspect in the apical direction . a comprehensive diagnosis and meticulous treatment planning are essential for the management of complicated crown - root fractures which could be attempted by extraction followed by the implant , surgical extrusion , crown lengthening , and orthodontic extrusion . extraction should not be the first choice because every attempt should be made to preserve the natural teeth . surgical extrusion is a simple , less consuming procedure but the main drawback is the risk of root resorption because of the damage to the periodontal ligament . have done an orthodontic extrusion in relation to maxillary central incisor with the successful clinical outcome . orthodontic extrusion or forced eruption extrusion is one of the easiest orthodontic movements to achieve because it closely simulates natural tooth eruption . it is a conservative procedure that permits retention of a tooth without loss of bone or periodontal support . an adult might ignore the entire plan of the treatment because of the placement of brackets on the labial surface which makes them feel unesthetic . white spots will appear on the labial surfaces surrounding the orthodontic attachments may be detected after the removal of appliance leading to unesthetic appearance . lingual orthodontics is the most esthetic treatment modality and is the prime treatment choice for adult patients as the brackets are invisible . 2007 carried out a similar case of lingual orthodontic extrusion of maxillary central incisor which is on par with our present study . at the end of this procedure , there was some discrepancy with the gingival margin which was corrected using the periodontal procedure . the combined use of other branches of dentistry such as orthodontics , prosthodontics , periodontics is a promising way to achieve best results . in this case , we have achieved extrusion without compromising the esthetics which ensures psychological comfort to the patient .

dental trauma is one of the most common and significant problems met in all dental offices almost every day . in particular , injury to the anterior teeth is more vulnerable as it may affect the psychosocial behavior , severe emotional complications can occur leading to disturbances in their mental attitude . cosmetic ( lingual ) orthodontics is the recent development in the field of dentistry in the last few decades . patients are more concerned about their appearance during the treatment and are affected by psychosocial issues because of labially placed brackets , thus leading to the evolution of lingual orthodontic appliances . in this article , we are sharing our clinical experience treating a complicated crown - root fracture using the lingual orthodontic technique .

galactorrhea refers to the discharge of milk from the breast , unassociated with recent childbirth or nursing . galactorrhea occurs when serum prolactin levels are raised for reasons ranging from pituitary tumors to drug treatments . a number of drugs , including psychotropic drugs , cause hyperprolactinemia , some doing so consistently ( e.g. , certain antipsychotics ) , and some , rarely ( e.g. , certain antidepressants ) . a 27-year - old housewife presented with a 2-year history of sadness , anxiety , occasional tearfulness , pessimism about the future , low self - confidence , diminished interest in daily activities , and diminished interest in social life , poor appetite , and poor sleep . a diagnosis of moderate depression with somatic symptoms was made , and she was started on escitalopram 5 mg / day along with clonazepam 0.75 mg / day . she was instructed to increase the dose of escitalopram to 10 mg / day after 4 days and taper and withdraw the clonazepam at the rate of 0.25 mg / week . after about 18 days of treatment , she developed painless engorgement of her left breast associated with galactorrhea . under the assumption that this symptom was a selective serotonin reuptake inhibitor ( ssri)-related adverse effect , escitalopram was tapered and withdrawn across 2 weeks and agomelatine ( 25 mg / day ) was initiated . the breast engorgement and galactorrhea subsided 7 days after discontinuation of escitalopram ; neither symptom re - emerged during 9 months of maintenance therapy with agomelatine . this author identified 23 relevant reports and presented a table of the 12 reports to which he had full text access . , galactorrhea has been identified in relation to all the marketed ssris : fluoxetine , fluvoxamine , sertraline , paroxetine , citalopram , and escitalopram . as far as we could ascertain , unilateral galactorrhea with ssris has been reported only by koch and zellmer , 1 month after commencing treatment with citalopram ( 20 - 60 mg / day ) , and by canan et al . interestingly , unilateral gynecomastia without galactorrhea was reported by karakurt et al . in association with venlafaxine ( 150 mg / day ) treatment ; this drug is also a potent serotonin reuptake inhibitor in addition to being a noradrenaline reuptake inhibitor . galactorrhea occurred early in our patient ; that is , <3 weeks after treatment onset . in addition , galactorrhea occurred at a low - dose of medication ; that is , at 10 mg / day of escitalopram . ssri - related galactorrhea is reported to occur as early as 1 - 3 weeks ( commonly ) to as late as 5 months ( uncommonly ) after treatment initiation with doses that are in the low to medium range . in our patient , galactorrhea stopped 1 week after escitalopram withdrawal ; this is also in line with previous reports where most cases experienced relief from galactorrhea 1 - 3 weeks after ssri withdrawal , rarely earlier , and rarely later . these drugs may rarely raise serum prolactin levels by serotonin receptor - mediated downstream presynaptic inhibition of dopamine release by tuberoinfundibular dopaminergic neurons , or by direct stimulation of hypothalamic serotonin postsynaptic receptors . these and other mechanisms were discussed in greater detail elsewhere ; galactorrhea can be a consequence of the hyperprolactinemia . curiously , galactorrhea with ssris has been reported even with serum prolactin levels in the normal range , and prolactin - independent mechanisms for antidepressant - related galactorrhea therefore require to be identified . unfortunately , our patient could not afford laboratory investigations and so we could not assess the serum prolactin level .

galactorrhea is a rare adverse effect of selective serotonin reuptake inhibitor treatment . we report a 27-year - old woman who developed unilateral breast engorgement with galactorrhea 18 days after initiation of escitalopram ( 10 mg / day ) . the symptom remitted 7 days after withdrawal of escitalopram and did not subsequently recur during maintenance therapy with agomelatine ( 25 mg / day ) .

plica neuropathica ( polonica ) is a rare acquired disorder of the hair shafts in which groups of hair are matted together forming a malodorous , encrusted and sticky , moist mass . first records of dreadlocks go back to 2500 bc with the dreadlocked hindu deity shiva and his followers reported in the vedic scriptures of india as jataa , meaning twisted locks of hair . the term is probably derived from the dravidian word catai , which means to twist or to wrap. later , it was also described in poland in the eighteenth century . plica neuropathica or dread locks. le page coined the term plica polonica in 1884 when he described a 17-year - old girl with a sudden onset of tangled scalp hair . le page attributed this strange phenomenon to nerve force while the parents of the child considered it a this phenomenon was historically linked to a common condition of scalp hair in poland during the 19century . the hair was matted into a thick , moist mass , due to deficit hair care . the polish custom of wearing tight fur caps and the superstitious belief that a lousy scalp was healthy contributed to the frequency of plica polonica in poland . some of the risk factors reported for this condition are psychological disturbances , secondary scalp infection or infestation of scalp or use of shampoos containing cationic detergents . there are sporadic reports of this condition in various dermatology journals from india[1710 ] and abroad . surprisingly despite the role of psychological disturbance as risk factors for this condition only few cases are reported in psychiatry journals . a , 38 yrs old , muslim , illiterate housewife hailing from low socio - economic rural background presented with eight months history of gradual onset problems characterized by persecutory delusion , auditory hallucination , fearfulness , irrelevant talk and decreased interest in household activities . two weeks after the onset of the illness relatives took her to a mosque for religious treatment . one day after the religious rituals her relatives noticed sudden tangling of scalp hair in the hair lock on the vertex . on asking , both patient and relatives expressed the concern that the hair lock should be removed only at the same mosque after the illness is completely cured . further interview revealed that twenty years back she had a similar type of illness lasted for two months which was subsided after religious treatment in the same mosque . she was admitted in the hospital for detailed evaluation and was diagnosed to have paranoid schizophrenia as per dsm iv criteria . because of her odd hair condition dermatological consultation was sought and was diagnosed as plica polonica . during the period of inpatient stay of three weeks she was treated with daily dose of chlorpromazine 400 mg , trihexiphenedyl 4 mg and nitrazepam 10 mg on as needed basis . at the time of discharge patient showed remarkable improvement in the psychopathology except the odd hairstyle . both the patient as well as relatives refused to comply with the therapist 's instruction to cut the hair and were very keen to take her to the same mosque for removing the hair lock and to donate the same to god almighty . three weeks later patient with relatives came for follow up in the out patients department . it was reported that she was taken to the same mosque where her lock was removed in a religious ritual and at the same time she was continuing the psychiatric treatment in the same prescribed dose . at the time of review her hair condition was perfectly normal and there was no obvious psychopathology except slight drug induced sedation . plica neuropathica has been reported very rarely though it is seen more frequently in our culture . this entity has been found to be associated more in women who are disturbed psychologically . this could probably due to the repeated manipulation of the hairs by the psychologically disturbed women . hysteria was described as a prominent feature in five of the seven women previously reported with plica neuropathica . undfortunately noe of these reports are from psychiatry journals . in these patients plica neuropathica was characterized by sudden onset and a scalp healthy in appearance and free of offensive odour and parasites . in the previously reported case also by the same author plica was formed suddenly in a woman with schizophrenia diagnsis . plaited hair has been regarded as a safety valve in severe illness and , if a patient could this was exactly the explanation given by the index patient as well as in the previously reported case by the same author . another belief is that clipping the plica could result in death . in the index patient psychiatric illness otherwise there were no predisposing or precipitating factors like kinky hair , febrile illness , or change in toilet soap or use of shampoos prior to the formation of plica . moreover , as reported previously , the formation of plica was sudden and it was associated with a delusional conviction of superstitious belief shared by relatives . as it was suggested elsewhere plica could probably be produced by the application of tar , pitch or wax by those people in the mosque with faith in the statuary influence of a plica . a remote possibility is that the patient , while sleeping or as an unconscious habit , could have produced this condition by vigorously rubbing together strands of kinky hair . bogaty and dunlap described a laboratory method for matting hair and found that increased matting occurred with mechanical action , bleaching solution treatments and fine or dense hair . this process of matting is essentially similar to the felting of fibers familiar in the wool and textile industries . in conclusion the reason for the sudden development of plica in the index patient still elude . in our culture it is a common religious custom to raise a plica for wish fulfillment or to have a divine image among the public . once the desired goal is achieved they remove the plica in religious centers specifically set for these rituals . it would be worthwhile to examine the psycho - socio - physiological basis of this behavior , which may open new avenues in transcultural psychiatry .

plica neuropathica ( polonica ) is a common but rarely reported scalp hair condition . in this condition the hairs of scalp in a localized area is compacted into irregularly twisted , irreversibly entangled plaits . psychological disturbance is a risk factor for plica formation . we report a case of plica neuropathica in an adult female with schizophrenia .

although pure embryonal carcinoma is a relatively rare neoplasm , it is the most common component in mixed germ cell tumors . embryonal carcinoma tends to occur at a young age , the average age being 31 years . many ( 66% ) patients with a tumor composed predominantly of embryonal carcinoma , have metastasis at the time of diagnosis ; subcutaneous metastasis of embryonal carcinoma is rare.[57 ] here , we report a case of chest wall subcutaneous metastasis of an embryonal carcinoma , emphasizing the role of fine needle aspiration cytology ( fnac ) as a modality for early diagnosis and treatment . a 27 year - old man presented with a gradually increasing , subcutaneous swelling in the anterior chest wall , extending up to the axilla . the swelling measured 810 cm , was firm in consistency , fixed to the chest wall , and was non tender with prominence of overlying veins . the patient was subjected to fnac , which revealed syncytial clusters of anaplastic tumor cells exhibiting pleomorphism and anisonucleosis . cells had round to irregular , vesicular nuclei and prominent nucleoli [ figure 1 ] . a diagnosis of a poorly differentiated neoplasm suggestive of embryonal carcinoma , was made . with these cytological findings , the patient was evaluated in detail and a mass was detected in the left testis . adenocarcinoma - like cluster of large malignant cells with large nuclei , coarse chromatin , and occasional prominent nucleoli ( h and e , 400 ) ultrasonography ( usg ) of the whole abdomen showed multiple liver metastasis , spleen metastasis , enlargement of the retroperitoneal and paraortic lymph nodes , and bilateral pleural effusion . biopsy of the testicular mass confirmed the cytological diagnosis of an embryonal carcinoma [ figure 2 ] . extragonadal germ cell tumors are also encountered , they commonly arise in the midline of the retroperitoneum or the mediastinum . primary cutaneous extragonadal germ cell tumors on the other hand are very rare ; only two cases have been reported . the diagnosis should be rendered only after extensive search for primary in the gonads , mediastinum and retroperitoneum have failed to yield positive results . reported subcutaneous deposits of an embryonal carcinoma . on analysis of their institute 's 30 year fnac was instrumental in suggesting a diagnosis and the subsequent search led to the discovery of the primary in the testis with dissemination in the abdominal lymph nodes , liver and spleen . testicular germ cell tumors are the most commonly occurring neoplasm in young males . although the overwhelming majority are malignant , they are curable . the high sensitivity of germ cell tumor to platinum based chemotherapy , together with radiation and surgical measures leads to high cure rate of 99% in the early stages , 90% , 75 - 80% and 50% in advanced disease with an embryonal carcinoma is an aggressive tumor due to its tendency to early hematogenous spread emphasizing the need for early detection and treatment . cytomorphological features such as syncytial aggregates of round to irregular nuclei with prominent nucleoli and scant cytoplasm are quite distinctive . fine needle aspiration is an excellent cytological method for the early diagnosis of embryonal carcinoma , based on which the patient can be spared the morbidity and expense of extensive surgical procedures . moreover , early treatment with the administration of chemotherapy can produce high cure rates , thereby saving the lives of patients

embryonal carcinoma affects young males in the prime of life with a majority of these tumors already having metastasis at the time of diagnosis . subcutaneous metastasis from embryonal carcinoma are very rare and often associated with wide spread disease and poor prognosis . we report a case of chest wall subcutaneous metastasis of embryonal carcinoma in a 27 year - old man that was the first presentation of the disease and was diagnosed on fine needle aspiration cytology ( fnac ) . subsequent search led to the discovery of the primary in the testis . the cytomorphological features of embryonal carcinoma are quite distinctive and fnac plays a vital role in early diagnosis . the criteria for diagnosis includes presence of cellular smears exhibiting disperse cells as well as cell aggregates forming microglandular patterns . cells have large nuclei with prominent nucleoli and pale indistinct often vacuolated cytoplasm . early diagnosis and treatment with platinum based chemotherapy in conjunction with radiotherapy and surgery have high cure rate .

rhabdomyolysis ( rhabdo - striated , myo - muscle , lysis - break down ) refers to clinical and biochemical syndrome due to skeletal muscle injury and spillage of large quantities of intracellular contents in to circulation . there are more than 100 causes with different mechanisms that can damage the skeletal muscle leading to rhabdomyolysis . the incidence varies with underlying cause and increased incidence seen after earth quake and war zones . exertional rhabdomyolysis is seen in weight lifting , marathon race , and military basic training . knochel called exercise induced rhabdomyolysis as white collar rhabdomyolysis because of increased incidence noted in educated and professionals who are not accustomed to strenuous exercise . it may present as asymptomatic illness with elevated creatine kinase to life - threatening complications such as cardiac arrhythmias , cardiac arrest , compartment syndrome , disseminated intravascular clotting , and acute kidney injury ( aki ) . the diagnosis is based on the inciting event , myoglobinuria , and serum creatine kinase levels more than 5 times the reference value . a 26-year - old female presented with history pain in the back , lower limbs , decreased urine output , and dysuria of 3 days duration . two days before the present complaints , she had performed sit - ups while holding her ears ( super yoga brain ) for 108 times in a temple . on examination , she was afebrile , no icterus , pulse rate 120/min , blood pressure 100/80 mmhg . investigations revealed myoglobinuria , total leukocyte count 9.3 10 /l , hemoglobin 11.5 g / dl , platelet count 283 10 /l , urine sodium 48 meq / l , fena 2.08 , tests for hiv , hepatitis b and c are negative . urine and blood cultures were negative . computer tomogram of the abdomen showed normal sized kidneys and free fluid in the pelvis . rhabdomyolysis diagnostic profile , renal parameters , and blood gas analyses are shown in tables 13 ] . the national hospital discharge survey report 26,000 cases of rhabdomyolysis every year in usa . among 337 military recruits olerud et al . noted rhabdomyolysis in 40% of cadets during first 6 days of intense physical training . excessive physical exertion of any kind can cause exertional rhabdomyolysis , especially in untrained individuals in hot or humid climate and accounts for one - third of all causes of rhabdomyolysis . incidence of aki is less ( 19.1% ) in exertional rhabdomyolysis compared to rhabdomyolysis due to other causes ( 34.2% ) . rhabdomyolysis accounts 7 - 10% of all causes of aki in usa but may be as high as 50% . a variety of insults with different pathogenic mechanisms are involved in muscle injury but the final common pathway is increased intra cytoplasmic calcium which activates proteases , phospholipase , nucleases and release of oxygen free radical causes myocyte disintegration and spillage of intracellular contents in to circulation resulting in electrolytes disturbances , metabolic acidosis , hypotension , clotting abnormality , and aki . myoglobinuria is a key player in the complex pathogenesis of aki only in presence of hypovolemia , hypotension , and aciduria ( nephrotoxic factors ) . the 3 different pathological mechanisms involved in the development of aki are : ( 1 ) renal hypo perfusion resulting from hypovolemia - induced renal vasoconstriction and myoglobin scavenging of nitric oxide . ( 2 ) heme protein exerts direct toxicity on tubular epithelial cells and free radical release by myoglobin causes oxidative injury to the tubular epithelial cells . ( 3 ) the precipitated myoglobin , tamm horsfall protein , uric acid crystals in presence of acidic urine causes tubular obstruction and decreases glomerular filtration rate . this patient performed sit - ups for 108 times which is a form of eccentric exercise that has caused severe muscle injury . she presented with typical features and investigations revealed myoglobinuria , hypocalcemia , elevated serum creatine kinase , phosphate , uric acid , liver enzymes , lactate dehydrogenase , renal parameters and fena > 1 , metabolic acidosis confirming exercise induced rhabdomyolysis and aki . in this case patient was taken up for hemodialysis on alternate days initially for 2 weeks and then thrice a week for another 2 weeks . patient 's urine color , output , and all the deranged parameters returned to normal by 4 weeks . rhabdomyolysis is not an uncommon condition and the gravity of this condition is not appreciated and adequate attention is not given . both traumatic and nontraumatic it has characteristic clinical , laboratory features but high index of suspicion is important for early diagnosis . history of inciting event , elevated serum creatine kinase levels more than 5 times the reference value , myoglobinuria are confirmatory for diagnosis of rhabdomyolysis . the renal outcome depends on quick and aggressive management but not on creatine kinase levels .

rhabdomyolysis is a clinical syndrome resulting from the disintegration of muscle cell and spillage of toxic intracellular contents into circulation . strenuous , unaccustomed exercise leads to exertional rhabdomyolysis and cause aki . we report a 26-year - old female who developed white collar rhabdomyolysis with aki after performing sit - ups ( super yoga brain ) for 108 times in temple . she was managed with hemodialysis and supporting therapy . she made a full recovery after 4 weeks . awareness of this condition and early diagnosis is highlighted .

eight million people , ninety - five percent of whom live in developing countries develop this disease each year . these figures increase annually and will certainly continue to increase.1 this worldwide increase is also attributable to its interaction with the human immuno - deficiency virus ( hiv ) epidemics.12 tuberculosis of the spleen is not uncommon , but splenic abscess formation as a result of tuberculosis is rare.34 presented here is a case of tuberculous splenic abscess presenting as a subcutaneous abscess . a 55-year - old male presented with a gradually increasing mass on the left lateral lower chest and upper abdomen over a period of one year . he had no other medical problems and no history of contact with a tuberculous patient . on examination , a lobulated subcutaneous mass measuring about 7 cm in diameter , soft to cystic in consistency , immobile and attached to the skin which was tense and slightly red , tender but not warm , not pulsating , and with no bruit was found on the left lower chest and upper abdomen laterally . chest x - rays showed a calcified lesion near the hilum of the right lung suggestive of an old pulmonary tuberculosis . ct scan of the abdomen revealed a splenic abscess communicating with another subcutaneous abscess through the lower chest wall ( figure 2 ) . based on these data , a complicated tuberculous splenic abscess was the most probable diagnosis . abdominal x - ray showing calcified lesions in the left upper quadrant an enhanced ct scan of the abdomen showing a splenic abscess communicating with another subcutaneous abscess through the lower chest wall under general anesthesia , the subcutaneous abscess was incised and drained , and splenectomy was performed simultaneously . the spleen was found to be enlarged , fibrotic , and adherent to the lower chest wall . there was an abscess cavity within the spleen communicating with the subcutaneous abscess through a small tract in the lower chest wall below the insertion of the diaphragm . histopathology of the spleen revealed the characteristic tuberculoid granuloma with epithelioid cells , langhans multinucleated giant cells , and caseation necrosis ( figure 3 ) . a histopathology slide of the spleen showing the characteristic tubercle granuloma with epithelioid cells ( right side of the picture ) , langhans multinucleated giant cell ( center ) , and caseation necrosis ( left side of the picture ) the patient was started on isoniazid ( inh ) 300 mg od , rifampin 600 mg od , ethambutol 600 mg od and pyrazinamide 500 mg od for 5 weeks , then maintained on the former two drugs . the patient 's condition improved on anti - tuberculous medications and showed good clinical progress at one - year follow - up . though the prevalence of tuberculosis in the developed countries declined significantly over the last few decades , in the developing countries it remains a major public health problem.5 the decline in the developed world can be attributed to mass vaccination and the advanced health care systems , whereas in developing countries poor socioeconomic status , overcrowding , poor nutrition , and lack of medical care all contribute towards the increased incidence of tuberculosis . consequently , certain organs of the body such as the lungs , renal cortex , and growing ends of bones are more commonly involved than other organs , such as the liver and spleen , where the oxygen tension is low.5 splenic involvement is usually associated with disseminated ( miliary ) tuberculosis , and tuberculous abscess formation in the spleen is attributed to the over - reaction of the host immune response with the formation of caseation necrosis . splenic tuberculosis cases are usually asymptomatic and in less than half of cases with abscess formation , they may present with the classic symptoms of fever , chills , tenderness in the left upper quadrant , and splenomegaly.6 the diagnosis of splenic tuberculosis can be reached by a high index of suspicion especially in endemic areas . calcifications in the spleen is an important radiological sign of tuberculosis.6 isolation of tubercle bacilli by the ziehl - neelsen staining and culture techniques of aspirates from the splenic abscess , and the characteristic histopathologic finding of tubercle granuloma of the spleen establishes the diagnosis of tuberculosis . tuberculous splenic abscess has been successfully treated with anti - tuberculous drugs78 alone , and by splenectomy.69 however , surgical treatment is preferred in a solitary tuberculous splenic abscess in otherwise fit patients,9 and in such complicated cases as this case . penetration of tuberculous splenic abscess into the subcutaneous tissues or to the outside is extremely rare . this patient was managed surgically , and treated with anti - tuberculous drugs for almost a year , as splenic tuberculosis is usually associated with a disseminated disease . in conclusion , because of the rising incidence of tuberculosis,1 unusual presentation of tuberculosis should be suspected as the disease is becoming increasingly more common .

a 55-year - old male presented with painful lobulated mass on the left lateral lower chest and upper abdomen . evaluation revealed the mass as a subcutaneous abscess originating from and communicating with a splenic abscess . the patient was treated by incision and drainage of the subcutaneous abscess along with splenectomy , and antituberculous therapy . histopathological examination of the spleen confirmed the diagnosis of splenic tuberculosis . postoperatively , the patient improved , and was discharged ten days later on antituberculous drugs . one year later , the patient remains asymptomatic and shows progressive improvement .