Datasets:

mtc

/

pubmed-2shot-full-test

like 0

angelman syndrome is characterized by the deletion of 15q11.2q13 and is characterized clinically by psychomotor retardation , a happy disposition with paroxysms of laughter , and epileptic seizures . valproic acid ( vpa ) is often prescribed for the epileptic seizures associated with this syndrome . although vpa - induced pancreatitis is relatively uncommon , serious adverse effects including diabetes , pancreatic cancer and pseudocysts have been reported . splenic vein obstruction can also arise as a complication of chronic pancreatitis [ 2 , 3 ] . here , we report a case with remarkable collateral veins caused by splenic vein obstruction associated with chronic pancreatitis . a 36-year - old man had been followed for vpa - induced chronic pancreatits for 17 years , and intravenous hyperalimentation nutrition had been administrated . in 2006 , abdominal ct and ct angiography showed multiple pancreatic calculi , splenic vein obstruction , and perigastric and subphrenic dilated collateral veins into the superior mesenteric vein ( fig . 1 ) . an upper gastrointestinal endoscopy revealed stomach varices ( lg - f , f2,rc+ ) on the posterior wall of the gastric body ( fig . gastric varices caused by splenic vein obstruction as a result of chronic pancreatitis were diagnosed , and these varices were thought to be the cause of the upper gastrointestinal bleeding . endoscopic treatment and catheterization with balloon - occluded retrograde transvenous obliteration were difficult to perform because of the lg - f varices , and no vein approach from the inferior vena cava was available ; therefore , surgical treatment was indicated . a total gastrectomy , splenectomy , and enterostomy were performed , and the patient has not experienced any further episodes of bleeding since the operation . although vpa - induced pancreatitis is very rare , it has been estimated to occur in 1:40,000 patients . it is a fact that many causes exist for pancreatitis , however vpa is most suspected as a cause of pancreatitis in this case . furthermore , it is suggested that numerous pancreatic complications and/or pancreatitis - associated diseases may affect the course and determine the prognosis of chronic pancreatitis , and biological markers and/or imaging procedure development were needed to detect chronic pancreatitis at its reversible stage [ 5 , 6 ] . thrombosis of the splenic vein has been reported in 720% of patients with chronic pancreatitis . additionally , bleeding occurs in approximately 510% of patients with chronic pancreatitis [ 7 , 8 , 9 ] . the causes of gastrointestinal bleeding associated with chronic pancreatitis include splenic vein obstruction , sinistral portal hypertension , rupture of a pseudoaneurysm , bleeding from a pseudocyst , and peptic ulcer arising from chronic alcohol use or the loss of exocrine function . splenic obstruction may result from the following [ 11 , 12 ] : ( 1 ) extrinsic compression by a pseudocyst , ( 2 ) fibrosis of the pancreatic parenchyma , and ( 3 ) injured endothelia and thrombosis as a result of perivenous inflammation from pancreatitis . in patients with cirrhosis , the collaterals are hepatofugal ; this often leads to the formation of gastroesophageal varices . in contrast to generalized portal hypertension , the collaterals are hepatopetal in splenic vein thrombosis . splenoportal collaterals decompress the short gastric veins through both the gastric coronary vein into the portal vein and via the gastroepiploic arcade into the superior mesenteric vein [ 13 , 14 ] . splenic vein obstruction leads to isolated varices in the fundus of the stomach or hypersplenism , without associated varices in the esophagus . new therapeutic agents have been shown to retard the progression of chronic pancreatitis in a mouse model and may be useful in the treatment of drug - induced pancreatitis . if the long - term administration of a drug like vpa is needed , the possibility of gastric varices or splenic obstruction arising from chronic pancreatitis should be considered .

valproic acid ( vpa ) is a commonly prescribed and approved treatment for epilepsy , including angelman syndrome , throughout the world . however , the long - term administration of drugs like vpa is associated with the possible development of gastric varices and splenic obstruction as a result of chronic pancreatitis . such cases can be difficult to treat using endoscopy or interventional radiology because of hemodynamic abnormalities ; therefore , surgical treatment is often necessary .

obturator hernia is a rare pelvic hernia with an incidence of 0.07%1.4% of all intra - abdominal hernias and accounts for 0.2%5.8% of all mechanical small bowel obstruction cases . primary closure of the hernia defect is difficult because adjacent tissues are not easily mobilized . a variety of techniques have been described , however surgical repair has not been standardized . a 70-year - old female presented to the surgical emergency with complaint of colicky pain in the whole abdomen along with bilious vomiting and abdominal distension for over 10 days . physical examination revealed abdominal distension , exaggerated bowel sounds , absence of tenderness and rectal ballooning . biochemical parameters were normal ; however , the patient had evidence of previous healed pulmonary tuberculosis and emphysema on chest x - ray . contrast - enhanced computed tomography abdomen of the patient revealed evidence of small bowel obstruction , but no obvious etiology . thus , the patient was taken for emergency laparotomy via midline vertical incision . upon exploration , she was found to have left - sided obstructed richter - type obturator hernia [ figure 1 ] with tip of involved bowel having questionable vascularity . the hernia sac was thus approached via upper medial thigh incision and reduced [ figure 2 ] . resection anastomosis of the involved segment was done along with preperitoneal mesh plug repair of hernial orifice . she developed ventilator - associated pneumonia and expired on postoperative day 7 . during the survival left - sided obstructed richter - type obturator hernia discovered upon exploratory laparotomy hernial sac and incarcerated bowel seen after reduction the female predominance has been contributed to pregnancy , which causes relaxation of the pelvic peritoneum and a wider and more horizontal obturator canal . this hernia is seen thrice more often on the right side than the left , along with a rare but well - documented , concurrence of bilateral as well as femoral hernias . hernia is asymptomatic till bowel obstructs and presents with acute or intermittent small bowel obstruction . in a typical case , the patient may complain of pain along the medial aspect of thigh exacerbated by the movement of hip or thigh consequent to compression of obturator nerve . another , hannington - kiff sign ( absent adductor reflux in the thigh ) is more specific but much less commonly seen . various investigation modalities employed to assist diagnosis include ultrasonography , herniography , and computed tomography ( ct ) of the abdomen . ct scan of the abdomen has maximum specificity and sensitivity and is recommended for the suspected obturator hernia and intestinal obstruction without obvious cause . the accuracy of ct scan in diagnosing obturator hernia is approximately 90% , higher with strangulated hernias . it may reveal small bowel loops behind the pectineus muscle , air in the under pubic channel . for acute presentation , midline infraumbilical vertical approach is preferred , while other approaches such as retropubic , preperitoneal , groin or laparoscopic approaches may be used if hernia is diagnosed preoperatively . the laparoscopic surgery has the advantages of less postoperative pain , shorter hospital stay and lower complications but is reserved for the nonstrangulated hernia . both transabdominal and extraperitoneal approaches have been described with transabdominal approach preferred for the emergency setting . very often obturator hernia is detected during totally extraperitoneal ( tep ) repair for inguinal hernias . this reflects the importance of inspecting all the myopectineal orifices during the tep approach to allow for the diagnosis and repair of asymptomatic obturator hernias . the author concludes that obturator hernia is an important diagnosis to be considered in elderly patients with intestinal obstruction . early diagnosis and surgical treatment contribute significantly to reduce the mortality and morbidity rates .

a 70 year old lady presented to surgery emergency with small bowel obstruction without any obvious etiology . on exploration she was found to have an obstructed obturator hernia , which is a rare pelvic hernia with an incidence of 0.07 - 1.4% of all intra - abdominal hernias . diagnosis is often delayed until laparotomy for bowel obstruction . strangulation is frequent and mortality remains high ( 25% ) . early diagnosis and surgical treatment contributes greatly to reduce the mortality and morbidity rates . a variety of techniques have been described , however surgical repair has not been standardized . it is an important diagnosis to be considered in elderly patients with intestinal obstruction .

mycetoma is a chronic pseudotumourous infection of the skin and subcutaneous tissue , caused by fungi ( eumycetoma ) or bacteria ( actinomycetoma ) , and generally inoculated traumatically . mycetoma is usually localised to the foot and principally occurs in tropical and subtropical regions . we describe here the case of eumycetoma of the foot in a patient who has had a renal transplantation previously and also had a history of tuberculosis . we report the case of a 40-year - old man who hurt his right foot a few months before in the tropics . his medical history revealed that he has previously undergone renal transplantation and has suffered from tuberculosis . he presented a right foot with a lesion localised on the first toe which was swollen and excoriated ( figures 1 and 2 ) and was self - treated ineffectively with various local antiseptics for several months . the ultrasound of the right foot showed inflammation involving the first metatarsophalangeal joint and a plantar abscess of 3 0.8 2.3 cm that extended later to the dorsal part of the joint . three nodules in the plantar part and six nodules on the dorsal part were found . the decision to not treat with oral itraconazole was taken because of the favourable evolution of the foot . pain diminished after a few days , and the patient was able to walk after a few weeks . about 23 cases of eumycetoma due to fusarium species have been reported in immunosuppressed patients . morphological identification of the fusarium genus was often difficult , and species - level identification was only achieved in eight cases . classically , identification is based on the white yellowish colour of the grains , the light brown colonies and genus characteristic sickle - shape spores . fusarium species are cosmopolitan fungi , which are thought to be inoculated into the skin by penetrative trauma . our patient with a recent history of foot injury probably acquired the infection in djibouti . the clinical evolution was successful and the patient was able to walk after a few weeks .

a 40-year - old kidney transplant male recipient was hospitalized for chronic abscess of the right foot in a context of immunodepression . the patient came from djibouti and was in belgium for a few days . he presented a right foot with a swelling localized on the first metatarsophalangeal joint which was excoriated ( figures 1 and 2 ) and was self - treated ineffectively with various local antiseptics for several months . he was in the operating room for an open biopsy done by plantar and dorsal approach to confirm the fungal infection . treatment was not started with oral itraconazole because of the good evolution of the lesion . pain diminished after a few days , and the patient was able to walk after a few weeks .

we present a case of chordoma , causing caudal compression , which was initially presumed to be a metastatic deposit from a renal cell carcinoma on the basis of radiological investigations . consequently the patient received initial surgical intervention in the form of spinal decompression with posterior stabilisation , where extra - lesional resection would have been more appropriate . a 72-year old man presented with an 8-month history of lower back pain and increasing left leg pain and weakness . an abnormal appearance of the l3 vertebral body on plain radiographs prompted ct investigation which suggested pathological fracture of l3 with posterior convexing of the vertebral body and epidural mass . also noted was a mass within the right kidney which was felt to be in keeping with the appearances of renal cell carcinoma . mri confirmed a solitary vertebral lesion causing posterior convexity of the vertebral body with extension into the pedicle , causing significant compression of the thecal sac and clumping of nerve roots . based on the radiological presumption that this was a secondary deposit from a renal cell carcinoma within the right kidney , plans were made for posterior spinal decompression and stabilisation , and tissue biopsy was felt to be unnecessary . pre - operative embolization of the tumour was attempted , however , no tumour enhancement was demonstrated during the aortogram , and embolization was therefore not performed . decompression and posterior stabilisation from t12 to l5 was performed and biopsies of l3 sent for analysis . the biopsy revealed trabecular bone and marrow fat replaced by malignant tumour , in - keeping with chordoma , not the presumed diagnosis of renal cell carcinoma . mri of lumbar spine showing mass causing compression of the cauda the patient developed an ileus post - operatively but soon settled and his lower back pain gradually improved . unfortunately his lower back pain returned 6 months later , and subsequent imaging showed enlargement of the lumbar spine mass causing further compression of the cauda . this subsequently required further surgery in the form of tumour debulking with anterior stabilisation of l3 . thought to arise from cellular remnants of the notochord ( the mesodermal precursor of the vertebral column ) , chordoma is a rare , slow - growing , locally - invasive malignant tumour . the vast majority affect the base of the cranium and sacro - coccygeal region with round 15 - 20% involving the vertebral body(1,2 ) . it is generally accepted that en - bloc surgical excision with wide , tumour - free margins is the treatment of choice . adjuvant radiotherapy may also be used post - operatively , however chordomas are relatively radio - resistant and the value of radiotherapy in their treatment is still a matter of debate . chordomas are well known for their high local recurrence rates following surgery and distant metastases following treatment is reported in greater than 40% of patients ( 3,4,5,6 ) . it is extremely rare for chordoma to present in a lumbar vertebral body and this case report highlights an unusual presentation of spinal pathology . much more common is the presentation of metastatic deposits from a primary tumour elsewhere . in 2005 , patchell et al ( 7 ) published their randomised trial which established the superiority of direct decompressive surgery plus post - operative radiotherapy over radiotherapy alone for patients with spinal cord compression from metastatic disease . since then we have noticed a dramatic increase in the volume of referrals of patients with this condition . in the case of our patient , it was assumed that this l3 lesion was metastatic deposit from renal cell carcinoma based on radiological appearances . pre - operative biopsy would have established the true nature of the disease process and altered management significantly . pre - operative work - up including tissue biopsy and mdt discussion is vital to guide management . although rare , chordoma and other primary bone tumours should always be considered as a potential diagnosis of a vertebral lesion , despite its location . with our experience of the increasing presentation of spinal metastatic disease , it is important to be aware that primary tumours of the spine still do occur even when pointers to metastatic disease are present . three dimensional imaging can occasionally be misleading , and diagnostic assumptions can not always be reliably made based on radiological investigations alone .

chordoma is a rare , malignant neoplasm thought to develop from the notochord . it most commonly occurs in the base of the cranium or the sacro - coccygeal region but around 15 - 20% affect the vertebral body . extra - lesional resection with or without adjuvant radiotherapy is generally accepted as the mainstay of treatment for this slow - growing tumour . we present a case whereby a patient with a solitary l3 vertebral body lesion causing caudal compression was treated with spinal decompression and posterior stabilisation . pre - operative biopsy was not performed as the lesion was presumed to be a metastatic deposit from a co - existing renal mass . intra - operative biopsy , however , identified the tumour to be chordoma of the l3 vertebral body which would have been more appropriately treated with en - bloc excision . this case highlights the importance of pre - operative tissue diagnosis , and that , although rare ( 0.8 per 100,000 ) , chordoma should always be considered .

the objective of this paper is to demonstrate a possible and avoidable complication of laparoscopic colonie surgery . a 47-year - old woman underwent gasless laparoscopic - assisted sigmoid colectomy . on the 20th postoperative day , she developed bowel obstruction . abdominal exploration revealed a loop of the small bowel incarcerated in the mesenteric defect caused by the previous operation . despite technical difficulty , complete closure of the mesentery after bowel resection is strongly recommended for prevention of transmesenteric incarcerated hernia after laparoscopic surgery . the cause of the bowel obstruction is an incarcerated richter 's hernia in the trocar site . here we report a case with a transmesenteric hernia after laparoscopic sigmoid colectomy in which a loop of small bowel was incarcerated in a surgery - related mesenteric defect . a 47-year - old woman was admitted to our hospital for surgical treatment of sigmoid colon cancer . barium enema and colonoscopic study demonstrated a 1.5 cm 1.8 cm polypoid lesion in the sigmoid colon ( figure 1 ) . based on a diagnosis of submucosal cancer , laparoscopic - assisted sigmoid colectomy was selected for the optimal treatment . the operation was performed with curative intent using a gasless technique ( figure 2 ) previously described . lymph node dissection with low ligation of the inferior mesenteric artery was per - formed simultaneously . the mesenteric defect resulting from bowel resection was not completely closed because of technical difficulty . pathological examination revealed a well differentiated submucosal invasive cancer . on the 20th postoperative day , the patient developed abdominal distension , nausea and vomiting . plain abdominal x - ray films demonstrated a small bowel obstruction . a decompression tube ( long tube ) was inserted , and , on the 26th postoperative day , the bowel obstruction showed improvement . however , after initiating liquid meals , the patient again developed bowel obstruction . abdominal x - rays after ingestion of contrast medium showed a severely dilated small bowel ( figure 4 ) . the anal edge of the dilated loop was located near the anastomosis , and laparotomy was performed . the postoperative course was uneventful , and the patient was discharged on day 21 after the second procedure . laparoscopic approaches to colonie malignancies have gained acceptance for selected patients as a new , minimally invasive therapeutic modalities . the incidence of bowel obstruction after laparoscopic colectomy is reported to be 0.8 - 2.5% . the most frequent cause of the bowel obstruction is richter 's hernia at the trocar site . such conditions have been reported after gastroentero - logical as well as urologie and gynecological laparoscopic operations . to prevent richter 's hernia , vanclooster and tsang reported cases developing hernia after laparoscopic herniorrhaphy in which a loop of small bowel became incarcerated in the incompletely closed peritoneum . in this case , which to our knowledge is the first case in the literature , a loop of small bowel became incarcerated in the incompletely closed mesentery . closure of the mesentery after bowel resection is sometimes very difficult due to the limited operative field , especially at the most proximal portion of the mesentery . however , this case strongly suggests the need for complete closure of the mesentery to prevent bowel incarceration .

background and objectives : laparoscopic - assisted surgery has been applied for a variety of colonie surgery . the objective of this paper is to demonstrate a possible and avoidable complication of laparoscopic colonie surgery.case presentation : a 47-year - old woman underwent gasless laparoscopic - assisted sigmoid colectomy . on the 20th postoperative day , she developed bowel obstruction . decompression with a long tube failed to resolve the bowel obstruction . open laparotomy was performed . abdominal exploration revealed a loop of the small bowel incarcerated in the mesenteric defect caused by the previous operation . adhesiolysis was performed , and the post - operative course was uneventful.discussion:despite technical difficulty , complete closure of the mesentery after bowel resection is strongly recommended for prevention of transmesenteric incarcerated hernia after laparoscopic surgery .

although it can be observed worldwide , most of the patients are originated from middle east and mediterranean region.1 fmf is an inherited disease with autosomal recessive trait . the disease is caused by mutations in the mefv gene which is related to regulation of inflammatory process . approximately 95% of patients with fmf have peritoneal involvement.2 acute abdominal attacks are a serious problem . recurrent peritonitis may also result in intraabdominal adhesion formation with intestinal obstruction . in this report , a patient operated due to adhesive intestinal obstruction with fmf was presented . delay in diagnosis and treatment twenty - four year old turkish man , presented with history of nausea , vomiting and weight loss in the last ten days . he had been followed - up as an acute fmf attack in a different hospital before admission to our clinic . on physical examination the arterial blood pressure was 100/60 mm - hg with the pulse rate of 78/minute - rithmic . laboratory results were as follows : white blood cell count : 12,200/mm ( 200010,000 mm ) , crp : 138.2 mg / dl ( 05 mg / dl ) , esr : 23 mm ( 1 hour ) , 52 mm ( 2 hour ) . there was a small bowel air - fluid level in abdominal x - ray on right side ( fig . he was given intravenous fluids ( isotonic 1000 cc and isolyte 1000 cc solutions ) before operation . jejenal loops were found dilated . there were intrabdominal adhesions in between liver and peritoneum . there was an adhesion formation in small intestine causing total intestinal obstruction about 7075 cm distal to the treitz ligament ( fig . parenteral nutrition with kabiven peripheral infusion emulsion ( 3.7 ml / kg / hour ) was started postoperatively . paralytic ileus that has been developed after surgery was treated with mobilization , restricting oral intake and fluid resuscitation . tunca m had been reported that the most common surgical operation performed in fmf patients was appendectomy with the frequency of 19%.3 in other studies , the appendectomy rate had been found as 9% in patients with fmf.4 the pathological examination of these cases showed that 4% of appendix were normal without any inflammation signs . schwabe ad et al reported that about 86% of operations performed in fmf patients were non - therapeutic.5 intraabdominal adhesions secondary to recurrent peritonitis are common in fmf . a clinical study reported by ciftci et al revealed that intestinal obstruction can be detected in 3% of patients with fmf.6 berkun y reported that small bowel obstruction rate was 2.1% in fmf patients without prior abdominal surgery.7 multiple laparotomies also increase secondary adhesion formation in fmf patients . reported series of patients with intestinal obstruction and fmf in last twenty years in literature while most of the adhesions are benign in nature , some may cause serious intestinal obstruction with strangulation and perforation . trele ag reported two patients with intestinal necrosis after adhesive intestinal obstruction due to fmf peritonitis.8 our patient was suffering from intestinal obstruction for about ten days . nausea , vomiting and abdominal pain are common symptoms in acute attack and intestinal obstruction . while acute fmf attacks usually subside within 1224 hours , intestinal obstruction usually deteriorates within the time . abdominal x - ray was normal except a small bowel air - fluid level on right side . it is also important to point out that using colchicine is not a guarantee for prevention of adhesion formation . berkun et al stated that spontenous or post - surgical adhesive obstructions can be seen under colchicine treatment .

familial mediterranean fever ( fmf ) is a recurrent disease characterized by inflammatory process effecting synovial membranes such as peritoneum , pericardium and joints . it usually presents with acute abdominal pain . intestinal obstruction secondary to adhesions may be observed in fmf patients . sometimes diagnosing intestinal obstruction can be a challenging problem . we were presented a patient with fmf and adhesive intestinal obstruction . he was operated on after 10 days of symptoms . delay in diagnosis and treatment of the case discussed with literature review .

a 5-year - old boy was admitted to a district hospital with diagnosis of a right hydrocele . patient never had any respiratory problems and was taken up for surgery , but at the time of induction of anesthesia , the patient developed severe respiratory distress , so operation was postponed . later , chest x - ray done showed a dense homogenous opacity at left middle and lower zone , arising from the left paracardiac region [ figure 1 ] . x - ray of thorax revealing large mass in left mediastinum computed tomography ( ct ) scan of the chest revealed a well - defined hypodense moderately enhancing non - calcified posterior mediastinal mass ( 4.9 4.6 6 cm ) in the left paravertebral region [ figure 2 ] . magnetic resonance imaging ( mri ) of the chest showed no extension of the tumor into the spinal canal [ figure 3 ] . thus , excision of the mass was done by left posterior lateral thoracotomy [ figure 4 ] . thirteen months after surgery , he is asymptomatic with normal radiology . computed tomography scan of thorax showing mass in the left posterior mediastinum region mri of thorax showing posterior mediastinal mass with no spinal extension excised specimen of posterior mediastinal mass

ganglioneuroma is a rare benign neurogenic tumor which represents the final maturation stage of neuroblast tumors . here , we are discussing an interesting case of incidentally detected posterior mediastinal ganglioneuroma which should be kept in mind when dealing with any child with respiratory distress .

double pyramidal lobe ( dpl ) of the thyroid gland is an extremely rare anatomical variation that has been reported only twice in the literature [ 1 , 2 ] . the presence of this variation may encumber the completeness of total and subtotal thyroidectomy , which is usually the treatment of choice for benign and malignant diseases of the thyroid gland . this is the first case of total thyroidectomy on a patient with dpl reported in greece . the patient had been receiving t4 per os as medication for 2 years according to the endocrinologist 's instructions but the size of the nodules had been increased . at the admission to our institution , the patient had had palpable , movable thyroid nodules , without hoarseness or palpable cervical lymph nodes . blood tests , including t3 , t4 and tsh had been in the normal spectrum . an ultrasound scan had revealed several tumescent nodules on the right and the left thyroid lobes . following these , total thyroidectomy had been scheduled . during the operation , 1 ) . gentle resection of both pyramidal lobes was performed in addition to complete removal of the thyroid tissue in order to minimize the potentiality of local recurrence of the disease ( figs 2 and 3 ) . whole the anterior cervical region was meticulously investigated for possible thyroid tissue remnants with emphasis to the prelaryngeal region between the isthmus of the thyroid gland and the hyoid bone . the operation was uneventful and the drainage placed was removed the second postoperative day when the patient was discharged . at the follow - up , the 10th postoperative day , the patient had no complications . nodules of the thyroid parenchyma are visible . : a crude measurement of the thyroid gland size . the pyramidal lobe may be considered as an anatomical anomaly , a morphological variation or a typical part of the thyroid gland . the prevalence of its presence is 1265% [ 5 , 6 ] . as part of the thyroid gland , pyramidal lobe may originate from the right , the left lobe or the isthmus of the gland . this lobe may be connected to the thyroid cartilage or it may be attached to the hyoid bone [ 4 , 7 ] . its length and size may vary , so that the pyramidal lobe can be characterized short ( 15 mm ) , medium ( 1630 mm ) or long ( 31 mm ) . typically though its length is twice longer in females comparing to males . only two other similar cases have been documented in the literature [ 1 , 2 ] . additionally , it is said that the presence of an extended lower part of the thyroglossal tissue leads to augmentation of the size of this lobe . although rare , the presence of dpl is of great clinical significance . in fact , the pyramidal lobes as parts of the thyroid parenchyma may be striked by diseases that affect the rest of the thyroid gland . diffuse thyroid diseases , such as multinodular goiter , grave 's disease or hashimoto thyroiditis do more often affect the pyramidal lobe rather than focal thyroidopathies , such as thyroid tumors , due to its minor size in comparison to the rest of the gland . occurring to this , macroscopic , complete resection of the pyramidal lobes in total thyroidectomy , as in the present case , is compulsory , since any thyroid tissue remnant poses the possibility of recurrence of benign or malignant diseases of the thyroid gland [ 5 , 7 , 8 ] . indeed , pyramidal thyroid tissue remnants can result in recurrence of benign multinodular goiter , years after the inadequate total thyroidectomy , developing as midline neck swelling . moreover , incomplete removal of pyramidal lobe may decrease the successfulness of postoperative radioactive iodine ablation , because the remnant lobe absorbs a large amount of the isotope . when recurrence occurs , a reoperation poses a higher relative risk of complications comparing to an extended , meticulous primary total thyroidectomy . in case of probable recurrence of malignant diseases due to pyramidal remnants , scintigraphic imaging , cervical computed tomography and fna test are required to establish the diagnosis . thus , dpl should be carefully removed , as performed in the presented case , and the anterior cervical region should be promptly investigated intraoperatively for thyroid tissue remnants [ 4 , 7 ] . unfortunately , preoperative diagnosis of pyramidal lobes that could ameliorate surgical planning and technique is uncommon . ultrasonography may be helpful , but preoperative scintigraphic imaging rarely detects its presence [ 5 , 7 ] . in conclusion , dpl is a variation of key clinical significance since it affects the completeness of surgical treatment and the recurrence of benign and malignant thyroidopathies . surgeons should be always aware of this anatomical anomaly and certify the performance of complete resection of both pyramidal lobes in hemithyroidectomy and total thyroidectomy in order to achieve better therapeutic outcomes .

abstractdouble pyramidal lobe is a scarce anatomical variation of the thyroid gland . its presence impinges on the completeness of total and subtotal thyroidectomy and the postoperative treatment . surgeons should be always aware of this variation in order to perform sufficient resection of the thyroid gland and minimize the possibility of recurrence of benign and malignant thyroidopathies .

epididymo - orchitis is an important condition to recognise in a patient presenting with testicular pain . identification is crucial as it can be managed conservatively with antibiotics , unlike testicular torsion that requires urgent surgery . testicular infarction secondary to epididymo - orchitis can be difficult as clinical examination and laboratory investigations do not reliably differentiate it from uncomplicated epididymo - orchitis . conservative management , however , does not preclude the need for follow - up and reassessment if symptoms do not resolve . failure to do so can result in infarction , and as reported in this case , rupture of the testis . in addition to the risks included with surgery , if the patient had not completed his family , the resulting infertility would add a significant morbidity . in this case , early recognition and investigations with appropriate treatment were unable to prevent this outcome . a previously healthy 50-year - old man presented to hospital with a 4-day history of macroscopic haematuria , left testicular pain and dysuria . he was commenced on cephalexin by his general practitioner after his urine grew escherichia coli ( e. coli ) , and scrotal ultrasound showed left epididymo - orchitis . on arrival to hospital , he was afebrile and haemodynamically stable . investigations showed an elevated c - reactive protein ( crp ) of 253 mg / l and white cell count ( wcc ) of 22.0 10/l . his symptoms improved , and he was discharged home after 48 hours with 2 weeks of norfloxacin . he re - presented 17 days later with worsening scrotal swelling and pain , with no other systemic symptoms . he was afebrile and haemodynamically stable and examination found a swollen , tender , erythematous scrotum . there was a 1 1 cm defect in the left scrotum with purulent discharge , where the patient reported squeezing a pimple two days earlier ( fig . 1 ) . figure 1:the 1 1 cm defect in the left scrotum with purulent discharge found on examination . the 1 1 cm defect in the left scrotum with purulent discharge found on examination . repeat scrotal ultrasound showed an infarcted left testis with rupture in the mid - zone anteriorly with associated scrotal wall cellulitis ( fig . figure 2:ultrasound of the left testis on re - presentation to hospital showing : ( a ) absent blood flow consistent with infarction ( b ) rupture in the mid - zone anteriorly ( indicated by arrows ) . ultrasound of the left testis on re - presentation to hospital showing : ( a ) absent blood flow consistent with infarction ( b ) rupture in the mid - zone anteriorly ( indicated by arrows ) . he was commenced on intravenous flucloxacillin and gentamicin and underwent a left orchidectomy . intraoperative examination found oedematous scrotal wall with significant left testicular adhesions , and seminiferous tubules were visible through the defect in the left testis ( fig . 3 ) . figure 3:intraoperative photograph showing the seminiferous tubules through the defect in the left testis . postoperatively he recovered well and was discharged 2 days later with 4 weeks of ciprofloxacin and to follow up at the urology clinic . epididymo - orchitis is a common diagnosis in men presenting with unilateral testicular pain , which can be of an infectious or non - infectious aetiology . with infections , sexually transmitted pathogens such as neisseria gonorrhoeae and chlamydia trachomatis are the most common cause in men younger than 35 years , while in older men , urinary tract pathogens such as e. coli are the most common . however , complications such as abscess formation and testicular infarction may occur which are rare [ 2 , 3 ] . complications have been reported to be more common with urinary tract pathogens than sexually transmitted pathogens . in context of epididymo - orchitis , testicular infarction is caused by the compression of the testicular vasculature by the inflammation and swelling of the epididymal tissue . endothelial damage secondary to bacterial toxins leading to a vascular thrombus has also been reported to contribute . clinical examination and laboratory investigations do not reliably differentiate testicular infarction secondary to epididymo - orchitis from uncomplicated epididymo - orchitis . diagnosis is usually made by ultrasound with colour duplex , which is followed by orchidectomy if infarction or torsion is detected . risk factors predisposing to necrotic and perforated epididymo - orchitis are difficult to identify ; however , complex hydrocele on ultrasound may be associated . diagnosis is usually confirmed by ultrasound or intraoperatively . in this case , the clinical findings pointed to a more complicated case , which was confirmed ultrasonographically and intraoperatively . awareness of such consequences is important as testicular pain or acute scrotum is a common emergency and general practice presentation . immediate recognition and intervention is important as a delayed diagnosis can lead to sepsis and infertility .

epididymo - orchitis is a common diagnosis in men presenting with unilateral testicular pain . it can be of an infectious or non - infectious aetiology . clinical examination and laboratory investigations do not reliably differentiate testicular infarction secondary to epididymo - orchitis from uncomplicated epididymo - orchitis . definitive diagnosis is usually made by ultrasound . misdiagnosis and under - treatment can lead to poor outcome , such as infarction and loss of the affected testis . we present an uncommon case of epididymo - orchitis resulting in testicular infarction and rupture despite normal initial investigations .

causes of sbo include adhesion , internal hernia , volvulus and intussusception . given the alteration of gastrointestinal anatomy after bariatric surgery , diagnosis of sbo may be delayed and obscured by vague symptoms . we report a case of sbo presenting with concurrent intussusception and volvulus in a bariatric surgery patient . it is essential to have a high degree of suspicion to diagnosis sbo early and intervene promptly . a 43-year - old woman [ body mass index ( bmi ) 27.4 kg / m ] with a past medical history of morbid obesity ( bmi 53.1 kg / m ) had progressively worsening upper abdominal pain and distention with associated bilious vomiting . her past surgical history included a laparoscopic roux - en - y gastric gastrojejunostomy ( lrygb ) and cholecystectomy 7 years ago . the bypass procedure was complicated 2 years later by sbo secondary to an internal hernia , which required exploratory laparotomy and repair . four years after her lrygb , a ventral hernia developed , which was repaired laparoscopically with mesh . an upright abdominal x - ray demonstrated dilated loops of small bowel with air - fluid levels suggestive of sbo . subsequent contrast - enhanced computed tomography ( ct ) of the abdomen and pelvis showed dilated loops of small bowel with evidence of strangulation and a mesenteric whirl sign converging at a suture line ( fig . 1 ) . figure 1:axial abdominal ct scan demonstrating a target sign mass consistent with intussusception with its inferior aspect tapering to a point consistent with volvulus . axial abdominal ct scan demonstrating a target sign mass consistent with intussusception with its inferior aspect tapering to a point consistent with volvulus . intraoperative assessment revealed an infarcted volvulus segment of small bowel with twisted mesentery and proximal obstruction . sbo is a recognized complication following lrygb surgery for morbid obesity with a reported frequency of 0.24.5% . causes of sbo after bariatric surgery include adhesion , internal hernia , volvulus and intussusception . sites of internal hernias include the transverse mesocolon defect , petersen 's space and jejunal mesentery defect . intussusception is a rare cause of sbo and represents 1% of all cases of sbo . intussusception is often a late complication and may be related to significant and rapid weight loss after rygb . retrograde intussusception is the most common type reported after both rygb and lrygb [ 58 ] . anterograde and retrograde intussusception after rygb may be caused by separate mechanisms , but the etiology of both remains unclear . others propose that a suture line might act as a lead point for intussusception , as we found in our anterograde intussusception . another proposed cause of retrograde intussusception is disordered motility involving an ectopic pacemaker causing retrograde peristalsis . in our patient to our knowledge , our case is the first concurrent presentation of intussusception and volvulus in an lrygb patient presenting with sbo . both small - bowel volvulus and intussusception are often difficult to diagnose in the bariatric population . the ct scan of the abdomen with oral contrast is the best diagnostic tool for patients presenting with sbo after rygb [ 1 , 5 ] . nevertheless , a high index of suspicion is required to detect intussusception and small - bowel volvulus . volvulus and intussusception after lrygb for morbid obesity are both rare and challenging entities requiring a high index of suspicion , early diagnostic evaluation and surgical intervention . due to the surgical alteration of gastrointestinal anatomy following bariatric surgery , we report the first case of concurrent intussusception and volvulus in an lrygb patient presenting with sbo .

gastric bypass patients are at risk for small - bowel obstruction secondary to adhesions , internal hernias , intussusception and volvulus . most gastric bypass patients do not present with classic obstructive symptoms . we present a rare case of concurrent intussusception and volvulus in a woman with previous history of internal hernia following laparoscopic roux - en - y gastric bypass surgery .

the debate about intensive insulin therapy continues to be fought , with a recent paper from saudi arabia by arabi and colleagues . in 2001 , a landmark paper by van de berghe and colleagues showed that an intensive insulin regime resulted in a significantly lowered mortality in a surgical intensive care unit ( icu ) compared to standard insulin therapy . as intensive insulin therapy is a relatively simple intervention with a promising survival benefit , it is no wonder it was widely adopted by icus around the world . however , a more cautious attitude has recently been adopted following the negative results of a follow - up study by van de berghe in the medical icu and the results from the visep study suggesting harm from tight glycaemic control . in arabi 's mixed medical and surgical icu single - centred study , 623 patients were randomly allocated to either intensive insulin therapy ( aiming to keep glucose levels between 4.0 and 6.1 mmol / l ) or conventional insulin therapy ( between 10.0 and 11.1 results showed there was no statistical difference in icu mortality between the two groups ( 13.5% versus 17.1% ) . there was also no difference in any of the secondary end points except hypoglycaemia , which occurred more frequently in the intensive insulin therapy arm . based on these results , the authors stated that they ' do not advocate universal application of intensive insulin therapy to icu patients ' . the study was powered for an absolute reduction of 8% based on extrapolating the results from van de berghe and colleagues ' study , which showed an absolute mortality reduction of 3.4% . therefore , it may be criticised that this was an underpowered study ; the trend was to a reduction in mortality a non - significant absolute risk reduction of 3.6% . to look for a small absolute reduction of mortality aptly named nice - sugar , it completed the last of the recruitment in november 2008 and results are now awaited . more evidence that tight glucose control may not be beneficial for as part of an observational study , these patients received intensive insulin therapy to try and keep their systemic glucose levels between 4.4 and 6.7 mmol / l . mmol / l ) , tight ( 4.4 to 6.7 mmol / l ) , intermediate ( 6.8 to 10.0 mmol / l ) and high ( > 10 tight glycaemia control was associated with a greater prevalence of low cerebral microdialysis glucose levels and more brain energy crises . the number of brain energy crises was also associated with an increased risk of hospital death . it is well accepted that hyperglycaemia should be controlled after head injury but clearly we need to be careful because tight control may cause harm . meanwhile , the search for improvement in survival from out of hospital cardiac arrest continues . approximately 70% of patients with cardiac arrest have underlying acute myocardial infarction or pulmonary embolism . patients who had a presumed cardiac related cardiac arrest were randomised in the pre - hospital setting to either tenecteplase or placebo . if the patient was in asystole or pea ( pulseless electrical activity ) , the drug was given immediately . if in a shockable rhythm , then it was given after the third shock if there had been no return of spontaneous circulation . unfortunately , the results showed no improvement in survival or in any of the secondary outcomes . although this study shows that there is no evidence for routine use of thrombolysis in cardiac arrest , the authors make it clear that the results do not suggest that thrombolysis should be withheld in patients in whom the primary pathological condition is known to be responsive . indeed , patients who were presumed to have a pulmonary embolus were excluded from the randomisation and given tenecteplase . doig and colleagues presented a clustered randomised controlled trial across 27 icus in australia and new zealand to see if evidence - based feeding guidelines could be implemented and reduce mortality . half the participating icus carried on their normal feeding policy whilst the other half implemented evidence - based guidelines with specific measures aimed at improving compliance with the guidelines . the results of the study show that although guideline icus fed patients earlier and achieved calorific goals more often , there was no significant difference in mortality , icu length of stay or hospital length of stay . it could be that original research from which the guidelines were taken either overestimated the benefit of early feeding or was not transferable to this patient setting . other explanations may be that compliance with the guidelines was not 100% or the ' hawthorne ' effect of the control group . knowing that they were being studied may have led to improvements in their nutrition management regardless of guidelines . but the important take home message is that implementing nutrition clinical care guidelines improves feeding regimes . although it seems rational to have outreach teams that respond to a set of deranged physiological parameters , few studies have showed evidence for their benefit and others show no benefit . a prospective cohort study looked at over 24,000 adult inpatients admitted for 20 months before and after a rapid response team was introduced . the general trends in the first 20 months ( that is , the decreasing number of cardiac arrest calls ) were taken into consideration in the statistical analysis . although there was a reduction in the number of out of icu cardiac arrests , this did not translate into a significant difference in hospital mortality . it may be that introducing a rapid response team allows a more dignified death in those whose resuscitation is futile and , therefore , reduces the number of cardiac arrest calls without improving mortality . on the other hand , mortality may not have been affected because the interventions were ineffective .

studies with negative results rarely hit the headlines . but the results are often just as important as the positive ones . a number of ' negative headline ' studies are looked at in this review : intensive insulin therapy regime , thrombolysis in cardiac arrest , the effects of nutritional guidelines and rapid response outreach teams .

rup has long championed public access to research articles via a six - month embargo , and we thus support this aspect of the wellcome trust policy and the new rcuk policy . however , we question the value of a provision in their policies that specifies licensing terms for reuse of content by third parties . both organizations now require that the articles for which they have paid an immediate access fee be made available under a creative commons attribution license ( cc - by ) . this means that third parties are allowed to copy , distribute and transmit the work , to adapt the work , and to make commercial use of the work , [ as long as they ] attribute the work in the manner specified by the author or licensor ( 1 ) . cc : creative commons a nonprofit organization that provides standardized copyright licenses , which define the terms of reuse of creative work . by : attribution nc : noncommercial published work can be reused without permission , as long as it is for noncommercial purposes . sa : share alike any subsequent distribution must follow the rules set out in the original license . indeed , we could not release all of our content under a license that permits unfettered commercial reuse of the work . this would allow commercial content aggregators to bundle and sell our content without any recompense to us , thus jeopardizing our subscription revenues . , our content has been released to the public under a cc - by - nc - sa license , which allows third party use of the content for noncommercial purposes but prevents its use for commercial gain without expressed permission ( 2 ) . subscription - based publishers who do take immediate access fees from rcuk and the wellcome trust will , by necessity , have content under two different licenses the one that applies to the bulk of their content and preserves their subscription revenues and the license that applies to immediate access articles funded by rcuk and the wellcome trust . this will add considerable confusion to the research community about what third parties can and can not do with a particular journal s content . there is an initiative by the national information standards organization to tag individual articles with licensing information and to make that metadata accessible to the public ( 3 ) , but those discussions are in their infancy , and implementation is probably several years away . a final issue with the licensing provision is that it is not necessary to achieve one of the stated goals of the wellcome trust to ensure that the content will be fully accessible by anyone the need to differentiate access to content for mining from the right to mine content has been considered in detail elsewhere ( 5 ) . the intellectual property office of the uk government recently issued a clarification of the rights afforded by existing uk copyright law to allow non - commercial researchers to use computers to study published research results and other data without copyright law interfering there is legal precedent in the united states to indicate that the right to mine text and data from published research articles can fall into the category of fair use , and thus any entity noncommercial or commercial may be permitted to do so under any license ( 7 , 8) . the designation of fair use is context specific and is often controversial , confusing , and ambiguous . thus , to clarify the rup s position , we have added a statement to our licensing policy specifying that anyone , including commercial entities , is permitted to mine the text and data : the rup acknowledges that text or data mining by commercial entities for their internal research purposes is allowed without further permission from rup . available to the public for free or for a fee based on text or data mining without further permission from rup , but they may reproduce only snippets of text up to 156 characters in length , or thumbnails of images up to 72 pixels in the long direction , as part of such a service ( 10 ) . the rup s existing license to publish does not restrict mining of the content to advance scientific research by commercial or noncommercial entities ; it only restricts reproduction of the content for commercial gain . this restriction is an essential component of the business models of the vast majority of publishers , which remain subscription based ( 11 ) . cc : creative commons a nonprofit organization that provides standardized copyright licenses , which define the terms of reuse of creative work . by : attribution must be given to the original work . nc : noncommercial published work can be reused without permission , as long as it is for noncommercial purposes . sa : share alike any subsequent distribution must follow the rules set out in the original license . this provides easy access to a machine - readable form of the content for text and data miners . we encourage all publishers to participate in this service . if all participants would agree that text and data mining constitute fair use , the content could be mined by any third party regardless of the copyright / licensing terms attached to it . the name open access subset is actually a misnomer , as the content does not have to be available on an immediate basis ( or under a cc - by license ) to be included . efforts to open up citation data for mining ( 12 ) are commendable if one is trying to break the stranglehold on citation data by large commercial entities , but citations are only a small portion of the textual data in an article . there are no licensing or technical barriers to making all of the text and data published by subscription - based publishers available for mining .

the existing public access policy for our three journals the journal of cell biology , the journal of experimental medicine , and the journal of general physiology is fully compliant with new policies from the research councils uk ( rcuk ) and the wellcome trust . in addition to mandating public access , the new policies specify licensing terms for reuse of content by third parties , in particular for text and data mining . we question the need for these specific terms , and we have added a statement to our licensing policy stipulating that anyone , including commercial entities , is permitted to mine our published text and data .

pseudoaneurysms of the axillary artery are uncommon and usually encountered after penetrating or blunt trauma to the axilla ( 1 ) . in the case of blunt trauma there tends to be an associated bony injury to the shoulder and most often an anterior dislocation ( 2 ) , in which axillary artery damage has been reported at around 0.3% prevalence ( 3 ) . other injuries that have been described are fractures of the neck of the humerus and proximal humerus ( 4 ) . the usual presenting complaint is a mass near the site of the trauma that is pulsating , painful , and warm . indeed clinical suspicion can be lessened by the absence of hard initial signs of arterial injury ( 6 ) and the patient may present much later with potentially irreversible sequelae , particularly brachial plexus injuries ( 5 ) . here we describe a unique case , where the patient presented without typical features of pseudoaneurysm and no dislocation or fracture and indeed the full consequences of the injury only became apparent when significant secondary neurological deficit had occurred . a 30 year old patient presented to our institute after six months of an injury sustained to his left shoulder during a fall from a tree with complaints of progressively growing mass in left axillary region and gradual progression of neurological deficit to the point at which the arm became useless and insensate . on examination 1 ) . clinical photograph of pseudoaneurysm of left axillary artery the left radial , ulnar and brachial pulses were palpable but decreased as compared to the right side . subsequent doppler study to look for vascular compression revealed pseudoaneurysm of axillary artery , which was confirmed by ct angiography ( fig . ct angiographic cut showing pseudoaneurysm 3d reconstruction of ct angiogram showing displacement of vessel and leakage of blood into pseudoaneurysmal sac the patient was taken up for surgical management . exploration was done and the proximal and the distal part of the axillary artery were controlled with umbilical tape and brachial plexus cords were identified and preserved . after administering 1 cc heparin ( 5,000 iu ) intravenously , we clamped the proximal and distal vascular structures and opened the capsule of the pseudoaneurysm with a direct incision . the capsule was dissected and evaluated histopathologically and microbiologically . in order to avoid increasing the risk of major hemorrhage or nerve injury , we did not resect the aneurysmal pouch completely . saphenous vein graft interpositioning was then performed because vascular structure was not conducive to end - to - end anastomosis . there had been no recovery of neurological function in the arm at two months follow up . aneurysms at less common locations are generally due to major trauma , syphilis , marfan syndrome , or infection . atherosclerotic aneurysms are often seen in large arteries and in patients of advanced age , but pseudoaneurysms due to penetrating or blunt trauma are seen in patients of every age and at any location ( 7 ) . frequency of pseudoaneurysms in the upper extremities is much lower than that in the lower extremities . however , as lifespans increase and diagnostic and evaluation processes improve , the detection of such pseudoaneurysms is becoming more common . infection , polyarteritis nodosa , congenital arterial defects , and especially trauma play a role in the pathogenesis of upper extremity pseudoaneurysms . if the only causal factor is trauma , the aneurysm takes the form of a pseudoaneurysm . sometimes , as in our report , patients are admitted to hospitals with pseudoaneurysms months or years after the trauma ( 7,8 ) . pseudoaneurysms typically present as a mass near the site of the trauma that is pulsating , painful , and warm . since this patient presented late and without any typical features of pseudoaneurysm or evident bony injury , it was misdiagnosed as soft tissue tumor . pseudoaneurysms after blunt trauma to the shoulder tend to occur in the third part of the axillary artery . one theory for this is the lesser mobility of this region of artery because of the relatively fixed nature of the circumflex humeral and subscapular arteries , leading to tearing of the axillary artery with attempts at mobilisation ( 3,4 ) . pseudoaneurysms of axillary artery are very rare in absence of bony injury in blunt trauma ( 9 ) . in our case patient this has been described by several authors and can occur as a primary injury or delayed , as the aneurysm grows in size and compresses the plexus ( 10 ) . delay in decompression is of paramount importance for recovery ( 1 ) . in this case decompression two months post surgery , assessment by the rehabilitation team had not shown any sign of recovery . the poor outlook is supported by several authors , including robbs et al ( 5 ) , who reported 12 cases of delayed ( after one to six weeks ) compression of the brachial plexus by an axillary pseudoaneurysm in a variety of injuries . the outcome of the six patients presenting initially with total brachial plexus lesions were that none recovered fully and one showed no recovery whatsoever at 18 months . the lesion was repaired by open surgical approach so as to remove organised thrombus , which was causing compression of the neurovascular bundle of arm . an endovascular approach with insertion of a covered stent is a less invasive option for early cases of pseudoaneurysms .

traumatic pseudoaneurysm of the axillary artery is a rare sequela of injury to shoulder region . we report here a unique case of delayed presentation of axillary artery pseudoaneurysm after a blunt injury , clinically mimicking soft tissue tumor without evidence of gross bony injury . the gentleman presented after six months of injury with a progressively growing mass in left axillary region and neurological deficit . ultimate management of the lesion was surgical resection and saphenous vein graft interpositioning . unfortunately the lack of subsequent neurological recovery parallels some of the findings in the literature , from cases where decompression of the brachial plexus was not undertaken soon enough .

to report an unusual case of a branch retinal arterial occlusion and bilateral multifocal retinitis in a young woman with cat scratch disease . a 23-year - old woman was referred to our clinic complaining of a sudden scotoma in the upper part of the visual field of her left eye . fundoscopy revealed occlusion of an inferior temporal branch of the retinal artery in the left eye and bilateral multifocal retinitis , which was confirmed by fluorescein angiography . both retinitis and arterial occlusion were resolved , the visual field was regained and the patient reported elimination of her symptoms . cat scratch disease should be considered in the differential diagnosis in young patients with retinal occlusive disease . humans can be infected by cat scratches , bites or contamination of open surface wounds with cat saliva and feces of the cat flea . it normally manifests as a localized papule , macule or pustule at the inoculation site followed several weeks to months later by a regional , tender lymphadenopathy . general symptoms , such as headache , anorexia , sore throat , nausea and vomiting , are commonly present as well . in about 510% of cases , cat scratch disease may present with a wide spectrum of ocular symptoms , ranging from the most common primary oculoglandular syndrome , to neuroretinitis and rarely to vascular ( arterial / venous ) occlusions . we describe here the occurrence of a branch retinal arterial occlusion in a young woman diagnosed with cat scratch disease . a 23-year - old woman was referred to our clinic with a 2-day history of scotoma in the left upper visual field of her left eye . examination of the anterior segment did not reveal any abnormal findings , while a mild vitritis was noted in both eyes . fundoscopy revealed an occlusion of the inferior temporal branch of the left retinal artery ( fig . 1 ) and multiple foci of retinitis in the posterior pole of both eyes , more prominently in the left . fluorescein angiography was subsequently performed , which confirmed the diagnosis of arterial occlusion and the presence of vasculitis ( fig . 2 ) . leakage of the inferonasal part of the left optic disc was also noted . two weeks after presentation her clinical symptoms started to improve , while fundoscopy and fluorescein angiography showed resolution of the retinal arterial occlusion . laboratory analysis showed a positive igg titer for b. henselae ( igg = 512 , positive > 128 , indirect immunofluorescence ) that continued to rise during the second month of the disease ( igg = 1,024 ) and declined afterwards . based on the elevated serum igg titers , the diagnosis of cat scratch disease was established . the patient could not remember any incidents of being scratched or bitten by a cat despite the presence of 2 kittens in a nearby premise . the patient was advised to take oral doxycycline 100 mg bd for 4 weeks , but discontinued the treatment 3 weeks later . at follow - up , 2 months after the initiation of treatment , there was complete resolution of both the arterial occlusion and retinitis . by that time , some hard exudates had started to appear in the left macular region , without forming the typical ring of a macular star ( fig . branch retinal arterial or venous occlusions have been previously reported in patients with cat scratch disease . bartonella 's propensity to colonize and cause direct damage to the vessel wall , leading to vascular thrombosis and occlusion , has been reported as well [ 2 , 3 ] . moreover , the inflammatory process from an adjacent or even distant area of inflammation may further incite edema and thickening of the vessel wall , expediting the occlusion of the vessel . the case presented here stresses the importance of a high index of suspicion for the possibility of bartonella infection whenever a young patient appears with occlusion of the retinal vessels ( arterial / venous ) , since vascular occlusions of atherosclerotic origin are relatively rare in this specific age group . cat scratch disease may occur in individuals who do not own a cat , and a history of an animal scratch or bite is not necessary . the disease can be transmitted by arthropod vectors , ticks , fleas or biting flies . the authors have no proprietary interest and there was no financial support for this study .

purposeto report an unusual case of a branch retinal arterial occlusion and bilateral multifocal retinitis in a young woman with cat scratch disease.methodsa 23-year - old woman was referred to our clinic complaining of a sudden scotoma in the upper part of the visual field of her left eye . fundoscopy revealed occlusion of an inferior temporal branch of the retinal artery in the left eye and bilateral multifocal retinitis , which was confirmed by fluorescein angiography . subsequent indocyanine angiography did not reveal choroidal involvement . laboratory analysis showed rising igg titers for bartonella henselae.resultscat scratch disease was diagnosed , and a 4-week course of doxycycline was initiated . the patient responded well to the antibiotics . both retinitis and arterial occlusion were resolved , the visual field was regained and the patient reported elimination of her symptoms.conclusionscat scratch disease should be considered in the differential diagnosis in young patients with retinal occlusive disease .

to report a case of retinal detachment with a macular hole following photodynamic therapy ( pdt ) using verteporfin and intravtreal bevacizumab injection in the treatment of myopic choroidal neovasclarization ( cnv ) . a 58-year - old woman was diagnosed with myopic cnv and treated with a combination of pdt with verteporfin and intravitreal bevacizumab injection that same day . the patient developed a sudden decline in vision one week after the second injection ; and was subsequently diagnosed with retinal detachment associated with a macular hole . she underwent standard three - port pars plana vitrectomy with internal limiting membrane peeling , fluid - air exchange and silicone oil injection . the retina was still firmly attached at the patient 's final follow - up visit . pdt and intravitreal bevacizumab injection used for the treatment of myopic cnv can be associated with retinal detachment with a macular hole . patients need to be informed about this potential complication , and a higher index of suspicion may be warranted in patients who report sudden vision loss after the treatment . a 58-year - old woman was diagnosed with cnv secondary to pathologic myopia in her right eye ( right eye = -17 d , left eye = -15 d ) ( fig . the best corrected visual acuity in the affected eye as measured with a snellen chart was 20/200 . after an informed discussion of available therapies , the patient received combined pdt and 1.25 mg intravitreal bevacizumab injection . four weeks after the initial treatment , the patient received a second intravitreal bevacizumab injection . both treatments were uneventful . a week after receiving the second injection , the patient presented with worsening vision in her right eye . her visual acuity was counting fingers at 1 m. examination revealed retinal detachment involving the posterior pole with a macular hole . ocular coherence tomography ( oct ) confirmed the presence of a macular hole ( fig . the patient underwent standard three - port pars plana vitrectomy with internal limiting membrane peeling , fluid - air exchange and silicone oil injection . during the operation , peripheral fundus examination was performed with scleral indentation , and no additional peripheral hole was observed . on follow - up one week later , the macula had flattened and visual acuity was 20/400 . the development of retinal detachment with a macular hole may occur as a spontaneous process in highly myopic eyes.4 however , the retinal detachment with a macular hole in our patient occurred shortly after pdt and repeated injections of intravitreal bevacizumab . several possible mechanisms may have induced the development of retinal detachment with a macular hole . the intravitreal injection may have induced vitreous incarceration at the needle insertion site , causing vitreoretinal traction leading to development of a macular hole and subsequent retinal detachment.5 - 7 we performed a combined treatment , and there has been a report of macular hole development several weeks after pdt treatment using verteporfin . lastly , bevacizumab itself may have caused the macular hole by modulating the permeability and activity of the cnv and inducing contraction of the vascular membrane , leading to exacerbation of tangential traction on the overlying retina.9 - 11 the short duration in the onset of retinal detachment with a macular hole after the second injection of intravitreal bevacizumab also suggests a possible causal role of the drug . in conclusion , pdt and intravitreal bevacizumab injection in the treatment of myopic cnv patients need to be informed about this potential complication , and a higher index of suspicion may be warranted in patients who report sudden vision loss after the treatment .

purposeto report a case of retinal detachment with a macular hole following photodynamic therapy ( pdt ) using verteporfin and intravtreal bevacizumab injection in the treatment of myopic choroidal neovasclarization ( cnv).methodsa 58-year - old woman was diagnosed with myopic cnv and treated with a combination of pdt with verteporfin and intravitreal bevacizumab injection that same day . she received the second injection of intravitreal bevacizumab four weeks after the initial treatment.resultsthe patient developed a sudden decline in vision one week after the second injection ; and was subsequently diagnosed with retinal detachment associated with a macular hole . she underwent standard three - port pars plana vitrectomy with internal limiting membrane peeling , fluid - air exchange and silicone oil injection . the retina was still firmly attached at the patient 's final follow - up visit.conclusionspdt and intravitreal bevacizumab injection used for the treatment of myopic cnv can be associated with retinal detachment with a macular hole . patients need to be informed about this potential complication , and a higher index of suspicion may be warranted in patients who report sudden vision loss after the treatment .

a 65-year - old man with a past medical history of morbid obesity , hypertension , paroxysmal atrial fibrillation , depression and arthritis developed substernal chest pressure and palpitations and presented to the emergency department in september 2013 for evaluation . his family history was significant for renal cancer in his mother , breast cancer and lung cancer in his sisters , diffuse large b cell lymphoma in his brother , colon cancer in his maternal grandfather , head and neck cancer in his paternal grandmother , bladder cancer in his maternal uncle , and childhood leukemia in a nephew . the general physical examination revealed an obese man with a heart rate of 140/minute but was otherwise unremarkable . the abdominal exam revealed no tenderness or hepatosplenomegaly . a complete blood count ( cbc ) evaluation of the peripheral blood smear revealed a mild basophilia ( 2% ) and myelocytes ( 1% ) and meta myelocytes ( 1% ) . examination of the marrow revealed a slightly hypercellular marrow with a granulocytic hyperplasia [ fig . 2 ] . karyotype analysis revealed 46 , xy , t(9;22 ) ( q34;q11.2 ) in 20 cells analyzed and was the sole abnormality observed . fish performed with the abl1/bcr probe identified the fusion of the abl on chromosome 9 with the bcr gene on chromosome 22 in 90.5% of the metaphases . quantitative reverse transcriptase - polymerase chain reaction analysis revealed the presence of the bcr - abl transcript ( p210 form ) in 162/200 ( 81.0% ) cells scored . the initial hematology opinion recommended initiating tyrosine kinase inhibitor therapy , and the patient sought a second opinion . considering his asymptomatic presentation and stable blood counts , the treating physicians supported a plan of active surveillance with periodic cbcs and differential and ldh . cml was the first malignancy to be linked to a clear genetic abnormality , the philadelphia chromosome . this chromosomal abnormality is so named because of the city in which it was first discovered and described in 1960 by peter nowell and david hungerford . the fusion protein results in increased activity of a tyrosine kinase and several other signal transduction pathways with deregulation of the normal control mechanisms of granulopoiesis . in most published series of consecutive patients diagnosed with cml the total leukocyte counts are elevated . in one recent series , 245 patients were analyzed and 178 of these ( 72.6% ) were in chronic phase . canellos and whang - peng reported on a 43-year - old male with a leukocyte count of 8800/cmm but 6% metamyelocytes and 7% myelocytes . the ph was detected in 22% of the metaphases and the patient remained asymptomatic for five years without treatment before developing a blast crisis . a second case was reported more recently by hudnall and coworkers from the university of texas , galveston . their case was complicated by the simultaneous presentation of hodgkin lymphoma , stage iii , successfully treated . the total leukocyte count remained normal for 15 months after recognition of the bcr - abl transcript .

chronic myelogenous leukemia ( cml ) , in the chronic phase ( cp ) , is often suspected as a result of a complete blood count ( cbc ) , which shows increased granulocytes , mostly mature including a peak in myelocytes , increased basophils , and rarely blasts and/or promyelocytes . morphologic dysplasia is not present . cml is confirmed by detecting the characteristic philadelphia chromosome ( ph)[t(9;22)(q34;q11.2 ) ] by routine cytogenetics or fluorescent in situ hybridization ( fish ) or molecular studies ( rt - pcr ) for the bcr - abl fusion gene.the most common feature of cml is an elevated wbc count , usually above 25103/l , and frequently above 100103/l . we report a case of confirmed ph+cml with a normal cbc detected because of the presence of rare myelocytes and 2% basophils [ fig . 1 ] . previous leukocyte counts for the preceding eight years were normal with the exception of one done four months prior to his presentation that showed an abnormal differential with 1% basophils , 2% metamyelocytes and 2% myelocytes .

a 45-day - old male weighing 4,030 g with a length of 54.8 cm presented to the hospital with unexplained persistent irritability and decreased feeding . a plain chest x - ray showed an abnormal air shadow below the sternum ( fig . 1 ) . the patient was the second born of twins at 36 weeks and five days of gestation . his birth weight was 2,070 g. the right inguinal hernia was treated with surgery 33 days after birth at another hospital . the morgagni diaphragmatic hernia and left inguinal hernia were diagnosed using computed tomography of the chest and abdomen ( fig . an operation was performed 66 days after birth , at that time the patient 's weight was 4,100 g. a one - stage aparoscopic repair was planned to repair the morgagni and left inguinal hernias . under general anesthesia , the transverse colon was herniated through the diaphragmatic defect , which did not have an anterior rim . the transverse colon with the hernia sac was pushed back into the abdominal cavity , and then the hernia sac was removed . the small bowel was reduced , and the internal inguinal ring was repaired with a 3 - 0 black silk purse - string suture . there were no complications during the operation . the patient was discharged uneventfully on postoperative day 7 . at the 1 year follow - up laparoscopic congenital diaphragmatic hernia repair in an infant was first reported by van der zee . currently , using a laparoscopic approach to treat morgagni or inguinal hernias has gained increasing popularity . there are a number of advantages of laparoscopic surgery including minimal pain due to smaller incisions and a short recovery time . the development of minimally invasive surgery ( mis ) for infants and young children was first reported in the 1990s . however , the advancement of this technique has been significantly restricted due to the lack of pediatric - sized laparoscopic instruments . as the development and increased supply of laparoscopic instruments for small infants and children have become available , there are potential problems with anesthesia such as decreased oxygen saturation , transient hypotension , hypercarbia , and respiratory acidosis due to insufflation with carbon dioxide gas . because carbon dioxide insufflation can rapidly worsen the respiratory and hemodynamic conditions of small newborns , it is necessary to select healthier newborns that can tolerate carbon dioxide insufflation . there are specific surgical problems associated with laparoscopic surgery in infants such as difficulty of placement and stabilization of the trocar , difficulty of movement in the small abdominal cavity , and the fact that the abdominal wall is very flexible . for these reasons , iwanaka et al . reported a high rate of visceral injuries in small infants . even though special attention is needed for such patient groups , good result the patient was only in the third percentile of standard growth in korea . despite his small size , he was hemodynamically stable and had stable respiratory function . if he had undergone open surgery , he would have required separate or longer incisions for both hernias . for this reason , one - stage laparoscopic repair of the morgagni and inguinal hernias was used . typically , the location of the ports , in thoracoscopic or laparoscopic surgery , is made according to the baseball diamond concept of triangulation of the instruments and scope . in the current case , two trocars for the instruments were inserted at the same level of the camera port ( paraumbilical ) ( fig . these port locations allowed for the correction of both hernias on the cephalad and caudad position of the camera port . in this small infant with a morgagni and inguinal hernia , one - stage laparoscopic surgery can be performed without making an additional incision line depending on the location of the ports .

the development of morgagni hernias is related to malformations of the embryologic septum transversum after failure of the sternal and costal fibrotendinous elements of the diaphragm to fuse . the overall incidence of morgagni hernias among all congenital diaphragmatic defects is 3% to 4% . inguinal hernias are the most common hernias in males and females ( 25% and 2% , respectively ) . an inguinal hernia is defined as a protrusion of the abdominal cavity contents through the inguinal canal . the combination of morgagni and inguinal hernias is rare , and treatment using laparoscopic surgery has not been previously reported . this case presents a one - stage laparoscopic repair of morgagni and inguinal hernias in a 2-month - old male .

a 20-year - old male soldier was referred to our clinic for the evaluation of refractory chronic bacterial conjunctivitis . over the previous 4 months , he had been treated for copious mucous discharge , conjunctival injection , and superficial punctate keratitis on both eyes at an army hospital and a local eye clinic . the transfer note stated that citrobacter koseri was cultured from a conjunctival swab , but targeted topical and systemic antibiotic treatment based on antimicrobial susceptibility testing had not been effective . in our clinic , he also complained of ocular redness , pain , and severe discharge in both eyes . slit lamp examination showed multiple punctate erosions on the inferior cornea and severe conjunctival injection on both bulbar and palpebral conjunctiva ( fig . moxifloxacin 0.5% ophthalmic solution ( vigamox ; alcon laboratories , fort worth , tx , usa ) was prescribed for use every 2 hours . as s. xylosus was reported to be resistant to moxifloxacin , topical vancomycin eye drops were added ; however , despite 4 weeks of topical antibiotic treatment , the patient showed no improvement . on the repeated conjunctival swabs , microorganisms continued to be cultured , but different bacterial strains were observed , including a. baumannii and chryseobacterium indologenes . the patient 's complete blood count was normal , and serologic tests such as human immundeficiency virus antibody were negative . during the repeated smear and culture of conjunctival swabs , 3 ) , revealing that the condition was a self - inflicted bacterial keratoconjunctivitis involving the patient 's own semen . we informed the patient and his father of the smear results and recommended a psychiatric consultation . many different types of self - inflicted eye injuries have been reported including self - enucleation , penetrating orbital injuries using pens and pencils , endophthalmitis , corneal infection , lens dislocation , and retinal detachment . they are usually associated with psychiatric disorders , such as schizophrenia , drug - induced psychosis , obsessive - compulsive disorder , depression , and mental retardation . organic mental disorders like temporal lobe epilepsy , encephalitis , or neurosyphilis also have been associated with self - inflicted eye injuries . the diagnosis of self - inflicted eye injuries can be divided into malingering and factitious disorder according to the existence of external incentives . the intentionally feigned signs and symptoms of malingering are consciously motivated by a secondary gain , a recognizable external incentive . however the feigned symptoms of factitious disorder satisfy the unconscious need for a primary gain which arises from the motivation of assuming the sick role . external incentives , such as an exemption from military duties , a re absent in the case of f actitious disorder . malingering can also be distinguished from factitious disorder by whether or not there is implied psychopathology . however , it can be difficult for an ophthalmologist to distinguish whether conjunctivitis is self - inflicted or not . furthermore , it is even more difficult to discern whether a self - inflicted behavior arises from conscious or unconscious origins , and whether the patient 's primary motive is to assume the sick role or to acquire secondary gains . collateral information from family , friends , or a psychiatrist is needed . in this case , the patient was compulsorily conscripted into the army . whenever he sought treatment for his eye problem , he could avoid military duties , and he showed a surprising lack of concern that his condition was not responding to treatment . he was diagnosed as malingering because the signs and symptoms were thought to be motivated by a secondary gain , an exemption from military duties . they summarized the reliable signs of self - inflicted conjunctivitis as follows : purulent discharge purposely left on the lashes and periorbital skin , severity of the discharge greater than that of the conjunctival hyperemia , severity of the conjunctival chemosis less than that of the conjunctival hyperemia , predominantly inferior conjunctival involvement , and uninvolved cornea . however , in this patient , the conjunctival hyperemia was severe on both superior and inferior conjunctiva and many microorganisms continued to be cultured from conjunctival swabs . this patient caused mucous discharge , severe conjunctival hyperemia , and bacterial conjunctivitis with his own semen . in previous reports , various methods , such as paper , cotton wool , jequirity , and castor oil were used to produce keratoconjunctivitis . in cases of chronic keratoconjunctivitis that do not respond to appropriate antibiotic treatment , self - inflicted disease or malingering laboratory examination can provide diagnostic clues , including unusual pathogens like those seen in this patient . the attitude of the patient may also provide helpful information for diagnosis , because some factitious patients show a happy , unconcerned , and/or detached attitude regarding their medical problems . malingering does not imply psychopathology ; however , psychiatric consultation should be considered in these patients because the condition may coexist with true mental disorders such as major depressive , bipolar , and personality disorders .

this case report describes a case of self - inflicted chronic bacterial keratoconjunctivitis involving the patient 's own semen . a 20-year - old male soldier was referred to our clinic for the evaluation of refractory chronic bacterial conjunctivitis . over the previous 4 months , he had been treated for copious mucous discharge , conjunctival injection , and superficial punctate keratitis in both eyes at an army hospital and a local eye clinic . despite the use of topical and systemic antibiotics according to the results of conjunctival swab culture , there was no improvement . during the repeated smear and culture of conjunctival swabs , surprisingly , a few sperm were detected on gram staining , revealing that the condition was self - inflicted bacterial keratoconjunctivitis involving the patient 's own semen . thus , in cases of chronic keratoconjunctivitis that do not respond to appropriate antibiotic treatment , self - inflicted disease or malingering should be considered .

a 56-year - old man was admitted to our hospital because of an anterior neck mass . the patient had no other specific history , including familial history , and had good general status . on the physical examination , an approximately 4.0 cm movable , non - painful , and soft mass on the anterior neck was observed . a neck computerized tomography showed a small fatty mass at the subcutaneous tissue of the anterior neck . periodic acid - schiff ( pas ) stain was positive in the secretory granules and intraluminal secretions of the eccrine glands ( fig . on immunohistochemistry , the myoepithelial cells surrounding the eccrine glands were positive for smooth muscle actin ( fig . they proposed the name " adenolipoma of the skin " due to the presence of eccrine sweat glands in the benign tumors of adipose tissues . daboin et al.5 reported on 6 patients with adenolipomas of the head and neck region : 3 in the parathyroid , 2 in the thyroid , and 1 in the parotid gland . the microscopic features of adenolipomas arising in the thyroid gland showed neoplasm surrounded by a fibrous capsules and were also composed of fat and thyroid follicles . the adenolipomas of the parathyroid gland were also an intimate admixture of mature adipocytes and small chief cells arranged in nests and acini . it is the author 's conclusion that the concept of adenolipoma is an admixture of mature fat tissues , which are the main components of common lipoma , and glandular tissue , which are present at each of the viscera and in the tissues where the tumor occurs . our case was a variant of superficial lipoma that was characterized by the presence of eccrine sweat glands . eventually , we were able to diagnose this case as adenolipoma of the skin due to the eccrine glands of the skin adnexa entrapped in the mature adipocytes . adenolipoma of the skin presents as a solitary , slow - growing , and painless tumor.3 the main sites in which the tumor occurs include the thigh , shoulder , thorax , and upper extremities . the tumor size varies from 1.0 cm to 6.0 cm in diameter.4 conventionally , adenolipomas of the skin consist of a proliferation of mature adipocytes admixed with several benign - looking eccrine glands and ducts . however , according to the previous report by kazakov et al.,1 adenolipoma of the skin has a conventional lipomatous component , but the lipomatous component may also correspond to the lipomatous component of spindle cell lipoma . the eccrine gland and duct can be observed in various morphologies ; including cystic duct dilatation , epithelial hyperplasia , and clear cell or squamous metaplasia.1 the differential diagnosis of adenolipoma of the skin includes common lipoma , eccrine angiomatous harmatoma,2,6 and nevus lipomatous superficialis.2,7 adenolipoma is observed with a similar clinical manifestation to common lipoma , but adenolipoma looks a little smaller and may be more common in older age compared with common lipoma.2 eccrine angiomatous harmatoma is a developmental disorder and is typically a solitary lesion on lower extremities . histologically , eccrine angiomatous hamartomas usually occur in the deep dermis and contain an increased number of eccrine structures and numerous capillary channels surrounding or intermingled with the eccrine structures.6 nevus lipomatous superficialis shows groups of soft and flattened papules or nodules that have smooth or wrinkled surfaces . on histopathologic findings , nevus lipomatous superficialis is characterized by groups and strands of fat cells embedded among the collagen bundles of the dermis.2,7 because adenolipoma of the skin is an extremely rare tumor , we need to prove whether the glands and ducts entrapped in the mature adipocytes are true skin adnexal components . the intracytoplasmic granules and intraluminal secretions of secretory cells lining the lumen are pas - positive . myoepithelial cells surrounding eccrine glans are positive immunohistochemically for smooth muscle actin , p63 and s-100 protein . therefore , these special and immunohistochemical stainings are helpful in diagnosis . the treatement and prognosis of adenolipomas are the same as that of common lipoma because they are considered to be benign .

we report here a case of adenolipoma of the skin , an unusual variant of lipoma , arising on the neck . a 56-year - old man visited our hospital due to an anterior neck mass . an excisional biopsy was performed . the mass revealed a tan - yellow soft cut surface . we could not find any difference from other lipoma on gross inspection . microscopically , the mass showed proliferation of mature adipocytes admixed with several eccrine units . the eccrine units were demonstrated by periodic acid - schiff - positive granules in the secretory portions and by positivity of smooth muscle actin in the myoepithelial cells surrounding the eccrine glands . the tumor was completely excised , and the patient has been followed up without any evidence of recurrence so far .

prevalence of massive obesity continues to increase and only bariatric surgery has succeeded in providing sustained weight loss ( 1 ) . laparoscopic sleeve gastrectomy ( lsg ) accounts for approximately 30% of bariatric procedures performed worldwide ; and its coexistence with partial situs inversus is one in a million . most of the global documented procedures in situs inversus involve gastric bands , gastric bypass and cholecystectomies ( 2 ) . very limited / solitary data on lsg in partial situs inversus with this being the first of its kind in india . situs inversus partial is a congenital developmental anomaly wherein the abdominal organs are reversed or mirrored to the opposite side of the body through the sagittal plane . in contrast , situs inversus totalis is a similar condition in which both the thoracic and abdominal contents are reversed ( 2 ) . transmitted through an autosomal recessive inheritance , these anomalies have been in vogue since the 17 century . a 32 yr old morbidly obese female weighing 111 kg and bmi of 41.41 was electively admitted to the hospital . she had tried a number of diet and exercise programmes but failed to sustain reduced weight loss . she was a known case of partial situs inversus as diagnosed earlier during her pregnancy few years ago . she underwent standard pre - operative workup including physician , psychological and anaesthetic assessment satisfying our selection criteria for surgery . she had no history of diabetes or ischemic heart disease though blood pressure was 130/80 mmhg . stomach was on the right side , normal in shape , increased size , normal mucosal pattern , no ulcer . ileocecal junction , caecum and appendix was in left iliac fossa . descending and sigmoid colon located on the right side close to ascending colon . ct scan of chest / abdomen and pelvis showed enlarged mediastinal lymph nodes and situs inversus . patient was admitted one day prior to surgery and lsg was performed in january 2011 . primary operating surgeon stood on the left side of the patient as contrast to usual right side . operative feel was uncomfortable ; as in a right handed person writing by a left hand . most of the time single hand technique had to be used instead of both hands . upper gi contrast studies postoperative upper gi contrast study was performed and showed no evidence of leak and a well designed vertical sleeve of the stomach . she was given standard advise to remain on liquid diet for 2 weeks , followed by 2 weeks of soft diet , before reintroducing solids . situs inversus is a rare congenital developmental anomaly with autosomal recessive inheritance wherein the position of organs in chest and abdomen are reversed along sagittal plane . the incidence of partial situs inversus in less than 1 in 22000 . if associated with primary ciliary dyskinesia , sinusitis and bronchiectasis and infertility in males , it is called kartagener syndrome found in 25% of patients ( 3 ) . incomplete or partial situs inversus is invariably associated with cardiac abnormalities like septal defects , pulmonary arterial stenosis , tetralogy of fallot , transposition of great vessels , and alimentary tract problems like atresia and stenosis of duodenum ( 4 ) . most of the individuals are unaware of their usual anatomy until they seek medical attention for an unrelated condition , when it is discovered incidentally . in our patient , though there was cough , dyspnoea and chest pain , routine chest x - ray was normal as the defect involved only abdominal organs . laparoscopic bariatric surgery in situs inversus has been reported in very few cases , wherein one patient underwent laparoscopic gastric banding ( 6 ) , laparoscopic gastric bypass ( 5 ) and lsg each ( 3 ) . in india , so far this case stands as the first of its kind in partial situs inversus ( 2,4 ) . certain aspects of this type of surgery are challenging and it is recommended that an experienced laparoscopic surgeon carry out the procedure . using a mirror image approach to all parts of the operation enabled us to successfully complete the procedure . using this technique , our operating time was only slightly longer than normal ( 120 mins v / s 60 mins ) . lsg is thus a safe and feasible surgical procedure in situs inversus patients with very good results .

laparoscopic surgery in a patient with partial situs inversus may pose interesting challenges to the surgeon . here we report a case of a morbidly obese young female with partial situs inversus who underwent laparoscopic vertical sleeve gastrectomy ( lsg ) . the peri - operative challenges very many and these have been enumerated . the mirror image approach is recommended in such cases for a successful surgery which was not employed in this case . postoperative barium swallow was normal and the patient has been on regular follow up .

evidence on therapies for the psoriasis of difficult - to - treat areas like palms and soles , nail , scalp intertriginous areas is grossly lacking management of psoriasis is always difficult . apart from being very notorious in showing frustrating therapeutic response in many cases , this has a natural tendency toward frequent relapse . most of the systemic drugs that are used traditionally to treat this disease are known to have significant adverse effects on the body . long - term safety data are lacking for most of the newer drugs like biologics . to add trouble to this , there are some body areas that are even more resistant to treatment or are too sensitive to be treated with strong topical drugs necessitating systemic drugs more frequently in these locations . this article has focused on the available evidence on the treatment of such difficult - to - treat areas such as palms - soles , scalp , nails , and intertriginous areas and suggested the most logical therapeutic recommendation in such conditions . this article has been prepared after reviewing extensively the published and one unpublished article searching three internationally accepted large database called pubmed , embase , and cochrane database . inclusion criteria were published articles on the treatment of difficult - to - treat psoriasis as mentioned above . keywords used were psoriasis , hand , feet , palm , sole , intertriginous , flexure , scalp , and nail . in this era of evidence - based medicine , there is progressively increasing trend toward following scientifically logical treatment protocol as suggested by quality studies or from meta - analysis and systematic reviews . evidence - based therapeutic guidelines assist the practicing physicians and dermatologists in delivering uniform , scientific , and evidence - based treatments to the patients . this article has been prepared after critically reviewing these articles on psoriasis management and evaluating their level of evidence ( loe ) as per the oxford centre for evidence - based medicine 2011 guideline [ table 1 ] . the oxford 2011 levels of evidence while dependency on evidence as obtained from meta - analysis and systematic review has increased exponentially , it is now also known that therapeutic recommendation , although should be based on , but not limited to the strict theoretical outcome obtained from these evidence - based analyses . preparing any therapeutic suggestion socioeconomic , cultural , genetic , and ethnic factors play a significant role in therapeutic response of a drug . a major drawback while formulating any therapeutic guideline is lack of multiple well - designed trials conducted among population for which guideline is being planned . best care has been employed to prepare an appropriate and logical suggestion for the use of practicing physician to be used among indian population and people of similar ethnic and socioeconomic background . evidence - based medicine is the most accurate method of collating the available scientific data . however , there are some weaknesses too . outcome of even systematic review may not find the universal truth . result of very high - quality evidences such as meta - analysis has been contradicted by subsequently done large rct . some bias may still exist . nevertheless , the great scientific credibility of evidence - based medicine being stated and accepted , there is no scope for ignoring one vital issue in planning a therapeutic recommendation based on the scientific evidence . result obtained from rcts and even systematic reviews may not appear feasible in the practical field . as mentioned earlier , many social , religious , economical , and regional factors become crucial while proposing any therapeutic recommendation to be successfully used in the field . this review is an updated evidence - based review of the available articles on the management of psoriasis of difficult - to - treat areas and a proposed therapeutic recommendation based on the evidence . it is expected that this will be helpful for the practicing physicians of india and many other countries having similar patient profile in terms of socioeconomic , cultural , racial , and genetic parameters . this document provides updated evidence on the management of psoriasis of difficult - to - treat areas and suggests practical , scientific and logical treatment options for these conditions . this document provides updated evidence on the management of psoriasis of difficult - to - treat areas and suggests practical , scientific and logical treatment options for these conditions . this document provides updated evidence on the management of psoriasis of difficult - to - treat areas and suggests practical , scientific and logical treatment options for these conditions .

psoriasis is resistant to treatment and it shows frequent relapse ; systemic treatment is often associated with toxicities , and long - term safety data are lacking for most of the newer drugs like biologics . moreover , some body areas such as hands , feet , intertriginous areas , scalp , and nails are even more resistant . frequently , systemic treatments are necessary considering the higher psychological impact on the patient . there is a lack of agreement on the best therapeutic modalities in the management of psoriasis involving difficult - to - treat locations . at present , there are no indian guidelines for these conditions . available literature has been reviewed extensively on the treatment of psoriasis involving difficult - to - treat locations ; level of evidence has been evaluated as per the oxford centre for evidence - based medicine 2011 guideline , and therapeutic suggestions have been developed . best care has been employed to consider socioeconomic , cultural , genetic , and ethnic factors to prepare a therapeutic suggestion that is appropriate and logical to be used among indian population and people of similar ethnic and socioeconomic background .

a 79-year - old woman presented with complaints of redness and purulent discharge in the left eye for the previous 2 days . samples were taken from the inferior fornix for microbiological examination using two separate conjunctival swabs . the cultures were then inoculated onto blood and chocolate agar , incubated at 36c for 48 hours and evaluated with a neisseria haemophilus identification ( nh ) card on a vitek2 compact system ( biomerieux , marcy , ietoile , france ) . the patient was empirically put on fucidic acid ( fucithalmic gel 1% ) therapy four times daily , but did not respond to this treatment . on the third day , treatment was changed to ofloxacin ( exocin 0.3% , allergan ) four times daily with fluorometholon ( efemoline 1% , novartis ) four times daily added in spite of the fact that usage of corticosteroids is controversial as it may contribute to progression of the infection by inhibiting the immune response . then , a second sample was taken . in the first sample , gram stain revealed large numbers of polymorphonuclear leukocytes and gram variable diplococci [ fig . 1 ] . on sheep blood agar and chocolate agar plates , small the same organism grew in the culture of the sample taken at the second visit . the identification of the organism was accomplished by standard biochemical tests and with a nh card on vitek2 compact system . the organism was oxidase positive , dnase negative , catalase positive , nitrate reduction positive and produced acid from glucose , fructose , maltose , and sucrose . using the vitek2 system , the organism was identified as n. sicca with a bionumber of 0632400000 and 98% probability . there are no accepted criteria for evaluation of the antimicrobial susceptibility of this organism according to the clinical and laboratory standards institute ( clsi ) . furthermore , in vitro susceptibility testing of the isolated bacteria can not always guide the therapy of conjunctival infections , while susceptibility interpretations of minimum inhibitory concentration ( mic ) values are based on serum concentrations . mic values of ceftriaxone ( 0.125 g / ml ) , benzylpenicillin ( 2 g / ml ) , tetracycline ( 1 g / ml ) and netilmicin ( 1 g / ml ) were determined using etest ( ab biodisk , solna , sweden ) on muller hinton agar with 5% sheep blood agar . as the patient did not respond to the previous treatments and slit - lamp examination findings remained the same , she was given netilmicin ( netira sifi , spa , catania , italy ) drops four times daily . three days later , there was no evidence for conjunctivitis and the patient 's complaint resolved . any organism cultured from conjunctival samples needs to be interpreted within the context of the clinical case and other supportive laboratory evidence . if clinical suspicion is high and many polymorphonuclear leukocytes and organisms are seen in gram stains of samples , even unusual or environmentally isolated organisms should be reported to avoid false - negative reporting . the isolated microorganism , n. sicca , did not respond to wide spectrum antibiotics such as fucidic acid and ofloxacin , but responded to netilmicin . this fact implies that netilmicin may be used empirically in future conjunctival infections caused by this organism . as the patient was not known to be immunocompromised or diabetic , and had no history of using any eye drops on a chronic basis which might change the conjunctival flora , n. sicca was considered as the causative agent for her conjunctivitis . although there was no history of trauma mentioned , as she was a farm worker she might have been unaware of a minor trauma which might have caused unilateral conjunctivitis . one conjecture for the source of the bacteria might be the oropharyngeal flora as some neisseria species are found in the oropharnyx . following a medline search incorporating keywords neisseria sicca and conjunctivitis , to the best of our knowledge , conjunctivitis caused by this organism has not been previously reported . n. sicca has been implicated in cases of meningitis , pneumonia , endocarditis , peritonitis and urethritis . when microbiological examination is considered in conjunctivitis cases , this procedure helps the laboratory to define the causative organism and consider the pathogenicity of the isolated bacteria . this case confirmed the potential pathogenicity of n. sicca in conjunctiva and emphasizes that positive cultures for this organism should not be readily dismissed ; netilmicin proved an effective treatment in such cases .

we report the first case , in medline - based literature , of conjunctivitis caused by gram negative diplococcus , neisseria sicca . although it is not widely accepted as such , isolation from cultures of repeated eye swab samples suggests that n. sicca may be a pathogen in conjunctival infections . positive culture for this organism should not be readily dismissed . such conjunctivitis responded favorably to treatment with netilmicin eye drops .

paracoccus is a gram negative coccoid bacterium , which comprises a wide number of species and comes under rhodobacteraceae family . members of this genera are versatile exhibiting a tremendous range of metabolic flexibility , utilizing a variety of organic compounds including potentially hazardous pollutants 1 such as n , n - dimethylformamide 2 , pyridine 3 , chloroacetamides 4 , n - methylpyrrolidone 5 and known for its adaptation to the prevailing environmental conditions . many studies on the attributes of multifaceted paracoccus towards utilization of various compounds are underway and continued to be an emerging area of interest in bioremediation . mku1 from the textile industrial effluent near tirupur , tamil nadu , india 6 and the genome of paracoccus sp . the genomic dna was isolated and the whole genome sequencing was performed using the miseq illumina sequencing platform . paired end reads with the insert size of 300 bp has achieved 100 fold genome coverage with the paracoccus sp . the raw sequence reads r1 and r2 of about 1,609,204 reads respectively generated by illumina sequencing were merged using pear software tool 7 and the de novo assembly was done using dnastar 's seqman ngen software ( version 12.0 ) . the assembly yielded 242 contigs ( n50 contig size , approximately 58 kb ) accounting for a total length of 5.3 mbp with the largest and smallest contigs of about 338,971 bp and 628 bp respectively . mku1 genome assembly showed a size of 5,388,713 bp with a mean gc content of 66.7% . gene predictions and annotations were performed with rapid annotation using subsystem technology ( rast ) database 8 and ncbi prokaryotic genome annotation pipeline ( pgap ) ( http://www.ncbi.nlm.nih.gov/genome/annotation_prok/process/ ) . based on rast results , there were 5421 genes , 342 pseudogenes and 1 crispr array annotated from ncbi pgap . three complete 5s rrna , one partial 16s rrna and two partial 23s rrna encoding regions were predicted from rnammer 1.2 9 . the phast server 11 predicted five prophage regions with the sizes of 13 kbp , 21.7 kbp , 15.4 kbp , 9.2 kbp and 95.3 kbp . it was found that some mobile elements , hypothetical proteins , uncharacterized conserved proteins , abc transporter related proteins and some predicted transcriptional regulators of different families such as merr , gntr and laci are found as the novel regions in paracoccus sp . as paracoccus sp . is biochemically versatile genus , well known for its unique nitrate reduction properties and various metabolisms of utilizing variety of compounds , rast functional annotations of paracoccus sp . mku1 showed that there are 99 genes involved in nitrogen metabolism , where 37 genes involved in denitrification ; 206 genes involved in stress responses ; 75 genes involved in resistance to antibiotics and toxic compounds including cobalt , zinc , cadmium , mercury and chromium ( figure 1 ) . analysis of genes for enzymes involved in dmf degradation pathways showed the presence of methylamine dehydrogenase and formamidase . furthermore , there are 115 genes involved in degradation of various aromatic compounds , where 29 genes are involved in peripheral pathways for catabolism of aromatic compounds and 73 genes are involved in metabolism of central aromatic intermediates . the genome analysis showed the presence of genes involved in the degradation of various xenobiotics namely toluene , benzoate , p - hydroxy benzoate , aromatic amines , biphenyls , catechols and chloroaromatic compounds . in addition , pathways of salicylate and gentisate catabolism , protocatechuate and catechol branch of beta - ketoadipate pathways , homogentisate pathways known to be involved in aromatic hydrocarbons degradation are also found . the draft genome of paracoccus sp . mku1 provide insights into the genes involved in the degradation of various xenobiotics , which can further open up the opportunities for potential exploitation of the versatile bacterium for bioremediation of xenobiotic compounds . dna sequence raw data has been uploaded in sequence read archive ( sra ) with the accession number srx1601982 . dna sequence raw data has been uploaded in sequence read archive ( sra ) with the accession number srx1601982 .

paracoccus sp . mku1 , a novel dimethylformamide degrading bacterial strain was originally isolated from an industrial effluent , tirupur region , tamil nadu , india . here , we report the draft genome sequence of paracoccus sp . mku1 , which could provide the genetic insights on its evolution and application of this versatile bacterium for effective degradation of xenobiotics and thus in bioremediation .

ectopic thyroid gland can be found in the region of the neck , the mediastinum , the pharynx , the larynx , the esophagus , the trachea , and around the aorta . patients with ectopic mediastinal goiter are usually asymptomatic and reported as incidental finding on chest radiograph . we present image findings of iodine-131 ( i-131 ) uptake in a mediastinal ectopic benign colloid goiter in i-131 whole body scan ( wbs ) and hybrid single - photon emission computed tomography / computed tomography ( spect / ct ) in the case of papillary carcinoma . a 29-year - old female presented with palpable thyroid nodule which was confirmed as papillary carcinoma , and she underwent total thyroidectomy . she was referred for i-131 wbs , which showed residual thyroid in the anterior neck along with an intense uptake in the mediastinum [ figure 1 ] . spect / ct of the chest [ figure 2 ] revealed an anterior mediastinal mass measuring 7 6 4 cm with calcification . total excision of the mass with thymectomy was done , and histopathology revealed primary ectopic nodular colloid goiter with adenomatous hyperplasia with no malignancy . she underwent radioiodine ablation therapy with the dose of 100 mci ( 3.7 gbq ) and post therapy i-131 wbs showed good residual thyroid uptake with no residual in mediastinum [ figure 3 ] . after 6 months , her thyroglobulin was < 0.2 ng / ml , and i-131 wbs showed complete ablation of the residual thyroid [ figure 4 ] . whole body iodine-131 scintigraphy shows uptake in thyroid remnant and in mediastinum single - photon emission computed tomography / computed tomography of chest showing increased uptake localized to anterior mediastinal mass lesion posttherapy whole body iodine-131 scintigraphy after mediastinal mass excision showing only remnant thyroid uptake with no residual disease in mediastinum iodine-131 scintigraphy after 6 months showed complete ablation of the remnant thyroid mediastinal ectopic thyroids with no connection to normal thyroid gland are very rare , accounting for < 1% of all cases , but rare mediastinal ectopic thyroid is also important to consider in the differential diagnosis of mediastinal masses . mediastinal tumors include primary thymic carcinomas , neuroendocrine carcinomas , germ - cell tumors , and lymphomas , as well as neurogenic , endocrine , and mesenchymal tumors . more rarely , primary thyroid tumors ( adenomas or carcinomas ) may occur in the mediastinum without cervical disease . biallelic mutations in foxe1 have been shown to result in thyroid ectopy in mice ; however , till date , no mutations in known genes have been associated with human ectopic thyroid tissues . thyroid scintigraphy with i-131 or technetium-99 m is highly sensitive and specific for detecting normal and ectopic thyroid tissues . integrated i-131 spect - ct imaging has an additional value in patients with thyroid cancer , for characterization of tracer uptake seen on planar imaging as well as for precise localization of malignant lesions in the neck , chest , and skeleton . this localization of i-131 uptake may have a clinical impact on patient management by influencing referral for i-131 treatment , tailoring of the administered radioiodine dose , and/or the addition of surgery or external radiation therapy when indicated . mediastinal goiter can remain asymptomatic until the structures located in the thoracic inlet are compressed . the chief complaints in reported mediastinal ectopic thyroid cases are painful or pulsating retrosternal mass , dyspnea , and cough . surgery for mediastinal goiters should always be considered , even in elderly patients because they can be malignant and can have mass effects on the surrounding structures . this interesting case illustrates the use of i-131 wbs and spect / ct in an ectopic mediastinal nodular benign colloid goiter .

ectopic thyroid tissue primarily occurs along the course of the embryologic migration of the thyroid gland . mediastinal thyroid may be differentiated into primary and secondary form . primary mediastinal goiters are quite rare , occurring in < 1% of all goiters . we present findings of 29-year - old female , case of papillary carcinoma of the thyroid who underwent iodine-131 whole body scintigraphy after total thyroidectomy showed a primary mediastinal mass lesion along with residual thyroid . she underwent mediastinal mass excision through sternotomy and biopsy confirmed as ectopic nodular colloid goiter with no malignancy .

good oral health is an essential part of general health ; however , there is a widespread perception that oral diseases are limited to the scope of dental practice . scarce integration exists between dentists and other health - care professionals in academic , research , and professional fields . poor oral health reflects social inequalities ; therefore , the prevention of oral diseases should be a priority in developed and underdeveloped countries around the world . compelling evidence links periodontal disease with systemic conditions of medical interest including diabetes , pregnancy complications , cardiovascular disease , respiratory diseases , osteoporosis , rheumatoid arthritis , and cancer . the prevalence of periodontitis in india is reaching epidemic proportions with serious implications for general health . it is expected that health - care providers will see and refer these patients to dentists in greater numbers . hence , evaluating medical doctors knowledge will assist in providing appropriate level of continuing - education programs and assessment for efficacy . therefore , the study aimed to assess the views and knowledge of medical doctors on the association between periodontal disease and general health and their willingness to advise their patients to seek dental treatment . this study was carried out by a cross - sectional survey using a self - administered , structured questionnaire distributed to medical doctors at hospitals and medical college in nellore district . all physicians and internists participated in the study voluntarily , following an explanation of its purpose and objectives . the respondents were divided into four groups based on the type of service followed those practicing in public service ( group i ) , those having only private practice ( group ii ) , those practicing in teaching institute ( group iii ) , and internists ( group iv ) . the questionnaire was designed by a principal investigator and distributed by the principal investigator and co - investigators . the questionnaire included 22 multiple - choice questions addressing : socio - demographic personal characteristics , physicians perceptions of the relationship between oral health and general health , dental referral , and source of information about oral health . all 267 ( 100% ) respondents knew at least few signs and symptoms of periodontal disease and were of the opinion that there existed a relation between oral health and general health . among all , 86.1% ( 230 ) of respondents agreed that they referred their patients to dentists but of them only 10.1% ( 27 ) of respondents referred without the patient asking for referral , 25.8% ( 69 ) of respondents referred to a specialist , and only 9.7% ( 26 ) respondents enquired about their dental treatment in the subsequent visit [ table 2 ] . among 267 respondents , only 57 ( 21.3% ) statistical analysis and comparison between socio - demographic and personal characteristics did not show any significant associations , owing to the small sample size . sociodemographic personal characteristic variables ( n=267 ) referral to dentist ( n=267 ) source of information about oral health ( n=267 ) medical doctors may have an advantageous position compared to the dentists to provide early patient counseling about oral health because children and adults attend advisable offices more often than to dental offices and are more likely to be affiliated to medical than to dental insurance . moreover , they are more likely to work in rural and underserved areas than dentists , which represent a remarkable opportunity for physicians to work as active players in oral health promotion . early diagnosis of gingivitis and periodontitis by medical doctors , along with patient referral to dental care , will surely improve the oral health and general health status of the population . to date , many studies have demonstrated that periodontitis is a risk factor for many systemic conditions . although this information is easily available in the medical literature , little information is available regarding the knowledge of medical doctors with regard to periodontitis . despite the evidence linking periodontitis with systemic diseases , most medical doctors are unaware of the potential benefits of maintaining a good oral health . among medical doctors practicing in nellore district , this study showed that while knowledge regarding signs and symptoms of periodontal disease and relation between oral health and general health was high , importance of regular dental check - ups was low even though most of the dental clinics ( 89.5% ) are within 1 km from their work place . among 267 respondents , only 69 ( 25.8% ) referred their patients to a specialist and only 27 respondents ( 10.1% ) referred for regular dental check up . screening and referral by health - care professionals may benefit their patients by improving access to dental care . therefore , there is a need to educate doctors about oral health and general health . doctors should be informed about the increased risk of periodontal problems and the importance of having dental check - ups . these results might not reflect the actual opinions of all medical doctors due to small sample size . sample size should be large enough to divide into groups and to detect significant differences for some of the outcomes between the groups and this survey should be conducted in other parts of india and the world . the potential benefits of physicians as active players in oral health need to be emphasized in medical schools and continuing medical education programs , where curriculum contents in oral health may be largely insufficient . it is time to change the perception of dentists and dental hygienists as the only ones responsible for maintaining good oral health in the population .

the study aimed to assess the knowledge of medical doctors on the association between periodontal disease and general health and their willingness to advise their patients to seek dental treatment . in a cross - sectional survey , randomly selected medical doctors ( n = 267 ) practicing in nellore district were interviewed through a questionnaire survey about their knowledge of periodontal diseases and the bidirectional relationship between general health and periodontal diseases . data were analyzed through percentages . all the medical doctors ( 100% ) were aware that there existed a relation between oral health and general health . but only 10% of respondents refer their patients to dentists without patients asking for referral . very few respondents ( 21.3% ) knew about different branches of dentistry . screening and referral by healthcare professionals may benefit their patients by improving access to dental care . therefore , there is a need to educate doctors about oral health and general health .

it inhibits bacterial dna synthesis and is used to treat a number of bacterial infections . norfloxacin is registered for therapeutic use in acute recurrent urinary tract infections , prostatitis , bacterial gastroenteritis , gonorrheal urethritis , proctitis , and cervicitis as well as for prophylactic use in neutropenic patients . a 48-year - old woman presented in the emergency department with giddiness , restlessness , and rash over thigh and abdomen . the patient reported these symptoms after taking two doses of oral norfloxacin for suspected urinary tract infection from a practitioner . there was no history of allergy , diabetes mellitus , hypertension , and ischemic heart disease . on physical examination , she was afebrile with pulse rate of 84/min , blood pressure 124/80 mm hg , and respiratory rate 20/min . the patient 's initial laboratory evaluation showed random blood sugar 46 mg / dl and simultaneous serum insulin level was 37.8 u / ml ( normal range : 6.0 - 27.0 u / ml ) . other hematological and biochemical blood tests were within the normal range . electrocardiogram ( ecg ) , chest x - ray , and abdominal ultrasonography did not reveal any abnormality . she had symptomatic relief after administration of 50 ml of intravenous 50% dextrose ; hence , subsequent treatment with intravenous dextrose was not required . concurrent therapy at the time of the patient 's hypoglycemic event consisted of oral paracetamol 500 mg . no fever was recorded during the hospital stay . from hospital admission until the day of discharge , there was no further episode of hypoglycemia and her blood glucose level was in the range of 71 - 140 mg / dl . published reports are available for ciprofloxacin , gatifloxacin , and clinafloxacin,[17 ] but , to our knowledge , there are no published reports of hypoglycemia with norfloxacin . the primary theory of fluoroquinolone - associated hypoglycemia is twofold , consisting of both pharmacokinetic and pharmacodynamic effects . the pharmacokinetic mechanism involves drug drug interactions , while the pharmacodynamic mechanism comprises the possibility of enhanced pancreatic -cell stimulation and subsequent increased insulin release . other investigators have also demonstrated the effect of lomefloxacin and norfloxacin on adenosine 5-triphosphate ( atp)-sensitive potassium channels in pancreatic -cells . in our patient , laboratory evaluation showed relatively inappropriate insulin elevation at the time of hypoglycemic episodes , consistent with pancreatic -cell stimulation . causality analysis by using naranjo adr probability scale indicated a probable relationship between the adverse effect of hypoglycemia and norfloxacin therapy in this patient . the urticarial rash also strongly supports a probable relationship between the adverse reaction of hypoglycemia and norfloxacin therapy . hypoglycemic stress can activate the release of corticotrophin - releasing hormone ( crh ) by postganglionic sympathetic neurons as well as the hypothalamus . concurrently administered drugs should be considered for their potential to cause hypoglycemia alone or as a result of a drug drug interaction . however , in our case , oral paracetamol is less likely to cause hypoglycemia either alone or as a result of a drug drug interaction .

fluoroquinolone - induced hypoglycemia is not a common adverse drug reaction . however , it has been reported with most of the available agents and appears to be more common in elderly patients with a history of type 2 diabetes who are receiving oral sulfonylureas . the exact mechanism of this effect is unknown but is postulated to be a result of blockage of adenosine 5-triphosphate ( atp)-sensitive potassium channels in pancreatic -cell membranes . this report highlights hypoglycemia with urticaria as an adverse drug reaction of norfloxacin in a middle aged non - diabetic patient . clinicians should be alert about the possibility of its potential adverse effect in patients who are receiving norfloxacin therapy .

a 65-year - old male presented with sudden visual loss of his right eye of 4 days duration . his initial best - corrected visual acuity was 0.05 and a relative afferent pupillary defect ( 1.8 log unit ) was present . fundus examination of his affected eye demonstrated optic disc edema and a flame - shaped peripapillary hemorrhage ( fig . 1 ) . the optic disc edema involved the whole disc , with the exception of the superior zone . the early phase of an intravenous fluorescein angiogram showed a segmental perfusion delay of the optic disc ( fig . the erythrocyte sedimentation rate , c - reactive protein levels , and protein c concentration were all normal . the patient did not show any characteristics of arteritic anterior ischemic optic neuropathy and was diagnosed with acute naion . the patient was informed of the natural history of naion and the fact that there is no proven effective treatment for naion . after full explanation of the expected effects and possible complications of ivta , the patient provided informed consent . an intravitreal injection of 4 mg/0.1ml triamcinolone acetonide ( ta ) was performed in the affected eye . the ivta injection was performed in a surgical room under sterile conditions with topical anesthesia ( alcaine , alcon , usa ) . the injection was administered with a 30 gauge needle , 4.0 mm from the inferotemporal limbus . to prevent infection and ocular hypertension due to the ivta , the patient received topical antibiotics ( vigamox , alcon , usa ) following the injection and his intraocular pressure was measured 24 hours after the ivta injection and at each follow - up visit . measurements of the patient 's best - corrected visual acuity by snellen acuity , goldmann perimetry , applanation tonometry , slit lamp biomicroscopy , and fundus examination of the affected eye were performed at 2 weeks , 1 month , 3 months , and 6 months following the ivta . the patient 's best - corrected visual acuity changed from 0.05 before the injection to 0.16 at 2 weeks , 0.3 at 1 month , and 0.4 at 3 months postoperatively and at the final visit . the optic disc edema had markedly decreased at 1 week and disappeared at 2 weeks following the injection . at 3 months after the ivta injection , we observed a segmental pale neuroretinal rim ( 5 o'clock-11 o'clock ) during the fundus exam ( fig . the area of the pale neuroretinal rim corresponded with the previous segmental perfusion delay seen with the fluorescein angiogram . the patient did not develop intraocular pressure exceeding 21 mmhg , progression of cataract , or endophthalmitis during follow - up . the patient presented here showed a relatively good recovery of visual acuity and a rapid resolution of optic disc edema . the patient 's best - corrected visual acuity improved by five snellen lines following the ivta injection . there was also a marked decrease in optic disc edema during the first week after the injection and resolution of the optic disc edema by the second week . the natural course of optic disc edema in naion has been reported to spontaneously resolve within 6 - 8 weeks.2,8 we suggest that rapid resolution of the optic disc edema in this patient may be the major cause of visual acuity recovery . it has been inferred that rapid reduction of optic disc edema by ivta could prevent further tissue damage by stopping a vicious cycle of ischemia , edema , and compartment syndrome occurring in naion.2,6 another possibility may be that ivta could serve to decrease macrophage presence in the affected areas of infarcted brain and optic nerve;9 however , we do not have any histological proof of this hypothesis . the result of the present study corresponds with karderli et al.6 who reported that ivta led to recovery of visual acuity in 4 naion patients . however , our finding is different from those of jonas et al.,7 who reported that ivta was not effective in visual acuity recovery for 3 naion patients . twenty mg of ta is 5 times greater than the 4 mg used in our study and by karderli et al.6 ; a higher dose of ta remains in the eye longer . one of the patients in the study by jonas et al.7 developed ocular hypertension following ivta injection . a high intraocular pressure might interfere with vascular circulation and axoplasmic transport in the affected eye . in addition , they did not mention the duration of optic disc edema following the ivta injection . this is the first case report that demonstrates visual acuity recovery in acute naion following ivta injection in a korean patient . considering that there is no proven effective treatment for naion , ivta injection could be an alternative and effective treatment option for acute naion without any systemic complications . however , large randomized controlled trials may be necessary to establish the efficacy and safety of ivta injections as the treatment of choice for acute naion .

the purpose of this case report is to evaluate the visual outcome of an intravitreal triamcinolone acetonide injection ( ivta ) as a treatment for a patient with acute nonarteritic anterior ischemic optic neuropathy ( naion ) . a 65-year - old male patient with severe visual loss due to acute naion was treated with 4 mg/0.1ml ivta . fundus examination and measurements of the patient 's best - corrected visual acuity and visual field were performed before and after the injection at 2 weeks , 1 month , 3 months , and 6 months . the best - corrected visual acuity changed from 0.05 before the injection to 0.16 at 2 weeks , 0.3 at 1 month , and 0.4 at 3 months and at the final visit . optic disc swelling had markedly decreased at 1 week postoperatively and disappeared at 2 weeks after the injection . the clinical course of this patient suggests that an ivta may be effective in increasing visual acuity following an acute naion . a large randomized controlled trial is needed to assess the efficacy of ivta as a treatment for naion .

in an interesting study in 34 comatose survivors of cardiac arrest ( cscas ) , alvarez and colleagues compared the performance of repeated standard electroencephalography ( seeg ) and continuous eeg ( ceeg ) . they evaluated the two main objectives of eeg monitoring in cscas , namely the assessment of background activity and reactivity and the detection of postanoxic status epilepticus ( pse ) . the entire ceeg recording was compared to two extracts , which served to replicate seeg . the extracts were taken early during therapeutic hypothermia ( th ) and shortly after the return to normothermia , respectively . agreement between seeg and ceeg was 97.1% ( 95% confidence interval , 84.6 to 99.9% ) for evaluating background discontinuity and reactivity and 94.1% ( 95% confidence interval , 80.3 to 99.2% ) for pse detection . studies done after the introduction of th confirmed the crucial contribution of eeg to neurological monitoring . cerebral background activity and reactivity in the absence of sedation are among the most reliable predictors of the neurological outcome [ 2 - 5 ] . in addition , eeg monitoring ensures the detection of pse during th , at a time when neuromuscular blocker therapy eliminates any clinical seizures . eeg monitoring also provides information on the effectiveness of the treatment given to control pse . finally , after rewarming and neuromuscular blocker withdrawal , eeg monitoring helps to characterize subcortical postanoxic myoclonus , which must be distinguished from pse . as emphasized by alvarez and colleagues , eeg monitoring can be carried out continuously or intermittently . despite the absence of proof of superiority , however , the equipment and staff time needed for ceeg monitoring are not available in all icus . in addition , ceeg is of interest only if an expert is continuously available for real - time interpretation of the traces . however , caution is in order regarding the practical impact of the results obtained by alvarez and colleagues . in several studies that used continuous amplitude - integrated eeg or ceeg , a continuous background pattern during th or normothermia was almost invariably associated with recovery . similarly , reactive ceeg background activity was associated with recovery , whereas nonreactive ceeg background activity during th predicted death . in the study by alvarez and colleagues , early seeg would have led to an erroneous assessment of the potential for recovery in 1 of the 34 patients , whose background activity and reactivity improved a few hours after the cardiac arrest . such changes in background activity and reactivity would probably be more common with sedation protocols using propofol instead of midazolam ( as used in the study by alvarez and colleagues ) . pse occurs during th in about 15% of patients , during rewarming in 8% to 20% , and shortly after the return to normothermia in 33% . whereas pse is independently associated with poor outcomes , favourable outcomes have been reported in some patients with pse occurring after ( but not during ) th . early identification and aggressive treatment of pse may improve outcomes , although this possibility remains unproven to date . nevertheless , early pse diagnosis and treatment are currently a major objective in cscas . according to the study by alvarez and colleagues , obtaining two seeg recordings , during th and after the return to normothermia , respectively , moreover , the rewarming phase carries a high risk of pse but was not investigated in this study . ceeg : continuous electroencephalography ; csca : comatose survivor of cardiac arrest ; eeg : electroencephalography ; pse : postanoxic status epilepticus ; seeg : standard electroencephalography ; th : therapeutic hypothermia .

electroencephalography ( eeg ) monitoring is an important tool in the management of comatose survivors of cardiac arrest . the results serve to predict the neurological outcome , identify postanoxic status epilepticus , and assess the effectiveness of antiepileptic treatments . continuous eeg monitoring might seem the most attractive option but is costly and requires the continuous availability of an expert to interpret the findings . alvarez and colleagues compared repeated standard eeg to continuous eeg monitoring in comatose survivors of cardiac arrest . they found close agreement between these two strategies . however , their results do not constitute evidence of similar performance . in comatose survivors of cardiac arrest , repeated standard eeg should be used only when continuous eeg monitoring is unavailable .

an 84-year - old man visited our hospital with a chief complaint of right scrotal swelling . he had a 1-month episode of a rapidly growing painless mass on his right scrotum . his past medical history was unremarkable , and he had no previous history of trauma or infection . physical examination revealed a nontender , hard , 6.0-cm mass in the testis of the right scrotum . there were no features of cavernous diseases such as cutaneous port - wine hemangioma , varicose veins , or bony hypertrophy . the laboratory results , including complete blood count , serum electrolytes , and serum tumor markers , were all within the normal range . scrotal ultrasonography ( us ) demonstrated a hypoechoic , multilobulated mass with septation in the right testis , and low blood flow was seen on color doppler us ( fig . 1 ) . there was no extension to the perineum or groin and no regional lymph adenopathy . the testis was diffusely thickened and showed dilated blood vessels filled with blood ( fig . 3 ) . the postoperative course was uneventful and no recurrence was seen after 1 year . they belong to the group of low - flow vascular lesions and have radiologic features of both venous and lymphangial malformations . although hemangiolymphangiomas occur relatively rarely , some cases have been reported as part of a congenital cavernous syndrome such as klippel - trenaunay - weber syndrome . klippel - trenaunay weber syndrome is a rare congenital soft tissue anomaly characterized by the presence of multiple hemangiomas , asymmetric limb hypertrophy , and arteriovenous fistulas . although hemangiolymphangioma is considered a benign disorder , it has a tendency to infiltrate adjacent tissues and to recur locally . it can occur in a variety of anatomic locations , including the axilla , abdominal cavity , and extremities . our patient had cavernous hemangiolymphangioma of the testis without other lesions , making him an unusual case in the literature . the coexistence of these two pathological entities suggests a possible common etiology and pathogenesis related to anomalies of lymphojugular sacs developing in embryos . although the diagnosis of hemangiolymphangioma is essentially made by pathologic study of the surgical specimen , modern radiological techniques , such as computed tomography scan , magnetic resonance imaging , and blood - pool scintigraphy using technetium - human serum albumin combined with diethylenetriaminepenta - acetic acid studies , can show the vascular component of the mass before surgery and could be very helpful in diagnosis and in planning an appropriate surgical procedure . in our case , we recommended that the patient undergo a computed tomography scan , but he did not want to undergo further costly imaging studies . the prognosis of hemangiolymphangioma is generally considered to be favorable , with only a rare incidence of malignant transformation . also , in our patient , the postoperative course was uneventful and no recurrence was seen after 1 year . hemangiomas usually do not cause difficulty in diagnosis , because the patients present with a palpable scrotal mass . furthermore , doppler us is a helpful diagnostic tool to demonstrate the nature of the mass and to differentiate it from other testicular neoplasms . lymphangiomas are congenital lymphatic malformations thought to result from the failure of the sequestered embryonic lymph sacs to communicate with the venous system . histologically , lymphangiomas are classified as capillary , cavernous , and cystic according to the size of the dilated lymphatic space within the tumor . about 95% of lymphangiomas occur in the neck and axilla , and the remaining 5% occur in the mediastinum , mesentery , retroperitoneum , and in bone . lymphangiomas in the scrotum are extremely rare . because lymphangiomas are multiseptated tumors , they appear as multiseptated hypoechoic masses on us . in our patient , us demonstrated a hypoechoic , multilobulated mass with septation in the right testis . the testis was diffusely thickened and showed dilated blood vessels filled with blood . histological examination of the resected specimen showed features of both hemangiomatous and lymphangiomatous components . to our knowledge , this is an extremely rare case of cavernous hemangiolymphangioma of the testis . therefore , we report this case as a reminder that hemangiolymphangioma can occur in the testis without cutaneous hemangiomatosis in older patients .

hemangiolymphangioma is an extremely rare malformation of both the lymphatic and blood vessels . to date , however , there are no reports in the literature of a hemangiolymphangioma of the testis . an 84-year - old man visited our hospital for investigation of a 1-month episode of a rapidly growing mass in his right scrotum . scrotal ultrasonography revealed a multilobulated mass with septation in the testis . testicular tumor markers were within the normal limit . radical orchiectomy was performed . at surgery , a red , wide - based , nodular tumor was found on the testis . histological examination of the resected specimen showed it to be a cavernous hemangiolymphangioma . here we report this first case of a cavernous hemangiolymphangioma of the testis without cutaneous hemangiomatosis in an elderly patient .

congenital hypertrophy of the upper extremity is a rare , nonprogressive phenomenon , involving the hand and forearm and sometimes the whole extremity . we report a 28-year - old male with hypertrophy of both hands to illustrate this unusual clinical syndrome . a 28-year - old , right - handed , healthy male had been suffering from pain and cramping sensations in both his hands for years since working as a crane driver . his work involved operating a crane with a joystick in each hand . as long as he could remember , he had had big hands compared to those of his peers of the same age . physical examination revealed an increased muscle bulk of both hands and the right forearm , with the right hand being slightly bigger than the left hand . in particular , both abductor pollicis muscles , the dorsal intrinsic hand muscles , and the abductor digiti quinti showed an increased muscle belly volume ( fig . 1 ) . motor and sensory functions of the hands were normal , as was the rest of the neurological examination . laboratory tests , including sedimentation rate and creatine phosphokinase revealed no abnormalities . t1- and t2-weighted mri showed diffuse enlargement of the muscle mass , in particular of both abductor pollicis muscles , the intrinsic muscles , the abductor digiti quinti , and the right forearm flexor compartment ( fig . the maximal axial diameters of the muscle belly of the first dorsal interosseus muscles were 24 16 mm ( right ) and 25 18 mm ( left ) . the only normal values we could find in the literature were from 5 healthy males who had a muscle belly width of 9.6 0.5 mm on ultrasound ( mean of radial and ulnar muscle proportion ) . there are no normal values known for the abductor pollicis muscle [ 1 , 2 ] . the right forearm axial diameter measured at maximum ( 10 cm from the elbow ) 54.75 53.12 mm , compared to 50.04 50.58 mm for the left arm . the muscles had a normal density without signs of architectural change , fatty infiltration , tumors , or fluid accumulation . visual ultrasound assessment also showed a normal echogenicity ( i.e. heckmatt grade i ) of the muscles . needle electromyography examination of the right abductor pollicis brevis , biceps brachii , left extensor digitorum communis , abductor pollicis brevis , and abductor digiti minimi showed sporadic polyphasic , large motor unit potentials with a normal interference pattern . because of the mild enlargement , its nonprogressive nature , and the absence of other abnormalities , no further workup ( such as muscle biopsy or search for a somatic mutation in pik3ca ) was performed . on the basis of the patients history , physical examination , and imaging , given the work - related nature of the symptoms , he was referred to a rehabilitation physician who successfully instructed him how to avoid cramps and pain . the condition varies in severity and has been reported under different names , such as aberrant muscle syndrome and congenital monomelic hypertrophy [ 2 , 3 , 4 , 5 , 6 , 7 , 8 ] . on mri and ultrasound , muscle tissue is characterized by normal signal intensity and architecture . the condition is most likely not due to selective hypertrophy ( i.e. a training effect ) but to a local increase in muscle mass because of a local genetic variation or mosaicism affecting the growth rate . the etiology of this focal muscle bulk increase is unknown and does not seem to be confined to a peripheral nerve , part of the plexus , or nerve root territory , i.e. neurogenic hypertrophy . previous ( unilateral ) cases told a similar story with old photos as evidence [ 4 , 5 ] . cases of bilateral involvement have been described four times so far ( table 1 ) [ 1 , 6 , 9 , 10 ] . in the 3 adult cases , only the first dorsal interosseus muscles were involved , whereas our patient had diffuse involvement of all hand muscles , with prominence of the abductor pollicis muscles . to our knowledge , this is the first adult case in which a bilateral diffuse involvement of muscles of the hand is described . biopsies ( from unilateral cases ) showed only a slightly more - than - normal variation in fiber size , without signs of inflammation , pathological blood vessels , fibrosis , or loss of muscle fibers . the syndrome is distinctly different from other causes of hand or upper - limb hypertrophy such as proteus syndrome or freeman - sheldon syndrome . other possible causes such as nerve hamartomas are progressive in nature , and were excluded by imaging . muscle hypertrophy due to nerve damage , so - called neurogenic pseudohypertrophy , is electromyographically characterized by early recruitment of large motor unit potentials at a high firing rate . only muscles innervated by the specific damaged nerve are enlarged in those cases [ 7 , 12 ] . in adults decreasing the muscle volume ( including the excision of possible aberrant muscles ) is therefore only recommended for cosmetic purposes . instructions and avoidance of heavy manual labor are usually enough to alleviate the symptoms . although rare , congenital monomelic hypertrophy should be considered in the differential diagnosis of the hypertrophied hand .

congenital hypertrophy of the hand is a rare phenomenon . the condition is characterized by hypertrophy of muscles , varies in severity and has been reported under different names . some patients also have aberrant muscles . electromyography is unremarkable , and the signal intensity on mri and ultrasound is normal . the etiology is unknown and does not seem to be confined to a peripheral nerve , part of the plexus or nerve root . the condition is assumed to be congenital . we report a 28-year - old male with asymmetric hypertrophy of both hands and give a review of the 4 other cases known so far .

a. vancoresmycina was isolated from indian soil that produces novel glycopeptide antibiotics and a polyenic compound . a. vancoresmycina strain dsm 44592 which was isolated from soil , was obtained from an open collection of the german collection of microorganisms and cell cultures ( dsmz ) , braunschweig , germany , deposited by prof . strain a. vancoresmycina dsm 44592 is gram - positive bacteria , aerial mycelium with color ranged from brown beige to saffron yellow . its peptidoglycan contains meso - diaminopimelic acid ; diagnostic sugars are arabinose and galactose , mycolic acids are absent ; mk-9 ( h4 ) is the principal menaquinone ; phospholipids are phosphatidylethanolamine , hydroxyl phosphatidylethanolamine , diphospha - tidylglycerol and phosphatidylinositol . genomic dna was extracted from a 48 hour old culture using zr fungal / bacterial dna miniprep as per manufacturer 's instructions . the genome of a. vancoresmycina strain dsm 44592 was sequenced using the illumina - hiseq 1000 paired - end technology produced a total of 62,283,914 paired - end reads ( insert size of 350 bp ) of 101 bp . we have used ngs qc toolkit v2.3 to filter the data for high quality ( cut off read length for hq = 70% , cut off quality score = 20 ) , vector / adaptor free reads for genome assembly . a total of 57,704,188 high quality , vector filtered reads ( ~ 647.6 times coverage ) were used for assembly with soapdenovo v1.05 ( at hash length of 69 ) followed by gapcloser ( at hash length 15 ) software . the final assembly contains 786 contigs of total size 9,037,069 bp , with n50 contig length of 18.4 kb ; the largest contigs assembled measures 87.7 kb . this draft genome comprising 9,037,069 nt was annotated with the help of rast ( rapid annotation using subsystem technology ) system server . a total of 8340 predicted coding regions ( cdss ) , 3 rrnas and 54 trnas were predicted . rast annotation indicates that strain streptomyces sp . aa4 ( score 521 ) , saccharomonospora viridis dsm 43017 ( score 400 ) and actinosynnema mirum dsm 43827 ( score 372 ) are the closest neighbors of the strain dsm 44592 . genome annotation available at rast indicates that the strain dsm 44592 contains the genes for glycolysis and gluconeogenesis , tca cycle and pentose phosphate pathway . genes of alkaline phosphatase , galactosidase ( alpha and beta subunit ) , mannosidase ( alpha and beta subunits ) , catalase ( ec 1.11.1.6 ) and ferroxidase ( ec 1.16.3.1 ) are also present in the genome annotation of strain 44592 . we have mapped all predicted 8340 cdss to kegg pathways with the help of kass server and found that genes of rifa , rifb , rifc , rifd , rifj , rifk , rifl , rifm and rifn are present in the genome , mapped on the ansamycins biosynthesis pathway . genes of glucose-1-phosphate thymidylyltransferase [ ec:2.7.7.24 ] , dtdp - glucose 4,6-dehydratase [ ec:4.2.1.46 ] , dtdp-4-dehydrorhamnose reductase [ ec:1.1.1.133 ] and dtdp-4-dehydrorhamnose 3,5-epimerase [ ec:5.1.3.13 ] are present and mapped at the pathway of polyketide sugar unit biosynthesis ( fig . the a. vancoresmycina dsm 44592 whole genome shot gun ( wgs ) project has been deposited at ddbj / embl / genbank under the project accession aouo00000000 of the project ( 01 ) has the accession numbers aouo01000000 and consists of sequences aouo01000001 aouo01000784 . the authors declare that there is no conflict of interest on any work published in this paper .

we report the 9.0-mb draft genome of amycolatopsis vancoresmycina strain dsm 44592 t , isolated from indian soil sample ; produces antibiotic vancoresmycin . draft genome of strain dsm44592 t consists of 9,037,069 bp with a g+c content of 71.79% and 8340 predicted protein coding genes and 57 rnas . rast annotation indicates that strains streptomyces sp . aa4 ( score 521 ) , saccharomonospora viridis dsm 43017 ( score 400 ) and actinosynnema mirum dsm 43827 ( score 372 ) are the closest neighbors of the strain dsm 44592 t .

the humerus bone is the upper arm bone that connects the shoulder , by articulating the humeral head with the glenoid of the scapula , to the elbow by articulating the testal humerus with the ulna and radius , as shown in figure 1 . the supracondylar region is the area in the distal part of the humerus just above the growth plate . about 87 per cent of the elbow fractures occur in the distal humerus and about 80 per cent of them occur in the supracondylar . these fractures may be in the distal of the supracondylar region and called lower type or may be in the proximal part of the supracondylar region and called upper type . accurate reduction and stable fixation are needed to avoid posthealing complication , namely , deformity and limitations of movements . these fractures most often require surgical treatment unless the bones are held in proper position . sometimes surgeons want to know which alternative they should give preference , for the benefits of the patients . fixation of unstable schf in children by two k - wires is the treatment of the choice by many surgeons ( figure 2 , ) . these k - wires can be parallel from lateral side or crossing from medial and lateral sides . in present work , surgeon 's treatment of schf using k - wire fixation ( distal humerus type ) is modeled , analyzed , and evaluated . the research role is to gather information from ct scan and x - ray developed in kku hospital . based on these obtained x - ray and ct scan for particular patient , a cad solid model can be developed . the developed cad solid model is to be coupled with the finite - element analysis to study the strength of different injury treatments adopted by orthopedic surgeons that suit that particular patient . tochnog is explicit - implicit fe program that can be used in the analysis of structures , thermal , elastic , or elastic - plastic engineering problems . tochnog and gid programs run under linux operating system . in the beginning , a data file of the fe model was generated using gid preprocessing program then completed using a text editor . next , the tochnog fe module called to run the fe analysis using the developed data file , followed by visualizing the fe results using gid postprocessing program based on the output files written by the tochnog fe module . the x - ray and ct scan the x - ray image is imported as rusted image to autocad program to measure the outer dimensions and to obtain the 2d geometry of ct scan at different levels . next , the 2d drawing is imported to gid program and joined to complete the 3d solid model . the solid model mainly consists of three main parts or three volumes , see figures 3 and 4 : top bone ( volume 1 ) , mid bone ( volume 2 ) , and bottom bone ( volume 3 ) . figure 3 shows the solid model development for the parallel k - wire fixation treatment , while , crossing k - wire fixation solid model is shown in figure 4 . the mid - part of the solid model is divided into two main parts : the external ( cortical bone ) part with wall thickness of 2 mm which is the harder and high strength bone , and internal ( cancellous bone ) which has lower strength and hardness compared to cortical bone , see figure 5 . constrain conditions along three directions are assigned on the top surfaces of humerus bone as shown in figure 6 . three types of loading conditions were considered , normal load of 50 n along lateral x - direction , normal load of 50 n along later y - direction , and combined normal loads plus 1 nm torsion load . assigned material properties for the developed solid model are given in table 1 . two main finite element meshes were generated for modeling parallel k - wire fixation treatment model and the other for crossing k - wire fixation model . the finite element ( fe ) meshes were generated using 4-node tetrahedral elements , see figure 7 . the number of nodes and elements for the two fe meshes are shown in table 2 . furthermore , as shown in figure 8 , four finite element models were developed to model two types of fractures at the top and bottom positions . moreover , a friction contact surfaces were modeled in the assigned crack areas to simulate the node slipping conditions under different loads . a low friction factor of 0.1 was assigned in the crack contact areas to simulate the patient condition immediately after the surgery treatment . both peak normal principal stresses and von - misses stresses are reported at the two selected crack areas , see figures 9 and 10 . summary of the fe results for top and bottom crack positions are shown in tables 3 and 4 , respectively . the reported fe results are given for three assigned loading conditions and for two parallel and crossing k - wire fixation techniques . it is clearly observed that maximum stresses on the top fracture are minimum for crossing k - wire fixation when compared with parallel k - wire fixation . for example , the maximum stresses were reduced by 62% for lateral x - direction loading , and by 21% for lateral y - direction loading , and 20% for combined loading . on the other hand , figure 12 shows the von - misses stresses results for bottom fracture area . it is clearly observed that maximum stresses on the bottom fracture are minimum for parallel k - wire fixation treatment when compared with crossing k - wire fixation . for example , the maximum stresses were increased by 19% for lateral x - direction loading but clearly decreased by 33% for lateral y - direction loading and 90% for combined loading . there are two types of treatment techniques commonly used for supracondylar humerus fracture in children . these treatments cover inserting crossing two k - wires or parallel key - wires fixation techniques . the present work showed that crossing k - wire fixation technique is beneficial for top fracture position , while parallel k - wire fixation technique is beneficial for bottom fracture position .

supracondylar humerus fracture ( schf ) is one of the commonest elbow fractures in children . it is common injury for children with age from four to fourteen . in current study , the finite element technique is used to evaluate two techniques , namely , parallel and crossed k - wire fixation for treatment of schf , using k - wire fixation .

the lesion is usually polypoid , located in the dermis , and is formed by coarse collagen bundles with sparse cells . it is also characterized by the presence of marked cellular atypia and pleomorphism without mitosis . we describe the cytomorphological features on fine needle aspiration ( fna ) smears of a histologically and immunohistochemically proven case of pf . a 38-year - old male presented with a superficial , painless , polypoidal , soft tissue mass since 6 months , measuring about 3 1.5 cm in size , and involving the back of the thigh . fine needle aspiration cytology ( fnac ) was done and slides were stained with giemsa stain . on fna , the swelling was diagnosed as fibrohistiocytic lesion with atypical cells and the mass was subsequently excised . cellular smears containing pleomorphic cells having very large nuclei ( monster cells ) with scanty cytoplasm . few of the nuclei revealing nucleoli ( giemsa , 400 ) on gross examination , the mass was well circumscribed measuring 3 1.5 cm . these cells were markedly atypical showing scant cytoplasm and large , pleomorphic , enlarged hyperchromatic nuclei with small nucleoli [ figure 2 ] . no mitosis or necrosis was evident in multiple sections examined . based on these features , diagnosis of pf section showing pleomorphic cells scattered between the collagen bundles ( h and e , 200 ) immunoprofile of lesional cells revealed positive staining for vimentin [ figure 3 ] and cd34 and negative staining for s-100 . pf is a benign fibrous lesion which is located mainly in the lower extremities , followed by trunk , head , and neck and rarely in the subungual region . most of these lesions occur in adults , with a peak incidence in the fifth decade of life . role of fnac in diagnosis of soft tissue tumor has been fairly documented as well as debated but the cytomorphological features on fnac of pf are not yet documented in literature . in contrast to the histological findings ( which is hypocellular ) , the fna smear in our case was cellular . majority of cells were pleomorphic with very large nuclei like monster cells of dermatofibroma and few of them possessed single nucleolus . small fragments of metachromatic stroma were present in the background representing collagen bundles . necrosis and mitotic figures were not seen in the smears . thus , on fna , pf can easily be misdiagnosed as malignant soft tissue tumor because it contains bizarre pleomorphic cells showing considerable atypia . this lesion has been shown to be benign despite the presence of pleomorphic or bizarre cells , although lesion may locally recur when incompletely excised . this also reveals the importance of mitosis and necrosis in making a diagnosis of malignant soft tissue tumor on cytology , as both these features were not seen in this tumor . histological examination of pf of the skin reveals a dermal tumor with striking nuclear atypia . in addition to these mononuclear cells , the atypical nuclear features can also be observed in multinucleated giant cells . degeneration , ischemia , or the paracrine influence of mast cells may create the cytological atypia in pf . in fact , some investigators have postulated that the pf of the skin is actually a variant of the sclerotic fibroma . lesional cells in pf are always positive for vimentin and negative for s-100 and cytokeratin . positive expression of muscle - specific actin , cd34 and rarely alpha-1 antichymotrypsin , has also been observed.[134810 ] the cytological differential diagnosis of pf of skin has not been discussed in literature . however , histological differential diagnosis includes : atypical fibroxanthoma , dermatofibroma with monster cells , giant cell fibroblastoma , desmoplastic spitz nevus , and desmoplastic melanoma . in our case , bundles of collagen were present with low cellularity , thus ruling out atypical fibroxanthoma and dermatofibromas with atypical or monster cells . dermatofibromas with atypical or monster cells also contains foam cells and hemosiderin - laden macrophages which were not seen in our case . giant cell fibroblastoma is usually seen in childhood and is characterized by infiltrative growth and features sinusoidal structures lined by atypical cells , whereas our case was an adult without infiltrative growth and sinusoids . desmoplastic spitz nevus and desmoplastic melanoma show some areas of melanocytic differentiation and cells are positive for s-100 protein , both these features were absent in our case . thus , from a clinical as well as pathological standpoint , recognition of a benign lesion of this type is very important since an incorrect cytological interpretation could result in inappropriate treatment .

pleomorphic fibroma ( pf ) is a benign , polypoid , or dome - shaped cutaneous neoplasm with cytologically atypical fibrohistiocytic cells . we describe the cytomorphological features of pf retrospectively with histopathological diagnosis in a 38-year - old male who presented with 3 1.5 cm swelling in the soft tissues of the thigh for 6 months . this lesion is benign despite the presence of pleomorphic or bizarre cells . we review the differential diagnosis of pf with other mesenchymal tumors . to the best of our knowledge , cytomorphological features on fine needle aspiration cytology of this tumor are not yet documented in literature .

we report here on a case of wound infection due to shewanella algae in the navel area of a patient . a 24-year - old man was admitted to the mehr outpatient clinic in bushehr , southern iran , in december 2010 with an infection in his navel area . a preliminary diagnosis suggested that the patient had a pilonidal cyst and/or un - shut suture from his neonatal period which had caused the infection in that area . interviewing the patient revealed that a purulent discharge had developed after he had been swimming in the persian gulf , 3 months earlier . the patient was prescribed a combination of cloxacillin ( 500 mg/6 h for a week ) , cefixime ( 400 mg/12 h for 5 days ) and ciprofloxacin ( 500 mg/12 h for a week ) . the affected area was also cleaned with 70% alcohol daily but the purulent discharge did not stop . a swab culture was taken from the lesion s exudate and submitted to the pathology laboratory . results indicated the pure growth of an organism forming light - brown mucoid colonies on 5% sheep blood agar . the organism was subsequently identified as a member of the s. putrefaciens group with the api 20e system ( biomerieux , inc . , further tests , including hydrogen sulfide production on tsi slants , growth on media containing 6.5% nacl and reduction of nitrite 1 , identified the organism as s. algae although the bacterium did not produce -haemolysis on sheep blood agar as shown by others 2,3 . pcr amplification of the 16s rrna was performed using the universal primer pair fd1 and rp2 4 , and sequencing of the pcr product showed 99% similarity to s. algae . the bacterium was susceptible to ceftazidime ( 30 g ) , ciprofloxacin ( 5 g ) , nalidixic acid ( 30 g ) , nitrophorantion ( 300 g ) , amikacin ( 30 g ) , ceftriaxone ( 30 g ) , cefotaxime ( 30 g ) , gentamicin ( 10 g ) , co - trimoxazole ( trimethoprim 1.25 g / sulfamethoxazole 23.75 g ) but was resistant to amoxicillin ( 30 g ) , vancomycin ( 30 g ) , doxycyclin ( 30 g ) , cephalexin ( 30 g ) , ampicillin ( 10 g ) , tetracycline ( 30 g ) , cephalothin ( 30 g ) and ceftizoxime ( 30 g ) . more than 50 species of shewanella have been described but with the exception of the recent case report of s. xiamensis causing a peripancreatic infection 5 , all other reported illnesses involving the genus shewanella have been linked to either s. putrefaciens and s. algae infection with the latter being more common in clinical cases 1,5,6 . these bacteria are found in marine environments and in countries with warm climates or during especially warm summers in other countries 1 with the most common portal of entry being injured skin 6,7 . the most common clinical syndrome reported in the literature is infection of the skin and soft tissues 810 . it often occurs in elderly patients with chronic ulcers of the lower extremities , but soft - tissue infections in healthy subjects have also been described 10 . meningitis 1,16 , and abscesses 17,18 . severe disease with bacteremia has been described in patients with predisposing factors such as immunodeficiency 6,19 , malignancy 8 , hepatobiliary disease 6,8 and renal failure 13 . only two cases of arthritis and two cases of osteomyelitis and one case of spondylodiscitis have been reported so far 13,20 . here , we report a wound infection caused by s. algae in a healthy young man without any underlying diseases . the source of organism that caused the cutaneous navel lesion was likely to be the marine environment and the bacterium was isolated in pure culture from the purulent discharge . to the best of our knowledge , this is first case of wound infection clearly caused by s. algae to be reported in iran . in this region , there has been only one more case of wound infection reported in turkey but the agent was shown to be s. putrefaciens 21 . commercial automated identification systems can not distinguish s. algae from s. putrefaciens and , therefore , it is possible that some of the isolates reported as s. putrefaciens might in fact have belonged to the species s. algae 1,2 . in this regard we recommend that molecular techniques such as 16s rrna gene sequence analysis be used to confirm identification of this bacterium , as has also been emphasized by others 20 .

shewanella algae was isolated from the purulent discharge in the navel area of a young male with a history of swimming in the persian gulf . a routine laboratory diagnosis procedure , followed by 16s rrna gene sequence analyses , was used to avoid misidentification with other species of shewanella . the bacterium was suscetible to ceftazidime , ciprofloxacin , nalidixic acid , nitrophorantion , amikacin , ceftriaxone , cefotaxime , gentamicin and co - trimoxazole but was resistant to amoxicillin , vancomycin , doxycycline , cephalexin , ampicillin , tetracycline , cephalothin and ceftizoxime . the patient successfully recovered after treatment with antibiotics .

traumatic hip dislocation has increased due to the higher incidence of accidents involving high energy trauma . inferior hip dislocation ( ihd ) is the rarest among all types of hip dislocations and few adult cases have been reported in the literature . we present an adult case of traumatic ihd following motor vehicle accident ( mva ) with a bifocal hip fracture detected after reduction . he crashed his car into the wall at 70 mph . at the emergency room , the patient presented with severe right hip pain and a fixed deformity in flexion and abduction . he was slightly dyspnoeic due to a right mild pneumothorax with an oxygen saturation of 98% on room air . an antero - posterior pelvis radiograph was obtained and showed inferior dislocation of the right femoral head with no associated fracture ( fig . reduction consisted of : counter - traction using a sheet passed under his hipadductioninternal rotationtractionabductionexternal rotation figure 1:antero - posterior radiograph showing right ihd . counter - traction using a sheet passed under his hip antero - posterior radiograph showing right ihd . pelvis ct - scan was performed and showed a bifocal fracture of the hip associating a non - displaced inter - trochanteric fracture and a non - displaced capital fracture ( fig . figure 2:post - reduction ct - scan of the pelvis showing a non - displaced fracture of the head of the femur and a non - displaced inter - trochanteric fracture of the right hip . post - reduction ct - scan of the pelvis showing a non - displaced fracture of the head of the femur and a non - displaced inter - trochanteric fracture of the right hip . a search of the literature revealed 16 studies reporting 34 cases related to luxatio erecta , inferior dislocation or infra - cotyloid dislocation of the hip , the majority of which being in non - english literature . until 2006 , only five cases were reported among adults . a study was published in 2012 reporting a bilateral ihd in a 30-year - old patient . bartley and dimon and ferguson and harris reported the condition in an adult and a young man , respectively . in our case , hence , it is clear that ihd is not restricted to children as previous literature showed a preponderant incidence in paediatric group , proposed to be due to the lax ligaments in children . only three articles reported three cases of ihd associated with an injury to the ipsilateral femur : one recording a case of an inter - trochanteric fracture with ihd ; another reporting a great trochanter fracture ; and one reporting an associated open sub - trochanteric fracture . in the present case , a non - displaced bifocal hip fracture was present . when the hip dislocates inferiorly , it is flexed and the distal end of the femur rises above the horizontal plane of the pelvis at the acetabular fossae level . the exact mechanism leading to the deformity is not always remembered and has not been described in detail because the reported cases were children or teenagers . the first mechanism is when force is applied to an abducted , flexed thigh that is externally rotated , the femoral head levers out of the acetabulum . this represents the more common mechanism and probably it is the case of our patient . the femoral head is seen anteriorly in the region of obturator foramen , although in some cases , it may be displaced further laterally to an ischial location . in the second mechanism , the femur is inverted and the head lies below the acetabulum and lateral to the ischial tuberosity . ct is advised to rule out any associated injury , but it should never delay reduction . such delay has been associated with worse prognosis and increased incidence of avascular necrosis . joint reduction can be achieved under general anesthesia ( ga ) by maintaining traction towards the head while gradually extending the thigh , sometimes with additional internal rotation . in our case , it showed a bifocal non - displaced fracture of the hip associating an inter - trochanteric fracture and a capital fracture . we could not identify whether the initial trauma was the cause of the fracture or the reduction manoeuver . since recommendations include 6-week immobilization followed by partial weight bearing , orthopaedic treatment was the choice for the non - displaced hip fracture . ihd is a rare injury and very few cases have been reported in the literature , especially in adults . to our knowledge , a bifocal prompt diagnosis and treatment are crucial in the management of these cases to avoid neurovascular complications , particularly avascular necrosis of the head of femur . the present study reveals that this condition is not exclusive to children and ct is a must to rule out associated injuries . closed reduction is usually possible under general anaesthesia and prognosis after reduction is excellent the sooner the reduction .

inferior dislocation is a rare type of hip dislocation , especially in adults . few cases have been reported ; most of them were isolated . this is the case of a traumatic adult hip dislocation after a road traffic accident . reduction was made under general anaesthesia ; a ct - scan after the reduction showed a bifocal non - displaced hip fracture . in this article , we present a small review of the literature and we discuss the possible mechanism of hip dislocation . we found through our case study that this condition is not exclusive to children and ct - scan is mandatory after the reduction of hip dislocation to eliminate any associated injury . to our knowledge , a bifocal hip fracture has not previously been documented , in the english language literature .

ultrasonography ( usg ) of the bladder neck revealed a well circumscribed , 4.5-centimeter exophytic lesion with rich flow in doppler mode . neoplastic markers , ca125 , ca19 - 9 , ca15.3 , and afp , were within normal ranges . the specimen from the transvaginal biopsy revealed smooth muscle tissue indicating a bladder neck leiomyoma . in the 36 week , a healthy girl was delivered via c - section . some weeks later , during the transurethral resection ( tur ) , after resecting the main body of the leiomyoma a superficial cut ( less than the resectoscope 's loop depth ) into the neck was performed to excise as much of the leiomyoma 's pedicle as possible without damaging the sphincter ( fig . one year after cesarean delivery and simultaneous excision of two small uterine leiomyomas both mother and daughter are well . the head covers the whole bladder neck surface stopping urine outflow in a flap - like manner and the leg ( arrow ) protrudes from the bladder neck from 2 to 5-o'clock . cystoscopy b during tur , note the yellow - whitish color of the tissue . cystoscopy c control cystoscopy after six months . t2-weighted mri image of bladder tumor ( arrow ) , a axial and b sagittal planes ; the pedicle invades the bladder neck without crossing its whole thickness . the foley catheter ( double arrow ) and benign bladder and urethral tumors are rare in pregnant women [ 1 , 2 , 3 ] . hormonally stimulated growth has also been suspected since women in childbearing age are predominant in this group of patients . although some have been described , the safety of tur , even bipolar tur , in pregnancy has not been confirmed .

a 29-year - old primigravida was admitted to the urology ward with acute urinary retention . the patient underwent cystoscopy , mri ( magnetic resonance imaging ) , and tissue biopsy , which consequently led to the diagnosis of bladder neck leiomyoma that obstructed urine outflow . subsequent to a cesarean section , a successful transurethral resection was performed . here the diagnostic complexity in the pregnant patient , clinical course , and outcome are described . one year after successful treatment both mother and daughter are in good condition .

cancer of unknown primary ( cup ) is a well - recognized clinical disorder , accounting for 35% of all malignant epithelial tumors . it is characterized as an aggressive disease with an early dissemination of metastases without a primary detected site after extensive laboratory and clinical investigations . the national comprehensive cancer network ( nccn ) have set forth guideline for work - up based on clinical presentation , with all including extensive history and physical exam , computed tomography ( ct ) of chest / abdomen / pelvis and site / gender - specific diagnostic studies ( i.e. mammogram and testicular us ) and tumor markers ( i.e. ca-125 and prostate specific antigen [ psa ] ) , as well as appropriate immunohistochemistry . a 72-year - old female with a history of chronic headaches and osteoarthritis , as well as surgical history of total abdominal hysterectomy and bilateral salpingo - oopherectomy ( soo ) due to ovarian cysts and dysmenorrhea , presents to her primary care with complaints of pain in the left side of her abdomen and feeling a lump in that location for the past 710 days . , she was found to have a bulge on the left side of the abdomen just lateral to the rectus muscle , it was firm and immobile and appeared to be outside the abdominal wall . she was sent for a ct scan of the abdomen and pelvis , which showed a hernia and was suggestive of carcinomatosis with omental and parietal implants . she was referred to a general surgeon and was scheduled for a diagnostic laparoscopy and an esophagogastroduodenoscopy ( egd ) . her egd was completely normal , but on her diagnostic laparoscopy she was noted to have diffuse tumor implants along the liver , diaphragm , peritoneum and omentum ( figs 1 and 2 ) . the largest omental implant measuring ~3 4 cm was herniated through the semilunar line of the abdominal fascia causing a spigelian hernia ( fig . it was decided to leave the hernia due to the size of the defect and requirement for a large mesh for repair in a cancer riddled abdomen that may be re - entered for debulking . the cancer stained diffusely positive for ck7 and ck20 ; suggestive of gastrointestinal , pancreatic , biliary or ovarian origin , less likely pulmonary origin . her pathology report from her prior soo was pulled and compared and showed both ovaries were benign serous cystadenoma and histologically no similarity between the patient s resected ovarian tumors and the current omental implants was noted . she underwent ct chest / brain , colonoscopy , mammogram and ca 19 - 9 level ; all returned normal . she underwent a positron emission tomography ( pet ) scan as well and only the known abdominal masses were suggestive of cancer . decision was made to treat the patient as primary peritoneal malignancy with a platinum - taxane based chemotherapy regimen . a subcutaneous port was placed and the patient was discharged and started on chemotherapy . cup is divided into two subsets , favorable ( 20% ) and unfavorable ( 80% ) , based on histopathology and clinical presentation ( table 1 ) . about 80% of cases that are first diagnosed as cup eventually have a confirmed type . roughly 60% of cup primary sites are adenocarcinomas arising from glandular cells ( lung , pancreas , breast , prostate , stomach , colon and liver ) while the remaining sites of origin include melanoma , sarcoma , lymphoma and neuroendocrine tumors . common presentations are non - specific such as non - tender swollen lymph nodes , palpable mass in the abdomen , pain in the bones and unexplained weight loss . patients with carcinoma of unknown primary site are heterogeneous with respect to tumor biology , clinical characteristics and response to therapy . extensive work - up with specific pathology investigations ( immunohistochemistry , electron microscopy , molecular diagnosis ) and modern imaging technology ( ct , mammography and pet scan ) have resulted in some improvements in diagnosis ; however , the primary site remains unknown in most patients , even on autopsy . , the patient has a mixed favorable and unfavorable profile since she has a cancer that closely resembles a colonic origin , but presented with liver metastasis . patients with a single , small , potentially resectable tumor cup is a clinical entity that is not as uncommon as previously thought . as our patients cup presented as a spigelian hernia this is quite a rare occurrence . spigelian hernias are anterior abdominal wall hernias that occur at a defect adjacent to the semilunar line and they comprise only 0.12% of all abdominal wall hernias and are difficult to diagnose clinically depending on its location . though rare concomitant disease processes , cup as a spigelian hernia should be included in the differential diagnosis of anterior abdominal wall masses , even in the absence of symptoms suggestive of cancer .

abstractcancer of unknown primary ( cup ) is a well - known entity that can present in a multitude of clinical presentations . based on the extent and organ of involvement , the presentation will be varied . for instance , patients presenting with axillary lymphadenopathy would lead toward a primary breast cancer , whereas patients presenting with abdominal distention due to ascites would tend toward a gastrointestinal origin . we present a case of a 73-year - old female who presented with an abdominal wall mass ; on laparoscopy , she was found to have a spigelian hernia due to an omental metastatic lesion from a cup .

a combination of horizontal and vertical third molar impaction is a rare occurrence.when the tooth is unable to erupt to its proper position and fail to achieve a normal occlusion , it is known as impacted tooth . in this scientific article , case report of a female patient aged 30 years reported with acombination of horizontally and vertically impacted third molars in the maxilla and mandible has been presented . the treatment included surgical removal of the impacted teeth without any damage to underlying structures . horizontal impaction of left maxillary third molar , vertical impaction of right maxillary third molar and left mandibular third molar is a rare occurrence . if symptomatic , surgical removal has to be planned as earlier as possible rather than late complications . when the tooth is unable to erupt to its proper position and fails to achieve a normal occlusion , it is known as impacted tooth . etiology includescrowding , ectopic position of the tooth germ , supernumerary teeth and soft tissue or bony lesions . most commonly , impacted teeth accounts to maxillary and mandibular third molars ( 3,5 ) . pathogenesis relates to the discrepancy of jaw size to the tooth ( 1 ) . a rare case of horizontal impaction of the left maxillary third molar , vertical impaction of right maxillary third molar and left a 30-year old female presented to the department of dentistry and faciomaxillary surgery complaining of discomfort in the right maxillary third molar region , left maxillary third molar region and left mandibular third molar region . general health examination revealed that the patient was conscious , oriented and afebrile , and the vitals were stable . on intraoral clinical examination , all the three mentioned regions revealed absence of clincial crown exposure . previous dental history revealed that the left mandibular second molar and the right mandibular third molar were extracted in a conventional manner and surgical method respectively before two years . radiographically , horizontal impaction of the left maxillary third molar , vertical impaction of the right maxillary third molar and the left mandibular third molar was seen in orthopantomogram ( opg ) ( figure 1 ) . the treatment procedure included planned surgical removal of the specific tooth under general anesthesia ( ga ) . under ga , the patient was draped , preparation was done , the mouth was propped and fraser suction was in place , topical local anesthetic was applied , incision was placed with the no.3 and no.11 bard parker surgical handle and blade , mucoperiosteal flap was raised with the help of periosteal elevator , overlying bone and the vertically impacted right maxillary third molar tooth clinically were seen . the flap was retracted with the help of austins retractor whereas the tongue - by - tongue depressor.with the help of micromotor handpiece apparatus which includes high speed sharp carbide burs , no.557/703 fissure burs , no.8 round bur , excess bone coverage was trimmed so that the vertically placed tooth was luxated in a slow manner and the whole tooth removed by maxillary third molar forceps . saline irrigation was done with 18 gauge needle and 10 ml syringe to reduce the heat production during bone cutting . the socket was curetted for fresh bleeding , bony margins were trimmed by bone rongeur , bone smoothening ws done by bone file , mucoperiosteal flap was replaced , soft tissue was held by adson forceps and 3 - 0 black silk sutures were placed with the help of needle holder along with cutting edge suture needle and excess suture material was removed by metzenbaum scissors . after a week of review , the sutures were removed with an evidence of excellent intraoral healing . a similiar procedure was done in relation to the left maxillary horizontal third molar impaction and the left mandibular vertical third molar impaction . orthopantomogram depicting maxillary right vertically impacted third molar(arrowhead ) , maxillary left horizontally impacted third molar(arrowhead ) , mandibular left vertically impacted third molar(arrowhead ) impaction of tooth is commonly seen involving mandibular third molars followed by maxillary third molars ( 5 ) . if left undiagnosed and untreated , sequential events such as periodontal disease , dental caries , odontogenic cyst and tumors , pain of unexplained origin , jaw fracture and resorption of root of the adjacent tooth might occur ( 6 ) occur . types of impaction include vertical , horizontal , mesioangular , distoangular and even inverted impaction . in complete submerged horizontal or vertical tooth impactions , a greater amount of bone guttering needs to be done , thereby leading to an increase in the size of the socket . careful consideration has to be given in order to avoid incidents such as tooth displacement into infratemporal space and pterygomandibular space , excess bleeding , and displacement of tooth into maxillary sinus and alveolar fracture . horizontal impaction of the left maxillary third molar , vertical impaction of the right maxillary third molar and the left mandibular third molar is a rare occurrence . if symptomatic , surgical removal has to be planned as earlier as possible rather to avod late complications .

backgrounda combination of horizontal and vertical third molar impaction is a rare occurrence.when the tooth is unable to erupt to its proper position and fail to achieve a normal occlusion , it is known as impacted tooth.case detailsin this scientific article , case report of a female patient aged 30 years reported with acombination of horizontally and vertically impacted third molars in the maxilla and mandible has been presented . the treatment included surgical removal of the impacted teeth without any damage to underlying structures.conclusionhorizontal impaction of left maxillary third molar , vertical impaction of right maxillary third molar and left mandibular third molar is a rare occurrence . if symptomatic , surgical removal has to be planned as earlier as possible rather than late complications .

pituitary surgery is often accompanied by disturbances of osmoregulation that may result from manipulation or vascular alterations of the neurohypophysis.1 hyponatremia after pituitary surgery is typically due to syndrome of inappropriate antidiuretic hormone secretion ( siadh ) and typically associated with a euvolemic state.2 here we report a case with hyponatremia after pituitary surgery that was successfully treated with tolvaptan . we found only four neurosurgical reports about tolvaptan in the literature.1 2 3 4 a 68-year - old man was detected with an infra- and suprasellar tumor with symptomatic panhypopituitarism and adynamia ( fig . 1 ) . he was treated with hormonal substitution including testosterone for > 5 years . 2 ) , which was slightly lower than the normal serum sodium level between 135 and 145meq / l . an endonasal transsphenoidal approach was performed , and the tumor was totally removed . four days postsurgery , the patient developed hyponatremia ( 125 meq / l ) and fell into a stupor . we infused 10% sodium chloride at a level of 1 ml per hour because the patient could not swallow . the hyponatremia improved gradually ( 132 meq / l ) 7 days postsurgery , and the patient could then swallow because he had recovered consciousness . he patient was given one 15-mg tablet orally of tolvaptan ( otsuka , tokushima , shikoku , japan ) per day . we stopped the infusion of 10% sodium chloride because the serum sodium level improved enough to keep the patient conscious . 2 ) . t1-weighted magnetic resonance images with gadolinium enhancement showing a pituitary tumor . four days postsurgery , the serum sodium decreased to 125 meq / l , and then 10% sodium chloride at 1 ml / h was infused . hyponatremia has been described following pituitary surgery , with an incidence varying from 3 to 25% depending on the series.1 3 the presence of preoperative hypopituitarism makes postoperative hyponatremia more likely.5 the timing of postoperative hyponatremia has been reported both as an early incidence peak occurring around postoperative day 2,5 as well as a slightly more delayed peak typically occurring between postoperative days 7 and 9.6 7 hyponatremia following pituitary surgery is predominantly due to siadh because mechanical irritation of the posterior pituitary lobe or the pituitary stalk is thought to be the underlying pathophysiologic cause of uncontrolled antidiuretic hormone release.8 9 cerebral salt wasting syndrome is unlikely after pituitary surgery.10 tolvaptan , an oral vasopressin receptor antagonist , is from a relatively new therapeutic class of agents for the management of hyponatremia . nephrologists have long believed that vasopressin receptor antagonists may be particularly effective at treating siadh due to intracranial disorders , trauma , or neurosurgery because they are the most physiologic approach to treat this common electrolyte disturbance.8 11 there are three receptors for vasopressin , of which the v-2 receptors mediate the antidiuretic response . the vasopressin receptor antagonists prevent binding of vasopressin , thereby causing loss of water without altering sodium and potassium excretion.12 13 14 in this case , tolvaptan was effective to improve the hyponatremia that occurred 4 days postsurgery in a relatively early phase . when the patient can swallow , it is much easier to administer tolvaptan than to infuse sodium chloride . still we can not conclude that our case presents a normal resolution of postoperative siadh .

hyponatremia is a frequent complication following pituitary surgery . we report a case with hyponatremia after surgery of a pituitary adenoma that was successfully treated with tolvaptan . a 68-year - old man with a pituitary tumor presented with mild hyponatremia ( 133 meq / l ) before surgery . the patient developed hyponatremia ( 125 meq ) 4 days postsurgery , and 10% sodium chloride was infused . seven 7 days postsurgery , hyponatremia was improved ( 132 meq / l ) , and tolvaptan 15 mg was given orally as a single dose instead of the 10% sodium chloride infusion . his serum sodium remained within normal limits . the syndrome of inappropriate antidiuretic hormone secretion ( siadh ) after pituitary surgery most probably led to the hyponatremia , and tolvaptan was effective because it is an oral vasopressin receptor antagonist .

takotsubo cardiomyopathy ( tcm ) has emerged as an important differential diagnosis in patients presenting with acute chest pain . tcm is associated with severe emotional or somatic stress and is characterized by extensive left ventricular dysfunction in the absence of coronary artery obstruction of sufficient magnitude to explain the extent of left ventricular involvement . thus , tcm is distinct from coronary artery disease ( cad ) and acute myocardial infarction ( ami ) . although patients with concomitant significant cad traditionally were excluded from the tcm cohorts , several groups , including our own , have provided substantial evidence for co - existing cad in some tcm patients. here , we take this association one step further and present a case in which the patient simultaneously suffered from ami and tcm , and in which we believe that a primary coronary event triggered tcm . an 88-year old woman presented to the emergency department with acute onset of chest pain . her copd was considered mild and had remained stable for many years . over the last year she had single - handedly been caring for her demented husband , a situation she described as increasingly stressful and anxious . electrocardiography ( ecg ) revealed atypical st elevation in precordial leads ( figure 1 ) . acute coronary angiography revealed a plaque rupture in the first diagonal branch ( figure 2a and 2b ) and percutaneous coronary intervention ( pci ) was performed . three days after the event , echocardiography was repeated and could not detect any akinesia ( video 1 ) . six months later , cardiac functions had further improved and was estimated to be entirely normal , without any trace of regional wall motion defects . thus , this patient adhered to the diagnostic criteria for tcm ( table 1 ) . ( a & b ) : evidence of plaque rupture in a small diagonal branch could be detected on the acute angiogram ( arrows ) . ventriculography ( c : diastole ; d : systole ) revealed typical left ventricular apical ballooning and an akinetic region that extended well beyond the vascular territory of the occluded vessel . although causality can not be conclusively inferred from this association , we believe that the somatic stress associated with ami may have caused tcm in this patient . thus , she can be considered to have been at increased risk of developing tcm . tcm is typically preceded by an acute somatic or emotional stressor and is believed to be caused by elevated levels of catecholamines . , among the somatic stressors known to be associated with tcm are intracranial events , severe infection , surgical trauma and respiratory disease . because a relationship has been described between tcm and many acute syndromes associated with increased somatic stress , it is intuitive to assume that ami , another acute condition associated with considerable somatic stress , could be associated with tcm . similar to other forms of severe somatic disease , ami is associated with increased levels of catecholamine . however , in ami , catecholamine is particularly high in the periinfarct zone . thus , if anything , ami would be expected to more frequently associate with tcm than other somatically stressful syndromes . we propose that tcm and ami may not be mutually exclusive conditions , and that they may be intertwined in ways we have yet to discover . if this is true , developing strategies for reversing takotsubo may improve the outcome in patients presenting with cardiogenic shock secondary to ami . recent evidence indicates that takotsubo is a cardiocirculatory syndrome that associates with low peripheral resistance and low blood pressure despite adequate tissue perfusion . in other words , patients with tcm display a different cardiocirculatory profile compared to patients with only ami . because standard acute heart failure therapy with vasopressors and/or inotropes may be directly harmful in tcm , clinicians would probably do well to withhold these therapies in hypotensive patients with tcm that do not display signs of tissue hypoperfusion . because optimal treatment of hypotensive patients may depend on whether or not ami is complicated by tcm if echocardiography had not been performed in this patient immediately on admission , we believe that this patient may have been diagnosed with only myocardial infarction and the diagnosis of tcm may have been overlooked . it may be prudent to perform echocardiography without delay in patients presenting with acute chest pain and elevated troponins .

takotsubo cardiomyopathy ( tcm ) is an acute cardiac syndrome characterized by extensive , but potentially reversible , left ventricular dysfunction in the absence of an explanatory coronary obstruction . thus , tcm is distinct from coronary artery disease ( cad ) and acute myocardial infarction ( ami ) . however , substantial evidence for co - existing cad in some tcm patients exist . herein , we take this association one step further and present a case in which the patient simultaneously suffered from ami and tcm , and in which we believe that a primary coronary event triggered tcm . an 88-year - old female presented with chest pain . echocardiography revealed apical akinesia with hypercontractile bases . an occluded diagonal branch with suspected acute plaque rupture was identified on the angiogram , but could not explain the extent of akinesia . cardiac function recovered completely . thus , this patient adhered to current diagnostic criteria for tcm . tcm is a well - known complication for other conditions associated with somatic stress . it is therefore intuitive to assume that ami , which also associates with somatic stress and elevated catecholamine , can cause tcm . our case illustrates that tcm and ami may occur simultaneously . although causality can not be conclusively inferred from this association , the somatic stress associated with ami may have caused tcm in this patient .

bolt gun or slaughterer s guns are used in meat industry for humane killing of animals . we report a case of 28 year old male , who accidentally shot himself with a bolt gun to his right thigh . a 28 years old male presented to our accident and emergency department after accidental injury to his right thigh with bolt gun . he had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of lower one third of thigh at lower and sustained grade ii compound fracture of right femur shaft at distal one third . the wound was treated with multiple debridements , negative pressure wound therapy and intravenous antibiotics based on culture and sensitivity . bolt gun or slaughterer s guns are weapons used in meat industry for slaughtering animals . wounds inflicted by bolt guns have specific morphological feature , distinctive from wounds made by other kinds of hand firearms . lesions caused by these weapons are likely to have a more serious character than is to be expected from the size of the entrance wound . the mainstay of treatment is liberal wound exploration , multiple debridement s and intra venous antibiotics based on culture reports to treat infection and prevent morbidity . bolt guns ( fig . 1 ) are weapons used in meat industry for slaughtering animals . wounds inflicted by bolt guns have specific morphological features , distinctive from wounds made by other kinds of hand firearms . lesions caused by these weapons are likely to have a more serious character than is to be expected from the size of the entrance wound . a 28 year old male while attempting to slaughter a calf holding its head between his thighs accidentally shot himself with bolt gun to right thigh and sustained grade ii open fracture of distal one third shaft of femur ( fig . he had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of his right thigh ( fig . 3 ) . radiograph of femurshows breech in distal one third of femur in anterior cortex . 4 ) confirmed there was no collection of pus in the posterior compartment of thigh . he had a further wound debridement andsecondary wound closure after eleven days of injury and then discharged to home . the limb was immobilized in an above knee cast for four weeks and knee was later mobilized using a knee ranger splint . injuries caused by bolt gun are rare , reported exclusively from central european countries and cases are reported about their use in homicide [ 6 , 7 ] and suicide [ 8 , 9 , 10 ] with mortality of more than 60% . [ 1 , 2 ] . the death by bolt gun is by concussive force and penetration of the bolt . the propulsive force of piston in bolt gun has such strength that lesions caused by these weapons are likely to have more serious complications than are to be expected from the size of entrance wound . wounds inflicted by bolt guns have specific morphological features , distinctive from wounds made by other kinds of hand firearms . selective features of bolt gun wounds are punched out round entrance and a double pattern of smoke soiling ( wide zone of carbon deposition ) . contamination of wound occurs by normal skin flora , clothes , water , soil and foreign bodies . these wounds are primarily infected with mixed bacterial flora of skin at the time of presentation to the hospital . the dead tissue and debris form an excellent culture medium , leading to local proliferation of microorganisms ; proliferation of bacteria can be demonstrated as early as six hours after injury . the wounds caused by bolt gun injury must be explored to detect any foreign bodies , and all devitalized tissue must be excised to minimize risk of infection . so , it is essential to get detailed information about the clothing at time of injury , especially hand injuries as they often appear uncovered on arrival in the emergency department . wounds inflicted by bolt guns have specific morphological features , distinctive from wounds made by other kinds of hand firearms . the wound is primarily infected at the time of presentation to the hospital . aggressive treatment with wound exploration , multiple wound debridement and intra venous antibiotics based on culture reports are the mainstay of treatment to treat infection and prevent morbidity . for the surgeon treating bolt gun injuries it is imperative that a multiple wound debridement s are performed and a high index of suspicious of retained foreign bodies such asskin , soil and tornclothing should be maintained .

introduction : bolt gun or slaughterer s guns are used in meat industry for humane killing of animals . injuries caused by bolt gun are rare , reported exclusively from central european countries . we report a case of 28 year old male , who accidentally shot himself with a bolt gun to his right thigh.case report : a 28 years old male presented to our accident and emergency department after accidental injury to his right thigh with bolt gun . he had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of lower one third of thigh at lower and sustained grade ii compound fracture of right femur shaft at distal one third . the wound was treated with multiple debridements , negative pressure wound therapy and intravenous antibiotics based on culture and sensitivity.conclusion:bolt gun or slaughterer s guns are weapons used in meat industry for slaughtering animals . wounds inflicted by bolt guns have specific morphological feature , distinctive from wounds made by other kinds of hand firearms . most of the time wound will be infected at presentation . lesions caused by these weapons are likely to have a more serious character than is to be expected from the size of the entrance wound . the mainstay of treatment is liberal wound exploration , multiple debridement s and intra venous antibiotics based on culture reports to treat infection and prevent morbidity .

spontaneous closure of idiopathic full - thickness macular holes ( ftmh ) is a well - documented observation . according to several authors , total posterior vitreous detachment is the suggested catalyst that precipitates this occurrence [ 1 , 2 ] . we report a case of a 28-year - old male with proliferative diabetic retinopathy ( pdr ) and vitreomacular traction ( vmt ) who developed a ftmh 2 weeks following an intravitreal bevacizumab injection . the patient had spontaneous closure of the macular hole within several weeks despite persistence of the vmt . a 28-year - old male with pdr , fibrovascular proliferation , and macular edema in both eyes complained of sudden - onset blurred vision in his left eye ( os ) . the patient had been treated over a 2-year period with focal and scatter laser photocoagulation as well as intravitreal bevacizumab therapy to treat both the proliferative retinopathy and macular edema . two weeks prior to the onset of his new symptoms , the patient had a best corrected visual acuity ( bcva ) of 20/40 os and a new mild vitreous hemorrhage due to pdr in his left eye which was treated with an intravitreal bevacizumab injection . examination on the day of the patient 's new symptoms revealed a bcva of 20/50 os . spectral domain optical coherence tomography ( oct , spectralis , heidelberg engineering , heidelberg , germany ) showed a taut anterior - posterior nasal vitreomacular membrane and an adjacent ftmh , measuring 363 m at its base ( fig . the patient was started on topical bromfenac 0.9% os every 12 h ( b.i.d . ) for adjunctive retinal edema management . eight weeks later , the patient 's bcva improved to 20/30 os and oct examination revealed spontaneous closure of the macular hole and persistent vmt in the nasal macula ( fig . 1 ) . the macular hole continues to remain closed 9 months following spontaneous closure . while the mechanism of ftmh formation associated with pdr is not well understood due to the complexity and infrequency of these holes , the rate of spontaneous closure of such entities has yet to be clearly elucidated . the incidence of spontaneous idiopathic macular hole closure was reported to occur in 11.5% of patients , all of whom had a posterior vitreous detachment . however , patients with diabetic retinopathy were excluded from that study . spontaneous macular hole closure in patients with coexisting diabetic retinopathy reported a case of a 72-year - old female with pdr and spontaneous closure of a ftmh in the presence of a complete posterior vitreous detachment . errera et al . reported the spontaneous closure of a ftmh and persistent vmt in an 81-year - old patient with non - proliferative diabetic retinopathy treated with laser photocoagulation 5 years prior . their hypothesis was that laser photocoagulation induced retinal pigment epithelial cell activation and subsequent mueller cell nuclear migration contributed to the spontaneous macular hole closure . the pathophysiological impetus for macular hole formation associated with diabetic retinopathy may be due to either vmt or retinal edema . demonstrated that the premacular cortical vitreous is thickened due to the proliferation of fibroblasts and fibrous astrocytes along native vitreous collagen in 77% of patients with diabetic macular edema . the authors further demonstrated single or multilayered cellular membranes developing along native collagen , leading to tangential vmt . according to steel and lotery , brazitikos and stangos postulate that intraretinal exudation may lead to retinal atrophy and intraretinal cyst formation . the horizontal orientation of the mueller cell processes and anatomically thin retinal tissue in the fovea , in conjunction with increasing pressure from the intraretinal exudation , predisposes the fovea to macular hole formation secondary to diabetic retinopathy [ 6 , 7 ] . it is unclear whether the intravitreal bevacizumab injection 2 weeks prior to the onset of symptoms played a role in our case . a single case of ftmh developing 2 weeks following bevacizumab therapy has been reported and attributed to contraction of the posterior hyaloid and the fibrovascular membrane . our case differs in that there is a focal area of nasal anterior to posterior vmt that remained unchanged prior to development of the macular hole and after its spontaneous closure . the role of the vmt as a cause is also questionable since the traction was present nasal to the macular hole , and ftmhs associated with vmt typically form at the point of traction . we can hypothesize that a temporary disturbance in the vitreous dynamics immediately following the injection led to a transient increase in the vmt resulting in macular hole formation . this theory may also explain the spontaneous closure , since there was no change in anterior to posterior traction before the macular hole developed or after it closed . kurz and kurz reported a single case of spontaneous closure of a ftmh treated with topical ketorolac . while complete posterior vitreous detachment was present in this case , the authors state that macular hole closure was potentiated by pharmacologically induced resolution of the macular edema . because our patient had a previous history of retinal edema , we elected to treat our patient with topical bromfenac 0.9% b.i.d . in summary , we report a case of a ftmh associated with pdr , vmt and edema that occurred 2 weeks following an intravitreal bevacizumab injection .

diabetic retinopathy worsens the prognosis of macular holes compared to those of idiopathic etiology . while spontaneous closure of idiopathic macular holes is a well - documented phenomenon , spontaneous closure of macular holes associated with proliferative diabetic retinopathy is rare . we report a case of spontaneous closure of a macular hole associated with proliferative diabetic retinopathy and persistent vitreomacular traction .

stress fracture is a partial or complete bone fracture that occur due to repeated application of stress lower than the stress required to fracture the bone in a single loading . the middle third of the ulna is the commonest site as this region has the thinnest cortex and smallest cross - sectional area morphologically compared to the proximal or the distal third , and is vulnerable to stress from torsional forces . we report a case of stress fracture in a cricketer , developed after doing excessive push ups . to the best of our knowledge , this case is the first report of ulna stress fracture after doing excessive push ups . a 24-year - old cricketer had a seven month history of increasing pain of the ulnar diaphysis of left forearm . patient reported that he had started on excessive daily training program seven months before this episode of pain . he used to do daily push ups for about one hour in the morning and evening . the pain in her left forearm gradually became worse , and he experienced difficulties while playing cricket . the pain relieved by taking some rest and by using analgesics . he continued to have persistent pain despite oral analgesics , but he continued the push ups . finally while doing push ups one day his pain over the forearm suddenly exacerbated followed by a feeling of snapping sound . following this , at that point he was unable to do any activities with his left forearm and he then presented with us . on examination , palpation along the left forearm elicited pain , tenderness , crepitus and mild swelling at the middle third of the ulna , however there was minimal pain on pronation and supination of the forearm and flexion and extension of the wrist and the elbow . it revealed undisplaced fracture of middle third ulna [ figure 1 ] . on reviewing the typical clinical history and radiographs radiograph of the left forearm showing stress fracture of middle third ulna as the patient did nt wanted surgery so he was treated with long arm cast for six weeks . after six weeks of conservative management , his pain disappeared and radiographs showed union at fracture site [ figure 2 ] . at one year follow - up , ( a , b ) anteroposterior and lateral radiograph of the left forearm showing complete union of the fracture after six weeks of immobilisation stress fractures of the ulnar diaphysis have been described in soft ball pitchers , body builder , bowlers and golfers . the aetiology of these fractures has been described as either a traction injury of the hand flexors and extensors or related to torsional forces associated with excessive pronation and supination . in all the reported cases , the patient returned to activity in four to six weeks after a period of rest from the aggravating activity , and after gradual resumption of activity . in our case , the patient had to put his hands on ground with elbow and wrist extended and put the whole body weight over it . the classic history of repeated stress over forearm , exercise associated bone pain and typical examination findings are highly correlated with diagnosis of stress fracture . this mechanism of axial loading has previously been reported in a case of cyclic weight bearing associated with crutch use . during axial loading , the radius carries most of the load ( 82% ) and the ulna carries a smaller load ( 18% ) , but the load along the ulna increases when the wrist is a position of flexion , ulna deviation , and forearm pronation . therefore we hypothesize that the cause of the fracture was due to axial loading during excessive muscle training . although surgical intervention in such cases are preferred , but since our patient did nt wished surgery so he was managed conservatively . it has been estimated that between 5 - 10% of all sports - related injuries involve stress fractures and a good proportion of these result in delayed union or nonunion . hulkko et al . , estimated delayed union or nonunion in 10% of stress fractures in finland . the reason for these poor results is twofold : delayed diagnosis due to late consultation of expert physicians , and too short a rest from hard physical activity . furthermore in many cases , the diagnosis is difficult and repeated clinical , radiological examinations are necessary for early diagnosis and management . the mechanism of stress in present case is only speculative , but it suggests the possibility of stress fractures of the ulna diaphysis in individuals participating in excessive training regimens such as that outlined in this report . stress fracture of forearm must be included in the differential diagnosis of athletes having forearm pain .

stress fractures are most common in the weight - bearing bones of the lower extremities and spine , but are rarely found in non - weight - bearing bones of the body . stress fracture of the ulna is extremely rare . we report a case of complete stress fracture of ulna caused due to excessive push ups in a young athlete . conservative management was successful in healing of fracture and returning this patient back to his previous activity level . physician should have high index of suspicion , whenever they encounter a young athlete complaining of forearm pain .

the ventriculoperitoneal ( vp ) shunt is routinely used for cerebrospinal fluid ( csf ) diversion . a relatively straightforward procedure , it can be done safely even in infancy . however , placement of the vp shunt may be associated with several complications ( infection , shunt malfunction , subdural hematoma , seizures , migrating catheter)1 . small amounts of blood are frequently seen on imaging in the ventricle or in the parenchyma along the catheter path , but clinically significant hemorrhage is rare2,3 . in fact , postoperative intracerebral or intraventricular hemorrhage secondary to shunt placement is rare ; only a few such patients have been reported4,5,6 . in 1985 , matsumura reported the first case of delayed intracerebral hemorrhage after vp shunting in a 17-year - old male on postoperative day 75 . we report two cases of delayed intracerebral hemorrhage , along the path of the ventricular catheter , occurring on postoperative days 3 and 5 . case 1 : a 32-year - old female complained of headache and dizziness for 2-month duration . computed tomography ( ct ) showed markedly enlarged ventricles ( figure 1a ) . there were no space - occupying lesions on magnetic resonance imaging ( mri ) . a diagnosis of hydrocephalus was made and a vp shunt undertaken with a medtronic strata programmable valve system ( pressure level , 2.5 ) . the vp shunt was inserted at the first attempt ; no blood was observed in the csf on ventricular cannulation . the patient recovered well and routine follow - up ct on postoperative days 1 and 3 showed collapsing ventricles without evidence of hemorrhage ( figure 1b , 1c ) . on postoperative day 5 , the patient suddenly developed a headache and dizziness while urinating . soon thereafter , the patient became unconscious ; ct showed a large hematoma along the path of the ventricular catheter associated with an appreciable intraventricular hemorrhage ( figure 1d , 1e ) . case 2 : a 58-year - old male underwent a decompressive left frontotemporal craniectomy and right frontotemporal craniotomy for traumatic intracerebral hematoma sustained during a motor vehicle collision 3 months previously . ct showed hydrocephalus with interstitial edema capping the frontal horns of the lateral ventricles ( figure 2a ) . a vp shunt was placed with a medtronic strata programmable valve system ( pressure level , 1.5 ) . a ventricular catheter was inserted into the anterior horn of the right lateral ventricle at the first attempt . twenty - four hours after surgery , ct imaging was normal and the pressure of the left decompressive window decreased ( figure 2b ) . emergent ct demonstrated hemorrhage along the path of the ventricular catheter and in both lateral ventricles ( figure 2c ) . delayed intracerebral or intraventricular hemorrhage after placement of a vp shunt has been reported , but is very rare2,7,8 . in our institution , literature reviews revealed that almost all instances of postoperative intracerebral hemorrhage secondary to vp shunt placement occurred soon after the operation9 . the hemorrhage might be caused by multiple attempts at ventricular puncture , puncture of the choroid plexus or incorrect placement of the tube within the brain parenchyma6,10,11 . other mechanisms whereby intracerebral hemorrhage might occur after ventricular cannulation included a coexistent bleeding disorder , disruption of an intracerebral vessel , hemorrhage from an occult vascular malformation and head trauma occurring shortly after shunt placement4 . misaki and alcazar explored the mechanism underlying the delayed aspect of the hemorrhage , suggesting erosion of cerebral blood vessels from the catheter as an explanation12,13 . although this did not explain all post - shunt hemorrhages , we thought that ventricular collapse after tube insertion ( postoperative ct imaging can show this ) might induce the tighter contact between the catheter and vasculature and lead to subsequent erosion of the vasculature . this may ( at least in part ) explain the delayed aspect of the hemorrhage . we summarized the reported cases of delayed intracerebral hemorrhage after shunt insertion based on the work of misaki13 ( table 1 ) . in conclusion , delayed intracerebral hemorrhage secondary to vp shunt is a rare but severe complication with a high mortality rate .

ventriculoperitoneal ( vp ) shunt has become a popular operation to achieve cerebrospinal fluid ( csf ) diversion , but is associated with many complications . postoperative delayed intracerebral hemorrhage is a kind of rare but severe event , which has not thus far been reported in retrospective case analyses . here we present two cases of delayed intracerebral hemorrhage , along the path of the ventricular catheter , which occurred on postoperative days 3 and 5 . we also provide a literature review regarding this rare complication .

for severe trauma patients , pre - admission mortality continues to be the most important reason for clinical trauma deaths9 ) . the most common cause of death from trauma at the scene is acute hemorrhagic shock5 ) . however , advances in emergency resuscitation and rescue teams have been credited with significantly improved outcomes among such patients . in particular , trauma victims who would have died due to sudden heart arrest at the scene are now brought to the hospital following resuscitation . most of these patients present with major organ injuries and hypovolemic shock at the time of trauma . , we report a case of ring fracture with pontomedullary laceration that led to sudden heart arrest . a 43-year - old man involved in a pedestrian accident was admitted from a local hospital to our institution and was comatose during resuscitation . at the scene , he was noted to have a glasgow coma score of 3 with nonreactive pupils 5 mm in diameter . on arrival , full medical examination revealed only bilateral otorrhea and rhinorrhea , involving some bruising in his face and jaw and right side of the scalp . computed tomography of the head showed diffuse brain injury with severe cerebral swelling , particularly right - side acute subdural hemorrhage . skull base ct revealed a ' ring ' fracture around the foramen magnum that involved the clivus , both petrous temporal bones and the posterior part of the foramen magnum . there were no signs of atlanto - occipital dislocation , and the remainder of the cervical spine was intact ( fig . in review of his medical history , he was healthy before the accident . on arrival to the nicu , the patient was in a coma , with a glasgow coma scale score of 3 , and showed fixed , nonreactive pupils 6 mm in diameter . there were no signs of brain stem activity , although his vital signs were stable . at 27 days after admission , magnetic resonance imaging revealed swelling of the brain stem and cerebellum combined with transtentorial and foraminal herniation ( fig . the patient remained fully comatose for 34 days after injury and then died of pneumonia with sepsis . specific types of skull base fracture , including ring ( complete or incomplete ) and hinge fractures , can be accompanied by brain stem injury7 ) . ring fractures that occur at the skull base involve separation of the rim of the foramen magnum from the rest of the skull , accompanied by the fracture of one petrous temporal bone to the other across the midline and then posteriorly around the foramen magnum through the occiput . these fractures cause traumatic brainstem injury , and the pontomedullary junction is the most frequently injured site6 ) . these lacerations may be either partial or complete and are associated with hinge or ring fractures or fracture of the cervical spine3 ) . the potential mechanisms responsible for ring fracture including the pushing of the spine against the skull base and an extraction force owing to hyperextension of the neck12 ) . in particular , ring fractures result from traction of the head caused by hyperextension or hyperflexion , a shearing effect , rotatory torsion or wedge compression against the frontal bone and the invasion of the vertebral column into the base of the skull . the causes of death in cases of ring fracture include dislocation of the atlantooccipital junction , pontine hemorrhage , brainstem injury and vascular injuries2 ) . although sudden heart arrest caused by brain stem injury represents a leading cause of death in the field1,8 ) , this condition remained unfamiliar to forensic doctors until recently . unexpectedly , victims of ring fracture show neither neck joint dislocation nor basal skull fracture . in such cases , soft tissue injuries to the chin area and hemorrhage can be observed in the neck muscles , indicating hyperextension or hyperflexion of the neck12 ) . however , mandible fractures reduce energy transfer to the temporomandibular joints and protect the skull base and the brain10 ) . in cases of chin impact , the presence of a mandible fracture reduces the incidence of the pontomedullar laceration by 2.3-fold compared to the absence of such a fracture12 ) . in addition , ring fractures can also be accompanied by cerebrospinal fluid rhinorrhea and/or otorrhea1 ) . with improvements in emergency resuscitation and rescue team efforts , more ring fracture patients who would have died due to sudden heart arrest at the scene are brought to the hospital following resuscitation . despite the presence of significant internal injuries , victims of immediate post - traumatic heart arrest may have surprisingly few external manifestations of trauma , although most of these patients suffered from combined injury at the time of trauma . ring fractures associated with pontomedullar laceration are the primary reason for head trauma - related sudden heart arrest . thus , primary emergency doctors must keep in mind that patients resuscitated immediately after trauma and showing cerebrospinal fluid rhinorrhea and/or otorrhea without combined injury may have suffered ring fracture and brain stem injury . ring fracture of the skull base is a commonly fatal injury detected in victims of head trauma . ring fracture can cause pontomedullary laceration and give rise to sudden cardiac arrest at the time of fracture . as a result , however , with improvements in emergency care , more patients with ring fractures survive to reach the hospital , and the diagnosis of ring fracture has become the job of neurosurgeons . accurate diagnosis and medical information improve the early evaluation of ring fracture and pontomedullar laceration . thus , for the greater number of patients who survive this type of injury , we should aim to provide an early diagnosis and precise medical information for patients and their families .

due to improvements in emergency resuscitation provided by rescue teams , more trauma victims who could have died due to sudden heart failure at the scene are brought to the hospital following resuscitation . most of these patients present with major organ injuries and hypovolemic shock at the time of trauma . however , head trauma associated with sudden heart arrest is rare . here , we report a case of ring fracture with pontomedullary laceration that led to sudden heart arrest .

pernicious anemia is an autoimmune disease that causes a variety of clinical features as described in table 2 . the incidence of disease peaks at the age of 60 with known associations with other autoimmune diseases such as vitiligo , hashimoto 's thyroiditis , hypoparathyroidism , and addison 's disease . it can also be associated with hypogammaglobinemia , premature graying or blue eyes , and blood group a. it is characterized by antibodies to intrinsic factor and/or parietal cells , which causes vitamin b12 deficiency due to failure of b12 absorption . anti - parietal cell antibodies ( pca ) are present in 90% of pernicious anemia patients , but lack specificity to the disease where 16% of healthy patients can have these antibodies , particularly women older than 60 . autoantibodies cause destruction of parietal cells and gastric atrophy , decrease in hydrochloric acid and serum pepsinogen , and increase in serum gastrin levels . among previous postulated theories regarding the mechanism for pernicious anemia , chronic helicobacter pylori infection can potentially lead to gastric inflammation , gastric atrophy , and intestinal metaplasia . these changes can predispose to gastric carcinoid and adenocarcinoma ( 1 , 2 ) . therefore , continuous surveillance every 3 years in patients with pernicious anemia and helicobacter pylori infection with endoscopy is strongly recommended ( 3 ) . other causes of vitamin b12 deficiency apart from pernicious anemia are listed in table 3 . clinical features of vitamin b12 deficiency causes of vitamin b12 deficiency common findings on peripheral smear are megaloblastic anemia with hypersegmented neutrophils . vitamin b12 deficiency leads to disassociation between the maturation of cytoplasm and that of nuclei exhibiting macrocytosis , immature nuclei , and hypersegmentation in neutrophils ( 4 ) . therefore , intramedullary cell death due to arrest of various precursor cells in hypercellular bone marrow causes release of ldh and low haptoglobin levels resulting in a presentation of similar to microangiopathic hemolytic anemia ( 5 ) . patients who present with normal vitamin b12 levels , but show clinical signs and symptoms of pernicious anemia , should have functional assays like methylmalanoic acid ( mma ) and homocysteine levels checked ( 2 ) . it is noted that competitive binding assays are susceptible to interference due to anti - if antibodies resulting in false normal vitamin b12 levels ( 2 ) . mma is mildly elevated in 30% of healthy patients , 15% of elderly and in renal failure patients . sometimes , iron deficiency anemia can be accompanied with vitamin b12 deficiency , which makes mean corpustular volume ( mcv ) appear normal . leukopenia , thrombocytopenia , and pancytopenia can occur in extreme deficiency cases , such as in our case . it is very important to rule out vitamin b12 deficiency before treating folate deficiency as neuropathy can worsen with improving anemia . high - dose oral vitamin b12 supplementation of 1,000 to 2,000 g / d is usually as effective as parenteral administration . if patients present with severe anemia and neurological complications , six shots without interval periods can be administered for 1 week . treatment should be followed with 1,000 g monthly i m injections or every 3 months based on severity . folate levels in pernicious anemia will be normal or increased as conversion of methyl tetrahydrofolate ( mthf ) to tetrahydrofolate ( thf ) is blocked because of lack of vitamin b12 . however , during supplementation of vitamin b12 , folate should also be supplemented in cases of severe anemia or pancytopenia due to increased folate utilization for cell production . b12 deficiency can have a multitude of presentations including strictly hematological abnormalities without neurological problems or vice versa , as in our case . it is recommended to have one - time endoscopy with biopsy in every pernicious anemia patient as it has been postulated to be associated with gastric cancer and carcinoid with subsequent 3-year surveillance . both pernicious anemia and autoimmune thyroid disease can cause hyper - homocysteinemia , a strong independent risk factor for cvd ( 6 ) . as in our case , vitamin b12 should be in differential diagnosis in any patient who presents with pancytopenia . the authors have not received any funding or benefits from industry or elsewhere to conduct this study .

pernicious anemia is an autoimmune disease with a variety of clinical presentations . we describe a case of pernicious anemia presenting with pancytopenia with hemolytic features . further workup revealed very low vitamin b12 levels and elevated methylmalonic acid . it is important for a general internist to identify pernicious anemia as one of the cause of pancytopenia and hemolytic anemia to avoid extensive workup . pernicious anemia can present strictly with hematological abnormalities without neurological problems or vice versa as in our case .

a 60-year - old woman presented for removal of an itchy subconjunctival mass in her left eye . her ocular findings were normal , except for a subconjunctival mass ( 1.51.5 mm ) . a parasite excised from the subconjunctival mass was identified as a sparganum , by microscopic examination after hematoxylin - eosin staining . the mummified parasite was identified as the plerocercoid phase of the sparganum , by microscopy . although rare , parasitic disease should be suspected in a palpable subconjunctival mass unresponsive to the medical treatment . a 60-year - old woman was admitted complaining of an itching sensation in the medial conjunctiva of the left eye , for several months . at the initial examination , her visual acuity was 20/20 , and the intraocular pressure was 16 mm hg in each eye . a 1.51.5 cm sized , tender and yellowish mass was detected in the nasal conjunctiva of the left eye . despite treatment with systemic antibiotics and anti - inflammatory agents for several months at another eye clinic , a white , flat , wrinkled , thread - like worm , 11 cm in length , was found in the nasal subconjunctiva of the left eye ( fig . 2 ) . on microscopic examination , it was a larva and a foreign body granulomatous reaction was seen in soft tissue . a section of worm had a non - cellular tegument , subtegumental cells , and parenchyma containing calcareous corpuscles and longitudinal smooth muscle fibers , which confirmed as a sparganum larva ( fig . serodiagnosis using an enzyme - linked immunosorbent assay revealed increased titer of sparganum specific igg ( 1.51 ) . the patient ate several snakes or frogs 20 years ago , and she she drank water from mountain springs for 6 months . given its rarity and the considerable variation in the manifestations , it is difficult to diagnose and differentiate sparganosis from a wide variety of inflammatory and neoplastic disorders . cause hydatid disease.4 human can also serve as the secondary intermediate host for some cestodes belonging to the order pseudophyllidea . in these cases , sparganum , the metacestode stage of cestodes , which is known as a plerocercoid is infected and results sparganosis.4,5 sparganosis is a zoonosis contracted from amphibians , reptiles , or mammals , and occurs occasionally in humans . the infection has been reported in many countries but is most common in eastern asia.6 after ingestion by a human , the sparganum larvae migrate through the viscera and can end up in many different tissues , where they grow . a mass lesion is the most common clinical sign.7 the early symptom of subconjunctival sparoganosis is similar to that of asymptomatic subconjunctival mass , allergic conjunctivitis , or blepharitis . and in addition to these of symptoms , subconjunctival sparganosis can cause similar symptom of orbital cellulitis , exophthalmos , and expose cornea ulcer . if the worm invades orbit , it lead to severe inflammation or blindness.8 human ocular sparganosis is a surgical disease because its diagnosis depends almost entirely on the demonstration of larva from the lesion . however , these informations have not always been helpful for correct diagnosis , because human sparganosis show great variations in the manifestation . in the differential diagnosis of human sparganosis , we must take into consideration trematodes , which present a thinner tegument without folds besides having genital organs and an alimentary canal , and the larval forms of other cestodes such as cysticercus , coenurus and hydatid . these , having a cystic wall , a scolex , a rostellum , suckers or hooks , are usually easily recognizable . the immunologic serodiagnosis of sparganosis , using indirect immunofluorescence or enzyme - linked immunosorbent assay , is helpful . no medication has proven effective against sparganum , and the principal therapy is surgical removal . in conclusion , although its rarity , parasitic disease should be suspected in a palpable subconjunctival mass unresponsive to the medical treatment .

purposeto present a case of ocular sparoganosis presenting as itching sensation.methodsa 60-year - old woman presented for removal of an itchy subconjunctival mass in her left eye . her ocular findings were normal , except for a subconjunctival mass ( 1.51.5 mm).resultsa parasite excised from the subconjunctival mass was identified as a sparganum , by microscopic examination after hematoxylin - eosin staining . the mummified parasite was identified as the plerocercoid phase of the sparganum , by microscopy.conclusionsalthough rare , parasitic disease should be suspected in a palpable subconjunctival mass unresponsive to the medical treatment .

the recommended methods of testing for her2 neu , its appropriate interpretation and the clinical consequences have also been the subject of extensive reviews [ 1 , 2 ] . when a tissue sample is adequately processed and interpreted by an experienced individual , in the presence of adequate controls , the results of the test are deemed to be reliable and do not require retesting . the heterogeneity of her2 neu expression by immunohistochemistry ( ihc ) and/or fluorescence in situ hybridization ( fish ) testing has also been studied with discrepant results and guidelines have been issued regarding the intratumoral heterogeneity of her2 neu expression by fish . however , the simultaneous coexistence of areas of negative expression and a 3 + expression by ihc on immediately adjacent tumor cells has not been discussed . a 63-year - old woman underwent mammograms , ultrasound and magnetic resonance imaging of the breasts for mammographically detected , suspicious abnormalities . the larger abnormality in the left breast at 11 o'clock was shown to be a hyalinazing , infiltrating duct cell carcinoma of the breast with negative estrogen receptors ( 0% ) , negative progesterone receptors ( 0% ) and negative her2 neu oncoprotein expression ( ventana medical systems , tucson , ariz . , the mib-1 was high ( 76% ) , the ck5 was positive ( 70% ) and the epidermal growth factor receptor was also positive ( 90% ) . the patient elected to have a left mastectomy and sentinel node biopsy and a prophylactic right simple mastectomy . the final pathology revealed a 2.5-cm , infiltrating , poorly differentiated duct cell carcinoma with clear margins . the nottingham histologic score was 8 ( grade iii ) , the estrogen and progesterone receptors were again negative ( 0 ) , but the her2 neu by ihc was positive ( 3 + ) . the patient is jewish ashkenazi and has a positive family history of breast cancer with negative brca 1 and 2 . the histopathology of the tumor was reviewed again , attempting to explain the disparity of the results , and we found that the majority of tumor cells expressing 3 + positivity for her2 neu by ihc were surrounding a defined area of the same histologic tumor that was negative for her2 neu , by the same ihc . 1 shows a whole mount of the tumor on a glass slide stained with ihc for her2 neu , showing malignant cells expressing 3 + positivity for her2 neu adjacent to negative expression . furthermore , in the area of her2 neu negativity , we were able to identify the needle tract left by the biopsy needle ( schematically represented by two parallel lines ) , and a small square was amplified to higher power showing the junction between her2-positive and -negative zones ( fig . when the testing for her2 neu results in 3 + positivity by ihc or her2 neu gene amplification by fish testing , the patient is treated with medications targeting this receptor . assuming accurate testing and interpretation , these tests are rarely , if ever , repeated again . the heterogeneity of her2 neu results has been partially addressed , but the particular variability found in this unique case has not been addressed yet . the clinical consequences for this individual patient would have been serious if the her2 neu positivity had gone undetected . we do not know the frequency with which a disparity of this degree occurs , but it is not even mentioned in reviews on this subject or consensus guidelines published previously . recent tests using dna microarray technology attempt to predict the risk of recurrence in patients with various cancers . , usa ) is a commonly used test , accepted by the national comprehensive center network , that analyzes the expression of 21 genes in breast tumors and reports a score that correlates with an estimated percentage chance of distant tumor recurrence . occasionally , in the practice of clinical oncology , experienced physicians find large inexplicable discrepancies between the risk of recurrence assessed by the available clinical information and their individual experience and that reported by the test itself . the result of the risk as assessed by the oncotype dx relies greatly on the her2 neu expression . there are also reports of patients with her2 neu - negative breast cancers that have responded to therapy with trastuzumab . a central review of her2 neu results has also been done in large trials with concordant results found only in 81% of the samples . however , the methodology did not include testing of the same specimen on which the original test had been done . finally , changes in her2 neu results have also been reported in the same tumor at different times . cases similar to the one reported here offer an obvious potential explanation for these disparities and unexpected responses to therapy . the clinical consequences of failing to identify the correct expression of her2 neu are serious ; therefore , we suggest that in patients in whom the original biopsy results of her2 neu are negative , by any testing method , a retesting of a larger sample of the tumor should be done .

we report on a patient with breast cancer in whom there were areas of the tumor that were 3 + positive and negative for her2 neu by immunohistochemistry , adjacent to each other . depending on the area tested the results were completely different . the clinical implications are important . we recommend retesting a large portion of the tumor in all cases of initially negative test results .

a highly schematic model of normal development to explain how the observed transdetermination might occur in the lungs of transgenic mice expressing a constitutive activator of wnt signaling . ( a , b ) the mesoderm associated with the endodermal epithelium normally emits wnt signals in two regions , at two different times . ( c ) because the competence of the endoderm - its potential to form different tissues - changes during this period , this results in the activation of different homeotic genes , and the formation of different tissue types . but artificially prolonged signaling would activate both homeotic genes , with unpredictable consequences that might include the formation of cell types belonging to both tissues .

the phenomenon of metaplasia , in which one tissue type is converted into another , is beginning to be explained in molecular terms . the transformation of lung to intestinal tissue has not previously been described , but it is now reported that it can be brought about by prolonged wnt signaling in late development .

a complex neuromuscular facial disorder resulting from the paralysis of facial ( vii cranial ) nerve due to an unknown etiology is termed as idiopathic facial paralysis or bell s palsy ( bp ) . although the exact cause of bp is not known , many neurologists believe that recurrence of a dormant viral infection can root the facial nerve to swell and becomes inflamed . approximately 23% of individual with bp have residual symptoms , such as incomplete motor recovery , synkinesis , hemifacial spasm , and crocodile tears.1 most of these sequelae affect the individual both socially and psychologically leading to decline in their quality of life.2 the purpose of this case report is to explain the role of proprioceptive neuromuscular facilitation ( pnf ) in speeding the recovery in a child diagnosed with bp . the patient is a 7-year - old male child diagnosed with bp of the right idiopathic facial nerve with severe right facial paralysis . he was presented with the left deviation of mouth angle at rest with incomplete eye closure on the right side , absence of forehead creases , nasolabial fold and typical bell s phenomena with muscle power ranges between non - functional to week functional on the 3 day from the onset of the above symptoms . to quantify the prognosis , facial grading system ( fgs ) goal - directed physiotherapy management used was approach to reduce the edema , prevent the occurrence of synkinesis , and strengthen the muscle and thereby to achieve maximal restoration of facial symmetry ( resting / functional ) . at first , facial massage ( stroking , tapping , hacking , kneading ( finger / thumb ) along with effleurage ) was given to drain the edema , improve circulation , prevent contractures , and improve perceptual awareness and then proceeded with the pnf approach - based kabat concept3 over the left side of the child s face . facial exercise was performed on the affected side in front of mirror to prevent muscle atrophy and thereby increases muscle function . sucking cheeks between the teeth , wrapping lips over teeth , making sustained fff sound , blowing paper , pronouncing vowels , and expressions such as smiling , snarling , flaring of nose , and raising eyebrows.4 the interventions were continued for 14 days . the fgs was recorded every 7 day of treatment to document the recovery ( figure 1 ) . baseline reading was noted on 3 day , second reading on 10 day , and final reading on 16 day . facial pnf technique helps in stimulating weakened facial muscles by irradiation principle which proved to be better than traditional therapeutic measures for the children with bp like electric stimulation . similar supportive report was documented by manikandan in adults with bp by a randomized controlled trial ( rct).5 we reported this in a single case as against rct . nevertheless , this was the first study to document the effectiveness of pnf in children with bp . facial pnf along with facial exercise and massage might be an effective rehabilitation approach in rehabilitating the children with bp .

bell s palsy ( bp ) in children is a rare case with no documented evidence regarding its rehabilitation management . till date , individuals with bp are being treated with electrical stimulation are proportionately greater than other conventional means such as facial exercise and massage . these conventional modes of treatment have proved to have less incidence of synkinesis with more benefits . here , we report a case of a 7-year - old boy diagnosed clinically to have right idiopathic facial nerve paralysis , who underwent 14 days of facial proprioceptive neuromuscular facilitation exercises along with facial therapeutic massage . documented improvements in facial grading system reveal promising outcomes . hence , we propose the above technique might improve the functional outcome in the children with bp .

extensive deformities of the thoracic cage may affect the function and growth of lungs leading to its inability to support normal respiration . jarcho levin syndrome ( jls ) is a rare lethal cause of such respiratory insufficiency . it is characterized by vertebral segmentation defects leading to congenital scoliosis and fusion of ribs . we present one such typical case of jls with associated cardiac defects presenting in early neonatal period . this was a case report of a 2.2 kg girl born at 34 weeks to an unbooked primi mother out of a non - consanguineous marriage presented on 2 day of life with severe respiratory distress and limited visible chest expansion requiring mechanical ventilation . her weight and head circumference were 2.2 kg and 31 cm , both corresponding to 50 centile while the length of 31 cm was less than 3 centile . upper to lower segment ratio was 1.3:1 ( normal is 1.7:1 ) suggestive of short trunk dwarfism . skeletal survey revealed a small volume rib cage with crab like appearance [ figure 1 ] . there was bilateral asymmetric costovertebral fusion of ribs with scoliosis to the right and hemivertebrae in cervical and thoracic spine [ figure 2 ] . there were no intrinsic abnormalities of ribs such as bifid , fused or broadened ribs . vertebral segmentation defects were seen throughout the spine . cardiac examination and echocardiography revealed dextrocardia and 8 mm ostium secundum atrial septal defect and a 2.5 mm patent ductus arteriosus , both with a left to right shunt . ultrasound abdomen , magnetic resonance imaging brain , screen for bacterial / intrauterine infections and karyotyping were all normal . . a clinical diagnosis of jls with lethal progressive respiratory insufficiency , dextrocardia and an acyanotic congenital heart disease was made . 3d reconstruction image showing crab like appearance of the thoracic cage 3d reconstruction image showing absent ribs and hemivertebrae thoracic skeletal anomalies present as a rare cause of progressive respiratory insufficiency . extensive vertebral and rib anomalies like jls , juene syndrome and ellis van crevald syndrome affect thoracic function and growth , which in turn affects lung growth . our case was befitting into the diagnosis of a severe lethal form of jls with thoracic insufficiency due to the presence of vertebral segment defects throughout the spine , asymmetric bilateral costo - vertebral fusion of ribs and scoliosis with limited thoracic volume and expansion leading to progressive respiratory failure and death in the early neonatal period . they described a syndrome with a spectrum of vertebral segmentation defects and rib anomalies . later in an article in 1996 mortier et al . classified congenital vertebral segmentation defects into three subtypes - jls , spondylothoracic dysostosis ( std ) and spondylocostal dysostosis ( scd ) . vertebral segment anomalies in std spare the sacrococcygeal region and they do not have intrinsic rib anomalies . it is characterized by involvement of > 10 contiguous vertebral segments , pebble beach appearance of vertebrae on x - ray , involvement of sacrococcygeal region with intrinsic rib anomalies . jls is a lethal subtype which presents with vertebral segmentation defects like hemivertebrae or block vertebrae throughout the spine with fusion of ribs at costovertebral junction bilateral asymmetrically leading to crab like appearance on x - ray . there is the presence of scoliosis and absence of ribs without intrinsic rib anomalies such as bifid , broadened or fused ribs . usually death due to respiratory insufficiency in the severe form of this condition commonly occurs within the first 2 years of life . however , our case presented and succumbed early in the neonatal period itself . jls has been reported to be associated with cardiac , urogenital , digital and neural tube defects . in a review , hatakeyama et al . reported association of congenital heart disease in 9 out of 87 cases of jls . diagnosis of this syndrome is purely clinical based on short trunked dwarfism associated with typical vertebral segmentation and costo - vertebral rib fusion defects .

a rare case of jarcho levin syndrome ( jls ) presenting as a lethal progressive respiratory insufficiency in early neonatal period is reported . the neonate had classical features of this syndrome including vertebral segmentation defects , typical costo - vertebral fusion defects and scoliosis resulting in small thoracic volume and limited chest expansion ; all consistent with a clinical diagnosis of jls with thoracic insufficiency . in addition , our case had a rare association of dextrocardia and acyanotic congenital heart disease .

blunt traumatic aortic rupture ( tar ) has traditionally been treated with early open surgical repair . recently , endovascular stent - grafting of tar has been described as a less invasive and possibly more favorable option . a 73-yr - old woman presented with multiple trauma and chest pain after a traffic accident . traumatic aortic injury was suggested by a chest radiography , which showed mediastinal widening and left pleural effusion . a spiral computed tomography ( ct ) scan revealed an extraluminal hematoma in the distal aortic arch with a contained aortic rupture ( fig . however , the patient had concomitant comminuted fractures in the right tibia , left femur , and the radius bilaterally , which required surgery . surgery for the tar was therefore delayed for about 1 month to allow orthopedic postoperative recovery . to allow a minimally invasive surgery , a hybrid aortic stent - grafting procedure was performed , consisting of a left subclavian artery ( lsca ) debranching procedure combined with proximal descending thoracic aortic stenting . median sternotomy for the debranching procedure was avoided by transposing the lsca to the left common carotid artery ( lcca ) through a 5 cm left supraclavicular incision . the lsca and lcca were dissected and freed from their surrounding attachments after moderate systemic heparinization with an intravenous ( iv ) of 5,000 iu . the proximal lsca was clamped and transected , and the proximal stump was closed with a continuous running suture of 4 - 0 polypropylene . the lcca was partially clamped and opened longitudinally , and the transected distal portion of the lsca was attached in an end - to - side manner . on postoperative day 5 , the interventional radiologist inserted a thoracic aortic stent percutaneously using the seldinger technique . a 5f - calibrated angiographic catheter was advanced into the aortic arch via the contralateral common femoral artery to determine the morphology and extent of the aortic rupture ( fig . the delivery system was advanced under fluoroscopy after iv injection of 5,000 iu heparin until the tip reached the origin of the lcca . finally a seal endoprosthesis ( s & g biotech , korea ) was inserted into the aortic arch to complete the procedure . a series of aortograms were performed during deployment to ensure accurate proximal and distal positioning . the proximal bare stent was placed precisely in the middle of the ascending aorta , allowing free blood flow to both arch vessels . intraoperative angiography was used for post - procedural assessment of stent - graft positioning and endoleak ( fig . 2c ) showed successful exclusion of the rupture site , with no any signs of endoleak or graft - related complications . at the first visit to the out - patient department , the patient was doing well and showed good healing of the supraclavicular incisional wound ( fig . emergency open thoracotomy for traumatic aortic ruptures is associated with a peri - procedural mortality rate ranging between 17% and 21% , and a paraplegia rate as high as 7% ( 1 , 2 ) , due mainly to the large proportion of patients who present with multiple concomitant co - morbid conditions . although delaying surgical repair of tar may overcome the high mortality and morbidity risks associated with emergency surgery , delaying open surgery has been found to have an in - hospital mortality risk of 2 - 5% ( 3 , 4 ) . recent results have suggested that endovascular stent - grafting may be a viable , ' minimally invasive ' alternative , which can achieve the same results as emergency open thoracotomy but with lower mortality and morbidity risks ( 5 - 7 ) . endovascular stent - grafting , however , has several drawbacks that may limit its broader application . for example , most tars occur at the aortic isthmus level , so the proximal landing zone in these patients is usually short . furthermore , obligate coverage of the lsca ostium is often required to achieve complete sealing of the rupture site , so it may cause ischemia or thrombosis ( 8 , 9 ) . proximal fixation was enhanced in our patient by deploying a graft with an extended bare proximal portion . this approach could ensure adequate anchorage without aortic arch branch occlusion , even in patients with short landing zones . furthermore , by transposing the lsca onto the lcca through the small supraclavicular incision , a full sternotomy could be avoided while preserving blood flow to the lsca . occlusion of the lsca during unprotected stent insertion is frequently regarded as inconsequential . in summary , this report presents our first experience with hybrid tar , combining supra - aortic branch transposition with endovascular stent - grafting . currently available techniques for stent - grafting of the descending aorta , combined with minimally invasive debranching procedures , may lead to the further development of safe and effective strategies that will avoid the high risks associated with conventional open surgery .

emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri - procedural mortality rate . endovascular stent - grafting , as a less invasive procedure , has shown encouraging results . this report describes a patient with a short landing zone , who was treated by transposing the supra - aortic branch without sternotomy , followed by covered stent - grafting with an extended proximal bare portion to enhance fixation .

human t - cell lymphotropic virus type 1 ( htlv-1 ) induces adult t cell leukemia / lymphoma ( atll ) , htlv-1-associated myelopathy / tropical spastic paraparesis ( ham / tsp ) and carrier [ 1 , 2 ] . htlv-1 infection is prevalent in southern japan , especially in kyushu , and the other endemic areas include the caribbean , papua new guinea , south america and africa . after several decades of carrier state , patients may develop atll or ham / tsp . approximately half of atll patients have direct skin involvement of neoplastic cells manifesting patch , plaque , tumor , multiple papules , erythroderma and purpura [ 1 , 2 ] . however , there exist htlv-1-associated reactive eruptions with a predominant infiltrate of non - neoplastic cd8 + t cells , such as chronic actinic dermatitis and alopecia areata . here , we report recurrent diffuse facial erythema with cd8 + t cell infiltration in an htlv-1 carrier . a 50-year - old japanese woman was referred to us for evaluation of her facial eruption . the patient had had three episodes of the eruption during the past year . in each episode , itchy , indurated erythema occurred diffusely on the face and neck , lasted for 2 weeks and spontaneously subsided without sequelae . on the fourth episode , we observed an erythematous eruption with swollen palpebrae and cheeks ( fig . leukocyte counts were normal without atypical lymphocytes , and the serum levels of lactate dehydrogenase and calcium were normal . c3 , c4 and c1-inh were normal , negating the possibility of acquired angioedema associated with lymphoproliferative disorders . by flow cytometry of the patient 's peripheral blood mononuclear cells , cd4 + ( 47.0% ) and cd8 + cells ( 21.7% ) were within normal ranges . cells bearing both cd4 and cd25 ( 10.916.5% , measured at three different times ) , a marker for atll cells or regulatory t cells , were slightly increased , but there was no abnormal population distinct from normal cd4 + t cells ( fig . the frequency of hla - dr+cd8 + activated t cells was slightly increased ( 6.2% ; normal < 3% ) . by southern blot analysis of htlv-1 proviral dna , phototests with uvb showed normal minimal erythemal dose , and uva did not induce erythema at 3 j / cm . a biopsy specimen taken from the neck revealed a perivascular infiltrate of lymphocytes , showing exocytosis into the hair follicle epithelium ( fig . 2d ) , sharing the phenotype with atll neoplastic cells or regulatory t cells . notably , an aggregate of cd8 + t cells ( fig . our patient was an htlv-1 carrier presenting with an unusual complication of transient facial erythema , histopathologically characterized by infiltration of cd8 + cytotoxic t lymphocytes ( ctls ) intermingled with cd4+cd25 + t cells . this provides a possibility that skin - affinitive htlv-1+cd4 + t cells propagated and subsequently disappeared as a result of ctl attack . such an infiltrate of cd8 + t cells has also been reported in chronic actinic dermatitis and alopecia areata of patients with ham / tsp and carriers . in association with htlv-1 infection , htlv-1-associated infective dermatitis is a chronic exudative eczematous eruption prevalent in children of the caribbean area and south america . this disease is seen in htlv-1 carriers , and some of the patients develop ham / tsp . a recent study revealed that the infiltrate was composed of t cells with a predominance of cd8 + cells . it is speculated that the eruptions mediated by cd8 + t cells can occur as a defensive reaction toward htlv-1-infected cells . although the recurrent facial erythema in our case is different from the skin manifestation of htlv-1-associated infective dermatitis , both eruptions seem to share the ctl - based pathogenesis . future accumulation of cases is required for explanation of the predilection site of face and neck in this condition . flow cytometric analysis of peripheral lymphocytes was approved by the ethical committee of hamamatsu university school of medicine .

human t - cell lymphotropic virus type 1 ( htlv-1 ) induces adult t cell leukemia / lymphoma ( atll ) , htlv-1-associated myelopathy / tropical spastic paraparesis ( ham / tsp ) and carrier . approximately half of atll patients have direct skin involvement of neoplastic cells . however , there exist htlv-1-associated reactive eruptions with a predominant infiltrate of non - neoplastic cd8 + t cells in atll , ham / tsp and carrier . a 50-year - old japanese female htlv-1 carrier had several episodes of itchy , indurated erythema that occurred diffusely on the face and neck , lasted for 2 weeks and spontaneously subsided without sequelae . histopathologically , cd3 + t cells infiltrated the upper dermis , and part of the infiltrating cells were cd4+cd25 + , sharing the phenotype with atll neoplastic cells . an aggregate of cd8 + t cells bearing the cytotoxic molecule tia-1 was also present . it is possible that skin - affinitive htlv-1+cd4 + t cells propagated and subsequently disappeared as a result of cytotoxic t cell attack .

it is caused by parasite plasmodium which is of mainly four species plasmodium falciparum , plasmodium vivax , plasmodium ovale and plasmodium malariae . vivax and falciparum malaria are responsible for most of the cases . approximately up to 40% of the world 's population is at risk for malaria infection and 100 countries are in endemic areas for malaria transmission . it is responsible for nearly 216 million episodes and 66,5000 malaria deaths cases as reported in 2010 . malaria is sometimes associated with other infective conditions which if not diagnosed may be fatal . here we present a case of vivax malaria associated with meningitis which was initially not diagnosed and later when the patient did not respond properly to antimalarial therapy was thought to have chloroquine - resistant vivax malaria . clinicians need to rule out co - existent conditions and need to look out actively for red flags of meningitis in all cases of malaria . a 24-year - old female admitted with complain of fever , headache , vomiting and neck pain for 1 week . previously before admission she was diagnosed to have vivax malaria by both microscopic examination and antigenic testing in some local hospital and she had received a course of chloroquine ( 600 mg stat dose followed by 600 mg after 24 hours and 300 mg after next 24 hours ) with intravenous ceftriaxone 2 g per day for 4 days . but her fever improved marginally and she was having a persistent headache , nausea , vomiting and neck pain . history , clinical examination and investigations ( hiv testing was negative ) during admission were not suggestive of any condition that might lead to immune - compromise in the patient . we suspected it to be a case of chloroquine - resistant vivax malaria and sent the blood sample for examination of malaria parasite . however , malaria parasite examination was found to be negative on both microscopic examination and antigenic testing . on thorough clinical examination she was found to have neck rigidity , a positive kernig 's sign and a positive brudzinski 's sign and mild splenomegaly . the patient was started on empirical antibiotic ( intravenous ceftriaxone 4 g per day ) as associated meningitis was suspected . simultaneously cerebrospinal fluid ( csf ) and other routine laboratory tests were sent for examination . her hemoglobin was 11 g / dl , total leukocyte count was 10,190/mm ( 41% neutrophil , 50% lymphocyte , 8% monocyte and 1% eosinophil ) and esr ( erythrocyte sedimentation rate ) was 42 mm on first hour . her csf examination showed a cell count of 170/mm with 10% neutrophil and 90% lymphocytes . csf protein was 121 mg / dl , sugar 53 mg / dl ( with a random blood sugar of 90 mg / dl at the time of sending csf sample ) and adenosine deaminase ( ada ) was 4.8 gram stain , ziehl neelsen ( zn ) stain , india ink preparation and culture of csf revealed no organism . her blood urea , creatinine , sodium , potassium and liver function test were within normal limit . she responded well to therapy and her symptoms gradually disappeared within 4 - 5 days . she was discharged after completing a course of ceftriaxone 4 g per day for 10 days . vivax malaria is a common infection in india and is usually chloroquine sensitive but chloroquine - resistant vivax malaria is also increasing . failure of subsidence of fever after chloroquine treatment usually raises suspicion of chloroquine resistance . however , malaria is sometimes associated with other infective conditions , which may also lead to failure of subsidence of symptoms as occurred in our case . the presence of neck pain and positive meningeal signs raised the possibility of having associated meningitis in this patient which was confirmed by csf examination . the csf report showed lymphocytic pleocytosis , raised protein level and a marginally low sugar level which was corroborative with partially treated bacterial meningitis as patient was already on ceftriaxone before admission . however , the possibility of viral meningitis can not be ruled out as we do not have such investigation facilities . it is important to note that in viral meningitis csf sugar level remains normal which in this case was marginally low which increases the possibility of partially treated bacterial meningitis . association of meningitis with malaria had very few previous case reports and in those reports meningitis was found to be associated with falciparum malaria . in a study falciparum malaria was found to be present in 16.7% of children ( less than 15 years of age ) having meningitis . to the best of our knowledge , this is the first reported case of an association of vivax malaria with meningitis published from south asian region . there is only another such reported case from papua new guinea to the best of our knowledge . failure to identify this condition may lead to misdiagnosis of drug - resistant malaria thereby altering the course of treatment and increased morbidity and mortality . possibility of associated infective conditions like meningitis should be kept in mind whenever a patient of malaria does not respond to antimalarial treatment along with the possibility of drug resistance . a detailed clinical examination and judicious use of laboratory investigations will help in proper diagnosis .

malaria is an endemic infectious disease in india . it is often associated with other infective conditions but concomitant infection of malaria and meningitis are uncommon . we present a case of meningitis with vivax malaria infection in a 24-year - old lady . this case emphasizes the importance of high index of clinical suspicion to detect other infective conditions like meningitis when fever does not improve even after anti - malarial treatment in a patient of malaria before switching therapy suspecting drug resistance , which is quite common in this part of world .

hela cells were incubated with 0.2 mci / ml na2so4 for 3 h in a humidified 5% co2 atmosphere at 37 c before ~2 g / ml ricin - sulf2 ( rs2 ) was added and the cells were grown for two more h. the cells were washed and lysed ( 100 mm nacl , 10 mm na2hpo4 , 1 mm edta , 1% v / v triton x-100 , 60 mm n - octyl--d - glucopyranoside , protease inhibitor ( roche ) ) . the nuclear fraction was removed by centrifugation at 6800 g before rs2 was immunoprecipitated with protein a sepharose beads ( ge healthcare ) . proteins in the supernatant were precipitated with 5% w / v trichloroacetic acid ( tca ) and dissolved in 0.1 m koh before their total -radiation was measured on a -counter ( packard ) . the immunoprecipitate was washed twice in 0.35% v / v triton x-100 in pbs , incubated for 5 min in sample buffer ( 0.063 m tris - hcl , 2% w / v sds , 0.0025% w / v bromphenol blue , 10% v / v glycerol in h2o ) at 95 c and run on a 420% sds - page gel . the proteins were transferred to immobilon pvdf - fl membranes ( millipore ) , visualized by autoradiography and quantified with quantity one software ( bio - rad ) . hela cells were incubated with 1 x 10 g / ml to 1 x 10 g / ml shiga toxin or 1 x 10 g / ml to 1 x 10 g / ml ricin for 5.5 h and 3 h , respectively . then the cells were incubated with 2 ci / ml [ h]leucine for 15 min before proteins were precipitated by washing the cells twice with 5% tca for 5 min . finally , the proteins were dissolved in 0.1 m koh and the radioactivity was measured by using a -counter ( packard ) . statistical significance was tested using student s t test for all experiments performed three times or more . hela cells were incubated with 0.2 mci / ml na2so4 for 3 h in a humidified 5% co2 atmosphere at 37 c before ~2 g / ml ricin - sulf2 ( rs2 ) was added and the cells were grown for two more h. the cells were washed and lysed ( 100 mm nacl , 10 mm na2hpo4 , 1 mm edta , 1% v / v triton x-100 , 60 mm n - octyl--d - glucopyranoside , protease inhibitor ( roche ) ) . the nuclear fraction was removed by centrifugation at 6800 g before rs2 was immunoprecipitated with protein a sepharose beads ( ge healthcare ) . proteins in the supernatant were precipitated with 5% w / v trichloroacetic acid ( tca ) and dissolved in 0.1 m koh before their total -radiation was measured on a -counter ( packard ) . the immunoprecipitate was washed twice in 0.35% v / v triton x-100 in pbs , incubated for 5 min in sample buffer ( 0.063 m tris - hcl , 2% w / v sds , 0.0025% w / v bromphenol blue , 10% v / v glycerol in h2o ) at 95 c and run on a 420% sds - page gel . the proteins were transferred to immobilon pvdf - fl membranes ( millipore ) , visualized by autoradiography and quantified with quantity one software ( bio - rad ) . hela cells were incubated with 1 x 10 g / ml to 1 x 10 g / ml shiga toxin or 1 x 10 g / ml to 1 x 10 g / ml ricin for 5.5 h and 3 h , respectively . then the cells were incubated with 2 ci / ml [ h]leucine for 15 min before proteins were precipitated by washing the cells twice with 5% tca for 5 min . finally , the proteins were dissolved in 0.1 m koh and the radioactivity was measured by using a -counter ( packard ) . statistical significance was tested using student s t test for all experiments performed three times or more .

we recently reported that erm ( ezrin , radixin , moesin ) proteins are involved in intracellular sorting of shiga toxin ( stx ) and its receptor globotriaosylceramide ( gb3 ) , and that depletion of ezrin and moesin reduced retrograde golgi transport of stx . in the same study , we found that knockdown of vps11 , a core subunit of both the homotypic fusion and protein sorting ( hops ) complex and the class c core vacuole / endosome tethering factor ( corvet ) , increased retrograde transport of stx and could counteract the inhibiting effect of moesin and ezrin knockdown . in this study we demonstrate that vps11 knockdown also leads to increased stx toxicity as well as increased retrograde transport and toxicity of ricin . additionally , we show that knockdown of vps11 restores the reduced gb3 level observed after moesin depletion .

panayiotopoulos syndrome ( ps ) is a benign , idiopathic , and probably genetically determined seizure susceptibility syndrome . although it was initially described in 1989 , it was formally recognized in 2001 as a distinct electroclinical syndrome of childhood by the international league against epilepsy . however , more than a decade later , this syndrome still remains an underrecognized entity resulting in diagnostic and therapeutic dilemmas . several atypical presentations of ps such as respiratory arrest , priapism , and syncopal attacks have been reported . because of these atypical manifestations , it is not uncommon for ps to be diagnosed late or even remain unrecognized . we herein describe a child with an unusual presentation of ps mimicking as septic shock . a 3-year - old boy was admitted with complaints of cough , cold , fever , and poor oral intake for 2 days . the episodes would begin with sudden onset vomiting accompanied by cyanosis and moderate to high - grade fever . after the vomiting , he would develop deviation of eyes to one side lasting for approximately 30 min . this was followed by loss of consciousness of variable duration , ranging from 1 h to 12 h. after the second episode , electroencephalogram ( eeg ) , cerebrospinal fluid studies , and neuroimaging were done which were normal . he was not started on any prophylactic antiepileptic medications , and a diagnosis of atypical febrile convulsions was made . there was no family history of epilepsy . on admission , he was febrile with mild congestion in the throat . this was followed by bluish discoloration of the extremities , tachypnea , and deviation of both eyes to the right side . he passed a large quantity of loose stools , had the second episode of vomiting , and became drowsy after the episode . his temperature was 39.9c , oxygen saturation 90% , blood pressure 72/30 mmhg , respiratory rate 39/min , and heart rate 220/min . he was shifted to intensive care unit for observation and monitoring . within 2 h , he started regaining consciousness and became hemodynamically stable . within 5 h of the episode , he was fully conscious with a normal neurological examination . complete blood count , serum electrolytes , blood gases , serum calcium , serum magnesium , and glucose levels were within normal ranges . however , the rapid recovery , normal investigations , and previous history of similar episodes ruled out septic shock . on follow - up after 2 months ps occurs in the age group of 114 years , with 13% of the cases occurring between 3 and 6 years . other autonomic symptoms reported are mydriasis / miosis , pallor , cyanosis , flushing , cardiorespiratory ( apnea / changes in heart rate ) and thermoregulatory alterations , urinary and / fecal incontinence , hypersalivation , and altered intestinal motility . behavioral disturbances , headache , or other nonpainful cephalic sensations are commonly observed at onset . this is usually followed by more conventional manifestations of seizures with the child becoming confused or unresponsive . eyes may deviate to one side ( 60% ) or there may be staring look . half of the seizures last for more than 30 min and can end with hemi or generalized convulsions . other , less frequent ictal features described include aphasia , hemifacial spasms , visual hallucinations , and oropharyngeal movements . fever is a common trigger for focal autonomic seizures in ps as seen in our case . diagnosis can be confused with other nonepileptic conditions such as atypical migraine , motion sickness , gastroenteritis , encephalitis , or syncope . the autonomic manifestations seen in our case were vomiting , diarrhea , tachycardia , and hypotension . eeg typically shows shifting and/or multiple foci often with occipital predominance , suggesting the possibility that the site of seizure onset is usually occipital . however , normal eeg recordings may occur in 25% of children as seen in our case . at least five of the following criteria need to be present to make a diagnosis of ps : infrequent seizures , prolonged seizures 5 min , ictal vomiting , eye deviation , autonomic manifestations , behavioral and altered consciousness . atypical presentations of panayiotopoulos syndrome reported in literature the pathogenesis of ps involves an epileptogenic activation of the low threshold central autonomic areas . however , the signals are not strong enough to activate the cortical areas that usually bring about motor or sensory manifestations . however , in some cases , the epileptogenic potential gradually becomes stronger and activates cortical center resulting in secondary generalizations with motor activity . prolonged seizures do not appear to result in residual deficits or have adverse prognostic significance . the risk of epilepsy in adult life appears to be no higher than in the general population . education and counseling of the parents / caregivers about its benign nature and excellent prognosis are important aspects of management . in case of frequent seizures , rescue therapy with benzodiazepines prophylactic therapy with antiepileptic drugs is indicated when seizures are unusually frequent , distressing , or otherwise significantly affecting the child 's quality of life . carbamazepine , sodium valproate , and levetiracetam have been used in various studies with good results . physicians should be aware of the varied presentations of this syndrome to ensure its early diagnosis and proper management .

panayiotopoulos syndrome ( ps ) is a benign childhood epilepsy with predominant autonomic symptoms . the syndrome can have varied presentations resulting in diagnostic dilemma . we herein describe a 3-year - old boy with ps , who had manifestations similar to septic shock . his investigations were normal and had a complete recovery . through this case , we wish to highlight the unusual presentation of ps as septic shock . physicians should be aware of the different ways in which this syndrome can present to ensure its early diagnosis and treatment .

a 13-year - old girl presented to our clinic with a 3-month history of abdominal pain centered in the right lower quadrant , nausea , decreased appetite , weight loss and severe fatigue . she had been admitted to another hospital 3 months earlier for analysis , without satisfactory results . was performed without signs of appendicitis . afterwards ct and mri of the abdomen were done and showed no abnormalities . we also conducted a colonoscopy which was unremarkable . because of her persisting symptoms and a family history of chronic appendicitis with similar symptoms the cross - section of the appendix showed a worm with morphologic characteristics of an enterobius vermicularis ( fig . this was later confirmed by a stool culture . the patient fully recovered without persisting symptoms . enterobius vermicularis infestation is treated with anthelmintics and re - infection is prevented by implementation of adequate hygiene . parasitic infection of the appendix occurs in 1.42.7% of patients with clinical symptoms of chronic appendicitis [ 1 , 2 ] . association with histological inflammation of the appendix is uncommon , therefore examination of the lumen is important for diagnosing unexplained appendicopathy .

parasitic infection of the appendix is rarely seen , but should be considered in patients with symptoms of chronic appendicitis . it is rarely associated with histological inflammation of the appendix , therefore radiographic imaging , performed during initial workup , remains unremarkable most of the time .

the incidence of pregnancy - associated cancer is relatively low , complicating 0.020.1% of all pregnancies . the most common tumors diagnosed during pregnancy are breast cancer , cervical cancer , melanoma , and leukemias / lymphomas . cancer of the rectum is a very rare disease during pregnancy , with an incidence of 1:50,000 to 1:100,000 pregnancies . however , mainly in industrialized countries where the incidence of pregnancies in advanced ages is increasing , obstetricians should be vigilant of this disease . we present a case of a young primiparous woman who had a quick and bad evolution of an adenocarcinoma of the rectum diagnosed during pregnancy . in this case a 17-year - old primiparous woman was admitted to our service with fever ( 38c ) , abdominal pain , weakness and recent weight loss of 5 kg . at general physical exam , her weight was 66 kg , and she reported a weight of 58 kg before pregnancy . the liver was enlarged , hardened and several nodules were observed . soft edema ( godet sign ) was present in the lower members ( fig . the obstetric exam showed a fundal height of 14.0 cm and a fetal heart rate of 144 beats per minute . the laboratory exams showed hb / ht of 12.7 g / dl/38% , fasting glucose of 89 mg / dl , -fetoprotein of 75.25 ng / dl and carcinoembryonic antigen of 4,487 ng / ml . she was hospitalized , and t2-sequence magnetic resonance imaging in the coronal plane was performed , which revealed an enlarged liver , with several nodules with central hypersignal , suggestive of metastasis ( fig . the obstetrical scan evidenced a unique and topic pregnancy with the fetus presenting biometric parameters of 21 weeks . the fetus showed no malformations , the amniotic fluid volume was normal and the estimated fetal weight was 411 g. the patient progressed to vomiting blood , and there was also blood in her stool . the sigmoidoscopy evidenced an ulcerative - vegetative lesion 10.0 cm from the anal verge ; the biopsy confirmed adenocarcinoma of the rectum ( fig . during pregnancy a woman 's body undergoes physiological changes that may make the diagnosis of several cancers more challenging . cancer of the rectum presents with different patterns of development ; in some cases it is insidious and in others it quickly progresses . in our case the adenocarcinoma of the rectum led to a fulminant outcome , with the patient dying two weeks after diagnosis . the diagnosis of adenocarcinoma of the rectum during pregnancy usually occurs in an advanced stage , and the clinical signs are rectal bleeding , transit disorder with alternating diarrhea and constipation , meteorism , abdominal pain or anemia . these symptoms usually are confused with the physiological modifications during pregnancy or hemorrhoid disease . in our case the treatment of cancer of the rectum during pregnancy depends on staging and some other parameters such as location , size and period of the pregnancy ( first or second half ) . surgery during pregnancy involves the risk of bleeding and miscarriage if done before 14 weeks . chemotherapy can be started during the second or third trimester without increased risk of fetal loss or malformation . radiotherapy is not possible during pregnancy because of the risk of lethal fetal malformation , and it should be delayed until after labor . , we presented a case of a fulminant outcome of adenocarcinoma of the rectum in a young pregnant woman . new studies are necessary to assess if the pregnancy induces changes in the course of this type of cancer .

cancer is the second leading cause of death during the reproductive years , but the incidence during pregnancy is low . the incidence of cancer of the rectum during pregnancy is very rare ( 1:50,000 to 1:100,000 pregnancies ) . usually , the symptoms of this type of cancer are nonspecific and sometimes they are confused with normal changes of pregnancy . the diagnosis of rectal cancer is usually made in the late stage of pregnancy . the treatment of this cancer involves surgery , chemotherapy and radiotherapy , but each type of treatment involves risks to the fetus and the pregnant woman . we present a case of a young primiparous woman who had a quick and bad evolution of an adenocarcinoma of the rectum diagnosed during pregnancy . this patient had extensive involvement of the liver with metastasis and she died two weeks after diagnosis . in this case , we present the clinical , radiological and pathology findings of this disease .

is an acute focal nephritis which also known as acute lobar nephronia ( aln ) . ultrasound , computerized tomography ( ct ) , and gallium-67 ( ga-67 ) scintigraphy are important tools in diagnosis of aln . we report the use of ga-67 scintigraphy in diagnosis and therapy monitoring of a patient with renal transplant and aln . we report a case of a 33-year - old female patient who had chronic renal impairment and received a cadaveric renal transplant 14 months before presentation . she presented with abdominal pain , fever , leukocytosis , and elevated serum urea and creatinine , and urine analysis on admission was unremarkable . she was hospitalized , and part of her work up included renal transplant ultrasound , renal transplant tc-99 m mercapto acetyl tri glycine study , and graft biopsy . whole body and spot view of the renal graft was performed 24 and 48 h postintravenous injection of 4 mci ( 148 mbq ) ga-67 using a gamma camera equipped with low energy general purpose collimator ( brightview - phillips ) . scan 48 h postinjection revealed diffuse abnormal graft uptake with multifocal areas of marked uptake [ figure 1 ] . repeat ga-67 scintigraphy following the same protocol of the first scan 2 weeks after intravenous antibiotic therapy showed significant response reflected by resolution of most of the focal areas of increased uptake [ figure 2 ] which was parallel to clinical improvement . gallium scan revealed abnormal diffuse uptake in the renal graft in right iliac fossa with multifocal areas of increased uptake in upper and lower pole ( arrows ) . findings were suggestive of multifocal acute lobar nephronia a repeat gallium-67 scintigraphy after 2 weeks of intravenous antibiotic therapy showed a significant response with resolution of almost all the focal areas of increased uptake in pretherapy scan ( arrows ) indication of good response . the patient was shifted to oral antibiotics and to be seen in the clinic after 2 weeks thereafter , several radiological reports have described this entity which was also called aln , acute focal bacterial nephritis or focal pyelonephritis . the process can affect one lobe ( unifocal ) or more than one lobe ( multifocal ) . clinically , the patient with aln usually presents with flank pain and fever with leukocytosis and urine bacteriuria . the diagnosis usually confirmed by radiological examinations including ultrasound , ct , and nuclear medicine tests . ultrasound is of vital importance in the diagnosis and in follow - up of treated cases . ultrasound usually suggests the diagnosis , but false positive and false negative cases have been reported . computerized tomography scan with contrast is of limited use when serum creatinine is elevated . technetium-99 m dimercaptosuccinic acid studies are more useful in the follow - up of the infected kidney rather than for initial diagnosis . ga-67 scintigraphy 48 h postinjection has been described to concentrate in the kidneys in several disease conditions such as inflammation , pyelonephritis , lymphoma , and other tumors as well as in acute tubular necrosis and chronic rejection of renal transplant . found that ga-67 scintigraphy was a useful tool in detecting renal transplant suppurations and can guide abscess localization by renal graft ultrasound . gallium-67 scintigraphy was very useful in the diagnosis and therapy monitoring of our patient with renal transplant patients and aln .

a 33 years old female patient with chronic renal transplant rejection proved by mag3 , ultrasound and graft biopsy presented with abdominal pain and fever . part of her work up included gallium-67 scan which revealed diffuse abnormal graft uptake with multifocal areas of marked uptake . findings were interpreted as acute lobar nephronia . repeat gallium scan two weeks after intravenous antibiotic therapy showed significant response reflected by resolution of most of focal areas of increased uptake which was parallel to clinical improvement .

the current issue of the nucleic acids research features 174 databases , of which 106 are new and 68 are updates of previously described databases . these new databases , as well as 15 ones described elsewhere , have been added to the nar online molecular biology database collection ( ) , bringing the total list to 968 . the geography of the database collection kept expanding and now includes the first database created by bulgarian ( and us ) scientists ( banmoki , , at no . 11 databases featured in the previous release of the nar database collection ( 1 ) have been dropped from the list . some of these ( crow21 , pir - nref ) have been superseded by newer and more advanced databases . three databases ( dbcat , genetpig and hugemap ) were discontinued owing to the demise of the french infobiogen centre [ some other infobiogen databases migrated to the new web site maintained by the institut national de la recherche agronomique ( inra ) ] . the bind project , which never lived up to its full promise , has gone commercial . in any case , these 11 databases comprise only a small fraction of total database list , which again held very nicely and showed surprising resilience . in the comment to the last year 's release of the nar database collection ( 1 ) , i have discussed the citation rates for various papers in the 2004 nar database issue and noted that the high - citation rate of certain databases reflects their worldwide acceptance as de facto standards of protein functional annotation [ uniprot , , no . 2 ] , domain structure [ , no . 210 , ref . 3 ] and however , citation data can be biased ; e.g. in many articles use of information from publicly available databases is acknowledged by providing their urls , or not acknowledged at all . besides , some databases could be cited on the web sites and in new or obscure journals , not covered by the isi citation index . with this in mind , i have tried here to use additional metrics for assessing the popularity of the nar database issue . first , i have checked the citations of the database papers listed on the google scholar web site , which reflects citations on the web sites . in addition , i have looked at the number of times that the full text of each paper ( in pdf or html versions ) was downloaded from the pubmed central web site ( ) . it should be mentioned that all papers in the nar database issue are freely available for downloading from pubmed central and nar web sites ; the numbers of downloads from both sites are believed to be somewhat similar . the nar website already lists the most frequently downloaded and most cited papers of all time , which include three papers on the pfam database published in nar , respectively , in 2000 , 2002 and 2004 ( 57 ) , as well as two papers on swiissprot ( 8,9 ) and one on the protein data bank ( 10 ) , the same databases whose descriptions topped the list of the most cited papers from the 2004 database issue ( 1 ) . it would seem that these three metrics all reflect usage of the nar database issue : the user typically starts by finding a database of interest in pubmed or some other bibliographic database , then proceeds to browse the full text in the html format . if the paper is interesting enough , s / he would download its text in the pdf format . finally , if the database turns to be useful , it might be acknowledged with a formal citation . indeed , the number of html downloads and pdf downloads for the same paper correlated very well ; the number of pdf downloads was about one - third of the html downloads ( figure 1 ) . the two most obvious deviations were the 2004 pfam paper ( 7 ) that is extremely well cited but moderately downloaded ( 791 citations , 1992 total downloads ) and my own comment ( 11 ) that is much more often downloaded than it is cited ( 59 citations , 1806 downloads ) . i am glad to report that , with a single exception , all papers in the 2004 nar database issue have now been cited at least two times ( and downloaded at least 260 times ) . that single non - cited exception is the description of the orfdb ( ) , the invitrogen 's collection of human and mouse orf clones ( 12 ) . this paper , which was never intended to be cited , has been nevertheless downloaded 983 times ( including 207 times as a pdf ) and apparently has served its purpose . obviously , a list of downloads is an interesting and valuable tool for analyzing various trends in science . for example , of all papers in the 2006 nar database issue , three of the top five downloads are all descriptions of microrna databases , mirnamap , mirbase and the argonaute ( 1315 ) , which obviously reflects the explosive growth of this area . highlighting such databases has always been and will remain the key goal of the nar database issues and the nar online molecular biology database collection . the total number of full - text html downloads ( closed squares ) and literature citations ( open squares ) as function of the number of the pdf downloads for 142 papers in the 2004 nar database issue .

the nar online molecular biology database collection is a public resource that contains links to the databases described in this issue of nucleic acids research , previous nar database issues , as well as a selection of other molecular biology databases that are freely available on the web and might be useful to the molecular biologist . the 2007 update includes 968 databases , 110 more than the previous one . many databases that have been described in earlier issues of nar come with updated summaries , which reflect recent progress and , in some instances , an expanded scope of these databases . the complete database list and summaries are available online on the nucleic acids research web site .

graves disease usually affects females , and in 2550% of the cases coexists with ophthalmopathy . thyroid eye disease is a relatively rare condition , which affects 2.916.0 of cases per 100,000 per year . here , we describe an interesting case of graves ophthalmopathy , which was misdiagnosed and treated as relapsing conjunctivitis . a 59-year - old female patient presented at the outpatients department of ophthalmology with the symptom complex of conjunctival hyperemia , epiphora , irritation , and a foreign body sensation in the right eye ( fig . she had been examined by multiple ophthalmologists prior to our evaluation , as the symptoms were present for 4 months , and she was treated as suffering from relapsing conjunctivitis . a full ophthalmic evaluation was performed , and the slit lamp examination revealed keratitis due to exposure , which was related to the widening of the interpalpebral fissure and accelerated tear film evaporation in the right eye . there was also a 2 mm difference in the readings with the hertel exophthalmometry examination between the eyes , while a sublte deficiency in the supralateral gaze position was revealed in the eye movements examination . in addition to this , a detailed medical history was carried out , with a clear result . the patient also underwent thorough clinical examination , and it is worthy to mention that she had neither diabetes nor other systemic diseases . the patient was referred for computed tomography ( ct ) of the orbits and brain and biochemical examinations ( ft3 , ft4 , and tsh ) to exclude the presence of an intraorbital mass and investigate the cause of exophthalmos . ft3 was significantly increased ( 4.9 ng / dl , normal ranges : 0.91.8 ng / dl ) and tsh was accordingly low ( 0.03 miu , normal ranges : 0.174.65 miu ) , indicating the diagnosis of graves disease , although there was no goiter . ct scan revealed enlargement of the extraocular muscles and excluded the diagnosis of an intraorbital mass ( fig . three months later , the ophthalmopathy improved on antithyroid treatment [ thyrostat 5 mg ( carbimazole ) , 3 tablets 3 times / day ] . moreover , artificial tears ( systane ultra lubricant eye drops , alcon ; 1 drop 6 times / day ) caused reduction of symptoms , while resolving corneal staining and hyperemia . therefore , the patient suffered from undiagnosed graves disease , without other signs and symptoms apart from ophthalmopathy . the classic symptoms of the thyroid eye disease include eyelid retraction , exophthalmos , dysmotility , and diplopia . nevertheless , there are patients who present only ocular surface irritation , hyperemia and conjunctivitis [ 2 , 3 ] . although these latter findings are well established , ocular manifestations are frequently overlooked , and diagnosis of thyroid disease is usually made when the classic features manifest . in addition to this , thyroid eye disease is often misdiagnosed as allergic or relapsing conjunctivitis , as tearing and hyperemia are the predominant features [ 2 , 5 ] . in such cases , the presence of eyelid retraction and restricted eye movements helps to differentiate thyroid eye disease from other causes of periorbital edema [ 2 , 3 , 5 ] . moreover , thyroid function tests ( ft3 , ft4 , and tsh ) can be helpful in the diagnosis of thyroid ophthalmopathy and should be included in the routine work - up . in conclusion , it is important not to underestimate the ocular manifestations when examining a patient , as potentially serious and systematic conditions may underlie these symptoms . furthermore , early recognition of graves orbitopathy is important , as response to medical treatment is dependent on the duration of the disease .

a 59-year - old female patient presented at the outpatients department of ophthalmology with epiphora , eyelid swelling , and a foreign body feeling in the right eye . the symptoms were present for 4 months , and the patient was treated as suffering from relapsing conjunctivitis . the slit lamp examination revealed keratitis due to exposure , related with the deficient closure of the eyelids . there was a 2 mm difference in the readings with the hertel exophthalmometry examination between the eyes . her medical history was clear , and she was referred for computed tomography of the orbits and brain and biochemical examinations ( ft3 , ft4 , and tsh ) to investigate the presence of an intraorbital mass . ft3 was significantly increased and tsh was accordingly low , indicating the diagnosis of graves disease , which presented without other signs and symptoms apart from ophthalmopathy . computed tomography scan excluded the diagnosis of an intraorbital mass . therefore , it is important not to underestimate the ocular manifestations of systemic diseases .

dilated cardiomyopathy , which mostly has an idiopathic etiology , or is caused by genetic inheritance or infection , can cause irreversible congestive heart failure . hypocalcemia is a rare etiology of reversible dilated cardiomyopathy.1 - 4 ) here , we report a case of dilated cardiomyopathy secondary to hypocalcemia that originated from a nutritional vitamin d deficiency induced rickets in an infant who was exclusively breast - fed by a mother who had vitamin d deficiency.2 - 4 ) the patient was a 2 month - old girl with cyanosis , irritability , respiratory difficulty , poor oral intake and seizure - like movements , and had cardiopulmonary resuscitation on arrival . she was born at 38 weeks of gestational age with a birth - weight of 2.8 kg . there were no medical or familial histories except an admission at an age of 10 days for hypocalcemic tetany . there were moist rales on both middle lung fields and chest wall retraction without cardiac murmurs or hepatomegaly . 1 ) . an echocardiogram revealed a markedly enlarged left ventricular cavity and a hypokinetic ventricular wall motion . left ventricular end diastolic diameter ( lvdd ) was 38 mm , left ventricular end systolic diameter ( lvds ) was 35 mm , ejection fraction ( ef ) was 17% , and fractional shortening ( fs ) was 8% , without any structural abnormalities ( fig . 2 ) . electrocardiography showed sinus tachycardia ( heart rate 191 beat / min ) , and normal qtc ( 0.415 seconds ) ( fig . arterial blood gas analysis were ph 6.988 , po2 325.9 mmhg , pco2 31.0 mmhg , and hco3 7.3 hypocalcemia as total serum calcium was 5.8 mg / dl , hyperphosphatemia as inorganic phosphorus was 10.9 mg / dl , and alkaline phosphatase was elevated ( 643 hormone levels that were changed included elevated parathyroid hormone ( 155 pg / ml ; normal 12 - 72 pg / ml ) , decreased 25-hydroxy vitamin d ( 2.6 ng / ml ; normal 9.1 - 37.6 ng / ml ) and decreased 1,25(oh)2 vitamin d ( 9.2 pg / ml ; normal 20.1 - 46.2 pg / ml ) . after calcium and vitamin d replacement , the patient showed rapid reductions in hypocalcemic tetany , and a rapid recovery of cardiac function and cardiomegaly on chest x - ray ( figs . 4 and 5 ) . the patient was discharged on the 15th hospital day and followed up by the outpatient department with calcium gluconate and calcitriol replacement . the mother had a vitamin d deficiency as indicated by a decreased level of 25-hydroxy vitamin d ( 4.3 ng / ml ) . the most common cause of dilated cardiomyopathy is an idiopathic etiology ( > 60% ) , followed by familial cardiomyopathy and acute myocarditis . other causes of dilated cardiomyopathy include viral infections , endocrine disorders and metabolic diseases.5)6 ) cardiotoxic drugs and systemic diseases can also cause dilated cardiomyopathy . on arrival , our patient 's serum chemistries revealed extremely low calcium and vitamin d levels . after calcium and vitamin d replacement , abnormal findings of calcium and vitamin d were corrected rapidly with the normalization of parathyroid hormone and left ventricular function recovered . in this case , electrocardiography showed normal qtc ( 0.415 seconds ) despite severe hypocalcemia , which was due to a rapid heart rate of up to 190 beats / min ( fig . 3 ) . therefore , hypoparathyroidism and pseudo - hypoparathyroidsm were recorded as the cause of the hypocalcemia.7)8 ) the common causes of late onset hypocalcemia in the neonate are as follows ; transient hypocalcemia due to maternal hypercalcemia , congenital hypoparathyroidism ( ex . digeorge syndrome ) , maternal vitamin d deficiency , phosphorus overloading , renal dysfunction , hypomagnesemia , chronic diarrhea and so on.5 - 8 ) throughout the hormonal tests , the confirmative diagnosis was congestive heart failure with dilated cardiomyopathy as a severe manifestation of hypocalcemia that resulted from vitamin d deficient rickets .

dilated cardiomyopathy , which mostly has an idiopathic etiology or is caused by genetic inheritance or infection , can cause irreversible congestive heart failure . hypocalcemia is a rare etiology of reversible dilated cardiomyopathy . here we report the case of a two - month - old girl with congestive heart failure who was diagnosed as having dilated cardiomyopathy secondary to hypocalcemia . after calcium and vitamin d replacement therapy , the patient showed a rapid reduction in hypocalcemic tetany and a rapid recovery of left ventricular function . the cause of the hypocalcemia was vitamin d deficient rickets . she was exclusively breast - fed as an infant , and her mother had a vitamin d deficiency and was diagnosed with osteomalacia .

lipomas are the most common benign soft tissue tumors and occur in the subcutaneous tissue . rarely , lipomas present in the deep soft tissue such as intermuscular , intramuscular , and parosteal sites . however , an intramuscular lipoma occurring in the proximal forearm causes paralysis of the posterior interosseous nerve ( pin ) because of its anatomical relationship in that area . below the elbow , the pin passes beneath the extensor carpi radialis brevis muscle and then continues between the superficial and deep layers of the supinator muscle . the proximal edge of the supinator muscle forms an arch , the arcade of frohse . a 48-year - old woman presented with spontaneous inability to extend the fingers of the left hand . she noticed a gradually increasing inability to extend the fingers over 6 months . she was unable to perform her domestic activities because of weakness and paresis of the hand ; she denied any trauma or other diseases . examination revealed a swelling of 5 3 cm in the anterolateral aspect of the left forearm in the region of the brachioradialis muscle just below the elbow . the swelling was firm in consistency , immobile , not fixed to the skin ; there were no dilated veins over the swelling or signs of inflammation . the elbow function was normal , as was the flexor strength of the wrist and fingers ; however , there was a decrease in the extension strength of the wrist and metacarpophalangeal joints of the fingers and thumb ( power 3/5 ) . magnetic resonance imaging of the elbow objectified an intramuscular mass , of 8-cm - long axis depending on the supinator muscle , pathognomonic of a lipoma ( figs . 1 and 2 ) . the dissection of the mass revealed that it is constricting the pin ( figs . 4 and 5 ) . histological examination of the tumor confirmed it to be a benign lipoma ( figs . 7 and 8) . in the early postoperative period , the radial nerve recovered its function . the patient recovered well , and 6 weeks after surgery , she resumed her activities . 6after excision of the mass , the superficial radial nerve and the pin were preservedfig . . 8 a lobules of mature fat cells ( hematoxylin and eosin , 40 ) . b mature fat cells entrapping skeletal muscle fibers ( hematoxylin and eosin , 100 ) t1 fat sat mri images , showing an intramuscular mass on the supinator muscle t1 mri images , showing an intramuscular mass on the supinator muscle the incision of the supinator muscle exposed a fatty mass the dissection of the mass revealed that it is constricting the pin liberation of the pin after excision of the mass , the superficial radial nerve and the pin were preserved a lobules of mature fat cells ( hematoxylin and eosin , 40 ) . symptomatic radial nerve compression is relatively uncommon , and when it is caused by a lipoma , it commonly occurs at the elbow level , compromising the posterior interosseous branch [ 3 , 4 ] . lipomas are benign tumors composed of mature adipocytes , and they represent one of the most prevalent tumors of mesenchymal origin [ 46 ] . lipomas and other tumors over the radial nerve are rare causes of chronic entrapment of the pin , but they can produce a classic picture of pin syndrome ( pins ) . there are some reports of compression neuropathies [ 710 ] of the upper limb caused by this kind of tumor . other causes of pin compression have been described : rheumatoid synovial cysts , ganglion [ 1214 ] , myxoma , pseudogout , and chondroma , among others . intramuscular lipoma shows an infiltrative nature to the surrounding striated muscle , and the lesion is usually not encapsulated , although the pathogenesis of an intramuscular lipoma remains obscure . the diagnosis of pins is based on clinical history and physical examination and is confirmed by electrophysiological studies . classically , this syndrome has neither pain nor other sensory symptoms , but there are cases of forearm pain and paralysis of the extensor muscles of the forearm . if there is any suspicion , based on clinical examination , of a mass as the causative factor of pins , mri scan is the imaging method of choice for evaluating their presence and extent . in this clinical case , however , the lipoma was located intramuscularly , and there was a palpable mass on the forearm . surgical excision of an intramuscular lipoma is recommended to prevent involvement of the pin or to ensure optimal recovery when the nerve is already compressed by the tumor . the recovery of the neurological deficit relates to the duration of symptoms , the longest reported duration of symptoms with full recovery postoperatively being 18 months . the prognosis after excision of a lipoma is excellent , with only one recurrence described in the literature . jrgens and hampt , in a study of 20 patients with pin paralysis , concluded that the result of the operation depended on the duration of the symptoms , so that long - lasting paralysis made reinnervation less likely to occur . according to the study by de - song et al . the prognosis of pins depends on an early diagnosis , followed by an immediate surgical excision based on mri findings . the paralysis of the pin is clinically evident ; electrophysiological exploration would confirm the diagnosis and the site of entrapment . after surgical excision of the mass , rehabilitation is needed for rapid functional recovery of the upper extremity .

lipomas are extremely common benign soft tissue tumors that are usually subcutaneous and asymptomatic . however , an intramuscular lipoma , occurring adjacent to the proximal radius , may easily cause paralysis of the posterior interosseous nerve because of a specific anatomical relationship of these structures in that area . in this report , we describe an unusual case of a 48-year - old - woman with a posterior interosseous nerve syndrome due to an intramuscular lipoma . the patient had good recovery after surgery and rehabilitation physiotherapy .

what is an important consideration for a rapidly enlarging adrenal mass that can not be distinguished from adrenocortical carcinoma by imaging ? adrenal oncocytoma of uncertain malignant potential is a rare cause of rapidly enlarging adrenal mass and should be an important consideration . a 68yearold female presented to the hospital with hypertensive emergency with a blood pressure of 210/100 mmhg . ct revealed a solid leftsided adrenal mass : 8.4 5.8 5.7 cm , hounsfield units ( hu ) of 75 and diffuse heterogeneous enhancement with scattered central and peripheral calcifications with no necrosis ( fig . this mass had increased since 2005 when measured as 2.7 1.9 2.0 cm with a hu of 22 and similar imaging characteristics ( fig . plasma metanephrine , aldosterone , renin activity , dehydroepiandrosterone sulfate , androstenedione , and 24 h urine cortisol levels were normal . aoc is composed of cells with atypical nuclei and oncocytes that are rich in granular eosinophil cytoplasm and mitochondria 1 . aoc is a rare tumor with less than 150 cases reported , of which only 14 are classified as aoc of uncertain malignant potential 2 . ( a ) contrastenhanced abdominal ct scan , arrow : adrenal nodule ( 2015 ) . ( b ) contrastenhanced abdominal ct scan , arrow : adrenal nodule ( 2005 ) . ( c ) hematoxylin and eosin stain ; original magnification * 200 of pathologic specimen , arrow : bright oncocytic pink cytoplasm .

key clinical messagea rare cause for rapid adrenal enlargement is adrenal oncocytoma of uncertain malignant potential . a full biochemical evaluation is warranted to screen secreting adrenal adenomas as well as to evaluate adrenal cortical carcinoma . careful pathologic evaluation is required as the diagnosis of aoc can not be made by imaging .

peripheral primitive neuroectodermal tumor ( pnet ) is an uncommon tumor and the overall incidence is 1% of all sarcomas . peripheral primitive neuroectodermal tumor ( pnet ) is so named because the majority of cells in the tumor are derived from the neuroectoderm but have not developed and differentiated in the way a normal neuron would , and so the cells appear primitive . this tumor can occur at any age , although the peak age incidence is during adolescence and young adulthood . in general , pnet is a very aggressive neoplasm with a poor prognosis , 5-year disease - free survival rate being 45%-55% . the most common locations of peripheral pnets are the thoracopulmonary region , the retroperitoneal paravertebral soft tissues , and the head and neck region . the incidence of peripheral pnet in the abdomen and pelvis , including the retroperitoneum , is about 14% of all peripheral pnets . a 37-year - old female presented with an episode of dull aching pain in the left loin . there was no history of hematuria , calculuria , lower urinary tract symptoms ( luts ) , headache , palpitation , excessive sweating , weight loss , jaundice , or fever with chills . her serum cortisol ( 8 a.m. , 4 p.m. , and midnight ) , dehydroepiandrosterone ( dheas ) , testosterone , electrolytes , urinary metanephrines , and normetanephrines were normal . her 24 h urine cortisol was raised and low - dose dexamethasone test was positive . ultrasonography revealed an 8 7 cm large heterogenous left adrenal mass with internal echogenic components . contrast - enhanced computed tomography ( cect ) abdomen and pelvis also showed an 8 7 cm left adrenal mass with no fat density [ figure 1 ] . left open radical nephrectomy , adrenalectomy , and spleenoraphy was done as the tumor seemed to infiltrate the kidney and was densely adhered to the spleen and the diaphragm . she was given hydrocortisone during the operation which was gradually tapered in the postoperative period . following excision of the mass , the 24 h urine cortisol level returned to normal . cect , coronal sections showing a heterogeneously enhancing left suprarenal mass gross specimen showed a 12 10 8 cm left adrenal mass , infiltrating the left kidney . cut section showed hemorrhagic and necrosed adrenal mass adherent to the kidney [ figure 2 ] . microscopy showed a predominantly necrotic and hemorrhagic tumor with few viable areas composed of diffuse sheets of small to medium sized round cells with round to oval vesicular nuclei exhibiting mitoses up to 10 - 15/50 hpf and containing scant to moderate cytoplasm . the tumor cell nests infiltrated the thick fibrous capsule and extended into the pericapsular adipose tissue . there was weak positivity with fli 1 , in at least 50% of cells [ figure 5 ] . cut section of the gross specimen showing the left adrenal mass with areas of hemorrhage and necrosis h and e , 20 , medium - sized round cells with round to oval vesicular nuclei exhibiting mitoses and containing scant to moderate cytoplasm cd 99 , 100 , cells showing strong positivity for cd 99 , diagnostic of pnet fli-1 , 40 , positive in at least 50% of cells in 1918 , stout first reported a 42-year - old man with ulnar nerve tumors and raised the concept of pnet . they are primitive derivates of neural crests which originated from basal embryo cells in the primitive neural tube . tumor sites are shown as rough - bordered , diffusely growing , and heterogeneously enhancing masses in computed tomography scans . immunohistochemical tests can provide valuable support to the definitive diagnosis of the tumor cd99 is highly specific and sensitive , as its detection rate in pnet is as high as 100% . besides cd99 , other markers of neural differentiation include : neuron - specific enolase , s-100 protein , neurofilament protein , synaptophysin , chromogranin a , etc . the fli-1 gene and fli-1 protein are also well - known for their role in the pathogenesis of ewing 's sarcoma and pnet . the majority of these tumors are characterized by the translocation t(11;22)(q24;q12 ) , resulting in a fusion of the ewing 's sarcoma ( ews ) gene on chromosome 22 to the fli-1 gene on chromosome 11 . the rarity of this entity is documented by zhang and li who noted that only 16 cases had been reported as of 2010 . since adrenal pnet is a very rare clinical disease , an effective treatment protocol is yet to be established . a recommended schedule is alternating use of the cav protocol ( cyclophosphamide : ctx ; adriamycin : adm ; and vincristine : vcr ) and the ie protocol ( ifosfamide : ifo ; and etoposide : eto ) .

peripheral primitive neuroectodermal tumor ( pnet ) is an uncommon tumor and the overall incidence is 1% of all sarcomas . pnet of the adrenal gland is an even rarer entity . a 37-year - old female was evaluated for an episode of loin pain . ultrasonography showed a large heterogenous left adrenal mass with internal echogenic components . computed tomography did not show any fat density within to suggest a myelolipoma . biopsy suggested a poorly differentiated neoplasm with a possibility of pnet of the adrenal gland .

esophagogastroduodenoscopy revealed a diffusely infiltrative submucosal lesion involving the upper body of the stomach along the greater curvature ( fig . the overlying mucosa was intact and non - ulcerative , but it showed tiny scattered mucosal openings with extruding mucus ( fig . abdominal computed tomography scan demonstrated diffuse wall thickening with suspicious perigastric infiltration , consistent with borrmann type 4 gastric cancer . the patient underwent four consecutive gastrofiberscopic examinations , with biopsies consisting of more than 10 pieces , but all biopsies were negative for adenocarcinoma . subsequently , the patient underwent a diagnostic laparotomy and total gastrectomy and was diagnosed with gastric - type ewda ( pt4an3am1 , stage iv ) . microscopic examination revealed numerous irregular - shaped mucinous glands that diffusely extended from the submucosal layer to the visceral peritoneum ( fig . the mucosal layer was spared for the most part , with only some carcinoma glands found in the deep portion of the mucosa . the tumor glands consisted of mucin - rich columnar cells with basally located , small , bland - looking nuclei mimicking hyperplastic foveolar epithelium or dilated pyloric glands ( fig . 1d ) , which deeply infiltrated the proper muscle with no desmoplastic stromal reaction ( fig . there were also areas showing distinctly lobular proliferation of small glands often surrounding a larger central duct ( fig . 1f ) ; such areas were frequently observed in the submucosa , and the central dilated duct occasionally opened through the overlying mucosal surface ( fig 1h ) , human gastric mucin ( hgm ) , and carcinoembryonic antigen ( cea ) ; focally positive for muc6 ; and negative for muc2 , cd10 , and p53 . we retrospectively reviewed the preoperative biopsy specimens and found a few scattered carcinoma glands in the basal portion of the oxyntic - type corpus mucosa ( fig . despite not being atypical enough to be considered definite carcinoma , the glands were indisputably noticeable , with large size , abundant clear cytoplasm , mild nuclear atypia , and unusual location compared to normal mucous glands ( fig . those atypical glands were more distinguishable on immunostaining for hgm , cea , and muc5ac ( fig . to date , only nine cases ( including the present one ) of gastric - type ewda have been reported in the english literature . the tumors in all reported cases were located in the upper or middle third of the stomach . grossly , they were polypoid masses or submucosal tumors mimicking borrmann type 4 gastric cancer . preoperative biopsy findings were available in seven cases , five of which were diagnosed as benign lesions , one as a suspicious carcinoma , and one as definite carcinoma on repeat biopsy . it is very difficult to diagnose gastric - type ewda in a preoperative biopsy specimen , especially in patients with borrmann type 4 lesions . nevertheless , the most important aspect in diagnosing gastric - type ewda in a biopsy specimen is observation of the subtle atypical changes of mucous glands : mucous glands with conspicuously abundant mucinous cytoplasm , mild nuclear atypia , and slightly larger size should raise suspicion of gastric - type ewda , particularly when they are abnormally clustered or seen in the deep portion of the corpus mucosa that is usually devoid of well - formed mucous glands . the histologic characteristics of gastric - type ewda , including deep invasion of extremely well - formed mucinous glands , minimal cellular atypia , and no significant desmoplastic stromal reaction , resemble those of minimal deviation adenocarcinoma ( mda ) of the uterine cervix . therefore , gastric - type ewda has been considered as the gastric counterpart of mda . according to the new world health organization classification published in 2014 , mda is classified as an extremely well - differentiated form of gastric - type endocervical mucinous adenocarcinoma . lobular endocervical glandular hyperplasia ( legh ) has been described as a distinctive hyperplastic lesion of the endocervix characterized by lobular proliferation of small , rounded , non - invasive glands often surrounding a central dilated gland . it has been postulated that legh is a precursor lesion of mda . in the present case , we found legh - like areas with distinct histological characteristics of legh that occurred concurrently with invasive mucinous carcinoma . in addition , they were predominantly observed in the submucosal layer , just as legh is usually confined to the inner half of the endocervical wall . legh - like lesions have never been described in the stomach before , which may provide evidence to support gastric - type ewda being the gastric counterpart of mda of the uterine cervix .

gastric - type extremely well - differentiated adenocarcinoma ( ewda ) is a rare type of gastric adenocarcinoma characterized by infiltration of well - formed mucinous glands with little or no nuclear atypia , which resemble foveolar epithelium or pyloric glands . because of its high degree of differentiation , preoperative biopsy diagnosis of gastric - type ewda is very difficult . we encountered a case of gastric - type ewda , manifesting as a borrmann type 4 lesion , in a 47-year - old man . despite four repeated biopsies , the preoperative biopsy diagnosis was not conclusive due to the scarcity of diagnostic tumor cells and lack of knowledge regarding the unusual histologic findings of gastric - type ewda . we herein describe the histologic findings of gastric - type ewda in detail , with the aim of facilitating a preoperative biopsy diagnosis and understanding of this rare type of gastric adenocarcinoma .

cardiac implantable electronic device ( cied ) replacement procedures are associated with higher complication rates compared to primo - implantation,1 and dual and triple chamber cied implantation are associated with higher complication rates compared to single chamber cied.1 infection related with cied implantation typically mandates removal of all foreign material . we present a case of skin fistula occurring after internal cardioverter defibrillator ( icd ) replacement , where the fistula healed with conservative management and without device explantation . a 75-year - old patient with dilated ischemic cardiomyopathy had a single chamber icd implanted for secondary prevention ; he was admitted for device replacement because of battery depletion . of note , the patient had no other significant co - morbidity conditions ( ie , no diabetes , no renal failure ) . the replacement procedure was achieved without any per - operative incident ; of note , the inner layer of the device pocket was well demarcated , whitish , thick , resistant , brilliant and relatively impermeable to fluids . the wound was closed superficially with metallic stitches ; according to our wound care protocol , we do not use skin adhesive nor absorbable intracutaneous suture . the patient was discharged on the second post - operative day and wound dressing was clean . antibioprophylaxis started pre - operatively was continued for seven days ; also , the patient was requested to undertake wound dressing every day with a registered nurse until stitches removal . on post - operative day 10 , stitches were removed , wound healing was normal , there was no signs of infection , only a minimal the patient presented on post - operative day 20 with a fistula located at the external edge of the wound that showed normal healing otherwise ( fig . the patient was afebrile , there was no significant redness or swelling over the device ; a thick reddish odorless fluid discharge from the fistula was taken for culture . despite the initial hypothesis of pocket infection and given that the patient was relatively device dependent , we decided to proceed with conservative therapy first : intensive local care and wound debridement along with oral antibiotics ( cefuroxime , 500 mg tid ) without removal of the device . we informed the patient that if the conservative strategy was not successful , a radical radical approach was to be implemented ( with removal of all material ) . the culture came positive for staphylococcus aureus ( sensitive to cefuroxime ) 72 hours later ; nevertheless , we continued the conservative treatment plan and there was a gradual improvement then complete healing and closure of the fistula within 15 days . in this presented case , we hypothesize that the initial mechanism causing the formation of the fistula was a tension hematoma that drained to the skin with subsequent superficial infection . the hematoma could not resolve or expand probably because of the hermetic and rigid characteristics of the remodeled inner layer of the pocket and finally it found an issue to the skin ( fistula ) . in addition , despite the positive microbiological result , there was a favorable outcome with the conservative approach and we considered a posteriori that it was a superficial infection secondary to the fistula . in case of deep pocket infection , symptoms would include draining pus with redness and inflammation all around the area of the wound , also irritation related to pathogens and related toxins would slow and impede the healing process and complete removal of foreign materials is classically the only way to cure pocket infection . strict peri - procedural protocol must be applied in order to decrease cied related complications , especially in patients with high risk of infection and/or hematoma ( anticoagulant therapy , elderly , diabetes , renal failure , replacement procedures ) . in this perspective , peri - operative antibioprophylaxis,2 anticoagulant therapy management,3 implantation technique , , we do not use skin adhesives because we estimate they are not safe enough to achieve wound closure in the immediate post - operative period.4 even though rare cases of pocket infection have been cured without removing the device,5 the classical management strategy consists of removal of all foreign materials to cure infection . in this presented case , we conclude that the fistula was related to a tension hematoma with subsequent superficial infection ; conservative management resulted in complete healing without removal of device . skin fistula occurring after cied implantation can be managed in some cases without device explantation ; in fact , not every fistula implies an underlying infection , it can simply be related to a tension hematoma . the occurrence of tension hematoma predisposes to fistula formation and the fistula also predisposes to secondary infection ; accordingly , a case - by - case decision should be taken before explantation of device especially in dependent patient .

skin fistula occurring after cardiac electronic device implantation is frequently related to pocket infection and this condition typically requires removal of device and lead(s ) . we report on a case of skin fistula occurring 3 weeks after internal cardioverter defibrillator replacement . conservative management consisted of local care along with oral antibiotics without removal of device ; this strategy resulted in complete healing and closure of the fistula .

hereditary hemorrhagic telangiectasia ( hht ) ( rendu osler weber syndrome ) is an autosomal dominant disorder with estimated prevalence of 1020/100,000 1 . the principal pathology is telangiectasia of postcapillary dilated venules , which merge with arterioles without the interposed capillary bed , forming direct arteriovenous communications . hepatic involvement is seen in 6784% 2 , with hepatic shunting causing increased cardiac preload , decreased peripheral vascular resistance , and adaptive increase in cardiac output . recently , bevacizumab , a vascular endothelial growth factor inhibitor , has been proposed for treatment of symptomatic hepatic involvement in hht 3 . we present a case where quantitative magnetic resonance imaging ( mri ) was used for treatment monitoring . a 55-year - old female with known hepatic hht deteriorated rapidly over a 6-month period evidenced by portal hypertensive gi bleeding , anemia , ascites , and cachexia . baseline mri was performed , comprising anatomic evaluation using contrast - enhanced 3d t1-weighted mr angiography and rapid t2-weighted imaging , followed by quantitation of hepatic artery ( ha ) and portal vein ( pv ) flow using phase contrast mri . the proper ha was tortuous and dilated ( 1.6 cm diameter ) , with tortuous , dilated lobar , and corkscrew segmental branches ( fig1a and b ) . the main pv was also dilated ( 2 cm diameter ) , with moderate volume ascites and small gastro - oesophageal varices consistent with portal hypertension . arterial appearance : dilated tortuous hepatic artery ( ha ) ( arrow ) ( a ) ; hepatomegaly ( 29 cm craniocaudal length ) and ascites ( arrow ) ( b ) ; average flow of ha versus portal vein ( pv ) following treatment ( c ) . bevacizumab ( 5 mg / kg ) was commenced , twice weekly for 12 weeks , then 12 weekly as a maintenance infusion . serial mri over the ensuing 9 months was performed , which demonstrated initial dramatic reduction in ha flow ( 104 to 24 ml / sec ) and increase in pv flow ( 216 ml / sec ) , commensurate with clinical improvement , with cessation of gi bleeding , resolution of ascites , and weight gain . from 6 months post initiation of therapy , recurrent symptoms developed approximately 10 weeks after each infusion , including intermittent melena , mild anemia , and ascites , with concurrent gradual deterioration in mri - derived blood flow parameters ( fig1c ) . after 9 months , infusion frequency was increased from 12 weekly to 10 weekly , with good clinical response . this is the first report using mri to provide anatomic and functional monitoring of bevacizumab treatment for hht . historically , liver transplantation was the only option available for hht patients with life - threatening high output cardiac and/or liver failure . bevacizumab therapy for hht was first proposed in 2008 4 , with an open label phase 2 study recently describing significant decrease in cardiac output , the primary outcome measure . while initial reports of bevacizumab are encouraging , young et al . highlight the need for further evaluation with longitudinal randomized controlled trials , and evaluation of specific impact on hepatic abnormalities 5 . color doppler ultrasound has been shown to be a suitable first - line hepatic imaging modality in the general hht population . however , it has acoustic window limitations and depends on operator experience and patient breath - holding ability . phase contrast mri is a commercially available sequence traditionally used to quantify hemodynamics for cardiovascular applications 6 . it entails application of gradient pulses to induce phase shifts in moving protons that can be measured for quantitation of blood velocity and flow . it does not require injected contrast and can be acquired in less than 3 min per acquisition with a free breathing approach . applied anecdotally to our case , serial ha and pv flow quantification enabled objective assessment of response to bevacizumab , in addition to standard morphologic assessment . cardiac output can also potentially be measured with breath - hold phase contrast mri through the aortic root at the same examination . in conclusion , we suggest mri as a potential objective , noninvasive means of titrating and monitoring bevacizumab therapy in the setting of hepatic hht .

key clinical messageour case report demonstrates the use of phase contrast magnetic resonance imaging ( mri ) in monitoring the functional status of liver vasculature in a patient with hereditary hemorrhagic telangiectasia ( hht ) who was treated with bevacizumab . our report provides additional information that can be further utilized in clinical settings and research .

breast cancer is the most frequent malignancy among women that can be a leading cause of death through middle - aged women . adjuvant chemotherapy , commonly include alkylating agents and anthracyclines , improves survival rate in operable breast cancer but treatment - induced acute myelogenous leukemia ( aml ) is now widely regarded as an important concern of survivors . numerous studies have reported an increased risk of aml after treatment of breast cancer ( table 1 ) . the aim of this study is to evaluate the treatment agents for breast cancer and their effect on risk of aml expression . in april 2009 , a 37-year - old woman referred to oncologic clinic in kermanshah , iran with a self - detected mass and pain in her left breast . the pathology report of biopsy confirmed invasive ductal carcinoma , with immunohistochemical ( ihc)-based estrogen receptor ( er ) and progesterone receptor ( pr ) positive results . the status of patient in sentinel lymph node biopsy , bone scan and computerized tomography ( ct ) scan of abdomen and pelvis were normal . she was consulted about radical modified left breast mastectomy axillary dissection , and then her therapy was started with the combination of anthracycline and cyclophosphamide for four courses , followed by four courses of paclitaxel with trastuzumab for one year ( 17 courses of trastuzumab ) . due to node - positive , she was treated in follow up with irradiation on site of surgery and left axillary area . after 18 months of the first treatment for breast cancer , she referred again to our clinic with gingival hyperplasia complaints . peripheral blood analyses indicated wbc count more than 40000/l with immature ( blasts ) cells . her bone marrow biopsy according to fab ( french - american - british ) classification was compatible with aml - m2 . she was treated with diagnosis of leukemia as a secondary cancer with 7 + 3 regiment that lead to complete remission and continued by two extra courses of high dose ara - c . she had a full match sibling donor for allogeneic transplant , but unfortunately she rejected procedure of bone morrow transplantation . aml is an aggressive hematologic cancer that is characterized by accumulation of immature myelogenous cells in the blood and bone marrow that cause by abnormal proliferation and accumulation of hematopoietic progenitor cells , and is one of the most common malignancies in adults . many studies ( listed in table 1 ) as well as other reports [ 6 , 7 ] have reported the incidence of leukemia as a complication of adjuvant chemotherapy or radiotherapy for breast cancer . in these studies , increased risk of aml has been especially reported for treated cases with cyclophosphamide and anthracyclines and paclitaxel . in majority of these cases , aml was developed after two or more years of starting chemotherapy for breast cancer and also the age of patients was between 36 to 69 years . table 1 also shows that majority of patients with breast cancer develop aml - m2 . in this study , the young aged patient diagnoses with aml - m2 in a short period of interval . she was a case of her-2 positive breast cancer and so treated with trastuzumab for one year + irradiation on site of surgery and left axillary area and also treated with cyclophosphamide and anthracyclines and paclitaxel . adjuvant chemotherapy for breast cancer has been shown to make an increase in the risk of secondary malignancies such as aml . as indicated in table 1 , irradiation and cyclophosphamide appear to be suspects of secondary aml incidence . since paclitaxel is by itself leukemogenic , its effect may be augmented by carboplatin ( ref ) . the interval between the alkylating agent exposure and the development of aml is usually 5 to 7 years ( 60 - 84 months ) . there is a strongly possibility that addition of paclitaxel - therapy to irradiation and cyclophosphamide will reduce interval period between two malignancies ( breast cancer and aml ) .

acute myelogenous leukemia ( aml ) is an aggressive hematologic malignancy that cause by abnormal proliferation and accumulation of hematopoietic progenitor cells . a 37-year - old woman referred to oncologic clinic with a self - detected mass and pain in her left breast . the stage of tumor was a . she was treated with the combination of anthracycline and cyclophosphamide for four courses , followed by four courses of paclitaxel with trastuzumab for one year . after 18 months of the first treatment for breast cancer , her bone marrow biopsy was compatible with aml - m2 . here , we are reporting a young woman case with breast cancer that developed aml malignancy during short interval of therapy .

although spinal subdural hematoma ( sdh ) is rare , the incidence has increased significantly in the era of magnetic resonance imaging ( mri)4,10 ) . predisposing factors for spinal sdh include trauma , coagulopathy , vascular malformation , iatrogenic maneuvers such as lumbar puncture , tumor bleeding , alcohol abuse , and spontaneity3,4,8,13 ) . we describe a case of spontaneous concurrent spinal and cranial sdh , in which spinal sdh was detected one day prior to a cranial lesion . a 39-year - old female presented with about a 10-days history of low back pain and pain radiating from both legs . the patient had no history of antecedent head or back injuries , but had intermittent pulsatile headache for 2 weeks . spinal mri showed a diffuse mass encircling the thecal sac , leading to moderate to severe central spinal stenosis at the l4 to s2 vertebral levels . axial mri revealed that the hematoma was located between the epidural fat and cerebrospinal fluid space , indicating localization in the subdural space ( fig . one day after admission , the pre - existing headache ( which had not been a complaint in the outpatient clinic ) became aggravated , and nausea and vomiting developed . computed tomography of the brain revealed a chronic cranial sdh associated with midline shift in the left hemisphere ( fig . the cranial sdh was evacuated , which prevented brain herniation if lumbar decompression was necessary . three months later , a lumbar mri showed complete resolution of the spinal sdh ( fig . simultaneous spinal and intracranial sdhs are relatively rare , having been reported in only 18 cases7 ) . furthermore , spontaneous spinal sdh concurrent with cranial sdh is extremely rare , reported in only three patients to our knowledge ; none had a history of trauma or surgical procedures . however , three patients had some medical history of anti - platelet therapy , aplastic anemia , or tumor metastasis6,10,17 ) . in our case however , there is a lack of bridging veins as a source of spinal sdh in the spinal subdural space compared with the cranial counterpart9 ) . therefore , the incidence of spinal sdh is significantly lower than that of cranial sdh . redistribution of cranial sdh to the spine might be a cause of spinal sdh10,15,17 ) . spontaneous rapid resolution of acute cranial sdh has been documented in some cases2,14 ) . unlike acute sdh , enlargement of hematoma caused by rebleeding might rupture the membranes , leading to redistribution of the hematoma to the spine , most likely resulting from gravity . in almost all previously reported cases of concomitant cranial and spinal sdh , the spinal sdh was located below the lower thoracic spine6 ) . in the present case , in addition , concomitant intracranial and spinal sdhs can develop in patients with intracranial hypotension caused by ventriculoperitoneal shunt placement 12,16 ) . low cerebrospinal fluid pressure decreases the subarachnoid space , leading to widening of the subdural space , which facilitates the migration of a hematoma and tearing of bridging veins . however , it may be a potential sequela of cranial sdh by migration or redistribution . as in the present case , a patient with spinal sdh may complain of headache , nausea , and vomiting derived from the brain lesion . therefore , the incidence of spinal sdh concurrent with cranial sdh could be underestimated11 ) . the present case suggests that a patient with spinal sdh , especially without direct trauma history , should be evaluated to check the possibility of spinal lesion accompanied by cranial lesion . the evacuation of the spinal sdh may lead to the development of tentorial herniation in patients with concomitant cranial sdh .

a 39-year old female presented with chronic spinal subdural hematoma manifesting as low back pain and radiating pain from both legs . magnetic resonance imaging ( mri ) showed spinal subdural hematoma ( sdh ) extending from l4 to s2 leading to severe central spinal canal stenosis . one day after admission , she complained of nausea and severe headache . computed tomography of the brain revealed chronic sdh associated with midline shift . intracranial chronic sdh was evacuated through two burr holes . back pain and radiating leg pain derived from the spinal sdh diminished about 2 weeks after admission and spinal sdh was completely resolved on mri obtained 3 months after onset . physicians should be aware of such a condition and check the possibility of concurrent cranial sdh in patients with spinal sdh , especially with non - traumatic origin .

chylous ascites is a rare clinical entity most commonly seen after major gastrointestinal surgery such as oesophagectomy , gastrectomy or pancreaticoduodenectomy . we present a case of chylous ascites discovered during a laparoscopic cholecystectomy in a young woman following an episode of mild pancreatitis . a 39-year - old female , with a history of anxiety , presented to our metropolitan hospital with a 3-day history of central abdominal pain radiating through to her back with nausea and vomiting . initial laboratory investigations revealed serum lipase of 640 u / l ( a normal range of 857 ) , bilirubin 9 mol / l ( < 25 ) , alp 160 u / l ( 30120 ) , ggt 132 u / l ( < 51 ) , ast 36 u / l ( < 41 ) and alt 39 u / l ( < 41 ) . after resection and delivery of the gallbladder , there was an ongoing accumulation of milky fluid within the hepatorenal space . the fluid appeared chylous and a midline laparotomy was performed with an aim to identify the leak site . at the base of the mesentery small blocked lymphatics two drains were placed , one in the gallbladder bed and other in the base of the mesentery . analysis of the fluid demonstrated a chyle leak with triglyceride level of 410 mg / dl and amylase of 60 . figure 1:intra - operative photo : dilated lymphatics at the base of mesentery ( arrow ) . intra - operative photo : dilated lymphatics at the base of mesentery ( arrow ) . post - operatively , the patient was kept nil - by - mouth and given total parenteral nutrition . chylous ascites or chyloperitoneum is defined as a collection of chyle within the peritoneal cavity . chyle is the only body fluid with a fat content greater than the plasma ; therefore , chylous ascites may be diagnosed when the ascitic fluid triglyceride level is > 110 mg / dl ( 1.25 mmol / l ) . the fluid is classically milk coloured , odourless and separates into a serous and fat layer . chylous ascites is a rare complication of pancreatitis . only seven other case reports whereby pancreatitis was the cause of chyle leak were found in the english - based literature [ 28 ] . more commonly , it is associated with major abdominal operations , such as aortic aneurysm repair , pancreaticoduodenectomy or retroperitoneal lymphadenectomy . traditionally associated with a very high mortality of up to 71% , chylous ascites outside the operative setting is mostly related to intestinal and haematological malignancies . of the seven case reports , four reported on chylous ascites being discovered after or during cholecystectomy after an episode of biliary pancreatitis [ 35 , 7 ] . three of the four cases were mild episodes of pancreatitis , all undergoing cholecystectomy within 58 days as in this case [ 4 , 5 , 7 ] . the presumed pathogenesis is disruption of abdominal lymphatic channels , thus it is most commonly seen after retroperitoneal surgical procedures . in the non - operative setting , such as pancreatitis , there must be disruption or obstruction to both the lymphatico - venous and lympho - lymphatic channels in order for sufficient lymphatic hypertension to occur such that peritoneal extravasation can occur . pancreatitis without cholecystectomy is a rare but recognized non - operative cause as well [ 2 , 6 , 8 ] . the two presumed mechanisms of pancreatitis - related chylous ascites are compression of lymphatics from an inflamed pancreas or direct damage of channels by pancreatic enzymes [ 3 , 4 , 8 , 7 ] . as with most fistulas , non - operative techniques include fasting patients , feeding patients with medium - chain triglycerides ( mct ) based diet or use of diuretics and somatostatin analogues . dietary manipulation such as fasting patient or feeding with mct diet reduces intestinal lymph flow . as such leak site the use of somatostatin analogues and diuretics is common ; however , the efficacy of these medications is not well understood . invasive techniques involving interventional radiology or surgery tend to be used as second - line therapies . surgical options such as exploration to ligate leaky lymphatic vessels or placement of a peritoneovenous ( pv ) shunt are considered last resort therapies . pv shunt unfortunately over the years has gained a notorious reputation in causing complications such as sepsis , disseminated intravascular coagulopathy and even mortality . in conclusion , the exact mechanism related to its pathogenesis is not fully understood , although two main theories exist . as exemplified by this case , chyle leak post - pancreatitis can be managed successfully with conservative measures incorporating an mct diet or parenteral nutrition .

chylous ascites is a rare clinical entity that historically has been accompanied by high mortality due to the association with malignancy . here we present a case of chylous ascites as a complication of mild pancreatitis in a young woman . we review the literature of similar cases , which revealed four similar cases with a range of outcomes . treatment options vary from dietary restriction of medium chain fatty acids , total parental nutrition , radiological intervention and surgery .

thirty clusters of 30 households were selected by using 2- or 3-stage sampling ( 8) . households were defined as groups of persons who slept under the same roof under 1 family head at the time of the survey ; occasional visitors were excluded . information collected included number , age , and sex of persons living in the household ; number of deaths ( age , sex , and date of death ) since the beginning of the recall period ; and cause of death . malaria was defined as the probable cause if a decedent s household reported presence of fever ( burundi ) or fever and shivering without severe diarrhea or severe respiratory infection ( ethiopia ) . * cmr , crude mortality rate ( deaths/10,000/d ) ; ci , confidence interval ; u5mr , mortality rate for children < 5 y of age ( deaths/10,000/d ) . data were analyzed by using epiinfo ( centers for disease control and prevention , atlanta , ga , usa ) . death rates were expressed as deaths/10,000 persons / day , and 95% confidence intervals ( cis ) were adjusted for design effects . mortality rates were compared with standard emergency thresholds of 1 death/10,000/day ( crude mortality rate [ cmr ] ) and 2 deaths/10,000/day ( under 5 mortality rate [ u5mr ] ) ( 10 ) . excess number of deaths probably due to malaria was estimated by applying the specific death rates due to self - reported malaria to the population and time period covered by each survey . in the total population , proportion of deaths probably due to malaria varied from 51.7% ( karuzi ) to 78.3% ( kayanza ) and from 53.0% ( ngozi ) to 64.3% ( kayanza ) for children < 5 years of age ( table 1 ) . deaths probably due to malaria ranged from 1,000 in kayanza to 8,900 in ngozi ; > 50% were among children < 5 years ( table 2 ) . when surveys covered most of the epidemic duration ( 74% in ngozi , 85% in karuzi , 83% in damot gale ) , malaria was the probable cause of death for a comparable proportion of the population ( 1.5% [ 8,900/574,400 ] in ngozi , 0.9% [ 2,800/308,400 ] in karuzi , and 1.9% [ 5,400/286,600 ] in damot gale ) . using estimates from respective surveys , the mid - period proportion of children < 5 years was calculated as follows : ( children alive at end of period + [ 0.5 deaths for children < 5 y during period])/(all persons alive at end of period + [ 0.5 all deaths during period ] ) . we provide novel data based on representative population sampling , rather than health facility based reporting . p. falciparum epidemics seem responsible for high death rates : the estimated number of deaths probably due to malaria at our sites ( 18,000 ) represents about 10% of the worldwide total estimated annual deaths due to epidemic malaria ( 2 ) . the limitations of retrospective mortality surveys are well known ( 11 ) ; hence , results should be interpreted with caution . reporting bias was minimized by defining a limited recall period and by training interviewers extensively . in kayanza , the survey was conducted before the epidemic peak ; the estimated death rate may have been lower than average for the entire epidemic , which may have led to underestimation of the true death rate . generally , postmortem diagnosis of malaria at the household level is difficult , and even advanced verbal autopsy techniques ( not used in these surveys due to lack of skilled human resources ) are of limited accuracy ( 12 ) . malaria deaths may thus have been overestimated , particularly in burundi , where fever was the sole criterion of probable malaria ; use of this 1 criterion may have masked other causes , such as acute respiratory infection . furthermore , in 3 of the areas surveyed ( kayanza excepted ) , the epidemics occurred concurrently with nutritional crises . malnutrition as a cause of death could not be assessed because of its implication in various infectious diseases , but high prevalence of malnutrition is usually associated with excess u5mr ( 13 ) . nevertheless , mortality rates among persons 5 years of age ( cmr [ u5mr proportion of children < 5 years in survey sample]/[1 proportion of children < 5 years in survey sample ] ) were also elevated . rates ranged from 0.5 in kayanza to 1.7 in damot gale , higher than the expected rate of 0.27 in sub - saharan africa ( 14 ) . in the absence of other specific causes of acute death for adults , we speculate that malaria was largely responsible for these excess deaths . at all sites , early warning systems were not operational and surveillance was ineffective , which led to substantial delays in epidemic detection ( 6 ) . first - line treatment regimens ( chloroquine in burundi , sulfadoxine / pyrimethamine in ethiopia ) were not very effective . in damot gale , access to treatment was poor ( data not shown ) , probably due to the dearth of health facilities . early diagnosis and prompt treatment of malaria remain cornerstones of the global malaria control strategy ( 15 ) . the degree to which these interventions will be made available will largely determine the death rates in future epidemics .

death rates exceeded emergency thresholds at 4 sites during epidemics of plasmodium falciparum malaria in burundi ( 20002001 ) and in ethiopia ( 20032004 ) . deaths likely from malaria ranged from 1,000 to 8,900 , depending on site , and accounted for 52% to 78% of total deaths . earlier detection of malaria and better case management are needed .

intracranial epidermoids are histologically benign and are congenital neoplasms of the central nervous system . as slow - growing lesions , the clinical presentation is usually non - specific in the form of mental status alteration or headache . we report a case of a large bulky right intraventricular epidermoid tumor with mass effect on the surrounding structures in a young male patient with unusual clinical presentation and pathological course . a 16-year - old male patient was admitted with a 4 month history of moderate intensity , gradually progressive holocranial headache associated with occasional episodes of vomiting . he also had gradually progressive diminution of vision since 4 months in the left eye . vision in the right eye was 6/6 and in the left eye was 6/18 with bilateral papilledema . pre - operative magnetic resonance imaging brain showed a large lobulated , well - defined mass lesion in the atrium and body of the right lateral ventricle , which was hypointense on t1 [ figure 1 ] and flair [ figure 3 ] sequences and hyperintense on t2 sequences [ figure 2 ] . the lesion was compressing the 3 ventricle and was displacing the brainstem caudally [ figure 3 ] . axial t1 weighted magnetic resonance imaging showing hypointense mass in the right lateral ventricle axial t2 weighted magnetic resonance imaging showing hyperintense mass in the right lateral ventricle coronal flair magnetic resonance imaging showing hypointense mass in the right lateral ventricle with pressure over the brain stem the patient underwent right parietal craniotomy and complete removal of lesion . the tumor was pearly white and avascular , occupying the whole of the atrium and body of the right lateral ventricle , and had displaced the septum pellucidum to the opposite side . a post - operative contrast computed tomography revealed near - total excision of the lesion and resolution of hydrocephalus . the patient had normal post - operative recovery and his vision in the left eye also improved to 6/12 . at follow - up of 6 months , the patient had improvement in his hemiparesis as well . histopathological examination confirmed lesion as epidermoid [ figure 4 ] ; grossly , flakes of pearly white fragmented tissue were submitted for formalin fixation and paraffin sectioning . the h and e , stained slide showed numerous anucleated squamous cells without any presence of identifiable basal germinal cells . no skin adenaxal tissue like sebaceous glands , hair follicles or mucinous gland was identified . ( h and e , 10 ) showed cyst wall made up of anucleated keratinized squamous cells . no germinal layer identified . the number of such cases has not increased in the era of advanced imaging tools . probably , there is a direct relation to the development of choroidal vessels , which explains the lateral migration through the choroidal fissure and subsequent entrapment of neuroepithelial cells . the tumors reported have a connection with median / paramedian structures , and the view that these lesions commence from quadrigeminal cisterns also needs serious consideration . literature review of lateral intraventricular epidermoid epidermoids grow by accumulation of keratin and cholesterol , which are the breakdown products of desquamated epithelial cells . they grow linearly rather than exponentially and hence are slow - growing lesions . therefore , they clinically manifest in the later decades of life this is because of the smooth and pliable nature of the cyst wall and its content , which allow progressive , slow molding of the surrounding neural structures . because of the rarity of lateral intraventricular epidermoid , no fixed pattern of clinical presentation has been described . usual clinical presentations described in the literature are non - specific , like headache , cognitive deficit or psychiatric symptoms . usually , patients with this type of lesions are in the 5 or 6 decades of life . in our case , the patient was only 19 years old , which shows that these types of lesions can also present in the young group of population despite their slow - growing nature and enough space to expand in lateral ventricular cavity . in contrast to the present knowledge that the csf obstruction is not seen even if this lesion is in the vicinity of the foramen of monro , our patient had obstructive type of hydrocephalus due to compression of the 3 ventricle . this resulted in papilledema and diminished vision , which improved after total microsurgical removal of the lesion . possibly , this is the first case that has presented with diminished vision and hydrocephalus with such a rare type of lesion . considering the symptomatic and clinical improvement in our patient , in addition to the rarity of these lesions in the lateral ventricle , intraventricular epidermoid can attain a large size in a short period and can manifest at a young age . it can also cause obstruction to the csf pathway and can manifest clinically as loss of vision and other features of hydrocephalus .

lateral intraventricular tumors are uncommon . they grow linearly rather than exponentially and hence are slow - growing lesions without causing mass effects and hydrocephalus . we report a rare case of large bulky right intraventricular epidermoid tumor in a child . this tumor was associated with mass effect on the surrounding structures and hydrocephalus .

a 41-year - old man presented with diffuse pain and discomfort in the left knee for two months . physical examination revealed a palpable bony hard mass of approximately 22 cm in size over the superolateral aspect of the left distal femur . there was no restriction in the range of movements of the knee joint , but pain was reported with over 90 degree flexion of the knee . the lysholm score was 80 , and the international knee documentation committee ( ikdc ) score was 79 points . simple radiography showed a bony mass arising from the superolateral aspect of the left distal femur without stalk ( fig . 1 ) . magnetic resonance imaging ( mri ) showed a prominence with the same intensity as a bone , arising from distal femur within the joint capsule . 2 ) . under general anesthesia , arthroscopic standard portals were made , and the superolateral view revealed an intra - articular cartilaginous cap . ligaments , cartilage , and menisci were intact , and patellar tracking was normal in a full range of knee motion . the histopathologic report showed that the bony outgrowth was mainly a cancellous bone with a cartilaginous cap , which is a feature consistent with osteochondroma ( fig . . arthroscopic excision of a symptomatic osteochondroma may be less painful and results in a faster recovery than the open incision approach . generally , osteochondromas occur around the growth plate of long bones in a skeletally immature person and move towards the diaphysis with the connected bone . therefore , it is rare that osteochondroma is located within the articular compartment of a joint in an adult3 ) . while intra - articular osteochondromas of the hip and ankle joint have been reported , these cases are rare2 ) . intra - articular osteochondroma in the knee joint has been reported only in two cases4,5 ) . they used an image intensifier to confirm the location , dissected the bony mass , and performed arthroscopic resection . while takahashi et al.5 ) resected the intra - articular osteochondroma by arthroscopy , their case involved multiple osteochondromas . in this case , simple radiography and whole body bone scan were normal in the other commonly involved sites , such as shoulder , hip , and ankle . to our knowledge , solitary intra - articular osteochondroma in the knee joint is a very rare case . in addition , the arthroscopic excision of osteochondroma of knee joint has been reported rarely . while the extra - articular tumors are usually symptomless , intra - articular tumors cause pain and discomfort with restrictions in the range of movements . the diagnosis of the tumors are made by a combination of clinical signs , plain radiography , and mri . mri usually shows a well - circumscribed lesion with signal intensity similar to that of a bone with a cartilaginous cap . mri of the this patient demonstrates diagnostic marrow and cortex continuity of a sessile osteochondroma ( fig . the size of the cap is very important to rule out malignant transformation , as a cap larger than 1 cm suggests malignancy . microscopic examination shows a cap of mature hyaline cartilaginous tissue covered by a fibrous membrane . the centre of the lesion consisted of mature bone trabeculae located beneath the cartilaginous cap containing bone marrow and amorphous calcified debris . to further rule out malignancy , cellular atypia and mitotic activity need to be evaluated7 ) . solitary intra - articular osteochondroma of the knee is an unusual case , which can be successfully managed with arthroscopy .

osteochondroma is the most common benign tumor of the growing bone commonly involving the knee joint region . it often involves the metaphysis of the long bone , occurring extra - articularly . in spite of this , solitary intra - articular osteochondroma has rarely been reported in the literature . a 41-year - old man presented with diffuse pain and discomfort of the left knee for over 2 months . clinical examination revealed a bony prominence involving the superolateral aspect of the left distal femur . diagnostic evaluation involved radiography , magnetic resonance imaging , and a diagnostic arthroscopy , which showed features of an intra - articular osteochondroma in the left distal femur . arthroscopic excision of the solitary intra - articular osteochondroma resulted in a complete relief of symptoms and return to full competitive activities . no recurrence of symptoms occurred during the one year of follow - up . solitary intra - articular osteochondroma of the knee is an unusual case , which can be successfully managed with arthroscopy .

solitary lipomas are seen predominantly in women , whereas lipomatosis occur more frequently in men . deep lipoma can affect thorax , mediastinum , chest wall , pelvis , retroperitonium and paratesticular regions . in the gastrointestinal tract , lipomas are found in submucosa and subserosa and act as a leading point for intussusceptions . a 32-year - old male came to emergency department following pain in the right iliac fossa ( rif ) for 1 day . he was admitted with provisional diagnosis of appendicitis and commenced on intravenous fluid and antibiotic overnight . next morning he complained of pain being constant and signs of peritonism were present for which he was prepared for theatre . but a torted pedunculated lipoma of 3 cm size was noted on right lower quadrant parietal peritoneum ( fig . 2 ) . peritoneal lesion smear showed mature adipose tissue in lobules separated by fibrocollagenous tissue and few congested blood vessels . acute abdominal pain is the most common case of hospital admission accounting for 5 to 10% of all emergency department visits . acute abdomen generally refer to previously undiagnosed pain that arises suddenly and is of < 48 h duration that seeks medical attention . as in this case , a torted lipoma of parietal peritoneum mimicked as acute appendicitis . lipoma is the most common benign form of soft tissue tumor composed of adipose tissue . one percent of lipoma has a tendency for malignant transformation and is more likely in lesions of lower extremities , shoulders and retroperitoneal areas . lipomas of an internal organ can be dangerous as in the gastrointestinal tract , leading to bleeding , ulceration and obstruction . others like lipoma of the superior vena cava , brain and spinal cord can pose a significant clinical challenge . . these tumors may report as simple abdominal discomfort , abdominal distention , abdominal pain or palpable mass . very rarely these peritoneal tumors can be included in differential diagnosis in patients presenting with diffuse or focal peritoneal disease . so far only one case of a torted pedunculated abdominal wall lipoma mimicking acute appendicitis has been reported . another case of pedunculated lipoma presenting as abdominal pain , nausea and constipation which was diagnosed on diagnostic laparotomy was reported by barut et al . . lipoma on usg appears as iso- to hyperechoic texture surrounded by thin , echogenic capsule . computed tomography is reliable on diagnosis of deep lipomas , which appears as a well - circumscribed mass with uniform fat attenuation . finding of macroscopically normal appendix during operation needs examination of other organs and parietal peritoneum . though a rare case it should be kept in mind for a differential diagnosis of an acute abdomen .

lipomas are found most often on the torso , neck , upper thighs , upper arms and armpits ; they can also occur almost anywhere in the body . parietal peritoneum lipoma is a rare intraoperative finding during abdominal surgery . we present a case of a torted , pedunculated parietal wall lipoma in the right iliac fossa that gave rise to a clinical diagnosis of appendicitis . so far only one case has been reported .

we report a case of mpbc with pulmonary metastasis occurring in a 59-year - old man . a 59-year - old man was referred to the breast team with a presumed right - sided breast abscess which had not responded to antibiotics . his medical history included epilepsy , hypertension and emphysema for which he takes tegretol and amlodipine . he is an ex - smoker with a 60 pack - year history and minimal alcohol intake . on examination he had a painful , fluctuant area in the upper outer quadrant of the right chest wall with skin ulceration . it was presumed that this was a simple abscess ; however , an inflammatory cancer needed to be excluded . under general anaesthesia , an incision was made over the area of flucuance . the immunoprofile was of a carcinoma and the ttf1 positivity suggested an origin from lung or thyroid . a computed tomography ( ct ) scan of the chest , abdomen and pelvis showed a 54 cm ulcerative right - sided breast mass , with a number of small rounded right axillary lymph nodes . there was moderate emphysema of the lungs and an 18 mm area of scarring in the apex of the left lung . it was decided that local control of the ulcerating breast mass was needed first and a right mastectomy with level 1 axillary clearance and latissimus dorsi flap reconstruction was performed . the tumour was 55 mm in diameter and showed staining with alpha smooth muscle actin and cytokeratins confirming a metaplastic immunophenotype . there was no evidence of lymph or vascular invasion ; however , one of the five lymph nodes removed contained macro metastasis with focal extra capsular tumour excision . a positron emission tomography scan was performed to investigate the lung lesion previously identified on ct . this showed a 2.4 cm hyper - metabolic lesion in the apex of the left lung which abutted the pleural surface but did not invade it . we initially felt that this was most likely to be a lung primary with breast metastasis . as a result , our patient underwent a three - port video - assisted thoracic surgery and wedge resection . a palpable nodule in the apical segment of the left upper lobe was resected with frozen sections sent . the histology from the lung demonstrated a poorly differentiated carcinoma with sarcomatous features in keeping with metastasis from a primary breast cancer . the morphology and immune profile of the lung tumour were similar to that of the breast tumour . vascular and visceral pleural invasion were present , but there was a clear 2 cm margin . following recovery from surgery , our patient was started on the fec 100 regimen ( 5-fluorouracil , epirubicin and cyclophosphamide ) . a bone scan prior to chemotherapy showed no evidence of bony metastasis and a ct scan showed no focal collection or residual mass in the right breast and no significant intrathoracic adenopathy . he was referred for radiotherapy of the chest wall and is about to start a course with 40 grays in 15 fractions to the right chest wall and supraclavicular fossa . mpbc is an aggressive breast cancer which presents with a larger tumour size and higher grade than invasive ductal carcinomas . mpbcs are a histologically diverse group of tumours characterized by two or more cell types . ductal carcinomatous epithelium transforms to squamous or spindle cell components or mesenchymal elements [ 2 , 5 ] . mpbcs have lower rates of nodal involvement than invasive ductal carcinomas ; however , the risk of metastatic disease is higher with mpbc . as a result , the prognosis is worse with 5-year survival ranging from 49 to 68% . other studies have also reported high rates of pulmonary metastasis suggesting similar clinical behaviour to sarcomas . once distant metastases develop in mpbc median survival surgical treatment is the first - line therapy for mpbc ; a study by pezzi et al . looking at the management of 892 women with mpbc found that 95% of patients had surgical resection . fifty - six per cent of these women had a mastectomy due to the large size of tumour . the benefit of chemotherapy in mpbc is unclear . a study looking at the use of chemotherapy in 7 patients with distant metastasis in 14 separate trials of chemotherapy found only one partial response observed to doxorubicin . there are a limited number of studies looking at the use of chemotherapy in mpbcs ; however , it appears that mpbc responses less well to chemotherapy than invasive ductal carcinomas . very few patients with mpbc receive hormonal therapy due to the low proportion of oestrogen- or progesterone - receptor positive cancers . our case describes a vanishingly rare male cancer that raised a diagnostic challenge about whether our patient had a primary breast tumour with a lung metastasis , a primary lung tumour with a breast metastasis or two synchronous tumours . additionally , this case highlights how important it was to consider the diagnosis of malignancy when treating an atypical abscess .

metaplastic breast cancers ( mpbcs ) represent < 1% of breast cancers . reports of mpbc in men are limited to case reports . we report a case of mpbc with pulmonary metastasis occurring in a 59-year - old man who initially presented with a presumed breast abscess . histology from the breast lesion revealed a poorly differentiated carcinoma and a computed tomography scan showed an ulcerative right - sided breast mass and an area of scarring in the apex of the left lung . the breast lesion and the lung lesion were resected separately and the histology from the lung showed a poorly differentiated carcinoma with sarcomatous features in keeping with metastasis from a primary breast cancer . our patient then proceeded to chemotherapy with fec 100 regimen ( 5-fluorouracil , epirubicin and cyclophosphamide ) . mpbc is an aggressive breast cancer that has a propensity to metastasis to the lungs . prognosis is poor .

it is well known that more than 90% of colorectal diseases are adenocarcinoma , with the majority of remaining cases having no epithelial histology such as carcinoid tumors , sarcomas , and lymphoid tumors . pure squamous cell carcinoma ( scc ) is not uncommon in glandular organs such as the uterus , lung , and pancreas , but a tumor of the intestinal tract is rare . the incidence of scc of the colon and rectum has been reported to be 0.25 to 0.1 per 1,000 colorectal carcinomas . after the first case report in 1919 , a total 72 pure sccs of the colon and rectum have been reported [ 3 , 5 , 6 , 7 ] . clinical characteristics , biologic behavior , and treatment response of this colorectal cancer are largely unknown . in this paper he visited our hospital with low grade fever , anorexia and abdominal pain , seven years after the first operation in may 2001 . abdominal computed tomography ( ct ) showed wall thickness and stenosis of the colon at the splenic flexure and lymph node enlargement around the tumor ( fig . 1 ) . colonoscopy revealed stenosis with ulceration in the colon at the splenic flexure . although chest , neck and cervical ct were done , tumors were only identified in the colon . although this tumor was a huge mass which penetrated the jejunum and adhered to the left kidney and left diaphragm , left hemicolectomy , partial resection of the jejunum and splenectomy were performed . the resected mass was huge , 11.0 8.0 cm , with penetration to the jejunum ( fig . 2 ) . pathology demonstrated scc of the colon at the splenic flexure invading the jejunum , diaphragm and capsule of the kidney ( fig . the first case of a pure scc of the colon was reported in the german literature by schmidtmann in 1919 . in japan , murakami et al . reported the first case of a pure scc of the colon in 1974 . since that initial description 72 cases of pure sccs of the colon and rectum have been reported ( table 1 ) [ 3 , 5 , 6 , 7 ] . certain criteria must be satisfied before a diagnosis of primary scc of the colon is made . second , a squamous - lined fistulous tract must not involve the affected bowel , because this may be a source of sccs . the prognosis of patients with colorectal scc is difficult to establish because of the rarity of these tumors . the colorectal scc seems to be more frequently locally invasive and more likely to involve regional lymphatics than the adenocarcinomas , probably because of a delayed diagnosis . in this case , the tumor was pt4 ( invasion of the diaphragm and capsule of the kidney ) and lymph node involvement . gelas et al . reported that surgical resection after neoadjuvant combination of chemotherapy and external beam radiation therapy was useful for rectal scc . juturi et al . reported that combination of cisplatin , 5-fluorouracil , and leucovorin would be a possible treatment option for patients with metastatic colorectal scc . reported that cisplatin , etoposide and 5-fluorouracil combination chemotherapy was effective and serum scc antigen level was a useful marker of response to chemotherapy . nowadays , we think that surgical resection may be the first choice and adjuvant treatment ( chemotherapy or radiation therapy ) may be done if the patient has a good performance status . in conclusion , advanced colorectal scc with invasion to adjacent organs and metastatic lymph nodes had a poor prognosis . however , surgical resection and adjuvant chemotherapy is a better approach to the treatment of colorectal scc .

it is very rare that squamous cell carcinoma ( scc ) arises from colorectal epithelium . an 89-year - old man was treated in 2001 with chief complaints of anorexia , abdominal pain , and low grade fever . the histological diagnosis as scc was determined by biopsy during a colonoscopy . we diagnosed primary scc of the colon because except in the colon no malignant lesions were found by systemic ct . surgical complete resection was performed . however , he died three months after surgical resection because of hepatic metastasis and cachexia . the prognosis of this disease seems to be worse than that of adenocarcinoma .

about 20% of patients admitted to intensive care fail to leave the intensive care unit ( icu ) alive , and a further 8 to 10% die in hospital . alas , no new product pharmaceutical or technological has had an obvious major impact on overall icu outcomes . activated protein c , for example , is currently used in about 2 to 4% of patients admitted to uk icus . assuming the 19% relative reduction in mortality reported in the prowess study , this translates to an outcome improvement in less than 1% of all patients admitted to the icu . yet more than a quarter of patients admitted to uk icus have sepsis diagnosed within 24 hours of admission , and probably as many again develop sepsis during their stay . i prescribe corticosteroids in septic shock with concurrent adrenal deficiency and use terlipressin in catecholamine - unresponsive septic shock but any benefit gained also applies to a minority of my septic patients . i can provide anecdotal examples where i am convinced that the above interventions have provided benefit to individual patients but can not persuade myself of their broad impact . the emphasis must surely be placed on early recognition of sepsis and appropriate interventions to prevent deterioration in organ function , such as rivers 's goal - directed strategy . however , such stratagems should ideally be implemented long before the patient requires intensive care ; otherwise , diminishing returns are likely . institution of such an approach once the patient has been admitted to the icu has not shown benefit in major studies , suggesting an evolution in pathophysiological mechanisms that are no longer amenable to pre - emptive or early therapeutic approaches . less aggressive ventilation with increasing tolerance of still - acceptable levels of hypercapnia and hypoxaemia . shorter - duration antibiotic courses with an increasing emphasis on monotherapy . less nutritional neglect but also less persistence with enteral feeding in the presence of gastrointestinal intolerance . less acceptance of high blood glucose levels . less attention to monitoring superfluous variables and derived parameters , but a greater emphasis on attention to basics including maintaining or restoring the adequacy of organ perfusion , although with the relatively insensitive tools that we currently have available . has ' less ' had a clearly demonstrable effect on outcome ? to give a few notable examples , mortality in studies of acute respiratory distress syndrome has fallen impressively from 4859% between 1983 and 1991 to 2526% since 2000 , and is probably related to less harmful ventilatory techniques , notably lower tidal volumes . randomised studies of non - invasive versus invasive ventilation in both respiratory and cardiac conditions show improved outcomes for non - invasive ventilation , possibly related to the avoidance of endotracheal intubation and the requirement for sedation . a lower haemoglobin threshold for blood transfusion is also beneficial , emphasising the likely immune - modifying effects of allogenic blood that are not immediately manifested as a transfusion reaction . similarly , a tight target range of blood glucose as part of a prolonged enhanced insulin - calorie regimen significantly improved mortality and morbidity . surely there is a lesson from the above that we must continue to apply but must also develop still further . the above advances have arisen from a realisation that overuse or misuse of drugs or devices , and/or excessively striving for physiological or biochemical normality , may provide short - term gains but at the expense of longer - term detriment . a greater understanding of both disease pathophysiology and iatrogenic harm will , i believe , lead to even better management , and thus further enhance outcomes .

although many pharmaceutical and technological advances are heavily touted , they have had relatively little impact on overall outcome improvements in the critically ill . acting on the increasing recognition that ' less may be best ' has , in my opinion , been the greatest single advance in patient management in the intensive care unit in the past 10 years . although certainly not qualifying as a ' brave new world ' in terms of daring and exciting innovation , the importance of ( often covert ) iatrogenic complications should not be underestimated .

a parastomal hernia ( psh ) is a type of incisional hernia occurring at the site of the stoma or immediately adjacent to the stoma . it forms when the abdominal wall is continually stretched by the tangential forces applied to the circumference of the abdominal wall opening . patient characteristics associated with increased risk of psh include obesity , weight gain after ostomy construction , poor nutritional status , immunosuppressive drugs , emergency construction of the stoma , chronic coughing , infection and underlying diseases such as malignancy . they typically present with a bulge at the site of , or adjacent to , the intestinal stoma with or without pain . symptoms range from mild abdominal discomfort , distension , nausea , constipation to severe abdominal pain , fever and an irreducible hernia . the hernia contents are almost exclusively limited to the mobile structures of the abdomen , i.e. intestines and their supportive tissue . an 81-year - old male patient was admitted to a surgical ward with acute onset of severe abdominal pain , vomiting and abdominal distension . clinical examination found circulatory instability , a peritoneal abdomen and increased leucocyte count and c - reactive protein on laboratory reports , with several litres of fluid aspirated after insertion of a nasogastric tube . his past medical record included rectal cancer 19 years ago managed with rectal resection and subsequently fitted left lower quadrant colostomy . he had developed a large psh over a period of several years . due to the patients reluctance to seek medical attention for the hernia , surgical correction had been deemed infeasible and a truss was fitted instead to the patient 's satisfaction . plain film abdominal x - ray showed not only a large part of the small intestine , but also the stomach located in the psh with signs of pneumoperitoneum ( fig . 1 ) . figure 1:plain film abdominal x - ray showing the trapped stomach in the large parastomal hernia on the patient 's lower left side . notice the fundus - like air on the outer left - hand side of the trapped part . plain film abdominal x - ray showing the trapped stomach in the large parastomal hernia on the patient 's lower left side . notice the fundus - like air on the outer left - hand side of the trapped part . acute , explorative laparotomy confirmed the finding of displacement of the stomach to the psh with a 7 cm perforation of the minor curvature secondary to necrosis . apart from the stomach , the hernia contained most of the small intestine including the omentum as well as part of the colon , all these intestines were found intact . the necrotic stomach tissue was surgically debrided , the defect closed in two layers and a feeding tube placed in the duodenum . the original defect in the lower left quadrant was found beyond repair and was instead enlarged to avoid incarceration in the future . due to the patient s severe septic state , further surgery on the abdominal wall or stomach the patient developed a secondary wound infection requiring vacuum - assisted closure , but otherwise had an uneventful 6-week admittance period with full recovery and subsequent discharge . the stomach is supported by the oesophagal fixation to the diaphragm and by the hepatogastric , gastrophrenic and gastrosplenic ligaments and its mobility restricted by these as well as the surrounding structures ( liver , diaphragm , left kidney , pancreas , spleen and colon tranversum ) . usually , the small bowel or omentum is found in a hernial sac of the abdomen . a stomach inside a psh is exceptionally rare with only a few other published cases in international literature [ 46 ] and one case of incarceration into an umbilical hernia . previously the stomach has been reported to herniate into the thoracic space secondary to trauma or surgery on the stomach or near the diaphragm with a few cases presenting with incarceration . finally , a more common type of hernias are the congenital diaphragmatic defects ( bochdalek 's and morgagni 's hernia ) usually identified upon neonatal ultrasound with just one case of delayed presentation , resulting in stomach incarceration , has been reported . the mechanisms for this displacement are unknown but increased mechanical stress over time could lead to stretching and elongation of the supporting ligaments and the oesophagus . alternatively , the stomach itself may elongate over time as the muscular structure allows for shape and size variation . although large hernias may remain asymptomatic , they should be evaluated on a regular basis as not only intestines may be at risk of strangulation but also other structures may herniate into large , untreated abdominal wall defects . presumably , a number of large , asymptomatic pshs may contain stomach or other immobile structures and the threshold for evaluating these pshs in case of symptom progression should be very low .

parastomal hernias ( pshs ) are a common type of incisional hernia and the most frequent complication to colostomies . usually only mobile structures of the abdomen herniate in the hernial sac of the non - traumatic hernia . this case describes a large psh adjacent to a lower left quadrant colostomy containing the mobile small intestine , part of the colon and a perforated stomach . the psh presented with acute abdomen requiring explorative laparatomy and debridement . large hernias may over time predispose to stretching of ligaments and mobilization of otherwise immobile structures with damage to these structures . the case report includes a short overview of hernia types associated with dislocation of the fixed organs of the abdominal space .

dp patients believe that their skin is infested by parasites that underlie their cutaneous surface [ 1 , 2 ] . secondary organic causes might be investigated before the final diagnosis ( neurologic , cardiovascular , renal , liver or endocrine diseases , nutritional disorders , infectious diseases , malignancy , substance abuse and pharmacological treatments ) . however , one theory suggests that patients with dp have an excess of extracellular dopamine within the striatum nucleus of the brain . the good response to pimozide treatment , which acts as an antagonist dopamine , could be explained by this theory [ 3 , 4 ] . a 73-year - old patient was referred to our dermatology department in july 2010 presenting with deep linear ulcers on the left side of the face ( fig . she had a personal history of diabetes , primary bile cirrhosis and ischemic cerebrovascular attack ( left medial cerebral artery ) with right - sided paralysis . the lesions began in 2001 with a lip erosion and they have become more severe around the last month before admission . during the years 2005 and 2006 , the patient was referred several times with severe pruritus without evident cutaneous primary lesions . dp was first suspected in 2007 as the patient insisted that she had an infection underlying her skin . she was referred to our psychiatry department , where a delirious disorder was suspected as well . her husband and one of their sons felt also infected . in order to isolate the patient from her family and her family from her she was treated as a true psychosis using olanzapine ; however , this treatment was ineffective , and pimozide was started in association with ziprasidone . several adverse extrapyramidal effects appeared , and an anticholinergic drug was needed ( dantrolene ) for control . in fact , our case presented some of the different causes for itching appearance . nevertheless , the morphology and localization of the erosions and ulcers were very typical of dp . furthermore , the treatment of dp is also difficult because patients have a fixed unshakeable belief that they are infested and they are searching for an antibiotic , antiseptic or an antiparasitic drug . antipsychotic drugs are not easy to introduce and maintain in these patients , although they are needed to control the disease . our patient was admitted because of the evidence of folie deux induced in her husband and to ensure the adherence to treatment . in patients with delusions of infestation , the typical antipsychotics , such as pimozide , have traditionally been the first - line options [ 1 , 2 ] . their extrapyramidal side effects are well known and , in fact , they appeared in our patient . the evidence from some case reports has indicated the beneficial effects of atypical antipsychotics such as olanzapine [ 8 , 9 ] or risperidone [ 10 , 11 ] . as our patient had not responded completely to this drug , ziprasidone we report a clinical case of dp treated with ziprasidone , an atypical antipsychotic with a lower risk of extrapyramidal symptoms . aripiprazole has also been shown to provide promising results . however , as dp cases are not common , it is difficult to study patient series of different treatments however , a close collaboration between clinical colleagues may help to improve treatment of dp patients .

delusional parasitosis is characterized by a patient 's fixed false belief of being infested with parasites or small creatures . the first - line treatment options are typical antipsychotics such as pimozide . however , the accompanying extrapyramidal side effects might limit their use . we report on a patient with a good response to pimozide combined with ziprasidone . ziprasidone is an atypical antipsychotic drug with a lower risk of extrapyramidal symptoms ; thus , it might be considered a good first or second treatment option for delusional parasitosis .

a 32-year - old indian man presented to the emergency department with 3 days history of left eye pain , redness and blurring of vision . he has no past medical history , but gave a preceding uncertain history of foreign body hitting his left eye 6 months ago whilst standing beside a co - worker who was hammering metal . he was given eyedrops by a company doctor and did not seek further treatment even though he continued to have blurring of vision for 3 - 4 months subsequently . on examination , his visual acuity was 6/6 in the right eye and hand movement in the left eye . examination of the right eye was normal ; however , in the left eye , there was a linear cornea scar superiorly and a siderotic white cataract with small breach in the anterior lens capsule . there were brownish orange pigment clumps on the anterior lens capsule suggestive of siderotic cataract clinically [ fig there were clumps of white lens matter inferiorly in the anterior chamber but the anterior chamber was otherwise deep and quiet with no signs of a hypopyon . ultrasound b - scan showed moderately dense mobile vitreous opacities with posterior vitreous detachment , with no retinal tear or detachment . on low gain , no intralenticular foreign body was seen and the posterior capsule was intact [ fig . 2 ] . orbital x - ray [ fig . 3 ] and computed tomography scan [ fig . anterior segment photo of the left eye showing brownish deposits on the lens and a white cataract ultrasound b - scan of the posterior segment in low gain settings . posterior capsule is intact and there is no foreign body seen intraocularly x - ray of orbits showing no radio - opaque foreign body in water 's view ( a ) , and in lateral view ( b ) computed tomography scan showing normal intact globe with no intraocular foreign body in right eye . however , it shows presence of opacified lens electroretinography examination was deferred at this stage and was decided to remove cataract and implant intraocular lens with intraoperative fundus examination for siderotic changes on the retina . after 1 week of treatment with eyedrops to reduce the anterior chamber inflammation , he underwent an uneventful left cataract aspiration and implantation of posterior chamber intraocular lens under regional anesthesia . fundus examination was performed intraoperatively and it did not show any retained intraocular foreign body , retinal detachment , retinal tear or vitreous hemorrhage . as there were no siderotic changes on the retina , electrophysiologic examination was not performed in postoperative period as well . special stain like prussian blue was also used to confirm the presence of iron pigments in the anterior capsule . histology of anterior lens capsule showing acellular membranous tissue with few residual corneal epithelial cells and some hemosiderin - laden macrophages ( h and e stain , 40 ) iron is a frequent component of metallic intraocular foreign bodies and may lead to ocular siderosis , which commonly presents as reduced visual acuity . cataract formation may be an indicator of early siderosis and has been associated with intralenticular foreign bodies.[24 ] there has been previous report of lens siderosis due to intraocular foreign body missed on imaging such as computed tomography and ultrasonography but later detected perioperatively . in this case however , there was no intraocular or intralenticular foreign body detected clinically or on imaging , but the patient still developed lens siderosis . as optic nerve and retina were healthy , there was no associated afferent papillary defect . we can not rule out the possibility of a dislodged or resorbed intraocular foreign body . there may have been a lodged intralenticular foreign body immediately after trauma which got resorbed over time . nevertheless , this case illustrates the importance of close monitoring of patients with history of trauma or previous penetrating injury to the eye , albeit no intraocular foreign body , as they might develop ocular siderosis at a later stage . in view of sight - threatening complications of siderosis , prompt intervention is indicated to preserve visual acuity and prevent progression of siderosis to involve the posterior segment .

cataract formation may be an indicator of early siderosis and has been associated with intralenticular foreign bodies . we report a unique case of histopathologically proven lens siderosis in a young man with a preceding history of trauma but no signs of retained intraocular foreign body . he presented with a total white cataract with brownish deposits on anterior capsule and underwent cataract surgery for same followed by histopathological staining of anterior capsule for iron deposits . this case illustrates the importance of close monitoring of patients with history of trauma or previous penetrating injury to the eye , albeit no intraocular foreign body , as they might develop ocular siderosis at a later stage .

pelvic adhesions are a common finding in gynaecological surgery . they tend to occur in women with inflammatory pelvic disease , endometriosis or prior pelvic / abdominal surgery . these adhesions often affect the uterine adnexa resulting in tubo - ovarian complexes that adhere to the pelvic sidewall . less commonly , the posterior or anterior cul - de - sacs may be obliterated posing a therapeutic challenge to the surgeon , especially a surgeon who performs minimal invasive surgery . a 34-year - old , gravida 2 para 2 patient was referred to us because of ovarian retention syndrome , with persistent pelvic pain . she had a history of two ovarian cystectomies and more recently she underwent laparoscopic hysterectomy with right salpino - oophorectomy . during that operation , the referring surgeon could not remove the left tubo - ovarian complex because it was buried in the left pararectal space . the ultrasound showed an enlarged left ovary , with a multilocular septated mass , the greatest diameter of which was 7 cm , and a ct of the pelvis confirmed these findings , with no evidence of free fluid or adenopathy . she was counselled on her options and due to the author 's experience with minimal invasive surgery , operative laparoscopy was selected . during surgery the patient was found to have the sigmoid colon adherent to the left pelvic sidewall overlying the adnexal mass and covering it completely . using harmonic scalpel dissection , traction and countertraction , the patient had a large cystic mass scarred into the left pelvic sidewall , with the ureter overlying the mass , and the uterosacral ligament medial to the mass which had dissected itself down into the pararectal space on the left side . the uterine vessels were re - discovered and re - coagulated , because dissection caused them to bleed . the cardinal web or tunnel was unroofed to the bladder allowing anterolateral retraction of the ureter away from the area of dissection . continued harmonic and blunt dissection was performed , freeing the mass from the area of the ureter and cardinal ligament . the mass was bluntly dissected free along the margin of the uterosacral ligament as well as out of the pararectal space , freeing it completely [ figure 1 ] . the adnexal tissue was removed en block utilizing an endopouch inserted through a slightly enlarged incision at the left lower quadrant puncture site . the pathology showed benign hydrosalpinx with extensive tubo - ovarian adhesions and mild inflammatory changes . the approach to the dissection of the pararectal space when there is distorted anatomy is not an easy task . in such cases , it is wiser to begin the dissection in an area of normal anatomy , usually at the pelvic brim . this allows exposure of the ureter and visualisation of the bifurcation of the iliac vessels . the infundibulopelvic ligament ( ip ) can then be taken to allow de - vascularisation of the diseased adexa and the ip can be used for traction to expose the area of dissection . the ureter is then dissected free from the mass to the level of the cardinal ligament . with the ureter and hypogastric vessels and the retroperitoneal margin of the rectum identified , the mass can then be dissected free from the pelvic sidewall and its adherence in the pararectal space without injury to the surrounding vital structures . when the masses are endometriotic , varying amounts of the uterosacral ligament may also need to be resected en bloc with the adherent mass . identification of the potential spaces of the pelvis , and opening them to assist in difficult dissections , is the transference of traditional gynaecological dissection principles used in open gynae - oncological surgery to the laparoscopic approach , which allows almost all benign gynaecological surgeries to be performed via the laparoscopic approach [ figure 1 ] .

pelvic adhesions affecting the uterine adnexa or cul - de - sacs are a common finding in gynaecological surgery . we present a referred patient with a history of laparoscopic hysterectomy and right salpingo - oophorectomy and an unresected left ovarian mass causing ovarian retention syndrome . the left ovarian complex was hidden in the left pararectal space . the laparoscopic technique for dealing with such a rare case is explained .

the antiphospholipid antibody syndrome ( aps ) is a prothrombotic condition characterized by the presence of antiphospholipid antibodies in patients with recurrent morbidity during pregnancy and/or thromboembolic complications . ulcers resembling pyoderma gangrenosum ( pg ) have been described in aps and may cause confusion in diagnosis . it is important to be knowledgeable about aps as they can provide crucial information to uncover or confirm aps , and early diagnosis will spare patients from more serious consequences of the disease . the lesions initially occurred as painful hemorrhagic bullae , which broke to form exquisitely tender necrotic ulcers that had violaceous indurated borders [ figure 1 ] . reddish painful lesions over the face and ears , pus - filled lesions over elbows , and bluish discoloration of a few digits were noted . there was no history of any precipitating factors , drug intake , chronic disease , peripheral vascular disease , or abortions . she had five children with no obstetric complications . however , the third delivery was a preterm delivery . investigations revealed elevated total leukocyte count , platelet count , erythrocyte sedimentation rate , and alkaline phosphatase . activated partial thromboplastin time and prothrombin time were also mildly elevated . international normalized ratio ( inr ) was normal . serum electrolytes , renal function tests , chest radiography , ultrasound abdomen , blood culture , and echocardiography were normal . skin biopsy revealed a sea of neutrophils in the dermis suggestive of pg [ figure 2 ] . staining with periodic acid schiff and gomori painful ulcers in a young female of child - bearing age prompted us to do further tests such as anticardiolipin antibodies and lupus anticoagulant test . necrotic ulcers seen over the feet ( a ) with bluish discoloration of fingers ( b ) , toes ( c ) , and ulceration in the oral mucosa ( d ) low power view 10x showing epidermis with necrosis , diffuse inflammatory infilterate in dermis ( a ) , high power view 40x showing sea of neutrophils in the dermis ( b ) clinical criteria for antiphospholipid antibody syndrome she was treated with oral warfarin that was gradually increased after monitoring inr . the patient showed good improvement with treatment [ figure 3 ] . a repeat lupus anticoagulant test after 12 weeks was also positive confirming the diagnosis of aps . healed lesions over dorsum of feet ( a ) , healed lesions over fingers on follow up ( b ) thrombosis , the main complication of aps , can affect vessels of nearly all sizes including dermal veins or arteries . cutaneous manifestations of aps include livedo reticularis , subungual splinter hemorrhages , digital necrosis , superficial venous thrombosis , post - phlebitis ulcers , circumscribed cutaneous necrosis , pseudovasculitis manifestations , extensive cutaneous necrosis , and primary anetoderma . cutaneous ulcers with sharp margins may be seen in aps , usually over the legs . pregnancy morbidity in the form of fetal loss or premature birth is a common finding in women with aps . this patient 's presentation was atypical as she presented with painful necrotic ulcers over the legs that resembled pg with a suggestive histopathology . however , it is said that this syndrome is a highly problematic simulator of pg because of the low specificity of histologic findings in patients with the syndrome and its frequent response to systemic corticosteroids . also , less than one third of patients with aps show histologic evidence of coagulopathy . in contrast with most cases of aps where usually thrombocytopenia is seen , our patient had an elevated platelet count . combined treatment with oral corticosteroids , immunosuppression , acetylsalicylic acid , anticoagulation , and local measures in patients with aps and leg ulcers resembling pg has been tried , with success . our case had an atypical presentation in that the initial feature was painful necrotic ulcers over the legs that resembled pyoderma gangrenosum and she had no systemic manifestations . nonetheless , it is very important to pin down this syndrome early due to its systemic complications .

cutaneous manifestations in antiphospholipid antibody syndrome ( aps ) though common , are extremely diverse and it is important to know which dermatological finding should prompt consideration of antiphospholipid syndrome . the cutaneous manifestations of aps vary from livedo reticularis to cutaneous necrosis , and systemic involvement is invariably an accomplice in aps . cutaneous ulcers with sharp margins can be seen in aps and they are usually seen on the legs . this case had an atypical presentation , as the initial presentation was painful necrotic ulcers over the legs , which resembled pyoderma gangrenosum and she had no systemic manifestations . there was no history of any arterial or venous thrombosis or any abortions . antiphospholipid syndrome can be tricky to diagnose when cutaneous lesions are atypical . nonetheless , it is very important to pin down this syndrome early due to its systemic complications .

this 65-year - old woman had exhibited progressive gait disturbance over a one year period . for 15 years , her son had been in a vegetative state due to head trauma , and she had taken care of him . that had been a source of enormous stress for her . when she presented in our clinic , she exhibited depressive mood ; however , she denied any autonomic symptoms , including postural hypotension , urinary frequency , or constipation . on neurological examination although the speed and amplitude of foot tapping were within normal limits , the amplitude of finger tapping decreased , additionally , speed slowed bilaterally . the motor power of her four extremities showed no weakness and there were no abnormalities on sensory examination . , both of her feet dragged and were slowed with a bilateral decrease in arm swing . when she concentrated hard on her gait or when she touched her hand to the posterior of her neck , her dragged and slow gait improved dramatically . also , her abnormal gait improved when the examiner touched his hand to her neck ( see video ) . subsequently , she was taken for an fluoropropyl carbomethoxy-3b-(4-iodophenyltropane ) ( [ f]-fpcit ) positron emission tomography ( pet ) scan for evaluation of basal ganglia lesions . results revealed a reduction in putaminal uptake bilaterally as compared to normal controls ( figure 1 ) . after two months of levodopa treatment , her bradykinesia on both fingers had improved ; however , her abnormal gait had not improved markedly . informed , written consent was obtained after the patient had been given a complete description of the study using a video clip . in this case , when the patient visited our clinic , she had some parkinsonian symptoms , including masked face , bradykinesia on finger tapping , festinating gait , and glue - like turning . in spite of these common features in pd , the patient s symptoms fluctuated and she had an underlying psychiatric comorbidity , such as anxiety and depression . because these findings were common factors for diagnosing of pmds , we suspected she had pmd . otherwise , she had been able to relieve her abnormal gait at will or by touching her hand to the posterior neck . these unusual improving features can be found in pmds rather than in organic disease.4 however , her symptoms did not change following placebo injection , although we found an improvement in her symptom through suggestion - like situations . a further , [ f]-fp - cit pet scan was compatible with pd and furthermore , her symptoms improved after levodopa treatment . evidence from some clinical studies has supported the use of cues , including auditory , or somatosensory cues , to improve gait performance in pd.5,6 executive functions , which has been defined as the ability to plan , manipulate information , initiate and terminate activities , and recognize errors,7 has been shown to play a major role in the gait of pd patient . attention is an important part of executive function , and in our case , the patient was able to improve her symptoms by focusing her attention . that is , by focusing on gait or touching her hand to the posterior neck during walking furthermore , as with suggestion , her symptom improvement which occurred by touching our hand to her neck during walking caused us to misdiagnose her condition as a pmd , initially . considering her [ f]-fp - cit pet scan finding and her response of levodopa , we were able to diagnose her with pd rather than pmd . although pmds can mimic the full range of abnormal involuntary movement , including pd , this case made us confuse to diagnose an organic disease , initially , due to dramatic symptomatic improvement by only her attention . she had bradykinesia in both hands , which manifested itself in finger tapping which was slowed and fatigued . segment 2 . during walking , she exhibited dragging and slowing gait with decreased arm swing . these symptoms improved dramatically , when she touched her hand to the posterior of her neck or when the examiner touched his hand to her neck .

the various reported psychogenic movement disorders ( pmds ) include tremor , dystonia , myoclonus , gait disorder , parkinsonism , tics , and chorea . although it is not easy to diagnose pmds , several features such as distractibility , entrainment , suggestion and placebo trial are quite helpful to diagnose . especially , distractibility or suggestion is a good tool to do in outpatient clinic easily . we describe a patient with parkinsonian features which were improved by internal suggestion to focusing attention . initially , we suspected her diagnosis as pmds ; however she was confirmed with organic parkinson s disease later .

it was described by bloch in 1927 as nevoid epithelioma type 1 , different from the melanoepithelioma type 2 or the ordinary pigmented variant of seborrheic keratosis . the condition is more commonly seen in light skinned and manifests as pigmented papules , plaques , cutaneous horns or nodules . a 62-year - old male was presented with a blackish verrucous outgrowth over the left inguinal region since the past 8 years . it started with a pigmented elevated lesion at the same site that gradually increased to the current size . other than occasional pruritus at the sites of occlusion and the feeling of heaviness while walking , the lesion had remained largely asymptomatic . dermatological examination revealed a single well - defined sessile deeply pigmented verrucous mass measuring 15 cm by 8 cm over the left inguinal region extending onto the medial aspect of the scrotum [ figure 1 ] . well - defined deeply pigmented verrucous mass measuring 15 cm by 8 cm over the left inguinal region with areas depigmentation and maceration at the sites of friction a clinical differential diagnosis of melanoacathotic variant of seborrheic keratosis , pigmented variant of seborrheic keratosis , giant condyloma acuminata and verrucous carcinoma were thought of . laboratory investigations including routine hematological and biochemical investigations comprising hepatic and renal profiles and urine examination were all within normal limits . histopathological examination of the biopsy specimen revealed hyperkeratosis , papillomatosis , acanthosis , with melanocytes spanning all layers of the epidermis with abundant melanin . the base of the tumor was lying in a straight line with the surrounding normal epidermis . high power microscopy revealed cells with ovoid nuclei and cleared cytoplasm with abundance of melanin [ figures 2 and 3 ] . dendritic melanocytes were demonstrated by the masson fontana silver impregnation stain [ figure 4 ] . all these findings confirmed the diagnosis of melanoacanthoma . at 4 magnification , h and e staining epidermis showing hyperkeratosis , papillomatosis , acanthosis , with melanocytes spanning all layers of the epidermis with abundant melanin and small horn cysts . base of the tumor is seen lying in a straight line with the surrounding normal epidermis 40 magnification , h and e staining epidermis showing cells with ovoid nuclei and cleared cytoplasm with abundance of melanin . pigment incontinence seen in the dermis masson fontana silver impregnation stain showing dendritic melanocytes patient was further referred to the department of plastic surgery where complete excision with adequate margin and suturing was done [ figure 5 ] . the appearance post - excision and suturing the lesions are usually solitary and common sites are the head , neck , trunk , often on the lip or the eyelid . some have suggested that it could be a localized phenomenon induced by trauma . the presence of large number of melanocytes even deep into the tumor mass instead of restricting itself to the basal layer differentiates it from pigmented variant of seborrheic keratosis . in this case , the lack of koilocytes ruled out condyloma acuminata and absence of cellular atypicality did not favor verrucous carcinoma . two histological types of melanoacanthoma have been described : ( a ) diffuse type where melanocytes are scattered unevenly throughout the lesion as was seen in this case and ( b ) clonal type where melanocytes and keratinocytes are clustered in small nests . electron microscopic studies have revealed that there is a defect in the transfer of the melanin from these highly dendritc melanocytes to the keratinocytes . immunoflourescent and immunoprecipitin studies have shown that melanoacanthomas are not related to malignant melanomas and hence simple excision or cryotherapy is curative . oral melanoacanthomas are rare reactive mucosal lesions that demonstrate hyperplasia of spinous keratinocytes and melanocytes and are unrelated to the seborrheic keratosis . there have been very few reports of atypical presentations of melanoacanthoma from this part of the globe . shankar , et al . reported a case of giant melanoacanthoma occurring in a 65-year - old farmer presenting as a painful verrucous itchy plaque , 10 cm by 5 cm on the left side of the lower back of 5 years duration , mimicking melanoma . the only other indian report by shenoy , et al . showed multiple lesions of maximum diameter 6 cm on the lower back , abdomen , inner thighs and external genitals . what prompted to publish this report was ( 1 ) the rarity of the condition ( 2 ) the unusual site of occurrence ( 3 ) the massive dimensions and ( 4 ) the clinical resemblance to verrucous carcinoma .

melanoacanthoma is very rare variant of seborrheic keratosis presenting as a deeply pigmented benign proliferation of melanocytes and keratinocytes usually presenting over the head , neck and trunk of elderly people . a sixty - two - years - old male was presented with a solitary slow growing asymptomatic hyperpigmented verrucous outgrowth with cerebriform surface measuring 15 cm by 8 cm present over the left inguinal region extending on to the scrotum since past 8 years . there was no associated lymphadenopathy . the histopathology revealed hyperkeratosis , papillomatosis , acanthosis with presence of melanocytes at all levels of epidermis with abundant melanin giving the diagnosis of melanoacanthoma . the patient further underwent surgical excision of the lesion . the case is being reported for its rarity , unusual location , massive size and clinical resemblance to a verrucous carcinoma .

a systemically healthy 1-year - old girl came to the outpatient clinic with a complaint of tearing on the temporal side of the right lateral canthus since birth ( fig . 1 ) . watering increased on weeping or blinking . on examination , a small orifice was found in the skin at the temporal side of the lateral canthus . we certified that the fistula was connected to the lacrimal drainage system by probing the orifice of the fistula and finding that the probe ran straight in the direction of the lacrimal sac ( fig . the skin was incised and a fistulectomy was performed 2 cm away from the orifice . the lower lid stretched as the dissected fistula was pulled ( fig . 2b and 2c ) . the remnant tract was closed with 6 - 0 vicryl and cauterization using a monopolar device . the nasolacrimal apparatus arises embryologically from a cord of surface ectoderm that invaginates between the maxillary and frontonasal processes , giving rise to the canaliculi proximally , and the lacrimal sac and nasolacrimal duct distally . incomplete separation of the cord from the surface epithelium or abnormal out - budding of the buried ectodermal cord can result in supernumerary punctae and canaliculi . patients with congenital lacrimal sac fistula commonly present with an epiphora or discharge . in spite of the congenital nature of these fistulas , the clinical presentation is often delayed for many years after birth due to the evaporation of small amounts of discharge . in this case , the patient had a history of epiphora since her birth , so the case was found early . in the past , electrocauterization and a simple skin excision were usually performed to alleviate symptoms , but these methods have not been used recently because of their poor success rates . jeong had good results with fistulectomy and silicone tube intubation when there existed lacrimation through the eye . . showed that if there is no lacrimation through the eye , a simple fistulectomy is good enough for a successful result . in this case , the patient had only lacrimation through the lacrimal fistula , and there was no combined nasolacrimal duct obstruction . fistulectomy alone caused the patient to be free of symptoms , and she is currently on observation . most of the congenital lacrimal sac fistulas have been unilateral and located at the inferolateral to the medial canthus . in this case , however , the patient had a unilateral fistula at the temporal region of the lateral canthus . a lateral lacrimal sac fistula can be confused with congenital lacrimal gland fistula . in this case the authors identified the lateral lacrimal sac fistula based on three observations : 1 ) saline drained through the lateral lacrimal sac fistula ; 2 ) the probe ran straight to the sac through the lateral lacrimal sac fistula ; and 3 ) the lower lid was stretched when the dissected fistula was pulled . thus we report a case of a congenital lacrimal sac fistula located on the temporal side of the lateral canthus .

we report a case of congenital lacrimal sac fistula located on the temporal side of the lateral canthus . a systemically healthy 1-year - old girl came to the outpatient clinic with a complaint of tearing on the temporal side of the right lateral canthus since birth . on examination , a small orifice was found in the skin on the temporal side of the lateral canthus . there was no evidence of inflammation or swelling within the opening . surgeons carried out an operation under general anesthesia . they passed a probe through the lacrimal orifice and advanced it toward the lacrimal sac . next , they introduced saline to the inferior punctum and found that it drained to the lateral fistula . the lower lid stretched as the dissected fistula was pulled . after the operation , the patient was free of the symptom . this paper is to report a case of congenital lacrimal sac fistula located on the temporal side of the lateral canthus .

tuberous sclerosis complex ( tsc ) is an autosomal dominant neurocutaneous syndrome with a high incidence of sporadic cases . it was first described in 1862 by von recklinghausen and later was more completely elucidated by bourneville , pringle , and vogt ( rushton , 1955 ) . it is a disorder of cellular differentiation and proliferation leading to the development of benign tumors such as neurofibromas and angiofibromas and with high penetrance but considerable variability in the expression . the genes thought to be responsible for tuberous sclerosis are located on chromosomes 9q and 16p . . ninety percent of tuberous sclerosis patients develop various seizure disorders , and 60% develop measurable mental retardation . tuberous sclerosis is characterized by variability and expressivity of clinical manifestations and is often age - related [ table 1 ] . school - aged children usually present with adenoma sebaceum , developmental delay , learning disability / retardation , and seizures . orofacial manifestations include fibrous hyperplasia , hemangiomas , facial asymmetry , bifid uvula , cleft lip and palate , macroglossia , high arched palate , delayed eruption , diastemas , and enamel defects . an 18-year - old female reported to the department of oral and maxillofacial surgery at dasmesh institute of research and dental sciences , faridkot with the chief complaint of painless swelling on the left side of face since 8 years and reddish discoloration of skin on the same side of face and neck since birth with no positive family history [ figure 1 ] . painless swelling on the left side of face history of repeated excisions of gingival growth was present since patient was 4 years old . on general physical examination , the patient was well - oriented to time , place , and person ; moderately built with normal gait and iq . magnetic resonance imaging ( mri ) brain and carotid angiograph were suggestive of cortical and sub - cortical hyperintensities with gyral calcification ; common with ( c / w ) tuberous sclerosis [ figure 2 ] . orthopantomography showed a multilocular mixed radiolucent - radiopaque lesion with incomplete septae involving the left mandibular region eroding the posterior ramus of mandible causing an altered shape of the left mandibular ramus , condyle , and coronoid process [ figure 3 ] . magnetic resonance imaging brain and carotid angiograph orthopantomography showing a multilocular mixed radiolucent - radiopaque lesion as our case showed only skin lesions , our line of treatment is regular age - dependent screening to access the patient 's behavioral , cognitive , and neurological functions . mri of the brain will be performed every year to assess the risk factors for developing astrocytomas . in this case , the prognosis seems good , as the patient presented with only oral and cutaneous manifestations without any mental retardation or convulsive seizures . the diagnosis of tuberous sclerosis has evolved from only clinical observations to the use of anatomicopathological studies to that using molecular biology . the disease develops as an abnormal growth of ectodermic and mesodermic cells producing benign tumors extending to areas of the head , heart , brain , and kidneys . the term epiloia ( epilepsy , low intelligence , and adenoma sebaceum ) was proposed by campbell and sherlock . this designation may be of some use in describing the disease although all the three signs are rarely present . we report this case as a rare phenomenon because of its sporadic occurrence in a young female who presented with oral and cutaneous manifestations without mental retardation or history of convulsive seizures , which to the best of our knowledge has not been reported so far . patients with tsc must adopt measures for careful oral and dental hygiene , with regular visits to the dentist , in order to eliminate potential irritative factors and ensure the early diagnosis of any possible lesions . the cerebral manifestations and renal complications of tuberous sclerosis exert an important influence on patient prognosis . the diagnosis and management of these patients vary depending on the specific systemic presentation of the disease . a dentist 's role in early diagnosis of such lesion is helpful in the management of these lesions . regular follow - up is helpful to prevent any systemic involvement if any in future . the need for a detailed medical history is therefore always beneficial for the proper management of these patients . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .

tuberous sclerosis complex ( tsc ) is a neurocutaneous syndrome , inherited as an autosomal dominant trait with a high incidence of sporadic cases and protean clinical expression , with a incidence of prevalence between 1 in 10,000 and 1 in 170,000 . the cardinal features of tsc are skin lesions , convulsive seizures , and mental retardation . we report a sporadically occurring case of definite tsc in a young female who presented with oral and cutaneous manifestations without mental retardation or history of convulsive seizures , which to the best of our knowledge has not been reported so far .

the preoperative diagnosis was intussusception of the colon with a benign tumor by ct - scan findings . laparoscopic reduction of intussusception due to a benign tumor is feasible and safe even in adults . mucinous cystadenoma is one of the causes of intussusception in adults and a good indication for the laparoscopic approach . this report describes an adult case of intussusception due to mucinous cystadenoma of the appendix treated laparoscopically . a 32-year - old female had intermittent abdominal pain and nonbloody diarrhea for 20 days . a barium enema showed a crab 's claw sign at the mid transverse colon ( figure 1 ) . a computed tomography ( ct ) scan showed a 3-cm , clear , low - density area in the transverse colon ( figure 2 ) . barium enema showed filling defect with crab 's claw sign at the mid transverse colon . enhanced computed tomography showed well - encapsulated , low - density area in the transverse colon . after adhesiolysis between the major omentum and the abdominal wall caused by the previous caesarean deliveries , the intussusception was confirmed at the middle of the transverse colon . next , gauze sponge sticks with these instruments were used to provide compression from the distal colon ( figures 4 and 5 ) . after laparoscopic mobilization of the right colon , the ileocecal portion was pulled out through a 5-cm longitudinal skin incision . ileocecal resection was accomplished , and end - to - end anastomosis was performed extracorporeally . the postoperative course was uneventful , and the patient was discharged on the ninth postoperative day . a 3-cm tumor was located in the appendix and invagination into the cecum was seen ( figure 6 ) . table 1 shows the causes of adult intussusception in 400 cases from japanese domestic reports . common causes in excess of 10% included cancer , lipoma , small bowel tumor , and lymphoma . however , the ct scan in this case revealed a well - encapsulated cystic lesion forming the lead point of the intussusception . it is possible to diagnose mucinous cystadenoma from its characteristic appearance as a well - defined , homogeneous low - density mass . complete resection of the tumor is sufficient treatment . in this process , we must avoid tumor rupture as some of these mucoceles could be mucinous cystadenocarcinoma , which can cause pseudomyxoma peritonei . if a tumor indicates the possibility of carcinoma , the mesenteric resection should encompass lymph node clearance . the laparoscopic approach to intussusception has been mostly reported in children . only one report exists of laparoscopic ileocolic resection for intussusception caused by mucinous cystadenoma of the appendix . in the textbook description , reduction is achieved by gently squeezing the mass from the distal side to reduce the intussusception rather than by pulling the ileum , which will cause tearing . we tried this maneuver laparoscopically by using a gauze sponge , which was atraumatic and proved very effective for the reduction of intussusception . in our opinion , laparoscopic reduction of intussusception is feasible even in adults ; however , it should be performed for benign disease .

objective : laparoscopic reduction of appendicocecal intussusception due to mucinous cystadenoma is herein described.methods:a 32-year - old female had intermittent abdominal pain and nonbloody diarrhea . the preoperative diagnosis was intussusception of the colon with a benign tumor by ct - scan findings.results:laparoscopic reduction of intussusception and ileocecal resection were successfully performed . gauze sponge sticks were used to provide compression from the distal colon . this maneuver was very effective to reduce the intussusception.conclusion:laparoscopic reduction of intussusception due to a benign tumor is feasible and safe even in adults . mucinous cystadenoma is one of the causes of intussusception in adults and a good indication for the laparoscopic approach .

it was first described by gossage in 1907 and later classified by hutchinson et al . , in 1974 into woolly hair nevus , autosomal dominant hereditary woolly hair and autosomal recessive familial woolly hair . association of generalized woolly hair is also described with cutaneous anomalies , such as keratosis pilaris or palmoplantar keratoderma , and extracutaneous anomalies , especially cardiac or of senses . localized variant of woolly hair ( woolly hair nevus ) is frequently described in association with a linear epidermal nevus ; however , no such association is described with generalized woolly hair . we describe the first case of generalized woolly hair in association with bilateral systematized epidermal nevus . a 6-year - old boy presented with abnormally curly scalp hairs and patches of darker skin over whole body , most evident over neck , trunk and arms . according to history given by parents , the child was born full term of non - consanguineous marriage with dark linear and whorled patches over his whole body including scalp and without hairs over scalp . when scalp hairs first grew , they were abnormally curly and slow growing . on examination the child had whorled and streaked linear hyperpigmented verrucous plaques affecting the whole body including scalp . scalp hairs were coarse , lusterless , dry and tightly curled [ figure 1 ] . also , parents of the patient did not have similar complaint . clinical image of the patient showing woolly hair and systemised epidermal nevus ( a , b ) . close view of neck ( c , d ) and head ( e ) better shows the findings hair microscopy - arrow showing hypopigmented and thin woolly hair lying alongside a normal hair of a child of same age histopathology of skin lesion [ figure 3 ] revealed papillated epidermal hyperplasia , with hypergranulosis and hyperkeratosis composed of compact ortho and parakeratosis consistent with epidermal nevus . histopathology ( hematoxylene and eosin stain , 40 magnification ) showing papillated epidermal hyperplasia , with hypergranulosis and hyperkeratosis composed of compact ortho and parakeratosis the term woolly hair has been derived due to coiling and crimping of hair similar to sheep wool . woolly hair is a rare congenital structural abnormality of the scalp hair without increased fragility , characterized by tightly coiled hair involving part or the entire scalp occurring in a non - negroid individual . woolly hair grows at a normal or slower rate as compared to normal hair and are different from curly hairs of negros because the curls are separable in negro hairs but not in woolly hairs . in 1974 , hutchinson et al . further classified woolly hair into a localized variant ( woolly hair nevus ) and two generalized variants , including autosomal dominant ( ad ) hereditary woolly hair and autosomal recessive ( ar ) familial woolly hair . epidermal nevi are nests of epidermal cells which are noted at birth or within the first year as a thin plaque or linear tan patch often along blaschko lines . extensive epidermal nevi , often in unilateral distribution , are called as systematized epidermal nevi . epidermal nevus can be an isolated finding or it can show syndromic / nonsyndromic association with other cutaneous / extracutaneous lesions . localized variant of woolly hair ( woolly hair nevus ) is frequently found in association with a linear epidermal nevus of focal or systematized distribution . generalized variants of woolly hair ( involving the whole scalp ) are also described in syndromic / nonsyndromic association with other lesions . notable syndromic association of woolly hair is found in autosomal recessive nexos disease and carvajal disease caused by mutation of desmosomal proteins plakoglobin and desmoplakin respectively . both diseases are characterized by triad of generalized woolly hair , palmoplantar keratoderma , and cardiomyopathy ( right ventricular in naxos disease , left ventricular in carvajal disease ) . therefore , with the diagnosis of generalized woolly hair , a thorough evaluation of all organ systems , especially of the heart , must be conducted . the absence of family history of similar disorder , with diffuse scalp involvement , in our patient probably suggests a hereditary form of woolly hair resulting due to de novo mutation . associated bilateral systematized epidermal nevus was also seen in our case . to the best of our knowledge , our case is of hereditary wooly hair in association with bilateral systematized epidermal nevus which is not described in literature previously .

woolly hair is a hair shaft disorder characterized by fine and tightly curled hair . woolly hair could be syndromic ( associated with systemic disease ) or non - syndromic ( not associated with any systemic disease ) . woolly hair is described in association with many skin , dental , ophthalmic and cardiac anomalies but association of woolly hair with bilateral systematized epidermal nevus described in our case is first of its kind .

we however , uniquely instilled steroids locally through a fiber - optic bronchoscope directly at the site of the lesion . we received a 22 year girl , a known schizophrenic , with alleged history of acid ingestion followed by multiple episodes of vomiting and abdominal pain . she presented in altered sensorium ( glasgow coma sacle ( gcs)-e2v2m3 ) with rapid shallow breathing . in view of her low gcs ( < 8) , trachea was intubated with a size 7.0 mm cuffed endotracheal tube in the emergency department and she was subsequently shifted to the critical care unit for further management . she was initially put on synchronized intermittent mandatory ventilation mode with tidal volume 450 ml , respiratory rate 12/min and a pressure support of 14 cm h2o . gradually her respiratory effort improved , and she could be weaned to continuous positive airway pressure mode with a pressure support of 10 cm h2o . eventually , she was weaned off to t - piece within 24 h of admission to icu and was extubated on day 2 of admission . post - extubation arterial blood gas analysis on fio2 0.21 was ph-7.443 , paco2 - 36.0 mm hg , and pao2 - 243 mm hg . after around 6 h of extubation patient started developing respiratory distress with inspiratory stridor and a respiratory rate of 40 - 42 breaths / min . a usg neck was planned to diagnose the cause and site of airway obstruction , and it revealed supraglottic tracheal narrowing and edema . as she could be intubated with a maximum tube size of 6.0 mm only , which offered resistance to breathing , a percutaneous tracheostomy was planned below the level of tracheal narrowing so as to bypass the pathology as confirmed by usg . we explored the option of nebulized steroids but owing to tracheostomy site being below the inflammation site , nebulized steroids would bypass the pathology and proven futile . we therefore planned topical instillation of dexamethasone right at the site of inflammation through a fiber - optic bronchoscope . the tip of the bronchoscope was positioned in the trachea so as to focus the lesion . the steroid solution was loaded in a syringe , which was attached to the oxygen insufflation port of the bronchoscope . the solution was then pushed down through the bronchoscope along with simultaneous fine rotation of the fiber - optic tip so that the steroid solution topically covered the lesion . this method of steroid instillation was performed once in 8 h. with progressive instillation of dexamethasone for 5 days , we noticed progressive resolution of edema and near normalization of tracheal mucosal epithelium [ figures 1 - 4 ] . initial bronchoscopic view with marked edema and airway narrowing marked narrowing with intense mucosal inflammation regressing inflammation progressive decrease in hyperemia and resolution of tissue edema although tracheal stenosis is infrequently associated with acid corrosive ingestion , its prevention is difficult and treatment prolonged and protracted . caustic ingestion results in thrombosis of small vessels with inflammation , formation of granulation tissue with subsequent collagen deposition and fibrosis , thus stricture formation . in the present case , initial improvement of ventilator parameters with eventual extubation indicated that the patient 's respiratory status improved and was nearing normal . however , development of stridor within a short span of 6 h of extubation prompted us to suspect that the patient had mucosal edema , which was initially contained due to the ett in situ . soon after extubation , it expanded leading to respiratory compromise , which was subsequently confirmed on usg . various treatment modalities both medical and surgical have been used in treatment of tracheal stenosis such as intralesional mitomycin injection , systemic steroids , surgical reconstruction , cryotherapy , electrocautery , bougie dilation , balloon dilation , and stent placement . steroids have potent anti - inflammatory action due to inhibhition of cytokines , enzymes and inflammatory mediators and induction of anti - inflammatory factors like lipocortins . systemic as well as percutaneous intralesional injection of steroids has been well - documented in treatment of tracheal mucosal inflammation . such topical use of steroids , intratracheally has not yet been documented in the literature ; however , studies have been carried out in the past with topically applied steroid on endotracheal tube resulting in a favorable outcome in terms of incidence of post - extubation cough and hoarseness . the present case report is just an introduction to what might be an established future therapy . firmer results shall be available if such case series is carried out over time , and if results be positive , this treatment modality might establish itself as a preferred alternative . systemic steroids in treatment of laryngeal stenosis have also been reported . however , systemic administration pre - disposes to a number of adverse effects such as infection , hyperglycemia , osteoporosis depending upon the dose and duration . such modality will thus be useful where systemic steroids are to avoided and there is some limitation of practicing other methods of steroid therapy like nebulization . we therefore successfully instilled steroid locally through a fiber - optic bronchoscope to regress inflammation and prevent subsequent scarring and fibrosis .

corrosive acid poisoning commonly results in chemical injuries to respiratory and upper gastrointestinal tract . corrosive mucosal erosion of the larynx and trachea may occur if the patient aspirates acid . we successfully used local anti - inflammatory action of dexamethasone instilled through a fiber - optic bronchoscope for regression of mucosal edema and prevention of subsequent development of stricture in a young female .

a 32-year - old caucasian woman presented with irritated soles , revealing multiple small blackish pits ( fig . 1a , magnification by dermatoscope in b ) and hyperhidrosis . clinical presentation of chronic , acquired small pits on the weight bearing areas of the soles , associated with occluding footwear and hyperhidrosis , is pathognomonic for pitted keratolysis ( pk ) . pk is caused by a cutaneous infection with gram - positive bacteria , particularly corynebacterium and a number of other species of normal skin flora . increases in skin surface ph , hyperhidrosis , and prolonged occlusion allow these bacteria to proliferate , producing two keratin - degrading enzymes , serine proteases p1 and p2 , which create pits by locally dissolving the stratum corneum 's corneodesmosomes and keratohyalin granules . the infection is confined to the plantar stratum corneum , does not impede patient activity but often presents with unpleasant symptoms such as malodor , pain and irritation . although histology was proposed as a sensitive diagnostic method , the diagnosis is fundamentally clinical . pk can be found in association with other corynebacterium infections , like erythrasma and trichomycosis axillaris [ 7 , 8 ] . pk can occasionally be misdiagnosed as a mycotic infection , and patients can present with ineffective previous antimycotic treatment . antimicrobials to reduce corynebacterial growth are the therapeutic mainstay , with topical or systemic erythromycin or imidazole derivatives [ 3 , 4 ] . it has been proposed that keratolytic products reducing the bacteria 's habitat may be beneficial . decreasing sweat production by topical aluminum hydroxide should be considered , and even botulinum toxin has been used in two patients with refractory pk due to prominent hyperhidrosis . socks and shoes should be changed regularly . occupational shoes should be ventilated properly , but these recommendations are usually difficult to implement in the workplace . reduction of friction to avoid hyperkeratosis , which represents the substrate that the corynebacteria can thrive on , is achieved by fitting shoes properly . here we advised the patient to wear non - occlusive footwear and use aluminum hydroxide 20% lotion for the plantar hyperhidrosis .

irritated hyperhidrotic soles with multiple small pits are pathognomonic for pitted keratolysis ( pk ) . here we show the dermatoscopic view of typical pits that can ensure the diagnosis . pk is a plantar infection caused by gram - positive bacteria , particularly corynebacterium . increases in skin surface ph , hyperhidrosis , and prolonged occlusion allow these bacteria to proliferate . the diagnosis is fundamentally clinical and treatment generally consists of a combination of hygienic measures , correcting plantar hyperhidrosis and topical antimicrobials .

lacquer cracks are considered to be healed mechanical fissures in the retinal pigment epthelium ( rpe)-bruch s membrane choriocapillaris complex and are seen ophthalmoscopically as yellowish linear lesions.1,2 we have reported the characteristics of lacquer cracks in the spectral - domain optical coherent tomographic ( sd - oct ) , fluorescein angiographic ( fa ) , indocyanine green angiographic ( icga ) , and fundus autofluorescence ( faf ) images.3 all the findings were compatible with the suggested pathophysiology of healed mechanical fissures in the rpe - bruch s membrane choriocapillaris complex . lacquer cracks generally occur in the posterior pole of the fundus , and to date , there has been only one case report on lacquer cracks that appeared in the peripheral fundus.4 however , the description of these lacquer cracks was limited . we report a patient with high myopia with lacquer cracks observed in the peripheral fundus . we present the characteristics of the cracks observed in the fa and faf images and also the three - dimensional magnetic resonance images ( 3d mri ) of both eyes of this patient . a 37-year - old man visited the high myopia clinic of the tokyo medical and dental university hospital with a complaint of decreased vision in both eyes . his visual acuity was 20/20 in both eyes , and the refractive error was 14.5 d od ( right eye ) and 14.0 d os ( left eye ) . dilated fundus examination showed that the optic disk cups were enlarged in both eyes , but there were no abnormalities in the peripheral region ophthalmoscopically ( figure 1 ) . he was suspected to have glaucoma in both eyes , and the goldmann perimetry was performed . a slight reduction in the sensitivity in the nasal visual field of the left eye was found . fa showed multiple arch - shaped , hyperfluorescent linear lesions running circumferentially in the peripheral fundus of both eyes . some of these lesions were observed to run parallel to each other ( figure 2 ) . faf showed hypoautofluorescence at the corresponding sites ( figure 3 ) . from these findings , we diagnosed these lesions as lacquer cracks in the peripheral fundus . however , the entire posterior region of the globe was enlarged in both eyes ( figure 4 ) . written informed consent was obtained from the patient for publication of this report and any accompanying images . the local committee of tokyo medical and dental university hospital judged that the ethical review of this case report was unnecessary . we reported earlier that lacquer cracks appeared hyperfluorescent during the entire angiographic phase of fa because of the window defect in the early phase and tissue filling in the late phase . these findings corresponded with the pathophysiology of lacquer cracks that are considered to be healed mechanical fissures in the rpe - bruch s membrane choriocapillaris complex.3 in the present case , fa showed hyperfluorescent , arch - shaped linear lesions running circumferentially in the peripheral fundus during the entire angiographic phase , and faf showed hypoautofluorescence at the corresponding sites . these linear lesions need to be distinguished from angioid streaks , pigmented peripheral streaks,5 and choroidal rupture . their ophthalmoscopic , fa , and faf appearances were completely different from these lesions , and the patient had no history of trauma to both eyes . although the direction and the area of the lesions were not typical of lacquer cracks , the fa and faf findings were the same as those of lacquer cracks in the posterior fundus . thus , these lesions were most likely also due to ruptures of the rpe - bruch s membrane choriocapillaris complex . lacquer cracks generally occur in the posterior pole of the fundus and are caused by an elongation of the globe.6 in the present case , 3d mri did not show any protrusions of the globe indicating a posterior staphyloma , but instead the entire posterior globe was expanded . it might be possible that the expansion of the peripheral area was the cause of the lacquer cracks occurring in the peripheral fundus . with increasing time , lacquer cracks progress to other myopic fundus changes including patchy atrophy , diffuse atrophy , and choroidal neovascularization.7 there have not been reports about peripheral myopic choroidal neovascularization before , and it is not certain whether peripheral lacquer cracks would cause myopic choroidal neovascularization in the future . however , we occasionally notice atrophic regions in relatively peripheral fundus in highly myopic eyes . these lesions might have resulted from peripheral lacquer cracks . therefore , cases with peripheral lacquer cracks should be followed regularly with attention paid to whether the myopic fundus changes develop not only in the posterior pole but also in the peripheral region . we report a case with peripheral linear lesions that have properties of the lacquer cracks found in the posterior pole of the eye . although peripheral lacquer cracks are rare and are sometimes difficult to be detected by ophthalmoscopy , they should be considered in the differential diagnosis of peripheral linear lesions showing hyperfluorescence in fa .

we report a case with lacquer cracks observed in the peripheral fundus . a 37-year - old patient with bilateral high myopia who visited our clinic was examined by fluorescein angiography ( fa ) and fundus autofluorescence ( faf ) to determine whether there were myopic fundus lesions . fa showed many arch - shaped , hyperfluorescent linear lesions running circumferentially in the peripheral fundus . faf showed hypo - autofluorescence at the corresponding sites . these characteristics were very similar to the lacquer cracks present in the posterior fundus in highly myopic eyes . although lacquer cracks in the peripheral fundus are rare , they should be considered in the differential diagnosis of peripheral linear lesions showing hyperfluorescence in fa .

urethral calculi are already an uncommon entity and giant calculi in the urethra are extremely rare . we present a case of giant urethral calculus secondary to a urethral stricture in a man . a 55 year male was admitted to our institution with complaints of pain and swelling in perineal region for 6 days and purulent discharge from the swelling for 2 days . patient was apparently quite well 4 months prior when he noticed a progressive thinning of urinary stream along with dysuria and burning on micturition . three months later the patient had an episode of retention of urine for which patient attended our outpatient department . a trocar suprapubic catheterisation ( spc ) was performed and a 16 fr foley s catheter was passed into the bladder . patient was asymptomatic for 1 month followed by reappearance of the swelling and pain in the perineal region . on local examination there was a swelling 2 x 2 cms in size in the left perineal region with purulent discharge . patient was subjected to retrograde urethography ( figure 1 ) and micturiting cystourethography ( figure 2 ) . patient was diagnosed as a case of urethral calculus with urethral stricture and was posted for urethral calculus removal with urethroplasty . the calculus of 30 mm x 20 mm x15 mm ( figure 3 ) was extracted successfully and end to end urethroplasty was performed . urethral stones are classified as ( a ) native or autochthonous and ( b ) migrant or secondary depending upon their site of origin.(1,2 ) migrant stones are much more common and are ones which have migrated from higher up in the urinary tract . native stones are struvite , calcium phosphate or calcium carbonate in composition , have no nucleus and are of uniform structure . they are formed in the urethra proximal to strictures , in congenital and acquired diverticula , with chronic infection with especially urea splitting organisms or with foreign bodies . . may present with a mass on the undersurface of penis , urethral discharge , dyspareunia , irritative voiding symptoms and haematuria migrant stones are calcium oxalate and phosphate in composition . they often cause acute symptoms causing retention , frequency , dysuria , poor stream or dribbling . urethral calculi are preponderantly found in the prostatic urethra , the bulb , the proximal penile urethra , the fossa navicularis and external meatus . treatment is contingent on the size and location of calculus and condition of the urethra . meatotomy may be used if stone is in fossa navicularis or external meatus small stones can be gently massaged with intraurethral instillation of xylocaine . calculi in posterior urethra can be pushed back into bladder in cases of urethral diverticulum , diverticulectomy and repair should be done .

primary urethral calculus is rarely seen and is usually encountered in men with urethral stricture or diverticulum . we present a case of giant urethral calculus secondary to a urethral stricture in a man . the patient was treated with calculus extraction with end to end urethroplasty .

vertebral artery dissection ( vad ) is an important cause of posterior circulation stroke in young and middle - aged patients . we present a case of a middle - aged male , who came with the complain of sudden onset headache , left - sided neck pain , and right - sided weakness which on neuroimaging revealed an extracranial left vad . a 46 years , nonhypertensive , nondiabetic , male presented with sudden onset headache , left - sided neck pain followed by difficulty in walking and right - sided weakness . no other significant history was found . on clinical examination , there was grade ii , power in the right upper and lower limb . contrast magnetic resonance imaging ( mri ) angiography with diffusion weighted sequence was performed which revealed acute infarcts in left occipital lobe [ figure 1a and b ] along with left vad involving cervical segment [ figure 2 ] . computed tomography ( ct ) brain and neck angiography with intravenous contrast was performed on siemens somatom definition flash 128 slice dual source , dual energy ct scanner which revealed linear , short segment ( 2.6 cm ) dissection of the left vertebral artery at the level of c5-c6 vertebrae with associated aneurysmal dilatation [ figures 3 and 4 ] . patient underwent digital subtraction angiography ( dsa ) which revealed , elevated intimal flap in the left vertebral artery with the development of false lumen showing stagnant contrast , suggestive of dissection , commonly referred as double barrel lumen [ figure 5 ] . apparent diffusion coefficient and diffusion - weighted ( b = 800 s / mm ) image showing acute infarct in the left occipital region . ( b ) apparent diffusion coefficient and diffusion - weighted ( b = 800 s / mm ) image showing acute infarct in the left occipital region ( a ) axial t1 fat suppressed image showing hypointense intimal flap . ( b ) contrast magnetic resonance imaging angiography showing left vertebral artery dissection ( a ) three - dimensional maximum - intensity projection computed tomography angiography showing vertebral artery dissection with focal dilatation of the involved segment . ( b ) three - dimensional volume rendering technique image showing vertebral artery dissection with focal dilatation of the involved segment computed tomography angiography axial section at c5-c6 vertebral level , shows hypodense intimal flap ( arrow ) digital subtraction angiography of left vertebral artery showing double barrel lumen with different contrast density since the extracranial vertebral artery was involved , conservative management was planned and the patient was started on oral anticoagulants and heparin . follow - up ct angiography after 6 months showed near complete regression of the left vad [ figure 6 ] . follow - up computed tomography angiography after 6 months showing near complete resolution of arterial dissection in the involved segment vad is an uncommon disorder with estimated annual incidence of approximately 1 - 1.5 cases/10,000 . however , it is an important cause of posterior circulation ischemia in young and middle - aged patients , female preponderance , and accounts for nearly one - fifth of such cases . dissection occurs , when blood under pressure finds its way into the vessel wall either leading to luminal narrowing and/or occlusion if the tear is sub - intimal , or formation of a pseudoaneurysm with potential risk of bleeding , if the dissection is sub - adventitial . headache and neck pain ( on the side of arterial dissection ) are important warning symptoms of dissection . although conventional catheter angiography has been the criterion standard for the diagnosis of arterial dissection , ct scanning , and magnetic resonance angiography are increasingly been used because of the inherently noninvasive nature of these modalities . various mri angiography techniques have been used ; these include three - dimensional time of flight , phase contrast techniques , a t1 or , occasionally , with a t2-weighted , fat suppression technique . computed tomography angiography ( cta ) has practical advantages such as the rapid acquisition of information in uncooperative patients , and in whom mri is contraindicated . dual energy technique provides an additional edge in vertebral arteries by enabling effective bone removal as most of the extracranial vertebral artery is covered by vertebral foramina . the most common finding seen in approximately 65% of patients with sub - intimal arterial dissection is a relatively smooth or slightly irregular , tapered , or spiraled luminal narrowing of the dissected segment . the double - barrel sign demonstrates a patent false lumen or the accumulation of blood beneath an intimal flap . management depends on the site of involvement . which states anticoagulation with heparin followed by oral warfarin therapy for extradural vad dissection and balloon / coil embolization or a surgical aneurysm clipping in cases of an intracranial involvement . imaging modality such as dual energy cta and mri can reliably and safely demonstrate the direct and indirect features of spontaneous vad . the routine use of dual energy cta and mri in stroke increases the detection of vad , therefore , promotes early diagnosis of vad , facilitating prompt initiation of appropriate management .

spontaneous vertebral artery dissection ( vad ) is relatively rare but an important cause of posterior circulation stroke . a 46-year - male complaining of sudden onset headache , neck pain with right - sided neuro deficit in the form of hemiparesis was evaluated by contrast magnetic resonance imaging and dual - energy computed tomography ( ct ) and brain neck angiography which revealed a short segment extracranial left - sided vad , associated with acute infarct in the left occipital region . the patient was managed conservatively and followed up for 6 months . follow - up ct angiography after a period of 6 months revealed the near complete resolution of the arterial dissection in left vertebral artery .

angiomyolipoma ( aml ) is a hamartomatous lesion usually seen in the kidney of patients with tuberous sclerosis . the correct histological diagnosis depends on the classical triad : mature adipose tissue , convoluted thick - walled blood vessels and irregularly arranged sheets , and interlacing fascicles of smooth muscle . despite the histologic similarity observed in renal and extrarenal amls , the purpose of the present report is to describe the rare case of cutaneous aml located in the anterior abdominal wall below the umbilicus in a female child and discuss its histological features . a 3-year - old female child was presented with an asymptomatic , single , nontender , subcutaneous swelling over the anterior abdominal wall near the umbilicus measuring 2.5 cm in size . intraoperative photograph showing well circumscribed nodule on gross examination , it was a well - circumscribed mass measuring 2.5 cm in diameter with a solid and cystic appearance on the cut surface [ figure 2 ] . it was composed of convolutions of ectatic , thick - walled blood vessels lined by plump endothelial cells and surrounded by bundles of smooth muscle cells . these three components were arranged irregularly and intermingled with each other [ figure 3 ] . compressed fibro - adipose tissue and blood vessels were seen outside the expanding margin of the tumor . based on the admixture of mature adipose tissue , convoluted thick - walled blood vessels and irregularly arranged sheets , and interlacing fascicles of smooth muscle , a diagnosis of aml was made . gross appearance of cutaneous angiomyolipoma shows variable - sized blood vessels , smooth muscle bundles , and mature adipose tissue ( h and e , 40 ) on gross examination , it was a well - circumscribed mass measuring 2.5 cm in diameter with a solid and cystic appearance on the cut surface [ figure 2 ] . it was composed of convolutions of ectatic , thick - walled blood vessels lined by plump endothelial cells and surrounded by bundles of smooth muscle cells . these three components were arranged irregularly and intermingled with each other [ figure 3 ] . compressed fibro - adipose tissue and blood vessels were seen outside the expanding margin of the tumor . based on the admixture of mature adipose tissue , convoluted thick - walled blood vessels and irregularly arranged sheets , and interlacing fascicles of smooth muscle , a diagnosis of aml was made . gross appearance of cutaneous angiomyolipoma shows variable - sized blood vessels , smooth muscle bundles , and mature adipose tissue ( h and e , 40 ) aml is a benign hamartomatous lesion usually observed in the kidney of patients with tuberous sclerosis . it is uncommon outside of the kidney , and the liver is the second most common site . it shows a female predominance and is composed of an admixture of small to medium - sized thick - walled blood vessels , smooth muscle cells , and adipose tissue . cutaneous aml , which is also known as cutaneous angiolipoleiomyoma , is a rare benign mesenchymal tumor . provided the first report of a cutaneous aml , under the name cutaneous angiolipoleiomyoma . to our knowledge , these tumors are usually solitary , asymptomatic , noninvasive , located most commonly in acral skin or on the ear . in 1990 , fitzpatrick et al . clinically , the tumors were acquired , solitary , asymptomatic nodules that were always acral in location . patients ages ranged from 33 to 77 years ( median 52.6 years ) ; the male / female ratio was 7:1 . the most common clinical impression is that of a cyst , a lipoma , or a vascular tumor . in contrast to the renal form , the cutaneous aml is a tumor differing in sex predominance , clinical associations , circumscription , solitariness , and hmb-45 immunoreactivity . histologically , they are composed of thick - walled blood vessels , smooth muscle cells , and mature fat in variable proportions . epithelioid cell component is usually absent in cutaneous amls , in contrast to renal amls , which may be responsible for hmb-45 negativity of the former tumor . our case differs from the other cases of cutaneous amls reported in terms of location and age . all cutaneous amls reported were located either in head and neck region or extremities , and were mostly seen in the 3377 years age group while in our case aml was observed on the anterior abdominal wall below the umbilicus in a 3-year - old girl . this case report suggests that the features considered diagnostic of aml can present in extrarenal sites and , therefore , this diagnosis can not be excluded on the basis of site alone . we conclude that cutaneous aml although uncommon should be considered in the differential diagnosis of any skin tumor with a combination of blood vessels , smooth muscle cells , and adipose tissue .

we report a case of cutaneous angiomyolipoma ( aml ) found on the anterior abdominal wall of a 3-year - old female child . histologic examination showed a well - circumscribed nodule in the dermis composed of an intimate mixture of convoluted thick - walled blood vessels , smooth muscle , and mature fat . this lesion differs from renal aml in terms of a lack of association with tuberous sclerosis , circumscription , absence of epithelioid cells , and male predominance . we concluded that the unique features of this lesion distinguish it from other lesions such as angiomyoma , angiolipoma , myolipoma , haemangioma , and other mixed mesenchymal tumors . this case report suggests that the features considered diagnostic of aml can occur in extrarenal sites and , therefore , this diagnosis can not be excluded on the basis of site alone .

a 41-year - old caucasian homosexual man , hiv - positive since 1992 , presented with oral hairy leucoplakia . hematological indices were ; cd4 113 cells / mm , hemoglobin ( hb ) 13.3 g / dl , wbc 3.8 109/l , and platelets 91 109/l . having defaulted , he re - presented ten weeks later with acute shortness of breath and lethargy . examination revealed pallor but no purpura , with hb 3.2 , wbc 1.7 , and platelets 54 . he also complained of a sub - acute painless decrease in vision affecting his right eye . retinal haemorrhages , cotton wool spots and a foveal premacular hemorrhage ( figure 1 ) . one year later visual acuities were 6/6 right and left with significantly improved normal retinal appearances . features include painless visual deterioration , visual field defects , retinal hemorrhages , and associated pale areas of opaque retina ( cunningham and margolis 1998 ; vrabec 2004 ) . other typical features of cmv retinitis which may help in differential diagnosis include an initially unilateral presentation , starting in the retinal periphery with areas of hemorrhage and adjacent infiltrate giving rise to the so - called cheese pizza appearance . lesions tend to increase in extent in a contiguous fashion ( brush - fire spread ) . as more posterior retina becomes involved , atrophy and scarring develop in the previously inflamed areas . hemorrhagic retinopathy has been described with retinal venous occlusion in hiv - positive patients ( friedman and margo 1995 ; mansour et al 1996 ) . retinal hemorrhages as part of anemia associated ischemic retinopathy have been reported in myeloproliferative disorder ( blood et al 1997 ) and pernicious anemia ( gupta et al 2001 ) . these patients were hiv - negative . beare and colleagues ( 2002 ) report two cases similar to ours in their survey of ocular disease in patients with tuberculosis and hiv presenting with fever in africa . these individuals had hemoglobin of less than 4.0 g / dl and widespread retinal hemorrhages including many which were white - centred , as exhibited in our patient ( figure 1 ) . ischemic maculopathy in hiv is recognized but uncommon , and in most of such cases associated with cmv retinitis ( cunningham et al 2001 ) . one of the serious adverse effects of azt is anemia due to bone marrow suppression . it usually occurs within six weeks of initiation of therapy ( fischl et al 1990 ) . features of acute retinal ischemia include venous dilatation and beading , the presence of numerous retinal hemorrhages and cotton wool spots ( cws ) . cws in microangiopathic hiv retinopathy tend to be small our patient s cws were large , possibly reflecting a greater degree of retinal ischemia ( mansour et al 1990 ) . our patient showed no evidence of any other condition associated with retinal hemorrhages or ischemia . as in diabetic retinopathy , the vascular and other features of ischaemia may reverse following management in our case by blood transfusion . clinicians should be aware of other causes of retinal hemorrhages in hiv - positive patients . careful clinical examination and ophthalmic review facilitate appropriate management , avoiding costly and toxic anti - cmv treatment . patients commencing antiretroviral therapy should be counseled regarding the importance of close follow - up and supervision .

opportunistic cytomegalovirus ( cmv ) infection is common in severely immunocompromised hiv - positive patients . the retina is the commonest site of involvement with hemorrhages a prominent feature . cmv retinitis affects 40% of hiv positive patients who have cd4 count of less than 100 cell / mm3 , and in these circumstances clinicians are likely to consider commencing anti - cmv therapy without considering other causes . we report a man with hiv who developed bilateral retinal hemorrhages and ischemic maculopathy in association with zidovudine ( azt)-induced anemia . retinal hemorrhages resolved following blood transfusion .

malignant syphilis ( also known as lues maligna or pustuloulcerative syphilis ) is a rare , severe variant of secondary syphilis , clinically characterized by large nodular and ulcerative lesions covered with thick crust . its incidence decreased at the beginning of the 20 century but an increase has been reported after 1987 , affecting patients with hiv infection . we present a patient with lues maligna as the first clinical manifestation of hiv infection . a 52-year - old homosexual male was admitted in our clinic with a three week history of an extensive , febrile , papulonodular rash affecting his face ( leonine facies , figure 1 ) , trunk ( figure 2 ) , extremities , including palms and soles ( figures 3 and 4 ) . the lesions were multiple , erythematous papules and nodules occasionally ulcerative with round or oval configuration . they had no pain or pruritus , no tendency to central healing and a number of these lesions were covered with a brown - black , thick crust . the patient had a temperature of 38.4c , his blood pressure was 120/80 mmhg , heart rate 100/minute and respiration rate 15/min . he also complained of general malaise , headache , myalgias and loss of approximately 8 kilograms within the last 3 weeks . a 4 mm punch biopsy was taken from the margin of an ulcerative lesion and histological examination showed dilatation of blood vessels with perivascular dermal infiltrate composed of many plasma cells ( figure 5 ) . figure 5histological examination revealed perivascular dermal infiltrate composed of many plasma cells ( hematoxylin and eosin stain , magnification x400 ) . histological examination revealed perivascular dermal infiltrate composed of many plasma cells ( hematoxylin and eosin stain , magnification x400 ) . nucleic acid amplification tests for cytomegalovirus , varicella - zoster virus and herpes simplex virus , were also negative . laboratory investigations revealed a positive serology for hiv ( elisa and western - blot ) , and venereal disease research laboratory test ( vdrl ) was reactive in 128 dilutions with a positive treponema pallidum hemagglutination ( tpha ) . at that time , his cd4 t lymphocyte count was 329/mm and his hiv viral load 65,855 copies / ml . serology for hepatitis b and c was negative and a chest x - ray film was normal . the possibility of neurosyphilis was considered but the patient did not consent in a cerebrospinal fluid examination . the patient started highly active antiretroviral therapy ( haart ) and also treated with four million units of intravenous aqueous crystalline penicillin g at four - hour intervals per day , preceded by a single dose of intramuscular prednisone 50 mg . topical fusidic acid ointment was also applied on ulcerative lesions , to avoid a superinfection . he responded very well to penicillin and no jarisch - herxheimer reaction was seen during treatment . he was discharged from hospital after 14 days of treatment . on follow - up visit , three months after treatment , the patient presented with postinflammatory hyperpigmentation and a few residual scars . vdrl test showed a titer of 1:4 , his cd4 t lymphocyte count was 504/mm and hiv viral load was 11,000 copies / ml . malignant syphilis was firstly described by bazin in 1859 as a nodular variant of syphilis . it represents an uncommon clinical manifestation that is possibly attributed to poor health , malnutrition , widespread use of antibiotics and corticosteroids and , most importantly , the presence of hiv infection . the diagnostic criteria of malignant syphilis include strongly positive serological test , a severe jarisch - herxheimer reaction and a good response to antibiotic therapy . in our case , the diagnosis of lues maligna was confirmed by the positive vdrl and tpha titers , the characteristic ulceronodular lesions , the plasma - cells infiltration and the rapid response to penicillin treatment . there was no jarisch - herxheimer reaction probably because of his immunosuppression or the pre - medication with the systemic corticosteroids . rapid plasma reagin ( rpr ) titers in patients with lues maligna may be extremely high and remain in such levels despite antibiotic therapy . nonetheless , negative rpr titers from prozone phenomenon have been reported . the exact mechanism of the development of malignant syphilis in hiv ( + ) patients is not yet known . it seems that the pathogenic interaction between hiv and treponema pallidum may reduce the immunologic response to treponemal infection through a decrease in cell - mediated immunity , macrophage functional defect and possibly , immunomodulation of the humoral immunity response . the natural course of syphilis may be altered in hiv - infected patients but in most cases the manifestations remain typical . physicians should recognize this condition and consider it in all hiv - infected individuals with ulceronodular skin lesions .

malignant syphilis is a rare and severe variant of secondary syphilis . it is clinically characterized by large papular , nodular and ulcerative lesions affecting the trunk and the extremities and covered with thick crust . we present a case of 52-year - old homosexual male who developed malignant syphilis and this was the first clinical manifestation of hiv infection . the patient was treated successfully with intravenous aqueous crystalline penicillin g. physicians should recognize malignant syphilis and consider it in all hiv - infected individuals with ulceronodular skin lesions .

hydranencephaly is a severe and rare developmental defect during the embryogenesis occurring in less than 1 per 10,000 births worldwide and may be caused by vascular insults , injuries , infections , traumatic disorders after the 12th week of pregnancy or genetic failures . hydranencephaly is classically characterized as absence of supratentorial brain structures supplied by the anterior and middle cerebral arteries , whereby basal and infratentorial brain structures supplied by the posterior circulation might be preserved . the absent brain is replaced by cerebrospinal fluid ( csf ) and the association to hydrocephalus is frequently given . diagnosis is usually made intrauterine by ultrasound ( us ) and/or magnetic resonance imaging ( mri ) and leads normally to abortion . we present a case of a 9 months old child with delayed diagnosis of hydranencephaly . a 9-month - old boy of a western european woman presented in our department with progressive gain of the head circumference after a medically non - observed pregnancy and a home delivery . the mother of the baby had a known psychiatric previous history but no other relevant medical conditions and did not want the pregnancy . as a result she did not seek regular medical supervision and gave up the baby directly after birth to a foster home . even postpartum , the child was seen infrequently by pediatric physicians . the only response on speaking or acting of the kid was gripping with the left hand . he presented several clinical signs for cerebrospinal hypertension , such as sunset phenomenon , venous marmoration and exposed fontanels . furthermore he developed diabetes insipidus , an adrenal insufficiency , recurrent seizures and central temperature regulation disorders . magnetic resonance imaging ( mri ) of the brain ( figure 1 ) showed complete agenesis of the supratentorial brain structures replaced by csf in terms of a hydranencephaly . infratentorially the pons , the medulla oblongata and the left cerebellar hemisphere had only been developed . figure 1a ) sagittal magnetic resonance imaging ( mri ) of the child s brain showing the lack of neocortex . only the brain stem seems to exist maintaining the vital functions ; b ) in the transverse mri there is a small part of brain which does not seem to have any structure . a ) sagittal magnetic resonance imaging ( mri ) of the child s brain showing the lack of neocortex . only the brain stem seems to exist maintaining the vital functions ; b ) in the transverse mri there is a small part of brain which does not seem to have any structure . after a long debate on ethics considering the incompatibility of this brain defect to a proper development we implanted a ventriculo - peritoneal shunt to prevent further gain of the head circumference . few months later the boy could move all extremities and make unintelligible sounds . in consideration of the disease and its prognosis we desisted from further the clinical presentation consists of a vegetative state with few reflexive functions like sucking , swallowing , crying , and moving the extremities , depending on the severity of the condition . the prognosis is poor with usually fatal outcome during the first year . despite the feasibility to diagnose hydranencephaly intrauterine via us and / or mri in the regular examinations by an obstetrician , delayed diagnosis is also possible , because the clinical status and facial configuration of the newborn can appear relatively normal at first .. therapy options are limited and the necessity of shunting in order to control the growth of head size has to be considered . a non - observed pregnancy , a birth at home and delayed diagnosis of this severe clinical condition in europe is very remarkable . it is justified to reflect upon medical termination of the pregnancy to prevent maternal morbidity after an early diagnosis of hydranencephaly . it is very important to keep in mind that even abnormalities like hydranencephaly can escape early diagnosis and lead to the delivery of a child which is highly handicapped . the social and psychological problems that can occur after a delivery of such a child can be devastating for the family . despite a very efficient pregnancy monitoring system like the existing one in europe , there are still families which do not visit the obstetrician and avoid monitoring during pregnancy . we would like to stress out the importance of educating mothers to participate in the child examination programs during pregnancy .

we present a case of a child suffering of hydranencephaly . the interesting fact in the case is that there were no embryological examinations during pregnancy and therefore could the anomaly , which would have been easily avoided by regular visits to the obstetrician , not be diagnosed timely . education of mothers is always necessary irrespective on how developed a country is and how good the medical treatment and diagnostic tools are . every pregnant woman needs to be well educated in matters of pregnancy monitoring .

solitary trichoepithelioma is rare benign tumor of the hair follicles with eyelid trichoepitheliomas being even rarer with < 30 cases reported so far . in a very large series of 83 trichoepitheliomas , gray and although they can present at any age , most common presentations are noted in the 4 decade . clinical examination alone can not clinch the diagnosis , and histopathological examination is essential for ruling out other close differential diagnosis of basaloid epitheliomas and basal cell carcinomas ( bcc ) . we present a case of a solitary eyelid trichoepithelioma along with its clinical and histopathological features . a 58-year - old male presented to us with a small , painless , asymptomatic lesion on the right upper lid since 15 years . on examination , the eyelid nodule was 5 mm 5 mm , firm , nontender , mobile , and not adherent to the overlying skin [ figure 1a ] . the eyelid skin had an extra fold secondary to dermatochalasis , however , there was no evidence of any skin ulceration [ figure 1a ] . the rest of the ocular examination was unremarkable except for the presence of a right lower lid senile entropion [ figure 1a ] . since the patient was scheduled for an entropion repair , he was also keen for simultaneous excision of the eyelid nodule , which was performed . postoperative period was uneventful and at the last follow - up , 3 months later , there was no evidence of any recurrence . . clinical photograph of the right eye showing a nodular lesion of the upper eyelid associated with dermatochalasis ( a ) . microphotograph showing horn cysts with central keratin ( h and e 40 ) , ( b ) , basaloid tumor cells are arranged in the cord and lacy patterns ( h and e 40 ) , ( c ) . high magnification microphotograph showing benign tumor cell admixed in a dense fibrous matrix ( h and e 100 ) , ( d ) gross pathological examination revealed a grayish white firm mass measuring 5 4 3 with the cut section being grayish white to grayish yellow without any areas of necrosis or hemorrhages . microscopic examination showed numerous well - formed horn cysts lined by a thin layer of basaloid cells with a keratin center [ figure 1b ] . the tumors comprised of basaloid cells without mitotic figures , forming cords , and lacy strands within a relatively dense matrix of the fibromyxoid stroma [ figure 1c and d ] . . they can be classified into three varieties : solitary , multiple , and desmoplastic . solitary trichoepithelioma does not follow an inheritance pattern and is usually firm , nonulcerated nodule usually < 2 cm in diameter . it appears most commonly in middle - aged individuals and most commonly on the face . the distinction between bcc and trichoepithelioma is clinically important since a bcc should be excised with a 34 mm margin of healthy tissue , while a trichoepithelioma may only require minimal resection . patient showed that 35% of the solitary trichoepitheliomas were misdiagnosed as bcc although they found ulceration to be present in only five of their cases . the presence of ulceration makes the clinician to error toward the diagnosis of either a bcc or sebaceous carcinoma . the histopathological features that go in favor of a trichoepithelioma include numerous keratinous cysts , lacy pattern of tumor cells , dense stroma , minimal inflammation , absent of minimum of abnormal hair follicles . in contrast , a basal cell carcinoma shows epidermal ulceration , very few keratinous cysts , minimal stroma , dense inflammation , and tumor lobules in adenoid and cystic patterns . simpson et al . presented the largest study ( n = 18 ) of eyelid trichoepitheliomas over a duration of more than 30 years . there was male preponderance ( m : f = 2:1 ) with the mean age at a presentation being 48.6 years ( range 373 years ) . all patients underwent excision ; however , two of them recurred after 10 and 12 years , respectively . although rare , solitary trichoepitheliomas should be considered in the differential diagnosis of firm , nodular eyelid lesions of middle - aged patients . the careful histopathological examination is mandatory for diagnosis . although recurrences are rare , all such patient should be kept on a yearly follow - up .

solitary trichoepithelioma of the eyelid is a very rare tumor , which needs to be differentiated from basaloid epithelioma and basal cell carcinoma . diagnosis is based on clinical and histopathological examination . we present a case of an eyelid trichoepithelioma presenting as a long standing nodule with associated dermatochalasis . although rare , this entity should be kept in the differential diagnosis of chronic , firm , nodular eyelid lesions .

one of the regions which did not escape this trend was jiu valley , a region which has known all the phenomena mentioned above along with economical convulsions which made the situation worse . one of the collateral effects of these economic convulsions was the reorganization of the health network in the region , which was characterized by the disappearance of a number of medical centres and/or significant reductions in their activity . this has lead to a particular situation characterised by a disproportionate influx to the remaining centres , thus losing the connection to the patients home and their health needs . as a result of this phenomenon , a great number of patients asked for medical care in the bigger hospitals of the region , which were forced to face unexpected challenges . in a previous study we carried out a characterization of the population of jiu valley based on the social and economic changes which obliged the population to adapt to the new situation and finally of the effect of all these changers on their health condition analyzing these evolutions , we realized that one of the ways to resolve this situation would be to improve the level of medical care and suggest a better diagnosis of tuberculosis . when we say better diagnosis we mean rapid detection , better results and thus higher sensitivity and specificity . the evolutions in this field were characterized by a transition from the conventional bacteriological practice ( carried out with good results ) to methods of molecular biology which are faster , more specific and sensitive and which allow an earlier identification of the resistance to antituberculous medication . last but not least , the medical act is of better quality [ 813 ] . our study included two groups , the first represented by 213 patients who were part of the 528 subjects recorded as pneumological patients in different hospitals in jiu valley . the second group was represented by a number of 49 patients who were referred to a tertiary center laboratory where they could benefit from the pcr methods . immune chromatography was used as a rapid alternative solution relying on the determination of the protein composition of mycobacteria . for the second group we used the techniques of molecular biology . distribution by age shows that patients belong to the active groups ( 3060 years ) , most of them being males aged between 4050 years . most of them were persons with medium education levels , originating from the six towns in the jiu valley , especially from the towns petrosani , lupeni and petrila . the microscopic results revealed that according to microscopic finding 98% were positive to a variable degree . could be determined based on bacteriological identification and we concluded that this method was very efficient . it allowed us to identify resistance to isoniazid ( hin ) , rifampicine rmp ) and finally to back up the diagnosis of multidrug resistance ( mdr ) . this method allowed us to obtain results very quickly ( 2448 hours ) . that is why the method looks very satisfactory , especially when we compare it to the 60 days necessary for conventional bacteriological examination . the value of the method was expressed by its sensitivity reaching almost 100% and it allowed the highest rate of mycobacterium identification . this study was the result of authors desire to better comply with the national tuberculosis control programme , as well as with the recommendations of the world health organization . we noticed that the jiu valley exhibits a poor situation when it comes to tuberculosis , the frequency of the disease being above the national average . in these circumstances , we find that our effort to improve the health situation of this population and to decrease tuberculosis is justified . we believe that the means which can help us see an improvement consist in better early diagnosis . we estimated the prevalence of tuberculosis by two methods : the bacteriological one and the pcr based one . a limitation of our study is the difficulty to compare the two groups that differ so much in terms of number of patients . as we revealed , the difference between the two groups of methods is represented by the time required for diagnosis and by the possibility to obtain very good information concerning resistance . this way we made early introduction of adapted antituberculous therapy possible which will have effects both on the health condition of patients but also on cost reduction because of an early efficient treatment . the methods of molecular biology have proven their high sensitivity and specificity in the diagnosis of tuberculosis . it allowed good identification of resistance to antituberculous therapy overcoming traditional methods . for the time the use of the methods of molecular biology seem to be the option for the future , offering chances of a very good and early diagnosis .

background and aimin the last decades , the inhabitants of the romanian region known as jiu valley underwent changes in their social and economic status which determined changes in behaviour and health , which influenced their general health condition . one of the consequences was the exacerbation of tuberculosis . in order to control this situation , there was a need to increase the efficiency of diagnosis . this optimization can be reached by a better detection of mycobacterium infection , optimal isolation of strains and identification of the resistance of strains to antituberculous drugs.methodsin order to identify the best diagnostic modality , we compared the efficacy of the classical bacteriological diagnosis , still performed in the field , to the modern methods of molecular biology . the study included two groups , one represented by 213 patients who were investigated using the classical bacteriological methods , and 49 who were diagnosed using the pcr method.resultsthe tuberculosis patients who have been evaluated only with the classical bacteriological methods where diagnosed as tb positive and treated according to the national guidelines , which are in agreement with the international guidelines . the pcr diagnostic methods had a superior diagnostic value compared to the traditional bacteriological method.conclusionsthe results revealed the superiority of the modern molecular biology methods based on pcr . however the bacteriological method remains useful in areas where pcr can not be afforded .