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zhengyun21

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PMC-Patients

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3959523-1

noncomm/PMC003xxxxxx/PMC3959523.xml

Intramural hematoma of the esophagus mimicking hemorrhaging esophageal cancer

A 77-year-old male presented with severe epigastric pain, hematemesis, hemorrhagic shock and respiratory failure due to aspiration. Apart from a two-week history of intermittent epigastric pain, there was no recent history of dysphagia, weight loss or anorexia. His past history includes a previous stroke, for which he took clopidogrel regularly. He was intubated for ventilatory support immediately. Blood products were also administered. Physical examination was unremarkable except for bibasal crackles. Gastroscopy was performed to achieve hemostasis. It revealed marked luminal occlusion by diffuse mucosal ulceration with active ooze, suspected to be malignancy (). A biopsy was taken for histological examination. After stabilization, a computed tomography (CT) scan with intravenous contrast revealed a thickened esophagus extending from T1 down to the stomach near to the gastro-esophageal junction (). The esophageal lumen was almost completely obliterated.\nThe diagnosis of intramural hematoma of esophagus (IHE) was made based on the history of anti-coagulant use and CT finding of esophageal wall thickening without any evidence of perforation. This was further supported by histological confirmation of esophagitis. He was conservatively managed; nutrition was provided parenterally, and continued to remain stable. He recovered from aspiration pneumonia over the next few days and was extubated. Repeat gastroscopy demonstrated an intact esophagus with small areas of linear superficial ulceration and scarring consistent with healing tear (). He was discharged on soft pureed diet for two weeks and remained asymptomatic at twelve-week follow up.

[[77.0, 'year']]

M

{'8583868': 1, '22160414': 1, '12894023': 1, '8117198': 1, '30589409': 1, '8379637': 1, '7028429': 1, '16722999': 1, '8826733': 1, '22244296': 1, '17952475': 1, '19762321': 1, '24714326': 2}

{}

3959539-1

noncomm/PMC003xxxxxx/PMC3959539.xml

Diffuse Caroli’s disease with atypical presentation: a case report

A female patient, aged 32, Caucasian, appeared to the outpatient clinic complaining of abdominal pain, that started six months ago, it was mild to moderate, continuous, recurrent, located in the upper right quadrant, relieved with simple analgesics. The patient also reported intestinal constipation, making use of laxatives, but had no fever, chills, jaundice, weight loss, nausea and/or vomiting.\nThe patient had a history of transient ischemic attack, which was investigated and attributed to an inherited thrombophilia (mutations A1298C and C677T on the methylenetetrahydrofolate reductase -MTHFR) which was treated with warfarin daily. She had a daughter with Turner syndrome (TS), but no history of abortion, liver disease or any thrombotic event in the relatives, and denied alcohol and tobacco consumption.\nThe clinical examination of respiratory, cardiovascular and gastrointestinal systems showed no significant findings. There were no jaundice, fever, no stigmata of chronic liver disease and no signs of portal hypertension.\nHematological and biochemical exams are shown in . Abdominal ultrasound showed sparse cystic anechoic formations in the liver parenchyma of about 1.1 cm. Magnetic resonance cholangiopancreatography (MRCP) () demonstrated multiple small cystic formations, with intimate anatomical relation with biliary branches. An MRI of the upper abdomen showed that such formations were randomly distributed in hepatic parenchyma ( and ).\nThe dilatation of intrahepatic biliary ducts with intimate anatomical relation with biliary branches, without cholangitis, chronic liver disease or signs of portal hypertension suggested an oligosymptomatic form of CD.\nSo far, the prognosis is favorable, since the patient has no cholangitis or no major clinical manifestations that modified her daily life.\nLiver biopsy was not performed, once the patient was using warfarin, and the procedure would bring more risks than benefits, reasons that prevent the definitive diagnosis.\nCurrently, the patient continues under clinical follow-up, with no other complaints.

[[32.0, 'year']]

F

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{}

3959541-1

noncomm/PMC003xxxxxx/PMC3959541.xml

A young lady with post-partum jaundice and right upper quadrant lump abdomen: an unusual etiology

A 22-year-old young lady was referred to the Gastroenterology department by her local physician with 4 weeks history of yellowish discoloration of urine and sclera. Lumpy upper abdomen and significant loss of weight (approx. 5 kg) were present for 3 weeks. There were no prodromal symptoms and she denied any history of pruritus or passage of light colored stool. Her drug and family histories were unremarkable.\nShe had normal full-term pregnancy with transvaginal delivery of a healthy infant 6 weeks previously. There were no complications during pregnancy and no evidence of jaundice or cholestasis during pregnancy. Patient had a sensation of a lump in the right upper hypochondrium which had been gradually increasing in size over the past 3 weeks. It was associated with colicky pain lasting for 15-20 min and then subsided gradually. The patient also had intermittent spikes of fever with chills for one week.\nOn general examination there was pallor, jaundice but no lymphadenopathy. Tenderness was present in the right hypochondrium and a globular bulge was felt 4 cm below the right costal margin. Hepatomegaly was present with left lobe enlargement more than the right lobe; margins were sharp with firm consistency. Routine investigations confirmed normocytic normochromic anemia (hemoglobin 6.4 g/dL) with conjugated hyperbilirubinemia (10.5/6.8 mg/dL) and deranged liver function test (). Ultrasonography was done showing grossly dilated common bile duct with large filling defect throughout. Gross dilatation of intrahepatic biliary radicals and common hepatic ducts were seen.\nContrast-enhanced computed tomography (CECT) study of abdomen was done showing grossly dilated gallbladder with moderate to gross dilatation of intrahepatic biliary radicals and common bile duct (). A large polypoidal intraluminal multifocal enhancing lesion filling almost the entire common bile duct, cystic duct was also seen multifocally in the gallbladder. Multiple small hypodense lesions seen in both lobes showing peripheral rim enhancement clustered around central intra hepatic biliary radical dilatations were suggestive of cholangitic abscess.\nEndoscopic retrograde cholangiopancreatography was performed under conscious sedation and after easy cannulation grossly dilated common bile duct was noted with obstruction and shouldering at mid common bile duct on air cholangiogram. A biopsy was taken from the mass lesion and sent for histopathological examination. Two plastic biliary stents 10 Fr x 10 cm were placed across the mass. Choledochoscopic image was taken by ultrathin neonatal endoscope ().\nHistopathology analysis of the soft tissue revealed multiple papillae lined by complex epithelial proliferation with severe dysplastic changes. Early invasion of stroma was seen with neutrophillic infiltration and dilatation of blood vessels (Fig. , ). These findings were in consistence with intraductal papilloma with severe dysplasia.

[[22.0, 'year']]

F

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{'6881913-1': 1, '1618388-1': 1}

3959546-1

noncomm/PMC003xxxxxx/PMC3959546.xml

Polycystic liver disease presenting as pruritus

A 52-year-old female presented with generalized grade three pruritus of six months duration. There was no history of any skin lesions, fever, abdominal pain, jaundice or fatigue. Neither did she have any history of leg swelling, facial puffiness, decreased urine output or gastrointestinal bleed. She was detected to be hypertensive one year back for which Amlodipine was prescribed. Examination revealed a 5 cm hepatomegaly more in the epigastric region along with separate masses in both lumbar regions which were bimanually palpable and ballotable. Liver function test revealed normal bilirubin and aminotransferases but a more than three times elevation of serum alkaline phosphatase and γ-glutamyl transferase. Renal function was normal and there was no proteinuria.\nInitial ultrasound scan was followed by CT scan of abdomen () which showed multiple noncommunicating cysts of varying size in both lobes of liver. There was mild dilation of intrahepatic biliary radicles in both lobes. Common hepatic duct and common bile duct (CBD) appeared normal. Both kidneys were bulky with multiple noncommunicating cysts.\nMRI abdomen () with MRCP () showed multiple T2WI high signal parenchymal cysts mostly in the left lobe of liver, the largest measuring 9.8 × 6.7 cm. Mild dilation of intrahepatic bile ducts was seen. A few small cysts in communication with the dilated bile radicles were also noted. The proximal CBD was not visualized due to compression by the cysts at the porta hepatis. The distal CBD was normal in caliber. Spleen and pancreas were normal. Both kidneys were markedly enlarged with parenchyma totally replaced by innumerable cortical cysts, the largest measuring 7×5.6 cm. The large cysts in the left lobe of liver and porta hepatis compressing the bile ducts were not communicating with the biliary system. A diagnosis of polycystic liver disease with Caroli’s disease and biliary obstruction was made. The patient also had polycystic kidney disease. Hence our patient presented for the first time with longstanding pruritus as the only manifestation of polycystic liver disease.\nThe patient was planned for laparoscopic deroofing of liver cysts. However she was lost to follow up.

[[52.0, 'year']]

F

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{}

3959928-1

noncomm/PMC003xxxxxx/PMC3959928.xml

Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding

A 55-year-old male diagnosed case of ethanol-related chronic pancreatitis presented with frequent episodes of melena associated with paroxysms of abdominal pain. He was given blood transfusions elsewhere for severe anemia. As patient had persistent GI bleeding with repeated drop in hemoglobin, he was referred for further evaluation and management. On clinical examination, he had profuse sweating, hypotension, tachycardia, severe pallor and mild tenderness in the epigastrium. His laboratory investigations revealed hemoglobin of 7.1 g% and hematocrit of 22%, mild renal failure and increased serum triglycerides. Contrast-enhanced computed tomography of the abdomen showed evidence of chronic calcifying pancreatitis (). Esophagogastroduodenoscopy with a standard scope and colonoscopy were normal. Repeat esophagogastroduodenoscopy with a standard scope after an episode of melena showed active bleeding from the ampulla (). Angiographic study could not localize the site of bleeding. Endoscopic ultrasound showed chronic pancreatitis with a heterogeneous inflammatory lesion in the body of the pancreas (). As the bleeding source could not be localized and the patient had ongoing melena and drop in hemoglobin, emergency exploratory laparotomy was performed after initial hemodynamic stabilization. Pancreas was seen adherent to splenic vessels and hilum. There was evidence of splenic vein rupturing into the main pancreatic duct. Distal pancreatectomy with splenectomy was performed. The patient had an uneventful recovery postoperatively. Postoperative histology demonstrated chronic calcifying pancreatitis (), lymphnodes with reactive hyperplasia and congested spleen (). He was discharged in a hemodynamically stable condition and there was no further recurrence of GI bleeding after 6 months of follow up.

[[55.0, 'year']]

M

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{'7809673-1': 1, '5572197-1': 1}

3959929-1

noncomm/PMC003xxxxxx/PMC3959929.xml

Infective endocarditis and infected aneurysm of splenic artery post colonoscopy

A 68-year-old male presented a two-week history of malaise, left-sided abdominal pain and intermittent fever. The only apparent incident of significance prior to presentation was a colonoscopy performed two weeks ago for investigation into his recent change in bowel habit. The colonoscopy was performed with adequate bowel preparation and revealed a 10 mm pedunculated rectal polyp. Apart from a rectal polypectomy with snare diathermy, 3 mm-diameter biopsies were taken randomly from the terminal ileum, ascending colon and descending colon. Hemostatic clips and adrenaline injection were not required as there was no significant bleeding. There was no significant past medical, surgical or dental histories. He does not take any regular medications and has no known allergies. There was no recent travel, sick or animal contacts. He does not smoke and only drinks alcohol socially. He denies any form of illicit drug use.\nHistological examination confirmed the rectal polyp as a tubular adenoma. He was well the next day following polypectomy but presented four days later with left upper quadrant pain radiating to the back and minor rectal bleeding. Six days following colonoscopy and polypectomy he developed sepsis, supported by leukocytosis of 18.1 (range 4-11), CRP of 234 (normal range <5) and ESR of 55 mm/h (normal 2-14). He was immediately commenced on amoxycillin/clavulanic acid and treated as colitis by his general practitioner. Due to a lack of clinical improvement despite oral antibiotic, a contrast CT scan of his abdomen and pelvis was performed. There were CT evidence of distal splenic artery aneurysm with complete obliteration distally as well as splenomegaly with most of the spleen occupied by multiple cystic lesions ().\nBlood cultures and CT-guided splenic abscess aspiration were collected immediately, followed by administration of intravenous antibiotics (ceftriaxone and metronidazole). Multiple sets of blood cultures and splenic aspirate cultures were positive for Enterococcus faecalis on day one, sensitive to amoxycillin and vancomycin. Transthoracic echocardiogram showed moderately severe aortic regurgitation and an aortic valve vegetation (1.4 × 0.9 cm) situated at the right coronary cusp with localized leaflet prolapse and perforation. Apart from that, no other valvular lesion was detected and both ventricular systolic functions were well-preserved. These findings were confirmed on a subsequent transesophageal echocardiogram.\nOpen splenectomy was performed via a roof-top incision. Macroscopically, the spleen was grossly enlarged with multiple loculations of abscess (). The infected aneurysm of splenic artery was densely adherent to the retroperitoneum and pancreas, rendering its excision challenging. A decision was then made to suture-ligate it proximally. Post-splenectomy recovery was uneventful. Bioprosthetic aortic valve replacement was performed one week after splenectomy. Culture of the native aortic valve was positive for Enterococcus faecalis. Recovery post-cardiac surgery was uncomplicated. He was then discharged on ampicillin 2 g every four hours for a total of six weeks. He remained well and asymptomatic at his follow up eight weeks after discharge.

[[68.0, 'year']]

M

{'20569943': 1, '20845280': 1, '16376097': 1, '15467002': 1, '17466802': 1, '12665767': 1, '19665088': 1, '17905558': 1, '17446442': 1, '21951473': 1, '24714871': 2}

{}

3959932-1

noncomm/PMC003xxxxxx/PMC3959932.xml

Recalcitrant plantar warts during azathioprine therapy for Crohn’s disease

We present a case of a 29-year-old man with ileo-cecal Crohn’s disease (CD), diagnosed 15 years ago. Initially, the patient received prednisone for induction therapy and was maintained on clinical remission with azathioprine 200 mg and budesonide 9 mg q.d. for the last 8 years. At the time of the patient’s first visit to our department he presented with persistent abdominal pain with alternating loose, non-bloody stools and constipation. Physical examination revealed mild left lower abdominal pain. Laboratory investigation showed no signs of inflammation. Imaging with magnetic resonance enteroclysis did not reveal any abnormalities. An ileocolonoscopy with biopsies did not show any active signs of CD activity. He was discharged on osmotic laxatives resulting in relief of his abdominal complaints.\nDuring our evaluation, the patient also reported severe warts at the soles of his feet. A few small warts were already present at the time of diagnosis of his CD, but they progressed after introduction of azathioprine. Physical examination showed hyperkeratotic plaques of coalescing warts, covering major parts of the weight-baring areas of his feet (). In addition to their unsightly cosmetic effect, the warts have started to impede his walking. He had been thoroughly evaluated by dermatology for alternative causes of plantar lesions. His warts had failed to respond to conventional therapies including liquid nitrogen (20-25 times), salicylic acid, and coagulation therapy. Eventually, azathioprine therapy was withdrawn, after considering the risks of reactivating his quiescent CD. However, withdrawal of azathioprine did not result in resolution of his warts. Currently, the patient is scheduled for laser surgery of his recalcitrant plantar warts.

[[29.0, 'year']]

M

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{}

3959943-1

noncomm/PMC003xxxxxx/PMC3959943.xml

Boerhaave’s syndrome as an initial presentation of eosinophilic esophagitis: a case series

(previously cited as an image of the month, Cohen et al [])\nA 56-year-old Caucasian male with a history of asthma, seasonal allergies, and occasional heartburn presented with nausea and vomiting followed by chest and epigastric pain. Computed tomographic (CT) scan revealed air and fluid surrounding the esophagus from the level of the bronchial bifurcation through the gastro-esophageal junction (GEJ), consistent with esophageal rupture complicated by pneumomediastinum and medastinitis. Patient was taken to the operating room and underwent primary repair of a 5-cm perforation located 3-cm proximal to the GEJ. Postoperative course was complicated by 3 months of continuous drainage from the site of rupture requiring mediastinal lavage and bilateral chest tubes. At 9-month follow up, the patient reported symptoms of heartburn, regurgitation and dysphagia to solid foods. Esophagoscopy revealed a characteristic feline appearance and biopsy showed intact squamous mucosa with a diffuse intraepithelial eosinophilic infiltrate exceeding 30 eosinophils per hpf, consistent with EoE. The patient was treated medically with a proton pump inhibitor and oral fluticasone.

[[56.0, 'year']]

M

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{'3959943-2': 2, '3959943-3': 2, '3959943-4': 2, '6719381-1': 1}

3959943-2

noncomm/PMC003xxxxxx/PMC3959943.xml

Boerhaave’s syndrome as an initial presentation of eosinophilic esophagitis: a case series

A 43-year-old Caucasian male with history of intermittent solid food dysphagia presented to emergency room with sudden onset nausea, vomiting, and intense epigastric pain. Thirteen years prior to presentation patient had a spontaneous esophageal rupture for which he underwent left thoracotomy and primary repair complicated by prolonged leakage of the esophagus requiring chest tube drainage. Work up at that time identified no obvious etiology.\nOn this presentation, CT scan revealed mediastinal air below the level of the carina compatible with rupture of the distal esophagus (). Water soluble contrast swallow demonstrated extravasation of contrast at the right aspect of the distal esophagus just above a narrowing with evidence of contrast draining above and below the diaphragm as well as air tracking into the mediastinum (). The patient underwent esophageal resection, cervical esophagostomy and jejunostomy. Intra-operative esophagoscopy revealed a ringed or feline appearance to the esophagus and a 1-cm rupture just proximal to the gastroesophageal junction. Full thickness resection specimen revealed increased transmural eosinophilia with multiple fields demonstrating >25 eosinophils/hpf and up to 55 eosinophils/hpf, consistent with EoE ( and insert).\nPostoperatively, the patient was treated with 40 mg of prednisone tapered over 30 days. Six months later, he underwent completion esophagectomy with gastric pull-up. Surgical specimen at that time showed no evidence of eosinophilia (), suggesting improvement following systemic corticosteroid therapy. Surgical anastamosis was uncomplicated.

[[43.0, 'year']]

M

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{'3959943-1': 2, '3959943-3': 2, '3959943-4': 2, '6719381-1': 1}

3959943-3

noncomm/PMC003xxxxxx/PMC3959943.xml

Boerhaave’s syndrome as an initial presentation of eosinophilic esophagitis: a case series

A 26-year-old Caucasian female with a history of asthma presented with 2 days of nausea, vomiting and subcutaneous chest wall crepitus. She was found to have pneumomediastinum and pneumopericardium with subcutaneous emphysema on CT scan (). Contrast swallow revealed no evidence of contrast extravasation (). The patient was managed conservatively and discharged after 48 h. She underwent follow up esophagoscopy 6 months later revealing proximal esophageal rings and intramucosal eosinophilic infiltration consistent with EoE.

[[26.0, 'year']]

F

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{'3959943-1': 2, '3959943-2': 2, '3959943-4': 2, '6719381-1': 1}

3959943-4

noncomm/PMC003xxxxxx/PMC3959943.xml

Boerhaave’s syndrome as an initial presentation of eosinophilic esophagitis: a case series

A 22-year-old Caucasian male with a history of Crohn’s disease presented with vomiting, neck and chest pain and difficulty swallowing without food impaction. He was found to have pneumopericardium and pneumomediastinum with air tracking to the soft tissues of the neck on CT scan. He underwent contrast swallow without any evidence of extravasation. He was managed conservatively. He returned 2 months later with chest pain for 2 days and was found to have recurrent pneumomediastinum. Repeat water-soluble contrast study failed to reveal any contrast extravasation. Esophagoscopy was performed revealing a ringed esophagus secondary to EoE.

[[22.0, 'year']]

M

{'8420741': 1, '30280106': 1, '23160304': 1, '18705580': 1, '21309916': 1, '21277394': 1, '12612531': 1, '18668459': 1, '16863702': 1, '19629944': 1, '18218284': 1, '18407800': 1, '27680593': 1, '18205276': 1, '16394804': 1, '8957408': 1, '16336613': 1, '32617387': 1, '29290036': 1, '17919504': 1, '21477849': 1, '31477179': 2, '28508384': 1, '15017642': 1, '24714779': 2}

{'3959943-1': 2, '3959943-2': 2, '3959943-3': 2, '6719381-1': 1}

3960811-1

noncomm/PMC003xxxxxx/PMC3960811.xml

Chylothorax in gastric adenocarcinoma: A case report and systematic review of the English literature

A 23-year-old man presented with diffuse swelling in the left half of the neck and the left half of the chest of 4 weeks’ duration and gradual onset of breathlessness of 1 week duration. He also complained of early satiety and unquantified weight loss. He was a farmer by occupation, did not smoke or drink alcohol and did not have any significant past medical history. On examination, he was afebrile and normotensive, with respiratory rate of 26 breaths/min and a pulse rate of 98 beats/min. His neck swelling was a diffuse lymphedema, extending to the upper chest, up to the mammary area. The jugular venous pressure was not elevated and there was no erythema, tenderness or elevation of local temperature over the swelling. The respiratory system examination revealed findings consistent with left pleural effusion. The rest of the physical examination was unremarkable.\nInvestigations showed a hemoglobin count of 13.7 g/dL, leukocyte count of 8000 cells/cm3 with 78% neutrophils and a platelet count of 2.1 × 105/L. His liver function tests showed a total protein of 5.5 gms/dL, albumin of 2.7 gm/dL, normal transaminases and alkaline phosphatase of 1848 U/L. His serum creatinine was 0.8 mg/dL and lactic acid dehydrogenase (LDH) was 203 U/L (normal 140-280 U/L). Chest radiography showed a large left-sided pleural effusion. Diagnostic pleurocentesis revealed milky white pleural fluid, with a cell count of 708/cm3 and differential count of 98% lymphocytes and 2% neutrophils. The fluid was consistent with an exudative effusion (by Light's criteria), with protein of 3.4 gm/dL, albumin of 2.4 gm/dL and LDH of 172 U/L. The other pleural fluid characteristics were glucose of 90 mg/dL, adenosine deaminase (ADA) of 5.8 U/L, amylase of 18 U/L, triglycerides of 274 mg/dL and cholesterol of 104 mg/dL. The pleural fluid analysis was suggestive of chylothorax. Cytology was negative for malignant cells in the pleural fluid and the gram stain revealed no microorganisms.\nAn appropriate low-fat diet for chylothorax was initiated, with most fats in the form of medium-chain triglycerides. He was also started on octreotide to reduce chyle formation. Intercostal tube (ICD) insertion and drainage was performed to relieve his grade IV breathlessness. Three hundred milliliters to 400 mL of fluid was drained per day during the first 6 days of hospitalization. A search for the cause of chylothorax was undertaken. The patient denied any history of recent trauma or abdominothoracic surgery. There was no history of any febrile illness suggestive of tuberculosis. A computed tomogram (CT scan) of the chest showed moderate lymphangitis in the left lung, left-sided pleural effusion, minimal right-sided pleural effusion and minimal ascites []. A CT scan of the neck region revealed multiple enlarged left submandibular, posterior triangle and supraclavicular lymph nodes, the largest measuring 2.2 cm × 1.3 cm []. The left internal jugular vein was narrowed by 80% as compared with the right jugular vein. This, along with the lymphangitis, was concluded as the cause of chylothorax.\nUltrasound-guided fine needle aspiration of the neck lymph node was suggestive of adenocarcinoma []. As part of the work-up for malignancy, his carcinoembryonic antigen was elevated with a level of 11.91 ng/mL (normal 0.2-3.8).\nUpper gastrointestinal endoscopy showed an ulcerated growth with everted margins measuring 2 cm × 2 cm in the posterior part of the stomach []. Biopsy of the ulcer confirmed it to be signet ring cell adenocarcinoma []. A diagnosis of gastric adenocarcinoma with metastasis to neck nodes was made. The chylous drain reduced to 100 mL/day after the first week. He was offered chemotherapy, which he wished to receive in his home town. The patient was discharged home at his request after ICD removal. On further telephonic follow-up, it was revealed that the patient expired 4 months after diagnosis after receiving alternative medicines.

[[23.0, 'year']]

M

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{'6633922-1': 1}

3960813-1

noncomm/PMC003xxxxxx/PMC3960813.xml

Visceral leishmaniasis with pleural effusion in an immunocompetent patient

A 62-year-old male patient, resident of West Bengal, was suffering from cough and chest pain for the last 6 months. He underwent initial management in a local hospital. He was a non-smoker and non-alcoholic. He had no history of fever, hematemesis, malena, diarrhea, headache, or body ache. He had not suffered from diseases like tuberculosis, asthma, chronic obstructive pulmonary disease (COPD), or gastroesophageal reflux disease (GERD). He was not taking any drugs at that time.\nInitial clinical evaluation in the local hospital revealed that the patient had moderate pallor, cachexia but no lymphadenopathy. Auscultation of chest showed bilateral normal breath sounds, Chest radiograph showed a small left-sided pleural effusion. Routine hematological investigations detected pancytopenia with hemoglobin level of 7.7 g/dl. Erythrocyte Sedimentation Rate was 100 mm/h. Mantoux test for tuberculosis was negative. Sputum culture for acid-fast bacilli (AFB) was negative. Ziehl–Neelsen stain of the sputum smears was also negative for AFB.\nThe patient was prescribed antitussives and analgesics, but no significant improvement occurred. He was then referred to our hospital for further management.\nAfter examining the patient, we obtained another chest radiograph that confirmed the presence of a small left-sided pleural effusion\n[]. Known causes of pleural effusion like heart failure, pneumonia, tuberculosis, or carcinoma of lung were absent in this patient. He did not have any symptoms of arthritis, which is commonly found in autoimmune diseases. Therefore, the cause of pleural effusion remained unexplained.\nOn thorough examination, a mild splenomegaly was detected. To detect the cause of splenomegaly, serum bilirubin, liver enzymes, and prothrombin time were estimated which were within normal limits. HBsAg, anti-HCV and anti-HIV antibodies were negative by ELISA technique. Widal test for enteric fever and test for malaria antigens were negative.\nTotal serum protein estimation was done, which was found to be within normal limits. However, the albumin/globulin ratio was reversed, being 0.2. Napier's aldehyde test was then performed which is based on the principle of hypergammaglobulinemia, that occurs in VL. About 1 ml of patient's serum was mixed well with a drop of 40% formalin, shaken and kept at room temperature. Opacification and solidification of serum was seen after 10 min signifying a positive result. Subsequently, bone-marrow aspiration was undertaken, which showed both intracellular and extracellular amastigote forms of L. donovani. Slight excess of plasma cells was also noted [].\nThe patient was treated with IV Sodium Stibogluconate with prompt clinical and laboratory improvement. Chest radiograph was done after 1 month, which showed resolution of preceding pleural effusion []. He was on follow-up for another 6 months, which was uneventful.

[[62.0, 'year']]

M

{'27932875': 1, '34047800': 1, '11073742': 1, '31999729': 1, '8432183': 1, '25546669': 2, '17068275': 1, '14560568': 1, '12715642': 1, '21577261': 2, '32509616': 1, '19149777': 1, '16771207': 1, '18159498': 1, '24669085': 2}

{'3090634-1': 1, '4602606-1': 1}

3960814-1

noncomm/PMC003xxxxxx/PMC3960814.xml

A case of concomitant Hodgkin's lymphoma with tuberculosis

A 29 year old woman presented to the local hospital with complaints of breathlessness and cough with expectoration for duration of eight weeks. On examination she was found to have enlarged cervical lymph nodes. Excision biopsy of the nodes were done and were subjected to histopathological examination (HPE), which revealed features suggestive of tuberculosis (TB), and hence the patient was started on anti tuberculous therapy (ATT) (isoniazid, rifampicin, pyrazinamide and ethambutol). She came to our hospital as there was no alleviation in her symptoms and increase in size of her cervical nodes in spite of her strict adherence to ATT therapy. A CT scan of thorax revealed enlarged paratracheal, subcarinal and hilar lymph nodes. An endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) of the enlarged nodes was done to reconfirm the diagnosis, HPE of which revealed a granulomatous inflammation. Though the tissue was negative for acid fast bacilli (AFB) on smear's test, she was continued on ATT due to the endemicity of TB in our country. One month later, her symptoms had subsided while her cervical nodes did not show any signs of regression. Her EBUS TBNA samples which were sent for AFB culture turned out to be positive. As her drug sensitivity patterns were not available at that point of time she was advised to continue the same ATT regimen. Three months later she returned to our hospital with complaints of cough, right sided chest pain and hemoptysis. A CT scan of her thorax was repeated, it showed an increase in the size of mediastinal nodes compared with her previous scan []. She was subjected to mediastinoscopy which revealed mediastinal nodes adherent to trachea and great vessels. HPE of the nodes revealed features consistent with Hodgkin's lymphoma, nodular sclerosing variant, along with necrotising granulomatous inflammation [Figures and ]. Immunohistochemistry confirmed the diagnosis [] and it was classified as stage 2 Hodgkin's lymphoma as per the Ann Arbor staging criteria. She was initiated on chemotherapy (adriamycin, bleomycin, vinblastine, dacarbazine) of six 6 cycles, followed by external beam radiotherapy on the linear accelerator, using 6 MV photons, a dose of 30 Gy in 15 fractions was delivered to the mediastinal tumour bed by image-guided radiation therapy (IGRT) technique. She was advised to continue her ATT for a duration of nine months. A positron emission tomography (PET) scan was done after the completion of chemo- radiotherapy that showed no lymph nodes. As she improved clinically no further workup was done.

[[29.0, 'year']]

F

{'16304386': 1, '16885473': 1, '20930445': 1, '16361138': 1, '15283847': 1, '21718857': 1, '10764337': 1, '31906982': 2, '12692526': 1, '32704391': 2, '4592905': 1, '11713103': 1, '15888727': 1, '30621144': 1, '17710027': 1, '18503635': 1, '22363173': 1, '15377659': 1, '24669086': 2}

{'6945787-1': 1, '7372392-1': 1}

3960815-1

noncomm/PMC003xxxxxx/PMC3960815.xml

“Diesel siphoner's lung”: Exogenous lipoid pneumonia following hydrocarbon aspiration

A 40-year-old male patient presented with a history of recurrent episodes of fever associated with cough and expectoration of 18 months duration. There was associated history of streaky hemoptysis on and off. There was no history of loss of weight, chest pain, wheezing or shortness of breath. Patient was a smoker with a smoking index of 300; however, no other significant personal or occupational exposure history was forthcoming. There was no past history of tuberculosis. He had been treated with multiple antibiotics over the past 1 year and empiric antitubercular therapy too had been administered, without any symptomatic relief. General physical examination was unremarkable. On chest examination, scattered crepitations were audible bilaterally. Rest of the systemic examination was normal. Baseline laboratory parameters were within normal limits. There was no leukocytosis. Liver and renal function tests and arterial blood gases were within normal limits. Sputum cultures were negative for bacterial, mycobacterial or fungal growth.\nChest radiograph [] demonstrated bilateral pulmonary infiltrates, more on the left lower zone and computed tomography (CT) of the thorax [] showed multifocal areas of low attenuation consolidation predominantly in the left lower lobe. There was no mediastinal lymph node enlargement, pneumothorax or pleural/pericardial effusion. Flexible bronchoscopy was performed, which demonstrated normal bronchial anatomy with no endobronchial growth or abnormality. Examination of the bronchoalveolar lavage (BAL) fluid and bronchoscopic lung biopsy demonstrated lipid laden macrophages in the alveoli and interstitium, confirming the diagnosis of lipoid pneumonia []. On subsequent enquiry, patient recollected history of multiple episodes of aspiration while siphoning diesel out of cars, when he used to work as an automobile mechanic. He had left the job 2 years back. A final diagnosis of exogenous lipoid pneumonia due to recurrent diesel aspiration was made. Patient improved symptomatically after bronchoalveolar lavage and was advised to follow-up regularly.\nAfter 2 months, patient presented with recurrence of fever associated with cough and expectoration. There was no symptomatic relief with a course of broad spectrum antibiotics and chest radiograph showed new onset infiltrates in the right lower zone. BAL fluid analysis demonstrated lipid laden macrophages. Stain for acid fact bacilli or fungus was negative. In view of recurrent symptomatic deterioration and no evidence of uncontrolled infection, patient was initiated on treatment with oral prednisolone (0.5 mg/kg/day), which was tapered over 6 weeks duration. A follow-up chest radiograph [] showed complete resolution of the radiographic abnormalities.

[[40.0, 'year']]

M

{'9244843': 1, '34094763': 2, '21128754': 1, '16394707': 1, '20062592': 1, '30687441': 1, '1714701': 1, '9171848': 1, '18443157': 1, '19969662': 1, '28764225': 1, '10415259': 1, '8236080': 1, '15072330': 1, '31193250': 1, '20118714': 1, '8836660': 1, '34984112': 2, '27965910': 2, '7773510': 1, '14561906': 1, '33505692': 2, '32039070': 2, '31795982': 2, '24669087': 2}

{'8713733-1': 1, '7813127-1': 1, '7004259-1': 1, '6892022-1': 1, '8169091-1': 1, '5124667-1': 1}

3960816-1

noncomm/PMC003xxxxxx/PMC3960816.xml

Transtracheal oxygen and positive airway pressure: A salvage technique in overlap syndrome

A 63-year-old white man with a history of hypercarbic-hypoxemic respiratory failure due to moderate COPD and with mild SAHS, presented with worsening fatigue, dyspnea, and development of peripheral edema. His initial polysomnography 10 years earlier revealed obstructive sleep apnea (OSA) with an AHI of 13.4/hour with oxygen desaturations to 62% on room air, entirely due to obstructive hypopneas. He was completely compliant with CPAP therapy at 11 cm of water pressure in addition to oxygen at 4 liters per minute (LPM), which had been demonstrated to adequately correct his sleep disordered breathing in the sleep laboratory. He was found to have emphysema with an forced expiratory volume in the first second (FEV1) of 67% of predicted. He quit smoking and was compliant with his bronchodilators and medical therapy for diastolic dysfunction.\nDespite medical compliance, 8 years later he complained of worsening fatigue. Daytime oxygen requirements while walking rose to 6 LPM and nocturnal oxygen saturations fell to 70% on 5 LPM of oxygen with CPAP. He had to stop working because it was impractical for him to have such high oxygen flows at work. Repeat polysomnography was performed for retitration of CPAP therapy. This demonstrated correction with CPAP at 15 cm of water pressure and 4 LPM of O2, yielding an AHI of 0 with saturations >90%.\nEchocardiography and cardiac catheterization showed diastolic dysfunction and no obstructive coronary artery disease or valvular disease. Diuretic therapy was intensified without improving oxygenation or symptoms. Computerized tomography of the chest with contrast showed baseline emphysema and no pulmonary emboli. Repeat pulmonary function was unchanged with FEV1 at 67% of predicted and stable lung volumes. Awake resting arterial blood gas on oxygen at 5 LPM was at baseline (pH: 7.45, PaCO2: 54 torr, PaO: 61 torr). A repeat nocturnal oximetry demonstrated desaturations to 75% on CPAP at 15 cm of water pressure with oxygen at 5 LPM. Interestingly, he never had erythrocytosis with a hemoglobin level of 13.6 g/dl.\nHe refused suggested tracheostomy in order to initiate nocturnal mechanical ventilation with a positive pressure ventilator, but agreed to have to TTOT in order to improve nocturnal oxygenation. A SCOOP® TTOT catheter was placed using a modified Seldinger technique. Subsequently, CPAP at 15 cm of water pressure was continued with TTOT at 4 LPM. Nocturnal oximetry on these settings showed no desaturations below 87% and <5 min with saturations below 90% []. A repeat blood gas after TTOT was not performed, as this would have required an indwelling arterial catheter to be representative of his true response to therapy while sleeping. Such maneuver was deemed too invasive for clinical therapy, considering his oximetry and overall clinical improvement. A daytime arterial blood gas, in a stable clinical state did demonstrate a decrease in PaCO2 to 48 while awake with TTOT. He had no complications of TTOT except for occasional mucous ball formation early in therapy and occasional tube dislodgment, which over time resolved with further patient education and the addition of guafenesin oral therapy. There were no problems related to air leaks or other pathology around the TTOT catheter site during CPAP therapy, and he markedly improved with decreased fatigue, dyspnea, and edema. He increased his activity level and lost 16 kg with diet and improved exercise tolerance. To determine if CPAP was still required, he was restudied without CPAP and with TTOT at 2 LPM. The overall AHI was 3.5/h, but with a supine AHI of 36/h. Saturations dropped to 87% with 17.2 min <89%. CPAP was reinstituted.\nOver the ensuing year he improved further clinically. He intentionally cancelled his disability payments and returned to work as a car salesman with TTOT at 2 LPM with SaO2>90% with ambulation.

[[63.0, 'year']]

M

{'10852759': 1, '2508522': 1, '2184489': 1, '4051407': 1, '28869230': 1, '8484632': 1, '2609134': 1, '18250217': 1, '21285058': 1, '1582276': 1, '24669088': 2}

{}

3960817-1

noncomm/PMC003xxxxxx/PMC3960817.xml

Solitary pulmonary nodule: A rare presentation of pulmonary mucormycosis in an immunocompetent adult

A 70-year-old male, smoker for 4 decades presented with high-grade fever for 2 weeks and episodes of hemoptysis for 5 days. He was admitted to our institution with massive hemoptysis. General survey revealed temperature was 102°F; pulse rate was 104/min, regular; respiratory rate was 28/min and blood pressure was 130/76 mm of Hg. Systemic examination including respiratory system was essentially normal. Routine blood and biochemistry showed hemoglobin was 8.7 gm/dL, total white blood cell count was 4600/mm3 with neutrophil comprising 77%, platelet count was 1,75,000/cmm, fasting sugar was 76 mg/dL, serum levels of urea was 28 mg/dL, and creatinine was 0.9 mg/dL. Blood for HIV I and II was negative, and there was no evidence of immunosuppression. His chest X-ray posterior-anterior view showed a nodular opacity in right upper zone. His hemoptysis was controlled with conservative management but fever persisted and we went for further investigation. Contrast-enhanced computed tomography (CT) thorax revealed an irregular, well-demarcated nodule (32 H.U) measuring 2.3 × 1.6 cm seen at anterior segment of right upper lobe with few areas of rarefaction within the nodule []. We suspected the nodule to be malignant and went for CT-guided fine needle aspiration cytology (FNAC) and true cut biopsy. CT-guided FNAC showed plenty of fungal hyphae in a necroinflammatory background with absence of granuloma or malignancy. Giemsa-stained smear showed broad, irregular, nonseptate hyphe with right-angled branching consistent with the diagnosis of mucormycosis []. Gomori's methenamine silver staining of CT-guided true cut biopsy also demonstrated the typical hyphae suggestive of mucormycosis. Hematoxylin and eosin staining of the true cut biopsy material showed wide areas of necrosis and inflammatory cell infiltration [].\nFungal culture of the specimen inoculated on Saboraud's Dextrose Agar medium yielded white colonies within 3 days and organism was identified as mucor. Fibreoptic bronchoscopy revealed bleeding coming out of right upper lobe bronchus along with congested mucosa. Bronchoalveolar lavage showed absence of malignant cells along with no growth of mycobacterium and fungus. Positron emission tomography-CT scan showed a non-FDG avid nodule with spiculated margin and calcification in anterior segment of right upper lobe []. The diagnosis of pulmonary mucormycosis was confirmed. As patient refused surgery, we started treatment with intravenous liposomal amphotericin B at a dose of 5 mg/Kg for a period of 4 weeks. Fever subsided after 4 days of starting liposomal amphotericin B and follow up chest X-ray and CT scan after 6 weeks were normal [].

[[70.0, 'year']]

M

{'10386506': 1, '20165666': 2, '33906622': 2, '30560048': 1, '26288745': 1, '19435437': 1, '22167397': 1, '23683872': 2, '29748841': 1, '20656848': 1, '10756000': 1, '15359632': 1, '11529408': 1, '31388490': 1, '24669089': 2}

{'2822332-1': 1, '8077830-1': 1, '3658989-1': 1}

3960818-1

noncomm/PMC003xxxxxx/PMC3960818.xml

Non-resolving pneumonia: A rare presentation of progressive disseminated histoplasmosis

A 17-year-old male patient, student and nonsmoker, consulted a local physician at Murshidabad, West Bengal with high grade intermittent fever with chills but no rigors, cough with scanty mucoid expectoration, dull aching chest pain, and generalized weakness for 5 days. The patient's chest X-ray postero-anterior (PA) view at that time showed middle lobe consolidation []. The patient was treated as CAP with oral amoxicillin + clavulanic acid (625 mg) 8 hourly and levofloxacin (500 mg) daily was added afterwards. As the patient's condition deteriorated with documented weight loss of 5 Kg in 2 weeks, his father brought him to our hospital. On examination, the patient was very toxic with blood pressure 90/60 mmHg, pulse rate 130/min regular, respiratory rate 32/min with moderate pallor. Examination of the respiratory system revealed crepitations in the right mammary area. Examinations of other systems were normal. We treated the case as non-resolving pneumonia and did antibiotics adjustment with the intravenous cefoperazone-sulbactam (1.5 g) 8 hourly and oral clarithromycin (500 mg) twice daily along with the other supporting treatment. The investigations revealed hemoglobin 6.4 g%, total white cell count 15200/mm3 with 94% neutrophils; fasting blood sugar 86 mg/dl, urea 45 mg/dl, creatinine 0.8 mg/dl, total bilirubin 0.96 mg/dl, alanine transaminase 78 U/L, aspartate transaminase 82 U/L and alkaline phosphatase 238 U/L. Routine urine examination was normal and culture revealed no growth after 72 h of incubation. Blood culture (two samples) was negative for bacteria. His sputum smear was negative for acid-fast bacilli for 3 consecutive days. Enzyme-linked immunosorbent assay (ELISA) for HIV 1 and 2 was non-reactive. Mantoux test with 5 T.U. was negative. HBsAg and anti-HCV were negative. USG whole abdomen showed hepatosplenomegaly. The patient's condition deteriorated further with appearance of right-sided pleural effusion [] and hepatosplenomegaly. Examination of pleural fluid showed cell count of 560/mm3 with 70% lymphocytes, protein 3.4 gm/dl, sugar 46 mg/dl, lactate dehydrogenase 600 U/L and adenosine deaminase 36 U/L. The patient's contrast enhanced computed tomography (CECT) of thorax showed organization of right middle lobe consolidation with enlargement of right paratracheal and subcarinal lymph nodes with central necrosis []. Fibre-optic bronchoscopy revealed pus coming from the right main bronchus and a gelatinous mass in the posterior wall of trachea and a widened carina with constricted right main bronchus []. Bronchoscopic biopsy from the mass showed inflammatory granulation tissue with proliferation of capillaries and infiltration of a large number of inflammatory cells. Gomori's methenamine silver stain showed fungal spores morphologically resembling Histoplasma capsulatum []. Bronchoalveolar lavage (BAL) and transbronchial needle aspiration (TBNA) from subcarinal lymph node also showed the presence of capsulated round microorganism on a background of inflammatory exudates compatible with Histoplasma capsulatum. Post-bronchoscopic sputum for fungal culture showed a growth of Histoplasma capsulatum. The patient did not have any past history suggestive of exposure to Histoplasma capsulatum. The patient was treated with intravenous amphotericin B 50 mg/day for 1 week followed by oral itraconazole 200 mg twice daily. Significant clinical improvement was noticed by 7 days and follow-up chest X-ray after one month showed a significant radiological resolution [].

[[17.0, 'year']]

M

{'14728631': 1, '22707773': 2, '3396672': 1, '13152378': 1, '17223625': 1, '15006826': 1, '2245668': 1, '9584414': 1, '10903235': 1, '19375629': 1, '24669090': 2}

{'3371525-1': 1}

3960819-1

noncomm/PMC003xxxxxx/PMC3960819.xml

Mounier-Kuhn syndrome masquerading pulmonary thromboembolism in an elderly male

A 70-year-old male presented with shortness of breath for 3 days. There was associated mild non-productive cough. Patient had a past history of episodes of cough with expectoration and fever on several occasion. However, the patient had never suffered such a severe respiratory embarrassment in the past. On examination, there was tachycardia (heart rate of 100 bpm), tachypnea (respiratory rate was 25/min) with SpO2 85% and FiO2 50%. Patient was afebrile and blood pressure was within normal range (measured on at least three occasions). On general physical examination, the patient had pallor. However, there was no cyanosis, clubbing or pedal edema. Cardiorespiratory examination was significant for bilateral crepitations and occasional bronchial breath sounds. The heart sounds were normal. Hemogram revealed mild anemia (hemoglobin 11.5 g%). However, the total and differential leukocyte counts as well as platelet counts were normal. Routine biochemical tests including renal and liver function tests were normal. Chest radiograph (CXR) revealed patchy areas of bronchiectasis in both lungs. In addition, there were fibrotic opacities, more on the right side []. Echocardiography revealed dilatation of the right atrium (RA) and ventricle (RV). Associated findings included decreased contractility of RV and moderate tricuspid regurgitation. A diagnosis of acute pulmonary thromboembolism (PTE) was suggested. Doppler ultrasound evaluation of bilateral lower limbs was negative for deep venous thrombosis. Well's pre-test probability score was 4.5 (pulmonary embolism more likely than alternate diagnosis and heart rate more than 100). CT pulmonary angiography (CTPA) was subsequently performed to establish the diagnosis. CTPA excluded the diagnosis of acute PTE; however, high resolution CT reconstructions revealed massive enlargement of trachea (maximum diameter of 33 mm) and right main bronchus (maximum diameter of 25 mm) with evidence of tracheal and bronchial diverticula. There was extensive bronchiectasis involving the right upper lobe with peripheral fibrotic opacities suggestive of parenchymal scarring [Figures and ]. The main pulmonary artery was dilated. Further, the echocardiography findings of dilatation of RA and RV were confirmed. The pulmonary artery hypertension (PAH) was explained to be due to extensive parenchymal disease. Retrospective evaluation of a CXR done 1 year back revealed tracheabronchomegaly. The lung fields were unremarkable. Thus, a diagnosis of tracheabronchomegaly with bronchiectasis and PAH was made and patient was put on oxygen therapy and chest physiotherapy.

[[70.0, 'year']]

M

{'13958486': 1, '27022496': 1, '6733410': 1, '18176298': 1, '28845373': 2, '17699133': 1, '32425272': 1, '7956426': 1, '3366947': 1, '21493699': 1, '24669091': 2}

{'5572046-1': 1}

3960820-1

noncomm/PMC003xxxxxx/PMC3960820.xml

A rare case of calcified pulmonary aspergilloma

A 40-year-old male patient presented with cough with expectoration, and blood streaked sputum, which was intermittent for 2 years. He was diagnosed to have pulmonary tuberculosis 2 years ago for which he took treatment for 8 months. On examination, vitals were stable, and respiratory system examination revealed bronchial breath sounds in left upper lobe with crepitations. Routine blood examination showed eosinophilia and raised erythrocyte sedimentation rate (ESR) 20 mm/h. Chest X-ray revealed presence of left upper lobe cavity with accompanying air crescent []. Sputum for acid fast bacilli (AFB) smear was negative.\nBronchoscopy revealed white mass lesion occluding the apical posterior segment, which was hard and powdery on biopsy []. Histopathological examination of the biopsy specimen showed necrotic tissue fragments and fungal mass, composed of dichomatously branching, acute angled septate hyphae of Aspergillus. Calcified concretions were seen surrounding the debris and stained positive for periodic acid Schiff stain (PAS) []. There was no lymphoid tissue in the specimen to suggest broncholith due to erosion of calcified node within bronchus. Ziehl Neelson staining of the bronchial lavage showed presence of AFB. Cytology of bronchial brush showed few endobronchial cells, metaplastic squamous cells and occasional atypical cells. Many clusters of necrotic cells with histiocytes, neutrophils, and acute angled septate fungal hyphae were seen in a background of necrotic material and red blood cells (RBCs), suggestive of an abscess with aspergillosis. Based on the bronchoscopy findings and histopathology report, he was diagnosed to have calcified aspergilloma in the left upper lobe with active tuberculosis. Antitubercular treatment was restarted under DOTS Category II, with INH, rifampicin, pyrazinamide, ethambutol, and streptomycin.\nFollow up of the patient was done, and bronchoscopy repeated after one year revealed disappearance of the calcified mass. AFB smear and fungal smear of bronchial lavage were negative. Lung biopsy showed no evidence of fungal elements.

[[40.0, 'year']]

M

{'22470708': 1, '20854667': 2, '5495645': 1, '21786444': 1, '24669092': 2}

{'2949699-1': 1}

3961609-1

noncomm/PMC003xxxxxx/PMC3961609.xml

A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft

A 74-year-old woman encountered an avulsion injury to the right leg by a moving wheel, which resulted in a circumferential degloving of the skin from mid-thigh to the dorsum of the foot (). The patient had been suffering from diabetes and hypertension for more than 10 years. After adequate debridement, the devascularized skin flap was defatted in attachment and used as a FTSG to cover the denuded area. Multiple but small areas of necrosis were found (). At postoperative day 21, debridement and STSG were performed. At a follow-up 2 months postoperatively, the appearance was acceptable (). At a follow-up at 13 months, no limitation of ambulation was evident.

[[74.0, 'year']]

F

{'3307597': 1, '3157528': 1, '6457549': 1, '343126': 1, '7039753': 1, '32367939': 1, '28443251': 2, '8657766': 1, '22544087': 1, '17857505': 1, '17431986': 1, '13510571': 1, '9385954': 1, '7870778': 1, '18580145': 1, '13657722': 1, '335416': 1, '4595232': 1, '4952282': 1, '22544108': 1, '11252097': 1, '27555888': 1, '7011158': 1, '15480715': 1, '13812150': 1, '3533379': 1, '28913226': 1, '3969411': 1, '24665420': 2}

{'3961609-2': 2, '3961609-3': 2, '5288623-1': 1}

3961609-2

noncomm/PMC003xxxxxx/PMC3961609.xml

A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft

A 54-year-old man was run over by a car, which resulted in an avulsion of skin on the lateral surface of the right foot (). The patient took warfarin regularly to prevent thromboembolism due to atrial fibrillation. After debridement, the devascularized skin flap was defatted and used as a FTSG. Necrosis was found at a small area where there was hematoma. A small STSG was done and recovery was uneventful. The appearance was good ().

[[54.0, 'year']]

M

{'3307597': 1, '3157528': 1, '6457549': 1, '343126': 1, '7039753': 1, '32367939': 1, '28443251': 2, '8657766': 1, '22544087': 1, '17857505': 1, '17431986': 1, '13510571': 1, '9385954': 1, '7870778': 1, '18580145': 1, '13657722': 1, '335416': 1, '4595232': 1, '4952282': 1, '22544108': 1, '11252097': 1, '27555888': 1, '7011158': 1, '15480715': 1, '13812150': 1, '3533379': 1, '28913226': 1, '3969411': 1, '24665420': 2}

{'3961609-1': 2, '3961609-3': 2, '5288623-1': 1}

3961609-3

noncomm/PMC003xxxxxx/PMC3961609.xml

A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft

A 20-year-old woman injured her right leg in a car accident. This was a circumferential degloving of the skin of the calf (). The patient received FTSGs made from the avulsed flap for coverage. On postoperative day 6, ongoing necrosis on the non-defatted area of the right calf was noted (). Debridement was performed and VAC was applied. At postoperative day 23, final coverage was done with acellular dermis and STSG from a thigh. At a follow-up at 6 months, no limitation of ambulation was evident. The patient requested camouflage surgery of the STSG area ().

[[20.0, 'year']]

F

{'3307597': 1, '3157528': 1, '6457549': 1, '343126': 1, '7039753': 1, '32367939': 1, '28443251': 2, '8657766': 1, '22544087': 1, '17857505': 1, '17431986': 1, '13510571': 1, '9385954': 1, '7870778': 1, '18580145': 1, '13657722': 1, '335416': 1, '4595232': 1, '4952282': 1, '22544108': 1, '11252097': 1, '27555888': 1, '7011158': 1, '15480715': 1, '13812150': 1, '3533379': 1, '28913226': 1, '3969411': 1, '24665420': 2}

{'3961609-1': 2, '3961609-2': 2, '5288623-1': 1}

3961611-1

noncomm/PMC003xxxxxx/PMC3961611.xml

Perforator Flaps after Excision of Large Epidermal Cysts in the Buttocks

A 77-year-old diabetic male visited our outpatient clinic complaining of a mass on the right ischium that had been growing for 11 years. Two years previously, he had undergone incisional drainage of the cyst at a local clinic, but after a year, the cyst had recurred and had grown even bigger. He was admitted for surgery, and the mass was removed under general anesthesia (). The defect measured 2.5 cm×4 cm at its outer surface with a 6-cm internal pocket. The defect was sufficiently small for primary closure, but there was a considerable amount of dead space resulting from the excision of the mass. To fill this dead space, a perforator near the defect was identified, and a PBIF 9 cm×4 cm in size was elevated from the buttock and used to cover the defect. First, the pivot point was closed; then, the remaining donor site was closed; and thereafter, the partially de-epithelized flap was inset to obliterate the dead space. Negative suction drainages were positioned at the donor site, and Dermabond (Ethicon) was applied to the flap to save it from contamination by fecal material. The patient was followed up for 9 more months, and there were no complications or recurrences ().

[[77.0, 'year']]

M

{'17291301': 1, '16681659': 1, '20634161': 1, '8446721': 1, '11322399': 1, '31605009': 2, '9068667': 1, '19333649': 1, '8883728': 1, '12828852': 1, '18650614': 1, '16772955': 1, '21044221': 1, '11743392': 1, '11167729': 1, '20517100': 1, '16520992': 1, '24665422': 2}

{'6789127-1': 1, '6789127-2': 1, '6789127-3': 1}

3961902-1

noncomm/PMC003xxxxxx/PMC3961902.xml

Management of unicystic ameloblastoma of the mandible in a 5-year old child

A 5-year-old boy presented to our unit Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India with a painless hard swelling in the lower chin region of 3 months duration. Extra oral examination revealed a facial asymmetry with diffuse swelling over the chin region. Swelling was found to be approximately 2 cm × 2 cm in size, overlying skin was normal in color and texture with no evidence of sinus/fistula.\nIntra oral examination revealed adequate mouth opening with intact deciduous dentition. Swelling was extended from right deciduous molar to left canine. Mucosa overlying was normal in color. Swelling was non-tender, non-pulsatile, bony hard, non-fluctuant, non-compressible on palpation with expansion of both, buccal as well as lingual cortical plates and aspiration from the swelling yielded cystic color fluid.\nPanoramic radiographic revealed that unilocular well-defined radiolucent lesion extending from lower deciduous first mandibular molar to right lower canine with evidence of roots resorption []. All other blood investigations were within the normal limit.\nOn the basis of lingual cortical bone expansion, presence of cystic fluid on aspiration and evident of root resorption of the teeth in the panorex, we made the provisional diagnosis of UA. Treatment was planned according to UA.\nEnucleation of the cyst with extraction of the involved teeth followed by application of Carnoy's solution for 3 min over the cavity was planned under general anesthesia (GA).\nTreatment performed - patient was taken under GA. Planned treatment procedure was carried out successfully. Specimen obtained was sent for histopathological examination.\nHistopathology report of the specimen revealed that type 1 UA as per the histological criteria defined by Ackerman et al. [Figure and ].\nPatient has been on regular follow-up since 2 years, patient is doing well with no signs of recurrence [].

[[5.0, 'year']]

M

{'7595787': 1, '922668': 1, '14356722': 1, '15290793': 1, '6697311': 1, '3150441': 1, '28717292': 1, '1695942': 1, '24665183': 2}

{}

3961903-1

noncomm/PMC003xxxxxx/PMC3961903.xml

Malignant myoepithelioma of the maxilla posing a diagnostic dilemma

A 55-year old man reported to our department with a 4-month history of a slowly enlarging, asymptomatic mass over the right facial aspect of the maxilla and also a rapidly enlarging asymptomatic mass involving the right side of the palate, since 20 days. History of the present illness revealed that the patient had undergone extraction of the maxillary right first molar due to pain and mobility at a private clinic 4 months ago. Initially, it was associated with five episodes of nasal discharge (blood-tinged), at intervals of 4-5 days, which stopped after taking medications.\nClinically, there was diffuse swelling of the right cheek with obliteration of the right nasolabial fold. The overlying skin was intact and normal. There was neither pain nor neurologic deficit. The orbit was intact. The submandibular lymph nodes bilaterally were palpable, measuring 1 × 0.5 cm in dimension, ovoid in shape, and freely mobile. Tenderness was elicited in the right submandibular group.\nA 6 × 3 cm in size, intraoral, smooth-surfaced, submucosal swelling in the right palatal region extending from the 1st premolar to the 3rd molar, with extension into the buccal vestibule through the missing 1st molar space, obliterating it to a minimal degree, was seen []. The overlying mucosa was intact and healthy. The teeth in around the tumor mass were mobile.\nAfter clinical examination, a benign tumor of minor salivary glands, arising either from the palate or right maxillary sinus, was suspected.\nPanoramic radiography revealed a well-defined, unilocular radiolucency in the right maxilla, extending from the right maxillary 3rd molar to the right 1st premolar, causing no displacement of the roots of the teeth. The maxillary sinus was completely surrounded by intact bone except in the region of the 1st molar where a discontinuity in the sinus floor was detected. Paranasal sinus radiography revealed a well-defined, radiopaque mass in the right maxillary sinus [].\nA computed tomographic (CT) scan revealed a well-defined, well-circumscribed, encapsulated mass, involving the right maxilla, extending superiorly to the sinus roof. The mass revealed soft-tissue extensions into the palatal vault. The maxillary sinus and nasal floor were completely surrounded by intact bone, except in the region of the 1st molar, where it appeared discontinuous [].\nAn fine needle aspiration cytology of the swelling was performed. The smear showed highly cellular, cohesive clusters of epithelial cells with distinct cell borders, resembling salivary gland epithelial cells. They were round to cuboid, with distinct nuclei and nucleoli. Many spindle-shaped, myoepithelial cells were also seen scattered singly and in small clusters against a fibrillar, myxoid stromal background. A basement membrane-like, pinkish substance was also seen scattered amidst the epithelial cells. Some of the epithelial cells showed the typical acinar pattern of arrangement against a background of abundant myxoid stroma. These features were in favor of pleomorphic adenoma.\nAn intraoral incision biopsy was performed under local anesthesia. The lesion consisted of friable, hemorrhagic soft tissue. Macroscopically, the specimen measured 1.5 × 1 × 0.8 cm in dimension, was soft to firm in consistency, ovoid, and whitish to brown in color. Microscopically, a parakeratinized stratified squamous epithelium with short rete ridges, elongated spindle-shaped cells arranged in fascicles focally and few myxoid areas were noted. The subjacent connective tissue was highly cellular with dense, mixed inflammatory-cell infiltrate, plasma cells and blood vessels. Upon histopathologic findings, the diagnosis of spindle-cell tumor was interpreted.\nThe patient underwent surgical intervention under nasotracheal, hypotensive, general anesthesia. The tumor was approached via a Weber-Ferguson incision. A wide, local resection was carried out in the form of a right subtotal maxillectomy including the all teeth of the involved quardrent, preserving the infra orbital rim and posterior wall of the maxillary sinus, and the defect was resected out []. The resulting maxillary defect was reconstructed using a temporalis myofascial flap. Neck dissection was not carried out in this case.\nThe resected specimen revealed a thick, fibrous pseudocapsule, consisting of highly cellular stroma of spindle cells, plasmocytoid cells, and epitheloid cells with mitoses and lesser degree of pleomorphism. Anastomosing cords of spindle cells in a fibro-myxoid stroma were the dominant feature appreciable. In some areas, cords of cells with epithelial islands, with luminal spaces and peripheral palisading, were seen. Areas of hyalinization and chondro-myxoid differentiation were also seen [].\nThe histopathological features of the tumor proper were diagnostic of Malignant Myoepithelioma of the maxilla. Inmunohistochemical study in our case favored the diagnosis of malignant myoepithelial tumor []. Most tumor cells were strongly reactive to pancytokeratin, epithelial membrane antigen, calponin, and nuclear positivity for S-100 protein. The immunoreaction for muscle-specific actin was negative.\nDistant metastasis was ruled out by a chest radiograph, ultrasonography of the neck and abdomen, and supplemental liver function tests. To date, the case we present had no clinical or radiological evidence of loco-regional and distant metastases following surgical intervention, posing a favorable to good prognosis.

[[55.0, 'year']]

M

{'15660092': 1, '12464204': 1, '24847433': 2, '10203226': 1, '12775221': 1, '1617588': 1, '12767885': 1, '24665184': 2}

{'4019922-1': 1}

3961904-1

noncomm/PMC003xxxxxx/PMC3961904.xml

Aggressive monophasic synovial sarcoma involving sublingual gland: First case

A previously healthy 35-year-old female patient presented with 1½ year history of gradually progressive swelling in the floor of mouth on the left side. She had no difficulty in speech or swallowing. Intraoral examination revealed a smooth swelling of floor of mouth on the left side []. There was no other lymph node palpable in the neck. Results of routine laboratory tests were within the normal limits. Cytological analyses fine-needle aspiration (FNA) of the mass pointed to a mixed salivary tumor-pleomorphic adenoma. Contrast enhanced computed tomography scan showed 3.2 cm × 1.8 cm well-defined homogenously enhancing lesion in the floor of mouth on the left side with no abnormal regional lymph nodes [].\nAt surgery, tumor was well encapsulated with lobulations and enbloc excision along with the capsule was done []. On histopathology, the tumor contained monotonous proliferation of small spindle shaped or ovoid neoplastic cells with pale, eosinophilic cytoplasm []. On immunochemical staining, tumor cells were strongly positive for Mic 2, calponin and focally for cytokeratin (CK), Vimentin and bcl2. They were negative for epithelial membrane antigen ( EMA), S100 protein and HMB45. Final diagnosis of monophasic synovial sarcoma from sublingual gland was made. Patient was advised adjuvant radiotherapy. With only 10# of radiotherapy she developed mucositis and refused any further treatment. On follow-up she developed huge recurrence locally and died of local disease after 6 months.

[[35.0, 'year']]

F

{'13197324': 1, '163680': 1, '8412164': 1, '3028451': 1, '1654252': 1, '1320596': 1, '6282438': 1, '10375108': 1, '17274049': 1, '11078492': 1, '24665185': 2}

{}

3961905-1

noncomm/PMC003xxxxxx/PMC3961905.xml

Chondrosarcoma of body of the mandible

A 60-year-old female patient reported to the department of oral and maxillofacial surgery, with chief complaint of painless swelling at right side of the mandible, which had been present for 6 months. Two months back, the growth was excised incompletely by a general dental practitioner; unfortunately, the excised specimen was not sent for histopathological examination and was discarded, following which the remaining growth grew rapidly.\nExtraoral examination showed a swelling at body of the right mandible measuring 6 × 6 cm [] extending intraorally from right mandibular canine to distal aspect of right mandibular second molar. Swelling was bony hard, ill defined, and caused obliteration of right lower buccal vestibule. There was no regional lymphadenopathy.\nA panoramic radiograph revealed a widened periodontal space and an irregularly-shaped osteoblastic lesion with radiopacity. There were signs of sclerosis and new bone formation in the body of right mandible, which was extending to the angle region. There were signs of patchy bony destruction near the root of molar and premolar teeth [].\nAn incisional biopsy was performed which histopathologically revealed areas of hyaline cartilage in lobules with increased cellularity and cellular pleomorphism. Intervening tissue revealed fibrocollagenous stroma. Periphery of the lesion demarcated cellular dedifferentiation into the spindle cells. Mitosis was frequent. Focal calcification and liquefaction were also evident within the cartilage []. The case was hence diagnosed as chondrosarcoma.\nA segmental resection under general anesthesia was performed extending from the right lateral incisor and the ramus of the mandible, as the mandibular basal bone appeared to be affected. The surgical margins were free of malignant cells.

[[60.0, 'year']]

F

{'29567926': 2, '11019556': 1, '8635057': 1, '269931': 1, '29491602': 2, '1462610': 1, '6400634': 1, '3049678': 1, '3455725': 1, '5239086': 1, '24665186': 2}

{'5851199-1': 1, '5851199-2': 1, '5824514-1': 1}

3961906-1

noncomm/PMC003xxxxxx/PMC3961906.xml

Extraosseous calcifying cystic odontogenic tumor: An uncommon variant

A 17-year-old male patient reported with a chief complaint of swelling in relation to the right region of the lower jaw, since 4 months. Patient denied any family, medical, dental or personal (habit) history. Extra-oral examination was insignificant. On intra-oral examination, a pinkish dome-shaped, oval nodular growth was seen measuring about 1 × 1 cm in diameter, in relation to 48 region. On palpation, it was asymptomatic, fluctuant and sessile. The overlying mucosa was normal with superficial blood vessels, giving a pinkish appearance []. No other intraoral deformity was noted. Intra-oral periapical radiograph (IOPA) shows no osseous involvement, but vertically impacted 48 []. All other teeth showed normal development and eruption. Based on these features a differential diagnosis of hyperplastic or reactive lesions arising from the gingival and eruption cyst was made.\nExcisional biopsy under local anesthesia was performed. Microscopic examination showed a cyst lined by an epithelium with numerous ghost cells and few calcified masses. The basal cells were cuboidal to columnar with darkly staining nuclei, polarized away from the basement membrane, and showed palisading appearance similar to ameloblasts []. Based on these features a definite microscopic diagnosis of ECCOT was made. No recurrence was noted at a one-year follow-up.

[[17.0, 'year']]

M

{'6948493': 1, '18221328': 1, '30150421': 1, '13949298': 1, '15287310': 1, '20953743': 1, '26557757': 1, '19400612': 1, '1891245': 1, '9526728': 1, '11846854': 1, '24665187': 2}

{}

3961908-1

noncomm/PMC003xxxxxx/PMC3961908.xml

Bilateral cavernous sinus thrombosis and facial palsy as complications of dental abscess

A 50-year-old, previously healthy, female patient presented with complaints of fever, pain, and pus discharge from right maxillary molars and swelling of right cheek since 15 days. Three days later she developed puffiness of both eyes.\nPatient was drowsy at the time of admission. She was mildly febrile. On examination, there was diffuse inflamed swelling over right maxillary region along with bilateral exophthalmos with chemosis and congestion of conjunctiva. Oral examination revealed right maxillary dental abscess related to molars. Central nervous system examination revealed nuchal rigidity. Bilateral ptosis with external ophthalmoplegia was present along with palsy of lower half of face []. Other neurological examination was normal. Other systems examination did not reveal any abnormality.\nHer baseline investigations revealed the following results: Total leukocyte count: 17000/mm3, Differential leukocyte count: P80L18E1M1, Erythrocyte sedimentation rate: 46 mm/h, serum Na+136 meq/L, serum K+3.4 meq/L, blood urea 20 mg/dL, serum creatinine 0.6 mg/dL, and random blood glucose 106 mg/dL. Her chest X-ray revealed multiple thin-walled abscesses (pneumatoceles) []. HIV Enzyme-linked immunosorbent assay was nonreactive.\nThe patient was first seen by oral and maxillofacial surgeon. Her orthopantomogram was done which showed opacity at the tips of right second and third maxillary molars []. Drainage of the dental abscess and extraction of the right maxillary molars was done immediately. The pus sent for culture grew Staphylococcus aureus. With suspicion of CST, the patient was transferred to neurology department. Her magnetic resonance imaging (MRI) brain was done which showed bilateral mastoiditis along with bilateral CST with abscess in right cerebellar and right cerebellopontine angle region with infarct in right parietooccipital and right high parietal region [Figures and ]. Magnetic resonance (MR) venography did not show involvement of any other major sinuses. The patient was started on intravenous fluids and antibiotics (vancomycin 2 g/day, ceftriaxone 2 g/day, and clindamycin 1200 mg/day). Anticoagulant was added in the form of enoxaparin 0.4 mL s.c. twice a day. Oral anticoagulant (warfarin) was added subsequently.\nThe patient improved during the hospital stay of 4 weeks and was discharged satisfactorily. At follow-up after 3 months, she had complete recovery.

[[50.0, 'year']]

F

{'21789100': 1, '11732931': 1, '16527775': 1, '331338': 1, '25621244': 1, '1747254': 1, '20873087': 1, '11112970': 1, '22993494': 1, '2685213': 1, '24665189': 2}

{}

3961909-1

noncomm/PMC003xxxxxx/PMC3961909.xml

Unilateral temporomandibular joint ankylosis with contralateral aplasia

A 6-year-old female patient reported to our outpatient department with the complaints of nil mouth opening, facial disfigurement, and night episodes of respiratory distress. On examination, the patient had no movements of the right TMJ, with pronounced antigonial notches on either side or reduced chin []. Systemically, the patient had all the signs and symptoms of obstructive sleep apnea syndrome (OSAS) with PC of the chest [Figures and ]. The patient's chief complaint was respiratory distress with facial asymmetry, which was first noticed in childhood and gradually progressed. Panoramic examination revealed that the right mandibular condyle exhibited ankylotic changes, while there was complete absence of the left condylar head and the ramus terminated relatively obliquely below the level of the sigmoid notch []. For obtaining further information, the patient was submitted to a DentaScan evaluation. The images revealed the complete absence of the left condylar head and neck []. On evaluating the patient for excluding the syndromes, the chest exhibited PC (pigeon breast) with shallow breathing and chest expansions. PA chest revealed a barrel-shaped chest with normal lung and heart fields. The patient was further evaluated for episodes of apnea and snoring.\nPreparations were made for emergency access to the airway. IV line was established and the patient was sedated for blind intubation. After successful blind nasotracheal intubation from the left nostril, access to bony chunk on the right TMJ region was made with the help of AlKayat–Bramley incision and the bony chunk was relieved. Intraoperative mouth opening of 3.5 cm was achieved and the gap was interpositioned with temporal fascia. Layer wise closure was done. Post-surgical active jaw physiotherapy was started after 48 h of surgery. Mouth opening was maintained at 3.2 cm after 15 days of follow-up.

[[6.0, 'year']]

F

{'1506969': 1, '19794884': 1, '15194071': 1, '13133340': 1, '3456239': 1, '7552889': 1, '18778456': 1, '271015': 1, '271211': 1, '7936579': 1, '10409817': 1, '11842835': 1, '12768421': 1, '2314852': 1, '1923435': 1, '17881603': 1, '3473352': 1, '17982540': 1, '2019890': 1, '25738097': 1, '27284559': 1, '24665190': 2}

{}

3961926-1

noncomm/PMC003xxxxxx/PMC3961926.xml

Tuberculous brain abscess in an immunocompetent adolescent

An 18-year-old male presented with complaints of sub-acute onset, moderate to severe, occipitonuchal headache associated with vomiting and low grade fever 1 year back. He was initially evaluated and treated by a primary care physician. The treatment records were not available with the patient. With some symptomatic relief after initial 2 months of treatment, he discontinued medications without any medical advice or further follow-up. For another 9 months he continued to have recurrent off and on headache at irregular intervals which used to get relieved with over the counter medications. Over the last 6 months he had symptoms suggestive of progressive gait ataxia and right upper limb intentional tremors. For last 1 month he had resurgence of the symptoms in the form of severe holocranial headache, vomiting and fever. There was no history of seizures, loss of consciousness, any bulbar symptoms, diplopia, facial numbness or weakness. There was no significant past medical history. He was unmarried, rural dweller with agriculture as main vocation. There was no history of any high risk sexual behaviour. His mother took treatment for pulmonary tuberculosis for 9 months, 15 years back. Her exact medication records were not available.\nOn examination the general physical examination was unremarkable. He was conscious and well oriented to time place and person. All the cranial nerves including fundus were within normal limits. There was horizontal nystagmus in right eye on right lateral gaze with fast component towards the side of gaze. There was hypotonia on right side with grade power five in all limbs. Deep tendon reflexes were bilaterally grade two. Pendular right knee jerk was observed. Sensory examination was normal for touch, pain temperature, joint position, and vibration sense. Right sided cerebellar signs were present in the form of intentional tremors, dysdiadokokinesia, past pointing, and dysmetria. Gait was ataxic, wide based with tendency to sway on right side. Rest of the other systemic examination was normal.\nClinically, space occupying lesion in the right cerebellum-infective granuloma/benign or low grade malignancy was suspected. Routine hematological and biochemical investigations including hepatorenal functions were within normal limits. No abnormality was detected on chest roentgenograph. Enzyme-linked immuno sorbent assay for the HIV was negative. Induration of 16 mm in diameter was noted on a tuberculin skin test. The Magnetic resonance imaging of cranium revealed Intra axial T2 hyperintense and T1 hypointense parenchymal lesion in right cerebellum []. The gadolinium contrast revealed ring enhancement and there was restriction on diffusion weighted image [Figures and ]. The Magnetic resonance spectroscopy study showed lactate and lipid peak []. In view of the radiological abnormalities, possibility of tubercular or pyogenic abscess was kept. Aerobic and anaerobic culture of pus drained from the burr hole was sterile. The microscopic examination of the pus smear demonstrated acid fast bacilli []. The pus culture using Lowenstein jensen media for mycobacteria was sterile after 7 weeks. Histopathology of abscess wall showed chronic inflammatory infiltrate without evidence of caseating granuloma or fungal elements. After drainage of the pus, anti-tubercular therapy was started which resulted in clinically significant resolution of the symptoms. He still continues to be on anti-tubercular therapy and is under regular clinical follow up.

[[18.0, 'year']]

M

{'18809555': 1, '11981617': 1, '10448488': 1, '9217600': 1, '24903315': 1, '20453413': 1, '629659': 1, '27226867': 2, '29142557': 1, '24678219': 2}

{'4877558-1': 1}

3961928-1

noncomm/PMC003xxxxxx/PMC3961928.xml

A rare case of Kartagener's syndrome

A 16-year-old boy presented with 3 months dry cough with intermittent breathlessness. He had no fever or chest pain or hemoptysis. Cough and breathlessness were not associated with any postural or diurnal variation. He used to suffer from frequent cough and cold since childhood. No family history of asthma or atopy was present. Clinical examination revealed normal physical development with mild pallor and digital clubbing. His apex beat was palpable on the right 5th intercostal space in mid-clavicular line on palpation otherwise inspection and percussion findings were normal. Chest auscultation revealed bi-lateral polyphonic rhonchi and basal coarse crepitations with clearly audible heart sounds on the right side. Cardio-vascular examination revealed right-sided 1st heart sound without any murmur. Other system examinations were normal.\nChest X-ray revealed dextrocardia with normal lung field []. Sputum smear examination for acid fast bacillus was negative and aerobic culture showed growth of Staphylococcus aureus. A high-resolution computerized tomography (HRCT) scan of thorax revealed bronchiectasis in lingul []. X-ray of paranasal sinuses revealed bi-lateral maxillary sinusitis with the absence of both frontal sinuses []. Ultrasonography of the abdomen revealed complete situs inversus. Observing the presence of bronchiectasis, sinusitis, and dextrocardia, his semen analysis was done and it revealed complete aspermia with normal seminal fluid content. Fine needle aspiration cytology (FNAC) of the both testes revealed the presence of normal mature sperm, which indicated the inability of the sperm to be transported to the seminal fluid. The Saccharin test revealed delayed movement (35 minutes) of the particle toward oropharynx, which was indicative of impaired nasal ciliary movement. Echocardiography showed dextrocardia with normal atrioventricular concordance without any structural abnormality. Routine blood count was within normal range. The pulmonary function test was of mixed pattern with significant bronchodilator reversibility.\nHe improved significantly after treatment with intravenous 1.2 g co-amoxyclav three times daily, oral 600 mg linezolid twice daily along with nebulized salbutamol and budesonide for 2 weeks.

[[16.0, 'year']]

M

{'301245': 1, '33912655': 2, '2233968': 1, '26960394': 2, '10193380': 1, '20530032': 1, '7383126': 1, '152870': 1, '3969467': 1, '7068928': 1, '21403791': 1, '2233964': 1, '24678221': 2}

{'8059757-1': 1, '4784470-1': 1}

3961929-1

noncomm/PMC003xxxxxx/PMC3961929.xml

Management of palato radicular groove in a maxillary lateral incisor

An 18-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of intermittent pain and discharge in the upper front tooth region since 6 months. No history of trauma was given. The patient medical and family histories were non-contributory, and the results of the extra oral examination were unremarkable.\nIntraoral examination revealed, discolored right lateral incisor with presence of grade I mobility. Examination on palatal aspect revealed a localized pocket of 8 mm depth with pus discharge from the pocket. On careful examination, a deep palatogingival groove was observed, which was extending deep into the apical region [].\nThe tooth did not respond to vitality testing using Electronic Pulp Tester (Parkell Electronics Division, New York, USA). Radiographic examination revealed a well-defined radiolucency in relation to right lateral incisor extending until the apical region of the right central incisor [].\nBased on the history, clinical and radiographic examination the lesion was provisionally diagnosed as pulp necrosis, suppurative periradicular periodontitis and moderate localized periodontitis secondary to the palatoradicular groove.

[[18.0, 'year']]

F

{'2319440': 1, '26587418': 1, '11199740': 1, '28853516': 1, '27141225': 2, '28503472': 1, '10632529': 1, '3183923': 1, '34447834': 1, '11199752': 1, '11202870': 1, '3271682': 1, '28119787': 2, '16728255': 1, '24678222': 2}

{'5227125-1': 1, '4841352-1': 1}

3961931-1

noncomm/PMC003xxxxxx/PMC3961931.xml

Primary tubercular mastitis masquerading as malignancy

A 35-year-old lady, agriculturist by occupation and mother of two children came with painful breast lump in the right side since 3 months. There was no history of fever, cough, or weight loss. Past history revealed that she had similar complaints in the left breast 5 months back which subsided on spontaneous rupture with discharging sinus along with a course of antibiotics. Family history revealed that the patient's in-laws were known cases of pulmonary tuberculosis on treatment.\nClinical examination revealed diffuse firm lump palpable in the right upper quadrant measuring 4 cm × 3 cm. Left breast showed a healed ulcer in the left upper outer quadrant. No axillary lymph nodes were palpable. A clinical differential diagnosis of breast abscess and malignancy was made.\nComplete hemogram, biochemical investigations and chest radiography were within normal limits. Eight milliliter of purulent material was obtained and on fine needle aspiration, smears showed features of granulomatous mastitis. Ziehl Neelsen stain for acid fast bacilli was positive []. Rapid slide culture for Mycobacterium tuberculosis showed growth after 1 week. Lowenstein Jensen (LJ) medium showed growth of typical tubercle bacilli after 4 weeks and confirmed by niacin tests []. A diagnosis of primary tubercular mastitis was made, a four drug regimen of anti-tubercular therapy was initiated and the patient responded well with drastic reduction of symptoms.

[[35.0, 'year']]

F

{'1941687': 1, '9258617': 1, '10833980': 1, '5705887': 1, '7638992': 1, '31115305': 1, '7362942': 1, '16177466': 1, '6890112': 1, '12151660': 1, '15520490': 1, '24678224': 2}

{}

3961932-1

noncomm/PMC003xxxxxx/PMC3961932.xml

Metachronous multifocal myxoid liposarcoma involving the gastrointestinal tract. Management and literature review

A 69-year-old female presented with a 2-year history of a slowly enlarging right buttock mass. Her past medical history was unremarkable, except for hyperlipidemia. Clinical examination revealed a large, non-tender right buttock mass. The remainder of clinical examination was unremarkable. Computed tomography (CT) scan showed a mass measuring 16 × 15 × 14 cm with imaging features suggestive of a liposarcoma []. Full blood count, biochemical investigations, and tumor markers were all within the normal range. The patient underwent a complete resection of the mass. Histological examination showed a myxoid liposarcoma with clear surgical margins. Staging investigations including CT of the chest and abdomen were unremarkable. Since an excision with clear surgical margins had been performed, the patient was not given any adjuvant treatment.\nEighteen months later, the patient was readmitted complaining of abdominal fullness and dull abdominal pain. Physical examination revealed a large, non-tender mass occupying the left abdomen and a cutaneous mass on the upper inner left thigh. CT scan of the abdomen revealed a large retroperitoneal tumor measuring 22 × 12.2 × 17.5 cm with imaging features suggestive of a liposarcoma. In addition, a smaller tumor measuring 7 × 5 cm was detected in the ileal mesentery close to the ileocecal valve []. At exploratory laparotomy, the retroperitoneal tumor was resected with clear margins. Segmental ileal resection was performed along with sigmoid resection, because a second intraperitoneal tumor was found in the sigmoid mesentery. Wide resection was also performed of the subcutaneous left thigh tumor. Histological examination of all specimens revealed a myxoid liposarcoma with 10-15% round cell component. In addition, the histology of the subcutaneous thigh lesion revealed the presence of tumor emboli within small veins. The patient was given postoperative adjuvant chemotherapy with 6 courses of ifosfamide 5 g/m2 and doxorubicin 50 mg/m2. Follow-up investigations after completion of chemotherapy were negative for recurrent disease. However, 2 years later, on CT scans, multiple intraperitoneal and left retroperitoneal masses were detected despite the excellent physical condition of the patient. At this point, the multidisciplinary team suggested chemotherapy with 3 courses of ifosfamide 6 g/m2, followed by 6 courses of doxorubicin 25 mg/m2. Despite initial stabilization, progression of the disease was noted and the patient was started on new chemotherapy with 6 courses of liposomal doxorubicin with simultaneous administration of granulocyte colony-stimulating factor and erythropoietin. Unfortunately, although the size of the lesions was initially stabilized, the disease progressed again. Finally, on May 2011, a new chemotherapy regimen consisting of trabectedin was started. After the administration of 6 courses, a significant decrease of the lesions’ size was noted, and, thus, it was decided to administer 3 more courses. Presently, the patient remains in a stable partial remission of the disease and is scheduled for new investigations.

[[69.0, 'year']]

F

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{'4603107-1': 1, '6864296-1': 1, '2221973-1': 1, '2221973-2': 1}

3961933-1

noncomm/PMC003xxxxxx/PMC3961933.xml

Giant cemento-ossifying fibroma of the mandible

A 34 year old female patient reported to Department of Oral Medicine and Radiology, with a chief complaint of swelling of the lower jaw since six years. She stated that a small swelling on the left side of jaw was noticed six years ago, measuring about 1cm in diameter, which gradually increased to the present size, involving both sides of the face. There were no subjective symptoms, except for difficulty in chewing food.\nGross facial asymmetry was noticed due to a swelling involving the middle and lower one third region of the face []. Bilaterally fullness of the cheeks and lower lip with obliteration of the mentolabial sulcus and nasolabial fold was noticed. A well demarcated swelling was noticed over the left cheek region and a diffuse swelling over the right side, which extended from the left ramus of the mandible to the right body of the mandible with obliteration of inferior border of the mandible. Swelling on the left side was roughly ovoid in shape, measuring about 8 × 6 × 5 cm[]. Skin over the swelling was stretched. On palpation the swelling is hard in consistency, lobulated and nontender; with no accompanying cervical lymphadenopathy.\nOn intraoral examination [], a diffuse swelling was seen extending from the left to right retromolar region. Bilaterally, vestibular obliteration was noticed due to buccal labial and lingual cortical plate expansion with normal appearing mucosa. Swelling was hard, lobulated and nontender. Correlating the history and clinical findings, a provisional diagnosis of benign fibro-osseous lesion of mandible was given and differential diagnosis of fibrous dysplasia, ossifying/cementifying fibroma and central giant cell granuloma (non- aggressive lesion) was given. Patient was further subjected to hematological, radiological and histopathological investigations. Routine hematological examination, serum protein, calcium, phosphorus and alkaline phophatase levels were estimated and the values obtained were within the normal range.\nPanoramic radiograph [] revealed a well defined mixed radiopaque and radiolucent lesion, extending from left ramus region to the right angle of the mandible, measuring about 11 × 7 cms. Internal architecture exhibited a cotton-wool pattern of calcification. Centrifugal growth fashion is appreciable, which causes a ball-like circular lesion and bowing of the inferior border of mandible. The inferior cortex is parallel to the tumor mass above with no evidence of erosion. Occlusal radiograph [], revealed irregular expansion of both bucco-lingual cortical plates and lingual displacement of involved teeth. Posterior-Anterior (PA) mandible view [] revealed a mixed radiopaque, radiolucent lesion involving the left ramus region and extending up to the right angle of the mandible.\nPlain axial view and 3D-CT scan [Figures and ] revealed a large expansile lesion within the mandible, which involves right and left body and left ramus of mandible, which exhibits mixed sclerotic and lucent areas measuring 11.8 × 7.0 × 7.3 cm.[]\nAn incisional biopsy was performed and the tissue was sent for histopathological evaluation [] which irregularly shaped bony trabaculae interspersed in connective tissue stroma which is fibrocellular. Trabaculae contains osteocytes in lacunae within them. Several spherical masses of a cellular calcified material resembling cementum were seen through the fibrous tissue. Fibroblasts in the stroma are numerous and spindle shaped with prominent nuclei which were suggestive of cemento- ossifying fibroma. Based on clinical, radiographic and histopathological findings a final diagnosis of giant cemento-ossifying fibroma of the mandible was made.

[[34.0, 'year']]

F

{'9102442': 1, '20089746': 1, '18923226': 1, '20026708': 1, '10543652': 1, '9775467': 1, '1742681': 1, '34337187': 1, '25738089': 1, '24678226': 2}

{}

3961934-1

noncomm/PMC003xxxxxx/PMC3961934.xml

Oral myiasis involving palatal mucosa of a young female

A 19-year-old female patient came with a complaint of massive, painful, and swollen with mobile upper anterior teeth with detached mucoperiosteum from the palatal mucosa since 1 month []. The swelling started slowly and attained the present size. She was associated with fever since 2 days and also complains of discomfort and unable to eat since 1 week. Patient was from a low socioeconomic back ground, residing in a rural area. She had a history of mouth breathing with poor generalized periodontal status. The swelling was extending from infra-orbital region bilaterally to the entire upper lip. Skin over the swelling appeared stretched, erythematous and there was localized rise in temperature.\nIntraoral examination revealed poor oral hygiene with severe halitosis. Swelling may be seen involving the lips, anterior portion of hard palate. Palatal flap in the premaxillary region was necrotized, detached from the underlying bone. Computed tomography revealed that there was no involvement of maxillary sinus, nasal cavity which was suspicious for involvement. Maggots were seen between the palatal bone and flap. The case was posted for surgery under local anaesthesia after taking informed consent. Turpentine oil was placed in the wound area during which maggots were coming out [Figures , and ]. Around 25-27 maggots were removed. Based on the clinical findings and the presence of maggots the provisional diagnosis was made as myiasis. The larvae were preserved in 40% formaldehyde and sent for pathological investigation. On pathological examination the diagnosis of larvae of Musca domestica was confirmed.\nComplete treatment was executed with Taxim 1 g, Metranidazole 100-ml IV injections along with intramuscular injection of Voveran injections for 10 days faster and better recovery. Postoperative healing was uneventful in the wound area. A week later patient discharged and was asked to report back after a period of 6 months to evaluate the healing status and the healing was uneventful and satisfactory [].

[[19.0, 'year']]

F

{'15322651': 1, '12694705': 1, '8604075': 1, '8445704': 1, '8431413': 1, '9452615': 1, '9601240': 1, '1488228': 1, '29744327': 1, '11310129': 1, '17596557': 1, '18978712': 1, '409819': 1, '24678227': 2}

{}

3961935-1

noncomm/PMC003xxxxxx/PMC3961935.xml

Lymphocutaneous nocardiosis caused by Nocardia otitidiscaviarum: A case report and review of literature

A 60-year-old male with a history of chronic obstructive pulmonary disease (COPD) was admitted to medical ward of our hospital. He presented with a month long history of breathlessness, cough with expectoration (Grade 4), high continuous fever, and ulcers on the right thigh which had been present for 15 days. One month prior, he sustained thorn prick injury while working in the field. An ulcer on right upper third of thigh began as a papule and gradually ulcerated over a period of two weeks. Many erythematous, painful nodules developed on the whole thigh and enlarged inguinal lymph nodes with inflammatory lymphangitic streaks.\nGeneral physical examination revealed mild pallor with clubbing (Grade 3). Vital parameters like blood pressure, pulse rate were within normal limits and respiratory rate was high. Local cutaneous examination revealed two ulcers on the right thigh and inguinal lymph nodes were enlarged and tender. The largest ulcer on the upper third of the right thigh measured 3 × 1.5 cm, excavated 0.5 cm deep with undermined edges with irregular margins. Another ulcer at mid thigh level was covered by scab and an ulcer in evolution was present just above the right knee.\nThe patient presented microcytic hypochromic blood picture and relative neutrophilia with 10.2 gm% hemoglobin. Erythrocyte sedimentation rate was 95 mm at the end of the first hour. Biochemical tests like, blood sugar, urea, creatinine were within normal limits. ELISA for HIV1 and two antibodies were negative. Chest X-ray revealed increased bronchovascular markings in para-hilar region with emphysematous changes. Gram stain of sputum revealed plenty of gram-positive capsulated diplococci and culture on blood agar yielded growth of Streptococcus pneumoniae.\nGram-stained smear from the discharge of ulcerative lesion revealed numerous pus cells and few irregularly stained gram-positive thin branching filaments. Modified Kinyoun's staining demonstrated acid-fast branching filamentous structures. Culture on Sabouraud dextrose agar, blood agar, and Lőwenstein-Jensen media yielded growth after 72 h, showing dry chalky, white-folded colonies with irregular margin. Biochemically, the isolate showed production of urease and reduced nitrates to nitrites. The isolate was identified as nocardia otitidiscaviarum by its ability to digest xanthine, hypoxanthine, and urea but not casein, gelatin, tyrosine.\nThe isolate was sent to Aerobic Actinomycetes Laboratory, Centers for Disease Control and Prevention, Atlanta, Georgia, USA for confirmation and molecular analysis. 16S rRNA gene sequencing was done. Purified genomic DNA was amplified using the Expand High Fidelity PCR System (Roche Diagnostics Corporation, Indianapolis, IN, USA) with primers fL1 5’- CCGAATTCGTCG ACAACA GA GTTTGATCCTGGCTCAG - 3’ and rL1 5’- CCCGGG ATCCAAGC TTACGGCTACCTTG TTA CGACTT -3’.[] Cycle sequencing was performed utilizing 16 universal primers[]; excess dyes were removed with magnetic carboxylate beads (Agencourt Bioscience, Beverly MA) and reactions were sequenced on an ABI 3100 (Applied Biosystems).\nThe 16S rRNA gene sequences were assembled in Accelrys SeqMerge and trimmed to a minimum of two confirming reads. The sequence (>1400 bp) generated was compared to the GenBank database gene sequences derived from related nocardia and submitted by other investigators.\nAnalysis of 16S rRNA gene of the isolate and type strain of N. otitidiscaviarum DSM 43242 showed 100% similarity. The partial gene sequence (1439 bp) was submitted to GenBank, accession number EU031786.\nThe patient was relieved of breathlessness and cough with expectoration, following treatment with amoxicillin and clavulanic acid 625 mg twice daily for eight days. For nocardiosis the patient was initially treated with oral trimethoprim-sulfamethoxazole (TMP-SMX, 80-400 mg), two tablets twice daily for one week with no clinical improvement. Antibiotic susceptibility testing of the isolate by MIC method carried out at CDC Atlanta revealed that it was susceptible only to amikacin (MIC = 4), minocycline (MIC = 1), and linezolid (MIC = 2) and resistant to remaining other routine anti-nocardial drugs. The patient was treated with amikacin and linezolid for four weeks; once a clinical cure was evident the patient was asked to continue linezolid orally for another eight weeks. Four months later, there was no evidence of nocardiosis in the patient.

[[60.0, 'year']]

M

{'11464085': 1, '28969125': 1, '3532961': 1, '27882160': 1, '3767403': 1, '10364586': 1, '14673241': 1, '8055469': 1, '6337576': 1, '12596292': 1, '6981158': 1, '8408800': 1, '12539073': 1, '34589411': 2, '28353613': 1, '32128191': 2, '17021075': 1, '7673554': 1, '7620008': 1, '24678228': 2}

{'7044388-1': 1, '8461374-1': 1}

3961936-1

noncomm/PMC003xxxxxx/PMC3961936.xml

Spontaneous pneumomediastinum with pneumopericardium, surgical emphysema, pneumothorax, and epidural pneumotosis: A rare association

An 18-year-old male was admitted in emergency department complaining of gradual swelling on face, neck and chest, hoarseness of voice along with difficulty in breathing. He had no previous history of cough, fever, loss of weight, night sweating, recent trauma, vomiting, foreign body lodgment, and drug abuse. He was non-smoker and non-alcoholic.\nOn physical examination patient was afebrile, his pulse rate was 110/min, respiratory rate 18/min, blood pressure 130/86 mm of Hg, and arterial saturation (Spo2) was 95% on room air. On palpation trachea was central and there was subcutaneous emphysema on face, neck, and chest region. On chest auscultation, the air entry was normal on both sides. Other clinical examination was essentially normal. ECG showed sinus tachycardia. Chest X-ray revealed surgical emphysema in soft tissue over chest and neck []. His routine investigations and biochemical results including arterial blood gas analysis were normal. Erythrocyte sedimentation rate was 20 mm/first hour. Fibroptic laryngosopy was normal. Computed tomography (CT) scan of neck and thorax showed evidence of marked pneumomediastinum and pneumopericardium, mild bilateral pneumothorax with few sub-pleural emphymatous bullae in both upper lobes, marked soft tissue emphysema along anterior and lateral chest, and also in superficial and deep neck spaces. Superiorly, the soft-tissue emphysema was extending along right infratemporal fossa and masticular space. Few air foci were also seen in posterior epidural space in cervico-dorsal spine [Figures –]. Trachea, main bronchi, visualized portion of oesophagus, pharyngeal, and laryngeal air appeared normal. No obvious rent was seen. Echocardiography was inconclusive due to poor visualization of cardiac structures which was due to presence of air in mediastinum and subcutaneous emphysema.\nThe patient was managed conservatively with 100% oxygen inhalation, regular blood gas analysis, broad-spectrum prophylactic antibiotics, analgesic and bed rest in intensive care unit. Progress was uneventful. He was absolutely normal on follow-up examination.

[[18.0, 'year']]

M

{'2018598': 1, '27213070': 2, '717713': 1, '18167231': 1, '8055982': 1, '12006470': 1, '33363883': 2, '11769580': 2, '2333705': 1, '27407750': 1, '24678229': 2}

{'7752392-1': 1, '4861796-1': 1, '4861796-2': 1, '4531731-1': 1}

3961937-1

noncomm/PMC003xxxxxx/PMC3961937.xml

Laparoscopic appendectomy for mucocele of the appendix

A 60-year-old female presented with pain in lower part of abdomen and palpable tender lump in the right ileac fossa. Ultrasound of the abdomen reports a cystic mass of size 12 × 15 cm with thin internal septations in the right adnexa. Her hemogram and biochemistry were within normal levels. We planned for diagnostic laparoscopy and further treatment. The pneumoperitoneum was created with veress needle using carbon dioxide and the pressure was kept at 11 mmHg. The table was kept in the Trendelenburg position with 15° left tilt. A 0° telescope was introduced through the umbilical port for the complete examination of the abdomen. Diagnostic laparoscopy revealed approximately 14 × 15 cm large bluish mucocele of the appendix with omental adhesions. The ovary, fallopian tube, and uterus were all normal looking. Two 5-mm ports were placed in the supra pubic area below the pubic hair line as the working port. The mucocele of the appendix was isolated after separating the mesoappendix from it with the help of bipolar cautery. Following this, the base of the appendix was ligated at the ileocecal junction and divided. Mucocele of the appendix [] was retrieved out in a plastic bag through the umbilical port. Hemostasis was obtained and a suction drain left in situ which was removed when non-productive. The umbilical port site wound was closed with 1.0 Vicryl. Cut section showed appendix was filled with mucin-like material []. She was started orally after 4 hours of operation and solid food on the next day. She was called for a revisit after a week for follow up.

[[60.0, 'year']]

F

{'1590322': 1, '2792684': 1, '9569300': 1, '4718184': 1, '14756359': 1, '25163976': 1, '8550701': 1, '4757938': 1, '15483768': 1, '1609724': 1, '12799327': 1, '10619300': 1, '3152405': 1, '3885692': 1, '9618138': 1, '12409708': 1, '26945579': 2, '24678230': 2}

{'4779566-1': 1}

3961938-1

noncomm/PMC003xxxxxx/PMC3961938.xml

Delivery after augmentation cystoplasty: Implications and precautions

A 23-year-old female presented to us with history of frequency, bedwetting, and recurrent fever for last 10 years. She also had several episodes of gross hematuria and occasional right flank pain. For last 2 years, urinary frequency gradually increased to every 15 minutes interval. The only significant past history was anti-tubercular treatment for pulmonary Koch's 12 years back. The patient was evaluated outside. Her urine microscopy showed pus cells, but the culture was sterile. Ultrasonography (USG) and intravenous urography showed right gross hydro-ureteronephrosis (HDUN) with small contracted left kidney with severe calcifications. Micturition cysto-urethrogram (MCU) showed no vesico-urethral reflux, but was suggestive of “Thimble bladder.” Cystoscopy showed small contracted bladder and ureteral orifices couldn’t be identified due to edematous changes. Bladder biopsy showed granulomatous changes. In view of solitary functioning right kidney with gross HDUN, percutaneous nephrostomy (PCN) was done outside. The patient was referred to us for further management.\nWe did right nephrostogram, which showed gross HDUN with smooth tapering at the right vesicoureteric junction []. Her serum creatinine was normal. We performed the augmentation ileal cystoplasty with right ureteric reimplantation. Postoperative course was uneventful. Double J stent was removed after confirming normal MCU without leak []. The patient was symptomatically improved.\nShe became pregnant after 1 year of AC. At that time, she had no urinary complaint and her continence was normal. Throughout pregnancy she had two episode of UTI, treated with intravenous antibiotics. We kept her on low dose prophylactic antibiotic therapy. Her antenatal USG showed symmetrical intrauterine growth retardation with polyhydroamnios. On routine antenatal investigation she found to have hypothyroidism, for that the thyronorm (75 μg) was started. Throughout the pregnancy she maintained the normal serum creatinine levels.\nAt full term, the induction of labor was tried, but was unsuccessful. As the pregnancy was high risk in view of primigravida with solitary functioning kidney, hypothyroidism, and the history of previous urological reconstruction, the cesarian section was planned in the presence of urologist. The abdomen was opened with previous midline scar. Intra-operatively the ureterovaginal fold was clearly visible. Urinary bladder was in place []. Few dense adhesions were seen between omentum and parietal peritoneum. Bowel loop, which was used for augmentation, was visible on right side of bladder and was undisturbed []. Incision was given over lower uterine segment and a live female baby of 2 kg was delivered. The cord blood sample was taken for the thyroid screening. The post-operative course was uneventful and the patient was discharged on day 3. At 3 month follow up, the patient had no urinary complaint.

[[23.0, 'year']]

F

{'2343363': 1, '12780859': 1, '28043107': 2, '2374220': 1, '14616465': 1, '17144396': 1, '9465600': 1, '1621320': 1, '11842538': 1, '9234621': 1, '11484743': 1, '25994430': 1, '28208926': 1, '31342172': 1, '17145363': 1, '3381188': 1, '24678231': 2}

{'5209573-1': 1}

3961940-1

noncomm/PMC003xxxxxx/PMC3961940.xml

External cervical resorption case report and a brief review of literature

A 23-year-old female patient reported to the Department of Periodontics in Thai Moogambigai Dental College with the chief complaint of pain in the left upper-front teeth region for the past 2 months, seeking treatment. On clinical examination, the tooth was found to be non-vital, and grade 1 mobility was observed. Temporary splinting was done from 13 to 23 to stabilize the tooth. Patient was then referred to conservative department to check the non-vitality and further management in relation to 21. The tooth was found to be non-vital and root canal treatment was performed. The patient was then referred back to Department of Periodontics for management of periodontal pocket of 10 mm in relation to distal aspect of 21. Radiographic examination revealed vertical bone loss and external tooth resorption on the distal aspect of 21 [Figures and ].\nOn subsequent appointment, scaling and root planning was done, and patient was reviewed after 2 weeks. On reviewing the patient, the pocket still persisted in distal aspect of 21 region. Therefore, flap surgery was planned and local anesthesia (2% lignocaine 1:80,000 adrenaline) was given. Sulcular incision was given and the flap was raised []. On raising the flap, there was resorption in the mesisl and distal aspect of 21 [Figures and ] and combined two-walled defect in the coronal aspect and three-walled defect in the apical region. The defect was then debrided, resorption was filled with MTA [], and covered with resin-modified glass ionomer filling material (RMGIC) [Figures and ] in a sandwich technique [Figures and ]. Osseograft and healiguide membrane was placed in the defect and sutured with 5-0 vicryl resorbable suture material [Figures and ]. The patient was reviewed 6 months later when the upper left central incisor was found to be asymptomatic, and radiographs showed no further signs of resorption on the tooth.

[[23.0, 'year']]

F

{'12657149': 1, '10356560': 1, '14761897': 1, '10323156': 1, '5234642': 1, '8908918': 1, '9298162': 1, '30349717': 2, '3481799': 1, '9171044': 1, '17580820': 1, '18634929': 1, '10356561': 1, '3857253': 1, '11411085': 1, '9579627': 1, '12190343': 1, '10323155': 1, '16683667': 1, '6945390': 1, '11585142': 1, '12296786': 1, '19992353': 1, '9182737': 1, '8034367': 1, '1447376': 1, '9526922': 1, '12917279': 1, '24678232': 2}

{'6186875-1': 1}

3961941-1

noncomm/PMC003xxxxxx/PMC3961941.xml

Low grade endometrial stromal sarcoma in a premenopausal woman

A 39-year-old female, reported with complaints of irregular bleeding per vaginum on and off for the past 2 months and retention of urine since the past 2 days. The patient was pale and ill looking. Per speculum examination revealed a large shaggy mass, 8 cm in diameter protruding out from the cervical os. The cervical rim was felt all around and the pedicle was high up. Uterus was 8 weeks in size, soft, anteverted, and both fornices were clear.\nUltrasound of the pelvis suggested a cervical mass lesion measuring 9 × 8 × 8 cm, well defined outline and heterogenous echogenicity. The uterus was bulky with the endometrial cavity pushed anteriorly and bilateral adnexae were normal. The clinical impression was that of a leiomyomatous polyp with the base in the posterior uterine wall. Polypectomy was done and sent for histopathological examination.\nGross examination of the polyp showed a globular mass measuring 6 × 5.5 × 4 cm. Cut surface was fleshy, grayish pink in color. [] Outer surface had a ragged appearance. Microscopic examination of the polyp showed a cellular tumor with a close morphological resemblance to nonneoplastic proliferative-phase endometrial stromal cells. The tumor cells were small uniform looking with dark staining round to oval nuclei, granular chromatin, and inconspicuous nucleoli [] Areas of sex cord-like differentiation [] were also seen. Mitosis was minimal and less than three mitotic figures per high power field were seen. Stromal myometrial interface was not provided hence myometrial invasion could not be commented upon. These histological features were suggestive of endometrial stromal tumor and the possibilities considered were endometrial stromal nodule (ESN) and LGESS. Subsequently, 9 days after the polypectomy, the patient was operated again and a hysterectomy with bilateral salpingo-oophorectomy was undertaken. On laparotomy, uterus was noted to be enlarged to 8 weeks size, with bilateral cystic ovaries and no enlarged regional lymph nodes were present. A polyp was seen protruding into the endometrial cavity from posterior wall of the uterus which measured 4 × 5 × 3 cm, with a fleshy, gray-white cut surface []. Microscopic examination of the polyp showed a similar histological picture as described. These tumor cells were arranged concentrically around spiral arteriole like vessels with cord-like projections into the myometrium. Lymphovascular invasion was not seen. Both ovaries showed luteal cysts and the tumor was restricted to the uterine wall. Immunohistochemical analysis showed neoplastic endometrial stromal cells, which were immunoreactive for CD10 monoclonal antibody [], while staining for Desmin was negative, thereby ruling out a smooth muscle origin. There were areas of sex cord-like differentiation that showed reactivity for Inhibin, which was not detected in the other stromal areas. The final histological diagnosis was LGESS with sex cord-like differentiation, International Federation of Gynecology and Obstetrics (FIGO) Stage IB.[]

[[39.0, 'year']]

F

{'20179433': 1, '19031927': 1, '961630': 1, '8381710': 1, '25861206': 2, '17347285': 1, '19853898': 1, '11979087': 1, '11499847': 1, '6490315': 1, '24678233': 2}

{'4389382-1': 1, '4389382-2': 1, '4389382-3': 1, '4389382-4': 1}

3961942-1

noncomm/PMC003xxxxxx/PMC3961942.xml

Dens invagination: A review of literature and report of two cases

A 12-year-old boy reported with a chief complaint of pain with respect to upper anterior tooth since 3 days. The patient was in good general health. Extra-oral examination revealed no significant findings. Intra-oral examination revealed a comparatively wider maxillary right central incisor with a deep anatomic pit on palatal surface []. The tooth was tender on percussion and did not respond to thermal and electric stimuli. The periapical radiograph revealed type II DI with open apex and periapical pathology with respect to maxillary right central incisor []. Endodontic treatment was started immediately.

[[12.0, 'year']]

M

{'14113292': 1, '10332241': 1, '7937265': 1, '30175195': 1, '3469397': 1, '13477660': 1, '13494010': 1, '20526277': 1, '5219633': 1, '15329576': 1, '7811661': 1, '12043878': 1, '4528397': 1, '5273860': 1, '17185134': 1, '8078663': 1, '14392027': 1, '15671826': 1, '14938059': 1, '17958073': 1, '1055979': 1, '30349703': 1, '287992': 1, '2333221': 1, '271933': 1, '15086751': 1, '9466013': 1, '4533608': 1, '28042279': 2, '9973708': 1, '3459853': 1, '15448469': 1, '19358374': 1, '11309867': 1, '9394390': 1, '3460012': 1, '29225653': 2, '8631289': 1, '4503859': 1, '16982283': 1, '13074201': 1, '24678234': 2}

{'3961942-2': 2, '5722112-1': 1, '5166320-1': 1}

3961942-2

noncomm/PMC003xxxxxx/PMC3961942.xml

Dens invagination: A review of literature and report of two cases

A 10-year-old boy reported with a chief complaint of non-eruption upper right anterior tooth. The patient was in good general health. Extra-oral examination revealed no significant findings. Intra-oral examination showed fibrotic gingival eruption bulge of maxillary left lateral incisor. The periapical radiograph showed type III DI with respect to unerupted maxillary left lateral incisor []. Keeping in view the age of the patient and that the contralateral maxillary right lateral incisor was erupted well, it was decided that an incision should be made on the eruption bulge. The incision was made, and patient was reviewed after 1 month. After eruption, the prophylactic composite sealant was applied on the invagination.

[[10.0, 'year']]

M

{'14113292': 1, '10332241': 1, '7937265': 1, '30175195': 1, '3469397': 1, '13477660': 1, '13494010': 1, '20526277': 1, '5219633': 1, '15329576': 1, '7811661': 1, '12043878': 1, '4528397': 1, '5273860': 1, '17185134': 1, '8078663': 1, '14392027': 1, '15671826': 1, '14938059': 1, '17958073': 1, '1055979': 1, '30349703': 1, '287992': 1, '2333221': 1, '271933': 1, '15086751': 1, '9466013': 1, '4533608': 1, '28042279': 2, '9973708': 1, '3459853': 1, '15448469': 1, '19358374': 1, '11309867': 1, '9394390': 1, '3460012': 1, '29225653': 2, '8631289': 1, '4503859': 1, '16982283': 1, '13074201': 1, '24678234': 2}

{'3961942-1': 2, '5722112-1': 1, '5166320-1': 1}

3961943-1

noncomm/PMC003xxxxxx/PMC3961943.xml

Oral rhabdomyosarcoma-embryonal subtype in an adult: A rarity

A 36-year old male patient was referred to our service for the evaluation of a painless swelling on his face that had appeared one and a half months earlier, with rapid evolution. During extra-oral examination, an extensive swelling on the right side of the face was observed, with un-defined limits. The skin overlying the swelling appeared shiny and stretched with ulceration []. The swelling was associated with difficulty in mouth opening and mastication. Medical history was non-contributory to the present complaint.\nOn intra-oral examination, brownish-black colored mass was verified involving the right buccal mucosa, with necrotic changes and sloughing. The mass extended anteriorly from the right mandibular first premolar region to the retromolar region posteriorly with involvement of the posterior-lateral aspect of hard palate []. On palpation, it was fibrous in consistency and non-tender. Ulceration was observed over the mass due to impingement of the teeth. No palpable cervical lymphadenopathy was present.\nOrthopantomograph revealed no changes in the adjacent bone. Computerized tomography revealed a large expansile lesion with respect to right gingivo-buccal space showing slight erosion of the maxilla []. Further to rule out distinct metastasis, chest radiography and ultrasonography of the abdomen were performed, that revealed no pathology.\nIn view of these findings, a diagnostic possibility of soft tissue sarcoma was hypothesized with differential diagnosis of Fibrosarcoma, Extra-osseous Ewing's sarcoma and Rhabdomyosarcoma. An incisional biopsy of the mass was performed and the histopathology of the specimen disclosed embryonal rhabdomyosarcoma [Figure and ].\nWithin a period of 10 days after the incisional biopsy, there was considerable increase in the size of extra-oral swelling along with an enormous increase in the intra-oral soft tissue mass involving the entire right buccal mucosa and hard palate [Figure and ]. Patient was referred to an oncology centre (Madras Medical College Tamil Nadu, India) and was treated with chemotherapeutic drugs (vincristine, etoposide and ifosfamide) over a period of 32 weeks [According to Inter-group Rhabdomyosarcoma Study (IRS)-IV protocol]. Adjuvant external beam radiotherapy with a dose of 50.40 cGy in 28 fractions was given for a period of a month. Partial recovery occurred during the treatment's initial phase [] but with tapering of chemotherapeutic doses, there was sudden flare up in the tumor size. After that unfortunately, we lost communication with the patient for further treatment and follow up.

[[36.0, 'year']]

M

{'27721622': 2, '12110339': 1, '11505068': 1, '25232439': 1, '11241248': 1, '32205980': 1, '17858752': 1, '12075208': 1, '12110348': 1, '27896667': 1, '16505791': 1, '7552885': 1, '31776147': 1, '29291204': 2, '8275414': 1, '2991766': 1, '30158795': 2, '25977692': 2, '10935489': 1, '12124838': 1, '24678235': 2}

{'4419229-1': 1, '5051305-1': 1, '5740190-1': 1, '6097379-1': 1}

3963199-1

noncomm/PMC003xxxxxx/PMC3963199.xml

Wernicke's encephalopathy following hyperemesis gravidarum

A 25-year-old woman, at 22 weeks gestation, presented with excessive vomiting for several weeks followed by progressive weakness of lower limbs, altered sensorium, and blurred vision. Her previous pregnancy had resulted in fetal loss, due to hyperemesis. On admission, she had stable vitals, with 7/15 Glasgow Coma Scale (GCS). Physical examination revealed sluggishly reacting pupils with papilledema, left sided facial twitching with ptosis of the eye, bilateral conjugate palsies with nystagmus, and flaccid paralysis of all four limbs with bilateral flexor plantar reflexes. Fetal sonography was normal. Her serum biochemistry during her stay is shown in . MRI finding was suggestive of WE [Figures and ]. She was electively intubated and ventilated and was administered intravenous thiamine 100 mg thrice daily along with other vitamins, electrolytes, and trace elements. Gradually, her ocular signs disappeared and she showed neurological recovery with improvement in muscle power.\nHowever, within next few days, her general condition deteriorated and she became hyperpyrexic (>40° C). A repeat MRI (brain) was highly suggestive of CPM []. She underwent lower segment cesarean section (LSCS) at 30 weeks and a male baby was delivered (weight 800 g, APGAR 6 and 8). Unfortunately, patient died of multiorgan failure on 4th postoperative day.

[[25.0, 'year']]

F

{'21912244': 1, '26693367': 1, '32983708': 2, '10413897': 1, '10987905': 1, '19913987': 1, '13616772': 1, '1115019': 1, '31041282': 2, '28367669': 2, '32582501': 2, '16551377': 1, '27209471': 1, '32934066': 1, '30112269': 2, '20642790': 1, '19477464': 1, '6886695': 1, '22844223': 1, '18091372': 1, '24701066': 2}

{'6089490-1': 1, '7515211-1': 1, '5805199-1': 1, '7306676-1': 1, '6482737-1': 1}

3963200-1

noncomm/PMC003xxxxxx/PMC3963200.xml

Cerebral fat embolism syndrome after long bone fracture due to gunshot injury

A 20-year-old male patient was admitted to the emergency department with sudden change in consciousness and muscle contractions after 1 day follow-up in a hospital for long bone fractures of femur and tibia due to gun-shot injury. On admission, he had generalised tonic clonic seizures and his Glascow Coma Scale was seven with localization of painful stimuli, incomprehensible muttering, and no eye opening. In the physical examination, blood pressure was 130/80 mmHg, pulse was 128/min, breath rate was 22/min and body temperature was 38°C. His pupils were isocoric and bilaterally responsive to light. He had decorticated posture in response to noxious stimulus. No lateralising motor deficit was found. There was a long bone splint on the left lower extremity. Examination of other systems were normal. The patient was intubated and respiration was supported by mechanical ventilation.\nThe results of hematologic and biochemical parameters of the patient with the range of normal values of our laboratory in the paranthesis were as follows at first admission: Hemoglobine: 11.1 gr/dl (13,6-17,2), platelet count: 75000/μl (156000-373000), glucose: 189 mg/dl (70-110), aspartate aminotransferase (AST): 143 IU/L (0-46), alanine aminotransferase (ALT): 53 IU/L (0-46), and creatine phosphokinase (CPK): 7866 IU/L (35-195). Other biochemical findings and blood gas analysis were normal. There were no abnormalities on a postero-anterior chest X-ray cervical and thoracic computed tomography (CT). An initial CT of the head was unremarkable for intracranial abnormalities. Magnetic resonance imaging (MRI) was performed diffusion weighted MRI trace images with a 2 mm slice gap, 5 mm slice thickness, Echoplanar imaging (EPI) sequence type, b value of 1000 mm/s2, signal intensity dots on a dark background. This resulted in a “starfield” appearance of the cerebral hemispheres [Figures and ]. Diffusion coefficient map slice of the patient revealed the hypointense punctuate to lesions in centrum semiovale and periventricular regions [Figures and ].\nAn electroencephalogram was performed and diffuse bioelectrical delay on the right hemisphere was found. With the above findings, the diagnosis of the case was cerebral diffuse FES. Antiepileptic therapy with phenytoin (2 × 150 mg) and low molecular weighted heparin therapy with enoxaparin sodium (2 × 4000 U) were administered.\nThe patient had hypoxemia and the arterial blood gas analysis revealed PaO2 as 65 mmHg, and saturation of arterial oxygen as 82% requiring mechanical ventilation, disturbance of conscioussness and sudden drop in hemoglobin and platelet count. Hemoglobin was 7.1 gm/dl and platelet count had decreased to 53000/μl at that time. The patient was rehydrated and administered with sulbactam/ampicillin (4 × 1 g i.v.) for fever and a possible infection due to open injuries. Three units of erhthrocyte suspension and 3 units of fresh frozen plasma were given to patient to replace blood loss. On the 5th day of hospitalization, the level of consciousness of the patient improved and mechanical ventilatory support could be discontinued.\nThe bone fractures were multi-fragmental in left tibia with articular defects. The fragments were inernally fixed. He subsequently had uncomplicated recovery and was discharged home after 27 days of hospitalization.

[[20.0, 'year']]

M

{'20728851': 1, '33788069': 1, '21286442': 2, '10721407': 1, '19946456': 2, '11740000': 1, '16990063': 1, '31239793': 1, '34876950': 1, '34729174': 2, '10718245': 1, '21477362': 1, '24701067': 2}

{'2783161-1': 1, '3030038-1': 1, '8557346-1': 1}

3963201-1

noncomm/PMC003xxxxxx/PMC3963201.xml

Lemierre's syndrome: An often missed life-threatening infection

An otherwise healthy 36-year-old male presented to our institute with a 4-day history of low-grade fever accompanied by sore throat, myalgia and nausea. Physical examination was remarkable for a temperature of 38.1°C and an injected pharynx without any neck tenderness or swelling. Complete blood cell count showed thrombocytopenia with platelet of 45,000/uL, hemoglobin of 14.8 g/dL and cell count of 8700 cells/uL (neutrophil of 85% and band form of 6%). Blood chemistry was remarkable for elevated creatinine of 2.1 mg/dL. He was diagnosed with viral upper respiratory tract infection and was admitted to general medicine service for rehydration. He received 2 L of intravenous normal saline over night; however, on the 2nd day of hospitalization, he developed high fever of 39.2°C along with pleuritic chest pain and low blood pressure of 80/50 mmHg. He was transferred to Intensive care unit and resuscitated with intravenous fluids. Blood cultures were obtained and empirical antibiotics (vancomycin and piperacillin/tazobactam) were initiated. Chest X-ray revealed bilateral patchy and irregular parenchymal opacities and subsequent chest computed tomography demonstrated right-sided pleural effusion and multiple thick-walled cavitary and nodular opacities consistent with septic emboli []. His blood cultures grew F. necrophorum on the following day and his antibiotic therapy was narrowed down to piperacillin/tazobactam. He responded well to intravenous fluids and antibiotics. His blood pressure was normalized without using any vasopressor or mechanical ventilation (he received 5 L of intravenous normal saline in total). Venous duplex ultrasonography was immediately obtained after the blood culture and demonstrated thrombus in the left IJV. Patient was finally diagnosed with Lemierre's syndrome and remained stable through rest of the hospital course. His pleural effusion was managed conservatively. Piperacillin/tazobactam was continued for 7 days and he was discharged home with a 4-week course of intravenous ertapenem and recovered well from the infection. He did not receive any anticoagulation during the course of his treatment.

[[36.0, 'year']]

M

{'34943737': 2, '4031037': 1, '7777368': 1, '12441902': 1, '9796654': 1, '10448489': 1, '22033390': 1, '22633566': 1, '24701068': 2}

{'8698451-1': 1}

3963202-1

noncomm/PMC003xxxxxx/PMC3963202.xml

Severe suicidal digoxin and propranolol toxicity with insulin overdose

A 32-year-old male doctor, known case of type I diabetes mellitus for last 4 years, on glargine insulin 30 units once daily and regular insulin 15 units thrice daily, presented to our casualty with an alleged history of ingestion of 100 tablets of 0.25 mg digoxin (total dose 25 mg) and 50 tablets of 40 mg propranolol (total dose 2 g) along with subcutaneous injection of 1,600 units of regular insulin about 2 h prior to presentation. He was conscious with the following vital parameters: Heart rate 74/min, blood pressure 106/70 mmHg, respiratory rate 26/min, random blood sugar level 58 mg/dl, and was maintaining normal oxygen saturation on room air. Systemic examination was unremarkable. His initial electrocardiograph showed normal sinus rhythm. Arterial blood gas analysis revealed: pH 7.391, pCO2 32.8 mmHg, pO2 102.4 mmHg, HCO3 19.5 mEq/l, Na 136 mEq/l, and K 3.73 mEq/l. He complained of nausea and had one episode of vomiting in the casualty. Gastric lavage was immediately done with 100 g activated charcoal and he was given 50 ml of intravenous (IV) 25% dextrose injection along with other relevant supportive management. Routine laboratory investigations were sent for along with serum digoxin levels, serum insulin, and C-peptide levels and urine toxicology screen. He was shifted to the intensive care unit (ICU) for further medical management.\nIn the ICU, the patient had bradycardia (maximum heart rate of 58/min and a minimum heart rate of 39/min). Injection atropine 0.6 mg IV was administered on two occasions. In view of recurrent hypoglycemia, IV bolus of 50 ml of 25% dextrose, followed by infusion of 20% dextrose at the rate of 100 ml/h was started. Initial investigations revealed serum digoxin levels of 7.5 ng/ml (normal range 0.7-2 ng/ml), serum insulin 500 μIU/ml, and serum C-peptide 0.43 ng/ml (normal range 0.48-3.3 ng/ml). Blood counts, liver, and renal function tests along with serum electrolytes and serial blood gas analysis were normal. Electrocardiograph showed sinus bradycardia.\nImmediate cardiology opinion was taken because of high serum digoxin levels and propranolol toxicity. To manage propranolol overdose, injection glucagon 5 mg slow IV bolus followed by an infusion at 5 mg/h was started. As digoxin specific antibody fragments (Fab) were unavailable, we tried to find other alternative approaches. As per the opinion of the nephrologist hemoperfusion with charcoal-based cartridge (Gambro Adsorba 300C and 150C) with a blood flow of 150 ml/h was done for 15 h after a written informed consent from the attendants. Close observation and regular monitoring of serum electrolytes with digoxin levels were done during this entire period.\nBy the end of day 1 of ICU stay, patient showed significant improvement and serum digoxin levels showed a decreasing trend []. On day 2, his heart rate varied between 58-66/min. Dextrose (20%) infusion was continued at a rate of 100 ml/h for 30 h and then reduced to a rate of 80 ml/h for the next 20 h. His random blood sugar levels hovered around 200 mg/dl. On day 3 he was started on oral diet and his maintenance Dextrose infusion was tapered down and finally stopped (total dose of IV glucose 1,115 g) [].\nGlucagon infusion was given at a rate of 5 mg/h for the 19 h and then tapered to 2 mg/h which was continued for next 21 h targeting a heart rate above 50/min and adequate perfusion (total dose of IV glucagon 142 mg) [].\nOn day 4, with a good hemodynamic profile and a serum digoxin level of 1.4 ng/ml, he was shifted to the step down unit. He continued to remain asymptomatic there and was discharged on the 6th day after consultation with a psychiatrist.

[[32.0, 'year']]

M

{'21563902': 1, '34112223': 1, '10873184': 1, '490791': 1, '22701832': 1, '17482022': 1, '713006': 1, '24701069': 2}

{}

3963203-1

noncomm/PMC003xxxxxx/PMC3963203.xml

Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit

A 69-year-old man with a history of primary lung carcinoma and a right frontal mass was admitted to our intensive care unit (ICU) after a craniotomy for brain biopsy and tumor resection. He had left facial weakness and hemiparesis after craniotomy and was treated with corticosteroids for vasogenic edema. On ICU day 5, he was noted to have a dilated and fixed left pupil (5 vs. 3 mm on the right) without ptosis, extraocular movement impairment, or mental status change. Emergent computed tomography (CT) of the head showed no evidence of mass effect or uncal herniation. Review of medications revealed that he received ipratropium bromide nebulizer treatment (500 μg) every 4 h for respiratory distress. His anisocoria resolved within a few hours after discontinuation of ipratropium bromide treatment.

[[69.0, 'year']]

M

{'2878329': 1, '27683661': 1, '25097368': 1, '18191575': 1, '29260071': 1, '16318649': 1, '16966571': 1, '18339219': 1, '9194739': 1, '24701070': 2}

{'3963203-2': 2}

3963203-2

noncomm/PMC003xxxxxx/PMC3963203.xml

Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit

A 32-year-old, previously healthy woman presented with headache, drowsiness, global aphasia, and right hemiparesis from a left frontal intracerebral hemorrhage. Moyamoya disease was diagnosed and she underwent urgent craniotomy for hematoma evacuation. Postprocedurally, her mental status improved with a persistent right facial droop and dense right hemiparesis. On ICU day 4, she was noted to have an isolated dilated and fixed right pupil (9 vs. 3 mm on the left). An urgent CT scan showed no evidence of mass effect or brain herniation. The patient had received nebulized bromide ipratropium every 4 h over the previous few days. The anisocoria resolved within 24 h of ipratropium bromide discontinuation.

[[32.0, 'year']]

F

{'2878329': 1, '27683661': 1, '25097368': 1, '18191575': 1, '29260071': 1, '16318649': 1, '16966571': 1, '18339219': 1, '9194739': 1, '24701070': 2}

{'3963203-1': 2}

3963204-1

noncomm/PMC003xxxxxx/PMC3963204.xml

Olanzepine-induced neuroleptic malignant syndrome in a case of multiple sclerosis

A 25-year-old man, with a background history of multiple sclerosis in remission for two years came to the Accident and Emergency department with weakness in his right arm and leg for 6 h. He also had ataxia. There was no focal/urinary incontinence or visual disturbances. He was started on methyprednisolone 1 g intravenously. On the third day, the patient had jerky movements and shivering. Axillary temperature was recorded at 38.6°C. He also had dysarthria, past pointing and blurring of vision and nystagmus. He was very anxious, tearful, and apprehensive; diagnosis of psychosis was made, and the patient was started on olanzepine 2.5 mg BD. He also had a lumbar puncture done for nystagmus and ataxia. On the sixth day patient was tachypneic and had tachycardia. He was very drowsy. Temperature recorded in the axilla was 45°C. Leucocyte count was 22,000 cells/mm3. Creatinine kinase (CK) levels were 15,650 u/L [normal 30-190 u/L], serum alanine aminotransferase was 146 [normal 15-45] and alkaline phosphatase was 660 [normal < 300]. Patient was tachycardic, diaphoretic with incontinence and altered consciousness. Patient was intubated and electively ventilated. His CK levels continued to rise. His urine output decreased with increasing levels of creatinine and urea. Hemodialysis was initiated due to oliguria and rising renal parameters. The temperature was measured continuously via a rectal probe. At all times temperature was above 40°C. A diagnosis of Neuroleptic malignant hyperthermia was made. Arterial lines and a central line were inserted. Patient was well hydrated. Active cooling measures were initiated. Bloods were closely monitored for evidence of Disseminated intravascular coagulation (DIC) and electrolyte imbalance. An antipyretic was started. Patient was started on bromocryptine 5 mg NG TDS, Dantrolene 200 mg IV QDS, baclofen 10 mg TDS and clonidine 100 micrograms BD. The symptoms of NMS started resolving after nearly 4 h. The tachycardia and muscle rigidity had significantly reduced by the first day. Patient made a complete recovery in two days. MRI of the brain revealed extensive plaques in brainstem and swelling of the brain. A diagnosis of multiple sclerosis with superimposed acute demyelinating encephalomyelitis was made. The patient was extubated three days.

[[25.0, 'year']]

M

{'16923659': 1, '19149529': 1, '2894782': 1, '17222339': 1, '19307047': 1, '20651315': 1, '18472502': 1, '19480467': 1, '8777769': 1, '13815606': 1, '24701071': 2}

{}

3963313-1

noncomm/PMC003xxxxxx/PMC3963313.xml

Diagnosis and management of cervical ectopic pregnancy

A 32-year-old woman, para 1, presented with mild pain abdomen and slight bleeding per vaginum for 5 days. Other relevant history included amenorrhea of 8 weeks' duration with a positive urine pregnancy test, following which she had vaginal bleeding for 12 days. She assumed that she had complete abortion and did not seek medical advice. When spotting resumed 3 weeks later, she presented to the hospital. Her previous menstrual cycle was regular. She had one child conceived through intrauterine insemination (IUI) and delivered by lower segment uterine section (LSCS) 3 years back. There was no history of contraceptive use. She refused a vaginal examination.\nTransabdominal and transvaginal ultrasonography (TVS) examination revealed a ballooned-out cervical canal with a gestational sac of 4.7 cm × 4.1 cm [] and an empty uterus with thickened endometrium [], respectively. The sac contained a fetus with a crown rump length of 2.33 cm, corresponding to 9 weeks' gestation [] with the presence of cardiac activity []. A presumptive diagnosis of CP was made. Magnetic resonance imaging (MRI) was used to confirm the diagnosis of CP and to rule out uterine scar pregnancy. The findings on MRI included a typical hour-glass configuration of the uterus with thickened endometrium, a ballooned-out cervix containing the gestational sac with fetal pole and closed internal os []. Thus, the diagnosis of CP was confirmed.\nSingle-dose intramuscular methotrexate 50 mg was administered the next day and manual vacuum aspiration (MVA) was performed on the third day. Cervical tamponade was performed with a Foley catheter, with its bulb inflated with 30 mL normal saline. At 4 weeks' follow-up, the patient was asymptomatic with a review TVS showing organized blood clot measuring 3.3 cm × 2.4 cm in the cervical canal []. Six weeks after the procedure, the patient resumed her periods and the review scan showed a resolving blood clot measuring 2.6 cm × 1.3 cm.

[[32.0, 'year']]

F

{'34577892': 2, '25883444': 1, '10528001': 1, '31508578': 1, '15066476': 1, '11821302': 1, '18239016': 1, '28261511': 2, '31372062': 2, '9159458': 1, '10601926': 1, '11209638': 1, '34858755': 2, '28450982': 1, '28511461': 1, '33408588': 2, '27803524': 1, '10664646': 1, '2487038': 1, '15193489': 1, '33560888': 1, '32066111': 1, '16924329': 1, '12640157': 1, '24672169': 2}

{'7755558-1': 1, '8614163-1': 1, '8471448-1': 1, '5312454-1': 1, '6630720-1': 1}

3963314-1

noncomm/PMC003xxxxxx/PMC3963314.xml

A rare case of Turner's syndrome presenting with Mullerian agenesis

A 35-year-old female presented with short stature and primary amenorrhea. Her height is 122 cm, weight 34 kg, and she showed fairly normal intelligence. She had a history of delayed milestones and stunted growth. She was born out of consanguineous marriage and her sibling is healthy []. Maternal age at the time of birth of the patient and her sibling is 19 and 25 years, respectively. Physical examination revealed a female phenotype with short stature and cubitus valgus. Her breast and pubic hair development were Tanner's stage I [].\nExamination of the cardiovascular, respiratory, and neurological systems is normal. Gynecological examination revealed short vaginal canal with no visible cervix. She was admitted with a provisional diagnosis of Turners's syndrome.\nLaboratory investigations revealed normal hematological and biochemical parameters except that her thyroid profile showed low triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH), suggestive of primary hypothyroidism. Magnetic resonance imaging (MRI) brain revealed normal brain parenchyma and pituitary. Two-dimensional (2D) echocardiography was normal. Her buccal smear was negative for sex chromatin (Barr body). Her pelvic ultrasound revealed absent ovaries, uterus, and cervix. Other organs like kidneys, pancreas, liver, and adrenals were normal. These findings were confirmed by MRI of the pelvis. Even though laparoscopy is the best confirmatory test, it could not be done due to denial of consent. Karyotyping was done which showed 45 chromosomes with one X chromosome missing (45, X) [].\nThis karyotype was found in all cells examined, thus confirming the diagnosis of Turner's syndrome.

[[35.0, 'year']]

F

{'23825392': 1, '28384960': 1, '6546317': 1, '6700887': 1, '28216916': 2, '30878957': 1, '17047017': 1, '23565439': 1, '24672170': 2}

{'5296832-1': 1}

3963326-1

noncomm/PMC003xxxxxx/PMC3963326.xml

A rare case of community-acquired native quadruple-valve endocarditis

We herein report the case of a 58-year-old man who was relatively well and healthy up to 1 month prior to his admission to our hospital (Rajaie Heart Center, Tehran, Iran, 2011), when he developed generalized edema with malaise, dyspnea, anorexia, and vomiting without fever. He sought medical treatment elsewhere; and after incomplete treatment, he referred to Rajaie Cardiovascular, Medical and Research Center with renal dysfunction and suspicious infective endocarditis.\nOn admission, the initial vital sign assessment revealed a blood pressure of 147/90 mmHg, pulse rate of 84/min, respiratory rate of 16/min, and temperature of 37.1°C. The patient was then subjected to cardiorespiratory examination, which showed soft S1, systolic murmur III/VI at the left sternal border and left ventricular apex, and fine rales in the lower third of both lung fields. The EKG findings included left axis deviation, left atrial enlargement, incomplete right bundle branch block, and high voltage QRS with ST-T change, suggestive of left ventricular volume overload.\nAdmission laboratory findings demonstrated white blood cells = 12000/ml (4000-1,00,000), hemoglobin = 8.2 g/dl (12-16), platelets = 84,000/ml (150,000-450,000), creatinine = 3.4 mg/dl (0.5-1.4), serum sodium = 141 meq/l (132-145), and serum potassium = 3.4 meq/l (3.5-5.5). In addition, during the patient's stay in our center, his blood cultures were negative five times.\nImaging revealed splenomegaly and most probably paranchymal renal disease (abdominal sonography). Additionally, Doppler sonography of the renal arteries demonstrated atherosclerotic change without significant stenosis.\nTransthoracic and transesophageal echocardiographic examinations [Figures –] showed two highly mobile masses on both anterior and posterior mitral valve leaflets (max size = 0.5 × 1.5 cm2) with severe mitral regurgitation due to malcoapted mitral leaflets, three highly mobile masses on the ventricular side of the aortic cusps (max size = 1 × 0.5 cm2) with mild-to-moderate aortic regurgitation, highly mobile masses on all the three leaflets of the tricuspid valve (max size = 2.2 × 0.75 cm2) with mild tricuspid regurgitation, semi-mobile vegetation on the medial, and lateral pulmonary valve cusps (max size = 1.75 × 0.9 cm2) with mild-to-moderate pulmonary regurgitation, moderate-sized perimembranous ventricular septal defect (0.7 cm) with a left-to-right shunt (QP/QS = 1.5, peak pressure gradient = 188 mmHg, and mean pressure gradient = 88 mmHg) with large highly mobile vegetation in the orifice of the ventricular septal defect on the right ventricular side, and moderate pulmonary artery hypertension (pulmonary artery pressure = 50 mmHg).\nThe patient's antibiotic treatment for infective endocarditis[] was continued for another 18 days, and he was dialyzed five times due to symptomatic uremia. He was also scheduled for surgery; however, his refusal to undergo operation and even to continue his treatment at the intensive care unit led to his consensual discharge from the hospital. We followed the patient through phone, and he told triple valve replacement was done for him in another center.

[[58.0, 'year']]

M

{'15888981': 1, '31020107': 1, '20138467': 1, '32699678': 2, '15061634': 1, '18323192': 1, '11559695': 1, '17616306': 1, '21308537': 1, '11168109': 1, '10862572': 1, '11864092': 1, '15310690': 1, '24672568': 2}

{'7370584-1': 1}

3963327-1

noncomm/PMC003xxxxxx/PMC3963327.xml

A successful treatment of rhinocerebral mucormycosis due to Rhizopus oryzae

A 65-year-old man with diabetes mellitus type 2 typically had headache (especially in parietal and frontal lobes), nose and the left eye discharge, was admitted in 2012 in Al-Zahara hospital in Isfahan, Iran. He had a fifteen-year's history of diabetes, hypertension, hyperlipoproteinemia, and kidneys dysfunction. He suffered from nightly headache even was not healed with opioid drugs such as morphine and methadone. Each episode of headache has been survived about four hours accompanied by nose and eye discharge. There was no fever, nausea, vomiting, dizziness, diplopia, blurred vision, and memory dysfunction. Proptosis of the left orbit occurred. Brain MRI found the left ethmoidal and maxillary sinusitis and subperiosteal abscess in left orbit. There was a signal change in the left frontal lobe as high signal intensity on T2 FLAIR with edema and minimal mass effect []. Endoscopy of the nose and paranasal sinuses was performed and sampling from tissue and discharges was done and then transferred to the clinical laboratory. Both culture results and the characteristic hyphae in sections [] confirmed mucormycosis. The isolate was identified as Rhizopus oryzae by sequence analysis (Gene Bank accession number is KF228585). The patient was transferred to the Department of Otolaryngology (ENT) and amphotericin B (50 mg/day) was prescribed for him, and debridement of sphenoid sinus walls was performed. Because of renal failure of the patient, drug regimen changed to posaconazole (PCZ)(5 mg/kg). After 20 days, headache recommenced and brain MRI showed invasion to the frontal lobe. He was nominated for craniotomy surgery and finally enucleation of the left eye was accomplished. At last, after revision of paranasal sinuses for assurance of eradication of the disease, the patient was released from hospital with drug regimen of posaconazole (5 mg/kg) for two weeks. We followed up him for one year and he is still alive.

[[65.0, 'year']]

M

{'22701840': 1, '20207339': 1, '14748801': 1, '32123659': 1, '30666711': 1, '16960917': 1, '22247451': 1, '19435437': 1, '17624436': 1, '12638836': 1, '18444535': 1, '34827246': 1, '28681007': 1, '34405152': 2, '24672569': 2}

{'8366463-1': 1}

3963328-1

noncomm/PMC003xxxxxx/PMC3963328.xml

Combined choroidal neovascularization and hypopituitarism in a patient with homozygous mutation in methylenetetrahydrofolate reductase gene

A 20-year-old male was admitted to Gulhane School of Medicine, Department of Endocrinology and Metabolism outpatient clinic, with the complaints of fatigue, anorexia, weakness, and absence of penile erection. A detailed medical history taking revealed that the patient had been diagnosed with hypothyroidism and growth hormone (GH) deficiency at the age of 10 and was subsequently started with treatment for both hypothyroidism and GH deficiency. After a 3-year levothyroxine and GH therapy, he himself had stopped the medication and was free of any drug for the past 7 years. He defined that his complaints increased in the last 3 months. He was hospitalized for further evaluation. On physical examination, his blood pressure was 90/50 mmHg and his pulse was 68 beats/min. He was 164 cm tall and weighed 58.5 kg. A eunuchoid appearance with an arm span that was more than 5 cm longer than height, and no facial and minimal axillary hairy were noted. Tanner score of the pubis was 2 and penis length was 5 cm. Right and left testicular volumes were 3.4 ml and 2.5 ml, respectively, on ultrasonography. He had no hyperpigmentation on his skin or oral mucosa. Other physical findings were unremarkable. Laboratory results are shown in .\nOn the 5th day of hospitalization while waiting for magnetic resonance imaging (MRI) appointment, the patient had rapid visual loss in the right eye. Best-corrected visual acuity (VA) was 20/50 in the right eye and 20/20 in the left eye. Dilated funduscopic examination revealed a yellowish elevated lesion near the optic disc, with macular edema and hemorrhage next to the temporal side of the optic disc in the right eye. Fluorescein angiography (FA) showed a hyperfluorescent lesion consistent with CNV [], and optical coherence tomography (OCT) showed a peripapillary lesion with subretinal fluid elevating the neurosensory retina in the macular area []. MRI of the brain revealed a hypoplastic adenohypophysis and a hypoplastic pituitary stalk. An ectopic neurohypophysis was found located in the area of the hypothalamus [, T1 weighted; , T2 weighted]. Because of his visual loss, Department of Ophthalmology did not allow insulin hypoglycemia test. Thyroid morphology was normal on ultrasonography. Thyrotropin releasing hormone stimulation test resulted in a maximum thyroid stimulating hormone (TSH) level of 7.6 μIU/ml by the 30th min. Because of his medical history, clinical and MRI findings, low thyroidal, (free T4) adrenal, (low cortizol) testicular, (low total testosterone) low GH, insulin-like growth factor 1 (IGF-1), and low-normal other pituitary hormone levels [], he was diagnosed as having hypopituitarism.\nFirst, prednisolone 5 mg/day was started; 1 week later, l-thyroxin 50 mg/day was added to the treatment. Since both hypopituitarism[] and CNV could be caused by hypoxia,[] conditions known to cause a hypercoagulable state were explored and an MTHFR C677T homozygous mutation was detected by polymerase chain reaction of genomic DNA.[] For the peripapillary CNV, three intravitreal injections of anti-VEGF antibody (ranibizumab) were administered for persistent fluid collection. Before the start of testosterone gel 50 mg/day treatment, acetyl salicylic acid (ASA) 100 mg/day was also added to the treatment. By the 6th month of follow-up, VA increased to 20/20 and OCT showed peripapillary scar formation and total resolution of the subretinal fluid []. No subsequent thromboembolic event was determined. On the annual control, 1 year after the event, he was still taking L-thyroxin, testosterone gel, prednisolone, and ASA. His vision on the right eye was stable with 20/20 and no thromboembolic event was determined.

[[20.0, 'year']]

M

{'11181567': 1, '16565760': 1, '17021318': 1, '20013527': 1, '27904604': 1, '15294883': 1, '21925119': 1, '2042546': 1, '22526618': 1, '22973354': 2, '21107737': 1, '15126525': 1, '11134099': 1, '2433658': 1, '16597813': 1, '17310026': 1, '17879504': 1, '15243582': 1, '22409559': 1, '7647779': 1, '9793407': 1, '24672570': 2}

{'3430070-1': 1}

3963347-1

noncomm/PMC003xxxxxx/PMC3963347.xml

Retrovesical hydatid cyst presenting with urinary retention and left kidney atrophy

We report the case of a 43 year-old male patient who presented to the clinic for left flank pain and progressive severe obstructive urinary symptoms for 6 months. His past medical history includes multiple laparotomies for abdominal bullet injuries in 1984, including splenectomy, appendectomy, and cholecystectomy.\nOn physical examination, he had left Costo-vertebral Angle (CVA) tenderness and a hard non-mobile suprapubic mass. A Foley catheter was inserted with difficulty, yet the mass persisted. Subsequently, a computed tomography (CT) scan of abdomen and pelvis was done, revealing a large pelvic cyst measuring 14.9 × 12.7 × 14.8 cm. The left ureter was encased by the large mass, with secondary left hydroureteronephrosis and severe thinning of the left renal cortex. The mass had an irregular wall with a soft tissue component seen at its right lateral aspect, measuring 2 cm in maximal thickness. The bladder was displaced anteriorly and superiorly to the right [].\nSerum creatinine level was 2 mg/dL. Indirect hemagglutination for Echinococcus granulosus was negative (titer < 1:32).\nThe patient underwent flexible cystoscopy, revealing a normal bladder with no diverticulae. He underwent an exploratory laparotomy, with excision of this large retrovesical cyst, along with a simple left nephroureterectomy. The pelvic cyst was unroofed after injecting citramide inside it and shielding the area around it with citramide-soaked pads. Because of excessive adhesions, we only performed an upper pericystectomy. Through the same incision, a left nephroureterectomy was done [].\nThe pathologic examination of the surgical specimen confirmed hydatid disease, and the remnant kidney was negative for the disease. The patient was started on albendazole for 2 months. He had a rapid resolution of urinary symptoms and improvement in serum creatinine. At 16-month follow-up, the patient is free of symptoms with no disease recurrence on repeated CT scan.

[[43.0, 'year']]

M

{'2741632': 1, '6624560': 1, '31934486': 2, '7870645': 1, '5943894': 1, '2188558': 1, '11431799': 1, '33532165': 2, '5445021': 1, '10835129': 1, '27190883': 1, '3731703': 1, '24669126': 2}

{'6942758-1': 1, '7845745-1': 1}

3963349-1

noncomm/PMC003xxxxxx/PMC3963349.xml

A case of polypoid and papillary cystitis mimicking an advanced bladder carcinoma with invasion of perivesical fat

A 69-year-old man was admitted to our hospital because of pain during urination and gross hematuria. There was no relevant medical history and no presenting complaints. Routine urine examination was positive for red blood cells and showed the absence of white blood cell, protein, and glucose. Blood urea, serum creatinine, and other biochemical blood tests showed no abnormal findings. There was no clinical sign of infection and no history of bladder catheterization. Ultrasound showed an irregular and isoechoic thickening of the left side of the bladder wall. Cystoscopic examination suggested a broad expanding mass on the left side of the bladder wall. Pre- and postcontrasted CT images revealed an irregular thickening of the left side of the bladder wall and an increased density of a surrounding fat tissue []. The irregular wall thickening showed isointensity relative to the bladder wall on T1-weighted images [], and inhomogeneous hypointensity on T2-weighted images [], and gradual and inhomogeneous enhancement were seen on dynamic contrast study []. In addition, there was obliteration of the normal hypointensity of the muscle layer of the bladder wall on T2-weighted images []. Furthermore, T1- and T2-weighted images including dynamic contrast study showed a stranding of perivesical fat [Figure and ], which suggested the perivesical fat invasion. The results of urine cytology showed no malignancy. However, imaging findings suggested an advanced bladder carcinoma invading muscle layer and perivesical fat.\nTransurethral partial resection of the bladder tumor was performed to obtain a histological diagnosis. Pathologic examination revealed a polypoid or papillary appearance of the mucosa, with submucosal edematous changes, neutrophil invasions, and granulomatous formations [Figure and ]. The patient was diagnosed as having a polypoid and papillary cystitis.\nHe was followed closely without any treatment, and both the irregular thickening of the bladder wall and the stranding of a surrounding adipose tissue nearly-disappeared on MR and cystoscopic findings after 3 months [].

[[69.0, 'year']]

M

{'3389451': 1, '380263': 1, '6708236': 1, '6709921': 1, '12899216': 1, '31179381': 1, '2219622': 1, '17102055': 1, '15232379': 1, '18379418': 1, '24669128': 2}

{}

3963350-1

noncomm/PMC003xxxxxx/PMC3963350.xml

Uncommon causes of anterior urethral diverticula in children: Two cases and review of literature

A three year old boy with a background of Russell Silver Syndrome presented to us with a soft, non-tender lump (1.5 cm) with a bluish hue on the ventral side of the penis in the region of the penoscrotal junction which persisted after voiding. [] The swelling was compressible and emptied on pressure with associated dribbling. Ultrasonography was performed to exclude renal anomalies. It showed that both kidneys were in orthotopic positions with no hydroureters or hydronephrosis. Micturating cystourethrogram (MCUG) revealed an AUD involving the mid portion of the penile urethra causing extrinsic compression of the urethra. [] The urethra proximal to the diverticulum was dilated and there was bilateral grade 2-3 vesicoureteric reflux. The posterior urethra was normal. Cystourethroscopy confirmed a large diverticulum of the anterior urethra without a valve. A provisional diagnosis of anterior urethral diverticulum was made. The patient underwent an open diverticular repair. A thin walled diverticulum was found extending into the subcutaneous plane. There was a wide communication with the native urethra. The diverticulum was excised and the defect was repaired in layers. He made uneventful recovery and the histology of the wall of the diverticulum revealed attenuated sparse smooth muscle with fibrosis.

[[3.0, 'year']]

M

{'3118550': 1, '18947773': 1, '17602414': 1, '19517125': 1, '16418968': 1, '22084741': 2, '17448778': 1, '6789371': 1, '20202229': 1, '4643279': 1, '19661640': 1, '15291870': 1, '351914': 1, '9258136': 1, '24669129': 2}

{'3963350-2': 2, '3195389-1': 1}

3963350-2

noncomm/PMC003xxxxxx/PMC3963350.xml

Uncommon causes of anterior urethral diverticula in children: Two cases and review of literature

A 13-year old boy complained of poor urine stream and post void dribbling over the last few years with no documented urinary tract infections. He underwent a cystourethroscopy two years ago at another hospital that showed a narrowing in the anterior urethra and was dilated. He represented with worsening symptoms about a year later. The most recent ultrasonography demonstrated poor bladder emptying with a post-void residual of 250 ml at his first attempt. There was no hydronephrosis or hydroureter. A micturating cystourethrogram showed an urethral diverticulum in the area of the bulb causing extrinsic compression of the penile urethra. [] The urethra was otherwise normal and no vesicoureteric reflux was noted. He was subsequently referred to our service. He underwent a cystourethroscopy which confirmed a large urethral diverticulum with a narrow neck in the anterior urethra close to the bulb. [] Urethroscopic examination of the diverticulum revealed a tiny communication in its posterior wall suggestive of a possible communication with the duct of the Cowper's gland. The rest of the urethra appeared unremarkable. The diverticulum was deroofed using a resectoscope knife with cutting current. The patient's symptoms resolved and a repeat urethroscopy 6 weeks later showed no narrowing of the urethra and a slight expansion of the urethra in the area of the diverticulum but was otherwise normal.

[[13.0, 'year']]

M

{'3118550': 1, '18947773': 1, '17602414': 1, '19517125': 1, '16418968': 1, '22084741': 2, '17448778': 1, '6789371': 1, '20202229': 1, '4643279': 1, '19661640': 1, '15291870': 1, '351914': 1, '9258136': 1, '24669129': 2}

{'3963350-1': 2, '3195389-1': 1}

3963352-1

noncomm/PMC003xxxxxx/PMC3963352.xml

Botryoid-type of embryonal rhabdomyosarcoma of renal pelvis in a young woman

A 22-year-old female patient complaining of left loin pain which was colicky in nature without other urinary tract symptoms or history of trauma. Physical examination was unremarkable except for mild left loin tenderness, her hematocrit and kidney function laboratory test were normal and urine analysis showed microscopic hematuria. Ultrasonographic examination reveals left renal pelvic soft tissue mass around 3 × 4 cm [], MRI confirms this finding and a tumor is confined to the left renal pelvis without evidence of abdominal lymphadenopathy [Figure and ]. Left retrograde pyelography showed renal pelvic filling defect and lower group calyx hydronephrosis []. Ureterorenoscopy could confirm tumor and biopsies were taken, but histopathology report did not give definitive diagnosis other than the presence of a malignant process.\nA left nephureterectomy with transurethral ureter stripping and ureter ostium resection on a presumption of transitional cell carcinoma is carried out. The surgical resection specimen showed a polypoid tumor with a grape-like appearance in the left renal pelvis [].\nMicroscopically there was a condensation of epitheloid to spindle cells underneath the basement membrane, forming the cambium layer. Immunohistochemical examination stains for vimentin, WT1, CD117, CD99, HMB45, CEA, CK7, and S100 were negative, stains for desmin, MYO D1 and actin, confirming the diagnosis of Botryoid-type of embryonal rhabdomyosarcoma.

[[22.0, 'year']]

F

{'27227946': 1, '11505068': 1, '6307217': 1, '11353062': 1, '12673941': 1, '11734690': 1, '16825824': 1, '10337369': 1, '24669131': 2}

{}

3963354-1

noncomm/PMC003xxxxxx/PMC3963354.xml

New compression mechanism in penile-scrotal lymphedema and sexual rehabilitation

The patient, a 58-year-old man, reported edema of the penile and scrotal region after surgery of the pancreas and spleen to remove a tumor 1 year and five months previously. The patient told that he was hospitalized for 46 days and was submitted to 16 sessions of chemotherapy. After discharge, he took bactrin for 30 days until returning for a follow-up consultation. He reported that the edema started in the pubic area, penis and scrotum, one year after surgery and that it did not reduce and caused pain and discomfort. The patient was initially attended in the Urology Department of Hospital de Base where he was referred to the Godoy Clinic in Sĕo José do Rio Preto for a vascular evaluation and treatment.\nDuring the physical evaluation, the patient complained of pain, discomfort, and difficulty to walk during his work. He also reported that he had discomfort to urinate which deeply disturbed him. A clinical diagnosis of lymphedema of the penis and scrotum was reached.\nTreatment involved the continuous use of a cotton-polyester compression garment, Figure and , for the penis and scrotum region, together with thorough hygiene skin care. The swelling was reduced significantly and within one week, an almost normal size was achieved. However, the patient was counseled to continue to use the compression garment. The patient reported that the discomfort had improved, he was able to urinate normally, he could walk normally at work, and that hygienic skin care was easier.\nHe had not been sexually active since the onset of edema and after the swelling had been reduced, he suffered erectile dysfunction. This was treated with the administration of 50 mg Sildenafil.

[[58.0, 'year']]

M

{'17385828': 1, '33179001': 1, '20428336': 1, '28083477': 1, '27284543': 2, '19093784': 1, '24669133': 2}

{'4880436-1': 1}

3963355-1

noncomm/PMC003xxxxxx/PMC3963355.xml

Percutaneous nephroscopic resection of pyelocaliceal transitional cell carcinoma in solitary kidney

An 82-year-old female was admitted because of painless gross hematuria for 3 months. Ultrasound and CT scan showed an atrophic left kidney and a soft-tissue-like lesion measuring 3 × 2 cm in right renal pelvis which obstructed the ureter-pelvic junction. The serum creatinine was 276 umol/l.

[[82.0, 'year']]

F

{'16444935': 1, '18761193': 1, '11098771': 1, '18929398': 1, '16765178': 1, '15869996': 1, '19140589': 1, '20495691': 1, '17437430': 1, '24669134': 2}

{'3963355-2': 2}

3963355-2

noncomm/PMC003xxxxxx/PMC3963355.xml

Percutaneous nephroscopic resection of pyelocaliceal transitional cell carcinoma in solitary kidney

A 72-year-old male presented with intermittent right flank pain and microscopic hematuria for 4 weeks. His left kidney, ipsilateral ureter, and bladder cuff had been removed due to left renal pelvic carcinoma 7 years before. A computed tomography of urinary tract (CTU) demonstrated an intraluminal filling defect, measuring 2 × 2 cm, with hydrocalycosis in middle and lower calyces [Figure and ].\nThere was no evidence of metastases. Since urine cytology was positive for urothelial carcinoma for three times, retrograde ureteroscopy was not performed.\nGiven the chronic renal insufficiency and a solitary kidney, tumor resection with monopolar electrocautery through percutaneous access was carried out after various options were discussed with the patients. With the patients under general anesthesia and in the prone position, the percutaneous nephrostomy puncture of the affected kidney was performed under both C-arm fluoroscopic and ultrasonic guidance. The dilated middle calyces were chosen for puncture. The tract was dilated to 30 Fr before an Amplatz sheath was inserted. A 24 Fr resectoscope (R. Wolf resectoscope) with monopolar electrocautery was used to resect the tumor (settings: Cut, 120; coagulation, 60) through the Amplatz sheath. A sessile cauliflower-like lesion was seen through the resectoscope. In case 1, CT scan of the abdomen on the 4th postoperative day revealed a tumor-like lesion measuring 1 × 1 cm in the middle of the pelvis. A second look was therefore performed for complete removal of the residual tumor 2 weeks after initial resection.\nIn both cases, the ureteropelvic junction (UPJ) appeared to be non-obstructed with a normal contour after the resection. A 22 Fr nephrostomy tube and 6 Fr double J stent were inserted for indwelling drainage.\nThe postoperative courses of the patients were uneventful. The renal function turned to be normal after 3 months in case 1. The serum creatinine increased to 175 umol/l transiently in case 2; so, the patient was discharged 5 days after the surgery. The nephrostomy tube was removed on the 4th postoperative day when CT scan showed no residual cancer in the renal pelvis. Pathologic study confirmed a TCC of T1G1.\nIn an effort to reduce the risk of tumour recurrence and progression, 80 mg of Bacillus Calmette-Guérin (BCG) in 100 ml of diluents was administered weekly via intravesical instillation for topical therapy. Both patients were followed up at 3 months with negative cytology and CTU which suggested free of any filling defects in collecting system. At 6 and 9 months, the patients remained free of recurrence in both collecting system and bladder, and maintained stable renal function. In addition, there was no evidence of metastatic disease.

[[72.0, 'year']]

M

{'16444935': 1, '18761193': 1, '11098771': 1, '18929398': 1, '16765178': 1, '15869996': 1, '19140589': 1, '20495691': 1, '17437430': 1, '24669134': 2}

{'3963355-1': 2}

3963356-1

noncomm/PMC003xxxxxx/PMC3963356.xml

Isolated ureteric endometriosis presenting as a ureteric tumor

A 32 year old lady presented with recent onset left flank pain which was not associated with any precipitating events. She had chronic lower back pain. She had no gross hematuria, fever or lower urinary tract symptoms. Her menstrual history was normal. She reported no abdominal or pelvic pain, no dyspareunia and had normal bowl motion. She gave no history of smoking, past medical surgical or gynecological treatment or intervention. Examination of the patient revealed no abdominal or pelvic tenderness or masses. Urine analyis showed microscopic hematuria and pyuria. Urine culture was positive for Klebsielae pneumoniae. Serum creatinine was 59 umol/L. CT scan without contrast showed no stones and mild left hydronephrosis. The patient was discharged on antibiotics and analgesics for follow up. A 7 day course of ciprofloxacin eradicated the infection. Imaging for evaluation of the lower back pain indicated osteoarthritis at vertebra L5-S1. A bone scan confirmed this diagnosis and accidentally revealed poor tracer uptake of the left kidney. The patient was referred to Urology.\nAn intravenous urography showed no excretion from the left kidney []. A diuretic renogram using 99mTc-MAG3 showed poor excretion of the left kidney []. A retrograde study was carried out which revealed a short narrow segment in the ureter at the junction of the lumbar and pelvic ureter []. Ureteroscopy showed a papillary growth obstructing the lumen of the ureter. A cold cup biopsy was taken from the lesion. A double J stent was left indwelling. Microscopic pathology was not conclusive indicating an inflammatory process. A repeat renal scan with the JJ stent indwelling for 16 days, failed to show any improvement in renal function or excretion []. The patient was informed that in view of the poor functioning kidney and the high risk of harboring a malignant ureteric tumor surgery is indicated. A robotic nephroureterctomy with a bladder cuff was carried out with an uneventful course. During the surgery the left ureter was seen at the pelvic brim surrounded by adhesions and scar tissue. No other gross lesions were identified intraoperatively. Macroscopic examination of the ureter at the site of narrowing showed a firm nodule covered by bluish-red mucosa measuring 1.5 × 1.5 cm. Microscopic examination of the ureteric nodule revealed benign endometrial gland and stroma underlining the normal urothelium [Figure –]. Immunohistochemical studies were performed for estrogen receptor and CD10. The endometrial glands were positive for Estrogen receptor [] while the endometrial stroma was positive for CD10 [].

[[32.0, 'year']]

F

{'19200964': 1, '15521864': 1, '16764874': 1, '15549259': 1, '18990377': 1, '20184728': 1, '2664621': 1, '19818156': 1, '18410936': 1, '18538172': 1, '24669135': 2}

{}

3963557-1

noncomm/PMC003xxxxxx/PMC3963557.xml

A novel immunodeficiency syndrome associated with partial trisomy 19p13

Patient 1, a 7-year-old boy was born prematurely in the 32nd week of gestation after an uneventful pregnancy (32+2 weeks, intrauterine growth retardation (IUGR), caesarean section, oligohydramnion) with 990 g body weight (<3%), 34 cm body length (<3%), and a head circumference of 26.5 cm (<3%); his APGAR score was 8/9/9; he was discharged from neonatal intensive/intermediate care at the chronological age of 8 weeks. He is the second child to non-consanguineous healthy parents of Turkish descent aged 34 years (mother) and 40 years (father). The second patient, a now 2-year-old boy, was born prematurely as the second child of a 29-year-old Austrian mother and a 35-year-old Austrian father after an uneventful (third) pregnancy at 31+1 weeks of gestational age (IUGR, caesarean section, APGAR 7/8/9, 660 g birth weight (<3%), 34 cm length (<3%), 26.5 cm head circumference (<3%)); dismissed from neonatal intensive/intermediate care at 3 months of chronological age (corrected gestational age: 42+6 weeks). Growth parameters, weight and head circumference of both patients have remained below the third centile, recent measurements are presented in . The parents and siblings of both patients are healthy, and the extended family histories are negative for syndromic disorders or immunodeficiency.\nUpon birth, both patients showed visible organ malformations including microcephalus, facial dysmorphism including flat nasal bridge, telecanthus, short upslanting palpebral fissures, low set ears, long philtrum, narrow lips, micrognathia (A,C), as well as urogenital malformations, a perineal hypospadia in patient 1 (B) and glandular hypospadia, horseshoe kidney, cryptorchism (), camptodactylia on both feet of toes II, III, IV and overlapping of right third/fourth toes (D) in patient 2.\nIn his 1st year of life, patient 1 suffered from a bilateral incarcerated inguinal hernia and thus had to undergo surgery. Additionally, he showed developmental hip dysplasia type IVa, which was surgically treated by Pemberton's acetabuloplasty. At the age of 5 years, hypospadia required surgery whereupon a penoscrotal fistula was detected that could not be fully corrected.\nAn extensive neurological examination in the 2nd year of life (chronological age: 18 months) showed profound neurological impairment and motor plus mental retardation. Neuropaediatric examination revealed muscular hypotonia, reduced muscle strength, brisk deep tendon reflexes, negative Babinski sign; furthermore, at 18 months the boy was unable to sit, to crawl, nor to stand free; and, without further specification, the neurological report mentions showed reduced fine motor skills and speech/language retardation., Testing of the sensory system and cerebellar function was unfeasible. Moreover, a strabismus convergens alternans of the left eye was noted at the age of 18 months. Additionally, moderate bilateral sensorineural hearing loss was detected by brainstem evoked response audiometry (summarised in ). Cranial MRI showed a hypoplastic inferior vermis and a slightly extended temporal lobe (data not shown). Furthermore, the patient suffered from EEG-verified epilepsy (habitual primarily generalised seizures, EEG pathology III°) treated with valproate, which resulted in decrease of frequency of seizures (not shown). Later neurological evaluations focused on the antiepileptic treatment, while ongoing physiotherapy and ergotherapy have been aiming to improve the psychomotor situation. Dysphagia prompted the implantation of a percutaneous endoscopic gastrostomy tube at the age of 6 years. Because of a severe osteopenia (z score: −4.6 (0.26/cm3)) resulting in a pathological fracture at the age of 6 years, he is treated with bisphosphonate intravenously (18 mg) every 3 months.\nSimilar to patient 1, patient 2 suffered from inguinal hernia leading to bilateral herniotomy at 3½ months of age. He was noted to have a persisting ductus arteriosus with marginal haemodynamic relevance. Because of delayed motor and mental development (see below), progressive failure to thrive and feeding problems, intensive physiotherapy and ergotherapy was provided, additional nasogastric tube feeding with formula diet was initiated at 8 months and percutaneous gastrostomy was performed at 20 months. Like patient 1, he is neurologically and intellectually impaired with profound psychomotor retardation and muscular hypotonia (eg, sitting and belly sliding/crawling only at 2 years of age; grabbing a spoon without ability to use it), speech delay (vocalising only syllables like ‘da’ at 2 years), pharyngeal instability, microcephalus, had neonatal seizures treated with barbiturate for 10 days and two generalised seizures in the context of suspected meningitis leading to temporal antiepileptic treatment with levetiracetam, from 18 months to 21 months of age. Denver test analysis at 2 years of age revealed social contact abilities corresponding to 15 months and motor skills corresponding to 6–9 months. Basal EEG activity was found to be mildly abnormal without focal activity, and in CNS-MRI profound atrophy with multiple diffuse white matter lesions and microcystic alterations of the basal ganglia were detected (). Additionally, patient 2 suffers from hypermetropia and divergent concomitant strabismus, largely resembling patient 1; however hearing tests were normal.\nBoth patients fulfilled the classical and revised criteria of a primary immunodeficiency disorder with frequent infections and showed laboratory signs of immune dysregulation. Starting from the age of 3 weeks after birth, patient 1 developed recurrent invasive bacterial infections including episodes of sepsis; a proven Staphylococcus capitis sepsis at the age of 1½ years was followed by a severe urosepsis at 3 years. Apart from two episodes of pneumonia, chronic relapsing productive bronchitis with laboratory signs of bacterial infections recurred more than eight times per year, requiring inpatient admittance and intravenous antibiotic treatment. Moreover, the boy suffered from recurrent urinary tract infections possibly related to the hypospadia, with microbiological evidence of extended-spectrum beta lactamase (ESBL)-positive-positive Escherichia coli infection on two instances. Considering the clinical history of repeated severe bacterial infections in this patient, laboratory investigations revealing selective antibody deficiency and decreased numbers of class-switched B cells (see below), he was started on intravenous immunoglobulin (0.4 g/kg, at monthly intervals) at 5 years of age. This resulted in a significant decrease in the occurrence of infections, especially of the upper respiratory tract and lower respiratory tract.

[[7.0, 'year']]

M

{'16395598': 1, '14708957': 1, '22425249': 1, '8387892': 1, '12100033': 1, '9672528': 1, '23996541': 1, '22773339': 1, '15921166': 1, '20503314': 1, '23143768': 1, '23351986': 1, '12700034': 1, '22801960': 1, '17598130': 1, '32425682': 1, '22052638': 1, '12362042': 1, '10706444': 1, '22197273': 1, '22129048': 1, '1975428': 1, '27484815': 1, '10600329': 1, '7573129': 1, '2339704': 1, '24216514': 1, '23203987': 1, '21984609': 1, '16499568': 1, '21063025': 1, '11001877': 1, '11480765': 1, '19874387': 1, '14755469': 1, '22132890': 1, '1563088': 1, '33150487': 1, '23220634': 1, '20613546': 1, '22566844': 1, '23760686': 1, '19610110': 1, '21352207': 1, '31418107': 1, '11175277': 1, '24431329': 2}

{}

3964157-1

noncomm/PMC003xxxxxx/PMC3964157.xml

Gastrointestinal tract metastasis from tubulolobular carcinoma of the breast: a case report and review of the literature

A 70-year-old woman was admitted to our hospital with pain and discomfort in the right side of the abdomen, weight loss over the preceding 10 months, and tenderness of a right abdominal mass that had begun to develop 3 months before. Ten years before, she had received a left radical mastectomy as well as a dissection of axillary lymph nodes. Histopathological examination suggested lobular infiltrating carcinoma and some of the signet ring cell carcinoma (). Metastases were identified in five out of eight left axillary lymph nodes, but were not found in the left greater pectoral muscle. Immunohistochemical stains showed tumor cells CK7 (+), GCDFP-15 (gross cystic disease fluid Protein-15) (+), and c-erbB2 (++). The final histological stage was assessed as IIIa (pT3N1M0) (NCCN clinical practice guidelines of breast cancer). After surgery, the patient received one cycle of adjuvant chemotherapy, but this was discontinued due to serious GI reaction. Then, she received treatment with capecitabine (2,000 mg orally twice daily on days 1–14 [21-day cycle] from March 2001 until March 2002) and radiation therapy at the left clavicle (60Co DT:50Gy/38f), the left internal mammary (12Mev DT:50Gy/32f), and the chest wall (6Mev DT:50Gy/32f). After radiation therapy, she received tamoxifen but this was discontinued due to severe endometrial thickening after 3 months. Before chemotherapy, further immunohistochemical stains performed by the oncology department showed E-cadherin (+), 34βE12 (−), ER (+), PR (+), CK19 (+), CK20 (+), suggesting the presence of ductal infiltrating carcinoma and not lobular infiltrating carcinoma.\nTen years later, she complained of pain and a hard mass with tenderness at the right side of her abdomen. A color Doppler ultrasound showed a 5.0 × 4.9 cm, isoechoic, and irregularly shaped mass near the second hepatic portal in right lobe of the liver and a 7.5 × 7.0 × 5.5 cm, low-echoic, and irregularly shaped mass at the right side of the abdomen. Abdominal magnetic resonance imaging (MRI) demonstrated space-occupying lesions on the anterior section of the luminal side of the mid-ascending colon and the right lobe of the liver. The enhanced computed tomography (CT) scan, after admission, also showed a 5.0 × 4.9 cm, low-density, oval, and sub-lobe opacity mass, which could be ring-enhanced in the right lobe of the liver, and a 7.6 × 5.9 cm soft tissue mass with density in the luminal wall of the ascending colon (). Cancer antigen (CA)-125 levels were significantly high, at 365.5 U/mL, while CEA, CA15-3, and CA19-9 levels were normal. Because of the clinical symptoms, a right colectomy was performed after admission. In the operation, a 10–15 cm mass at the hepatic flexure of the ascending colon that had projected into the lumen instead of breaking through the serosa (or serous membrane), was found. Abnormal mesenteric lymph node was not found. The surgeon suspected there was a primary colon cancer. Histopathological examination showed poorly differentiated adenocarcinoma that had infiltrated into all the layers of colonic wall from the serosa, and cancer emboli were found in colonic lymph vessels (). Immunohistochemical stains showed tumor cells CK7 (+), E-cadherin (+), 34βE12 (−), ER (+), GCDFP-15 (+), CK19 (+), CK20 (+), and liver cell (−) (). These results confirmed that the mass was metastatic ductal infiltrating carcinoma. The patient underwent transcatheter arterial embolization. She rejected intravenous administration (navelbine and cisplatin [NP] regimen) but received treatment with capecitabine (2,000 mg orally twice daily on days 1–14 [21-day cycle]) from December 2011 until February 2013. The symptoms were significantly relieved, and the patient was still living 24 months after diagnosis of the metastasis and at the time this paper was written.

[[70.0, 'year']]

F

{'7530983': 1, '1568609': 1, '11147591': 1, '34131569': 1, '21912949': 1, '924431': 1, '2450059': 1, '6345937': 1, '7682767': 1, '8901855': 1, '10919011': 1, '1607149': 1, '2157608': 1, '26349909': 1, '3366041': 1, '11051411': 1, '14759714': 1, '23129741': 1, '9448188': 1, '12684893': 1, '2839327': 1, '19866427': 1, '11344761': 1, '14509331': 1, '16459641': 1, '17036400': 1, '21431489': 1, '15737028': 1, '17143261': 1, '10950087': 1, '21425017': 1, '3954484': 1, '1514536': 1, '8211676': 1, '16941751': 2, '12099661': 1, '11989148': 1, '11289296': 1, '19896312': 1, '24672246': 2}

{'2687742-1': 1}

3964159-1

noncomm/PMC003xxxxxx/PMC3964159.xml

Oculogyric crisis in a patient taking metoclopramide

A 13-year-old female patient presented to the emergency department with double vision and involuntary upward and lateral deviation of the eyes. Three days earlier, she had presented at an outpatient clinic and metoclopramide therapy was started at 0.5 mg/kg three times daily for vomiting of 2 days’ duration. After treatment, the frequency of vomiting was reduced, but her eyes became deviated upward, starting from 30 minutes before presentation (). On initial presentation, she was aware of this situation and was in severe distress. On neurological examination, her consciousness was clear. Sustained conjugate upward and lateral deviation of the eyes (oculogyric crisis), and neck stiffness when only the neck muscles were contracted, were observed. Physical examination did not reveal any other dyskinetic movement. The patient could bring her eyes back to primary position with extreme effort, but she could not sustain the effort, and the eyes resumed their eccentric position within seconds. On ophthalmic examination, she exhibited isocoria, with her pupils giving indirect and direct light reflexes. Ocular motility and visual acuity could not be evaluated due to the presence of oculogyric crisis. Her intraocular pressures and biomicroscopic and fundoscopic findings were unremarkable. Vitals were normal and results of complete blood count, liver and kidney function tests, and electrolytes were within normal values. Based on the history and physical examination findings, a diagnosis of metoclopramide-induced dystonia was made. The drug was discontinued and the patient was treated with intravenous diphenhydramine 1 mg/kg. The symptoms disappeared rapidly, within 30 minutes of commencing treatment, and the patient was discharged after approximately 4 hours of admission with complete recovery. She remained well at follow-up 1 week later.

[[13.0, 'year']]

F

{'2627222': 1, '7970356': 1, '3559623': 1, '1836805': 1, '17195428': 1, '14482072': 1, '16882832': 1, '23129969': 2, '34349300': 1, '23984041': 1, '3703259': 1, '22964448': 1, '23267386': 2, '16702617': 1, '10331711': 1, '15891443': 1, '2044856': 1, '3929968': 1, '7416782': 1, '9516631': 1, '27003816': 1, '34013443': 2, '24672222': 2}

{'3487282-1': 1, '3527052-1': 1, '3527052-2': 1, '3527052-3': 1, '8134644-1': 1}

3964164-1

noncomm/PMC003xxxxxx/PMC3964164.xml

Spectral-domain optical coherence tomography imaging of macula-off rhegmatogenous retinal detachment

A 70-year-old Latin American woman presented for evaluation of decreased vision in the right eye for 3 days. Past ocular history was significant for bilateral uncomplicated cataract extraction with intraocular lens placement 4 months prior.\nOphthalmic examination revealed best-corrected visual acuity of 1/200 in the right eye and 20/20 in the left. A relative afferent pupillary defect was noted in the right eye. Intraocular pressure was 14 mmHg in both eyes. The posterior segment examination of the right eye demonstrated a bullous rhegmatogenous retinal detachment caused by a superotemporal horseshoe tear (). SD-OCT revealed marked elevation of the retina extending through the macula to the optic nerve ().\nThe patient underwent a scleral buckling procedure with cryotherapy 6 days after initial examination. The following day, 0.3 cm3 of 100% C3F8 (octafluoropropane) gas was placed in the right eye because of persistent subretinal fluid. Postoperatively, the patient’s retina remained attached, and vision slowly improved. Six months after successful retinal detachment surgery, the patient’s best-corrected visual acuity in the right eye was 20/60 (). SD-OCT revealed mild foveal atrophy in the outer nuclear layer, with mild disruption of the inner segment ellipsoid layer ().

[[70.0, 'year']]

F

{'9818620': 1, '23002414': 1, '15921745': 1, '11772595': 1, '21522038': 1, '18191657': 1, '23773202': 1, '21778929': 1, '673337': 1, '21937016': 1, '23591530': 1, '22275812': 1, '16794436': 1, '24672221': 2}

{'3964164-2': 2, '3964164-3': 2, '3964164-4': 2}

3964164-2

noncomm/PMC003xxxxxx/PMC3964164.xml

Spectral-domain optical coherence tomography imaging of macula-off rhegmatogenous retinal detachment

A 57-year-old Latin American woman presented for evaluation of decreased vision in the right eye for 2 days. Past ocular history was significant for bilateral uncomplicated cataract extraction with intraocular lens placement 5 months prior and a retinal tear in the right eye, status post-laser retinopexy.\nOphthalmic examination revealed best-corrected visual acuity of 20/70 in the right eye and 20/20 in the left eye. No relative afferent pupillary defect was noted. Intraocular pressure was 15 mmHg in the right eye and 18 mmHg in the left eye. The posterior segment examination of the right eye revealed a shallow rhegmatogenous retinal detachment caused by two temporal horseshoe tears (). SD-OCT demonstrated temporal subretinal fluid extending under the fovea ().\nThe patient underwent pars plana vitrectomy with air-fluid exchange, endolaser, and placement of C3F8 (octafluoropropane) gas in the right eye 1 day after presentation. Postoperatively, the patient’s retina remained attached, and vision slowly improved. One year after surgery, the patient’s best-corrected visual acuity in the right eye was 20/20 (). SD-OCT revealed intact foveal contour with normal-appearing inner segment ellipsoid layer ().

[[57.0, 'year']]

F

{'9818620': 1, '23002414': 1, '15921745': 1, '11772595': 1, '21522038': 1, '18191657': 1, '23773202': 1, '21778929': 1, '673337': 1, '21937016': 1, '23591530': 1, '22275812': 1, '16794436': 1, '24672221': 2}

{'3964164-1': 2, '3964164-3': 2, '3964164-4': 2}

3964164-3

noncomm/PMC003xxxxxx/PMC3964164.xml

Spectral-domain optical coherence tomography imaging of macula-off rhegmatogenous retinal detachment

A 49-year-old Caucasian woman presented with history of floaters in the right eye for 3 weeks and decreased vision for 1 day. Past ocular history was significant for bilateral LASIK (Laser-Assisted in situ Keratomileusis) for myopia 10 years prior.\nOphthalmic examination revealed best-corrected visual acuity of 20/200 in the right eye and 20/20 in the left eye. No relative afferent pupillary defect was noted. Intraocular pressure was 16 mmHg in both eyes. The posterior segment examination demonstrated a bullous rhegmatogenous retinal detachment caused by a superior horseshoe tear (). SD-OCT showed extensive subretinal fluid, with bullous elevation of the fovea ().\nThe patient underwent a successful scleral buckling procedure with placement of 0.5 cm3 of 100% SF6 (sulfur hexafluoride) gas. One month after surgery the patient’s best-corrected visual acuity in the right eye was 20/40 (). SD-OCT revealed intact foveal contour with normal-appearing inner segment ellipsoid layer ().

[[49.0, 'year']]

F

{'9818620': 1, '23002414': 1, '15921745': 1, '11772595': 1, '21522038': 1, '18191657': 1, '23773202': 1, '21778929': 1, '673337': 1, '21937016': 1, '23591530': 1, '22275812': 1, '16794436': 1, '24672221': 2}

{'3964164-1': 2, '3964164-2': 2, '3964164-4': 2}

3964164-4

noncomm/PMC003xxxxxx/PMC3964164.xml

Spectral-domain optical coherence tomography imaging of macula-off rhegmatogenous retinal detachment

A 50-year-old Caucasian woman presented with history of gradual decrease in vision in the right eye over several months. Past ocular history was significant for bilateral LASIK for myopia 1 year prior.\nOphthalmic examination revealed best-corrected visual acuity of 20/100 in the right eye and 20/15 in the left eye. No relative afferent pupillary defect was noted. Intraocular pressure was 10 mmHg in both eyes. The posterior segment examination demonstrated a rhegmatogenous retinal detachment caused by inferior retinal holes (). SD-OCT revealed shallow subretinal fluid extending under the fovea ().\nThe patient underwent a successful scleral buckling procedure with cryotherapy. At 3-month follow-up the patient’s best-corrected visual acuity in the right eye was 20/200 (). SD-OCT revealed intact foveal contour with disruption of the inner segment ellipsoid layer ().

[[50.0, 'year']]

F

{'9818620': 1, '23002414': 1, '15921745': 1, '11772595': 1, '21522038': 1, '18191657': 1, '23773202': 1, '21778929': 1, '673337': 1, '21937016': 1, '23591530': 1, '22275812': 1, '16794436': 1, '24672221': 2}

{'3964164-1': 2, '3964164-2': 2, '3964164-3': 2}

3964275-1

noncomm/PMC003xxxxxx/PMC3964275.xml

A Patient with Eosinophilic Gastroenteritis Presenting with Acute Pancreatitis and Ascites

A 68-year-old woman was admitted with abdominal pain, nausea, vomiting, and watery diarrhea after eating a high protein and fat diet ("Chueotang" which is loach in hot bean paste soup) 1 day ago. She had a history of recurrent epigastric pain and nausea for the past 3 years. There was no history of drug allergy, bronchial asthma, allergic rhinitis or hepatitis except for hypothyroidism. She had been taking levothyroxine, cimetidine, and rebamipide for 2 years and had not taken a new medicine recently. She was not consuming alcohol or any illicit drug. Physical examination was unremarkable except for mild epigastric tenderness. Laboratory investigations indicated a white blood cell count of 6,800/mm3 with high percentage of eosinophils (18.4%). The serum biochemistry showed an aspartate aminotransferase of 50 IU/L, alanine aminotransferase of 39 IU/L, amylase of 253 U/L, lipase of 478.71 U/L, and triglycerides of 66 mg/dL. Serum immunoglobulin E (IgE) and immunoglobulin G4 (IgG4) levels were in the normal range. Antinuclear antibody was negative. Abdominopelvic computed tomography (CT) was performed under the diagnosis of acute pancreatitis. It revealed diffuse wall thickening in the duodenum at the 2nd and 3rd portions, mild edema of small bowel loops and a moderate amount of ascites. However, there was no evidence of gallstones, abnormality of the pancreas or peripancreatic fluid collection (). We diagnosed her as Balthazar grade A of acute pancreatitis based on the elevated amylase/lipase and normal pancreas on CT. Esophagogastroduodenoscopy (EGD) was performed to examine the duodenal wall thickening found on CT. EGD findings showed mild erythematous mucosal change with atrophy on the antrum but the duodenum was unremarkable. Bowel rest and supportive care including intravenous fluids and acid-reducing agents were initiated. The level of amylase and lipase decreased to the normal range on the following day and her abdominal pain gradually decreased within a week. However, mild epigastric pain persisted and subsequent laboratory examination on the 7th hospital day showed that blood eosinophils had increased to 39.8% and the eosinophil count was 3.5×103/µL (normal, 0.04-0.5×103/µL). Stool examination for ova and parasites was negative. Allergen skin prick test was also negative. At that time, we thought of the possibility of EGE because her GI symptoms continued even after treatment and the eosinophilia was more aggravated without any other obvious cause. So we decided to perform EGD and colonoscopy again to take a biopsy from the GI tract. The 2nd look-EGD revealed aggravated linear mucosal erythema of the antrum and multifocal patchy erythematous mucosal lesions on the 2nd portion of the duodenum, which were not observed in the initial EGD (). However, there was no evidence of papillitis. Colonoscopy revealed erythematous mucosal changes of the terminal ileum. Multiple biopsies were obtained from the normal mucosa to the erythematous lesions on the stomach, duodenum and ileum. Histological examination indicated chronic inflammation with increased eosinophils in the lamina propria from the duodenal erythematous lesion (). The patient was treated with 30 mg of prednisolone and 10 mg of montelukast for 1 month. Her symptoms improved immediately and the eosinophil count normalized within 2 weeks. Prednisolone was tapered over 8 weeks and montelukast was used 4 more months. The follow-up EGD after 8 months showed normal antral and duodenal mucosa (). One year after presentation, her symptoms recurred, with elevated levels of amylase, lipase and blood eosinophil counts. The patient was treated with oral prednisolone and montelukast again, and then her upper abdominal pain resolved and the eosinophil count normalized.

[[68.0, 'year']]

F

{'4707722': 1, '17182992': 1, '20551940': 1, '22627371': 1, '15455985': 1, '27721930': 2, '12018905': 1, '18499023': 1, '26393130': 1, '2318432': 1, '34238222': 2, '32215125': 1, '12228038': 1, '9355030': 1, '23161306': 1, '33783592': 1, '23001826': 1, '16525206': 1, '9821185': 1, '26392801': 2, '19418590': 1, '24672666': 2}

{'8265096-1': 1, '5037340-1': 1, '4558742-1': 1}

3965699-1

noncomm/PMC003xxxxxx/PMC3965699.xml

Thanatophoric dysplasia in a dichorionic twin confirmed by genetic analysis at the early second trimester: A case report and literature review

A 30-year-old, nulliparous woman with a twin pregnancy was referred to our hospital during the 15th gestational week for a routine prenatal check. She had suffered from primary infertility secondary to bilateral salpingectomy, and underwent in vitro fertilization. She had conceived triplets and had chosen selective embryo reduction during the 8th gestational week. The couple was healthy, and neither the history of teratogenic exposure nor the family history were remarkable. Initial ultrasonographic examination (Accuvix XQ, Medison Co. Ltd., Seoul, Korea) with a 2-6-MHz transabdominal probe) during the 15th gestational week revealed a thick dividing membrane and two separated placentas, indicating dichorionic placentation. The amount of amniotic fluid of both fetuses was appropriate for gestational age. Whereas twin A showed normal growth, in twin B, all of the long bones appeared to be abnormally short (the long bone measurements with the femur measuring 11.6 mm, tibia 7.2 mm, humerus 11.5 mm, radius 7.9 mm, all compatible with <5th percentile). Curved femurs with a telephone-receiver-like appearance, short ribs, and a narrow thorax with prominent abdomen were also observed (). The femur length (FL)/abdominal circumference (AC) ratio was 0.12. The vertebral and skull ossification patterns were normal. No overt cloverleaf skull deformity was observed. The nasal bone was not visible but there are no other abnormalities in fetal face.\nThe couple was counseled about the increased risk of chromosomal abnormality or lethal TD. Thereafter, they decided to undergo an assessment of specific FGFR3 mutations by routine cytogenetic analysis. Amniocentesis of the twins performed during the 15th gestational week showed normal karyotypes (46, XY and 46, XY) for both babies. However, nucleotide sequence analysis of cDNA during the screen for mutations in FGFR3 for twin B revealed a C to T transition at nucleotide 742 (C742T) within exon 6. This heterozygous 742C->T (R248C) mutation in the FGFR3 causes an Arg248Cys (CGC->TGC) substitution. Molecular analysis of the same locus in twin A showed normal finding ().\nWe counseled the couple extensively, and explained that this genetic condition causes type-1 TD. Thereafter, they decided to proceed with selective fetal termination with the hope of proceeding with a normal singleton pregnancy. At the 19th gestational week, selective fetal termination was performed under ultrasonographic guidance using a 20-gauge needle and injection of potassium chloride into the fetal heart. The remainder of the pregnancy was uneventful and the patient delivered a healthy male infant weighing 3,575 g and a mummified, macerated fetus weighing 91 g during the 39th gestational week by Cesarean section due to persistent occiput posterior position.

[[30.0, 'year']]

F

{'21910223': 1, '11241532': 1, '17120245': 1, '19265753': 1, '12439497': 1, '10073901': 1, '16220775': 1, '8843623': 1, '3130852': 1, '6073727': 1, '7773297': 1, '3307430': 1, '31299979': 1, '7666392': 1, '10521749': 1, '9369835': 1, '24678489': 2}

{}

3965700-1

noncomm/PMC003xxxxxx/PMC3965700.xml

Arteriovenous malformation in uterine cervix during pregnancy

A 33-year-old pregnant woman, gravida 1 para 0, presented with vaginal spotting on her first visit to our hospital at the 32th gestational week. Cervical AVM had not been previously identified. Her past medical history was unremarkable, except that she was a hepatitis B carrier. She has have no pathological history on the uterine cervix. Obstetric sonography revealed a single active fetus in the cephalic position. The structural survey remained unremarkable, except an upper-normal amount of amniotic fluid (amniotic fluid index was 23 cm). The fetus was average in size (estimated body weight was 2,000 g). Ultrasonography revealed a 4.4 × 2.28 cm sized hypoechoic mass like lesion in the cervix and a suspected severe engorged vessel (). Placenta previa was not suspected. For the differential diagnosis of cervical varix and cervical AVM, Doppler velocimetry was performed. Color Doppler analysis demonstrated expanding of numerous vessels and rapid and turbulent blood flow in the cervix with a mosaic pattern. Pulsed Doppler evaluation revealed pulsed wave with high-velocity flow during both systole and diastole with the maximum systolic and diastolic velocity of 39 cm/sec and 22 cm/sec. Both the arterial and venous waveforms were mixed (). A presumptive diagnosis of uterine cervix AVM was made. The non-stress test showed a reactive pattern of fetal heart tone, but regular uterine contraction was noted. Subsequent speculum pelvic examination revealed an engorged vessel on the surface of the cervix which was suspicious for vessel disorder, but no bleeding was noted (). She was hospitalized for management of preterm labor and further evaluations of the engorged vessel on the cervix. After tocolytics, pain was subside. Pelvic magnetic resonance imaging (MRI) revealed about a 20 × 25 mm sized T2 high signal intensity lesion in the endocervix. This indicated the presence of an engorged vessel on the cervix; the possibilities of cervical AVM were considered ().\nAt 32 weeks and 6 days' gestation, active bleeding with a large amount of blood clot from AVM was detected by speculum pelvic examination. Hemoglobin measurement was dropped from 10.9 to 9.7 g/dL even after two units of packed red blood cells transfusion. Transvaginal sonography was performed, and there was no evidence of placental bleeding, for example, placenta abruption or placenta previa. To gain time for preparing emergency cesarean section, we performed clamping with ring forceps and ligation of bleeding points. Fetal cardiotocography showed reactive pattern of heart rate without any deceleration. After 20 minutes or so, there was no bleeding and we decided to maintain the pregnancy. At 34 weeks and 2 days' gestation, we performed emergent cesarean section under general anesthesia because of massive uterine bleeding which was uncontrolled with vaginal packing tamponade. A male infant weighing 2,700 g was delivered without difficulty; Apgar scores were 4 and 6 at 1 and 5 minutes, respectively.\nDuring the operation, we noticed a severe engorged vessel suspected as the venous sinus near to endocervix. Except that site, we could not find AVM or venous sinus on the whole uterine corpus. Massive active bleeding from the suspected uterine cervical AVM occurred. Direct suture ligation of the cervical AVM was performed inside of the uterus with ligations of both uterine arteries, and they were successful in arresting the bleeding. The operation was completed uneventfully, and the estimated blood loss during surgery was about 2,500 mL. We could maintain the hemoglobin level of 10.7 g/dL by transfusion with 7 units of packed red blood cells and 7 units of fresh frozen plasma. She was discharged in stable condition without vaginal bleeding associated uterine cervical AVM at postoperative day 7. Four weeks later, transvaginal sonography revealed remaining multiple AVM in the lower cervix (Peak systolic velocity 34 mm/sec) (). Eight weeks from delivery, AVM of the uterine cervix decreased dramatically and no visible vessel engorgement of the cervix was noted by speculum and transvaginal sonography.

[[33.0, 'year']]

F

{'11566093': 1, '11796897': 1, '22051867': 1, '9125624': 1, '11354845': 1, '11064013': 1, '11120411': 1, '21599808': 1, '10210350': 1, '9863910': 1, '9423639': 1, '12808674': 1, '9423660': 1, '1797218': 1, '9339531': 1, '24678490': 2}

{}

3965701-1

noncomm/PMC003xxxxxx/PMC3965701.xml

Successful laparoscopic surgery for 14-month-old infant with ovarian torsion

A 14-month-old girl weighing 10.4 kg visited our clinic with a 3-day history of irritability and vomiting. She have had no special medical history and other symptoms except for poor oral intake prior to this presentation. Furthermore, there were no abnormal findings in physical examination or laboratory tests except that her white blood cell count was within the upper limit (11,760/up; normal range, 4,000-1,2000/up). Transabdominal ultrasonography (USG) showed the enlarged right adnexa suggestive of ovarian torsion (). Magnetic resonance imaging (MRI) for pelvic organs revealed an edematous right ovary that was enlarged to 3.6 cm with decreased enhancement (). Thus, we planned to perform an emergent laparoscopic surgery for confirmative diagnosis and surgical treatment.\nAfter insufflation using a Verres needle, we inserted 5-mm diameter cannulas into the umbilicus, and two 3-mm ancillary cannulas were inserted into both lower quadrants of the abdomen (). During laparoscopy, abdominal pressure was maintained below 8 mmHg, and the edematous change of the right fallopian tube was found because the tube was twisted without knot formation or ovarian cysts (). Thus, we only untwisted the right adnexa using 3-mm diameter forceps, and completed all procedures without complications or bleeding. The operating time was 25 minutes, and her irritability decreased after surgery. She was discharged from the hospital 2 days after surgery. There was no abnormal finding when she visited our department 10 days after surgery.

[[14.0, 'month']]

F

{'11896219': 1, '7722827': 1, '9716771': 1, '11468611': 1, '10663837': 1, '22817767': 1, '19349004': 1, '23351494': 1, '25557598': 1, '23224440': 1, '19524743': 1, '17989986': 1, '31885967': 2, '11781981': 1, '33312872': 2, '17901133': 1, '15137012': 1, '15259587': 1, '24678491': 2}

{'6925918-1': 1, '7713650-1': 1}

3965702-1

noncomm/PMC003xxxxxx/PMC3965702.xml

Aggressive angiomyxoma of the vulva: A case report

A 35-year-old female presented with a slow-growing mass on the right labium majora. She visited the clinic because she felt uncomfortable as the size of mass had grown. The patient was referred to gynecological services for further evaluation with considerations of a fibroepithelial polyp, a vulvar fibroma or a giant acrochordon. Local examination showed a well-circumscribed pedunculated polypoidal mass measuring about 10 × 7 cm. The mass was non-tender, soft and spongy in consistency. The inguinal lymph nodes were not enlarged. At first, we supposed the mass to be vulvar hemangioma and performed a pelvis magnetic resonance imaging (MRI). The pelvis MRI revealed findings that were compatible with those of AA in the subcutaneous layer of the right labium majora. A well-defined mass-like lesion of about 10 × 7 cm was seen in the subcutaneous layer of the right labium majora. The mass showed bright signal intensity on T2WI and demonstrated delayed enhancement after contrast administration (). The patient underwent local excision of the tumor with ligation of the stalk. The tumor mass was about 10 × 7 cm and it was soft and pink-tan colored (). Microscopically, the tumor was composed of spindle and stellate-shaped cells embedded in a loose myxoid matrix. These cells showed low to moderated cellularity and had eosinophilic cytoplasm with no significant nuclear pleomorphism and mitosis. Variable-sized thin-walled capillaries and thick-walled vascular channels were haphazardly arranged in the stroma. Some of these vessels showed perivascular hyalinization in the vascular walls (). Immunohistochemical staining of the tumor was positive for estrogen receptor (ER), progesterone receptor (PR), vimentin () and negative for S-100. Based on these pathologic features, aggressive angiomyxoma was diagnosed. She was continuously followed-up in our hospital for 7 years after resection, with no clinical or radiologic evidence of recurrence.

[[35.0, 'year']]

F

{'25977826': 2, '16246403': 1, '16870390': 1, '10564384': 1, '9930798': 1, '33172469': 2, '19954923': 1, '16825121': 1, '23550881': 1, '27920855': 1, '6684403': 1, '31142482': 1, '16445665': 1, '24678492': 2}

{'4421102-1': 1, '7653999-1': 1}

3965703-1

noncomm/PMC003xxxxxx/PMC3965703.xml

A case of vulvar hematoma with rupture of pseudoaneurysm of pudendal artery

A 13-year-old female with gravida 0 and para 0 visited our emergency center and presented with sudden pain and swelling in the left labium. Her medical history included Rett syndrome and epilepsy, and she had used medication for this condition; however, the patient was not taking an anticoagulant medication upon admission. Because the patient was bedridden, a regular catheterization was performed by her mother to empty her bladder. A week before she presented in the emergency center, her parents found a 2×2-cm cystic mass on the left labium. Her pediatrician prescribed antibiotics and the mass size seemed to decrease daily with treatment. However, because the mass abruptly increased to 15×15 cm, her parents took her to the hospital.\nThe patient was alert and anxious. Her vital signs were recorded and her blood pressure was 120/76 mmHg, heart rate was 132 beats per minute, respiratory rate was 32 breaths per minute, and temperature was 37.3℃. Palpation of her perineum revealed that the patient had severe tenderness in this area. A genital examination revealed that there was a tense, 15×7-cm hematoma of the left labia majora that significantly distorted the anatomy, along with redness but no laceration (). There was no history of sexual assault or trauma, especially related to catheterization. Laboratory analysis indicated that the patient had a hemoglobin level of 13.3 g/dL (reference range, 12-16 g/dL), a hematocrit of 41.9% (reference range, 36%-48%), a platelet count of 28.5×104/µL (reference range, 13-40×104/µL), and an international normalized ratio of 1.08 (reference range, 1.00-1.10).\nComputed tomography of the pelvis with angiography showed marked dilatation of the vagina (7.0×4.8 cm in size) and left vulvar area (7.5×4.4 cm, red arrow) () and an abnormal, round high density in the left vulvar area, which was suspected to be a pseudoaneurysm. The radiologist confirmed extravasation of blood and active bleeding in the lower vagina and left anterior vulvar area. After evaluation and during urinary catheterization, the hematoma was opened. About 400 mL of bloody discharge was drained. The hemoglobin level dropped to 8.5 g/dL and the patient was given a transfusion of 3 units of packed red blood cells. Angiography subsequently confirmed the existence of a small pseudoaneurysm, and a branch of the internal pudendal artery and embolization were successfully adhered with a 1:5 mixture of lipidol ().\nThere was no indication of further vulvar bleeding after embolization, but the hematoma was still present and we therefore opted for evacuation as treatment. Under local anesthesia, the hematoma was evacuated and no vessels were ligated. No further bleeding was noted after this procedure. During the first postoperative day, her vital signs were stable, and the hematoma resolved on the second day. She was discharged from the hospital on the fourth postoperative day.

[[13.0, 'year']]

F

{'17364288': 1, '31079041': 1, '19121653': 1, '15372450': 1, '16788964': 1, '34149225': 1, '29207790': 1, '31692848': 2, '33944849': 2, '314075': 1, '29808742': 1, '3009282': 1, '32489909': 1, '19155949': 1, '11209635': 1, '26734132': 2, '17583256': 1, '23379450': 1, '24678493': 2}

{'6815487-1': 1, '6815487-2': 1, '4693693-1': 1, '8142749-1': 1}

3965704-1

noncomm/PMC003xxxxxx/PMC3965704.xml

Inguinal endometriosis in a patient without a previous history of gynecologic surgery

A 40-year-old nulliparous woman presented with a painful mass in her right inguinal area. The mass had grown for 2 years and had occasionally been tender, especially during menstrual cycles. The patient had no specific medical or surgical history. She experienced regular menstruation at 30-day intervals and experienced menorrhagia. Her menstruation period lasted 7 days.\nPhysical examination revealed a non-erythematous swollen and tender mass measuring approximately 2×2 cm located lateral and superior to the pubic tubercle. The size and position of the mass remained unchanged, even when the patient coughed or changed positions. The patient also reported intermittent vaginal spotting, for which she had undergone simultaneous transvaginal and inguinal ultrasonography.\nThe transvaginal ultrasonography revealed two left ovarian cysts measuring 1.0 cm that seemed to be endometrioma or hemorrhagic corpus luteal cysts (). Inguinal ultrasonography showed an ill-defined hypoechoic lesion (size, 1.1×1.2 cm) in the right pubic area, with increased vascularity (). She underwent repeated inguinal ultrasonography during her menstrual period. She felt tenderness and swelling of the lesion, but there was no change of mass size on inguinal ultrasonography. After being informed about the presence of hemangioma or arteriovenous malformation, the patient opted for surgical excision of the inguinal mass.\nAn oblique skin incision was performed along the line running from the pubic tubercle to the anterior superior iliac spine, at the superior margin of the inguinal ligament. After identification of the femoral vessels, the hard mass was widely excised to include a part of the round ligament. Chocolate-colored fluid was drained from the hard cystic mass during the procedure, and the mass was connected with the intraperitoneal round ligament at the inguinal canal. The inguinal canal was opened and the extraperitoneal portion of the round ligament was resected by gentle traction and then cutting at the level of the internal inguinal ring. The proximal stump was fixed to the surrounding fibrous structure of the inguinal canal. Histological examination showed a cuff of endometrial stroma surrounding the endometrial glands with hemorrhaging from smooth muscle and fibrous tissues (). After 2 months of the surgery, the patient's pain completely resolved and she was fully recovered without complications. Considering the possibility of recurrence of the inguinal endometriosis and progression of the ovarian endometrioma, we recommended her to use the oral contraceptives and planned regular follow-up.

[[40.0, 'year']]

F

{'20337210': 1, '21637357': 1, '29805826': 2, '33653321': 1, '33832157': 2, '27279405': 2, '17536539': 1, '25469350': 1, '20040781': 1, '17666654': 1, '2892706': 1, '20217409': 1, '2067761': 1, '33071634': 1, '8619458': 1, '2406743': 1, '11235045': 1, '24678494': 2}

{'5899860-1': 1, '8036060-1': 1, '4916760-1': 1}

3965705-1

noncomm/PMC003xxxxxx/PMC3965705.xml

A case of cystic adenomyoma of the uterus after complete abortion without transcervical curettage

A 30-year-old woman (gravida 2, para 1, and abortion 1) was referred to the emergency room of our tertiary center because of severe, progressive, and intractable dysmenorrhea for 1 year. Abdominal discomfort began on the third day of her menstrual cycle, accompanied by cramping pain, syncope, headache, and cold sweats. Her pain was not relieved by medication, including nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills. Her menarche had occurred at the age of 14 years, and she had no specific problems with secondary sexual development. Her menstrual cycle was regular (28 days) with a duration of 5 days and moderate bleeding. She had no dysmenorrhea prior to 1 year previously when this episode began. Four year ago, she had a natural singleton pregnancy, which culminated in the natural vaginal delivery of a full-term boy. Approximately 1 year previously, she was pregnant. However, at GA 6 weeks, she underwent a complete abortion spontaneously without any transvaginal procedures such as transcervical curettage. After the abortion, severe dysmenorrhea began and progressively increased. On physical examination, the pain localized to the right lower quadrant of the abdomen, and no tenderness to palpation or rebound tenderness was observed. Bimanual pelvic exam revealed a non-mobile, small, palpable mass on the right side of the uterus. Laboratory findings, including level of CA-125 (17 U/mL), were normal. Serum human chorionic gonadotropin level was near zero. Transvaginal sonography performed using a Volusion 730 Pro scanner (GE Healthcare, Milwaukee, WI, USA) showed a normal sized uterus, unremarkable endometrium, and intact ovaries. However, a 2×2 cm hypoechoic mass surrounded by a hyperechoic enhancing rim was seen on the anterior wall of the right side of the uterus. Within this mass, an inner hypoechoic cystic lesion measuring approximately 1.2×0.8 cm was seen (). The mass had no communication with the endometrium. Computed tomography of the abdomen and pelvis revealed a 2×2 cm mass on the uterine side of the uterus with an approximately 1.2-cm cystic area inside the mass (). The appendix was intact. No associated urogenital anomalies were detected. We believed that this condition represented a cystic adenomyoma in light of our previous case report [], and elected to perform laparoscopic excision of the mass.\nA laparoscopy was performed on the 20th day of the patient's menstrual cycle. Under general anesthesia, she was placed in the lithotomy position. An 11-mm trocar (Excel Endopath; Ethicon Endo-Surgery, Cincinnati, OH, USA) was inserted as the primary puncture after making a skin incision along the lower margin of the umbilicus. To create a pneumoperitoneum, CO2 was insufflated into pelvic cavity using a Veress needle. Subsequently, second, third, and fourth punctures using 12-mm and 5-mm trocars were carefully created in the left upper quadrant (umbilicus level), right lower quadrant, and lower midline area of the abdomen. A uterine manipulator was inserted to easily handle the uterus and adnexa.\nThe laparoscopic view showed a bulging mass measuring approximately 2×2 cm in the anterior portion of the right side of the uterus; the mass appeared to be a myoma (). After direct injection of diluted vasopressin (vasopressin 10 units diluted in 100 mL of normal saline) into the uterine mass, an oblique incision was made using monopolar cautery. During enucleation of the mass, chocolate-colored fluid leakage, consistent with an endometrioma, was seen (); the fluid was drained from the cystic portion of the mass (). A harmonic scalpel and a 10-mm screw were used for complete excision of the mass. The excision site was closed with interrupted endosutures using 1-0 monofilament (). Infusion of methylene blue dye through a uterine manipulator showed no communication between the mass and endometrial cavity. Operative time was 70 minutes, and estimated blood loss was less than 20 mL. There were no intraoperative or postoperative adverse events, and the patient was discharged 48 hours after surgery in good condition.\nOn macroscopic examination, the mass measured 2×2 cm in diameter. The inner surface of the mass contained a brownish discolored layer with the appearance of an ovarian endometrioma. Histological examination showed that the central cyst wall was lined with endometrial glandular epithelium and endometrial stromal cells within myometrium, and the surrounding myometrium revealed smooth muscle proliferation forming a myomatous mass compatible with an adenomyosis (). In the 2 years since the surgery, the patient has had regular menstruation with no dysmenorrhea.

[[30.0, 'year']]

F

{'21561337': 1, '17412338': 1, '17478374': 1, '32942350': 2, '16500348': 1, '19539912': 1, '23849619': 1, '33467841': 1, '24678495': 2}

{'8225500-1': 1, '8225500-2': 1}

3965801-1

noncomm/PMC003xxxxxx/PMC3965801.xml

Griscelli syndrome type 2: a novel mutation in RAB27A gene with different clinical features in 2 siblings: a diagnostic conundrum

A 5-year-old boy, born out of nonconsanguineous marriage, second in birth order, presented with high grade intermittent fever and a rash over the lower limbs, for 3 months. His elder brother had expired 6 months back at 7 years of age due to an undiagnosed medical condition. On examination, the patient, of average built and nutrition, was febrile, with a heart rate of 142/min, respiratory rate of 22/min, blood pressure of 102/64 mmHg, severe pallor, hepatosplenomegaly (liver 2 cm below right costal margin and spleen 3.5 cm below left costal margin) and a soft ejection systolic murmur. He had a generalized hypopigmented skin with golden-brown hair (). Both lower limbs showed multiple, well-defined, tender, erythematous to hyperpigmented, nodular lesions, extending from midthighs to feet, some having scab formation (). The parents revealed that their deceased elder son had similar hypopigmented skin, though no other family member was affected.\nInvestigations at admission showed hemoglobin, 4.1 g/dL; total leucocyte count, 2,500/mm3; lymphocyte, 73.7%; neutrophils, 18.6%; platelet, 33,000/mm3; erythrocyte sedimentation rate, 11 mm (1st hour); C-reactive protein, 21 mg/L. The peripheral blood smear showed normocytic, normochromic red blood cells with mild anisocytosis, with a corrected reticulocyte count of 3.2%. The bone marrow aspiration smears showed erythroid hyperplasia, predominantly normoblastic, with normal maturation of myeloid series, no megakaryocytes and no abnormal cells or parasite. Neither the peripheral blood smear nor the bone marrow aspiration smears showed large granules in neutrophils, ruling out the possibility of Chediak Higashi syndrome. The results of kidney and liver function tests, serum electrolytes, uric acid, chest skiagram and Mantoux test were within normal limits. The blood and urine cultures were sterile. Investigations to rule out common infections like Widal test, rapid malaria antigen test, rK 39 antigen, Dengue serology, and Weil Felix test did not reveal any abnormalities. Also, hepatitis B surface antigen and human immunodeficiency virus serology were negative and his immunoglobin levels were within normal range. Serum ferritin was 1,334 ng/mL. The antinuclear antibody (ANA) showed speckled positivity (1+), anti-dsDNA was borderline positive at 50 IU/mL, RA factor being negative. Ultrasound of the abdomen was normal except for enlarged spleen (13.5 cm) and enlarged liver (15 cm). Skin biopsy taken from the lower limb lesions was suggestive of erythema nodosum (EN) ().\nThe patient was treated with antipyretics, blood product transfusions and intravenous ceftriaxone. However, the patient's condition deteriorated with worsening pancytopenia, increasing size of liver and spleen and aggravation of the rash. Considering the weakly positive ANA and presence of EN, a possibility of a connective tissue disorder was considered and an empirical trial of oral prednisolone at 2 mg/kg/day was started.\nWhile investigations for this patient were in progress, efforts were made to trace the medical records regarding the illness of his elder sibling. This child had presented with fever with raised intracranial tension, rapidly progressive spastic quadriparesis, and papilledema. He had no organomegaly and his blood counts were normal. An initial computed tomography (CT) scan of the brain showed obstructive hydrocephalus. The cerebrospinal fluid (CSF) examination showed 25 cells, (100% lymphocytes) with protein 112 mg/dL and glucose 80 mg/dL. Based on the CT and CSF findings, he was started on antitubercular treatment with steroids. However he continued to worsen and a magnetic resonance imaging (MRI) of the brain was obtained which showed extensive signal abnormalities in the cerebellar white matter and cortex, with inhomogeneous signal abnormalities in the thalamus, basal nuclei, internal capsule, and cerebral white matter. There was evidence of obstructive hydrocephalus with impending tonsillar herniation. There was a dot-like contrast enhancement in the cerebellum. After an expert review of the MRI, a possibility of vascular-perivascular disorders like malignancies or hemophagocytic lymphohistiocytosis (HLH) was considered. Bone marrow examination was normal. The patient underwent a ventriculoperitoneal shunt surgery along with a brain biopsy from the right parietal region. However, a very small volume of material was available from the brain biopsy which showed nonspecific lymphocytic proliferation. The patient could not be investigated further, as he continued to deteriorate, and died two weeks later.\nAfter obtaining information about the elder sibling's illness, it was inferred that both the siblings were suffering from a common disorder of hypopigmentation with potentially fatal phases with two varied manifestations. A possibility of GS2 in accelerated phase was considered. Subsequently, a hair shaft examination of the younger sibling was done, which revealed large sized melanin granules, distributed irregularly along the length of the hair shaft mainly near the medulla. (). Under polarized light microscopy, the hair appeared monotonously white (). A genetic analysis was done to detect mutation in RAB27A gene. Genomic DNA was extracted from peripheral blood sample and sequencing of RAB27A gene was done. The sequence of the pairs of primers used to amplify these regions is shown in . Mutation analysis of RAB27A gene revealed a novel homozygous mutation in RAB27A gene on chromosome 15 (exon 3) showing a single-base substitution (c.136T>A p.F46I), leading to an amino acid change from phenylalanine (TTC) to isoleucine (ATC). This mutation is damaging by Polyphen. Parents were found to be heterozygous for the same mutation ().\nHence the patient was diagnosed as a case of GS2 with HLH; his elder sibling was retrospectively diagnosed to have GS2 with cerebral lymphohistiocytic infiltration. The patient achieved normalization of blood counts on oral prednisolone. The parents were counseled about the disease, and possible need for bone marrow transplantation.

[[5.0, 'year']]

M

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{'8167959-1': 1}

3965802-1

noncomm/PMC003xxxxxx/PMC3965802.xml

Shiga toxin-associated hemolytic uremic syndrome complicated by intestinal perforation in a child with typical hemolytic uremic syndrome

A 26-month-old female patient visited a hospital due to prolonged vomiting, poor oral intake and watery diarrhea for 5 days after eating a slushy. At the time of the visit, she was drowsy. Laboratory tests revealed leukocytosis, anemia, thrombocytopenia, and azotemia. Renal ultrasonography revealed diffusely increased parenchymal echogenicity with decreased perfusion in both kidneys (). Despite supportive care, her azotemia worsened; therefore, two days later, (the 3rd hospital day), acute peritoneal dialysis (PD) was started. On the 6th hospital day, when she was transferred to another hospital, her dialysate looked bloody. On the next day (the 7th hospital day), she presented with abdominal tenderness and leukocytosis of her peritoneal dialysate (1,140/mm3). Subsequently, the intraperitoneal antibiotic administration of cefazolin and ceftazidime was initiated. However, azotemia and leukocytosis of the peritoneal fluid persisted; thus, on the 9th hospital day, the patient was transferred to Seoul National University Children's Hospital for further management.\nAt our hospital, the patient was alert but appeared acutely ill. She was not feverish. Upon physical examination, her whole abdomen was tender, and mild pitting edema was present. Laboratory tests revealed a leukocyte count (white blood cell, WBC) of 60,960/µL; hemoglobin (Hb) level, 9.4 g/dL; hematocrit (Hct), 28.4%; reticulocyte count (Reti), 10.62%; platelet count (Plt), 24,000/µL; serum sodium (Na) level, 139 mmol/L; serum potassium (K) level, 3.4 mmol/L; serum chloride level, 106 mmol/L; total carbon dioxide level, 20 mmol/L; serum blood urea nitrogen/creatinine level (BUN/Cr), 109/4.8 mg/dL; and C-reactive protein, 5.37 mg/dL. Schistocytes were observed on peripheral blood smear. Shiga toxin was detected from stool sample by polymerase chain reaction of Shiga toxin gene. WBC and red blood cell count of the peritoneal dialysate were 4,600/µL (polymorphonucleocyte, 98%) and 9,800/µL, respectively. The peritoneal dialysate culture revealed Enterococcus species, which were resistant to ampicillin and sensitive to vancomycin; accordingly, cefazolin was switched to intraperitoneal vancomycin. However, her peritonitis did not improve; therefore, the PD catheter was removed on the 12th hospital day, and hemodialysis (HD) was started. Three days later (on the 15th hospital day), severe ileus developed with aggravated abdominal tenderness. An exploratory laparotomy was performed under the suspicion of intestinal perforation (), and a 15 cm long intestinal necrotic change from the terminal ileum to the cecum with small perforation of the terminal ileum was found. She underwent an ileocecectomy with double-barrel ileostomy (). Pathologic evaluation revealed segmental transmural necrosis with perforation, transmural hemorrhage and hyaline thrombi in the small arteriole and vein. After the operation, her general condition and laboratory findings improved. HD was discontinued on the 20th hospital day, and she was discharged on the 54th hospital day. At discharge, laboratory findings revealed a WBC count of 15,380/µL; Hb, 8.6 g/dL; Hct, 26.2%; Reti, 4.8%; Plt, 516,000/µL; and BUN/Cr, 12/0.6 mg/dL. The ileostomy was repaired one month after discharge, and she has been doing fairly well without specific complications. Laboratory findings at three years after discharge revealed a WBC count of 8,310/µL; Hb, 11.7 g/dL; Hct, 25.3%; Plt, 331,000/µL; and BUN/Cr, 16/0.56 mg/dL.

[[26.0, 'month']]

F

{'10654337': 1, '3510166': 1, '3047052': 1, '18704506': 1, '2273421': 1, '7738732': 1, '21809003': 1, '2269961': 1, '7931868': 1, '1773328': 1, '17968789': 1, '3535529': 1, '24678335': 2}

{}

3966098-1

noncomm/PMC003xxxxxx/PMC3966098.xml

Henoch–Schonlein purpura presenting sequentially as nodular rash, erythema nodosum, and palpable purpura

A 26-year-old farm laborer presented to our outpatient department (OPD) with a nodular rash that had developed on both elbows [Figure and ] following an insect bite while she sleeping. She had pruritus over the affected areas and her lower limbs as well, but without any rash []. She was treated with antihistamines in the emergency department. Two days later, she presented to the OPD with complaints of tender and erythematous nodules on the legs []. Her investigations revealed the following: Hemoglobin 10.9 g/dl, total leukocyte count 10.6 × 109/l with 76% neutrophilia, erythrocyte sedimentation rate 40 mm/h, urea 9.94 mmol/l, creatinine 44 μmol/l, platelets 284 × 109/l, and 40-50 RBCs/hpf on urinalysis without proteinuria. She was unwilling to be admitted and was, therefore, sent home and was prescribed acetaminophen and chlorpheniramine. She came back 1 week later with a purpuric rash on her lower limbs [], diffuse abdominal pain, and arthralgias of the knees, ankles, and elbows. Examination showed non-palpable purpura, pedal edema, tender peri-umbilical region, and an otherwise normal systemic examination. Her urea and creatinine were 12.07 mmol/l and 52.8 μmol/l, respectively. Microscopic hematuria persisted while the spot urinary protein was 23 mg/dl. Her electrocardiogram and liver function tests were normal, while ultrasonogram showed minimal free fluid in the pelvis. Her immunological profile was as follows: Rheumatoid factor negative, antistreptolysin O (ASO) titer <200 IU, antinuclear antibody 0.6 U (<1.0 U), complement C3 0.94 g/l, and complement C4 0.41 g/l. Testing for cytoplasmic- antineutrophil cytoplasmic antibodies (c-ANCA) could not be done since the patient refused to undergo any further investigations. She did not want a skin biopsy. She was initiated on methylprednisolone 8 mg daily, ranitidine, and hydroxyzine, and over the next 3 days, her signs gradually subsided. Her urine became bland prior to discharge, 7 days after admission.

[[26.0, 'year']]

F

{'22959234': 1, '16859592': 1, '23176134': 2, '18355896': 1, '11961015': 1, '19501230': 1, '5908713': 1, '10872192': 1, '30269303': 1, '12014385': 1, '9713395': 1, '24696039': 2}

{'3520703-1': 1}

3966100-1

noncomm/PMC003xxxxxx/PMC3966100.xml

Symptomatic cycling Cushing disease managed by simultaneous bilateral laparoscopic adrenalectomy in a 11-year-old boy

The present case is about a 11-year-old Saudi boy who was referred to our service for bilateral adrenalectomy. The patient had been diagnosed by the pediatric endocrinologist with cycling Cushing disease. He presented with a history of rapid weight gain, decreased school performance and emotional disturbances in the previous 18 months. These complaints came in cycles, each lasting 2-4 months before the patient returned to normal. Adrenal ultrasound and computed tomography scan showed normal adrenal glands, magnetic resonance imaging of the brain also showed normal pituitary and hypothalamic area. During one of these cycles, his weight increased by 4 kg, blood pressure was 140/100 and he exhibited the typical signs of Cushing's disease. Blood work confirmed Cushing's disease. His serum cortisol at 1 PM was elevated at 16.6 mcg/dL. Electrolytes showed sodium 143 mEq/L, potassium 4 mEq/L, chloride 103 mEq/L, total CO2 27, blood urea nitrogen 9 mg/dL and creatinine 0.3 mg/dL. 24 h urine for free cortisol was high at 542 mcg/24 h (normal 5-55 mcg/24 h). At 2 months later, the patient presented with a third episode and was admitted for a full work-up. Urine free cortisol was elevated at 350 mcg/24 h, at midnight serum cortisol was 19.9 mcg/dL and serum adrenocorticotropic hormone (ACTH) was <4 pg/ml. Am cortisol was 15.7 mcg/dL and ACTH was 5.4 pg/ml. The patient was subjected to small and high doses of dexamethasone suppression tests (1 mg and 5 mg respectively) but there was no change in cortisol or ACTH serum levels. These findings confirmed a diagnosis of Cushing's disease of adrenal origin and its cyclic nature presented Carney's complex syndrome as a possibility. Further investigations to exclude Endocrine and cardiac tumors as part of Carney's complex included ultrasound of the thyroid and echocardiography which were normal. Ultrasound of the testes showed bilateral diffuse macro-calcification as well as 0.8 × 0.8 cm hypo-echoic mass within the left testicle, which strengthened the diagnosis of Carney's complex. The patient had no abnormal skin rash and the family history was negative for any endocrine problems. Deoxyribonucleic acid analysis on our patient did not show the known mutation in Carney's complex (PRKAR1A) which is found in only 50% of those patients.\nBilateral adrenalectomy was the treatment of choice in this patient. The plan was to start with right laparoscopic adrenalectomy and proceed to left adrenalectomy with the possibility of converting to open. The patient underwent a successful simultaneous bilateral adrenalectomy; the operative time was 3 h and 30 min. The estimated blood loss was 50 ml. The patient resumed his diet and ambulated on the 1st post-operative day and was discharged from hospital on the 2nd post-operative day. The post-operative course was smooth and uneventful and he was started on replacement therapy post-operatively. At 3 months later, he was doing well with a remarkable improvement in his behavior and school performance. Histopathology report of his adrenal gland was consistent with micronodular adrenocortical hyperplasia.

[[11.0, 'year']]

M

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{}

3966435-1

noncomm/PMC003xxxxxx/PMC3966435.xml

Complete Ventricular Asystole in a Patient with Altered Mental Status

A 68-year-old male was transferred to our ED in Southern California via ambulance from the United States (U.S.)-Mexico border after being initially assessed in a Mexican medical clinic. Paramedics reported that he had presented to the clinic because of recurrent fainting episodes witnessed by his family in Mexico. According to the ambulance personnel, his electrocardiogram (ECG) performed at the clinic demonstrated third-degree atrioventricular block. The ECG that was performed in Mexico was not transported with the patient and was therefore not available for review.\nWhile at the Mexican clinic, the patient reportedly decompensated and had an episode of altered mental status with what were described as “unstable” vital signs. The full details of what occurred were not available, but it was reported that the practitioners at the clinic initiated transcutaneous pacing and administered an unknown sedation medication and started the patient on a dopamine infusion. He was then transferred to the U.S.-Mexico border via ambulance. Just prior to arrival at our hospital, the patient’s intravenous access was lost in the ambulance, and his transcutaneous pacing became ineffective. Upon arrival in the ED, he was lethargic and could not follow commands. He was cyanotic, had a weak but palpable pulse, shallow respirations, and a native heart rate of 30 beats/min with no capture by the pacemaker. We immediately increased the amperage of his transcutaneous pacer, which resulted in cardiac capture, and the patient developed a palpable pulse of 70 beats/min with improvement of his blood pressure to 114/53 mmHg. His core temperature was normal. The patient’s neurological exam improved as he now had spontaneous movement of all 4 extremities. His initial oxygen saturation was 88%, which improved with supplemental oxygen administered via bag valve mask. As his saturations improved, he began to be able to follow commands. However, he became agitated and combative and endotracheal intubation with rapid sequence induction was performed.\nFollowing intubation and mechanical ventilation, his oxygen saturation improved to 100%. An ECG obtained while the pacer was turned off () revealed ventricular asystole with preserved atrial function. Emergent cardiology consultation was obtained for transvenous pacer placement. Secondary assessment revealed no jugular venous distention, normal heart sounds without murmurs and clear lungs bilaterally. The abdomen was soft and non-distended. Extremities revealed resolving cyanosis without edema.\nThe patient’s daughter was contacted and arrived after intubation and initial stabilization. She reported the patient took atenolol for hypertension, smoked “heavily,” and was recently started on bupropion for smoking cessation. He had no known prior cardiac history. The prior week, while vacationing in Mexico with family, he had increasing weakness, shortness of breath, and several syncope episodes. According to the daughter, he had no recent chest pain, nausea, vomiting, or focal weaknesses. There was no history of trauma. She stated he had no recent increases in his medication dosages, and he had forgotten to bring his atenolol with him to Mexico.\nArterial blood gas following intubation revealed a pH of 7.13, pCO2 of 45 mmHg, pO2 of 422 mmHg, and a lactate of 14.2mmol/L. Bedside glucose was 220 mg/dL. Cardiac enzymes revealed a troponin T of 0.31μg/L with a normal creatine kinase. Complete blood count was unremarkable. His comprehensive metabolic panel was significant for an anion gap of 24 with normal electrolyte levels. His potassium was normal at 4.0 mEq/L. His creatinine and blood urea nitrogen were 2.3 mg/dL and 28 mg/dL respectively. Urine drug screen and serum alcohol were negative. The cardiologist’s official read of the ECG was complete ventricular asystole with preserved atrial function at a rate 100 beats per min. No p-wave enlargement was appreciated. Intervals, axis, and ST morphology could not be assessed due to the underlying rhythm.\nA sodium bicarbonate infusion was started and the patient was taken to the interventional cardiology suite for transvenous pacer placement. Afterward, he was admitted to the intensive care unit. On hospital day 2, a transthoracic echocardiogram was significant for mild mitral regurgitation and mild left ventricular hypertrophy. He was successfully extubated on hospital day 3, had intact mental status, and was able to consent for placement of implantation of a permanent dual chamber pacemaker. He was discharged after successful completion of the procedure with close follow up. His cardiac enzymes trended downward from initial presentation, and he did not have a percutaneous coronary angiogram performed during his inpatient stay. He was diagnosed with complete atrioventricular block due to advanced conduction disease with no reversible etiology. Amiodarone or other anti-dysrhythmic medications were not administered during his stay.

[[68.0, 'year']]

M

{'11801357': 1, '21119527': 1, '19593280': 1, '14464062': 1, '19385983': 1, '3519033': 1, '10646930': 1, '20102977': 1, '11325371': 1, '24672602': 2}

{}

3966444-1

noncomm/PMC003xxxxxx/PMC3966444.xml

Popliteal Artery Injury Associated with Blunt Trauma to the Knee without Fracture or Dislocation

Having the first intervention done at another health center, a 38-year-old male patient engaged in mining, presented to our emergency department (ED) with an isolated crush injury of the left leg 18 hours after lateral and medial sides of his left knee was temporarily squeezed at a high speed between a tree and an operative machine. The patient’s history revealed that he presented to the hospital 5 hours after the injury as the skin did not have a laceration. Investigation of the epicrisis reports and hospital records revealed that the patient underwent Doppler ultrasonography at the sixth hour. The Doppler examination revealed the presence of a probable thrombus\in the popliteal area. An embolectomy was attempted with a Fogarty catheter, but was unsuccessful as the catheter did not pass through the distal area. The patient presented to our ED at the 18th hour of the injury. In the immediate physical examination of the patient, the left knee level showed signs of paleness, coldness, anesthesia, hemorrhagic bullae, and ecchymosis posterior to the knee (). Tibialis posterior, dorsalis pedis, and popliteal arterial pulses were not felt. There was no motor function of the ankle and the toes. Successive tendon examination did not show any signs indicating a possible tendon injury. Radiographs of the leg did not show any bone pathology. The previously performed angiography revealed that the popliteal artery was totally occluded and there was no pathway to distal flow (). The patient was transfused 2 units of blood for hematocrit <27%, and as his general condition deteriorated an above-knee amputation was undertaken.\nUnder spinal anesthesia, the patient was placed in the supine position in a sterile field. Knee tendon examinations did not reveal any pathological finding under anesthesia.\nA fish-mouth incision was performed over the skin and the fascia. The bone was shortened 10 cm proximal to the femoral condyle. The popliteal artery and the vein were identified, tied, and cut. The proximal sciatic nerve was dissected, tied, and cut. The adductor magnus muscle was attached to the distal femur rudiment with ticron sutures. The amputation stump was sutured (). Following surgery, when the amputation was investigated, 3 cm of intimal damage to the popliteal artery was detected and necrosis of the muscle, tendon, and neurovascular structures was present at this level. During the post-operational period, no complications developed in the wound and the patient was followed-up on for 2 years.

[[38.0, 'year']]

M

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{'2908882-1': 1, '5299179-1': 1}

3966445-1

noncomm/PMC003xxxxxx/PMC3966445.xml

Emergency Department Crowding and Loss of Medical Licensure: A New Risk of Patient Care in Hallways

A 32-year-old overweight male with recently diagnosed type 2 diabetes presented to an urban, university hospital ED with a chief complaint of palpitations, shortness of breath, light-headedness, and “feeling ill.” He had seen his primary care physician twice in the previous weeks for similar symptoms, and he had started an exercise program to address his new-onset diabetes. After an unsuccessful attempt to see his primary care physician again that day, the patient came to the ED for care. The triage nurse charted the patient’s chief complaint as “chest pain with shortness of breath for one week increased with exertion” and recorded a heart rate at 140. The remaining vital signs at triage were a blood pressure of 128/71 mm/Hg, respirations of 28, and a temperature of 35 degrees C. Room air pulse oximetry was recorded at 95%. At the time of his arrival, the ED was over 250% of capacity (patients/beds), and the institution was on ambulance diversion. Since all 40 licensed ED beds were occupied, the patient was placed on a gurney in one of several narrow hallways within the ED. Twenty patients were already receiving hallway care when the patient presented to the ED, and another 40 were in the waiting room. The triage nurse immediately performed an electrocardiogram (EKG) per ED policy, which was immediately reviewed by an attending physician on duty at that time. This physician noted there was no ST-elevation myocardial infarction (STEMI) on the EKG and, at the request of a nurse, wrote orders for a basic lab panel. As it was the end of shift, this physician had no further involvement with the patient and did not mention his/her involvement to the next attending. On average, attending physicians in this ED screen as many as 25 patient EKGs for STEMI while providing direct supervision to an additional 30 patients during a 10-hour shift.\nFour hours after triage, the patient was formally evaluated by an off-service PGY1 (post-graduate year one) resident. The resident was aware that an attending physician had already viewed the EKG and ordered labs. The resident charted the results, including the comments from the EKG, and performed a history and physical. The prior attending was off-shift, thus the resident presented the case to a new attending physician. At that time the ED remained crowded, with all its resources overwhelmed. The oncoming attending physician had immediately become overwhelmed with critically ill and injured patients and was repeatedly confined to the resuscitation room with medical or trauma codes. During the first 2 hours of the shift, this new attending physician performed over 10 initial EKG screenings. At 5 hours post-arrival, the resident was able to present the case to the new ED attending physician, who then examined the patient in the hallway. The history obtained by the resident noted the patient never actually had chest pain, and this was confirmed by the attending physician. The point-of-care glucose was 463 mg/dL, and the initial diagnostic impression was probable hyperglycemia with dehydration. Because the patient was in the hallway, there was no formal location to maintain his paper records, and the EKG was no longer available for review. This attending physician did know that, per ED policy, a patient with dyspnea and chest pain would have automatically received a triage EKG and assumed it had been reviewed by the prior attending physician. If the initial screening review of the EKG had been concerning, the patient would have been moved out of the hallway to a monitored licensed bed, or “doubled up” in the central treatment area of the ED. Six hours after presentation the patient’s laboratory studies returned with results consistent with the initial impression of possible mild diabetic ketoacidosis (DKA) and dehydration. The blood glucose was 417 mg/dL, bicarbonate 19 mmol/L, and an anion gap of 15. Venous blood gas pH was 7.34. PCO2 was mildly decreased. Other labs were within normal limits. The patient was treated with 3 liters of IV normal saline, as well as 5 units IV and 5 units subcutaneous regular insulin. A chest radiograph was performed and was normal. Oxygen saturation was checked multiple times and ranged from 95 to 98% saturation on room air.\nAfter therapy, the patient’s glucose decreased to the 200 mg/dL range, and a repeat chemistry panel showed normal bicarbonate with no anion gap. The patient’s heart rate ranged from 66 to 114 for much of the stay in the ED, and by time of discharge was normal. The dyspnea had improved. The patient passed an oral trial of fluids, felt improved, and wanted to return home. Because this was a new onset DKA, albeit mild, an informal discussion was held with the hospitalist about admission. The hospitalist, based on the quick resolution of symptoms and patient’s access to his primary care physician, recommended outpatient management. The patient was then discharged home with the final diagnosis of hyperglycemia, mild DKA, dyspnea secondary to metabolic acidosis, and dehydration. A more aggressive regimen for his diabetes was prescribed, and home equipment for self-monitoring ordered. Close follow-up with his primary care doctor was specified. The patient was discharged 8 hours after arrival in the ED. Discharge vital signs were 154/86 mm/Hg, heart rate 94, respiratory rate 20, temperature 37 degrees C, and 98% room air saturation. He never occupied a licensed ED bed and was never on a cardiac monitor, as these were all in use.\nTwo days later, the patient developed severe shortness of breath; therefore, 911 was called and EMS activated. The patient had a cardiac arrest en route to the same hospital from which he was discharged two days earlier. Resuscitative efforts were unsuccessful, and the patient expired. An autopsy was performed and showed multiple acute and chronic pulmonary emboli as the primary cause of death. The initial EKG was retrospectively interpreted by a cardiology attending physician as showing “right axis deviation, multiple ST and T-wave changes suspicious for anterior ischemia.” The autopsy did not show coronary artery disease or evidence of myocardial infarction.

[[32.0, 'year']]

M

{'16515429': 1, '19561699': 1, '17976825': 1, '27294087': 1, '22168191': 1, '11867991': 1, '28507576': 1, '31490937': 1, '22766404': 1, '20852715': 1, '16490650': 1, '21675887': 1, '20880432': 1, '21317697': 1, '19345442': 1, '21459349': 1, '32726269': 1, '22235374': 1, '18989542': 1, '19007346': 1, '29945644': 1, '24672599': 2}

{}

3966448-1

noncomm/PMC003xxxxxx/PMC3966448.xml

The Ethics of the Missing Straw

The patient was a 34-year-old female with a chief complaint of abdominal pain. Her triage vitals were blood pressure 110/57; heart rate 93; respiratory rate 16; temperature 36.4°C. She stated she fell in her yard several days ago resulting in abdominal pain with some vaginal bleeding starting the morning of presentation. Upon further discussion during the physical exam, the patient admitted she missed her period and, in an effort to initiate it, stuck a drinking straw into her vagina. She inserted the whole straw inside and could still feel it poking her. She denied being pregnant and insisted she simply wanted to begin her period. Her pelvic exam was benign with a closed os, minimal blood in the vault, minimal right adnexal tenderness, and no signs of a foreign body or any lacerations. Basic labs revealed the patient was pregnant with a βHCG of 90,034. A subsequent ultrasound showed an intrauterine foreign body that appeared implanted within the myometrium with the width of a common straw and an indeterminate length. An approximately 8-week-old live intrauterine device (IUP) was noted next to the foreign body. Upon discussing these findings with the patient, she admitted she knew she was pregnant and was trying to perform an abortion with the straw.\nAn obstetrics (OB) consultation was placed. The initial OB consultant stated the patient was at high risk for septic shock and miscarriage. Recommendation, prior to the consultant seeing the patient, was to admit the patient for observation and antibiotics, as well as possible dilatation and curettage if she became unstable. However, shortly after requesting the consultation, a new OB attending took over the service. The new attending stated they did not believe the patient was in any danger of infection and thought it unlikely that anything had been inserted into the uterus dismissing the ultrasound finding simply as an “artifact.” The new OB consultant’s recommendation was to discharge the patient with outpatient follow-up. Feeling uncomfortable with simply discharging a patient who was potentially at high risk for infection, the EP performed a literature search which failed to provide guidance on the management of a patient with an intrauterine foreign body that was placed post-conception and/or non-sterilely. To make matters more confusing, the patient was an African immigrant and stated she did not want her husband to know of her condition or why she was in the hospital. She listed this as one reason why she would be unable to follow-up with an outside clinic. By this time, the husband arrived at the hospital and was becoming annoyed no one would tell him about his wife’s condition. The husband’s behavior was appropriate for the (unusual) situation and the patient denied sexual, physical or emotional abuse at home. With the EP present, the patient eventually discussed the situation with her husband. Both the patient and her husband repeatedly requested removal of the foreign body due to pain, and both unequivocally stated they felt the patient’s health was more important to them than the health of the fetus. The patient was reluctant to be discharged home. At the request of the patient and her husband, the EP contacted another hospital, and the OB on call there refused to accept the patient’s transfer.

[[34.0, 'year']]

F

{'1604719': 1, '19566574': 1, '17409036': 1, '12281977': 1, '16546816': 1, '7658045': 1, '9839740': 1, '12831609': 1, '14120954': 1, '24672597': 2}

{}

3966450-1

noncomm/PMC003xxxxxx/PMC3966450.xml

Incarcerated Diaphragmatic Hernia with Bowel Perforation Presenting as a Tension Pneumothorax

A 50-year-old female with a past medical history of hypertension, type 2 diabetes, gastroesophageal reflux disease, paraesophageal gastric hernia, diaphragmatic hernia, and sickle cell trait presented to the emergency department (ED) with acute onset left-sided pleuritic chest pain and severe dyspnea. Relevant past surgical history includes Nissen fundoplication and appendectomy. Upon her arrival she was hemodynamically unstable with a heart rate of 162 beats per minute, blood pressure 75/62, and respiratory rate of 36 per min. Her oxygen saturation was 98% on room air.\nThe patient was seen immediately. Upon initial examination she was noted to be in severe respiratory distress and could not speak more than one or two words between breaths. While attempting to obtain an initial history from the patient her BP began to drop further and she became more tachycardic. Monitor revealed continued sinus tachycardia with no ectopy. Upon auscultation it was noted that breath sounds were completely absent in the left hemithorax. Bedside ultrasound was immediately available and showed an abnormal pleural line, lack of comet-tail artifacts, and absence of lung sliding motion. This was felt to be consistent with pneumothorax. Due to her worsening cardiovascular instability it was decided that there was not sufficient time to obtain a portable chest radiograph and emergent needle thoracostomy was performed. After applying betadine solution to the overlying skin, a 14-gauge intravenous catheter was inserted in the left second rib interspace in the mid-clavicular line. Immediately a large release of air was appreciated. The patient’s BP increased from 63 systolic to 100 systolic and her heart rate began to decrease. Additionally, she was no longer exhibiting signs of respiratory distress as she was much less tachypneic and no longer using accessory muscles. The patient now demonstrated appreciable, however diminished, breath sounds on the left. Of note, this was the only intervention given to this patient at this time. At this point, the patient had not yet received any fluid resuscitation, vasoactive medications, nor antiarrhythmics.\nAt that point it was felt that the patient was stable enough to obtain a chest radiograph. The radiograph showed some residual pneumothorax but also showed what appeared to be bowel in the left hemithorax (). Lung markings could not be visualized 3 centimeters from the apex, although the exact size could not be determined due to overlying bowel. The radiologist’s report noted that the splenic flexure of the colon was herniated through the left hemidiaphragm. There was some aeration in the left upper lobe of the lung, the remainder of the left hemithorax was opacified. Cardiothoracic surgery was consulted, reviewed the chest radiograph and made the recommendation to replace the needle thoracostomy with a Heimlich valve to temporize the patient as we obtained an axial computed tomography (CT). After placing the Heimlich valve, a CT of the chest was obtained and showed a left diaphragmatic hernia with an intrathoracic loop of colon along with a loculated hydropneumothorax suspicious for empyema (). This was compared to a CT from 12 days prior when she presented to the ED with abdominal pain and vomiting. The previous scan showed no evidence of incarceration of the bowel loop or the presence of an empyema. She had been following the diaphragmatic hernia with a surgeon on an outpatient basis. On that visit, her symptoms resolved and was discharged. She returned 2 days prior to this presentation with posterior thoracic pain. At that time, chest radiograph was obtained and showed the known hernia but no acute process, specifically no pneumothorax. She was felt to have musculoskeletal pain and was once again discharged. However, the CT scan obtained on the current visit showed an increased amount of colon within the thorax and the colon appeared to be significantly more distended when compared to the prior CT. This was suspicious for incarceration of the colon.\nThe patient continued to remain hemodynamically stable while in the ED. Her surgeon that she was seeing regarding the diaphragmatic hernia was contacted and came to see her in the ED. Upon reviewing the radiograph and CT results, plans were made to take the patient to the operating room for an exploratory laparotomy. This revealed a 3.5 cm diaphragmatic defect approximately 3 cm lateral to the esophageal hiatus through which a 10 cm segment of transverse colon was incarcerated. The segment of incarcerated transverse colon appeared ischemic and there was a 2 mm perforation. General surgery could not reduce the hernia. Therefore, cardiothoracic was called in to perform a thoracotomy and radial incision of the diaphragm “because of the narrowness of the diaphragmatic hernia.” Bowel, as well as omentum, was found to be “edematous and matted,” and was reduced and passed into the abdomen. No frank pus or stool was observed in the thoracic or peritoneal cavities. The ischemic segment of bowel was resected to healthy colon both proximally and distally and a side-to-side anastomosis was created. A chest tube was inserted into the left posterior thoracic cavity and the diaphragmatic defect was repaired.\nCultures of serosanguineous secretion from the chest tube showed growth of Escherichia coli and Enterococcus Avium. She was placed on antibiotic therapy. She gradually regained bowel function and continued to improve quite well. She was discharged after a 9-day hospital stay in good condition.

[[50.0, 'year']]

F

{'30460027': 2, '25035733': 1, '20696690': 1, '16988292': 1, '19234255': 1, '16633757': 1, '18283482': 1, '18620592': 2, '24672600': 2}

{'6243315-1': 1, '2475514-1': 1}

3966457-1

noncomm/PMC003xxxxxx/PMC3966457.xml

Splenic Laceration and Pulmonary Contusion Injury From Bean Bag Weapon

A 58-year-old male with schizophrenia presented to the emergency department after being shot by law enforcement with two bean bag rounds. He was shot once in the upper abdomen. He reportedly turned and was shot again in the left flank; both shots were at an estimated distance of twenty feet. On arrival, the patient’s blood pressure was 84/52 and heart rate was 121 beats per minute. The patient was agitated and given 5mg intramuscular (IM) haloperidol, 50 mg IM diphenhydramine, and 1 mg intravenous lorazepam. The patient’s chest and back exam revealed a 2.5 cm abrasion and contusion to the left flank (). His lung examination was normal. His abdomen was thin, soft, and non-tender. He had another 2.5 cm circular abrasion to the upper abdomen/epigastrum (). Initial hemoglobin was 13.4 g/dL. We performed Focused Assessment with Sonography for Trauma examination, which demonstrated free fluid in Morison’s pouch () and the suprapubic window. The splenorenal space did not show any fluid.\nComputed tomography of the abdomen and pelvis with intravenous contrast revealed the following: a moderately displaced fracture of the left 11th rib, buckle fracture of the left 12th rib, trace left anterior inferior pneumothorax, American Association for the Surgery of Trauma grade 4 splenic laceration () with moderate perisplenic hematoma, mild perihepatic hematoma, and anterior abdominal wall/rectus sheath hematoma.

[[58.0, 'year']]

M

{'11574794': 1, '11379636': 1, '22273301': 1, '12435958': 1, '32351684': 2, '24672591': 2}

{'7180322-1': 1}

3966464-1

noncomm/PMC003xxxxxx/PMC3966464.xml

Phenytoin Toxicity from Cocaine Adulteration

In Houston, Texas, a 26-year-old male drug smuggler who swallowed several rocks of crack cocaine to conceal evidence while being apprehended by police was taken to our emergency department (ED) for medical clearance. Initially, he was asymptomatic, and his vital signs and physical exam were normal. After 2 hours of observation, he manifested clinical signs of cocaine toxicity including anxiety, pallor, diaphoresis, agitation, tachycardia, and hypertension. His vital signs changed; his blood pressure was 190/110 mmHg, heart rate 120 bpm, respiratory rate 22 breaths per minute, and temperature 99.6 F. His physical exam was otherwise unchanged. He was given intravenous benzodiazepine boluses and was admitted to a medical intensive care unit. Subsequently he developed confusion, truncal ataxia, diplopia, slurred speech, and multidirectional nystagmus; these changes were not explained by his pharmacological management. Additional examinations, including computer tomography of the brain, diagnostic lumbar puncture and extensive blood testing, were negative for any abnormalities. A neurology consult revealed uncertain diagnosis. A PHT level was obtained at the recommendation of the poison control center. The patient’s PHT level was 48 mcg/mL (therapeutic range: 10 to 20 mcg/mL). The patient had no history of seizures or records of prescribed PHT. Supportive care was continued, and eventually the patient was discharged with no further complaints 72 hours after MICU admission. To challenge the uniqueness of the use of PHT as cocaine adulterant a random blood screen of PHT levels was performed in 10 patients presenting with complaints related to cocaine use to an academic ED in New York City (7 were seen for chest pain, 1 for suicidal ideation, 1 for new-onset seizures, and 1 for headache associated with uncontrolled hypertension). One patient with chest pain had a PHT level of 4 mcg/mL. The patient presenting with headache had a level of 5 mcg/mL. None of the patients screened had any history of seizure disorders or medical indications for the use of PHT. The patients with positive screening tests were unaware of cocaine adulteration.

[[26.0, 'year']]

M

{'16886973': 1, '8363126': 1, '2516508': 1, '8612392': 1, '11113495': 1, '22455354': 1, '12144591': 1, '18425968': 1, '3043924': 1, '32926665': 2, '11038165': 1, '17132243': 1, '10080053': 1, '16174888': 1, '2428283': 1, '24672596': 2}

{'7434231-1': 1}

3967330-1

noncomm/PMC003xxxxxx/PMC3967330.xml

Three-dimensional virtual operations can facilitate complicated surgical planning for the treatment of patients with jaw deformities associated with facial asymmetry: a case report

The patient was a 26-year-old man who had a class III jaw deformity with a cant occlusal plane cant, along with transverse discrepancy of the maxillary and mandibular dental arch widths (the maxillary width was larger than the mandibular width), associated with an open bite and facial asymmetry. Crowding of the front teeth, an open bite of the front teeth, deviation of the mandibular center to the left, and a left molar crossbite were also observed ().\nAlthough the maxillary premolar tooth was extracted, and the alignment of the row of teeth was good in the mandible with no tooth extraction, the transverse discrepancy of the dental arch width had not improved ().\nThe facial angle between the FH plane (Frankfort plane; Or–Po, Or: Orbitale—the most inferior anterior point on the orbit's margin, Po: Porion—the most superior point of the external acoustic meatus) and the facial plane (facial plane; N–Pog, N: Nasion—the midpoint of the frontonasal structure—the intersection of the internasal and frontonasal sutures in the midsagittal plane, Pog: Pogonion—the most anterior midpoint of the chin in the midsagittal plane) was larger on the right side, which measured 87.29°, than on the left side, which measured 83.02°. The distance from the FH plane to the maxillary first molar was greater on the right side, which measured 59.57 mm, than on the left side, which measured 55.60 mm; the angle between the facial median line and the occlusal plane was 84°, showing a cant upon counterclockwise rotation.\nThe median line of the mandible also showed a cant upon counterclockwise rotation ().\nUsing virtual operations with SimPlant OMS, we performed an LF1 osteotomy: cant and yaw correction on the maxilla; intraoral vertical ramus osteotomy (IVRO) on the right side of the mandible (the side without deviation); sagittal split ramus osteotomy (SSRO) fixed semirigidly with a sliding plate on the left side of the mandible (the side with deviation); mandibular constriction (MC); and mandibular border genioplasty (bone removal) in the mental region.\nCant correction and yaw correction were implemented in the maxilla, while mandibular midline osteotomy was implemented in the mandible to shorten the mandibular width (MC), with a setback of the mandible on the right side and extension of the mandibular ramus height (downward shift) on the left side.\nFurthermore, mandibular boarder osteotomy, including genioplasty due to bone removal, was planned for the asymmetry of the mandible angle/mental region that remained after osteotomy.\nThis stage was designed carefully to avoid trismus due to bone inference with the coronoid process and the zygomatic arch ().\nIt is important to evaluate the case from the lower side of the face in cases of facial asymmetry, in addition to implementing a design such that the left–right asymmetry of the mandibular border, which forms the facial outline, is prevented from moving in this direction ( and ).\nPresurgical and postsurgical facial changes were simulated by mapping a picture of the patient's facial profiles onto the soft tissue on the 3D-CT images. The asymmetry was improved in the front and lower areas, including the facial profile, following the surgery simulation.\nThe reduction of the mandibular width was measured, upon confirming the precise occlusal relationship after osteotomy, by optical scanning of the dental cast to link the data to the 3D-CT images.\nCant correction and yaw correction were implemented in the maxilla with a LeFort I osteotomy, and the right molar tooth was impacted in the upper area, resulting in complete down fracture, while Piezo Surgery (Mectron, Carasco, Italy) was applied for bone removal in the area surrounding the descending palatine artery.\nMC was implemented using two lag screws, following a mandibular midline osteotomy.\nSetback of the mandible with IVRO was performed on the right side of the mandible, and extension of the mandibular ramus height (downward shift) with SSRO was performed by semirigid fixation, using the sliding plate and one additional screw fixation on the left side of the mandible.\nFurthermore, bone removal in the distorted position was applied to the asymmetry in the mental region that remained following osteotomy (). The seating of the condyles was good postoperatively.\nWith regard to the presurgical and postsurgical evaluations of the frontal cephalogram, as no precise superimposition was possible due to the discordance of the upper and lower slant (rolling) of the face on the frontal cephalogram, an evaluation was undertaken by rotationally transferring the presurgical 3D-CT image to the location matching the postsurgical frontal cephalometric X-ray image ().\nAlthough the distance from the FH plane to the upper first molar was greater on the right side prior to surgery, the postsurgical distance was improved and was almost equal on both sides ().\nWith regard to the dental arch widths of the maxilla and mandible (the distance between the first molars), although the width of the mandible was greater than that of the maxilla presurgically, that of the mandible was improved to create a normal relationship (the maxillary width is larger than the mandibular width) postsurgically ().\nRegarding the positional relationship between the right and left mandibular angles and the facial midline, although the positional relationship between the right and left mandibular angles was larger on the left side than the right side presurgically, the postsurgical location was improved to being almost equal on both sides. Furthermore, the total was shortened from 114 mm to 105 mm. The presurgical intersecting degree of 95° was improved to a perpendicular angle of 90° postsurgically ().\nSubsequently, with regard to the positional relationship between the right and left mandibular angles and the mandibular midline, although the right side was larger presurgically, it was improved to being almost equal on both sides postsurgically. The presurgical intersecting degree of 86° was improved to a perpendicular angle of 89° postsurgically.\nThe superimpositions of the presurgical–postsurgical frontal cephalotraces are shown in . Upon superimposing the postsurgical mirror image of the half on the right side onto the other side (orange), it was confirmed that the postsurgical image (red) was close to bilateral symmetry ().\nThe summary of the results regarding the presurgical and postsurgical frontal cephalograms is shown in . The occlusal plane measured 9°, while the median mandible measured 14° upon CR (clockwise rotation) ().\nThe superimposition of the lateral cephalotrace is shown in (). It improved from class III to class I.\nThe splint was removed 1 month after surgery and was replaced with occlusal guidance, using only intermaxillary elastics.\nThe facial pictures 3 months after surgery confirmed that the asymmetry in the frontal view, as well as the profile view, was improved. The asymmetry was nearly in accordance with soft-tissue simulation (). Furthermore, even in the upward view, left-right symmetry was almost obtained, similar to the soft tissue simulation ().\nThe intraoral photographs 3 months after surgery showed the accordance of the median of the maxilla and mandible, obtaining a class I occlusal relationship ().\nIt was confirmed that the seating of the mandibular head was well maintained even 3 months after surgery, resulting from the reduction in interference with the osteotomized segments, as a result of the surgery to reduce the mandibular width (MC) ().\nThe facial pictures and intraoral photographs 1 year and 6 months after surgery confirmed that the improved soft tissue symmetry in the frontal view, the profile view, the class I occlusal relationship without an open bite, the accordance of the median of the maxilla and mandible and the right temporomandibular joint seating without temporomandibular joint symptoms were maintained ().

[[26.0, 'year']]

M

{'33406617': 1, '28526831': 1, '21042192': 1, '8422026': 1, '22776556': 1, '23348338': 1, '23195368': 1, '15015172': 1, '22421859': 1, '23583007': 1, '22578567': 1, '23147319': 1, '23266152': 1, '22835657': 1, '22872832': 1, '23164998': 1, '20170994': 1, '15356482': 1, '23907678': 2}

{}

3967566-1

noncomm/PMC003xxxxxx/PMC3967566.xml

ST-segment elevation associated with allergic reaction to echocardiographic contrast agent administration

A 60-year-old man was referred for contrast-enhanced dobutamine stress echocardiography (DSE) for detection of ischaemia. Two years before, the patient had an inferolateral myocardial infarction treated with a primary percutaneous coronary intervention and implantation of a drug-eluting stent in the right coronary artery (RCA). A few months before DSE, he complained of recurrence of typical angina pectoris due to a stenosis proximal to the stented segment in the RCA, which was successfully treated with implantation of a second drug-eluting stent (Fig.). However, few weeks later, he developed new atypical thoracic symptoms, for which he was referred for DSE[].\nAt the beginning of the procedure, the patient’s blood pressure was 135/75 mmHg, his heart rate was 79 beats/min and ECG showed sinus rhythm and right bundle-branch block (Fig.). Before starting the infusion of dobutamine, SonoVue® was administered to optimise visualisation of the left ventricle. One minute after administration of a 1 ml bolus of SonoVue®, the patient started complaining of nausea with profuse sweating and hypotension (100/45 mmHg). These signs were treated as an allergic reaction with clemastine (2 mg), hydrocortisone (100 mg), oxygen and saline infusion. Two minutes later, sudden severe chest pain occurred and the ECG showed ST-segment elevation in leads II, III, aVF and V2-V4, with ST-segment depression in V2-V4, I, and aVL, and total AV-nodal block (Fig.). During this episode, echocardiography showed akinesia of the inferior wall, whereas baseline echocardiography showed only mild mid-inferior hypokinesia. After 8 min (as measured on the monitor), the symptoms started to decrease and the ST segments normalised (Fig.). Immediate coronary angiography was performed showing a good patency of the stents in the RCA. However, a 50 % stenosis was observed proximally to the stented segment, which was interpreted as a possible coronary spasm (Fig.). No significant pathology was observed in the left coronary artery. Intravascular ultrasonography of the RCA was also performed and showed minimal neo-intimal hyperplasia (Fig.) with no significant stenosis. Further angiographic projections confirmed complete resolution of the spasm (Fig.). The patient was admitted to the coronary care unit and observed for 12 h. His recovery was uneventful and troponin T remained within normal ranges (0.016 μg/l).

[[60.0, 'year']]

M

{'19525512': 1, '16249041': 1, '1793697': 1, '19356420': 1, '17223253': 1, '12032577': 1, '17174628': 1, '19145117': 1, '15682054': 1, '15497786': 1, '21604107': 1, '23081810': 1, '16709395': 1, '23821494': 2}

{}

3968079-1

noncomm/PMC003xxxxxx/PMC3968079.xml

Patency of small laser iridotomy evaluated using anterior-segment optical coherence tomography

A 49-year-old Japanese man presented with blurred vision in both eyes. Intraocular pressure (IOP) was 42 mmHg in the right eye and 70 mmHg in the left eye. Slit-lamp examination showed a cloudy cornea, and gonioscopy showed anterior chamber angle closure in both eyes. The patient was diagnosed with bilateral acute angle-closure glaucoma, and neodymium-doped yttrium aluminum garnet (Nd:YAG) laser iridotomy was performed to eliminate pupillary block in both eyes. After the procedure, IOP decreased to a normal level.\nOne month later, however, the patient presented with blurred vision in the right eye. Best-corrected visual acuity was 20/16 bilaterally. IOP was 70 mmHg in the right eye and 23 mmHg in the left eye. Slit-lamp examination of the right eye showed a cloudy cornea. Despite its small size, the previous laser iridotomy was observed at the 10 o’clock position in the iris (). Transillumination through the opening was also observed. Gonioscopy showed angle closure in all four quadrants. Following compression, gonioscopy showed that the closure was partially appositional, and more than half of the angle had synechiae. Based on the sudden IOP elevation associated with a cloudy cornea and blurred vision, we suspected recurrent acute angle-closure glaucoma in this patient, although the initial iridotomy appeared open on slit-lamp examination.\nTo further evaluate the precise condition of the initial laser iridotomy, we referred to cross-sectional images obtained using AS-OCT (CASIA SS-1000; Tomey Corporation, Nagoya, Japan). The angle mode was used for evaluation. The images showed a membrane that was not observed by slit-lamp examination, with an anterior bowing configuration at the base of the iridotomy (), suggesting increased fluid pressure in the posterior chamber. This observation indicated that pupillary block was the causative mechanism of the increased IOP in our patient, and retreatment with Nd:YAG laser iridotomy was performed at the same site.\nAfter the procedure, the IOP decreased to 9 mmHg. The anterior lens capsule was observed through the opening by slit-lamp examination (). A cross-sectional image showed a completely penetrated iridotomy with widening of the anterior chamber angle and straightening of the iris ().

[[49.0, 'year']]

M

{'29240598': 1, '20224953': 1, '3062535': 1, '16376666': 1, '23599331': 1, '21828152': 1, '2285680': 1, '23188727': 1, '24711692': 2}

{}

3968269-1

noncomm/PMC003xxxxxx/PMC3968269.xml

A rare variant angioarchitecture of upper abdomen

During routine dissection in subhepatic region of abdomen of a well embalmed 70-year-old male cadaver in the Department of Anatomy, M. L. N. Medical College, Allahabad, India, on 15 May 2012, following variations in the branching pattern of CT and SMA were encountered.\nThe CT was seen arising from left lateral aspect of the abdominal aorta at the level between T12-L1 vertebrae instead of its usual ventral origin. After a short course of 7 mm the CT was observed to give rise an additional branch i.e., gastroduodenal artery (GDA) (diameter, 5 mm) in addition to its usual three branches viz. LGA (diameter, 4 mm), SA (diameter, 8 mm), and CHA (diameter, 7 mm) (). SA followed an unusual straight course towards left and was not tortuous as it should be. CHA gave off right gastric artery (RGA) after a course of 12 mm from its origin and continued as left hepatic artery (LHA). LHA ascended towards the liver in the right free margin of lesser omentum, anterior to portal vein and left to the common bile duct; and gave off an unusually long cystic artery (CA) (diameter, 4 mm) before entering into liver parenchyma at the porta hepatis. SMA arose from the ventral surface of abdominal aorta at the level of L1 vertebra, 22 mm distal to the origin of CT; and descended behind the neck of pancreas, where it gave off a "replaced" right hepatic artery (RHA) (diameter, 6 mm) for the supply of right lobe of liver. No right sided hepatic arterial system was identified from the CHA. This replaced RHA exhibited a long and tortuous course towards the liver and was crossed in front by CA before its entrance into the porta hepatis. The CA was running laterally after its origin from LHA, in front of replaced RHA and gave off 2-3 small anastomotic branches running down towards hepatic flexor of colon, in addition to its usual superficial and deep branches to the gallbladder (, ).\nNo other anomalous blood vessel was identified. Diameter of all arteries was measured with the help of sliding vernier caliper and scale.

[[70.0, 'year']]

M

{'26435909': 2, '16228946': 1, '20200764': 1, '20809044': 1, '23112032': 1, '8024358': 1, '5917302': 1, '24693485': 2}

{'4586006-1': 1}

3968270-1

noncomm/PMC003xxxxxx/PMC3968270.xml

Multiple unilateral variations in medial and lateral cords of brachial plexus and their branches

During routine dissection for medical undergraduate teaching programme, standard skin incisions were made to expose the region of the right axilla and arm of a 58-year-old male cadaver. The pectoralis major and minor muscles were reflected laterally after detaching them from their origins, to expose the axillary neurovascular structures.\nThe lateral cord was giving off 2 LPNs-superior lateral pectoral nerve (SLPN) and inferior lateral pectoral nerve (ILPN) (). SLPN was seen to pierce the clavipectoral fascia and enter the pectoralis major muscle from its deep surface to supply it (comparable to a usual LPN). The ILPN was seen to arise from the lateral cord 1 mm distal to the origin of its superior counterpart and was observed to pierce the pectoralis minor muscle 5 mm inferior to its superior border.\nThe MPN was given off from the medial cord of brachial plexus as usual. The length of the main trunk was 3 cm and it divided into two branches-a cranial branch (branch 1) entering the lower part of pectoralis minor and a caudal branch (branch 2) which was seen to supply pectoralis major without piercing pectoralis minor ().\nThe MCN branched as usual from the lateral cord of brachial plexus but it did not pierce CB muscle (). Instead, it descended medial to the CB giving 4 branches (b1, b2, b3, and b4) and further pursued a normal course placed between biceps and brachialis. The first branch, b1, which was a short transverse branch to CB, was given off 2 cm distal to the origin of MCN and 4 cm from the coracoid process. It was seen to split into two before supplying CB. One centimeter distal to the origin of b1, a long oblique branch (b2) was given again to CB which disappeared within its substance to reappear again, posterior to the branch b3 and rejoining the main trunk of MCN caudal to b3. A third branch (b3) was given to BB, 6.2 cm caudal to origin of b2. The fourth branch (b4) was given to BB and brachialis as a common trunk at the same point where b2 rejoined the main trunk.\nThe MN was formed as usual by the union of MR and LR of MN arising from the medial and lateral cords of brachial plexus respectively. The MR of MN crossed the 3rd part of axillary artery from medial to lateral side to unite with the LR of MN which was 1 cm in length. In addition two neural communications were observed connecting the lateral and medial cords (). The cranial communication (* in ) was arising from the lateral cord 3 cm proximal to the origin of LR of MN and the caudal communication (# in ) was arising 1 mm distal to the cranial intercordal neural communication. Both the communications were seen running obliquely downwards and medially, anterior to the axillary artery and joining the medial cord. The cranial communication was bifurcating into two branches before joining the medial cord.\nFurthermore, ulnar nerve was seen to arise by two roots from the medial cord-root "a" and root "b" (). Root "b," 1 cm in length, arose at the level of intercordal neural communication and root "a," 2.5 cm in length, arose higher up in relation to the 2nd part of axillary artery. Both these roots joined to form the main trunk of the ulnar nerve.\nThe arterial pattern and the relations of axillary artery to the nerves were found to be normal. No such variation was observed in the left brachial plexus.

[[58.0, 'year']]

M

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{}

3968548-1

noncomm/PMC003xxxxxx/PMC3968548.xml

First Case of Liver Abscess in Scandinavia Due to the International Hypervirulent Klebsiella Pneumoniae Clone ST23

An 85-year old Caucasian man was admitted to the hospital with a history of 2-3 weeks of anorexia, fatigue, headache and dyspnoea. The patient had prior to hospitalization taken penicillin per os (p.o.) for seven days for pneumonia without effect. His only medical history was a pacemaker implementation one year previously, due to III degree AV-block. After admission the patient was treated with intravenous (i.v.) G-penicillin and gentamicin on suspicion of pneumonia and endocarditis. Chest X-ray and echocardiography were normal. Unfortunately, blood and urine cultures were taken after institution of antibiotics and showed no growth. Due to poor clinical response antibiotics were changed first to i.v. mecillinam on day 7, and later to i.v. cefuroxime on day 9.\nDue to elevated alkaline phosphatase an abdominal ultrasound and CT were performed on day 14 showing an abscess measuring 10.5 x 7.2 x 8.7cm in the right liver lobe. By ultrasonic guided abscess drainage, 20 cubic cm of pus giving growth to K. pneumoniae was removed. Antibiotics were stopped after two days and the patient was discharged without any further treatment or follow up.\nThe patient was re-admitted to the hospital 109 days later due to collapse at home. On suspicion of urosepsis he was treated with i.v. cefuroxime and later supplemented with gentamicin. Liver ultrasound showed no abscess, but as blood culture showed growth of K. pneumoniae a new CT scanning was performed. The CT scan showed a new liver abscess about 2 cm in diameter, in close relation to the original liver abscess. The original liver abscess area was reduced to about 3 cm in diameter, and was hypodense with possible signs of infections/edema. Ten days after admission antibiotics was changed to ciprofloxacin p.o. for 41 days. After discontinuation of antibiotics, the patient was followed weekly with blood samples, and was after one month declared free from infection, as both CRP and leukocytes had remained normal.\nThe patient had no history of foreign travel and also no contact with people from Southeast Asia. Eighteen months after the last follow up the patient was doing well and had no sign of relapse.\nThe K. pneumoniae blood isolate was hypermucoviscous as shown by the formation of a mucoviscous strings when a loop was passed through a colony. Capsular serotype was K1 and it belonged to ST23 as determined by the K. pneumoniae MLST scheme described by Diancourt et al. []. The isolate was positive for the following virulence factors: aerobactin, allS, kfu and rmpA as revealed by polymerase chain reaction using specific primers [].

[[85.0, 'year']]

M

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